Abuse and Neglect/Sexual Assault

CHAPTER 3 Abuse and Neglect/Sexual Assault



Anita Ruiz-Contreras, RN, MSN, CEN, MICN, SANE-A, FAEN



MAJOR TOPICS



General Strategy


Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Abuse/Assault Emergencies


Child Maltreatment

Intimate Partner Violence (Domestic Violence)

Elder Abuse/Neglect

Sexual Assault


I. GENERAL STRATEGY



A. Assessment




1. Primary and secondary assessment/resuscitation (see Chapters 1 and 31)


2. Focused assessment


a. Subjective data collection

1) History of present illness/injury/chief complaint
a) “Red flags” of history
(1) Inconsistent history: injuries/illness does not appear to have logically been caused by the stated history

(2) Changing or adding explanatory history when patient or caregiver is questioned

(3) Mechanism of injury unlikely in view of patient’s age, physical development, or condition

(4) Delay by caregiver in seeking treatment

(5) Overbearing individual who intimidates individual family members by body positions, facial expressions, or verbal threats

b) Vague complaints (e.g., headache, abdominal pain, weakness)

c) Recent injury

d) Stated assault

e) Efforts to relieve symptoms
(1) Home remedies

(2) Alternative therapies

(3) Medications
(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history
a) Current or preexisting diseases/illness

b) Previous history of abuse/neglect

c) Substance and/or alcohol use/abuse

d) Last normal menstrual period: female patients of childbearing age

e) Medications
(1) Prescription

(2) Over-the-counter/herbal

f) Allergies

g) Immunization status

3) Psychological/social/environmental factors
a) Fear of reporting abuse

b) Caregivers contributing factors (Table 3-1)

c) Fear of retaliation

d) Physical or social isolation of patient

e) Munchausen syndrome by proxy

b. Objective data

1) General appearance
a) Level of consciousness, behavior, affect

b) Vital signs

c) Odors

d) Gait

e) Hygiene

f) Level of distress/discomfort

2) Inspection
a) Soft tissue injuries: ecchymotic areas

b) Burns

c) Patterned injuries

3) Auscultation
a) Breath sounds

b) Heart sounds

c) Bowel sounds

d) Fetal heart tones if pregnant

4) Palpation
a) Skin temperature, moisture

b) Areas of tenderness, deformity

3. Diagnostic procedures


a. Laboratory studies

1) Complete blood count (CBC) with differential

2) Serum chemistries including glucose, blood urea nitrogen (BUN), creatinine

3) Serum and urine toxicology screens

4) Type and crossmatch

5) Urinalysis; pregnancy test in female patients of childbearing age

6) Baseline human immunodeficiency virus (HIV), and hepatitis B and C

7) Rapid plasma reagin (RPR)

8) Cultures for sexually transmitted diseases unless prophylactically treated

9) Evidence collection swabs (e.g., anogenital and oral areas)

10) Forensic testing: DNA, ABO blood groups

b. Imaging studies

1) Radiograph of injured/tender area

2) Battered-child (full body) radiographs

3) Head or abdominal computed tomography (CT) scan, as indicated by injuries

c. Other

1) 12- to 15-lead electrocardiogram (ECG)

2) Physical evidence collection (e.g., fingernail scrapings, clothing)

3) Alternate lighting source

Table 3-1 CONTRIBUTING FACTORS: CAREGIVERS



























Socioeconomic stressors Poverty Unemployment
Frequent geographic moves Isolation Domestic violence
Attachment problems Punitive child-rearing styles Parent stressors
Low self-esteem Abused as children themselves Depression
Substance abuse Character disorders Unrealistic expectations of the child
Triggering situations Discipline issues Argument/family conflict

Emergency Nurses Association. (2004). Emergency nursing pediatric course (p. 161). Des Plaines, IL: Emergency Nurses Association.



B. Analysis: Differential Nursing Diagnoses/Collaborative Problems




1. Risk for injury


2. Risk for ineffective coping


3. Risk for impaired skin integrity


4. Anxiety/fear


5. Pain


6. Risk for self-directed violence


7. Rape-trauma syndrome



C. Planning and Implementation/Interventions




1. Determine priorities of care


a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluids/blood products/medications

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension


3. Allow significant others to remain with patient if supportive


4. Educate patient and significant others



D. Evaluation and Ongoing Monitoring (see Appendix B)




1. Continuously monitor and treat as indicated


2. Monitor patient response/outcomes, and modify nursing care plan as appropriate


3. If positive patient outcomes are not demonstrated, re-evaluate assessment and/or plan of care



E. Documentation of Interventions and Patient Response




F. Age-Related Considerations




1. Pediatrics


a. Growth or development related

1) Dependent on caregiver to meet physical and emotional needs

2) If an experienced pediatric examiner is not available and the assault is not acute (recent), the examination may be postponed until a time when an examiner is available

3) Determine local policy or state law regarding consent when preparing to examine an adolescent. Patient may not want his or her parents contacted. Determine whether parental consent is required

4) Determine the adolescent’s knowledge base of sexual function and terminology

b. “Pearls”

1) The uncooperative pediatric patient should not be restrained in order to complete an examination. This could further traumatize the child.

2) Risk factors for abuse
a) Infant separation at birth as a result of prematurity or illness

b) Congenital anomalies or chronic medical conditions

c) Behavior problems, fussy infants

d) Developmental disabilities

3) Assess for possibility of long-term molestation in the pediatric age group

2. Geriatrics


a. Aging related

1) Each year it is estimated that 2.1 million older adults (age 60 and older) are victims of abuse or neglect

2) Increased incidence of soft tissue injury resulting from force
a) Soft tissue is more friable and may lead to increased bleeding

3) Consider patient comfort when performing pelvic examination

4) Dependent on caregivers to meet physical and emotional needs

b. “Pearls”

1) Women are more often victims because they make up a larger proportion of the older population

2) Determine patient’s degree of comfort when discussing sexual function and terminology


II. SPECIFIC ABUSE/ASSUALT EMERGENCIES



A. Child Maltreatment


Child maltreatment can be described as physical, sexual, or psychological abuse and neglect. Each has unique characteristics and requires individual approaches. Annually, more than 3 million reports are made to child protective authorities in the United States, and nearly 1.4 million children are victims of abuse. Approximately 1200 children die each year from injury or neglect. Many of these seriously injured and murdered children have previously presented to the emergency department for initial care.


Children who have been sexually assaulted or molested should be referred to a child abuse medical specialist or specialized program. The most important treatment priority is ensuring the health and safety of the child. The emergency care provider’s ability to maintain a nonjudgmental approach aids in his or her ability to communicate therapeutically with the patient and family.


Emergency care of the maltreated child includes a number of important steps. These steps include a suspicion of abuse, history taking, establishing the diagnosis, treating injuries, reporting to appropriate child protective agencies and/or law enforcement, documenting findings, discussing safety, and recommending follow-up physical/psychological care.




1. Assessment


a. Subjective data collection

1) History of present illness/injury/chief complaint (Table 3-2)
a) Injury
(1) Bruises, fractures, tissue disruption

(2) Burn

(3) Mechanism of injury

b) Lethargy, new-onset seizure, coma

c) Feeding problems; failure to thrive

d) Persistent vomiting, hemoptysis

e) Genital bleeding, discharge

f) Regressive or “acting out” behaviors

g) Recurring vague physical illness: Munchausen syndrome by proxy

2) Past medical history
a) Current or preexisting diseases/illness
(1) Leukemia, hemophilia, other blood dyscrasias

(2) Glutaricaciduria type 1: amino acid metabolism disorder resulting in retinal hemorrhages and subdural hematomas

(3) Osteogenesis imperfecta

(4) Mental, physical, or behavioral difficulties

b) Medications

c) Allergies

d) Immunization status

b. Objective data collection

1) Physical examination
a) General appearance
(1) Level of consciousness, behavior, affect: awake to comatose, behavior normal to quiet and subdued, or “acting out”

(2) Vital signs: normal to hypotension, tachycardia, tachypnea

(3) Hygiene: clean to unkempt, malnourished

(4) Moderate to severe distress/discomfort

b) Inspection
(1) Injuries in various stages of healing (e.g. fractures) (Table 3-3)

(2) Injuries that do not match the given history

(3) Injuries with identifiable pattern (e.g. hand, object)

(4) Multiple bruising of soft tissues in various stages

(5) Burns
(a) Identifiable pattern (e.g., cigarette, heater, hot water immersion)

c) Palpation
(1) Skin and mucous membranes

(2) Areas of tenderness

2) Diagnostic procedures
a) CBC with differential

b) Coagulation profile in any child with suspicious bruising

c) Urinalysis; pregnancy test in female patients of childbearing age

d) Liver transaminases and amylase

e) Stool guaiac

f) Radiographic bone survey
(1) Full radiographic abuse survey (skeletal survey) indicated in any child aged 2 years or younger

g) Head CT scan
(1) Noncontrast CT scan indicated in any child with head trauma

h) Abdominal CT scan
(1) Indicated in unconscious child or the child with signs of abdominal trauma

2. Analysis: differential nursing diagnoses/collaborative problems


a. Risk for caregiver role strain

b. Impaired parenting

c. Risk for impaired parent-infant/child attachment

d. Risk for injury

e. Ineffective individual and/or family coping

f. Risk for impaired skin integrity

g. Anxiety/fear

3. Planning and implementation/interventions


a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen as indicated

c. Establish IV access for administration of crystalloid fluids/blood products/medications as needed

d. Prepare for/assist with medical interventions

1) Initiate or continue Basic Life Support (BLS) and Advanced Life Support (ALS) per protocols if respiratory or cardiac arrest is present

2) Institute cardiac and pulse oximetry monitoring as indicated

3) Photograph all injuries when possible
a) Identify photograph with child’s name

b) Identify date of photograph

c) Identify body location of photograph; ruler or colorimetric chart may be added to aid in identifying size and type of injury

4) Assist with collection and maintenance of physical and forensic evidence as indicated (see Chapter 43)

5) Assist with treatment of injuries associated with abuse

6) Insert gastric tube and attach to suction as indicated

Related posts:

  1. Neurologic Emergencies
  2. Wounds and Wound Management
  3. Disaster Preparedness and Response
  4. Cardiovascular Emergencies

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Nov 8, 2016 | Posted by in NURSING | Comments Off on Abuse and Neglect/Sexual Assault

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