Download Caring for Abused Persons PPT

Caring for Abused Persons
Chapter 35
Self-esteem: how one feels about
oneself. Its components are selfacceptance, self-worth, self-love and
self-nurturing.
Abuse
• Most abuse of women, children and elderly is
intimate violence (perpetrator loved and
trusted person).
• World is no longer safe.
• Empowerment is foreign.
• Empowerment is the promotion of the
continued growth and development of
strength, power and personal excellence.
Woman Abuse
• Significant health problem crossing all racial, ethnic
and SES lines
• 2-4 million women abused each year
• Single, divorce separated women at highest risk
• Violence begins early in dating relationship
• Dynamics of intimate relationships
– Chronic syndrome characterized by emotional abuse, degradation,
restrictions on freedom, abuse, threats, stalking and isolation from
family
– Core pattern of coercive control
Battering, Rape and Sexual
Assault
•
Single greatest cause of injury to women
•
Women are aware that they are in danger of being killed.
•
Sexual assault occurs once every 6.4 minutes.
•
Types of rapists:
– Power (55%)
• Attack people own age, using intimidation and minimal physical force
• Premeditated
– Anger (40%)
• Target either very young or old
• May use extreme force resulting in injury
– Sadistic (5%)
• Most dangerous
• Premeditated, often torture or kill victims
• Derive erotic gratification
Child Abuse
• Can take several forms, varies from state to state
• Prevalence unknown
• Child neglect most common
– Failure to protect child
– Physical neglect
– Medical neglect
• Physical - severe spanking, kicking, shoving or any other type of
physical action
• Sexual abuse - ranges from mild (covert) to severe (overt)
– Incest
– Sexual abuse by a non-family member
– Pedophilia
Child Abuse (cont.)
• Emotional abuse
• Acts of omission, co-mission that psychologically damage the
child
• Types
– Rejecting
– Isolating
– Terrorizing
– Ignoring
– Corrupting
• Munchausen’s by proxy (factitious disorder)
• Children of battered women
Elder Abuse
• Estimated at 1.5 million cases
• Neglect (58.5%)
• Physical abuse (15.7%)
• Financial/material mismanagement (12.3%)
• Emotional (7.3%)
• Sexual (.04%)
• Risks
• Older age
• Impairment in ADL
• Dependency on caregiver
• Isolation, stressful events
• History of intergenerational conflict
Biologic Theories
• Neurologic problems
– Traumatic brain injury, seizure disorder
(post-ictal), dementia
– Orbitofrontal cortex damage
– Disruption of neurotransmitter system
• Links with substance abuse
Psychosocial Theories
• Psychopathology theory
– Type I - antisocial and violent in many situations
– Type II - antisocial and abuse family members
– Type III - dysphoric-borderline, only family
• Social learning theory
– Men who view violence as children become violent
as adults.
• Social
– Acceptance of violence as normal
– Family stress theory
Dynamics of Woman Abuse
• Feminist theories
• Men perpetuating control over women
• Patriarchal society
• Power inequity
• Borderline personality organization
• Consistent with cycle of violence
• Why women stay in relationships
• Economic
• Responsible for maintenance of marriage, family
Dynamics of Woman Abuse
(cont.)
• Traumatic bonding
• Explains why women stay in relationship
• Emotional attachments formed because of
intermittent abuse
• Structural components of relationship
– Power imbalance
– Intermittency in abuse
• Cycle of violence
Biologic Responses
• Depression
• Acute stress disorder (ASD)
• New disorder in updated DSM-IV
• Barrage of stress-related events persists for
two days
• If lasts longer, becomes PTSD
• Post-traumatic stress disorder (PTSD)
• Dissociative identity disorder (DID)
Post-traumatic Stress Disorder
• Lifetime prevalence: 1 to14%
• More prevalent in women than men
• 30% of women develop PTSD after
exposure to a traumatic event, 15% of
men
• May develop anytime after trauma
• Young and elderly more sensitive
PTSD
• Hyperarousal
– Stress system goes on permanent alert
– Dopamine hyperactivity
– Behavioral sensitization
• Intrusion
– Re-live as if it were continually recurring
– Flashbacks, nightmare vivid
– Amygdala involved in memory
• Avoidance and numbing
– Develop periods of dissociation
Dissociative Identity Disorder
• Formerly multiple personality disorder
• Two or more distinct identities with unique
personality characteristics and inability to
recall important information about self
• Prevalence unknown
Dissociative Identity Disorder
• Etiology unknown, but causative factors
include:
– A traumatic event
– A psychological or genetic vulnerability
– Formative environmental factors
– Absence of external support
Substance Abuse and Dependence
• Association between childhood abuse, PTSD
and substance abuse is well-established.
• Survivors who experience PTSD, depression
and other forms of hyperarousal or emotional
distress often abuse substances that inhibit
noradrenergic activity and lessen stress.
Psychological Responses
• Low self-esteem
• Alienation from self (painful feelings that go to the core)
• Alienation from others (painful feelings from being
disconnected to others)
• Guilt and shame
• Blame self for abuse
• Prevent victims from seeking medical care and reporting
abuse
• Anger
• Chronic irritability, unexpected or uncontrollable feelings
of anger
Social and Interpersonal Responses
• Problems with intimacy
– Difficulty forming trusting relationships
– Sexual problems common
• Revictimization
– Victims usually become victims again
– High risk for dissociative disorders
– Alexithymia may add risk for revictimization
Assessing for Abuse
• Health care providers often miss abuse
or re-victimize the patient by blaming.
• Establishing a nurse-patient relationship
is the most important step.
• Lethality assessment first
• Assessment questions
Biologic Assessment
• Past seven present medical history, ADLS
• Document injuries.
• Observe for:
• Elevated pulse and BP
• Sleep and appetite disturbances
• Nightmares
• Memory difficulties
• Substance abuse
Psychological Assessment
• Mental status evaluation
• Suicide assessment
• Observe for:
– Anhedonia
– Difficulty concentrating
– Feelings of worthlessness or guilt
– Thoughts of suicide or death
Social Assessment
• Social networks and support
• Daily activities
• Financial support
• Assess restriction of freedom
• Degree of dependency in relationship
Sexual Assault
• Assess for injuries.
• Collect evidence for forensic evaluation.
• Someone specially trained should
conduct it.
Nursing Management: Children
• Careful physical assessment
• Safety of child
• Breaking the silence
• Increasing self-esteem
• Dealing with loss
• Learning to trust
• Learning to protect oneself
• Assertive conflict resolution
• Empowerment
Nursing Management: Elderly
• Accurate assessment
• Determining danger
• Interventions depend on acceptance
• Included in mandatory reporting
• Improving functional level
• Involving other family members
Biologic Interventions
• Restoring physical health
• Teaching sleep hygiene, promoting
exercise
• Administering and monitoring
medications
• PTSD -benzodiazepine, -blockers and
antidepressants (SSRIs- Zoloft)
• Referring to treatment center for
substance abuse
Psychological Interventions
• Assisting with psychotherapy or
counseling
• Providing education
• Behavioral interventions
– Anxiety management
– Measuring gains in small steps
Social Interventions
• Family interventions
– Parenting skills
– Leisure skills
– Household organization
• Working in the community
– Assistance in developing support networks
– Home visits
Special Considerations in Sexual
Assault
• Early treatment crucial
• Diminish survivor distress
• Supportive, caring, non-judgmental
• Unwanted pregnancies
• STD, HIV
• Interventions
– Education
– Counseling
– Emotional support
Evaluation and Treatment
Outcomes
• Depends on the setting
• Follow-up important
• Referral for treatment of disorders
resulting from abuse (ASD, PTSD and
other anxiety disorders, DID, major
depression, substance abuse)