0133427269 Module32 Violence LectureOutline

Module 32 Violence The Concept of Violence Violence ( the use of excessive force against others or self FBI cites four categories murder, rape, robbery, aggravated assault All instances of abuse are also categorized as violence Affects people of all ages Can occur within any context Normal presentation Results from a combination of factors Predisposing factors Precipitating factors ( give rise to a specific incident of violence Protective factors Predisposing factors Include environmental, psychological, cultural, and behavioral variables Geographical and environmental factors ( living in impoverished area, especially near gang activity and drugs Families can be a factor ( history of abuse or neglect Individual or behavioral factors ( preoccupation with danger or violence, history of abuse or torturing animals, history of bullying Psychological factors ( aggressive tendencies, uncontrolled anger, extreme emotional distress, emotional instability, depression Protective factors Factors that reduce risk of violent behavior or being the target of violent action Determination and success in school Healthy and positive social relationships Parents who show an interest in their childs experiences Involvement in the community Participation in family activities Participation in cultural or religious practices Strong emotional support from friends and family Physical violence See CONCEPTS RELATED TO VIOLENCE, p. 1955 Alterations and manifestations Abuse ( intentional harm or injury Intimate partner abuse Child abuse Elder abuse Sexual abuse Physical or emotional abuse Interpersonal violence ( violence that occurs within relationships between family members, intimate partners, acquaintances, or strangers More than one type of violence can occur simultaneously Cycle of violence Tension builds as communication fails An abusive or threatening incident occurs Honeymoon period ( aggressor may show love and affection and may promise to change Trauma ( injury to human tissues and organs resulting from the transfer of energy from an external environmental source Intentional ( gunshot wounds, violence toward others, self-inflicted violence Unintentional (motor vehicle crashes, falls, pedestrian injuries Host (person or group at risk of injury Mechanism (source of energy transmitted to the host Mechanical energy most common type of energy Motor vehicle most common mechanical source of injury Guns are another common source Environment Physical environment Occupation Social environment Types of trauma Minor ( injury to a single part or system of the body Usually treated in physicians office or emergency department Multiple (serious single-system injury or multiple-system injuries Most often result of a motor vehicle crash Blunt (no communication between damaged tissues and outside environment Deceleration (decrease in the speed of a moving object Acceleration (increase in speed of a moving object Shearing (forces occurring across a plane Compression Crushing Penetrating (foreign object enters the body Other types of trauma Inhalation injuries Blast injuries Prevalence Violence is a widespread problem in the U.S. Affects people of all ages 3 million cases of child maltreatment reported each year 740,000 children hospitalized due to violence each year Elder maltreatment hard to assess ( estimated 7.6 10 of older adults are maltreated each year Emergency departments handle 42 million trauma-related visits each year Genetic considerations and nonmodifiable risk factors Genetic predispositions toward violence Genetics may play a role environment is often a cofactor in its manifestation Link between expression of violence by genetically predisposed children and the parenting practices of their caregivers X-linked gene MAOA is known to relate to an individuals propensity for violence Genetic disorders that relate to social and mental health that go untreated can manifest in violent behaviors Age Patterns of violence evolve through the lifespan Highest during adolescence and young adulthood Gender Strong influence on violence Women more often victims of intimate partner violence and sexual violence See ALTERATIONS AND THERAPIES Violence, p. 1958 Case Study Part 1 ( A gunshot victim is en route to the emergency department by ambulance , p. 1957 Prevention Violence is preventable Know the warning signs of violence ( uncontrolled anger, threatening language, aggression Avoid potentially dangerous situations Community-based prevention programs target underlying causes Nurses help prevent violence through educating clients about high-risk situations Assessing the signs of abuse and offering interventions can help prevent further violence Modifiable risk factors Abuse prevention Nurses role proactive in all settings Nurse must be aware of personal feelings about family violence Nurses to advocate for developing policies and programs to educate public Trauma prevention Motor vehicle safety ( safety belts, air bags, helmets, driving under the influence Relationships ( domestic violence, child abuse, elder abuse, neglect Communities ( gun control, gangs, condition of streets, neighborhood safety Assessment Always begins with ABCs ( airway, breathing, circulation Abuse assessment (nurses responsibility to be alert for symptoms of abuse Assessment interview Ensure privacy Establish trusting nurseclient relationship Offer option of answering questions with sometimes Physical examination Headbald patches Skinbruising Musculoskeletalfractures Abdomenbruising Neurologicalhyperactive reflexes Trauma Prioritize with ABCDEs ( airway, breathing, circulation, disability, exposure Trauma usually occurs suddenly, leaving the client and family little time to prepare for its consequences Death common result of serious traumatic injury Effects on the family May precipitate development of psychological crisis Assess family for variety of needs Referrals as needed Chaplain Foreign language interpreter Social worker Victim advocate Methods of assessment Airway and breathing assessments Circulation assessments Level of consciousness Pupillary function assessments Obvious injuries Scoring systems Champion Revised Trauma Score Glasgow Coma Scale Lifespan and cultural considerations No age group is immune to violence Cultural and spiritual considerations are numerous Some religions prohibit blood transfusions or all medical intervention Violence is a feature of gang culture and the drug culture Diagnostic tests Tests ordered depend on type of injury For victims of violence Blood type and crossmatch Blood alcohol level 2050 who are injured may be intoxicated May affect pain response and level of consciousness (LOC) Urine drug screen Drugs may alter pain response and LOC Pregnancy test Focused assessment by sonography in trauma (FAST) Evaluates the unwelcome presence of blood in body cavities Diagnostic peritoneal lavage Determines the presence of blood in peritoneal cavity May indicate abdominal injury Usually done in emergency department Computerized tomography (CT) scans Injuries to the brain, skull, spine, spinal cord, chest, abdomen Magnetic resonance imaging (MRI) scans Injuries to the brain and spinal cord Case Study Part 2 ( The ambulance arrives at the ED and paramedics emerge with the client, Mark Alvarez, a 32-year-old Hispanic male police officer, p. 1962 Interventions and therapies Independent Short-term interventions for victims of abuse Determine the immediacy of danger Convey that the person is not to blame and has the right to be safe Explore options for help Provide information regarding available services Abused children Primary consideration is childs safety Reassure child that he or she has done nothing wrong Avoid making negative comments about the abuse Abused older adults Short-term interventions Develop a positive relationship with both victim and abuser Explore ways for older person to maximize independence Explore need for additional home care services/alternative living arrangements Trauma interventions Client will often be in both physical and psychological shock Care depends on a team approach Nurses role begins with triagedetermining which client needs the most urgent medical intervention Based on the ABCDEs IV initiation often a high priority Collaborative Initial care ( physiological stabilization Pharmacologic therapy ( see MEDICATIONS Trauma, p. 1963 Psychosocial needs Multidisciplinary team Most families are open to accepting help in a crisis Legal aspects Nurses should know the laws associated with reporting abuse Review The Concept of Violence Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Part 3 ( One month following his right shoulder injury and surgery, Officer Alvarez presents to the clinic for his post-op visit, p. 1964 Exemplar 32.1 Abuse Overview Can happen to any individual at any age and from any demographic or sociocultural background Abuse is a growing problem in the U.S. Pathophysiology and etiology Abuse is often related to control One individual attempts to control another through abuse Three main forms ( physical, emotional, sexual Often categorized by age of the victim or the form of abuse Child abuse and neglect ( any recent act or failure to act on the part of a parent of caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation 9.1 of every 1000 children are victims of abuse or neglect ( 47 are under age 5 27 are under age 3 Three forms Neglect ( highest percentage of child mistreatment Physical abuse Sexual abuse Considerations for helping victims talk about their experiences A child-friendly environment ( shift control to the child Building rapport and trust ( never lie or make false promises to child Active listening ( and use of age-appropriate language start with safe topics use open-ended questions for questions concerning abuse Believing the child no matter what is disclosed ( children who have been abused are often terrified and convinced that adults wont believe them Potential for false reports ( false reports do occur, and nurses need to be mindful of that using open-ended questions cuts down on possibility of creating false memory in the childs mind Elder abuse ( intentional physical, emotional, or sexual mistreatment or neglect of an individual 65 years or older Elder abuse is on the rise but only 1 in 14 cases of elder abuse is reported Unwillingness to report family members, fear of retaliation, physical or mental inability to report the abuse Numerous consequences of abuse Decreased health Inability to heal from broken bones Increased risk for mortality Hospitalization for the victim often leads to individual being released to nursing home or long-term care facility Abuse also occurs in nursing homes, assisted living facilities, and paid home care Nurses need to be vigilant in assessing older adults for maltreatment Intimate partner violence (IPV) (inflicting sexual, emotional, or physical harm on a current or former partner or spouse Can occur among any couple of any age and any sexual persuasion Four main forms Physical violence such as punching, kicking, or biting Sexual violence such as forced sexual acts or physically violent sexual contact Emotional abuse such as humiliating the victim or controlling the victim by diminishing self-esteem Stalking such as repeated harassment or threats often including action such as following the victim or vandalizing property Victims are both men and women male victims are often denied help or ignored When assessing victims of IPV, remain nonjudgmental regardless of gender, sexual orientation, culture, or socioeconomic status Etiology Neurobiologygenes and neurotransmitters may contribute to violence Genes can be linked to how the brain processes situations and emotions Individuals with low levels of the MAOA genotype are more prone to become aggressive in high anxiety or emotional situations Psychopathology theory ( those with personality disorders and mental illness participate in family violence as a direct result of these illnesses Social learning theory ( violence is a learned behavior Violent people conditioned to respond aggressively and violently Learned from observation, victimization, behaving violently Risk factors Age Younger children and older adults at increased risk Gender Child abuse ( equal number of male and female victims IPV (higher incidence of women abused than men, but many men do not report being victims of IPV Elder abuse ( more women than men are abused Physiological development Illness and disability ( one of highest risk factors for abuse Individuals with disabilities seen by perpetrators as more vulnerable and less likely to report the abuse 11 of all child abuse victims have a physical or emotional disability Adult women with disabilities ( 67 subjected to physical abuse. 53 subjected to sexual abuse Adult men with disabilities ( 55 subjected to physical abuse Cultural factors Some cultures condone acts that Western culture would consider abusive Women at greater risk of IPV in cultures that grant men financial and physical control of women Socioeconomic factors Individuals from all socioeconomic levels can be victims or perpetrators of abuse Culture of poverty is a risk factor for child abuse and neglect Low socioeconomic neighborhoods have more gang- and drug-related violence that infiltrates family units Substance abuse Substance or alcohol abuse not necessarily a predictor of abusive behavior, but excessive use can make abusive situations much worse Alcohol and substance abuse is a leading risk factor for perpetrators of all forms of abuse Firearms in the home Statistics for intimate partner homicide, firearm violence, and related factors 36.5 of female homicide victims were killed by husband or boyfriend 42.9 of all murder victims were killed during arguments 72.5 of weapons used during all murders were handguns Murder rates and use of firearms are highest in metropolitan areas and lowest in rural areas Prevention Prevention of abuse most come from various levels individual, community, society, relationship, parenting Abuse is often part of a familial or personal cycle that has been going on for years ( until the abuser acknowledges the cycle, it is likely to continue Nurses can help by Observing for signs and symptoms of abuse in victims Assessing for excessive stress that may be a risk factor for perpetrators ( sudden unemployment, financial stress Reporting abuse of children Facilitating referrals for victims of IPV Clinical manifestations See CLINICAL MANIFESTATIONS AND THERAPIES Abuse, pp. 19721973 Manifestations of child abuse Many physical manifestations apparent ( broken bones in various stages of healing, head injuries, excessive bruising, burns or scars in specific shapes Long-term abuse ( poor language, cognitive, and emotional development Advanced visual and motor impairment can be a sign of abuse Behaviors inconsistent with developmental stage may be apparent Psychological manifestations ( depression, anxiety disorders, eating disorders, learning disorders Fear of adults, fear of anger or yelling, low self-esteem, over-reacting to small mistakes Manifestations of elder abuse Often manifests as neglect ( bed sores, untreated illnesses or injuries, soiled clothing or sheets, weight loss, poor hygiene Depression or withdrawal from normal activities Bruises, contusions, broken bones Manifestations of sexual abuse Victims may be withdrawn or combative Guilt, anxiety, depression, suicidal thoughts, and fear are common Children ( early sexual knowledge, early interest in sexual acts, regression in bedwetting, insomnia Physical manifestations at all ages ( injuries to genitals or anus, swollen genitals, bladder or kidney infection, STIs, pregnancy, PID Manifestations of IPV Physical manifestations ( broken bones, bruises, knife wounds, head injuries, headaches Victims may begin using alcohol or other substances to cope with or ignore abuse Depression, suicide attempts, fear, avoidance of social situations are not uncommon Abusers often cut off victims from any form of support Abusers will seek to control victims finances and decision-making abilities Victims often reluctant to seek help Controlling abusers will likely accompany victim to the hospital to prevent victim from reporting the abuse difficult for nurses to speak to the victim alone Lifespan and cultural considerations Important to differentiate true child abuse from cultural variations Cuppingheating bamboo cup and placing on skin treatment of headaches Cao giocoin or fingers forcefully rubbed on chest, back, or neck Some cultural conceptions of punishment can be considered child abuse from a Western perspective ( see FOCUS ON DIVERSITY AND CULTURE Cultural Interpretations of Abuse, p. 1970 Collaboration Multidisciplinary approach is needed to treat violent families Families more willing to accept help during a crisis Diagnostic tests Cannot prove that individual is being abused, but can show indicators of possible abuse Tests used to diagnose full extent of the damage ( x-rays, CTs, MRIs Swabs for DNA Urine samples to test for bladder or kidney infection Tests for STIs including HIV Pharmacologic therapy Physical abuse ( sedatives, anti-inflammatories, pain medications, antibiotics, tetanus vaccines or boosters Physical and emotional abuse ( pharmacologic treatment for PTSD, depression, insomnia Nonpharmacologic therapy Best approach is multidisciplinary, involving nurses, physicians, social workers, protective services personnel, law enforcement, lawyers Therapy, counseling, support groups Domestic violence shelters offer array of services Have available contact information for shelters in the community Working with children Ensure that team creates safe and predictable environment Plan interventions that encourage affective release in supportive environment Journal writing Nursing process Assessment Assess ABCs first Complete medical history of injuries that could be the result of abuse Consider clients emotional state Diagnosis Risk for Trauma Risk for Self-Harm Risk for Sexual Dysfunction Powerlessness Social Isolation Post-trauma Syndrome Planning Client will be safe and free from harm Client will ask for help in safely resolving the abusive situation Client will honestly convey feelings of fear, helplessness, anger, or depression Client will report suicidal ideation Client will acknowledge that she is not responsible for abuse Client will practice healthy coping methods Implementation Promote safety Report all suspected cases of child or elder abuse or neglect Report IPV and use of weapons per local laws Know the laws for the state in which you practice Provide clients with information about resources for seeking help Encourage clients to seek help Establish a therapeutic relationship Establish trust Ensure clients they are in a safe and judgment-free setting Use age-appropriate actions for children Use open-ended, not leading, questions Follow organizational protocols Facilitate communication Accepting help is often difficult for victims of IPV Refer to appropriate resources ( law enforcement, social workers, counselors, community liaisons to safe housing Promote empowerment Help clients achieve a sense of control within the situation Support groups and individual therapy are recommended Evaluation Client remains free from injury or harm Client seeks assistance when needed Client demonstrates knowledge of resources available Client verbalizes awareness that she is not responsible for abuse Client openly communicates fears with regard to the abusive situation Review Abuse Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 32.2 Assault and Homicide Overview Definitions Simple assault ( an unlawful physical attack by one person upon another where neither the offender displays a weapon, nor the victim suffers obvious severe or aggravated bodily injury involving apparent broken bones, loss of teeth, possible internal injury, severe laceration, or loss of consciousness Aggravated assault ( an unlawful attack by one person upon another for the purpose of inflicting severe or aggravated bodily injury, usually accompanied by use of a weapon or by means likely to produce death or great bodily harm Homicide ( the killing of one individual by another Among violent crimes in U.S., assault is most prevalent and homicide is least prevalent Nurses may be responsible for caring for perpetrators as well as victims all clients will receive the same quality of care regardless of the events Pathophysiology and etiology Violence may be traced to biological, situational, and cultural factors Origins of violence (socioeconomic disparity, other demographic factors Pathophysiology of aggression and fear plays a role ( both are primary emotions in assault and homicide Both attacker and victim feel aggression during the encounter Aggression ( any form of behavior directed toward the goal of harming or injuring another living being who is motivated to avoid such treatment Strong connection between aggression and stress Principle feeling of fear is stress-induced fight-or-flight response Etiology Majority of assaults have a conscious or unconscious etiology Intense frustration, when an individual is prevented from reaching a desired goal, may trigger violent aggressive tendencies Aggression can lead to assault or aggravated assault Complex of gene expression may render some individuals vulnerable to exhibiting aggression Testosterone has been correlated with higher levels of aggression in humans Family and society play major roles as well Childs formative years determine aggressive tendencies as adult Young males raised in socioeconomically challenged neighborhoods are more likely to be involved in violent behavior Risk factors Age Violence by youths is found in gangs, schools, and public areas Violent adolescents and young adults exhibit a range of problems Recklessness and instability of adolescence Witnessing violence in the family is a risk factor Culture National culture and subcultures affect predisposition to violence Exposure to violence in the media increases change of immediate aggressive behavior Gang culture promote violence Urban centers feature higher rates of violence than suburban or rural areas Southern states have highest homicide rates Socioeconomic factors Community violence associated with economic inequality Living in poverty contributes significantly to likelihood of being involved in assault or homicide Occupation Workplace homicide is fourth leading cause of job-related death Greatest risk ( those who exchange money with the public, make deliveries, carry passengers in vehicles, work alone or in small groups during the late night or early morning hours, or work in high crime areas Healthcare workers at greater risk than other service workers OSHA Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers Management commitment/employee involvement Worksite analysis Hazard prevention/control Safety/health training Clinical manifestations Clinical manifestations of aggravated assault Injuries and wounds of varying severity PTSD Warning signs Social situation of those involved Most cases of violence arise from disputes that seem trivial to outsiders Half of murderers know their victims The victim may have been the original aggressor A difference in power is a warning signs ( clients can become frustrated as they move through the healthcare system Lifespan and cultural considerations Some cultures more prone to violence than others Drug culture Hate groups Religious and political extremists pose a threat See FOCUS ON DIVERSITY AND CULTURE Race and Homicide, p. 1975 Collaboration Multidisciplinary approach necessary Preventive activities at community level include school nurses and counselors, health department nurses, social workers, protective services personnel, police, and workplace programs Working with victims of homicide and assault and their families requires a team effort Diagnostic tests Wide range of diagnostic tests used for victims of assault depending on injuries X-ray, CR, MRI Pharmacologic therapy Differs depending on type of injuries Pain medications Antibiotics and anti-inflammatories Anesthesia Nonpharmacologic therapy Violence prevention programs for children Communities offer violence prevention programs in schools, child-care centers, churches, and other community centers Second Step A Violence Prevention Program Steps to Respect A Bullying Prevention Program Nursing process Assessment Document all findings/care in specific detail Clients emotional state should be described as objectively as possible Assessment of risk in the community Identify risk factors at individual/family or population levels At community or population level, identify risk factors that lend themselves to high incidence and prevalence of societal violence Assessment of victims of assault or homicide Follow assessment guidelines for trauma Assess risk for revictimization prior to discharge Diagnosis Ineffective Airway Clearance Ineffective Breathing Pattern Ineffective Tissue Perfusion Risk for Infection Risk for Injury Acute Pain Chronic Pain Impaired Physical Mobility Fear Ineffective Coping Planning Clients airway will remain patent Client will demonstrate effective breathing Clients blood pressure and heart rate will remain within normal limits Client is comfortable and reports pain level of 3 or less on a 0-10 scale Clients wounds heal without infection Client will participate in all scheduled therapy Client will seek to make necessary changes to promote and enhance personal safety Client will verbalize emotions and concerns Implementation Focus on infection control, health maintenance, and recovery Injuries treated in order of severity Nurses work to keep client stable while preparing them for tests, surgery, or treatments Administer pain medications as prescribed Clinical priorities for gunshot victim Maintain airway and assist ventilation as necessary Control hemorrhage Prevent hypothermia Working with families Typically very upset Experienced nurse should work with families whole the victim is being treated Evaluation Client obtains pain relief Client seeks counseling as needed Family provides support and comfort Wound heals appropriately Client is able to return to work or school Client accepts responsibility for own actions Review Assault and Homicide Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 32.3 Rape and Rape-Trauma Syndrome Overview Sexual assault and rape are crimes of violence Rape ( penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim Rape-trauma syndrome ( a series of psychological sequelae that many victims experience following rape Shock and disbelief followed by fear, humiliation, shame, self-blame, and anger Sleep disturbances Some may develop PTSD See CLINICAL MANIFESTATIONS AND THERAPIES Rape-Trauma Syndrome, p. 1987 Pathophysiology and etiology Influencing factors Those who commit rape often know their victim ( spouse, ex-spouse, acquaintance, friend, or relative Both men and women commit rape Intrapersonal and interpersonal factors Serial rapists ( commit sexual assault two or more times Use of drugs or alcohol Act may be physically or emotionally violent or both No form of rape is easier than another for victims Sociocultural factors Biological factors ( psychological disorders that cause impaired decision making or deficient impulse control Environmental factors ( growing up in a setting where violence is common, or where women are seen as possessions Areas with high crime rates are more prone to rape Etiology Over 80,000 rapes reported in 2011 1 in 5 women and 1 in 71 men report having been raped Marital rape ( when one spouse forces another to have sex against his or her will Acquaintance rape ( broad term used to describe rape committed by someone familiar to the victim Largest percentage occurs on college campuses May involve use of date rape drugs Risk factors No specific factors exist for becoming the victim of rape At higher risk if under the influence of drugs or alcohol At higher risk if young Risk factors for committing rape difficult to determine ( an individual may have all of the following risk factors yet never commit rape Alcohol and drug use Lacking inhibitions to suppress associations between sex and aggression Holding attitudes and beliefs supportive of sexual violence, including coercive sexual fantasies Pattern of behavior that is impulse, antisocial, and hostile toward women Associating with sexually aggressive peers Having been sexually abused as a child Growing up in a family environment characterized by physical violence, little emotional support, and few economic resources Prevention Majority of programs aim to stop perpetrators from committing the act Often aimed at those who have committed sexual assault in the past Preventive measures for victims include Knowledge and awareness about situations that foster opportunities for rapists Self-defense classes Clinical manifestations Physical injuries Immediate injuries Swelling, redness, and lacerations around vagina and anus Injuries to the throat from forced oral sex or restraint Bruises Broken bones Knife and gunshot wounds Defensive and restraint injuries ( wounds to hands, arms, feet, and legs If victim was restrained ( injuries to wrists, ankles, neck Internal injuries ( present if client was beaten or raped with an object Long-term complications Pelvic pain Back pain Frequent headaches GI disorders Potential pregnancy complications Immediate response Feelings of shock, denial, disbelief, fear, anger, guilt, embarrassment, helplessness, loss of control, confusion, anxiety, nervousness Clients will be hesitant to trust others, especially of same gender as rapist Victims first response is often to take a shower ( advise clients against doing so because it will remove possible evidence Some clients present as though nothing has happened to them ( often a reaction of shock and denial Long-term response After initial shock, clients will begin to accept that rape occurred Emotional responses may include Anger Flashbacks Avoiding previously enjoyed activities and the setting of the rape Insomnia Eating disturbances Sexual dysfunction Depression Emotional distress can trigger use of unhealthy coping mechanisms Drug and alcohol use or abuse High risk sexual behavior Depression and suicidal thoughts Lifespan and cultural considerations Cultural considerations are numerous ( involve a cultures dominant definition of rape In patriarchal cultures, rape of a woman may not be considered of great importance In matriarchal cultures, the rapist will be ostracized and dishonored Marital rape is not acknowledged in a number of cultures Rape myths exist that blame victims Sex workers can be raped Nurses do not judge clients who claim to have been raped ( they provide quality care to all individuals Collaboration Interdisciplinary care begins immediately after the rape Includes law enforcement and mental health professionals Diagnostic tests Specimens not diagnostic collected for purpose of convicting rapist Vaginal, oral, and anal swabs Fingernail scrapings for skin samples Combing of pubic hair for rapists DNA Collection of victims clothing Testing for sexually transmitted infections and potential pregnancy HIV testing done at baseline, then at 3, 6, and 12 months Pharmacologic therapy Emergency contraception Pharmacologic treatment of STIs Nonpharmacologic therapy Support groups, therapy, counseling Clients feelings are validated as normal reactions Clients receive confirmation of their survival behaviors May help moderate depression Long-term goal is to help survivors understand their distress and take charge of their own recovery Nursing process Assessment Ensure clients safety Head-to-toe for serious or critical injuries Work to comfort and empower the client by explaining their choices in examination and resources Victims do not have to allow a rape kit to be collected, nor do they have to talk to a counselor If client agrees to be examined and collection of evidence, the nurse explains every step of the process and asks permission during the exam Diseases, infection, and pregnancy testing and treatments are discussed with client and interventions are planned Diagnosis Rape-Trauma Syndrome Risk for Infection Acute Pain Powerlessness Risk for Ineffective Coping Situational Low Self-Esteem Disturbed Self-Concept Fear Planning Client will receive treatment for physical injuries sustained during the rape Client will participate in follow-up care for physical injuries Client will follow a safety plan following release from medical care Client will gain control over remembering Client will work toward affect tolerance Client will gain mastery over symptoms Client will reconnect Client will discover or attach some kind of meaning to the event Implementation Identify and prioritize concerns Place client in a private room Treat injuries in order of severity Nurse works with client to relay the details of the incident Collect evidence Explain each step of the process Provide community resources Provide written list of community resources Evaluation Evaluation made within a few days after rape may reveal new manifestations Additional diagnoses may emerge Long-term goal ( client returns to precrisis level or higher level of functioning Client determines when recovery complete Review Rape and Rape-Trauma Syndrome Relate Link the Concepts and Exemplars Ready Go to Companion Skill Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 32.4 Suicide Overview Definitions Suicide ( act of an individual inflicting self-harm resulting in death Suicide attempt ( when the individuals attempt a suicide is not fatal Suicidal ideation ( when an individual constantly considers, plans, or thinks about suicide Suicide is 10th leading cause of death in U.S, Pathophysiology and etiology Depression ( major change in individuals that often accompanies suicide Influencing factors Genetics and neurobiology Studies show a genetic factor in suicidal behavior Risk is five times higher if a relative has committed suicide Genes and situational stressors work together to create conditions for suicidal behavior Decreases levels of serotonin in those who attempt or commit suicide Interpersonal factors History of being abused, raped, lonely, or a recent separation from a loved one Social isolation and alienation from society, family, friends Rapid social change resulting in loss of previous patterns of social integration Loss and grief closely related to suicide Comorbid disorders 90 of those who commit suicide have a comorbid disorder Depression Bipolar disorder Borderline personality disorder Conduct disorders Schizophrenia Drug and alcohol dependence Social factors Societal factors that affect suicide include recessions, bullies, dominant social beliefs Etiology Comes from a feeling that death is the only option that will successfully solve individuals emotional strain Some who attempt suicide do so with the mind-set that they would like to diem but if they do not, then at least others will realize how truly unhappy, lonely, or desperate they are Risk factors Gender ( men more likely than women to die from suicide Depression or other mental disorders Family history of abuse, violence, suicide Substance abuse disorders Previous suicide attempt See Box 321 FACTORS CONTRIBUTING TO HIGH SUICIDAL RISK, p. 1992 Prevention Prevention comes from knowing the warning signs Preoccupation with death Talking about wanting to end their pain Giving away possessions Taking unnecessary risks If nurse suspects a client is at risk Clients safety is main priority Do not leave client alone at any point Remove all dangerous items Contact primary care provider as well as suicide prevention counselor or psychiatric department of hospital Clinical manifestations See CLINICAL MANIFESTATIONS AND THERAPIES Suicide, p. 1994 Suicide is the most self-destructive behavior Chronic self-destructive behavior Behavior that harms self Is habitual Generally poses low level of lethality See FOCUS ON DIVERSITY AND CULTURE Suicide and LGBT Culture, p. 1993 Behavior Behavioral cues can indicate that a suicide attempt is imminent May say It wont matter much longer or I cant take this much longer Obtain a weapon Withdraw from relationships/become more isolated Change in school or work performance May mention feeling helpless May discuss life after death Use mnemonic IS PATH WARM for short-term indications of suicidal intent Cognition Variety of cognitive components Dichotomous thinking all or none good or bad Recurrent thoughts of self-blame Negative self-evaluation May have fantasies about continuing on after death For some, it is a cry for help Those rescued from suicide attempt remain at higher risk for suicide than general population Interpersonal relationships Periods of high stress Limited social network Carefully assess parents who have lost a child to a violent death for suicide potential Gay, lesbian, bisexual, transgendered adolescents 6 times more likely to commit suicide than heterosexual youths Copycat suicides Suicides publicized by media/television dramas about suicide, adolescent suicide increases several weeks after event Girls more susceptible Lifespan and cultural considerations Individuals age 25 64 mostly likely to commit suicide Individuals over 65 second most likely Older white men most likely Depression is leading cause Negative events that come with age ( loss of spouse, illness, isolation Those 10 24 least likely See FOCUS ON DIVERSITY AND CULTURE Suicide and LGBT Culture, p. 1993 Firearms, suffocation, and poison are most common methods of suicide Various ethnic groups have different suicide rates Whites and American Indians have higher rates than African Americans, Hispanics, Asians, and Pacific Islanders U.S. has suicide rate of 11 per 100,000 Greece, Spain, U.K have rates of 9 per 100,000 Hungary has rate of 40 per 100,000 Collaboration Includes nurses, physicians, and mental health professionals Pharmacologic therapy Assess for presence of comorbid disorders Most likely choices of medications Antidepressants Tricyclic antidepressants Selective serotonin reuptake inhibitors Drugs for bipolar disorder Mood stabilizers Nonpharmacologic therapy Therapeutic approaches to suicide prevention can be effective Group therapy, individualized therapy, family therapy Cognitive-behavioral therapy Address healthy coping mechanisms Writing therapy Nursing process Assessment Nurses working with suicidal clients should be direct but respectful when evaluation client Use specific words such as kill yourself when assessing for suicidal potential Nurses attain a full client and family history Presence of mood disorders History of suicide attempts Past instances of severe depression Determine level of risk client poses to himself Diagnosis Risk for Suicide Risk for Self-Harm Risk for Vascular Trauma Hopelessness Powerlessness Disturbed Self-Esteem Disturbed Self-Concept Planning Client will remain safe from self-injury Client will ask for help when needed Client will discuss any extreme feelings of depression or hopelessness Client will participate in regularly scheduled meetings with his therapist Client will demonstrate healthy coping mechanisms Client will begin to demonstrate a desire to live Implementation Critical to establish rapport and demonstrate empathy Maintain safety First priority of care is client safety Never lecture about negative consequences of suicide Develop no-harm contractbut not as substitute for ongoing suicide assessment Promote problem solving Listen carefully take all suicide talk seriously Have client write out list of reasons to live and reasons to die Have client describe the goal she hopes to achieve Remind client that suicide is one of several possible alternatives Develop a list of alternatives to meet clients goal Discuss potential outcomes of suicide Discuss potential outcomes of other alternatives Discuss death what it means to client, feelings about death, what client thinks it will be like Focus on the list of reasons to continue living Prevent future suicidal behavior Discuss with client/family that recurrence of suicidal thoughts/behavior may happen Encourage client/family to read books about suicide Assist client in developing a crisis care card Support families of victims May respond with shock, bewilderment, anger May have sense of relief when suicide ends suffering of loved one Death of child puts extreme strain on parents May be overwhelmed with feelings of guilt and powerlessness Nurse must quickly intervene to support family Help family members anticipate future difficulties Offer referral to a survivors of suicide support group Combat desperation and hopelessness Suicidal people may need to borrow nurses hope until they can regain their own Evaluation Client remains free from injury Client verbalizes emotions and concerns Client participates in all scheduled therapy Client demonstrates effective coping skills Client seeks help when needed Review Suicide Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 32.5 Unintentional Injury Motor Vehicle Crashes Overview Motor vehicle crash ( unintentional collision of one or more motor vehicles with another vehicle or object Significant cause of injury and death in the U.S. Etiology Three main causes Alcohol-impaired driving Speeding Lack of proper restraints See FOCUS ON DIVERSITY AND CULTURE Use of Safety Protection, p. 2001 Hazardous driving conditions also result in fatalities Risk factors Age Both young drivers and older drivers at particular risk Beginning drivers age 16 19 three times more likely to have an accident that those over age 20 Drivers over age 65 at risk due to preexisting health conditions Speeding and impaired driving Driver distraction ( texting, talking on cell phone, dropping a beverage Aggressive driving Prevention Graduated driver licensing Older adults need to have vision/driving ability screened regularly See Table 321 STRATEGIES FOR PREVENTING MOTOR VEHICLE CRASHES, p. 2000 Clinical manifestations Common injuries Physical injuries ( mild to severe Mild ( minor scrapes and contusions Severe ( whiplash, head or brain trauma, spinal cord injuries, facial injuries, internal organ damage, tearing of posterior cruciate ligament in knee Seatbelts can save lives, but also cause injuries ( fractured ribs, fractured collar bone, internal injuries, organ damage Emotional injuries PTSD Fear of driving or future car accidents Cultural considerations Native Americans and Alaska Natives at highest risk for MVCs Some religions prohibit blood transfusions or medical care, ever if injuries are life threatening Collaboration Team approach Multiple disciplines needed for trauma care Delegation of tasks and responsibilities improves clients changes for survival Diagnostic tests Varies according to injuries MRI, CT, x-ray, ultrasound EEG Surgery Often required for MVC victims Repair damage or stop internal bleeding Stabilize client until transplant can be performed Spinal surgery to remove bone fragments and stabilize the spine Pharmacologic therapy Pain medications Sedation may be necessary Nonpharmacologic therapy Clients need empathy, understanding, and support from nurses Physical therapy Rehabilitation Nursing process Assessment Primary consideration is ABCs Cervical collar ( stabilizes and maintains neutral alignment of cervical spine Longboard spinal immobilization Diagnosis Ineffective Airway Clearance Ineffective Breathing Pattern Risk for Decreased Cardiac Tissue Perfusion Risk for Impaired Peripheral Tissue Perfusion Risk for Deficient Fluid Volume Risk for Infection Impaired Physical Mobility Spiritual Distress Post-trauma Syndrome Planning Clients airway will remain patent Client will demonstrate regular, nonlabored respirations and oxygen saturation levels of 95 or greater Clients blood pressure will be maintained within normal limits Client will not develop cardiac dysrhythmias Client will demonstrate no signs or symptoms of infection Client will demonstrate no motor or sensory deficits Client will retain or regain mobility Implementation Maintain airway patency and ventilation Monitor oxygen saturation Monitor level of consciousness Assess for disability and expose obscured areas Prompt recognition of neurological deficits Remove clients clothing to allow for identification of injuries that may be obscured Promote fluid volume balance Insert large-bore IV catheter Both blood loss and shifting of fluids can lead to hypovolemia Foley catheter may be required Prevent infection Use careful hand-washing practices Use strict standard precautions and aseptic technique Monitor wounds for odor, redness, heat, swelling, drainage Monitor hidden wounds Take/record vital signs, including temperature, every 24 hours Provide adequate fluids and nutrition Assess for manifestations of gas gangrene Fever, pain, swelling Drainage with a foul odor Assess status of tetanus immunization Use strict aseptic technique with invasive procedures Promote mobility If no active bleeding/edema, provide active/passive exercises to affected and unaffected extremities at least once every 8 hours Help client turn, cough, and deep breathe use incentive spirometer at least every 2 hours If client unable to be moved/positioned, consider specialty bed Monitor lower extremities each day for signs/symptoms of deep venous thrombosis Offer spiritual comfort measures Give family information about option to donate organs Encourage family members to ask questions/express feelings Refer family for follow-up care Provide family of dying/deceased client a place and time to pray or observe faith rituals together Be present for the family Promote psychosocial well-being Assess emotional responses while providing physical care if client unconscious, encourage family members/friends to express their feelings Be available if the client wishes to talk about the trauma encourage expression of feelings Teach relaxation techniques Refer client/family members for counseling, psychotherapy, or support groups as appropriate Facilitate community-based care Type of home environment to which client will be returning Medications, dressings, wound care, equipment, supplies Special diet, if needed Rehabilitation plan and its effect on clients family Follow-up appointments with physician/trauma clinic Emotional changes that client may undergo as result of trauma Helpful resources Home health care Community support groups National Institute of Neurological Disorders and Stroke Evaluation Clients airway will remain free of obstruction Clients Respiratory rate remains within normal limits Clients oxygen saturation is maintained at 95 or greater Client develops no cardiac dysrhythmias Clients blood pressure is maintained within normal limits Client demonstrates no neurovascular deficits Client will retain mobility Client verbally expresses emotions and concerns Review Unintentional Injury MVC Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. 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