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2: PUBLIC HEALTH GUIDELINES
F. The child exhibits inappropriate behavior for his or her devel-
opmental age.
SUBJECTIVE DATA
A. Use open-ended questions during the history to evaluate
how injuries were sustained. As the interview continues, ask
specic questions related to responses. If the child can talk,
direct questions to them before the caregiver.
B. If this is the rst clinic visit, ask whether the child had rou-
tine healthcare, including immunizations.
PHYSICAL EXAMINATION
A. The physical examination should be performed with the
child totally unclothed; however, clothing can be removed
as the physical progresses from head to toe (i.e., upper body,
torso, lower body, lastly perineum/rectum). Detailed documentation of history is essential.
1. Check blood pressure, pulse, and respirations, and
height and weight to calculate body mass index (BMI) and
plot on growth charts.
2. A forensic examination requires thorough documenta-
tion of injuries.
a. Use color photographs before any treatment is
started.
b. Photograph damaged clothing.
c. Take at least one full-body photograph and a facial
photograph.
d. Take close-up photographs of all injuries.
e. Use a ruler to identify/document the size of injuries.
f. Document on the back of the photographs the cli-
ent’s name, date, photographer’s name, as well as
any witnesses to the examination. The photographer
should also sign each photograph.
3. General observation:
a. Observe the interactions between the caregiver and
the child. Is the child fearful or reluctant to have the
examination? Are there signs of discomfort during the
examination with movement such as range of motion
(ROM)?
b. Evaluate the child’s overall appearance. Is the
child clean and are their clothes appropriate for the
season? Observe for poor hygiene, body odor, malnourishment, dehydration, depression, violence, withdrawnness, behavioral compliance even during a
painful examination of the rectum/genitalia, and level
of consciousness.
c. Dermal examination: Evaluate from head to toe,
including the palms, soles of the feet, and between the
toes; observe for injuries in different stages of healing
and new trauma, including burns, lesions, swelling,
bruises, and signs of pinching. Evaluate the corner of
the mouth for signs of being gagged. Examine the head
for alopecia from hair pulling. Evaluate bruises and
burns for the characteristics of shapes (e.g., iron, handprints, long belt marks, and loops, bite marks, andligature marks).
d. Eye examination: Observe for retinal hemorrhages,
black eyes, periorbital edema, and papilledema (indicates increased intracranial pressure).
e. Ear examination: Evaluate hearing, hemotympa-
num, or possible laceration to the external canal, and
insertion of foreign objects.
f. Nasal examination: Evaluate the presence of blood,
swelling, and foreign objects.
g. Mouth and throat: Evaluate the presence of caus-
tic ingestion; observe for ligature marks and cry/voice
quality.
4. Auscultate:
a. Heart.
b. Lungs.
c. Abdomen in all four quadrants.
d. Over the globes of the eyes if warranted (bruit may
indicate traumatic carotid cavernous stula).
e. The carotid arteries bilaterally if warranted (bruit
may indicate carotid dissection).
5. Palpate:
a. Examine for facial fractures; palpate for instability
of the facial bones, including the zygomatic arch.
b. Palpate the abdomen in all four quadrants for
guarding, tenderness, and masses (hematoma).
c. Examine for any trauma to the spine.
6. Perform neurologic examination:
a. Assess mental status and memory: Determine
whether the client is awake, alert, cooperative, and oriented (to person, place, time, and situation). Temporary
impairment of memory is one of the most common deficits after a head injury.
b. Assess cranial nerve function:
i. Ophthalmoscopic/visual examination (cranial
nerve II).
ii. Pupillary response (cranial nerve III).
iii. Extraocular movements (cranial nerves III, IV,
and VI).
iv. Facial sensation and muscles of mastication
(cranial nerve V).
v. Facial expression and taste (cranial nerve VII).
c. Perform a motor examination on all four extremities.
d. Perform a sensory examination on all four
extremities.
7. Perform genital/rectal examination:
a. Evaluate the genitals/anal area for redness, swell-
ing, bruising, hematomas, abrasions, or lacerations.
b. Evaluate for evidence of sperm.
c. Evaluate for presence of condyloma.
d. Evaluate for presence of foreign bodies.
DIAGNOSTIC TESTS
A. Diagnostic tests and x-rays are ordered dependent on the
type of presenting complaints and physical examination.
1. Complete blood countwith differential and peripheral
smear; bleeding evaluation, including prothrombin time/
partial thromboplastin time (PT/PTT), alanine aminotransferase (ALT), and aspartate aminotransferase (AST),
to evaluate injury to the liver, serum amylase, or lipase to
rule out pancreatic injury.
2. Urinalysis.
3. Drug screen/toxicology (urine and serum).
4. Obtain forensic DNA samples from the skin, under the
nails, vagina, rectum, and saliva from bite marks using
sterile cotton-tipped applicators that have been moistened
with sterile saline. These should be sent to a crime laboratory as soon as possible.
5. Test for sexually transmitted infections/HIV.
6. Pregnancy test (age appropriate).
VIOLENCE: INTIMATE PARTNER
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49
7. Radiographs for facial injury, anteroposterior and lat-
eral radiograph for any areas of bone tenderness, swelling,
deformity, or limited ROM.
8. Neuroimaging CT/MRI for any suspected nonacciden-
tal head injury (e.g., head trauma, history of shaking, and
scalp hematoma).
DIFFERENTIAL DIAGNOSES
A. Congenital syphilis.
B. Rickets.
C. Osteogenesis imperfecta (OI).
D. Mongolian spots.
E. Impetigo.
F. Dermatitis herpetiformis.
G. Folk-healing practices.
H. Immune thrombocytopenia (ITP).
I. Malignancy.
J. Meningitis: neurologic signs.
PLAN
A. General interventions:
1. Each state may have a requirement for parental per-
mission before taking any photographs.
2. Safety planning is the rst priority.
3. Increase public awareness.
4. Failure to report a suspected case of sexual abuse may
incur criminal charges.
B. Client teaching
1. Reinforce that abuse/neglect is not the client’s fault.
2. Help is available.
C. Pharmaceutical therapy
1. Prescribe antibiotics to treat sexually transmitted infec-
tions or wounds.
2. Antidepressant therapy may be appropriate.
FOLLOW-UP
A. Each state mandates reporting of child abuse. Refer to your
state requirements or laws. CPS is responsible for investigations. Depending on your locality, police involvement may
be mandatory. The Child Abuse Prevention Services (CAPS)
website lists individual state abuse hotlines at www.capsli.or
g/reporting-abuse/individual-state-hotlines. Documentation
of suspected child abuse is extremely important. Document
injuries in detail. Provide factual information.
B. Hospitalization may be required, depending on physical
ndings, child safety, and parental observation.
C. Abused and neglected children are at high risk of depres-
sion, anxiety, eating disorders, discipline problems, drug/alcohol use, runaway tendencies, and low self-esteem. Therapy
and follow-up vary for each individual child. Family participation in a recommended treatment program is helpful. The
goal of treatment is to help the child regain their prior state of
mental and psychological health. Neglect is the major reason
that children are removed from a home, especially when the
parents have drug/alcohol problems.
D. Identify other children in the same household at risk of
child abuse.
CONSULTATION/REFERRAL
A. Consult with other healthcare providers who have greater
experience with abuse (e.g., CPS, physician, psychiatrist or
psychologist, social worker).
B. Refer for a nurse in-home assessment if available/indicated.
C. Specialty consultations:
1. Genetic consultation: OI.
2. Orthopedic consultation.
3. Plastic surgeon.
4. Child psychiatrist.
5. Ophthalmology.
RESOURCES
Childhelp Prevention and Treatment of Child Abuse: www.
childhelp.org
Childhelp National Child Abuse Hotline: 1-800-422-4453
Rape, Abuse & Incest National Network (RAINN): 1-800-656-HOPE
Stop It Now: 1-888-PREVENT (1-888-773-8368)
BIBLIOGRAPHY
American Society for the Positive Care of Children. (2018). Physical child
abuse. https://americanspcc.org/physical-child-abuse/
Boos, S.C. (2020, January 6). Physical child abuse: Recognition. https://ww
w.uptodate.com/contents/physical-child-abuse-recognition?topicRef
=6600&source=see_link#H3275964756
Boos, S.C. (2021, November 11). Physical child abuse: Diagnostic evalu-
ation and management. https://www.uptodate.com/contents/
physical-child-abuse-diagnostic-evaluation-and-management#H21
Centers for Disease Control and Prevention. (2019, February 26). Violence
prevention, risk and protective factors. https://www.cdc.gov/violencepr
evention/childabuseandneglect/riskprotectivefactors.html
Childhelp. (n.d). Child abuse statistics & facts. https://www.childhelp.org
/child-abuse-statistics/
Futures Without Violence, Formerly Family Violence Prevention Fund.
(n.d). The facts on children’s exposure to intimate partner violence. https://
www.futureswithoutviolence.org/the-facts-on-childrens-exposure-to
-intimate-partner-violence
Giardino, A. P. (2017, April 24). Physical child abuse. Medscape. http://eme
dicine.medscape.com/article/915664-overview
HelpGuide.org. (n.d). Child abuse and neglect: Recognizing, preventing,
and reporting child abuse. https://helpguide.org/articles/abuse/
child-abuse-and-neglect.htm/
Prevent Child Abuse America. (2016a, February). Fact sheet: Emotional
child abuse. www.preventchildabuse.org/images/docs/ emotionalchi
ldabuse.pdf
Prevent Child Abuse America. (2016b, February). Fact sheet: Maltreatment
of children with disabilities. http://www.preventchildabuse.org/image
s/docs/maltreatmentofchildrenwithdisabilities.pdf
Prevent Child Abuse America. (2016c, February). Recognizing child abuse:
What parents should know. www.preventchildabuse.org/images/docs/
recognizingchildabuse-whatparentsshouldknow.pdf
Rape, Abuse & Incest National Network. (n.d.[a]). State resources. https://
www.rainn.org/state-resources
Rape, Abuse & Incest National Network. (n.d.[b]). Victims of sexual
violence: Statistics. http://www.rainn.org
U.S. Department of Defense. (2019, April 30). Sexual assault accountability
and investigation task force. https://media.defense.gov/2019/May/02
/2002127159/-1/-1/1/SAAITF_REPORT.PDF
VIOLENCE: INTIMATE PARTNER
DEFINITION
A. Intimate partner violence (IPV) is dened as intentional
power and control or victimization of a person with whom the
abuser has had or is currently in an intimate, romantic, or spousal relationship. Domestic IPV crosses all cultures and economic
boundaries; it encompasses violence between both genders,
including gay and lesbian relationships. Abusive behaviors can
occur in a single event, sporadically, or continually. The Duluth
Model Power and Control Wheel from the Domestic Abuse
Intervention Project illustrates the abuser’s power and control
over the client (Figure 2.5). The following is a list of the many
forms through which IPV may manifest itself.
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2: PUBLIC HEALTH GUIDELINES
USING
ECONOMIC
ABUSE
Preventing her from getting
or keeping a job • making her
ask for money • giving her an
allowance • taking her money • not
letting her know about or have access
to family income.
USING MALE PRIVILEGE
Treating her like a servant • making
all the big decisions • acting like the
“master of the castle” • being the one
to define men’s and women’s roles.
V
L
A
C
I
S
Y
H
P
USING COERCION
AND THREATS
Making and/or carrying out threats
to do something to hurt her
•threatening to leave her, to
commit suicide, to report
her to welfare • making
her drop changes •
making her do illegal
CONTROL
USING
CHILDREN
Making her feel guilty
about the children • using
the children to relay messages
•using visitation to harass her
•threatening to take the
children away.
P
H
Y
S
I
C
A
L
V
E
L
I
O
things.
N
USING
INTIMIDATION
Making her afraid by using
looks, action, gestures
• smashing things • destroying
her property • abusing
pets • displaying
weapons.
POWER
AND
MINIMIZING,
DENYING,
AND BLAMING
Making light of the abuse
and not taking her concerns
about it seriously • saying the
abuse didn’t happen • shifting
responsibility for abusive behavior
• saying she caused it.
I
O
L
E
N
C
E
S
E
X
U
A
L
USING
EMOTIONAL
Putting her down • making her
feel bad about herself • calling her
names • making her think she’s crazy
•playing mind games • humiliating her
USING ISOLATION
Controlling what she does, who she sees
and talks to, what she reads, where
she goes • limiting her outside
involvement • using jealousy
to justify actions.
E
C
ABUSE
•making her feel guilty.
L
A
U
X
E
S
FIGURE 2.5 The Duluth Model Power and Control Wheel from the
Domestic Abuse Intervention Project.
Source: Reproduced with permission from Domestic Abuse Intervention Programs. Retrieved from https:
//www.theduluthmodel.org/wheel-gallery/.
1. Physical abuse, sexual assault, coercion, social isola-
tion, emotional abuse, economic control, and deprivation are associated with IPV. There is no typical abuser,
although all abusers tend to be violent in the home setting
and their behavior at work is normal.
2. Forms of physical violence include threatening or
assaulting with weapons, pushing, shoving, slapping,
punching, choking, kicking, holding, throwing objects,
and binding.
3. Psychological abuse includes threats of physical harm
to the client or others, humiliations, intimidation, degradation, ridicule, false accusation, isolation, and deprivation of food, economic coercion, access to healthcare, and
transportation.
4. Psychological abuse in LGBT relationships includes
the threat to “out” their partner as well as threats related
to custody of coparent children.
5. Digital abuse is use of technologies and/or social
media networking to intimidate, harass, or threaten.
Intimate partner stalking can occur during a relationship
or after the relationship ends.
a. Monitoring cell phone activity.
b. Demanding passwords.
c. Cyberbullying.
d. Nonconsensual sexting.
e. Posting photographs or other types of humiliation
on social media.
f. Threatening texts or stalking on social media.
6. Sexual abuse is nonconsensual (unwanted kissing or
touching) or painful sexual acts.
7. Reproductive coercion is another form of IPV.
a. Partner sabotage of safe-sex practices (e.g., refusal to
use condoms, exposing the client to sexually transmitted infections).
b. Refusal/control of contraception.
c. Forcing the individual to have an abortion or utiliz-
ing physical violence to endanger a pregnancy.
d. Controlling access to healthcare.
The exact incidence of IPV is unknown due to lack of reporting. The
United Nations estimates that more than 603 million females live in countries where domestic violence is not considered a crime. The most significant reason for missing the diagnosis of IPV is failure to ask the client.
INCIDENCE
A. Domestic violence is the leading cause of homicide in
females globally.
B. One in three females and one in four males have experi-
enced physical violence by an intimate partner.
C. Up to 75% of domestic assaults occur after separation;
females are most likely to be murdered when reporting abuse
or attempting to leave an abusive relationship. Presence of a
rearm in a domestic violence situation increases the risk of
homicide by 500%.
D. Stalking is often linked to both IPV and sexual assault.
Examples of stalking include the perpetrator approaching
VIOLENCE: INTIMATE PARTNER
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51
the client or showing up at places the client frequents, threatening physical harm, damaging personal property, making
unwanted online contact (via email, instant message, or social
media) or unwanted telephone calls, leaving unwanted gifts
or strange items, and sneaking into the client’s car/home.
E. An estimated 4% to 15% of females presenting to EDs have
situations related to domestic violence.
F. Females who separate are at risk of violence approxi-
mately three times that of divorced females.
1. More than half of the children who witness domestic
violence intervene in some way, including yelling to the
abuser to stop, calling for help, and trying to get away.
G. The incidence of abused males is estimated as one in
three. Males are also victims of attempted or complete rape at
approximately 7% during their lifetime.
H. Pregnancy and the postpartum period have an increased
incidence of violence.
1. One in ve young females and 35% of females overall
have experienced pregnancy coercion.
2. 53% of young females have experienced birth control
sabotage.
3. It is estimated that 324,000 of intimate partner abuse
occurs against pregnant individuals.
a. The American College of Obstetricians and
Gynecologists (ACOG) recommends screening for IPV
at the rst prenatal visit, at least once per trimester, and
at the postpartum checkup.
I. Sexual violence, rape, physical assault, or stalking by an
intimate partner occurs in 11% of lesbians and in 15% of males
with male partners.
J. Among college-aged females, 20% to 30% report violence
during a date.
K. Physical, emotional, or verbal abuse is estimated in one in
three adolescent girls from a dating partner in the United States.
1. The tween population (ages 11-14 years) reports that
half of their friends have experienced dating violence.
2. The tween population reports that their friends are vic-
tims of verbal abuse.
3. Teen clients are more likely to smoke, use drugs, and
have other risky behaviors.
L. Females and males in the military are recognized as a
vulnerable population susceptible to abuse due to their geographic location away from family and friends and the social
isolation within the military culture.
1. Males are far more likely to consider sexual assault as
hazing, bullying, physical abuse, or an act with the intent to
humiliate rather than sexual harassment or sexual assault,
thus contributing to the low reporting rate by males.
2. In 2018, the Department of Defense estimated that
in the U.S. military approximately 30% of instances of
unwanted sexual contact were reported.
3. Most sexual assault incidents in the military involve
individuals who know each other. In reported cases, the
parties often agree sexual activity took place but contest
matters of consent.
4. Most criminal investigations conducted today involve
the need to analyze computers, laptops, cell phones,
internet-connected home assistants, digital data stored in
vehicles, and so forth. Digital devices almost always contain relevant evidence (e.g., emails, texts, photographs,
internet search logs, geolocation data, and social media
uploads/downloads) particularly helpful in sexual assault
case-associated crimes (e.g., stalking).
PATHOGENESIS
A. IPV is not associated with an underlying medical condi-
tion. The cycle of abuse has four phases:
1. Tension building, in which the client tries to avoid vio-
lence and is described as “walking on eggs,” unsure what
will trigger an abusive incident.
2. Explosion and acute battering occur.
3. “Honeymoon phase,” noted period of reconciliation.
4. Calming stage. Strive to maintain peace and calm-
ness. Justication/explanation for the abuse is discussed.
Clients stay with their partners for multiple reasons,
including fear, shame, denial, religious reasons, lack of
resources, custody issues and other legal issues, fear of
being “outed,” and family pressures.
PREDISPOSING FACTORS
A. Sex: Clients are predominantly female.
B. Race: African Americans, American Indians, Hispanic
females, and Alaskan Natives.
C. Higher incidence in interracial couples.
D. Pregnancy.
E. History of violence:
1. Violence present in the family of origin.
2. Abuse as a child: 50% report abuse as an adult.
F. History of drug use.
G. Posttraumatic stress disorder (PTSD).
H. Lack of social support systems.
I. Impulse control disorders.
J. Poor economic status.
K. LGBT.
COMMON COMPLAINTS
A. Vague complaints.
B. Sexual problems.
C. Depression.
D. Chronic pain inconsistent with organic disease.
E. Chronic headaches/migraines.
F. Stress:
1. Anxiety.
2. Panic attacks.
G. Alcohol or drug abuse (the batterer, client, or both).
H. Current or past self-mutilation.
I. Gynecologic and obstetric complaints:
1. Dyspareunia.
2. Frequent vaginal or urinary tract infections.
3. Pelvic pain/infection.
4. Recurrent sexually transmitted infections.
5. Unintended pregnancy.
6. Late prenatal care.
7. Miscarriage.
8. Preterm bleeding/delivery.
J. Complaints of falls and other recurrent accidents.
K. Eating disorders.
L. Gastrointestinal complaints/irritable bowel syndrome.
M. Musculoskeletal complaints.
OTHER SIGNS AND SYMPTOMS
A. Multiple prior visits to the ED for traumatic and nontrau-
matic complaints.
B. A delay between injury and ofce visits (may result from
lack of transportation or the inability to leave the house).
C. Noncompliance with the treatment or missed appoint-
ments (lack of access to money or telephones).
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2: PUBLIC HEALTH GUIDELINES
D. Suicide attempt (25% higher in females with IPV).
E. A partner who accompanies the client at all visits.
SUBJECTIVE DATA
A. The “gold standard” research method to document the
prevalence of females' exposure to violence includes conducting the interview one on one, in private, and asking specic
direct questions.
1. The batterer often refuses to leave the client alone and
may answer questions for the client. Translators should not
be a member of the client’s or suspected abuser’s family.
2. Use direct questions: female-validated Partner Violence
Screen (PVS):
a. Have you been hit, punched, kicked, or otherwise
hurt by someone in the past year? If yes, by whom and
were you injured?
b. Do you feel safe in your current relationship?
c. Is a partner from a previous relationship making
you feel unsafe now?
d. Are you here today because of injuries from a
partner?
e. Are you here today because of illness or stress related
to threats, violent behavior, or fears of a partner?
3. Assess whether the client has ever told family or
friends, called hotlines, or attempted to leave the abuser.
4. Has the client sought help with law enforcement or
legal help, that is, led a criminal complaint or got an
order of protection?
5. Are there any weapons in the home?
a Has the abuser ever threatened or tried to kill you?
b Are you thinking of suicide? Have you ever consid-
ered or attempted to commit suicide because of problems in your relationship?
c Have you ever considered or attempted killing your
batterer?
d Do you have a plan?
PHYSICAL EXAMINATION
A. Enforce the need to interview and conduct physical exami-
nations in private. Do a full-body examination, including the
head/scalp:
1. Most injuries are to the central (breast, chest, and abdo-
men) area, which is easily concealed by clothing.
2. Other frequent sites of injury include the head, face,
throat, and genitals.
3. Explain the physical examination and touch with
permission.
4. Forensic examinations need thorough documentation
of injuries:
a. Take color photographs before any treatment is
started.
b. Photograph damaged clothing.
c. Take at least one full-body photograph and a facial
photograph.
d. Take close-up photographs of all injuries.
e. Use a ruler to identify/document the size of injuries.
f. Document on the back of the photographs the cli-
ent’s name, date, and the photographer’s name, as well
as any witnesses to the examination. The photographer
should also sign each photograph.
g. Use direct quotes of the client’s history of the violence.
B. Check blood pressure, pulse, and respirations.
C. General observation:
1. Observe for depression/ withdrawnness or at affect,
anxiousness, fearfulness, evasiveness, poor eye contact,
and wearing heavy makeup or clothing to conceal signs of
abuse.
2. Evaluate voice changes, such as dysphonia and aphonia.
3. Observe for difculty breathing.
D. Inspect:
1. Dermal examination for the presence of cigarette
burns, impression marks, rope burns, welts, abrasions,
scratch marks, claw marks, bite marks, ligature marks,
petechiae, and contusions at multiple sites (e.g., back, legs,
and buttocks).
2. Eye examination:
a. Observe subconjunctival hemorrhages from
strangulation/struggle.
b. Perform a funduscopic examination (if indicated
secondary to trauma).
3. Evaluate the genitals for lacerations and hematomas of
the vagina or labia.
E. Auscultate:
1. All lung elds.
2. Heart.
3. Bowel sounds in all four quadrants of the abdomen.
F. Palpate:
1. Evaluate skull/facial trauma to the maxillofacial area,
eye orbits, mandible, and nasal bones. Facial injuries are
reported in 94% of clients.
2. Evaluate for dislocations, fractures (including spiral
fractures), sprains, and contusions to the wrists and forearms, and shoulders.
3. Palpate the abdomen, liver, and spleen for tenderness.
G. Percuss abdomen, chest, and areas of injury (if indicated
secondary to trauma).
H. Perform a neurologic examination (if indicated secondary
to trauma).
I. Perform a genital/rectal examination:
1. Evaluate the genitals/anus area for redness, swelling,
bruising, hematomas, abrasions, or lacerations.
2. Perform bimanual examination (females).
3. Order an anoscopy (if indicated).
4. Evaluate for evidence of sperm (recto/vaginal).
5. Evaluate for presence of condyloma (perineum, rec-
tum, vagina).
6. Evaluate for the presence of foreign bodies (recto/
vaginal).
DIAGNOSTIC TESTS
A. Diagnostic tests and x-rays are ordered dependent on the
type of presenting complaints and physical examination.
1 Administer a domestic abuse assessment screening
tool and have the client mark a body map of injuries
(Exhibit 2.2).
2 Complete blood count with differential and periph-
eral smear, bleeding evaluation, including PT/PTT, ALT,
and AST, to evaluate injury to the liver, serum amylase, or
lipase to rule out pancreatic injury.
3 Urinalysis.
4 Drug/toxicology screen (urine and blood).
5 Obtain forensic DNA samples from the skin, under the
nails, vagina, rectum, and saliva from bite marks using
sterile cotton-tipped applicators that have been moistened
EXHIBIT 2.2 Abuse Assessment Screening Tool With Body Map
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VIOLENCE: INTIMATE PARTNER
53
Source: Reprinted with permission from Parker, B., McFarlane, J., Soeken, K., Torres, S., & Campbell, D. (1993). Physical and emotional abuse in pregnancy:
A comparison of adult and teenage women. Nursing Research, 42(3), 173–178. https://doi.org/10.1097/00006199-199305000-00009
with sterile saline. These should be sent to a crime laboratory as soon as possible.
6 Test for sexually transmitted infections/HIV.
7 Pregnancy test (if indicated).
8 Radiographs for facial injury, anteroposterior, and lat-
eral radiograph for any areas of bone tenderness, swelling,
deformity, or limited range of motion.
9 Ultrasounds as indicated.
10 Neuroimaging CT/MRI may be used for any sus-
pected nonaccidental head injury (e.g., head trauma or
scalp hematoma).
DIFFERENTIAL DIAGNOSES
A. Rape.
B. Other: related to presenting symptoms.
PLAN
A. General interventions:
1. Provide a safe environment. Assess for immediate
danger.
2. Clearly document the history, physical ndings, and
interventions. Report specic details about abuse.
3. Determine the risk to the client and any children.
4. Evaluate the need for ED/hospital admission.
5. Battery is a crime; assess the client’s readiness for police
intervention and need for a court order of protection.
6. Help develop a safety plan.
a. Plan a safe place to go in advance, choose a place
where the client will be able to alert authorities that their
partner does not know about. Make up a code word to
alert family and friends that the client is in danger.
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2: PUBLIC HEALTH GUIDELINES
b. Ask the client to inform their school or place of work
so that a safety plan can be implemented with their
support.
c. Memorize important phone numbers in case the cell
phone is taken away.
d. Keep an extra set of house and car keys in a safe,
hidden place, or with someone who can be trusted.
e. Keep extra money available.
f. Encourage changing email addresses, cell phone
number, and other contact information on social network sites.
7. Assess readiness to leave: Signs include collection of
important papers (e.g., birth certicates, custody papers,
divorce papers, and legal agreements, address book, copies of restraining orders), access to money/credit cards,
and telling family and friends.
8. Familiarize yourself with the local resources, such as
hospital programs, shelters, social welfare services, and
support groups.
9. Provide contact numbers for shelters/social welfare
services. Have the client hide information in their shoes.
10. Counsel that violence may escalate.
B. Client teaching
1. Reinforce that the violence is not the client’s fault.
IPV is very common and the client does not deserve to be
abused. Discuss the cycle of abuse.
2. Violence increases in frequency and severity.
3. Help is available.
C. Pharmaceutical therapy
1. Prescriptions are related to physical injuries.
2. Treatment may be offered for sexually transmitted
infections in the oral anal genital areas.
3. Tranquilizers may impair the client’s ability to ee or
defend themselves and should not be prescribed.
FOLLOW-UP
A. Develop a follow-up plan.
1. What type of help does the client want?
2. Does the client have a plan for returning? Is the bat-
terer home? Do they think it is safe?
3. Do they have a place to stay with family or friends, or
do they want to go to a shelter?
4. Give the telephone numbers for shelters and crises
hotlines.
B. Screen the client for abuse at all subsequent visits.
C. Mandatory reporting:
1. States require reporting when domestic violence
involves a child younger than 18 years and abuse or
neglect of the child is suspected.
2. Abuse of a disabled person must be reported to the
Disabled Persons Protection Commission.
3. Reporting elder abuse may be mandatory in your state.
D. Your state may mandate reporting and intervention with
law enforcement. Refer to the Domestic Violence, Sexual
Assault, and Stalking Data Resource Center at www.jrsa.org/
dvsa-drc/st-summary.shtml.
E. The 2013 National Protocol for Sexual Assault Medical
Forensic Examination for Adults and Adolescents is available
at ncjrs.gov/pdfles1/ovw/241903.pdf.
F. Protection order: Clients may request a Domestic Violence
Protection Order (DVPO), preventing perpetrators from contacting them. Refer to a community advocate or legal advisor
for assistance.
CONSULTATION/REFERRAL
A. Facilitate referrals to a shelter, counseling, and legal services.
B. Contact a Sexual Assault Nurse Examiner–qualied
healthcare provider if indicated.
C. Refer to community or private support groups and agencies.
D. Refer for a consultation with a psychiatrist if the client is
homicidal or suicidal.
E. Refer for a neurologic or neurosurgical consultation for
intracranial injuries or focal neurologic ndings.
F. Refer for an orthopedic consultation for fractures.
INDIVIDUAL CONSIDERATIONS
A. Pregnancy:
1. Pregnancy is a known period of increased risk of
violence.
a. The genitals, breast, and abdomen are common sites
targeted for trauma.
b. Clients may present with a miscarriage or prema-
ture labor.
c. Blunt trauma is a common injury in pregnancy.
d. Perform universal screening at each trimester and
postpartum as abuse often begins during pregnancy.
RESOURCES
Dating Abuse Stops Here: www.datingabusestopshere.com
Domestic Violence, Sexual Assault and Stalking Data Resource Center: w
ww.jrsa.org
Futures Without Violence (Formerly Family Violence Prevention Fund): ww
w.futureswithoutviolence.org
National Domestic Violence Hotline: 1-800-799-7233
National TEEN Dating Abuse Helpline: 1-866-311-9474
Rape, Abuse & Incest National Network (RAINN) Hotline: 1-800-656-4673;
www.domesticviolence.org
BIBLIOGRAPHY
American College of Obstetricians and Gynecologists. (2019). Domestic
violence during pregnancy. https://www.acog.org/About-ACOG/
ACOG-Departments/Violence-Against-Women/Domestic-ViolenceDuring-Pregnancy?IsMobileSet=false
American College of Obstetricians and Gynecologists. (2012,
February). Intimate partner violence. Committee Opinion, 518,
1–5. https://www.acog.org/Clinical-Guidance-and-Publications/
Committee-Opinions/Committee-on-Health-Care-for-UnderservedWomen/Intimate-Partner-Violence?IsMobileSet=false
Break the Cycle. (2014). Learning about dating abuse. http://www.breakthe
cycle.org/learn-about-dating-abuse
Dating Abuse Stops Here. (n.d). Warning signs in depth. www.datingabuse
stopshere.com/warning-signs/warning-signs-indepth
Dating Abuse Stops Here. (2019). Create a safety plan. www.datingabusest
opshere.com/create-a-safety-plan/
Devries, K. M., Mak, J. Y. T., Garcia-Moreno, C., Petzold, M., Child, J. C.,
Falder, G., Lim, S., Bacchus, L. J., Engell, R. E., Rosenfeld, L., Pallitto,
C., Vos, T., Abrahams, N., & Watts, C. H. (2013, June 30). The global
prevalence of intimate partner violence against women. Sciencexpress. http:
//www.sciencemag.org/content/early/recent
Futures Without Violence, Formerly Family Violence Prevention Fund.
(n.d). The facts on children’s exposure to intimate partner violence. https://
www.futureswithoutviolence.org/the-facts-on-childrens-exposure-to
-intimate-partner-violence
HelpGuide.org. (n.d.[a]). Domestic violence and abuse: Signs of abuse and
abusive relationships. https://www.helpguide.org/articles/abuse/
getting-out-of-an-abusive-relationship.htm?pdf=12327
HelpGuide.org. (n.d.[b]). Help for abused men: Escaping domestic violence by
women or domestic partners. https://www.helpguide.org/articles/abu
se/help-for-med-who-are-being abused.htm
National Coalition Against Domestic Violence. (2020). Domestic
Violence. https://assets.speakcdn.com/assets/2497/domestic_
violence-2020080709350855.pdf?1596811079991
Ofce for Victims of Crime. (2018). Stalking. https://ovc.ncjrs.gov/ncvrw
2018/info_yers/fact_sheets/2018NCVRW_Stalking_508_QC_v2.pdf
VIOLENCE: OLDER ADULTS
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55
Parker, B., McFarlane, J., Soeken, K., Torres, S., & Campbell, D. (1993).
Physical and emotional abuse in pregnancy: A comparison of adult
and teenage women. Nursing Research, 42(3), 173–178. https://doi.org
/10.1097/00006199-199305000-00009
Rape, Abuse & Incest National Network. (n.d.[a]). State resources. https://
www.rainn.org/state-resources
Rape, Abuse & Incest National Network. (n.d.[b]). Victims of sexual vio-
lence: Statistics. http://www.rainn.org
Ross, R., Roller, C., Rusk, T., Martsolf, D., & Draucker, C. (2009). The
SATELLITE sexual violence assessment and care guide for perinatal
clients. Women’s Health Care: A Practical Journal for Nurse Practitioners,
8(11), 25–31. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3324
818/pdf/nihms316342.pdf
United Nations Development Programme. (2013, November 25). Violence
against women is not acceptable and can be prevented. https://www.undp
.org/content/undp/en/home/presscenter/pressre-leases/2013/11/
25/violence-against-women-is-not-acceptable-and-can-be-prevented
.html
U.S. Army SHARP: Sexual Harassment/Assault Response & Prevention.
(n.d). What we know about sexual assault of military men. https://www.s
exualassault.army.mil/whatweknow_militarymen.aspx
U.S. Department of Defense. (2019, April 30). Sexual assault accountability
and investigation task force. https://media.defense.gov/2019/May/02
/2002127159/-1/-1/1/SAAITF_REPORT.PDF
U.S. Department of Justice, Ofce on Violence Against Women. (2013). A
national protocol for sexual assault medical forensic examinations: Adults/
adolescents (2nd ed.). Author. https://www.ncjrs.gov/pdfles1/ov
w/241903.pdf
Weil, A. (2020, September 25). Intimate partner violence: Intervention
and patient management. https://www.uptodate.com/contents/
intimate-partner-violence-intervention-and-patient-management#H2
4185127
World Health Organization. (2011). Intimate partner violence during preg-
nancy. https://apps.who.int/iris/bitstream/10665/70764/1/WHO_
RHR_11.35_eng.pdf
INCIDENCE
A. The U.S. Census Bureau’s 2017 National Population
Projections, based on the 2010 Census, estimates that by 2030
all baby boomers will be older than age 65, meaning that one
in every ve residents will be in retirement age.
B. The incidence of elder abuse, neglect, exploitation, and
self-neglect is approximately 1 in 10 Americans aged 60 years
and older. The incidence is underreported because of the
reluctance to report abuse, fear of implicating family members, and fear of being removed from the home.
C. Abuse is not uncommon in the institutional setting.
D. The highest rate of abuse is among females older than age
80, with the abuser being the spouse or an adult child. In case
of cognitive impairment, the client may not remember or recognize abuse.
PATHOGENESIS
A. Maltreatment of vulnerable adults occurs by people who
have an ongoing relationship with the older person when there
is an expectation of responsibility: sons/daughters, spouses/
intimate partners, other family members such as grandchildren, and others, including paid and unpaid caregivers. There
are several identifying psychopathologies in the abusers.
1. Physical frailty and mental impairment of the client
play an indirect role. The client may have a decreased ability to defend or escape.
2. Caregiver stressors from caring for the elderly client,
including the client’s physical and verbal demands, contribute. Psychosocial factors of the caregiver, mental illness, and alcohol or drug abuse also contribute.
3. The child who was once abused may continue the cycle
of violence transferred to the parent.
VIOLENCE: OLDER ADULTS
DEFINITION
A. Abuse in older individuals, dened as older than age
65, is associated with loss of functional capacity, depression,
cognitive impairment, and increased morbidity and mortality. Perpetrators include partners and family members (of all
ages), as well as strangers. There are several types of maltreatment in this population.
1. Physical abuse: willful unnecessary restraint, iniction
of physical pain, or injury.
2. Sexual abuse: nonconsensual sexual contact.
3. Psychological abuse: iniction of emotional harm, bul-
lying, ridicule, verbal abuse, terrorizing, and threatening
to place in a long-term facility until the elder submits.
4. Neglect: failing to provide for needs and protection of
a vulnerable adult.
5. Self-neglect (subset of neglect): malnutrition, dehydra-
tion, lack of personal hygiene, listlessness, and hoarding.
6. Abandonment: desertion.
7. Financial exploitation: misappropriation of resources,
utilities turned off for nonpayment, essential purchases
including food or medicine not made, discrepancies in
personal bookkeeping including unexplained credit card
activities, recent change in property titles, deeds, and renancing mortgages.
8. Healthcare fraud and abuse: not providing care
but charging for services, and overmedicating or
undermedicating.
9. Connement: restraining or isolating an older adult
other than for medical reasons.
PREDISPOSING FACTORS
A. Age: 65 years and older.
B. Institutionalized.
C. Cognitive impairment/diminished capacity.
D. Decreased capacity for performing activities of daily living
(ADLs):
1. Difculty feeding self.
2. Difculty bathing and dressing self.
3. Difculty going to the toilet and performing personal
hygiene.
E. Decreased capacity performing instrumental activities of
daily living (IADLs):
1. Ability to prepare meals.
2. Ability to do household chores.
3. Ability to use the telephone.
4. Ability to manage personal nances.
F. Females have a higher incidence of physical/sexual abuse.
G. Male sex is associated with self-neglect associated with
impaired ADLs and IADLs.
H. Family stressors involving the caretaker.
COMMON COMPLAINTS
A. Depression.
B. Falls.
C. History of hip fracture.
D. Pressure ulcers.
E. Bruises, lacerations, and burns.
OTHER SIGNS AND SYMPTOMS
A. Abrasions, lacerations, or bruises that are seen in unusual
locations or poorly explained may be a sign of physical abuse.
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B. Indications of healing spiral fractures on x-ray.
C. Poor nutrition: lack of resources/transportation to obtain
food; caregiver not providing adequate nutrition/withholding
food.
D. Multiple hospitalizations.
E. Recurrent urinary tract infections.
F. Noncompliance: may not be able to pay for medications;
medications may be withheld or even given in excess by the
caregiver.
G. Complaints of sexual abuse:
1. Pain or soreness in the genital area.
2. Bruises or lacerations on the perineum/rectum.
3. Vaginal or rectal bleeding.
H. Traumatic tooth and/or hair loss.
I. Sedation from overmedicating.
J. Changes in personality.
SUBJECTIVE DATA
A. The caregiver often refuses to leave the client alone and
may answer questions for the client.
B. The caregiver has a different explanation of the injury.
C. Ask the client directly about abuse, neglect, or exploitation.
1. Has anyone at home threatened or ever hurt you?
2. Are you afraid of anyone at home?
3. Are you left alone for long periods of time?
4. Who cooks your meals? How often and what amounts
of food do you eat?
5. Who handles your nancial business? Have you signed
any documents that you did not understand?
D. Assess the client’s living arrangements. Has the client ever
told family or friends of their concerns, called hotlines, or
attempted to leave the caregiver?
PHYSICAL EXAMINATION
A. Assessment:
1. Observation: If abuse is suspected, enforce the need
to do the physical examination in private. Do a full-body
examination.
a. Forensic examinations need thorough documenta-
tion of injuries.
i. Take color photographs before any treatment is
started.
ii. Take at least one full-body photograph and a
facial photograph.
iii. Take close-up photographs of all injuries.
iv. Use a ruler to identify/document the size of the
injuries.
v. Document on the back of the photographs the
client’s name, date, and the photographer’s name,
as well as any witness to the examination. The photographer should also sign each photograph.
vi. Use direct quotes of the client’s history.
B. Check blood pressure, pulse, respirations, and height and
weight to calculate body mass index (BMI).
C. General observation:
1. Observe for depression, withdrawal demeanor, at
affect, fearfulness, poor eye contact, inappropriate dress,
and signs of malnutrition.
2. Observe for poor hygiene, presence of urine and feces,
matted or lice-infected hair, odors, dirty nails and skin,
and soiled clothing.
3. Assess cognitive abilities, depression, and functional
ability of ADLs and IADLs.
D. Inspect:
1. Perform dermal examination for signs of burns, tears,
lacerations, impression marks, and bruises in different
stages of healing. Frequent areas of the body involved are
the neck, arms, and/or legs. Evaluate for the presence of
decubitus/pressure ulcers. Signs of dehydration include
dry fragile skin, dry sore mouth, and mental confusion.
2. Perform oral examination for poor oral hygiene,
absence of dentures, and dry mucous membranes.
3. Evaluate the breasts and genitals for lacerations and
hematomas of the vagina or labia.
E. Auscultate:
1. All lung elds.
2. Heart sounds.
3. Bowel sounds in all four quadrants of the abdomen.
F. Palpate:
1. Evaluate for dislocation, fractures, sprains, and contu-
sions to the wrists, forearms, and shoulders.
2. Palpate the abdomen for tenderness.
G. Percuss:
1. Abdomen and chest (if indicated).
H. Perform genital/rectal examination:
1. Evaluate the genitals/anus for redness, swelling, bruis-
ing, hematomas, abrasions, or lacerations.
2. Evaluate for evidence of sperm.
3. Evaluate for presence of foreign bodies.
DIAGNOSTIC TESTS
A. Diagnostic tests and x-rays are ordered dependent on the
type of presenting complaints.
B. Obtain a CT for evaluation of injuries to the head and
assault to the face, neck, or head. A CT or Doppler ultrasound
may be ordered for abdominal injuries.
C. Order laboratory testing to evaluate dehydration, mal-
nutrition, electrolyte imbalance, and medication/substance
abuse:
1. Complete blood count.
2. Chemistry-7.
3. Urinalysis.
4. Calcium, magnesium, and phosphorus.
5. Drug/alcohol screen.
6. Serum levels for relevant medications.
D. Obtain DNA samples if sexual abuse is present.
DIFFERENTIAL DIAGNOSES
A. Depression.
B. Abdominal trauma.
C. Sexual assault.
D. Gait disturbance/fall.
E. Pathologic fracture.
F. Epidural/subdural hematoma.
PLAN
A. General interventions:
1. Provide a safe environment.
2. Clearly document the history, physical ndings, and
interventions.
3. Determine the perpetrator(s).
4. Evaluate the need for ED/hospital admission.
B. Client teaching
1. Reinforce that abuse/neglect is not the client’s fault.
Elder abuse is very common.
2. Help is available.
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C. Pharmaceutical therapy:
1. Ensure prescriptions are related to physical injuries.
2. Recommend treatment for sexually transmitted infec-
tions in the oral, anal, and genital areas.
FOLLOW-UP
The Department of Health and Human Services National Center on Elder
Abuse Administration on Aging maintains a State-by-State Resource site
that includes directories, helplines, hotlines, referral sources, state government agencies and laws, and regulations related to elder abuse; it is
located at ncea.acl.gov/Resources/State.aspx.
A. Develop a follow-up plan. All states have legislation pro-
tecting against abuse, neglect, and exploitation of the older
population.
B. Know whether your state has mandatory requirements to
report any suspicion of elder mistreatment.
C. Abuse of a disabled person must be reported to the
Disabled Persons Protection Commission.
D. Know whether your state has additional regulations
related to self-neglect. Contact adult protective services or law
enforcement agencies.
E. The American Medical Association and the American
Academy of Neurology advise screening persons 65 years and
older for abuse.
CONSULTATION/REFERRAL
A. Schedule a social work consultation to coordinate an
in-home geriatric assessment visit.
B. Facilitate referrals to a shelter, counseling, and legal
services.
C. Contact a Sexual Assault Nurse Examiner-qualied health-
care provider if indicated.
D. Refer to the community Area Agency on Aging for
assistance.
E. Refer for a psychiatric consultation if indicated.
F. Refer for a neurologic or neurosurgical consultation for
intracranial injuries or focal neurologic ndings.
G. Refer for an orthopedic consultation for fractures.
RESOURCES
The AARP: www.aarp.org
Clearinghouse on Abuse and Neglect of the Elderly (CANE): www.elder
abusecenter.org
Help hotline for suspected elder abuse, neglect, or exploitation:
1-800-677-1116
National Adult Protective Services Association (NAPSA): www.
napsa-now.org
National Center on Elder Abuse Administration on Aging (NCEA): www.
ncea.acl.gov
BIBLIOGRAPHY
Aravanis, S. C., Adelman, R. D., Breckman, R., Fulmer, T. T., Holder,
E., Lachs, M., O'Brien, J. G., & Sanders, A. B. (1993). Diagnostic and
treatment guidelines on elder abuse and neglect. Archives of Family
Medicine, 2(4), 371–388. https://doi.org/10.1001/archfami.2.4.371
Halphen, J. M. (2021, Sep 13). Elder abuse, self-neglect, and related phenom-
ena. https://www.uptodate.com/contents/elder-abuse-self-neglect
-and-related-phenomena#H850296811
HelpGuide.org. (n.d). Elder abuse and neglect: Warning signs, risk fac-
tors, prevention, help. https://www.helpguide.org/articles/abuse/
elder-abuse-and-neglect.htm
National Center on Elder Abuse. (n.d). State resources. https://ncea.acl.
gov/Resources/State.aspx
National Council on Aging. (n.d). Elder abuse facts. https://www.ncoa.org
/public-policy-action/elder-justice/elder-abuse-facts/
Schulman, E. A., & Hohler, A. D. (2012). The American Academy of
Neurology position statement on abuse and violence. Neurology, 78(6),
433–435. https://doi.org/10.1212/WNL.0b013e318245d21c
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