Abuse is a global health problem. Because the nurse is often the first person the victim sees after the incident, you're in a unique position to recognize, treat, and advocate for patients who've experienced abuse. We help you understand your professional responsibilities when caring for these patients.

Abuse is the mistreatment of one human being by another. When we talk about family violence, we can mean any mistreatment between two or more members of a family, including, but not limited to, parent to child, adult child to elderly parent, sibling to sibling, or intimate partner to intimate partner. Domestic violence is a broad term used to describe child abuse, elder abuse, and abuse of women and men. Abuse isn't the accidental causing of injury; it's an intentional hurting of another person that can manifest itself in many ways, including physical, sexual, and emotional abuse.

As a nurse, it's your responsibility to learn how to identify the signs and symptoms of abuse and to take action to help the abused patient.

Prevalence of abuse

Abuse is present in all cultures, in every social class, and in all ethnic groups. One in three women worldwide is a victim of domestic abuse at some time in her life. Violence against women by their partners often increases during pregnancy. Women with disabilities are also at an increased risk for abuse. Although abuse is often thought of as men using power over women, men may also be victims of abuse. Individuals in same-sex relationships experience abuse at the hands of their partners at about the same rate as heterosexual couples. More than 15 million children are exposed to domestic violence nationally, and approximately 1 million additional children experience some type of abuse from family members. Elderly people are also victims of abuse. There are 2 million or more cases of elder abuse in the United States alone each year. Unfortunately, these data represent only a snapshot of the bigger picture because not all cases of abuse are reported. This is especially the case in same-sex relationships in which victims are less likely to report the abuse than victims in heterosexual relationships.

A person's level of education, age, financial status, and religious or other institutional affiliations don't preclude the chance that abuse may take place. It's a myth to believe that abuse is limited to a certain region, a particular social class, a socioeconomic or educational level, or a specific ethnicity. In other words, where there are humans, there may be abuse. Sometimes you may not recognize abuse because of your own customs, biases, or values. Nurses are human, too!! For instance, you may have trouble distinguishing between appropriate parental disciplining of a misbehaving child and parental action that crosses the line between acceptable and nonacceptable adult supervision and caretaking. It's important for you to recognize indications of abuse when a patient presents with symptoms of mistreatment by family members, acquaintances, or other caregivers. Let's take a closer look.

Types of abuse

If abuse is physical, the patient may present with current or past injury to the skeletal structure or internal organs, as well as visible external signs of damage to parts of the body such as bruising and abrasions. Physical abuse can cause chronic pain and debilitation and may affect the patient's immediate and future ability to perform activities of daily living.

Abuse can also be sexual, in which there's inappropriate and/or aggressive contact with the victim's or perpetrator's genitalia or other "private" areas. Rape is one type of sexual abuse; however, sexual abuse isn't limited to vaginal or anal penetration (see A closer look at sexual assault). In addition to physical pain, sexual abuse can cause the patient tremendous anxiety and fear, and can even develop later into a situation in which the patient imitates the perpetrator's aggressive behavior and abuses someone else. Battering involves repeated physical or sexual assault in a context of coercive control and, more broadly, emotional degradation, threats, and intimidation.

Emotional abuse includes belittling, name calling, verbal attacks, and other aggressive demoralizing behavior, which can injure the patient psychologically and lead to long-term consequences that diminish quality of life. If a person's self-esteem and sense of self-worth have been destroyed, it may be difficult for that person to function. The patient may lose hope in the future and resort to unhealthy behaviors, such as drug abuse, crime, and abusing others, in an attempt to gain control.

Neglect and deprivation are also types of abuse. Whether the perpetrator withholds financial resources, education, food, clothes, shelter, or medical attention, neglect can cause irrevocable injuries, with serious consequences to the patient's physical and emotional well-being. Without basic necessities, the victim's capacity to thrive is disrupted. This situation may lead to chronic suffering or even death.

Identifying abuse

A standard set forth by The Joint Commission requires that healthcare institutions have in place criteria to identify, assess, and provide appropriate treatment for victims of abuse, neglect, or deprivation (see The victim's rights and the nurse's legal obligations). Professional nursing and medical organizations, such as the American Nurses Association; the Association of Women's Health, Obstetric, and Neonatal Nurses; the American Medical Association; and Physicians for a Violence-Free Society, support universal screening of all patients for abuse as a prime opportunity to solve this problem.

When a patient presents with an unlikely or repeated injury, is in a state of constant vigilance to prevent injury, or has difficulty with or age-inappropriate behaviors concerning sexual parts of the body, you should question the nature and source of the injury and take a proactive role to help the patient. See Assessing for abuse, maltreatment, and neglect for questions you can ask. The most common physical injuries of abuse are unexplained bruises, lacerations, abrasions, head injuries, and fractures.

Be alert for the red flags of abuse:

* patterned injuries, such as from a belt buckle, or cigarette burns

* multiple injuries in various stages of healing

* unexplained injuries or those that don't fit the patient's account of how they happened

* injuries in hidden areas

* extreme bruising and/or abrasions on the buttocks, shoulders, or genitalia.

There are few signs and symptoms specifically diagnostic of battering. You may see an injury that doesn't fit the account of how it happened. For example, a bruise on the upper arm may be explained as the result of walking into a door and dismissed as inconsequential. Manifestations of abuse may involve suicide attempts, drug and alcohol abuse, frequent ED visits, vague pelvic pain, somatic complaints, and depression. Besides physical injuries, patients may present with anxiety, insomnia, or gastrointestinal symptoms related to stress. Individuals in abusive situations often report that they don't feel well, possibly due to the stress of fear and the anticipation of impending abuse. However, there may be no obvious signs and symptoms.

Signs of neglect and deprivation are subtle and may be difficult to detect. The most common clinical manifestations of neglect are malnutrition and dehydration. Excessive thirst or hunger in the absence of medical disease indicates possible deprivation. Inappropriate clothing for extreme weather conditions and disheveled appearance are clues to neglect, as is an elderly patient brought to the hospital in soiled clothing or with bedsores. If a dependent patient with adequate resources and a designated care provider shows evidence of inattention to hygiene, nutrition, or known medical needs (such as unfilled prescriptions or missed appointments with healthcare providers), you should suspect neglect.

Figure. Abuse can happen to men and women, young and old.

How can you help?

In a clinical setting, your most important role is to provide a safe environment for your patient; treat your patient's injuries; and observe, listen, and document the facts. Treatment focuses on the consequences of the abuse and preventing further injury. If the patient is in immediate danger, separate the patient from the perpetrator whenever possible. If abuse is the result of stress experienced by a caregiver who's no longer able to cope with the burden of the role, respite services may be necessary.

Remember, documentation is important. What information does the patient provide? Getting the story requires separating the patient from the perpetrator. Ask the caregiver to leave the room. Tell the caregiver that privacy is necessary to ensure the patient gets the best care possible and that the caregiver can return after the exam is complete. Keep in mind, however, that most patients won't readily identify their abuser.

Documentation includes noting the time and place of injury, direct quotes in quotation marks of the patient's version of what happened, a body map detailing the location and type of all injuries, and all other pertinent facts. Don't draw conclusions about the situation, summarize the patient's story, or use legal or otherwise neutral official language that might shed doubt on the truth of the patient's statements. Just observe, listen, and document what the patient says. If you approach getting the facts about the patient's injury as gathering evidence, your notes may later help authorities have a clearer idea of the truth. It's the pieces of information you record, not any assumptions you make, that could later help the patient in legal proceedings. Make sure your handwriting is legible or use a computer to document so that the information is clear.

After you've assessed the harm done, provided appropriate care, ensured patient safety, and documented your findings, your next important job is to refer your patient to the appropriate authorities and/or agencies. Even if you aren't sure but suspect that your patient is a victim of abuse, report your suspicions. You won't be penalized and you may save your patient's life.

Don't insist that your patient leave the abuser. Help your patient develop a safety plan that's appropriate and makes sense. Keep in mind that competent adults are free to accept or refuse the help offered to them. Some patients insist on remaining in the abusive environment. The wishes of patients who are competent and not cognitively impaired should be respected; however, all possible alternatives and available resources should be explored. This means not falling prey to blaming the victim but instead providing your patient with appropriate resources.

Community services are available to assist families in breaking the cycle of violence. Encourage treatment for all family members. Organizations such as The National Domestic Violence Hotline and Family Violence Prevention Fund recognize that abuse is a family problem. These organizations provide education, crisis intervention, and referral services to support individuals, families, and communities to identify strategies to prevent abuse, build leadership, and develop self-sustaining programs of nonviolence.

Additional resources are only a phone call away. These include hotlines such as:

* National Domestic Violence Hotline: 1-800-799-SAFE (7233); TTY: 1-800-787-3224

* ChildHelp USA National Child Abuse Hotline: 1-800-4-A-CHILD (422-4453); TDD: 1-800-2-A-CHILD (222-4453)

* National Youth Crisis Hotline: 1-800-442-HOPE (4673)

* Elder Abuse Hotline: 1-800-252-8966

* Parent Hotline: 1-800-840-6537.

As a nurse, you play an essential role in screening for abuse by being on the lookout for the red flags of physical, sexual, or emotional abuse, as well as injuries sustained from deprivation or neglect. It isn't only your ethical and moral duty, but also your legal obligation to report abuse when you encounter a patient who has experienced this kind of injury.

The best approach when caring for a victim of abuse is to establish a trusting relationship; treat all immediate injuries; and record a clear, factual account of the case, including any patient narrative that explains the time, place, and nature of the conflict and participants in the conflict. After screening and documenting, it's just as important to refer your patient to the proper authorities and agencies where further help will be available. By being alert to this major global health problem, you can offer intervention for a problem that might otherwise go undetected.

A closer look at sexual assault

Sexual assault occurs every 6 minutes in the United States. Men, women, and children may be victims. The definition of rape is forced sexual acts, especially if these acts involve vaginal or anal penetration. Perpetrators and victims may be either male or female. Rape trauma syndrome is the emotional reaction to a sexual assault and may consist of shock, sleep disturbances, nightmares, flashbacks, anxiety, anger, mood swings, and depression. It's important and helpful for survivors to discuss the experience and obtain professional counseling. Rape crisis centers offer support and education and help people who've been sexually assaulted through the subsequent police investigation and courtroom experience.

Screening for abuse, rape, and violence should be part of routine assessment because patients often don't report or seek treatment for assault. Often, the assailant is a partner or date. The manner in which the patient is received and treated in the ED is important to his or her future psychological well-being. Crisis intervention should begin when the patient enters the healthcare facility.

Most hospitals have a written protocol that addresses the patient's physical and emotional needs, as well as collection of forensic evidence. In many states, the emergency nurse has the opportunity to become trained as a sexual assault nurse examiner. Preparing for this role requires specific training in forensic evidence collection, history taking, documentation, and ways to approach the patient and family. Sexual assault nurse examiners, ED staff, and gynecologists perform the painstaking collection of forensic evidence that's needed for criminal prosecution. Oral, anal, and genital tissues are examined for evidence of trauma, semen, or infection. Saliva, hair, and fingernail evidence is also collected. Cultures are obtained for sexually transmitted diseases, and postexposure prophylaxis is provided. Emergency contraception is explained and provided if requested and appropriate. Emotional counseling is provided, and follow-up treatment visits are arranged.

Source: Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:1620-1623,2550-2553.

The victim's rights and the nurse's legal obligations

As a nurse, you commit to the idea of nonmalfeasance-of not doing wrong. In addition to your ethical and moral responsibility, you have a legal obligation to report abuse, especially mistreatment of children and other vulnerable groups. Federal and state laws require healthcare professionals to report suspected abuse of children, the elderly, and physically or mentally compromised individuals. However, laws that require the reporting of intimate partner abuse vary from state to state.

The Child Abuse Prevention and Treatment Act of 1974 gives support to states on issues related to prevention and treatment of child abuse and neglect. This law has been amended several times; it was most recently reauthorized under The Keeping of Children and Families Safe Act of 2003. The federal Violence Against Women Act, originally signed into law in 1994 and amended in 1996, establishes domestic violence as a national crime. These federal laws define child abuse and neglect, intimate partner violence, perpetrator penalties, and victims' rights. It's important to familiarize yourself with the reporting laws in your state and the procedures set forth by your institution for reporting abuse.

Assessing for abuse, maltreatment, and neglect

The following questions may be helpful when assessing a patient for abuse, maltreatment, or neglect:

* I noticed that you have a number of bruises. Can you tell me how they happened? Has anyone hurt you?

* You seem frightened. Has anyone ever hurt you?

* Have you been hit, slapped, kicked, pushed, shoved, or otherwise physically hurt by someone within the last year?

* Sometimes patients tell me that they've been hurt by someone at home or at work. Could this be happening to you?

* Are you afraid of anyone at home or work, or of anyone with whom you come in contact?

* Has anyone forced you to engage in sexual activities within the last year?

* Has anyone prevented you from seeing friends or other people whom you wish to see?

* Have you signed any papers that you didn't understand or didn't wish to sign?

* Has anyone forced you to sign papers against your will?

* Has anyone failed to help you to take care of yourself when you needed help?

* Has anyone prevented you from using an assistive device (such as a wheelchair or walker) within the last year?

* Has anyone you depend on refused to help you take your medicine, bathe, groom, or eat within the last year?

Use the acronym SEE to help you remember what to do when you suspect that abuse may be the reason for a patient's injuries:

Screening. Screen for abuse by listening to the patient and looking carefully at all injuries.

Evidence gathering. Record the where, when, and who of the injury without making assumptions.

Effort: Make the effort to report your findings to the proper authorities and to direct the patient to the appropriate agencies.

On the web

These online resources may be helpful to your patients and their families:

Chan YC, Lam GLT, Cheng HCH. Community capacity building as a strategy of family violence prevention in a problem stricken community: a theoretical formulation. J Family Violence. 2009; 24(8):559-568.

Moylan CA, Herrenkohl TI, Sousa C, Tajima EA, Herrenkohl RC, Russo MJ. The effects of child abuse and exposure to domestic violence on adolescent internalizing and externalizing behavior problems. J Family Violence. 2010;25(1):53-63.

Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:1620-1623,2550-2553.

Tingberg B, Bredlov B, Ygge BM. Nurses' experience in clinical encounters with children experiencing abuse and their parents. J Clin Nurs. 2008;17(20):2718-2724.