Conditions; perpetrator, vulnerable person, crisis
Acute: occurs immediately after assault, may last
couple of weeks
-disorganization in lifestyle, somatic symptoms
-expressed style: overt behavior (crying, sobbing;
smiling, laughing, joking; restlessness, agitation,
hysteria; volatility, anger; confusion, incoherence,
disorientation; tenseness)
-controlled style; covert behavior, ambiguous rxs
(confusion, incoherence, disorientation; masked
facies; calm, subdued appearance; shock, numbness,
confusion, disbelieving appearance; distractibility,
difficulty making decisions)
-somatic rx: physical symptoms- physical trauma
(bruises, soreness); skeletal muscle tension (HA,
sleep disturbances, grimaces, twitches); GI
symptoms (stomach pains, nausea, poor appetite,
diarrhea); GU symptoms (vaginal itching, vaginal
discharge, pain or discomfort)
-emotional rx: intense feelings- fear of physical
violence & death; denial; anxiety;; shock;
humiliation; fatigue; embarrassment; desire for
revenge; self-blame; lowered self-esteem; shame;
guilt; anger
Child Abuse Assessment: TRIADS
Type of abuse (physical, sexual, psychological)
Role of offender (intra- or extra-familial)
Intensity of abuse (age began, # of times, # of
offenders)
Autonomic response (numbness, depression,
defiance, somatic complaints)
Duration of abuse
Style of offender (spontaneous, repetitive,
patterned, ritualistic)
Long term reorg: occurs >2wks after:
-intrusive thoughts- anger, violence, flashbacks,
dreams, insomnia
-↑’d motor activity- moving, trips, changing phone
#, frequent visits to old friends
-↑’d emotional lability- intense anxiety, mood
swings, crying spells, depression
-fears & phobias- indoors/outdoors (if rape occurred
there), being alone, crowds, sexual encounters &
activities
Verbal techniques for de-escalation:
-respect for personal space
-interaction should not sound threatening,
accusatory or challenging
-pay attention to body language
-investment of time
-look for quiet place in view of staff
-nurse’s safety (jewelry, back up staff, don’t block
door, don’t confront w/ show of force)
Rape-trauma syndrome: compound rx- ally
symptoms of R-T syn in addition to reliance on
alcohol or other drugs
Violence
Neurobiology: higher incidence w/ partial complex
seizures; ↑’d norepi & dopamine assoc w/ violence
& aggression; ↓’d serotonin w/ impulsivity;
episodic dyscontrol tx’d anticonvulsants & antipsychotics; ♂ tendency ↓’s w/ aging
Factors assoc w/ violence: alcoholism, criminality,
antisocial personality disorder
Types; physical, sexual, emotional, neglect,
economic maltreatment
Expressive- goal to cause injury to other; intense
emotional upheaval & poor impulse control;
partners share responsibility; aka mutual combat
model
Instrumental- purpose is control; roles of victim &
perpetrator clearly defined; used to exploit &
control; wife battering model
Sexual Assault
-depression & anxiety ↑’d in ♀ w/ marital rape;
correlation between sexual abuse as child & rape
Rape-Trauma Syndrome: Acute Phase & Long
term reorganization process
Rape-trauma syndrome: silent rx- complex stress
rx in which individual in unable to describe or
discuss the rape
-symptoms- abrupt changes in relationships;
nightmares; ↑’ing anxiety; marked changes in
sexual behavior; sudden onset of phobic rx; no
verbalization of occurrence of rape
Quick assessment: physical trauma; psychological
trauma; support system; level of anxiety;
community supports; encourage to tell story but do
not press
Rape survivor short term goals:
-begin to express emotional rxs & feelings before
leaving ED
-list psychological rxs possible during long term
reorg
-state intention to keep f/u appts
-anxiety level will lessen from severe to mod before
leaving ED
Nursing interventions: follow protocol; do not
leave client alone; be nonjudgmental; ensure
confidentiality; be empathetic; encourage to talk;
keep accurate records; engage support system if
client permits; emphasize client did right thing to
save life; arrange for support f/u
Gender identity & sexual disorder:
There is no universal “normal”. Normal or
satisfying is whatever gives pleasure & satisfaction
to those involved w/o threat or coercion or injury to
others
Biopsychosocial theories
Intrapersonal- problems w/ individual; arrested
psychosexual dev’t; performance anxiety; fear of
intimacy; negative self-concept
Behavioral- social learning; conditioned to respond;
contributing factors (poor communication skills,
concern w/ sexual performance)
Sociocultural- based on cultural values &
understanding; ethnocentrism; how people
communication about sexuality is culturally
determined
Biologic- neurologic basis for gender differences;
prenatal androgen level; adult levels of sex
hormones
Gender identity disorder- feel intense discomfort
in body & have intense desire to be other sex
-DSM IV dx criteria:
Paraphalias-strong OCD component
-fetishism- sex fantasy w/ nonliving objects; not
typical to culture; not a problem as long as not
harmful w/ consenting adults
-transvestic fetishism- men who dress in women’s
clothes (vice versa); most have normal sexual
relationships & children
-sexual sadism & masochism- highly stigmatized
in N.Am though ~ 10% participate; usually w/
willing partner
-exhibitionism- exposure to unwilling people;
usually immature ♂, introverted w/ difficulty
relating to adults esp ♀’s; wants surprise, not
interested in sex
-voyeurism- enjoy watching (peeping toms);
generally don’t want to participate
-frotteurism- gets pleasure from close physical
contact; rub against in elevators, buses, close spaces
-pedophilia- adult who is sexually aroused by &
engages in sexual activity w/ children; at least 16
yrs old & at least 5 yrs older than child; difficult to
tx; very hard to change; tx w/ chemical castration,
still repeat offenders
Eating disorders
Anorexia nervosa- wt 15% or more below min
requirements; view selves as fat even when
emaciated; much of self-id & success r/t body
image; rare in men; not hereditary, more
environmental; seen in sports that emphasize
thinness
-types: restricting type- limit calories; binge/purge
type
-comorbid w/ dysthymia, major depression;
correlation w/ cluster B’s; common sexual abuse
history
-risk assessment: client’s perception of problem;
eating habits; h/ dieting; methods used to achieve
control; value attachment; social fxn’ing; MSE
-subjective symptoms: terrified of gaining wt;
preoccupied w/ thoughts of food; see themselves as
fat; peculiar handling of food (cutting in sm bits,
pushing around plate); may develop rigorous
exercise regimen; self-induced vomiting, laxative,
diuretics; cognition so disturbed that self-worth
judged by wt
-objective symptoms- ammenorhea; dry yellow skin
w/ lanugo; recurrent fainting & cardiac
dysrythmias; bradycardia; cold extremities;
peripheral edema; muscle weakening; constipation;
hypotension
-dx lab results- T3 & T4 low; EEG abnormalities;
impaired renal fxn; dehydration; ↓’d bone density;
hypokalemia; pancytopenia
-care tips: empathize; do not blame; do not take
parental or authoritarian role; goal of tx wt gain
(what client fears most)
-interventions: assist w/ nutrition teaching; teach
parents about disorder, nutrition; schedule time
(reduces anxiety, provides control); meal planning;
-meds: SSRI’s for relapse prevention when
maintenance wt is reached; atypical antipsychotics
helpful in improving mood & ↓’ing obsessional
behaviors & resistance to wt gain
Bulimia nervosa- at or above min wt; purging type
or non-purging (fasting or excessive exercise); often
abuse substances that effect wt; diffuclty w/
impulsivity & compulsivity
-comorbid w/ depression can lead to suicide
attempts
-tx combination of therapy (CBT) & medsantidepressants (Fluoxetine)
-symptoms- tooth erosion, tooth decay; parotid
gland swelling; gastric dilation or rupture; calluses
or scars on hands (Russel’s sign); peripheral edema;
muscle weakening; hypokalemia; hyponatremia;
cardiomyopathy; ECG changes; salivary stones
-client may experience shame, guilt, out of control
feeling
Binge Eating disorder- pattern of overeating w/o
compensatory behaviors
-frequently a symptom of affective disorder
(depression)
-tx- SSRI’s (Zoloft) & CBT
Crisis- major stressor or life change; 3 typesmaturational, situation, adventitious
-maturational- time when adaptation & adjustment
to new responsibilities are necessary
-situational- event that poses threat or challenge to
an individual
-adventitious-disaster, not part of everyday life;
unplanned & accidental; natural (fire, flood),
national (war, terrorism, plane crash), crime of
violence (rape, murder, bombing in crowded area)
-community- effects entire community
-cultural- person experiences culture shock in
process of adapting to new culture
Four phases of crises:
-phase I- threat results in anxiety; client uses avail
coping skills to overcome
-phase II- ↑’d anxiety, ↓’d ability to cope; trial &
error attempts
-phase III- use of whatever means necessary to
bring anxiety under control; automatic relief
behaviors (withdrawal &flight);cognitive skills to
redefine crises & counseling are used
-phase IV- panic state; can result in depression or
psychosis
*want to resolve @ phase I; III & IV require
intervention
Factors affect coping: # of current stressors;
unresolved losses; comorbid psych or med
disorders; excessive fatigue or pain; environment
Hans Selye’s Stress Theory: persons have different
abilities to respond
-general adaptation syndrome- bodies rx to stress;
“fight or flight”
1.alarm rx; ↑ adrenaline, primal rx
2.resistance: remain until crisis resolves itself
3.exhaustion; body can no longer maintain
resistance
Nurses role in crises: psych assess (clients
perception, situational supports, coping skills); plan
for recovery; implement plan; eval outcome
-persons; equilibrium can be affected by: unrealistic
perceptions of event; inadequate situational support;
inadequate coping skills
-nurse problems- needing to be needed; unrealistic
goals for client; difficulty dealing / suicide;
difficulty terminating
Rules for nursing intervention: client is in charge &
able to make decisions; nurse pt relationship is a
partnership; client safety & anxiety reduction
guide initial intervention
Critical Incident Stress Debriefing (CISD)tertiary intervention for group that has experienced
crisis; 7-phase group meeting offers opportunity to
share thoughts & feelings;
-phases: introductory, fact, thought, reaction,
symptom, teaching, reentry
Complimentary therapies
Relaxation-progressive muscle relaxation (PMR);
countdown, guided imagery
Hypnosis- assistance of client to altered state of
consciousness, to create focused experience
Massage- stimulation of skin & underlying tissues
to ↑ circulation, induce relaxation response
Music therapy- specific types of music to effect
changes in behavior, emotions & physiology
Pet therapy- use of animals to provide affection &
attention as well as diversion
Anger control- teaching aimed at helping clients to
facilitate anger in an effective way; nurse attempts
to learn client’s triggers; provide healthy outlets
such as physical exercise or journaling