Assessing and Supporting Abuse Victims
Physically Assessing the Patient for Abuse
Abuse may be suspected if the patient appears withdrawn and passive, avoids eye contact, and cries easily. When asked how the injury occurred, the patient may hesitate or provide an explanation that seems false. Assess whether the patient's story of how he/she was injured matches the injury. If the patient has scattered bruises in various stages of healing, especially on the back of the arms or in the chest and abdomen, assess for defensive wounds.
If the patient complains of pelvic or rectal pain or other gynecological issues, assess for tears in the anal and vaginal area.
Patients suffering from drug overdose may also be domestic violence victims, particularly if the drugs in question are benzodiazepines, antidepressants, and/or narcotics.
Domestic violence victims will often seek medical attention for vague complaints such as chest pain, insomnia, fatigue, abdominal pain, chronic diarrhea, or nausea. Such complaints may be a silent way of seeking help.
Assessing the Patient Using Therapeutic Communication
Watch the victim's demeanor. He or she may appear nervous, uncomfortable, and anxious in the presence of their partner. (Perhaps they are recently divorced or separated.)
If the victim is accompanied by their partner, note if the potential abuser appears overbearing and does the majority of the talking for the victim. In this situation it is important for the nurse to tactfully excuse the partner from the room. One tactic might be to ask the possible victim for a urine sample and then following them to the bathroom to do an abuse screen and obtain a urine sample. (It is important to obtain the sample in order to decrease suspicion from possible abuser.)
Questions to Ask Victims
Take this opportunity to further assess the patient with questions. Remember the "Four W's":
- What happened?
- Who did this?
- Where did this happen?
- When did this happen?
Other questions or statements that are direct but not offensive or accusatory might be:
- You seem very anxious and nervous. Is everything all right at home?
- When I see injuries like this, I wonder if someone could have hurt you.
- Is there anything else that we haven't talked about that might be contributing to this condition?
Supportive Statements for the Victim
- I believe you and this is not your fault.
- No one deserves to be treated that way.
- I am glad you were able to tell me this.
Sometimes, having someone just listen without speaking can be very empowering for the victim.
What Not to Say to the Victim
- What could you have done to avoid the situation?
- Why did he hit you?
- Why do you stay with a person like that?
It is important for the nurse to be prepared for the fact that the victim may not admit to the abuse or try to seek help. It is important to document your suspicion in a very objective fashion. For instance, don't refer to the patient as having "choke marks on their neck." Instead, describe what you see as "reddened marks around the trachea and neck." It is also important to document all interventions you attempted. If the victim is harmed after leaving your facility, you and your employer may be held liable.
The Victim is Ready to Leave...Now What?
A large part of the nurse's role is preventing harm to others who may be involved in a dangerous situation. If the victim is ready to leave the abusive relationship it should be a priority to ensure their safety. It is important to determine the level of fear of the victim and what the victim thinks their immediate dangers are. A few questions to assess their situation might include:
- Are there are weapons in the house?
- Does the patient have a support system? Do they have family or friends who could provide a safe place of escape?
- Is the abuser or victim having any homicidal or suicidal thoughts?
- Are there children or other dependents living in the violent household?
Determine if the victim has already attempted to seek help. If the victim's case goes to trial it is important to have clear, concise documentation of abusive patterns. Have there been previous police reports or court hearings regarding the abuse that is occurring? Clearly document and photograph (if necessary) injuries that could be evidence for the prosecution. In most states, nurses are mandated to report abuse to the appropriate authorities.
Many facilities have a social work team that can help assist the victim plan an exit strategy for leaving their abusive situation. Immediate needs may include transporting the victim to a domestic violence shelter. In many communities this is a great safe place for the victim to live temporarily. Some even provide medical care, counseling, and job training. This usually includes the victim gathering all their important belongings prior to leaving the abuser: identification, legal documents, medications, sentimental items, etc.
Statistically, the most dangerous time for the victim is when he or she attempts to leave. Healthcare personnel and social work personnel need to proceed with caution when planning an exit strategy for the victim. The victim should not be told to leave without adequate planning and preparation.
If appropriate, give the patient your facility's domestic violence resource card or write contact numbers down on a small piece of paper that can be easily hidden. Other resources available to domestic abuse victims include:
National Domestic Violence Hotline
National Coalition Against Domestic Violence
National Resource Center on Domestic Violence