Guidelines 2016 – Assessing Victims of Abuse and Violence
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
Abuse and/or violence in a relationship is said to occur when one person physically, sexually, verbally, and/or emotionally abuses or economically abuses or controls another person and/or destroys the property of the person. experiencing fear for one’s person in a relationship is characteristic of an abusive situation, regardless of whether there is physical violence. fearing physical harm is enough to consider the relationship abusive. Power or control by one person over another in a relationship can constitute abuse; power and control in a relationship are hallmarks of abuse. constant degradation damages ego, self-esteem, and confidence. dating violence affects an estimated one in five adolescents, and domestic violence affects one in four to one in 10 women. Partner violence and control may also negatively affect obstetrical and reproductive health. specifically, controlling and coer- cive relationships have been documented to interfere with a woman’s ability to use contraception and condoms as she may desire.
II. HISTORY
consider each woman in any setting as abused until proven otherwise.
A. What the patient may present with
1. description of abuse or violence in the relationship
2. unexplained symptoms or injuries such as bruises or fractures inconsistent with any disease pathology
3. numerous psychosomatic complaints with no physical evidence
4. Vague physical complaints
5. Woman’s partner gives history and answers questions directed toward the woman
6. delay between presenting injury or problem and seeking care
7. Woman seems embarrassed or evasive in giving history
8. Woman seems fearful, withdrawn; does not name friends or family members as resources
9. inability to negotiate condom use in her sexual relationship and repetitive contraceptive method changes
b. Additional information to be considered (see questions on the Abuse Assessment Screen and the Danger Assessment in Appendices B and C, respectively)
1. Psychiatric assesment and alcohol and/or drug abuse by patient and/or partner
2. suicide gestures or attempts—suicidal ideation
3. report of many accidents in medical record, repeated visits to emergency department
4. Any gynecologic or gastrointestinal complaints
5. level of anxiety the woman demonstrates over the visit or the physical exam
III. PHYSICAL EXAMINATION
A. unexplained bruises; whiplike injuries consistent with shaking; erythematous areas consistent with slapping; lacerations, burn marks, fractures, and/or multiple injuries in various stages of healing
b. injuries on body hidden by clothing and injuries inconsistent with common accidents, such as on the genitals, breasts, chest, head, face, and abdomen
c. injuries at the back of arms consistent with a defensive posture
d. evidence of sexual abuse, such as lacerations on breasts, labia, urethra, perineum, and anal area
e. Healed fractures or scars
f. fractures inconsistent with story of accident
G. Apprehensiveness during examination and injuries and other findings that are inappropriate to her story or inexplicable
H. Abuse can have no symptoms; could be a well woman without visible injuries
IV. LABORATORY EXAMINATION
A. As indicated by physical findings
b. may include x-rays for evidence of new, healing, or old fractures
V. INTERVIEWING THE WOMAN
A. Provide a safe place alone and private where partner/spouse/abuser cannot hear
b. Assure her of confidentiality and safety
c. Phrase questions in a nonthreatening way, conveying empathy, such as, “i noticed you have some bruises. can you tell me how they happened? Have you been hit by someone? Has anyone hurt you in any way? When was the last time you cried?” (see also questions on the Abuse Assessment Screen in Appendix B).
d. Assess for current danger and for emotional and/or physical injuries (see the Danger Assessment tool in Appendix C)
e. Assess for ability to make, and negotiate, her personal and safe reproductive health choices
VI. DOCUMENTING EVIDENCE
A. collect data from medical records and those of other health care providers.
b. record the most recent, as well as past, incidents.
c. record any witnesses to abuse.
d. Quote the woman’s statements of abuse objectively with “Patient states…”
e. Protect patient by avoiding subjective charting, using statements such as, “Allegedly abused” or “refuses exam.” these statements imply provider subjective suspicion or lack of patient cooperation; instead, use “Patient is unable to tolerate exam at this time.”
f. if the woman denies any abuse, record your assessment and suspicions for possible future use.
G. record any injuries or symptoms in detail about size, location, duration, onset, age, and pattern. make a body map and locate injuries
in as much detail as you can. indicate any evidence of sexual abuse or restraint marks on skin.
H. collect physical evidence of injuries and label after obtaining with the woman’s written permission to do so.
i. Photograph all evidence of injuries with the woman’s written permission.
VII. TREATMENT
A. Assure the woman that she is not alone.
b. Assure the woman of confidentiality and that only she can authorize the release of evidence to the police, the release of her records, and your verbal testimony.
c. Provide support that she does not deserve abuse and that no person should perpetrate any kind of abuse or violence on her.
d. show her the documentation in her record and indicate that its purpose is to protect her.
e. Provide resources for her safety and for escape if she decides to do so; empower her to make her own plans and choices.
f. teach her about the patterns of violence and the laws in your state concerning abuse and violence in relationships; have copies of the state laws available.
G. if she chooses to remain in the relationship, you can offer her emergency numbers of police, any domestic violence units or special forces, local emergency room(s), and shelters; help make a safety plan (money, car keys, important documents, where to go); for undocumented immigrant women who need counseling, give phone numbers of culturally sensitive programs.
VIII. REFERRALS/CONSULTATION
A. medical consultation as appropriate for treatment of injuries
b. Police, if woman chooses to file a complaint or police report
c. shelters, special services for women in abusive/violent relationships
d. mental health consultation if you believe the woman is suicidal or if the woman wishes to speak with a mental health clinician
e. substance abuse or alcohol abuse treatment programs as appropriate and desired by the woman
IX. FOLLOW-UP
A. Plan a return visit so the woman has another opportunity for con- tact with you. she may seem fine but may be degraded, depressed, afraid, or subjugated by a powerful partner, who may control finances or children’s money and welfare and may be occasionally rewarding and caring.
b. As appropriate for care of injuries, presenting concerns, contraceptive needs, treatment of sexually transmitted diseases, vaginitis, or gynecologic conditions
Appendix B’s Abuse Assessment Screen and Appendix C’s Danger Assessment may be photocopied or adapted for your patients.
See Bibliographies. Website: www.nnvawi.org