20.3 Abuse and Neglect Assessment

Intimate Partner Violence

Intimate partner violence, sexual assault, and rape have long-lasting effects on the people who experience them. Violence or abuse by a current or former spouse or dating partner is known as intimate partner violence. These crimes happen to both males and females and are often associated with substance use. A recent national survey found that 22 percent of women and 14 percent of men reported experiencing severe physical violence from an intimate partner in their lifetimes (U.S. Department of Health and Human Services, 2016). Intimate partner violence is a significant public health issue with many individual and societal costs. About 35 percent of females and more than 11 percent of males who have experienced intimate partner violence experience some form of physical injury related to the violence, and some deaths occur. About one in five homicide victims are killed by an intimate partner, and more than half of female homicide victims in the United States are killed by a current or former male intimate partner. Such abuse can cause ongoing psychological trauma for the person experiencing it (Mehr et al., 2023). A psychological trauma refers to a person’s emotional response to a distressing experience.

When assessing for intimate partner violence, the nurse asks the patient questions about exposure to abuse. However, a patient may not always feel they can be forthcoming and honest about abuse they may be experiencing. Shame, fear, and uncertainty can all affect a patient’s responses to the nurse’s screening questions about violence and abuse. Therefore, the nurse also observes the patient for possible signs, both physical (like bruises) and behavioral, that could indicate abuse.

Physical Abuse

The term physical abuse is described as the cruel and violent treatment of another person. Physical abuse is what many think of when hearing the word abuse or violence. Physical abuse can include hitting, slapping, kicking, punching, strangling, physically restraining a person against their will, reckless driving, invading someone’s physical space without their consent, or in any other way forcing them to feel unsafe (REACH Beyond Domestic Violence, 2023).

Assessing and screening people who have experienced sexual violence can be complicated. The nurse must be mindful that the evidence of violence might be visible or invisible. The nurse should see if any patterned injury is found, which is a form of physical abuse that leaves a patterned mark on the person. This type of injury can be caused by a weapon’s impact on the body or by contact with the body by a patterned surface. Random bruising, cuts and scrapes, welts, and other visible injuries can also occur. If the injuries are on easily seen parts of the body (face, arms), the nurse should be aware that the patient may attempt to conceal the injuries (makeup, long sleeves) or come up with an explanation (“I fell down the stairs”) that does not necessarily fit the pattern or severity of the injury.

There can also be psychological and behavioral signs of abuse that the nurse needs to be able to spot, including anxiety, fearfulness, hypervigilance, depression, low self-esteem, or submission (e.g., not making eye contact). The patient may also have vague, nonspecific symptoms (such as headaches) that may not have a clear physical cause and could be a manifestation of the extreme stress they are enduring in their environment.

If the abuser has accompanied the patient to their appointment and is in the room, the nurse should be alert to how this will affect the assessment process. Even if the nurse asks the partner to leave the room, the patient still may not feel safe enough to be honest with the nurse when questioned. The nurse’s observations and context from the patient’s medical record (such as frequent ER visits for injuries sustained due to “clumsiness” or accidents) can help them create a more complete picture of the patient’s risk for violence and abuse.

Sexual Violence

Forcing or manipulating someone into unwanted sexual activity without consent is known as sexual violence. Although sexual violence is a type of physical abuse, it also has psychological and emotional components. Sexual abuse can involve rape or other forced sexual acts, withholding sex, or using it as a weapon. Sexual relations have many emotional and cultural implications. Because of this, there are many ways it can be used for control and to gain power over another person. In the United States, marital rape was not illegal in all fifty states until 1993. This is significant because many people falsely assume that sexual relations are something they are entitled to (REACH Beyond Domestic Violence, 2023). People who have experienced sexual violence are prevalent in society. Nurses should be mindful of this in all patient interactions. For instance, one out of every six women has experienced attempted or completed rape (RAINN, 2024).

Assessing and screening people who have experienced sexual violence can be complicated. The nurse must be mindful that the evidence of violence might be visible or invisible. The nurse should assess for all components of sexual violence, from the physical to the emotional. Taking a careful history, being a keen observer of the patient’s current state, and using screening tools to identify abuse and risk of abuse are key aspects of doing an assessment for sexual violence (Table 20.11).

Psychological or Emotional Abuse

A verbal or nonverbal (nonphysical) behavior that controls, isolates, or inflicts anguish, mental pain, fear, or distress on a person is referred to as emotional abuse. Examples include humiliation or disrespect, verbal and nonverbal threats, harassment, constant monitoring, stalking, and geographic or interpersonal isolation (National Domestic Violence Hotline, 2021). Threats of violence are a form of emotional abuse, because they leave the person anxious, fearful, and dreading the day the abuser follows through on their threats.

When the nurse assesses for emotional abuse, it must be done with care because the patient is particularly vulnerable to the nurse’s tone and nonverbal behavior. It is critical that the nurse establish rapport with the patient to create a safe, open, nonjudgmental environment. The patient may struggle to trust the nurse and may be hesitant to answer even basic questions as part of the assessment. The nurse may be able to encourage disclosure by asking open questions and actively, empathetically listening when the patient does respond. A patient experiencing abuse may constantly seek approval and be overly apologetic, so the nurse’s demeanor should remain supportive and open.

Throughout the conversation, the nurse also needs to pay attention to the patient’s nonverbal cues and communication. For example, is the patient anxious, fidgeting, keeping their eye on the doorway? Are they unkempt or showing signs of stress? Are they showing signs of substance use? Have they lost or gained weight since their last appointment? Do they look as though they are not sleeping well? Are there signs of lacking self-care (e.g., body odor, unwashed hair)? The nurse can also question the patient about these factors directly—for example, asking about sleep, diet, and stressors.

If the patient does disclose potential abuse to the nurse, they may blame themselves and justify their partner’s behavior. Even if the nurse provides reassurance that the abuse is not the patient’s fault, they may not be receptive to it. In fact, the patient may attempt to “backpedal” or “take back” what they said if they fear there will be repercussions from the abuser, or if they have doubt because the abuser has consistently made them question whether the abuse is real.

Coercion/Coercive Tactics

A form of psychological and emotional abuse where control, manipulation, and oppression are strategically used by the abuser to maintain power and influence over someone else is called coercive control. To assess for coercion, the nurse must pay attention to the patient’s behavior with their partner compared to when they are alone. It is best if the nurse can assess the patient without their partner present. If the partner is present, the nurse must consider their behavior as well. For example, are they touching the patient in any way? Physical touch can be used to direct the patient to answer questions in a certain way. Does the patient look to their partner for direction at every question asked? They may be seeking approval or permission.

Risk factors include being a female between the ages of 18 to 29 with low income, low education, emotional or financial dependency, low self-esteem, and/or a history of being physically abused. Coercive control is ongoing and often entails manipulative strategies where the person is denied autonomy and a sense of self. Coercion is especially dangerous because the person may not realize they are being manipulated and controlled until their self-esteem and senses of autonomy and safety have unraveled completely (Psychology Today, 2022).

Financial Abuse

The illegal, unauthorized, or improper use of money, benefits, belongings, property, or assets for the benefit of someone other than the property owner is known as financial abuse. People of advanced age, people with disabilities, and other at-risk populations are at higher risk of financial abuse. People experiencing financial abuse often cannot acquire, spend, or maintain their own financial resources. Financial abuse can also be a coercive means of keeping someone in a relationship. People are often too afraid to leave because they cannot financially support themselves. Financial abuse is a form of exploitation, which means mistreating someone to benefit from their work or resources.

To assess the patient for financial abuse, the nurse can start with open-ended questions such as, “Do you have any concerns about managing your money?” or “Do you have stress related to paying bills or earning income?” that help establish the patient’s thoughts about their personal finances. Then, the nurse should get more detail about how involved the patient is with their finances, such as “Do you feel in control of how your money is used?” or “Do you know how your money is used?”

As the nurse is gathering information, they should observe the patient’s demeanor and responses throughout the conversation. Do they appear anxious and confused when discussing their financial situation? Do any of their answers fail to “add up” when considering the patient’s employment and lifestyle? Do they seem to be unaware of key aspects of their financial well-being, such as how much debt they have or whether they have a savings account?

Patients who struggle to understand their money due to financial illiteracy and are dependent on a partner to “handle the money” in the relationship are not necessarily experiencing financial abuse. However, the assessment process helps the nurse differentiate between a reliance or arrangement that is beneficial from one that is exploitative.

Child Abuse

All fifty states and the District of Columbia have laws mandating that certain professionals and institutions refer suspected mistreatment, abuse, or neglect to a Child Protective Services (CPS) agency. Each state defines child abuse and neglect based on federal legislation, which defines child abuse and neglect as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act, which presents an imminent risk of serious harm” (U.S. Department of Health and Human Services, 2023b).

While all states in the United States have mandatory reporting laws, states do vary in terms of scope. For example, in New York, a nurse who doubts the explanation for a child’s injury would have reasonable cause to suspect child abuse and would therefore be required to report it. Some states include specific time frames within which the report must be made—Connecticut, for example, stipulates the report must be made within twelve hours of when the nurse first suspects that abuse has occurred.

To assess a child for abuse, the nurse needs to consider the patient’s history, current presentation, and any relevant risk factors. There are screening tools available to the nurse that have been adapted for use in children. The nurse needs to consider the individual child’s needs, the clinical setting, and the timing of the assessment when selecting which tool to use.

In addition to the questions asked by screeners that can help identify abuse, the nurse must be aware of the signs of possible abuse when observing the patient. The nurse looks for similar clues in appearance, demeanor, and behavior that they would check for in an older patient. However, the child’s age will determine how the nurse conducts the assessment. A nonverbal child will primarily need to be observed and history gathered from the record and caregivers. The nurse notes any concerning findings on the physical exam, such as injuries, as well as any developmental or emotional findings (such as delays). Children who are old enough to converse can be asked simple questions about what they do at home during the day and the people who live in their house with them. For example, you can ask the child to tell what happens at bedtime and bath time, and have them describe their daily interactions with the other people in their household. The nurse can also directly ask a child whether they feel hurt, sick, hungry, or scared. Older children may be able to answer more complex questions, such as discussing how punishments are handled at home, what happens when there are disagreements or fights, and whether they are worried about their safety or the safety of someone else (a sibling or parent). An older child can also be specifically asked if anyone has ever touched them in a way that made them uncomfortable or hurt them.

The nurse needs to notice the dynamic between a child and caregiver. While any young child who has had few experiences with healthcare providers may look to a caregiver often for guidance on how to act or what to say in the clinical setting, this can also represent a controlling, potentially abusive dynamic between the child and adult. The nurse needs to look for other indicators—such as bruising, signs of neglect, many ER visits for accidental injuries, or somatic complaints of vague, nonspecific symptoms such as stomachaches—to get a more complete picture of the child’s experiences.

The abuser may not be the caregiver that brings a child to the appointment. If the abuser has brought the child in, the nurse has a clear opportunity to observe the dynamic. If the other parent has brought the child in, the nurse should be aware that the parent, too, may be abused as well. When speaking to the caregiver, the nurse should observe them for signs of domestic violence or other forms of abuse that could also be affecting the child.

Neglect

In cases of child neglect, a caregiver fails, refuses, or is unable to provide the necessary care, food, clothing, or medical or dental care for reasons other than poverty. Neglect seriously endangers the physical, mental, or emotional health of the child. Signs of child neglect include the following:

• having poor hygiene or body odor
• being inappropriately dressed for the weather
• needing medical or dental care
• being left alone unsupervised for long periods
• appearing malnourished
• being constantly hungry, or begging for or stealing food
• exhibiting extreme willingness to please
• being frequently absent from school
• arriving early and staying late at school, play areas, or other people’s homes

Adolescent Relationship Violence

Violence in adolescent relationships is growing in prevalence. In the United States, about 19 percent of teens report being physically, emotionally, or sexually abused by someone they’re dating (Abrams, 2023). Harassing someone with unwanted obsessive attention, also known as stalking, is a common form of abuse seen in teen relationships.

The nurse can use screening tools to assess teens for current dating violence as well as their risk for experiencing it in the future. Adolescents can be asked direct questions about their relationships, including whether any person they have dated has ever hurt or abused them. As with other people who have experienced abuse or are currently being abused, a teen patient may not speak up out of fear or may try to cover up the abuse. The nurse also needs to use their observation of the patient during the encounter and the patient’s history to get a proper assessment. Other risk factors in a teen’s life, such as experiencing abuse at home, poverty, and substance use, also need to be taken into account.

Education is one of the most effective ways of combatting violence in adolescent relationships. The Centers for Disease Control and Prevention (CDC) recommends interventions for families and communities who want to educate their youth on how to avoid violence in their relationships (Figure 20.4).

Figure 20.4 Educating teens is the most effective way of preventing adolescent relationship violence. (credit: Centers for Disease Control and Prevention, Public Domain)

Elder Abuse and Neglect

An intentional act or failure to act that causes or creates a risk of harm to an adult aged 60 or more is called elder abuse; this abuse is perpetrated by a caregiver or a person the elder trusts. As with other forms of abuse, elder abuse can be physical, sexual, emotional, or financial.

Elder neglect is the failure to meet an older adult’s basic needs, including food, water, shelter, clothing, hygiene, and access to medical care. Older adults are an at-risk population. Therefore, the nurse should continually evaluate these at-risk populations for signs of abuse and neglect.

Bullying in Schools

Using the imbalance of power, children and adolescents who bully others find a way to control or harm others in an aggressive and continual way. The power imbalance can stem from their physical strength, popularity, socioeconomic status, or access to private or possibly embarrassing information about the target of their bullying. Acts such as spreading rumors, purposely excluding a person from a group, physical aggression, and making threats can all be bullying strategies (Stopbullying.gov, 2023).

The nurse can directly ask a child or teen patient if they have experienced bullying, but they should be aware that the patient may be reluctant to answer—particularly if they fear that speaking up will only make the situation worse. Bullying can also be more subtle than other forms of abuse, but that doesn’t mean it’s not pervasive and serious. The advent of technology, the internet, and social media mean that children can be targeted by bullies not just when they’re physically at school, but constantly. The ability of bullying to spread beyond the classroom and playground has also intensified as more students have become technologically connected.

Caregivers can also provide insight into a child’s behaviors, particularly if they have noticed changes that seem related to school. For example, does their child frequently say they feel sick or try to find ways to avoid going to school? Have their grades dropped? Do they no longer hang out with the same friend group or seem isolated?

The nurse should also consider whether the child or teen is in a high-risk group for being bullied—for example, do they have a mental or physical health condition? Do they identify as LGBTQIA+? Are they from a family with low income?

Workplace Violence

Workplace violence includes any act or threats of physical violence, intimidation, harassment, or other threatening behavior happening on the job. Workplace violence comprises verbal or physical abuse and even homicide. According to a recent Bureau of Labor Statistics Census study, workplace violence is currently the third-leading cause of fatal occupational injuries in the United States. Research has identified factors that could increase the risk of workplace violence for some workers on some job sites. Some of these risk factors include working where alcohol is served, working alone, working in law enforcement, and working as a healthcare professional (U.S. Department of Labor, 2022).

The nurse may choose to assess the patient for workplace violence risk when talking about employment. For example, the nurse can talk to the patient about what they do for work and ask them if there are specific stressors or safety concerns related to their occupation. Part of this can be asking about any problems with coworkers, managers, and other employees that could point toward workplace violence.

Risk of Behavioral Issues

People who have experienced abuse are at a higher risk of suffering negative short- or long-term effects as they grapple with what has happened to them. Even if a patient does not currently present with signs or risk factors, the nurse needs to consider the patient’s history. Past abuse and trauma may affect the patient in the present assessment.

Behavioral issues are prevalent among people who have experienced violence and abuse, and symptoms of depression, anxiety, insecurity, poor anger management, poor social skills, manipulative behavior, impulsiveness, pathological lying, and a lack of empathy are common.

Risk of Mental Issues

The psychological impact on people who have experienced abuse can be extensive. Nurses often have opportunities to evaluate people with serious mental illness who been abused or perpetrated abuse on others. Studies show clear evidence that people who have experienced violence are at a higher risk for anxiety, depression, and suicidal ideation (Health.gov, 2024).

Future Risk of Violent Perpetration

During assessment, the nurse should be aware that a patient who has experienced abuse may have the potential to become an abuser themselves. While they need to assess the patient for signs that they are experiencing abuse, there could also be signs of the patient abusing someone else in turn. For example, a spouse being abused by a partner may become abusive toward their child.

A strong relationship exists between victimization and offending, also known as the victim-offender overlap. While most crime victims do not become offenders, sadly, most offenders have been victims. The National Crime Victimization Survey (NCVS) revealed their findings: Americans experienced 5.4 million violent victimizations. Additionally, children are at a higher risk of victimization than adults are. Sixty-one percent of American minors (under age 17) were exposed to violence in the past year, and 39 percent of children and caregivers reported multiple victimizations (DeLong & Reichert, 2019).

Future Risk of Victimization

If a patient has been abused in the past, the nurse needs to assess their risk for repeated victimization—even if the patient is not currently experiencing abuse. Having been abused in the past places a patient at higher risk for future abuse.

While there are numerous crime prevention programs throughout the United States, many of these programs are utilized by the people who are least likely to be victimized. Most people do not become crime victims, but those who have been victimized face the highest risk of being victimized again. Previous victimization is the single best predictor of future victimization. Repeat victimization is not only predictable but in most cases, repeat victimization occurs within a week of the previous victimization. Some repeat victimization occurs within twenty-four hours of the first. Repeat victimization is prevalent, and it accounts for a large percentage of all crime.

An international victims’ survey reports that 31 percent of sexual assault victims experienced repeat victimization; 56 percent of simple assault victims experienced repeat victimization, and 50 percent of robbery victims experienced repeat victimization (Oudekerk & Truman, 2017).

Future Health Risks

Multiple studies show that people who have experienced violent crime, especially those in the Black or Hispanic populations, are more likely to have certain health risks, including obesity. The correlation between crime victims and obesity is much higher in neighborhoods that experience high rates of violence. Research has also shown that as violent crime rates rise in a neighborhood, the rates of obesity also rise (Stolzenberg & Flexon, 2019).

Focused Assessment for Violence of General Population

A focused assessment is a detailed nursing assessment focusing on one body system. When performing a full assessment, nurses should include a psychosocial assessment that includes screening for abuse and neglect. Further assessment may be warranted if the patient has specific risk factors that increase their risk for abuse or neglect. Some signs and symptoms of abuse may be obvious, such as a young woman with a black eye. Others may require more critical thinking. Examples include a listless child, a depressed woman having an anxiety attack, or an older adult whose clothes are tattered. These situations require that the nurse apply their critical thinking skills to determine if the patient may or may not be a victim of abuse; it is important to assess, not assume.

Focused Assessment for Violence of At-Risk Populations

An at-risk population is a group of individuals at increased risk for health problems and health disparities. Examples of at-risk populations are the following:

• the very young and the very old
• individuals with chronic illnesses, disabilities, or communication barriers
• veterans
• racial and ethnic minorities
• individuals who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQIA+)
• victims of human trafficking or sexual violence
• individuals who are incarcerated and their family members
• rural Americans
• migrant workers
• individuals with chronic mental health disorders
• individuals without homes

These individuals typically have less access to needed health services, resulting in significant disparities in life expectancy, morbidity, and mortality. They are also more likely to have one or more chronic physical and mental health illnesses. Advancing health equity for all members of society is one central goal of public health. Health equity, as defined by the U.S. Department of Health and Human Services, is the “attainment of the highest level of health for all people” and “achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequities, historical and contemporary injustices, and the elimination of health and healthcare disparities” (Health.gov, 2024).

Nurses should be vigilant in assessing these at-risk populations for abuse and neglect. Many people in a relationship with a person who is abusive are too afraid of the repercussions of coming forward, but the nurse can be an ally by providing a safe, nonjudgmental space in which patients can reach out for help. In many relationships with a person who is abusive, the abuse gets worse as time goes on. Standard practice requires focused assessment, screening, and patient teaching in these situations. A nurse is a mandatory reporter, meaning if they witness abuse or know of an abusive situation involving children, older adults, people with disabilities, or anyone experiencing sexual abuse, they must report the abuse or suspected abuse to the authorities. The laws vary by state, so check the laws in your state or municipality.

Special Nurse Credentialing: Forensic Nurse Examiners

A sexual assault nurse examiner, or SANE nurse, is a registered nurse or advanced practice nurse specializing in providing health care to people who have experienced sexual assault. SANE nurses are sometimes called forensic nurse examiners. SANE nurses collect forensic evidence, test or treat sexually transmitted infections and HIV, handle concerns about pregnancy, and assist in finding local sexual assault advocacy. SANE nurses can also testify as fact or expert witnesses in a criminal or civil trial (Office of Justice Programs, 2020). SANE nurses typically work in the emergency department (ED). When a person who has experienced sexual assault arrives at the ED, the SANE nurse takes a complete history and a history of the assault, knowing the important legal considerations involved.

Accurately Documenting Sustained Violence

Documentation of sustained violence is very important, especially if the person hopes to pursue a legal protection order. When there is an established pattern of abuse, recurrent and historical abuse, documentation of the history of that abuse is vital in painting a clear picture of the patient’s experience. While nursing documentation helps paint a picture of the victim’s experience, asking the victim to keep a personal log of incidents will help tell the whole story. The victim’s log should contain the following information:

• date of incident
• what the abuser did to them
• time of incident
• what the abuser said to them
• length of time the incident lasted
• how they felt as a result of the incident
• location of incident
• list of witnesses
• name of the abuser
• any other helpful information, such as photos or medical records

In nursing, there is a science to documenting an assessment of abuse in a way that is objective and paints a clear picture of what is happening to the patient. Follow these guidelines when charting signs of potential abuse (Lentz, 2011):

1. Be objective when documenting injuries that could have been caused by domestic violence.
2. Use quotation marks to denote the patient’s words or phrases, such as, Patient states, “[patient exact words here]” or Patient reports, “[patient exact words here]” to quote the patient directly.
3. Avoid speaking in legalese. The nurse’s documentation should reflect objective and subjective information but avoid legal jargon (such as using words like alleged.)
4. Only identify the person who injured the patient by placing quotations around who the patient names, or use the phrase as stated by patient.
5. Avoid writing down any personal conclusions about the situation, such as, "Patient is a battered woman."
6. Do not use the term domestic violence or anything similar to describe the patient’s diagnosis.
7. The nurse should follow their own observations of the patient’s demeanor and overall appearance.
8. Record the time of day the patient was examined and, if possible, indicate how much time has passed since the incident.
9. Write legibly or utilize a computer when charting.
10. Follow the facility’s policies and procedures and local laws to report any child, elder, or sexual abuse, or abuse to any at-risk person.