Mental Health Chapter 10

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Chapter 9

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the statement

C. Mat& each item in column 1l aescriMng it in c01utnn L

column r 1. Inabi&r to act or reaa in a n

appropriate manW?X 2. H a w positive and negative f&gs abnultaneousfy 3. ~mlanged of amme sadness affompaaied W $nikf&@ and social withdxawal 4,False idem that cannot be drangetl by logical atgment 5. Pe*ns'tbatominrfie absence of stimuEi 6. Imitating mo+3oqs of &em Z bvolmtaty repetition of words s p k w ?g ~thers 8. Made-up words to q r e s s a&ed thought6 9. Characferized by anxiety that is &poportionate r0 rhe strases pf d d y living

feew

a Delusion b. Dpl~ymic dimrder c lddadapdve behavior Echolalia e. Echopmda E mcinatim & ArdbMh W e t y disorder i Neologktn KI.

D. Briefly answer the foIIaving. I. Diffmtiate between mo&rate and severe d t y and ptlnic

a. List four gpea of schizophreaic disorders.

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eelu us ion and &@&t Suiddal Uients %en Suicide Suicidal Assessment Hamidda Rise m Cbild and Bdo1esm Vilence libw Artult W e Ctient Abuse Sstual Ahwe W d Abuse Elder Abase Incest

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Yioience and Djsturbed BehaVMr~

ZUQ Chapter 10

KEYrTERMS violence aggression

anger cimtlict resoluian

dnect message a&ve listening explore altematrVeS contract talking down therapeutic neutraliv impulse control macho image suicidal icleation

vi&ization sectmion restraint least-restrictivemode b&vimal flag@% contraband teen suicide homicide Duty to warn perpetrator rape shaken-babysyndrome incest

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VioXenWis an nrgent public health with homiade being the sceond lading sause of death in our society for peopIe between the ages offifleen and in New YO& homicide is the leading cause Of death among youths fifesen to m e e n yeam old Many people are of homicide and subsequently wperience posttraumatif strej3.sdismder, dep?mion, and anxiety disorda Enoughviolen~~ has o d m themfkpla'ce that a Vbience Workplace Awmeness Week was des,ignated fdthe month ofO&ber. Our s o w also has seen an increase in the numba of people eeposed to vioIenewho s-ed terrorism, deprivation, losses, a~saults,rape, md murder memw Paa of the broad spechm afMolence is met mqrderg4idde pacts. The Centers for Disease Control and Pmmtbn May 1k295) del3o.e @ i u h as the threatened or actual use of p b i d foEe or power against another p-a against oneseK or against a group or wmmunity-thatresdfs i n i n j ~death, , or deptlmtion IfiacIudm sonetal yiolence md deprivation ofequalay and justice The management of vioIm, both ph+I and psychologimI, is a neglected proklm in h e r i a Violence b seldom addressed in wbooks; you may see mkide listed but n a other topics such ;rs ho&cide, violence, bissaulc aggTesston, or agbtion, %The= violence is the behaviorr the DSM AWR assists the clinician Mith a differmtfal &gno&: substma i n t a s d d n , bipok &order lrnrrnic episod~~ disso datve ideatity disopde~~ antisbeial p ~ s &order, o ~impulse eontrel dkmder, anaar intermittent acp10srOe d i ~ o r d eWhen ~ a pawn lases control and the a@ression is dirested t& pmperty or people, gathq information &ma the client for a diagnfs of m t e m t explosive disorder. The= are also rampant a& acts viaimhrion [e& spouse Wd, and elder &a& rap&and in-) that are farms of perpetrated yiolence. Violent behavior among hospfa2ized medid and surgical client%Has been on the increaset hnd the incidence ofc16enb approachin$&Wieewith eoncealedvaeapabsisnmvalmownfkct We may expect the sick, su@ring cfent to became suicidal or depressed but are taken aback when the client rejects aur help or makes mmaaonabIedernands and bewmwi must& unruly, and a w . Additon(d$yy, manypsythkiafcdients have a dual diagnasis (e.g., p m noid sehieopBrrnia and substvlce ahus& whi& increases the rlsk of violent behavicm. mawgemsat of of~ruptivea~saultzve,or outirfmntmi behavior requires the demJopment of a m d knowledge b e and PQCtical intermtion skiUq as well as Pp-g in and the praezice of kchnipaflor the &en€with dfskbed behavio~:h a m ofviolent episoda befrrre theg ej3.ral;ite is d e hest w p t o i d m e

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CONSTRUCTIVE USE

. ANGER AND ALIENATION

DESTRUCTIVE USE

C W c t resolution js a.mrnp8 of @dthese f e w 8 of dkmtion and age^ Coaflim tesolutian f ~ n he a fana* dirm W @ @ e @&he ~iE@r%& w-, ~-TB& and ,aC O Rach of these area.$ canbe &fined ;~s f o M message: @ear d w k t mu m~ do not W a n t or f& T want y0u.b Stop ye&$ &s@a,a

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Vlolence and Dtsturbed Behavion

m of sudden change ladtion] in the normal behavior patterns afthe etiest These can include pa-, &es$ns8, wrinejng ofthe bids,kid&% M rm b g and withdrawal, fkuf-&&#, sh"houting, u n m t e d joldng at an&& -m.r rt%%~ing medimtiom, arguing r e M i to obey unit & scheddes, cmsing sarcasm and co-t demands On the pbpical change w e d by a chmnic h e . % 8nd the p r o w of therapeutic drug3 i n m e the inCiden'Z ofas618dtiVebebad019. m & c hlin syndrome, brain l&m,and membouc or cndoainr disorders a]ao wm m t i v e bebuim. One needs to aobservu:the &entLscadti011and drug,r P ! w bW~uskan agitaM a t mag ine d'w symptonm of toxic drug i d s ~ linternr tiom and a d & m syndrome CTable 10-21. R ~ c -& h th;rt caw@of disruptyvebehavim in&a&efar, m a t i o n , @ty t e r n , rejedion, fwIlggs of fnferiority, inrmsion of W~UII s p d l a & of privaq, and g k f Ommon behaViod d % ~ dm occur au eithex &&naive or off* acttons. A &ears fedibgs pffea~and helpie9s~essare motmated by a mse o f s e 1 E p s a tiah Offensioe action3 are a& meant to d e s w or p u d h .& It is possible that f& can result in auidde. S g r ~ a 9 m e , g , and physical agg~e~sion t~ s d o r o t h e is ~ S e e a On the,other hand, clients with p a w e behadom aremablem accept and aeJenowlew their feelings of anger, These Wfs win. usually withdraw. Dbturbed behavior moves stlong a mntinuym from verbad to nhwid violence to desmstion of seIf or othw. Thee is & a It26

irnportimt to be a

hierardp ofviola beha~om@me 10-11. An importantaspect afthe mntrol ofthe aq#r and alienation is personal W-awmenms, This self ammn prevent escalafing anger and &nation L m ta tnzst

your ownf e w and ,iuifpments. " ~ m pmkwn m viewpoint when you have a gut feelfng of une&inesS, look at the f~lbwhg feelihgs: fm, age$aaxiely, need tb set out, frustratio~helplessness, gui& aenial, M t h W Observe the envim e n d and factors that in&ence that environment =th ward to &en& watch for periods of &eased d t y Eollawedby periods of inarctivity on your units tie, during shifi repon or the idle time WOEbedtime whae limits be tested]. O b m e rhe tinit ozgaahtion ofmalea and &aales and the age -1e. On the p W M c uait,a h a will develop a Flient hierar&y ofgocia1status snd power influeace This be m w e d at unit ~ n n i t y m e t ~ s . W e a health professionals, can b a d m m m~ d d e b * patterns in the cilienis history and increase the insecuri@thatd u p I i m datiollshfpsoafside the h o s p i So one concept i r r y J w t to understandis thempolticneUhUty. Ther-neutr*i$ not a blank $Beennot a dep~&&~, mt ~ ~ ~ ~ ~ p o 1 1 ~fti isv ea n response w ; that is neutral and dwofd of needs, ?alumt and rnomliq It is predimtesr on is hdpfd to that particular cUhltrather than the prohi& As Maffonapsychlatricunitweneedror&ewourb&aorregW y and proour f&gs. We aeed to asr~mswhether the need is o m m&&. V% need m ask &e my @&ngs ofpowed-s related to my interaction with a dient? Do I fear ].om of e o m I ? Ibxd.13m need to remember that pc~yerl%ssnw is d i B d t to deal with m our culture b e m w we do not ~ a h uwhess e and ~ n e m h i l * - ---. J. An important chara&rWc o f d e nnit lmaieu irr the al,lowance of open dfalogue. Communication needs to be W W d and m a strained. In open dialogue, no to pi^ are oBlimits. There m always four dhctiom of wmm-ion: &t-sW ~taff.cIien4M - s t a f f , and ctientdmt

1

Violence and Disturb~dBehaviors

srdtddd ideation:Wdde is the arxiag out of rilge fdr tmvard someone else ;tnd directed toward the self; remember that suitide and hamkide ate &e upposae sides ofa win -tmsiatr in a relatiomhip: teasing in a hostile wiry,caustic hurnor, protowtivr and unpredictable behaviors B p"y&sis: wsess &stay of habcinations, delusions, ,ad Wught processes. Are the client thoughts l o g i d quenti& and relevant? m mpitiae ~ a i n n e i nasms tear* disodpafation,impjudgment, and conmtratfon dvictl~nnhmtk~n: assess for &dJaddt a b m nk?glecC ~ heen, or wi'hesing piabization

Sowtimes we model our client's bamuni& p a w father &an offering a .mew c o m m u n i . d &-A In our seEa$msmat we need tQ fuld oxit w k t pushed our bum& Is oneptze$ed by ho$tili~, pmfmigy, oufof~~ntroI papla or sed-&s? Do I -pond to the client in a m r n p e r i t i m m ~ ? Staff also need m i l t 4 support so that fheg an e d d y and tog&& work cm iseum md begin to deal with them IncBasbg ~ D U I bmwkdge %ofp~pSyopatb01~ is veq helpful, acl is tba d d o p ment oftreatment mtemmtlm. Member &at inappmprlate or negative,staffbebavion am lead to violeihm @gmc Z-22. Working with a violent && is less a n x i e l p - p r o v ~w b a a s p t ~ ~ t approach ?d to a8s-t is f~%wed.lhm a t h d n a i l m s m e n t of Holenee canbe most hdpful Collect data on pmen? m prtevioudi him o f v i o b Ikr you tent3 to be a What is the most violent a d that you haQe en$,aefBd in? task

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BECLUSION AND RESTRAINT Seclusion is the placement of a client, alone, in a spexitieally dwiglockable room with direat o b m t i o n amiIab1e fhrovgh a wiad m S e d i a n should be m i a d a reatment him^ before pmgmsshg to the ultimate act ofrestl.afrrt @the cJia& Rgmmbq that we are ;?.wags looking for the l e a s t - m emode that provides v@balichemiml intervention befm initiating &&on. Sedwion is innuend by unit pHosapFq, a& aazude, st& avdab* stafodem ratias [inmewed census, &x-ed m,gmec a1 milieu May1ho!diW& and the W 8 e*r, routine trainin$in the pteyention d managment of disturm behavioz The geal of sedwion is ta get the dent to settle dom, he coopmat&e, and usually shp. Serious considemdon must be gimn to the mcornw-@ cslmin$ ofthe mom w$usthe s m o q depdvation that may lead to increased menial detedw&on, T m kcPoxs s h ~ d d kept b ~ in mlrmd when considering sedusion: the diont's potential for harm TO &or others axd the udit amironmerit &at acceleratea&e dients agitation.&ch unit also n e e a c k iml indicator checkbt to iniW seduian and a ~eadinas-tct-xelm fbm-restmin~ guideline @igure 10-3). Earfi fwtyhas a policy and procedure that direefy addresses ~dusionand maaint po&fs. i9edmiaire&&1 lams afe aste man&% (St%!p u t indiWual state kw.1 The procedure might boIve callin$ a n w w far a sioleaf dim* and a number to dial Ce.g., 511) or m o w a mde T b k inkmatian n s d s fo be pest& where all M.haue m d v acws tn.it .At ti1~1e.s~ thi facility security officcm nccd to be c a l l a hmmer, the officen will only take part in the action when specifically request-

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Violence and Oisturhed 9e.haviors

154 Chapter 10 -

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Ifthe nucse mppms that a feen may be thinking of suicide,he or she should verify the suspicions. Not only is it proper to ask the d h t s about their intentions, but it is a responsibility Teem are mually wy willing to talliabout theiirintentiow.The nurse can say, %ave you had any thoughts of suiade?"or "Are you planning to hurt yourseiPIKBmt questioning shauld be done far all suicidal clients, nor j'ttst teenagers. The teenager contemplating suicide nee& to be placed in a prok t b e emrironme'nt CertaMy, if the musaPive m s o r is one fhat mn be &aged, it should be Wen care of immediate& If it cannot be changed,the client needs to be warshed wry carefdy. Sometimes a

s DespZmEg mma @ Prolonged depression

Change in eating or sleephg patterns W Problwi?h school grades for the adolescent U Loss of previous interest in soeial situations Uncharacterisric behavior such as n&le% dtiving or serious drug abuse A vacant st= As previously stated, adolescence,menopaus&and aging are dtid events in the life cycle. Duting these s t a p there are many stressots that may culminate in suicidal tendendes. 1mmediate1yprecipitatingfactors may ixichde loss of a loved one, rejection divorce, or fear of a physical or menu b r e a k d m These factors plus a sense of social isolation and nothingness can provoke a suicide w o r n .

Wm nosuicide conbct is used to prevent teens h m m & q scti.

dde attempts whLle treatment is in progress. Ado1escents are asked to promise in daing tbigt they Mtin not try ta harm themselves for a speci6c pziod of time. At the end of each period, the eonttatt is renewed. Even thou& teem may use the threat ofsuidde to gain afm60oa, it is more o h a q$for help A threat whahw expressed or inWt& shouldnever be ignored. If dients have the apportuntty,theywill pmbably attempt suicide and m y be succmsfd Nmm a n help suicidal teens by encowaging ac'tivitim that will improve &-image and by showing the dients &a%the nurse cares &oat them persvndy Teens need adult guidance in developing goals and support in adjusting to their changing S&QIE. They need to deveiop berter copin$ mechnbms and to lea^ pwb1einsoluin$ metfiods. Most basifany, thq need to know that someone b list* and M y hearing them, For more information on deprdon and suidde, see Chapters 11and 12. Assess the client for a suicidal plan of action, as a plan inmeages the risk ofmieide and need for cloaer Ob$e~ation. The nurse 1nuet connect with&e m i d d k t and attempt to build arelatlomhip. To prevent self-&e$trnctme actions, the nurse first o b s m the

Teen Suicide Teen suicide is an ever-increasing pb1em. The depressed adolesa t is of gmwin$ concen to the co~flm~dty It is important &at the client be identified as quickly as possible so that proper treatment can

be started Usaally teens m g of individual suicide or teen suicide pacts give one Or more of thefollowin$dues Tbey e x p w their inwtiom or feehgs to someone They withdraw to an a b n o m l dGrades usually drop drastimuy, and they pay le%s attention to appearances. Teens sometirnes overindulge inalcohol or drugs, and their drivinp; becomes more recke~s.It is suspectedthatmany deaths attributed to acddents are in re* suicides. W~his problem exists is not readily known but there are SWeral possible fact- that copfribute to the a d o l e s d s dedsion to end his or her life. The many stressors teens must &ee in their W i t i o n to adulthood are often ovenyhehning. They may be unable to cope with a hss such as rejeaon by a @]friend or boyfchd or the actual death of a Mend. They may fear that they cannot meet the He q e c tatiom that have been set by self or parents, or they may simpJy be lonely and b d , There seems to be an increase m teen suicide when Lhere is little or no adult guidance or support, where drugs and alcobal are abused) inteens who are pregnant or where a Eend or classmate has committed suicide. Ado1es~entsmost apt to take their own lhies feel that they have no purpose. They feel tky are of little value because they mntribute nothing worthwhile to toouq, Their selfesteem are low Bmuse they haveno control ovet theirlives,dq m o t dhange things.

client dose.

Suicidal Assessment Intent or p h B e i n g thoughts of suicide versus a spedfic I

plan flow, nredilun or htgh khaliy1 k6story: Assessment of previous attempts Chow mmy, types, kthality) and impulsivity Recent Iosse~ Drk@ngidmgabuse Depression EisToq of mental i L h s s hother htgb-tisk tinne fm suidde is when a person js coming ous of depression and now has the ento conceptutuae and carry out a

Vlokwce and Disturbed Behavion

sdcide plan. The st& of a medimlsmcal area in which suicidal clients are being cared for until they are medically stable for transfer to a psychiaMc setting need5 to recognize ways to safey alter a comman envimmlent Staff and client sefety is imponant when dents who have a potential i%r vhlence are being treated outside of a psychiatric unit If the dient is housed on a nonpsy&atric unit and is experienring any degree of suiddal ideation, high-risk snicide precantiom will immediately be initiated and a nursing staff member will be assjpsled to monitor the client on a one-toone basis [wia d 5 length] at all times. The client is to remain in his .ishex pajamas, resuicted to the unib and not a l l d the use of any metal or sharp obects. Imposed mtricti011~ are a restdcrion of the dent's rights; however, the restribion is justified because of the client's risk to self The rationale for t h e actions should be dearly explained to the client The nursing s t a f f member Wiped to the client will document the clienrs W c a l status erw i two horn in the medical recnd Assessment is frequmdy made for f i e lethality of the client's thoughts or plans. Time is then planned to sit with the client and enamage verbaIization This win acknowi%e the person's feeIing8 of helplessness and provide an oppoWty to discuss alknatives to suicide. Listening and reDback f e w expressed clemamtrates to the suicidal person that you an? a m of his or her pain and tvilling to stay and pmvide a d e envimnmea Suicide assessment induBes the level of lethality (low, moderate, high)?a distinct plan (client states, '? will take this ballpoint pen and stab mmelf in the chesfl, and gathering family histo'y of suicide attemp& and client's histarYof~vious sttpmpts. Look atthe history of impulsive actin$ out by this client and hiS or her current &l otrefsors.Are thought problems, such as ballucinatlons, delusions, or thonght broadcating present? Has the client been Rnalizing his or he-r life by giving things away? %%at are this p d a lar client's personal strength%resomces, and supgartsystems? Ifthe client appears m have no ento acr, do not decrease* ilance became the client remains at serious risk Place the client on Sukide Preaiqtions to ensure pmtectioh and safety. A A n t placed on high-risk precautions needs a staffmernbet on a one-toae basis. Tbls places the client under constant observi\tion, and the staff member stays dire* with the client h ~ o u attempts, s ihat is, suicidal geSNring orm&pulatiVe or serious suicidal attempts, are the bast predictors of a dient at risk. Research indicates that suicide o a s at a far $rater rate among alcoholics and other substance abusers thanit doe8 among the general population, When the client is being dis&Wed ffm the hospital to the wf~nunity?check the &en% mources for: -family, relattvos, dose

m

h d @ , p h ~ d q~ ,pmfessiad , thaapists, and agenda Does this ~ t h a P e ~ p ~ l e . t o ~ ~ e adereasupporf t e ~ ? I s s~atan? Are th.mp-~Siti&t h o @ &abom % the f b t U f t ok an ettitude that thaeisnopointinIivingP Wcide resear& is c ~ ~ ~ e nneeded r t y in c&&n tirw %we hdude genetkcfactors i n I c u h g the part that thgr play in gulcidg, and Metes in suicide in a m f t t t y of cultum-men, women,wmg, white, IBspani$,Asian, and African-American.

a,

Nursing care wan: : The Client with Fl~iririqlTendenpit Tim James, a Been-year-old, is a lanky, six-foot-tall highschool basketball playet. He studies hard and tries to get good gmd- because his father expects him to excel and his aunt is a teacher at the local high school. His peer group ~ s ehim s b w e he is so tall and has bright red hair. The m u m he is t a w this semester are challenging, and his grades are b e e ning to slip. His father is pufting pressure on him to study harder. In the last month his girlkiend, whom he had been dating for a year) decided she wanted to date other gup. Dm has become very quiet and started spending more time alone listening:to music in his room At the last basketban game, the score was tied with thutysecondF to go and he was at the faul lina He mimed both shuts. The otheP team got the ball and made a threepoint basket rightb&reth@. bmm sounded the end of the game Tiw blames himself for the tesm not twinning the game. His mather taIked ta his aunt about his recent behavior, and his aunt told the school counselor. When Tim and the counselm talked, hesaid. ? am so tall and ugh No girl will ever want to date me. I can never please my dad. I can't wen play b&etbalI good any more. Last night I started to take a whole bottle of aspirin but my mom knocked on the door and went& to talk to me, so I didn't take &a, The " counselor recommended Tim see the nurse practitioner on the p~ychiatricunit to do a suicide-rlsks c r e w ,After the initial intemiew and tesiing, the nurse practitioner recommended that Tim be admitted to the adolescent psychiztric unit Tim and his parents consented and Tim is -ed.

Violence and DFsturbed Behav~ors

&

NursFng outcomes 1. Tim will iden* three activities that he does well b y 2. Tim will state needs and feelings assertively -. 3. Tfm wiII list coping mechanisms he can u8e to mana$e stiessful sitrrafinns at discharge.

Nursing Interventions

I I

la Encourage Tim to iden* advities he does we&

Examine Trm"s personal belongings for forntmband.

Acknmledge Tim's thoughts of suicide.

tmm, ~ supportke

aS relarionship.

B

S

~

Reinfmce l'im's s&eya1uittion & attempts at loohng fdward to fume events,

.

Rationales la. By di-

amtipies he does welI, Tim can take pride in thew and build

i?&esteem.

L%m~~ing Tlm'a suicidal i d w encomagle~him to amees hit;feeIings and

By etabli~hin$trust and suppor~Tim win be cornf d e to share his

wm?Impss e l f d n a ation

~ E B Wand make p

I I

lb. Ackwwledge Tim's positive aspects, ZELEncourage Tim to keep a journal ofhis fa* and thoughts. 2b, Dewlop a relariomhq~of tnw with Tim so he feels f?ee to share his needs md feelings.

Zc Share ways Tm can enpress hslfassertively

@J

M far

tbe future>

7.d. Refer Tim to an ~~

ness dam

ZPm is qressing a After three days an the psyskhtric dake to live and has contracted vdth the chid specialist to share anythoughts and f~Iingsof s a d &

2e. Dlsnrss healthy ways l"lm can o o m d m t e and itlteract w i t h his friends. 3a. Encourage Tiin to list pa* rive wid negative methods

he has prwtously used to handle stress. 3b. Discuss healthy mahods Tlm an use to handle stregs,

Ib. Reinforcing Tim's

wts,

will build hi9 sdtedteem.

Za. Writiag; fedings a d

thought6 in a journal gives Tirn a nomhreaening way to vent 2b. An open, trusting rationship will help Tim &el more free to share his feelings.

2c By expressin%&elf more assertively, Tim will he able to verbaIize his needs and W q s . 2d. An assprrimess clasa will teach Tim new wap to comnunicare efFectk1y. de. Dlrmshealthy c o m u nicadon and inrera&re skills with Trm exposes him to newways to intera& with his peers. 3a. %ring p a t coping methods a s ~ i s f Tan s in identlfytlfy ing positive and negative coping mechanism. 3b. Discussing healthy methods to bandle stress gives Tim more options to ban ae stress effecti*

asp chapter 10 HOMICIDE Homicide b an act ofviolence d i e d toward anothw with an intent to kill. It is OWFespbnsibiI&yto focus attenwn nn the clienrs Q ~ M status a d look for i n w e d agitation, spedfic %, and their ~W of this vio1- act ag fh& O& ~ecowe.lissm5mmt must be made of % availability of both a weapon and a 6uim & open-ended approach *e clients are asked directly abom theis desperae though@is an &e* and sde w q to Jlandle client A hmb.ark case, Dr@@ as. R q p t s of thr, U m * qc&fomia, CalifamiaAppeI1al.e Cowt 141 Ca. 92 1197n bmnght to f o m the rights of fhe h e t versus the rights of the public A & ~CO-- t d a t e d to the pmider (a psy&W) an a w theat of violthe means of b m t o a reasoaablyidentifiable victim, 8 t t t - a ~a made to the psychiatri~tindicating imminent danger to t h a petson "d that physical Piolrslce w& be used to cause s&m p-onal

&at he is a good baskem p T g Fand bas an creative wr&zg He yeEeM high mks kqing a j o d to catnlog his fedin@, atbough nervto emnb a teen a~s&-M*~. he

Tim

@eenb.

NURS~JW DIA~~NOSIO to* related to m * ConrtPm ~ i mas , evidea~d by father's PresslfreOn tiaJ1$d&ther

,

b gthat he l o s t ~ game. ~ b ~ a&rn and ~ b m

@

Nursing OUtCOmag

~ursing~nte~enuons

to Ib*D b a s fa attend &mW ~ @ * i m .

xl' bwMenthfherdm ~ e s s i mwin show l'kn that &e i % d y eoncerneti abut ad

,

Wd=c%se, the dctb was murdered, and fhe f d y injurg. In b~oughtsnit ag~tfheps~chiatrist This court decision bra* aboat tin most stafesf the health pm*de?s Duty b W m In Sep-ber 1987, the state ofIndiana stated &at p ~ d ofm mental heaIth %mice6 have a duty to wam of a &mVs vivlmt behap iof. awiders include boapitab, m f e i n s t i t ~ mphpidang , psyChalagisgr,sarial workers, nurses, a d wuege ~ m d i n gcenters. efforts must be made to no* a p o h depmenf crr other law d m x n e n t agenq having jmisdiaion in fhe dimt's o r e W s place of ~esidence.A dvil commitment fo take custody of the client may need to be sought,The men.talheaithpr~~9sionatwho pro vide8 illfoxmation k t must be disclosed to -ply with fhis act and &mid liability maw state swum that proteet the dim& privacy and m n t i - d e o Ethe ~ ~Zctimis, a mihor, &e must be noti6ed Cumax hospital polid= and ~ S C ~ & W S need to reflect the @ions caf% a& an&mental h d t h papidm nmst research the lam af their parpicalar st-

--SE IN CHILD AND --JOL€SCENT VIOLENCE 1990i

*

f&

is

therapy and c o ~ c a ' f i o seB* n thoughts and fffibg96aefami. m- kit. i5 ~WW s@

than 4UOD teenagers m e Idled by h. M;my amate the nise in violme in this age category to low sodoew~omiCswi h@ PW*~ d m w *dab* bfgum,substance abuse, ~ Q o r aChild sbwe, ~ or d a caltme ~ ofviolmce. ~ ~ A pri-~ '*for youth & the Y- Z'OOg by the public health seryice is =dIIC-

k?@

Chapter 10

ti^ in assault injuries Cage twenv-threea d older), reduetian in phpical fighting (age fourteen to seventeen), ductionm weaponwartying

adolescents (age fourha to seventeen], and coordination of a a m prehensive violence-preventionprogram, Since violence is an interpep sond conflict a rmge of nonviolent options and responses must be available. School education strategies may include conflid resolution and mediation, crime pimention, law-related educatiibn, handgun violence education, life sk& tr-g, selfesteem development publie education, and media education A creatively designed program to resolve a&d may focus around less phpical violence in the classroom, 1esSname d i n g t faver verbal p u t - d ~more , &g behaviom, and haeasing m e s s to cooperate, understand, and look at the other poin6 of vim. Peer edw cation with stmigat talk about risk and flfearm safety comes have been implemented in some school programs.

ABUSE With increased media caverage, thae is awarenefs and emphasis on W 1 v and sodal vjolence. It is a compler social plohlm A violent ad has victim, a perpetr'tuc and frequently witnesses. There are W e and male perpetrators. hlultiple strcswrs contribute to violmu:

a

educated to identi@the abused person and utilize the Adult Abuse Pratocol LPr$ure 10-G).hviod;v,personnel may have &tanced themselves to avoid feeling vulnerable or overwhelmed with the severity of the inwe's or ~vaundste.g, mudeafion of an -1. The battered personhrictim m y describe his or her injuries as accidena seIf-idhded, or undefined. Victim's behavior8 frequently are evasive, fearful depres~edwith numbness, ratio~~alization, self-blame, and denial, If learned helpIessness has been part of his or her Iifetyle, there is a belief that the victim has no control over life's events. Usnany he or she has participated in a victimipeqxtmtor (abuser) relationship in whieh tension builds. The perpetrator has an explosion of rage and batters the victim A honeymoon period BIed with apologies and possibly gifts fokuus. Atl too soon, an a l t e o n occurs and the cycle of*lence begins over and over again

a

\/iblence and Disturbed Behavi~rs

j, Chapter 10

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Papeles Importarlte: partldas dB nactiniento hjos y .perso.nasque la commpanm n,rje@s de social security, medicald, ADWSI, mpoJas.'d&laoFdende protecclon en contra clde 6u-espwo.uaraUdy$u.famlla, documentos Ue.proLpl@z(d,&@m@p+de s ~ ~ q 0s e vlvienda, numeros de:wCtlerras banaripls~b'i6nsesA3ie. ahorros o cheques. Y cuelgirler o h tba cig.dcj:w;mentaclon que sea Ue importancia'&rasu familk DE NOTINCAR: S I I ~ es posible irate de no hacer byebadis de h r g e dustabcua cye que estas pueden ser menhe localzadesl. Advlerta (3 ~oinuniquesecon.les de sus hJos,a la corte. y a el Depattmemntode ~ y u de no dei nlngun ~ $ ~ @ ; & e a~ap~a-d~,~@ i i ~ ~ ~ 9e ~su. ~ ~I~ REWRDE

;

FIGURE 10-5 (Continuedl

Sexual Abuse

m w

Rape is a s a f a . l assault a forcible, degrading, a d is sexual mtermr$d by force, without coosent of the pa-. act 0 f ' ~ e ~ s iand o na &lent sexual &e.

cif-f@$a;b,me '1

~t

an

l/ialenc@and Disturbed Behaviors 1 -

Chapter 10

@dentis@suspect that thehormonal balance of the vichm is upset by the rape dus premting conceptidnl Rape kitsare available in emergency iroow.~.These kits contain materials far u ) proof ~ of the occurance ~ of a rape [such as sperm). The emergenq room st& must be careful about collecting and h a n w eaiden~e.This proof, such as dippings of %ernails and combings of pubic W,might be compared by the police to the slfin and hair samples of a pasible suspect A rape viciim winwant to take a shower or barhe, but the nofge shonld not permit this until all evidence ha8 bem collected It is e-ely important fhat the victim understand each prom dure and the r w o n for it No one other than the doctor, nnrse, and polke is allowed access to theevidence. AU slides and smears must be protected if there is a dctim advocate yro$ram: in tbe arm the staff should be contacted. Someonefrom the p r o p tvillu$u& come to the emergenoywom to provide ~ q p o rfor t thevictim Later, someone fmmtheprogramwillvlsitherforca~andrefd The nurse should be aware of the sodolopid aspects af rape The attacker i s usually a person with a strong hostilip toward women. He has the need to controlby sexually domiaaw women. Rape W give the man a sense of porn, and he feels that power will emu* potency, siricemanyrapists have d i f k d t y vuith action or e j a h t i m Pram fixwoman's point of view, rape @CtS a feeling of loss M the victtm 8he may develop a wide range of feelings-anggar 5 and anxiety. This i n t e r d i d rage can lead to depression The n W sbo*1Id anticipate the *ctimJs @ef mused by the degradation of @e & It is irupomi to also note that she may not receim loving suppoaive responses &om @ stn@ ac. p o r n in her life. W e hm bands or && may withdraw h m her. W~hersrqect the using a blaming statement such as, Thkgs like this just don't to good @rl.g:f~veafamily members may ask questiom SU& did gou walk alohein the darIr?Qulmdn"t you Uve ~ m 10d or 4li&%you %hi back" Tbe nurse neds to recognize that s i g d w t others mag!n#d urntilate &eir G:&gs a$i theps&- for a raexpbtion fbr@ violent behalaior against someone they lave.Rape v i c W of && o t h h urn suffer a tramtic C o d i q m y be neamary for t&ewoman, spouse, and l 0 ~goal- is for ~ the~WOW tQ retmp to indqadent in all phasw of her life

Cu1l.D ABUSB child abuse is d e e d as maItreatment of a child by the &Id's caretaker. It i9 not a nay p h e n o m e ~ nChiIdren from bkth through adolescence ha* been victims of physical and sexual mistreatment and neglecttbmughouthis~.Recentiy, natiod attention has focused on the shaken-baby syndrome, which OCW I I ~a wetaker violently shakes an &t or young bal?y. The severe head trauma causes retinal hemohhage, subdural hemato-, and cerebral edema witb w t & a l pressure leading to sePious bpairment or deaZh If nurses work wiih they will at some m e become inmlved with a child who has been abused In most states, nurses are part of the group %@red to report suspected caw of child abuse. iPb* ciln be suspected when the paren& story does not explain the injury or when the parents fi-equen* change doctors oi- clinics. Abuse also may be suspected when there are many uneyplained old injuries or when there are multiple scars in various sages of h e a l q An abused child may be , w s s h i e or apathetic and unresponsive lD-81. There may be an unredllstic fear of adults or an overatt a h e n t to the parents. In some immces, the chiId my become the caretaka of the w e n t Most abused childpen p t e c t their parents because of few of abandonment or reprid It is a nmels obhgatbn to rQort suspicio11~ to social sepvice agmde~.

& o ~ sirme or no dlstEsatb2llng separated m .Lfrlghten@ofparmts)

C!flUSUglJY :@iY.&f@SNJ:

Wean ao@:.ga,op~y

m parents

za'Chapter I t

Violence and Disturbed Behaviors

shaved or b w n against a wall became he &tubs a parent The ttiirteenyear-old maybe beaten and eonfrnedto home indefinitelybecause of a r&e infiactian The pdrent~myexpect complete obedieilce, which is impossible for the Meen-m-old. Abusing parents, like a l l dependent people, cannot handIe criticism weIl The person who is ~ W toghelp must be nonjudgmental and nonauthmttarian. The helper must develop a mting ielationship with the parent which maytake weeks or months, and mustalso supply the nurturing support the parent is lacking. The helper needs ta a h v the parent ~o be dependent while guiding the parent toward gwMtth and independence. Sin*. stress is a factor, the nurse needs to edwhere the parent is on Maslow's hierarchy of needs [see Chapter 3 Undastanding Self and Others>.Ifphysical d, such as food..shedter,and employmentare not being &t the parent shonld be refened for help in these areas. Marital or personal counseling bya psychologist or professional nurse C O U I ~ S ~ Omay I be needed. The parent may also benefit fmm assistance in budgeting, m a r k e w and child carer Growth and development ofthe normal chiId are often uncleat to -the abmia p m n t The selkoncept can be imp& by providing s u w experiences forthe p e t 9nd o f f a g reaIistic campliments. Parents Anonymous is a self-help p u p of abusing parents who have j a w together to help each other learn to handle stress and do problem solvtng, Homemaker home health aides and nohprofessionals trained to help abusing parents in their homes provide assistance and support Child abuse is a widespreaci and complex problem that requires a rnultidi6dplitlary approach. Nmses a play an important role bemuse they can represent a knotv1edge.ablebut nonauthoritarian figme to the parent

parents are not p & ~ t i ~T h e 'we ~h~ majorits" of to seriouT;ly hurt The @Q~C and 6 a$ emicatbnal EeveLss The parm,cmi?S fmm an amv mge busin$p m t has alow s e l t e c e p t aid p0cJ.r mpin$ abused as (HV 10-9).Re or she ~&pam&ng %WUsand 0 b pmnthas, -tic qectations of the Ehild dm to a a md, b&]acrp,e a,&& ,(~rn~h~ys n i m s of dfscipbe *aSt &miF B~or she is wali?d e ~ e n d e n t ~h ~e da sp~use istoo $ e p e n b n~ d , B e averageeabG&gp@mt F*to e &dies.'& a @ulG be DT she.iti po&*F ta o&m and M:m ofken lone. ~ e * ~ ~ a p t ~ b e a J & o f ~ ~ d i t l P ; . &abused& ~~~d*2~ anqor be ha do^ often as in M~~~~~dm* done mallchikbx.l t y p % ~ l d ~ of age are often [email protected]*~! w m ekh t$n te 8:d ,,& && m w e for and place adcM Kr&son the P w a @ %~btea~ but y ; if&nme is gpingto hdp p~?l%nt chil&ababustj, in$& child Ifabilsir is Yo s q r b ~ hkw n d he aE parentrambe helped &QS* parent m y use *use, as dbdpllfi~wp is ndt @ aMi:.@. ,-mg&+rd may be beaten b,&uSe ~ h ~ :m+jebm&beca~ d a ~ ~ she muldn~ @tqawtr+~fi"~~

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ELDER ABUSE

C

It is estimated that approximatelyo n e d o n elderly persons are mistreated. Most abuseoccms in the home byfamiIy members, but abuse also happens in institutions. Elderly persoas may be psychoIogidy. physicaIl~,and fIti&dally mistreated They may be abandoned, expIoited, ar neglected. Abuse does not have to result in fractures, malnu@iti~t4 Qrbdses. Not giving the elderly person g l a s ~ hearing q aides, or d e & ~ e~~ u l be d considered abuse. P;rilure to Bathe or shave a mident can be c~midesedneglect Speaking in a loud voice or dkrespe-y is,verbdabuse. Haleling,a resident too fidy.and causing bruising is are abusive whether or not they are intentional.

:--..

Chapter 10

Just as in child abuse, elders are more likely to be abused by someone who is frustrated, fatigued or over&eSsed. Abusm are often &ly themselves. They tend to have msdbtiC e~p~%tiions of the older personi$ abilifies. Por instance, a caregiver m y be unable to accept incontinence in the elderly parent The thstmtion the cmegkr feels is translated into humiliation for the elderly person and rough handling eaeh ttme the elder person is found wet Abused elders me v&bdmm frightened, or aggressive and may be unresponsipe, p a r t i d d y with strangers. They may complain of abuse, but u 6 d y tbqr do not IPney remain m e t because of a fear of retalatiian.The abused is most &en female and dependent The abuaer is vexy similar in personality to the child abuser-he or she has a lav selfancept poor coping 5Mlls, and u n r d h t i c expeWons; la& i n v n a l sldlls; and has a poor support system (seeChapta 8).

INCEST Incest is deftned as a sexual relationship between blood i-elaW. It ranbe either a forced or a consensualrelatiomhip. These &tionships may involve father ahd dallghter,mother and son, or brother and sisrer. This section will deal only wiih forced incest The sexual relationship may include foreplayiw&g Wing,mutual masturbation or intawme. T h i a ~ c a n b e a v e r y t W Z Wone t i ~f ~ y 0 ~ and adolescents. It may predispose them to sexual d d j u s m t or psychobgiml problems such as phobias and d e p m s k reactions. According to Briere (1989), p a s t i n w u s relationships have three phases reaction adaptation and m ~ iDuring d these pbases the victlm is going ta deal with intrusive (flashbacks, mghtmerq of the incest) and avoidant symptom (withdawal and disso&Itian?. Anxiety) depressioa and angw are the emotional effects. Impulsive hehaviom, - -- - tJst is, selfmutilation, drugidcoho1 abuse, h y p e m d activity or suicide, may ooccur. m th-v, ,t&evictims need to be reminded how far they haw -. come and h&much they have accomplished It must be realized fhat there is much nmbiig, emotionally and sexu*. B r i m fIM9) disa cusses an impaired self-derence (Where do Istart? Where does he or she stop?). The pitXim, who is now the suwivor, will have ditsdt91 with the consolation of selE thedo% the therapist must align with the smbor's strong, healthy parts. Understand two things when approa&ing the & a t : stay with reality and provide concrete infomWion Many ofthe survivois symp toms have sewed a purpose and provided him or her with a mom adapfiveway of dealing with their abuse The basie phdos~phyof th& treatment is respeb, positive regard and the as~Ufnpi0nof the victim'*

SUMMARY .

Violence in our moiety is rampant We must leam to understand our r01- in the pmtmton and magcment ofour&er~rS,violbehaviors and also om roles in the nurs$lg eare of the victims. The care pmder's own fear and angel must be a t w i t h appmpriate1y and personal safq issues explored. Violent assaultive behavior is a true emqency. A safesafe, s ~ * ; temaW appmach and learned and prastioed mmagemmt techniqaes will provide therapeutic inwmentions for the violent dients. If newsay, W wiIl bdve restraint Postwnferencks after a viclent episode allow time for the s m t o discuss their ox& safety n d s and [email protected] u r i n g t h e s ~ a n & ~t h~etp&& carsful and thorough doamentation must be followed Qlild abuse is gefinad as maltreatment of a ehnd and most often occurs by the child's caretaker. Children &all are abused, though the the young are uswdIy the most seriously injured. N w e s are re-d to r e p suspected mes of child abuse Ahwe canbe suspectedwhehthe p m t ' s story does not expW the injw or when parents kequantly change doctors or It may &O k suspected when +hereare many unexplained old injuries and whm there. aremultipie sears in various sages ofhding, m e b&mbr of an abused rhild m y range from agpmion to spa&$ The abused child usually protects the parent Abusing p e n t s wme &om all economic and educatiod levels. % m 6 seems to be an important factox The child tfiat is abused is often seen as Merent in appearauce or'behmior. Ifthenme is to help prevent rhild abuse, fie or she m w look beyond the injured child and assiat the pment kbuing pmmts need help in handling , learning new ways to discipline; gettng infofnxtloa on normal growth and d e w l o p m ~and providing child mre They rmry need pmfwional counseling to aid m personality growth Child abuse is a uuidesprd pmblean that a multidisciplinary approach.Health careprofessionah are mandated to report suspected child [and e l k ] abuse. [See individual state

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laws.) Famiy and sorial vioIence m cornpiex issues is our culture A$ healtb proIession& we need To deal with aur own beliefi and biases. Rape and in- are Wenlt areas for care ppoviders, and kn0ur1edgeabIetmpporthn: w e must be $men.

3. Whieh stafPbe?h;laior may in-

the poss~EAEtyofviolence? D A, negotfaw with a client P B,c o n t r a w with a client R Clababelingadbnt P D.actk&listenhgtoaeIian 4. C m c h v e uses of anger incIude all of the fobwing except 0 A, increaajng mcrtiv-s skills. P B. increasing feelings of isohtion. P C developing mmal undemanding. D D. increasing pemnal aleVe&qg. 5. A suicide attempt on the p& of a teenager is usually a Q A. meana of geWg attention. Q E. psychotic behavior. D C.resultofadam

P D. forhelp. 6. ?he paref~twho abuses a child should be 0 A, understood a d cmmseled. Q B. loeked away in j& 0 G admitted to a psyehiauic hospifal. D D. e n t o m ~ e d to give up custody of his or her dxild. 7. %hi& ofthe follaving is a major fwtor in child abuse? P d the parenfb econbmic leML P B, the pamat's age P C. stress c ~ u p l d w i t poor h coping &ills. P D. the number of children in the home. APPXX YOUR LEARNING B. M d t Q l e choice. Select the one best answec 1. A depressed, ~uicidalclient b admitted to thepsychiatric unit Which personal potsession should the n m e remove from the client? R A Thp elienfs wedding band D B. A cardboard nail 61e 0 C. A battery-operated CD player P D. A leather belt 2. The nurse adraLnistes PO medication to a client on suicide observation. Whith adion should o w M? 0 A, Perfom a mmth check to C B & ~ the medieation was swallowed D B.Tail the &eat the name and purpose of the medimtioa C. A$k the d h t ifhelshe 8TNaIlaved the medieation D D. Cheek the client% idenfEicatian bracelet

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eigw-two-year& widow is a$mittted With major dqfessian Sinee her h b m d died Wo years ago, she hzts not rwun~edher n& @tillactivities, Iost 23 p o d >apd stopped talcbg medMtion prescribed Eor her cardiac prob1 m .m c h action by tbe ame wouId be most impo-t? 0 A Weigh the client every morning after breakfast CI B. Record ultal signs q h , i n c l u w the ~pical heart rate. n C. Ask the c a i r n if she is having suicidal tho@bts. P D. Initiate a moderate epescise pmgram for the diem 4. A hospitalized client diagnosed with an aptisociaI pmonsliq &order c h r m a chair against the wall. The registered n m e Pays to the pmetical nurse, 'Tm gohag to Can a code and assemble the team io place tfiis &entin s~clrrsioa" W& response fy the praairal rime would be moat approprlte? r3 & M m athez cllenta: an the unit to safety and p q m k% with pladng the client inseclusion msis?the Q 8.?W the regkmed nmse, "I have an exdent relation-

?,I &I

Q C. Reassure the client that the rapist will be posecuted.

D. Allow the diere to eaprm5 her feelings and no*

victim

a68istance

C. Brie& answer the followjne. "

1. L & the three chief life streams that contribute to violent

behauiop.

3. List the three cornpments ctfa suici& asemsment

&~withthigclient Pdliltetotrytotdk himdoVM 0r& 0 C,Recorned to the registere4 nurse that the client

should be restraind rather thaq xcluded. 0 D.CaIl the pbysidan and get a telephone arder fm sd0$ion or restfaint 5. The nursing team diseuse3 a recent increase inviolent behapion on the awte psychiaWcunit Wkid OirC-* has

mast likely antributed tci this Bimtion? Q A. A: n w series of remeational therapy &ties is being oBered Q B. The rrnie w@ recently marpet& and repain& in mht colors. Q C. AU sMmembers regularly axtend the -unity meet-

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P ZE,The~wspa$membershaa,job&Thetbeinthe past w t k L 6. A twentyEve-yearaidvictim of date rape is broughtto tbR emagency d e p m e n t Dming the e d u a t i m the client ~TNsiS~mYfaultIwa~~t~eantomy~ead'~&is the nurse's be% response? O A. Ask fhk dient what methwds she used ro t q to =apt: fmm her boyhend to the 0 B. ihmediately locate a physidan who G l h t

4. List and briefly desmibe tke three phaam ofpos&exud abuse.

5. Describe the role of the menM health care provider in mmplwith the Titl:asoffDutyto aotn of a Glient's Vialmt

BeMor.

6. I.M five behavior$ that might be m i t e 4 by an abuxd eNI&

7. Lit stx charaaexistia of the abusiq p a n t