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Was this injury caused by abuse? Check for signs
An intoxicated woman came by ambulance to St. Luke's Hospital in Cedar Rapids with cuts on her wrists, and she wouldn't tell ED nurses what happened.
"Her cuts were very deep and serious. The doctor was worried that she could have cut an artery in one or both of her wrists," says Holly Eastman, RN, BSN, CEN, SANE-A, an ED nurse who cared for the patient.
Would you assume this patient's injuries were self-inflicted? The patient had an initial negative domestic violence screen and denied that she had ever been hurt in the past. However, Eastman discovered that the woman had frequent previous ED visits with various vague complaints, sometimes involving minor physical injuries.
"I became more concerned that her injuries were the result of abuse, and therefore decided to complete a full abuse assessment," she recalls. "Upon asking more direct questions, she disclosed to me that her boyfriend had cut her wrists with a knife and threatened her saying, 'You'll never tell them what really happened. The doctors are going to think you did this to yourself.'"
The woman tearfully described physical, emotional, and psychological abuse that she'd endured for two years, which was progressively getting worse. "Fortunately, we were able to intervene and provide assistance before it was too late for this patient," says Eastman.
Even if your patient denies abuse, documents all physical injuries on your nursing assessment form, says Eastman. Also, she says, document any of these indicators of possible abuse: multiple injuries, injuries/ bruising in multiple stages of healing, frequent ED visits with various complaints, and any injuries not consistent with the patient's history.
Victims of intimate partner violence have different patterns of facial injury than with trauma from other causes, according to a new study that reviewed six years of medical and dental records from women treated for facial trauma at the University of Kentucky Medical Center in Lexington.1
Of the 326 women treated for facial trauma, 45 patients were identified as assault victims. The study found that women who are injured by an intimate partner tend to suffer from distinct types of upper facial injuries, such as brain injuries or breaks around the eye socket or cheekbones. Those injured from other causes, such as a car accident or fall, are more likely to suffer lower facial fractures, such as a broken jaw.
"The main unexpected finding was the number of injuries about the eyes. These by far were greater than the mandible," says study author Oneida Arosarena, MD, FACS, an associate professor of otolaryngology at Philadelphia-based Temple University's School of Medicine.
Even with directed questioning, women might not reveal the mechanism of injury, so you will need to consider other indicators, she says. These include a history of repeated falls or accidents, or bruises in different stages of healing. "A full body examination is important, as often the attacker will not hit a woman in the face," says Arosarena.
3 screening tips for possible abuse injuries
According to Holly Eastman, RN, BSN, CEN, SANE-A, an ED nurse at St. Luke's Hospital in Cedar Rapids, IA, every ED patient should be screened for domestic violence, regardless of age, gender, sexual preference, cultural beliefs, or economic status.
"It is often challenging to determine with certainty whether an injury was caused by abuse," she says.
Your patient might deny vehemently that the injury was caused by physical abuse, even though the injuries are highly suspicious, or might disclose abuse but refuse any assistance or referrals. "In any case, it is our job as emergency nurses to complete an abuse assessment and document any and all physical injuries, as well as screening for other types of abuse such as emotional, psychological, or sexual," says Eastman.
Here are three tips for screening:
• Talk to your patient alone.
According to Oneida Arosarena, MD, FACS, an associate professor of otolaryngology at Philadelphia-based Temple University's School of Medicine, interviewing your patient by herself is key. "They are more apt to be candid if away from their attacker or family or friends," she says.
• "Normalize" the screening process.
Eastman says, "Similar questions should be asked to every patient, just as we routinely ask about medications and allergies." She recommends telling patients, "Because violence is so common is our society, we've begun to ask about it routinely," or "I don't know if this is a problem for you, but many men and women are dealing with abusive relationships. Some are too afraid to bring it up themselves, so we've started asking about violence routinely."
• Follow up with direct questions.
Eastman says to ask patients the following:
— Do you feel safe at home?
— Do you feel controlled or isolated?
— Have you ever been afraid of anyone you've been in a relationship with?
— Have you ever been emotionally or physically abused by your partner or someone important to you?
— Have you ever been hit, kicked, or punched by someone close to you?
— Has your partner ever refused to practice safe sex?
— Has your partner ever forced you to have sex when you didn't want to?
— Are you in a relationship in which you have been hurt or threatened?
"Oftentimes, patients who deny abuse when initially screened may disclose abuse as these types of direct questions are asked," says Eastman.
Watch how the family of your patient communicates
When assessing a patient for possible abuse, Bari Lee Mattingly, RN, pediatric trauma nurse coordinator at the University of Kentucky Hospital in Lexington, suggests "looking at the family dynamics as a whole."
Consider these questions: Do other members of the family seem to be afraid of a particular member of the family? Is there someone that seems very argumentative? Do other members of the family have bruises? Does anyone seem unusually submissive to a certain family member?
If you suspect child abuse is occurring, Mattingly says to "document your findings thoroughly in the medical records, and report your suspicions to the appropriate social services agency in your area. Your actions may save your patient's life."