On completion of this course the student will understand the various types and definitions of abuse, the nurses’ role in the different forms of abuse, signs and symptoms to look for, and nursing obligations R/t Domestic Violence.


  1. The student will be able to verbalize the different types of abuse and their role in each type.
  2. The student will be able to ID S/S of abuse and have the knowledge on what their role is when abuse is present.
  3. Student will have the ability to follow through on behavior modifications and direct patient to needed treatment.
  4. Student will have knowledge of confidentiality and their obligations R/T.


Domestic violence: is a term that is used in many types of abuse, such as child abuse, elder abuse, spousal abuse, and even sibling abuse. Domestic violence is a major problem in the world, but on the home front it reaches epidemic proportions. It is estimated that one-fourth of all homicides in this country occur within a family situation, and one half of these are husband-wife killings..

Abuse: What a little word with so much meaning and so much pain hiding behind it. Mosby’s medical dictionary simply says; “To physically or verbally attack or injure."

Abused person: “An individual who has been harmed or mal-treated by another person or by a situation."

Elder Abuse: A reportable offense of physical, psychological, or material abuse, as well as violation of the rights of safety, security, and adequate health care of older adults.

Child Abuse: The physical, sexual, or emotional maltreatment of a child.

Spousal abuse: The physical, sexual, or emotional affliction of pain, mentally or physically from one's spouse.

Assault: American Heritage Dictionaries version: a violent verbal attack, or unlawful attempt or threat to injure another.

Battery: American Heritage Dictionaries version: The unlawful beating of a person.

We use to think of abuse or domestic violence as a physical issue. Things have changed for the better, we are now looking at all areas of abuse..

Physical Abuse : pushing, scratching, slapping, hitting, choking, holding biting, throwing. Being locked out of the house, driving recklessly when you are in the car, throwing objects at you, threatening to hurt you with a weapon, abandoning you in dangerous places, refusing to help you when you are pregnant, injured or sick.

Emotional Abuse : Ignoring your feelings, ridiculing your beliefs, withholding approval, threatening to take your children, telling you about their affairs, manipulating you with lies, threatening to leave you, taking car keys or money, keeping you from working or going to school, humiliating you in public or private, abusing your pets or children, calling you names, or driving your friends and family away. Also included in the category of emotional abuse is verbal abuse, Economic abuse, (control of all money by the abuser), social abuse (control of friends and all of relationships, phone calls, and going out of the home), and gestures such as threatening looks and facial expressions.

Sexual Abuse : insisting that you dress in an uncomfortable sexual way, calling you names like whore and bitch, forcing you to strip, forcing unwanted sex acts, withholding sex, criticizing you sexually, insisting on unwanted touching, insisting you should have sex with any man.

I am sure most people reading this will say “WOW I did not know that was abuse” and many of you have experienced some or many of these abuses in your life and possibly have done some of these things to other people. Many times emotional abuse can be much more damaging then a physical attack.

Statistics of Domestic Violence

Spousal Abuse

1.) There are almost 4 million reported incidents of domestic violence against women every year. Most of these are in the home.

2.) Women are 10 times more likely to be the victim then men. In 1991, more than 90 women were killed every week from domestic violence. Nine out of ten where murdered by men.

3.) Weapons are used in 30% of domestic violence cases.

4.) 15% to 25% of pregnant women are battered. 22-35% of women who visit the ER, are there for injuries related to on going abuse.

5.) Medical expenses from domestic violence total at least $3 to $5 billion a year. Businesses lose another 100 million in lost wages, sick leave, absenteeism and non-productivity.

Child Abuse:

1.) As violence against women becomes more severe and more frequent in the home, children experience a 300% increase in physical violence by the male batterer.

2.) 3.3 million children in the United States, between the ages of 3 and 17 years, are at risk to exposure to parental violence.

3.) Many parents minimize or deny the presence of their children while the spouse in being assaulted. Yet in interviews the children of battered women tell stories of what they have seen and heard; and can describe in detail, accounts of violent behavior that their parents did not even realize they saw.

4.) 62% of sons over the age of 14 were injured when they attempted to protect their mothers from attacks by an abusive male.

5.) Of children who witness their mothers being abused by their fathers, 40% suffer anxiety, 48% suffer depression, 53% act out with their parents, 60% act out with their siblings. These children suffer poor health, low self-esteem, poor impulse control, sleeping difficulties, and feelings of powerlessness. They are at risk for alcohol and drug abuse, sexual acting out, running away, isolation, loneliness, fear and suicide.

6.) More then 50% OD all child abductions result from domestic violence.

7.) Many fathers end up injuring the children while throwing furniture or other household items at the battered spouse. The youngest children sustain the most serious injuries, such as concussions and broken bones.

8.) Events can be witnessed in many ways, not just visually. Children hear their mother's screams and cries; the abuser's threats; sounds of fist hitting flesh, glass breaking, wood splintering, cursing and degrading language. Children also witness the consequences of the abuse after it has occurred, their mothers bruises and torn clothes, holes in the walls, broken furniture, and many tears. Children sense the tension in the house, and they too have to walk on egg shells waiting for the next explosion.

Elder Abuse:

1.) Approximately 1 out of every 25 elderly persons are victimized every year.

2.) Of those who experience elder abuse, 37% are neglected and 26% are physically abused.


Spousal Abuse:

Violence between partners may be triggered by many factors. Substance abuse is usually involved in the majority of spousal abuse. Stress, such as employment, or loss of employment; finical problems, jealousy, and pregnancy are factors as well. Another contributor is childhood experiences, leading the abuser to think abuse is a normal part of life, as a result of a modeled behavior. There is the sadistic personality who enjoys the pain they inflict also. Mental or physical disorders can also cause a person to act out against their partner. 5

In the past spousal abuse was a family problem and the police did not like to become involved. When a victim would call the police a majority of the time they would drop charges, and it would be a great cost to the city for these fights. In today’s court system it is no longer up to the victim to drop charges, only the DA can do that.

After years of shoving spousal abuse under the carpet, the government stepped in and made a lot of changes; there are now available funding and programs to help the battered spouse. When the seriousness of spousal abuse started showing up in the courts and even on television, people stepped out of the closet and took a stand.

The OJ Simpson trial showed us the fatalness of this once kept secret issue...Death..

There is no typical profile of an abuser or their victim; young, old, black, white, single, married, professional, unemployed, rich, poor, all people are subject to becoming an abuser or being abused.

There are more cases of the abuser being male, then female. Man has always been treated as the boss, the king; testosterone is a very strong and driving hormone.

Many men are even surprised to learn what they have done is a crime; take sex, most men assume it is their wives' duty to give him sex and when she does not, he can take it anyway. Today this is called rape. This surprises many.

One of the most frequently asked questions about spousal abuse is, “Why don’t they leave?” There are many reasons abused persons do not leave their abuser. Ignorance, love, fear, pride, embarrassment, loyalty, finical dependence, low self-esteem, or a combination of several of these.

How could someone love some on who abuses them? If most of us look around in our lives, we have all been in some sort of relationship where abuse was present in some form; be it our children going through puberty, our parents to us, or a best friend. Did we stop loving them for it? Most of the time the abused person has low self-esteem and feels this is were they belong. Many say “death due us part” so they stay.

Child abuse:

Per (Children’s Defense Fund c1995) Every 7 hours in the US a child dies from abuse or neglect. 80% of child abuse comes from a parent not a stranger. Child neglect, that happens much more frequently then abuses, and often time goes unnoticed, but can be just as damaging. Child neglect is a failure to meet basic physical, or psychological NEEDS. This can range from a home, food and clothing, to a hug, warmth, and praise.

Per (National Ass. Education of young children)

Child abuse is a non-accidental injury of a child by parent or guardian. Inter-generational transmission is when a child is abused by an adult, then the child gets older and becomes abusive to the adult.

Physical abuse occurs more often with boys. When they asked the guardian why, they replied, “They were attempting to discipline the child." With sexual abuse it’s more often with girls. When they asked the guardian why, they said, “They were attempting to educate the child."

Emotional abuse is damage to the self-esteem. Usually abuse is an unplanned reaction to stress. The majority of abusive actions are impulsive.

Sexual abuse can be rape, (Forced sex without child’s consent), molestation, (sexual advances toward a child can include- kissing, touching, or foundling sexual areas, this may be done to the child from the abuser or they may force the child to do this to them). Incest; (sex with family members; this can be father, stepfather, brother, aunt, etc..). Child pornography, (photographing or taping a child involved in sex acts or implied sexual behavior). Child prostitution (forcing a child to engage in sex acts for money)

Unwanted children are most at risk, especially if there has been any extended separation between parents and child. Removal of the child from the home works but they are only safe, from the people who harmed them, temporarily.

Behavioral Teratogens: (How to create a monster): CHILD ABUSE!!!!!

Alcohol Consumption while pregnant is the #1 cause of mental retardation Worldwide. Fetal Alcohol Syndrome (visible)

Tobacco-Smoking while pregnant is the #1 cause of low birth weight. Their at risk for keeping themselves warm. They could have breathing difficulties, or learning disabilities.

Illegal and Prescription Drugs: A new born could be addicted to drugs when born, and will have to go through withdraws. Children born to mothers who used drugs during pregnancy can end up with a wide variety of congenital disorders, from malformations; learning disabilities, and/or severe life long total incapacitates.

I have taken care of multi drug children ranging from 2 - 18 years of age. These special angels just lay on their backs 24 hours a day with cortical blindness, meaning their brains are so fried from their parents abuse that their brains do not know how to recognize! They have eyes so beautiful but can not see. Their eyes have all the appropriate functioning mechanisms but the brain does not have a clue what anything is.

These beautiful defenseless children make noise but cannot not speak, they have toes and feet but will never walk, they have mouths and lips and throats but can not swallow. They will never play or feel the grass on their feet, they will never drive a car or fall in love and get married. They will never feel the joys of having children or growing old, all of this because their parents could not stay clean. I personally believe this is one of the largest forms of child abuse..

Signs to look for in child abuse:

Bruises or welts on face, back, buttocks, abdomen, chest, and inner thighs. (The shape of what ever was used to cause the bruise or welt might be able to be seen.)

Burns and scalds on the feet, hands, back or buttocks, (internal burns leave a pattern from the item causing the burn such as, cigarettes, irons, ropes, stoves.

Fractures of nose, skull, arms, and legs.

Bite marks.

Sexual abuse you may see; bleeding, cuts and bruises of the genitalia, anus, or mouth.

Stains of blood on underpants. Painful urination, vaginal discharge, Genital odor, difficulty sitting or walking, and pregnancy.


We have seen an increase in the abuse of our elders. This is one of the saddest parts of nursing I have had to deal with. Our parents, grandparents, aunts and uncles, and someday ourselves.

Begging neglected and abused. These are the people who deserve the most, they have given to us their whole lives and now when they older and need our help, where are we. The world has gotten to be a very busy place, the extended family in the United states is almost unheard of. The number of long term nursing facilities has greatly increased, yet the care has declined. The government has recognized the problem and we have agencies that try to keep a watchful eye on most licensed facilities; this is helpful but the neglect and abuse still runs ramped.

The medical/Medicaid system allows a nursing assistant to have a case load of 10 patients in an eight hour shift, within a long term nursing home. There is no way a single person can give the quality of care it requires to get up, dress, bathe and give oral hygiene and feed 10 people in eight hours.

In turn the patient suffers, if you look at the different kinds of neglect and abuse you will find that the simplest of things fall into place with the elderly. A person who has had a stroke, has little to no functioning to their one side (hemiparesis), many times they have difficulty speaking, to dress or eat become a great feat. To even quench a persons thirst with a sip of water many times goes unnoticed and the person sits unable to ask for one of the basic needs of life, unable to say they have to go to the bathroom, so they become incontinent, this is a huge form of abuse.

We have such an increasing number of senior citizens that we have lost the true ability to care for them in the dignified way they deserve to be treated. Board and care facilities are used frequently and give more freedom to the elder, but the watchful eye is less visible there.

I have been involved in an elder abuse case where the owner of the Board and care thought it was OK to slap a resident when they acted out, This same Board and care owner had been licensed in two other states and when things went bad and she was caught inflecting abuse on her residents, she simply moved to another state and opened a new one.

There are not enough quality places to put our elders; and the government cannot take care of it for us. I see 82 year old men and women at their homes unable to care for themselves, but no one is able to help. The family is not near by and they are to busy to help; their jobs are their lives, when in fact the parent is the one who gave them life..

To die with dignity has been a God given right that has been denied to our elders lives. Neglect is a given. How many of you have tried to live on 600 dollars per month; our social security. Rent, utilities, medications, transportation, food, clothing, and so on; it is impossible.

Elders go without food, without heat, some without their needed medications, this is neglect. Without a hug, many of our elders lose their spouse after years of being together; like losing one's self, many of these people go unloved and it goes unnoticed. Because we are all so caught up in our own selves.


Living conditions are unsafe, unclean, or inadequate.

Personnel hygiene is lacking, a person or their clothes are dirty.

Weight loss, signs of poor nutrition and dehydration.

Frequent injuries, bruises, broken bones.

Withdrawn, quiet, fearful and anxious, agitated.

The person does not want to talk or answer questions.

Phases of Domestic Violence:

There is a Tension building stage. Tension is a normal factor in everyone’s life and relationships, but some people for some reason, react to tension with violence.

In this stage the family, (family can consist of many different people, it can even include caregiver), be it spouse, child, or elder, can many times can sense the increasing tension in the abuser. They may not know why or what is causing this tension to build but it becomes a routine set of signs and symptoms they have seen before. Many times' things such as drug or alcohol consumption will be a big clue that tension is building up.

People walk on egg shells when they see this behavior coming. The abusers may begin to verbally attack to wear down the victim. They belittle their victim to get them defenseless first. The abused person many times try to be so good and on their best behavior to avoid the tension from getting worse; as if they have done something wrong.

The battered wife cowers, the small child hides and the elder they just hope for the best and many times say nothing at all. Many times the tension stage goes to phase two, the acute battering phase. Remembering our definitions of assault and battery, and the different types of abuse: phase two can be either of these two offenses and all different kinds of abuses.

An abuser does not have to hit their victim to injure the them. Verbal abuse, emotional abuse can be just as damaging, many times with these sorts of abuse's tension continues, and physical abuse comes sooner or later.

So phase one tension building, phase two the act of abuse and phase three; is the loving reconciliation. Most of the time the abuser feels bad for the damage they have done and their guilt kicks in. They promise never to do it again, and they tell their victim how much they mean to them, the tear's flow, until the victim feels loved and safe again, and the cycle repeats itself.


Nothing changes without a lot of hard work and desire. Anyone can promise to change but it is the actions behind the words. I once heard the definition of insanity; is trying to do the same thing over and over again and expecting different results. Many times it can be as easy as getting rid of the causative factor! Drugs and alcohol. Many abuses come with substance abuses!! There is no easy resolution to this.

One of the hardest things a person will do in their life is to admit they have a problem, and then do something about it. The abuser can make promises to quit, but unless their heart is in it, they will not; and once again the wife, children and elders will suffer.

There are programs everywhere, twelve step programs, anger management groups, parenting classes, and more.


It is one of the hardest thing a person can do, to walk away from the abuser and take care of themselves first; then leave it up to God to fix everything else. Many times the abused spouse enables the abuser to keep abusing, by staying and allowing it to continue.

In the health field we can pretend we do not see the bruises; we can close our eyes to the neglect, or we can do something about it.

We are mandated reporters and the laws have changed; in most states you now have to give your name when filing a report with CPS (child protective services), or to APS (adult protective services); but it’s OK, get involved.

When off duty, you still have a moral obligation to call the police when you hear a neighbor screaming, or to call CPS when your child’s friend has bruises all the time. I called CPS once, my daughter told me in private that her girlfriend’s dad was molesting her; CPS went out to the school that day and pulled this young girl and her sister out of school. After talking to them they were taken away from the home. My daughter got angry at first for breaking her trust. As she looks back, now, she knows she might have of lost the friendship of that child but she kept her safe and free from the continued abuse.

People die, lives are lost all from forms of domestic violence.. We have been given the opportunity to help in our medical lives as well as our personal lives. Go that extra mile, reach out your hand, Help the hurting. You can make a difference.