HA-RLE Worksheet # 7

ASSESSING FOR VIOLENCE

Case Study:

Read the following case study. Then work through the steps of analysing the case study data.

1. First identify abnormal data and strengths in subjective and objective findings;
 Subjective Data
 10 years old child
 The mother gives a history of coming home from work to find her daughter
sitting on the couch watching television.
 Her daughter did not go to the door to greet her or look toward her when she
said hello.
 The mother thought the daughter’s behavior was odd because she always
greeted her at the door with a hug.
 As she approached her daughter, she noticed that she was clutching her right
arm as if in pain.
 The mother asked what was wrong, but the daughter remained silent.
 “Nothing is wrong.” As verbalized by the client.
 The mother gives a family history of having an alcoholic husband who usually
drinks himself to sleep.
 She said he has abused the child physically and psychologically in the past, and
she brought her to the emergency room because she fears he has hurt the child.
 Objective Data
 The client appears scared, insecure, and withdrawn when asked about the
abuse.
2. Assemble cue clusters;
 Family history of having alcoholic husband
 The father abused the child physically and psychologically in the past
 Clutching her right arm as if in pain
 The child’s behavior was odd because she always greeted her mother at the door with a
hug.
3. Draw inferences;
 Abuse
 Low self-esteem
 Risk for trauma
4. Make possible nursing diagnoses;
 Impaired comfort related to noxious environment stimuli as manifested by the change
in behaviour.
5. Identify defining characteristics;
 Abused the child physically and psychologically in the past
 The child appears scared, insecure, and withdrawn
  Daughter’s behaviour was odd
6. Confirm or rule out the diagnoses; and
 Impaired comfort related to noxious environment stimuli as manifested by the change
in behaviour.
7. Document your conclusions.
 Based on the data gathered, the client shows impaired comfort as evidenced by her
sudden change in behaviour and she also appears scared in and in pain.

Case Study:

A 10-year-old child is brought into the emergency department by her mother. The mother appears

anxious but sits quietly next to her daughter in the waiting room. When called into the triage area, the

mother gives a history of coming home from work to find her daughter sitting on the couch watching

television. Her daughter did not go to the door to greet her or look toward her when she said hello. The

mother thought the daughter’s behavior was odd because she always greeted her at the door with a

hug. As she approached her daughter, she noticed that she was clutching her right arm as if in pain. The

mother asked what was wrong, but the daughter remained silent. Then she said “Nothing is wrong.” The

father is sleeping upstairs. The mother gives a family history of having an alcoholic husband who usually

drinks himself to sleep. She said he has abused the child physically and psychologically in the past, and

she brought her to the emergency room because she fears he has hurt the child. When the child is asked

about the abuse she appears scared, insecure, and withdrawn.

Questions:

a. How may the nurse obtain subjective information from the child when she is reluctant to

speak?

 The nurse ask the mother of the child to obtain subjective information. However, if the

nurse have a question that the client is the only one who can answer, the nurse must

make the child comfortable with her to communicate by establishing first a good

rapport to the client.

 b. Given the information provided by the mother, what further assessment should the nurse

conduct?

 The nurse assess for the effect on mental, cognitive and behavioural status of the child

when her/his father abused the child physically and psychologically in the past.

 The nurse may advice the mother to visit a psychologist or psychiatrist to conduct a

further assessment because the child may be suffering from trauma.

NURSING INTERVIEW GUIDE TO COLLECT SUBJECTIVE DATA

QUESTIONS FINDINGS
Intimate Partner Abuse Screening for Women
1. Physically hurt by anyone in the past N/A
year? By whom?
2. Fears of others at home or N/A
elsewhere? Be sure to acknowledge
abuse if present, be supportive, and
help the client develop a safety plan.
Elder Abuse Screening for Geriatric Clients
1. Activities in a typical day? N/A

2. Hurt by anyone in the past? Threats N/A

from anyone in the past?
3. Afraid of anyone at home? N/A

4. Client ever made to do anything he or N/A

she did not want to do?
5. Ever touched without permission? N/A

6. Belongings taken without permission? N/A

7. Made to sign papers without N/A

understanding them?
8. Often alone? N/A

9. Has help ever been refused when N/A

needed?
10. Has anyone ever refused to give or let N/A
the client take medications as
needed?
Child Abuse Screening for Children and Adolescent
Determine developmental level by asking the
following:
1. What is your name? Please spell N/A
 it.
2. When is your birthday? N/A

3. How many eyes do you have? N/A

Using the child’s or adolescent’s
answers, formulate
developmentally appropriate
questions to determine if the child
or adolescent was ever abused
physically, emotionally, or
sexually.

Activity: PERFORMING PHYSICAL ASSESSMENT FOR FAMILY VIOLENCE

Use the following guide to perform an assessment for family violence. Column 1 serve as a
reminder as to what part of the exam you will do next. Column 2 will be used to record your
findings. Your instructor may ask you to turn this in to be evaluated.

PHYSICAL ASSESSMENT GUIDE TO COLLECT OBJECTIVE DATA

Questions Findings
1. General Survey N/A

2. Assess mental status N/A

3. Evaluate vital signs4 N/A

4. Inspect skin N/A

5. Inspect head and neck N/A

6. Inspect eyes N/A

7. Assess ears N/A

8. Assess abdomen N/A

9. Assess genitalia and rectal area N/A

10. Assess musculoskeletal system N/A

11. Assess neurologic system N/A