Table of Contents:

1. Aggression & Violence

2. Abuse
3. Sexual Assault

Aggression, Abuse, & Assault

1. Aggression & Violence
Displays of aggression and violence from clients in y Use therapeutic communication.
health care settings often result from:
Remain calm: Use a low voice and non-
y Psychiatric disorders (schizophrenia, mania) threatening tone to avoid escalating the situation
y Substance abuse or intoxication (See THERAPEUTIC COMMUNICATION CHEAT SHEET).
y Inability to cope with stressors (pain, fear, loss of control) y Validate the client’s feelings.
y Example: “It sounds like you’re feeling
Prevention
unheard. That must be really frustrating.”
The best way to manage violence in the health care
Set clear limits.
setting is to prevent it by: y Example: “You have the right to be upset, but
y Building a strong therapeutic relationship name-calling is not acceptable.”
y Remain nonjudgmental and express empathy. y Offer simple choices to help the client feel
y Use short, frequent check-ins discussing non- empowered.
threatening topics to build rapport. y Example: “Would you like to sit down and
y Encourage the client to express feelings before talk, or would you prefer to take a walk
they escalate. with me?”
y Encouraging healthy coping strategies y Modify the environment.
y Help client find healthy and safe outlets to y environmental stimuli (excessive noise or
manage negative emotions (physical activity, activity) toagitation and risk of escalation.
relaxation techniques).
Move an aggressive client away from other
y Intervening early clients to protect them from harm.

Act immediately when signs of escalating y Safety and support
aggression are observed (TABLE 1). y Call for additional staff to assist if escalation
continues.

TABLE 1: SIGNS OF ESCALATING AGGRESSION
Maintain personal space (at least an arm’s length
from the client) to maintain a non-threatening
y Irritability presence andrisk of injury.
y Pacing
Stand near an exit with a clear path to the door
y Shouting, threatening words or gestures to ensure a safe exit if needed.
y Defensive posturing (tensing, clenching fists) y Avoid blocking the exit, as this can appear
y Violence toward objects (punching walls, confrontational and escalate aggression.
slamming doors, throwing objects) y Do not allow the client to position themself
between the exit and the nurse.
De-escalation y Seclusion and restraint
y Restraints should only be used when client
When signs of escalating aggression are noticed,
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presents an imminent danger to self or others.

immediately implement de-escalation techniques to

Use less restrictive measures first (verbal
defuse tension andrisk of violence.
de-escalation).

 Escalating aggression: Signs of escalating aggression � Aggressive clients: When interacting with an
include irritability, pacing, and shouting. Upon aggressive client, the nurse should maintain at least
recognizing these behaviors, the nurse should intervene one arm’s length of personal space and position
immediately by remaining calm and setting clear limits. themselves near a door with a clear path to exit.

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2. Abuse
FIGURE 1: THE CYCLE OF ABUSE
Abuse can take many forms (physical,
emotional, sexual, financial,
neglect). Nurses must recognize the
signs of abuse (TABLE 2), provide
support, and intervene appropriately.
The cycle of abuse
y Abuse often follows a repeating
cycle that escalates over time
(FIGURE 1).
y Victims may stay in abusive
relationships due to fear, financial
dependence, children, or hope
for change.
Nursing interventions
y Screen all clients for abuse using
nonjudgmental questioning.
y Example: “Do you feel safe
at home?”

Interview the client alone to ensure TABLE 2: SIGNS OF ABUSE
privacy and safety.
y Document injuries using objective descriptions and Type of Abuse Common Signs
include photographs (with consent).
y Mandatory reporting Physical Abuse y Bruises in various stages of

Vulnerable populations: Notify protective healing
services of any suspected or actual abuse of y Explanation of how injury
children or older adults as required by local law. occurred is vague or
y Domestic and intimate partner violence: Adult inconsistent with the injury
victims cannot be forced to report. The decision observed.
is theirs.
y Offer support and encourage client to seek
Emotional Abuse y Withdrawal
help (domestic violence hotline, shelters).
y self-esteem
y Use therapeutic communication.
y Express concern and reassure that abuse is not
Sexual Abuse y Genital injuries
the client’s fault.
y STIs

Do not blame, shame, or pressure the client to
y Inappropriate sexual
leave the situation.
knowledge or behaviors
y Say: “I am worried about your safety.”
y Do not say: “You need to leave your partner.”
Financial Abuse y Unexplained financial losses
y Missing possessions Mental Health

Neglect y Malnutrition
y Poor hygiene

 Mandatory reporting: All suspected and actual cases of child abuse must be reported to protective services
immediately. Adult victims of domestic abuse have the right to choose whether to report the abuse.

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2. Abuse, Continued y Provide emotional support and advocacy.
y Reassure clients that the assault was not

Create a safety plan.
their fault.
y Help the client identify a safe place to go.
y Offer crisis intervention resources and
y Encourage the client to keep an emergency bag
encourage follow-up counseling for
if planning to leave an abusive situation (clothes,
long-term support.
money, documents).

Give the client a sense of control by offering
y Establish a code word to discreetly signal for
choices like:
help from friends or family.
y “Who can we call to support you?” (family,
y Provide resources based on client needs
friends, victim advocate)
(domestic violence shelters, social support
y “Would you like to shower or change
services).
your clothes now?” (offered after exam is
complete)
3. Sexual Assault

Adult victims: Have the right to choose whether
Sexual assault victims require medical and emotional to report the assault or press charges
support along with forensic evidence collection for
Administer prophylactic medications.
legal documentation. y Sexually transmitted infection (STI) prevention
Nursing priorities (antibiotics for gonorrhea, chlamydia)
y Ensure client’s safety and privacy. y Emergency contraception if indicated

Place client in a private room.

Limit room access to only essential health care
personnel.
y Preserve forensic evidence.

When possible, instruct the client to not shower
or change clothes before the exam, as this can
compromise evidence.
y Use a rape kit for evidence collection (performed
by a trained Sexual Assault Nurse Examiner
[SANE] if available).

Explain each action when collecting evidence
tofear and anxiety (“I am going to uncover your
legs now”).
y Document findings objectively (photographing
injuries if client consents).

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 Safety planning: Assist victims of abuse to create  Sexual assault: To preserve forensic evidence,
a safety plan by identifying a safe place to go, instruct a client who has been sexually assaulted
packing an emergency bag, establishing a code not to shower or change clothes before the
word for help, and providing resources for shelters exam.
and crisis services.

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  Name three signs of escalating aggression. If a  Assist victims of abuse to create a _____ by
client demonstrates escalating aggression, the nurse identifying a safe _____, packing an emergency
should remain _____ and set clear _____. ____, establishing a _____ word for help, and
providing resources for shelters and crisis
 When interacting with an aggressive client, the services.
nurse should maintain at least _____ (how much?) of
personal space. Where should the nurse stand in the  To preserve forensic evidence, instruct a client
room to ensure safety? who has been sexually assaulted not to _____ or
_____ before the exam.
 All suspected and actual cases of _____ abuse must
be reported to protective services immediately. Adult
victims of domestic violence ___ (do or do not?) have
the right to choose whether to report the abuse.

4. safety plan, place to go, emergency bag, code word 5. shower or change clothes
Answers: 1. Irritability, pacing, shouting; remain calm, set clear limits 2. one arm’s length; Near a door with a clear path to exit 3. child; do

Mental Health

References:

Callahan, B., Hand, M., & Steele, N. (Eds.). (2023). Nursing: A Pollard, C. L. & Jakubec, S. L. (2023). Varcarolis’s Canadian
concept-based approach to learning (4th ed., Vol 2). psychiatric mental health nursing: A clinical approach (3rd
Pearson. ed.). Elsevier.

Lowdermilk, D., Cashion, M. C., Alden, K. R., Olshansky, E.F., & Videbeck, S. L. (2023). Psychiatric-mental health nursing (9th ed.).
Perry, S. (2023). Maternity and women’s health care (13th Wolters Kluwer.
ed.). Elsevier.
Attributions:
Morgan, K. I. (2024). Davis Advantage for Townsend’s psychiatric
y Cycle of Abuse: Created with BioRender.com
mental health nursing (11th ed.). F. A. Davis.
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