Module 13: Stressors Affecting Abuse and Neglect Across the Lifespan

Learning Objectives:

Key Focus Areas:

Key Terms:

Stressors Affecting Abuse and Neglect Across the Lifespan

Module Overview: This module examines various forms of abuse and neglect across the lifespan – from children to adults and elders – and the stressors involved. It defines physical, sexual, emotional/psychological abuse and neglect, explores their clinical presentations and red flags in pediatric, adult, and geriatric populations, and discusses the Cycle of Violence in intimate partner violence (IPV). Nursing assessment strategies are outlined, including trauma-informed interviewing, thorough documentation, screening tools, and mandatory reporting requirements in the U.S. We also cover immediate nursing interventions, long-term support planning, and the impact on nurses (emotional responses, burnout risk, and self-care). Finally, we identify community and institutional referral pathways, supported by visual aids such as injury pattern charts, cycle of violence diagrams, and documentation examples.

1. Definitions and Clinical Presentations of Abuse and Neglect

Physical Abuse: Physical abuse is the intentional use of physical force that results in (or has high risk for) injury or harm​cdc.gov. Examples include hitting, kicking, shaking, choking, burning, or using objects/restraints to inflict injury. Clinical Presentation: Victims may display unexplained bruises, welts, fractures, burns, or other injuries at different healing stages. Injuries often have patterns (e.g. belt buckle shapes or hand marks) or occur in atypical locations not prone to accidental trauma​dhs.wisconsin.gov. The individual might withdraw from touch, startle easily, or offer implausible explanations for injuries. Over time, chronic pain, frequent medical visits for injuries, and behavior changes (fearfulness, flinching, “walking on eggshells”) can be noted.

Sexual Abuse: Sexual abuse refers to any forced, coerced, or exploitative sexual contact or activity without consent. In minors or vulnerable persons, any sexual act is abusive. This includes direct contact (fondling, penetration, rape) and non-contact exploitation (exposure to pornography or sexual trafficking)​cdc.gov. Clinical Presentation: Possible signs include trauma to genital or anal areas (bruising, bleeding, pain), sexually transmitted infections, or unexplained pregnancy in an adolescent​dfps.texas.gov​dfps.texas.gov. The person may have difficulty walking or sitting, suddenly refuse physical exams or activities like gym, or display age-inappropriate sexual knowledge or behaviors​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Children might regress (bedwetting, thumb-sucking) or run away, whereas adults might present with depression, anxiety, or sexual dysfunction. Any disclosure of sexual assault should be taken seriously.

Emotional/Psychological Abuse: Emotional abuse (also called psychological abuse) involves behaviors that harm an individual’s self-worth, mental health, or emotional well-being. This may include constant criticism, humiliation, threats, intimidation, isolation, or manipulation by the perpetrator​dhs.wisconsin.gov. Clinical Presentation: There are often no visible injuries, but the impact is evident in the victim’s behavior and affect. Children may exhibit developmental delays, extreme behavior (either overly aggressive or excessively withdrawn), low self-esteem, or anxiety/depression​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. They might be overly compliant (trying hard to please) or show infantile behaviors inappropriate for their age. Adults facing psychological abuse may appear fearful, anxious or chronically apologetic around the abuser, have trouble concentrating or making decisions, or describe feeling “worthless.” Elders may become withdrawn, confused (which can be misattributed to dementia), or fearful of a particular caregiver. In any age, emotional abuse can manifest as sleep disturbances, psychosomatic complaints (headaches, stomachaches), or high levels of distress in the presence of the abuser.

Neglect: Neglect is the failure of a caregiver to meet the basic needs of someone dependent on them – such as a child, a person with disability, or an elder. This includes not providing adequate food, hydration, shelter, hygiene, medical care, education, or protection from harm​dhs.wisconsin.gov. Neglect can be intentional (willful deprivation) or unintentional (due to caregiver ignorance or burnout), but in either case it endangers the person’s health and development​dhs.wisconsin.gov​dhs.wisconsin.gov. Clinical Presentation: Signs of neglect often emerge gradually. In children, you may see consistent malnutrition or hunger (e.g. child is underweight or constantly begs for food), poor hygiene (dirty, severe body odor, unchanged diapers or clothing), untreated medical or dental problems (like infected wounds, dental caries), or lack of appropriate supervision for age​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Neglected children might be frequently absent from school or come very early and leave late, as if avoiding home​ncbi.nlm.nih.gov. In older adults, neglect may present as pressure ulcers, dehydration, over-sedation or missed medications, unsafe living conditions (no heat, pests, clutter creating fall hazards), or missing assistive devices (glasses, hearing aids)​dhs.wisconsin.gov【105†】. Caregiver statements minimizing these issues or making excuses (e.g. “she never wants to eat” or “I’m doing the best I can”) can be red flags. Neglect is often accompanied by emotional effects: the individual may appear listless, depressed, or hopeless.

Physical signs of elder abuse often overlap with neglect. Physical Signs of Elder Abuse. Common indicators include unexplained weight loss and dehydration (from neglect of nutrition or fluids), missing daily living aids like eyeglasses or hearing aids (suggesting care is not being taken), untreated injuries such as bruises or sores, poor hygiene and unsanitary living conditions, and unattended medical needs like missing medications【105†】. These signs warrant further assessment for abuse or neglect in vulnerable older adults.

2. Red Flags of Abuse and Neglect by Population

Abuse and neglect can affect anyone, but there are population-specific red flags to help clinicians recognize when maltreatment may be occurring. It’s critical for nurses to maintain a high index of suspicion when patients (or their dependents) present with certain patterns of injuries or behaviors. Below we outline key warning signs in pediatric, adult, and geriatric populations:

In all populations, mismatches between history and exam are critical red flags. For example, a toddler with a spiral arm fracture said to have “fallen off the couch” (a low-height fall causing a high-energy injury) or an elder with bruises on the thighs that they can’t recall obtaining. If the story “doesn’t fit,” suspect abuse. Also be aware of situational stressors that can increase abuse risk: family financial strain, caregiver substance abuse, social isolation, and caregiver burnout are known contributors​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. These factors don’t excuse abuse but help identify high-risk situations.

3. The Cycle of Violence (IPV) and Clinical Implications

Intimate partner violence often follows a repetitive Cycle of Violence (also known as the Cycle of Abuse) that has been classically described in three phases. This concept, first described by psychologist Lenore Walker, helps clinicians understand why a person abused by their partner might remain in the relationship and how the pattern can escalate over time​nursing.ceconnection.com​nursing.ceconnection.com. The phases are:

Illustration of the power and control dynamics in abusive relationships. Power and Control Wheel. Developed by the Domestic Abuse Intervention Project (Duluth, MN), this wheel diagram shows how physical and sexual violence (outer ring) are used alongside more subtle tactics (inner slices) to maintain an abuser’s control over a partner【77†】. These tactics include using coercion and threats, intimidation, emotional abuse, isolation, minimizing/blaming, using children, misusing male privilege, and economic abuse. The cycle of violence is driven by this need for power and control. After violent incidents, an abuser’s promises to change often give way to these controlling behaviors again, perpetuating the cycle.

Clinical Implications of the Cycle: Knowing about the cycle of violence helps nurses approach IPV cases without judgment. Rather than asking “Why doesn’t she just leave?”, nurses recognize that during the honeymoon phase the victim may feel genuine love or hope, and during tension-building they may feel paralyzed by fear or self-blame​consultqd.clevelandclinic.org​consultqd.clevelandclinic.org. This understanding fosters empathy. It also underscores the importance of repeated screening – a patient may deny abuse during a honeymoon phase but disclose it during a tension or explosive phase when they feel more fearful. Nurses can gently educate patients that this cycle tends to repeat and often escalates, which can plant a seed that help might be needed. Another implication is safety: the most dangerous time for a victim can be when they try to leave, because the abuser loses control and may resort to extreme violence​consultqd.clevelandclinic.org​consultqd.clevelandclinic.org. Thus, if a patient indicates they plan to leave, the nurse should emphasize the importance of a safety plan and connect them to resources (like shelters or hotlines) immediately. Understanding the cycle also reminds healthcare providers to be patient and supportive even if the patient returns to the abusive situation multiple times; breaking free often requires multiple attempts, and our role is to consistently offer nonjudgmental support and information.

4. Nursing Assessment Strategies

Identifying abuse or neglect requires keen assessment skills and a compassionate, trauma-informed approach. Nurses are often on the frontlines of detection – our assessment can literally save lives. Key strategies include skilled interviewing (with privacy and empathy), meticulous documentation, use of validated screening tools, and applying trauma-informed care principles throughout. This section details how to assess patients when abuse or neglect is suspected:

Interview Techniques: Begin with creating a safe and private setting for conversation. Whenever possible, separate the patient from any accompanying person who might be the abuser. For example, in suspected IPV, ensure you speak with the patient alone – one red flag is a partner who refuses to leave; insist gently but firmly on private time for the health assessment​consultqd.clevelandclinic.org. Use a calm, nonjudgmental tone and open-ended questions. Start with general health questions to build rapport, then ease into more sensitive areas. Instead of directly asking “Are you abused?”, which can cause denial or fear, try framing questions in a normalized way: “Because violence is so common, I ask all my patients – do you feel safe in your home and relationships?” or “Sometimes when I see injuries like these, people have been hurt by someone they know. Is that happening to you?” Such phrasing signals concern without accusation. Avoid leading or loaded terms – words like “alleged” or “claims” should not be used in conversation or documentation, as they suggest doubt of the patient’s story​med.unc.edu​med.unc.edu. If the patient is a child, follow appropriate protocols: very young children may not be interviewed directly about abuse (that is left to trained child forensic interviewers), but school-age children can sometimes share if asked in a gentle, age-appropriate way (e.g., “Has anyone made you feel unsafe or hurt you?”). With elders or disabled adults, ascertain cognitive status first; if impaired, rely more on physical findings and collateral information, but still attempt to ask simple, direct questions (“Is anyone hurting you or not taking care of you?”). Throughout the interview, practice trauma-informed principles: ensure the patient feels safe, explain each step of the exam to restore a sense of control, and express empathy ("What happened to you is not your fault. You are not alone, and help is available."). Use of professional interpreters is crucial if there is a language barrier – never use a family member to translate in a potential abuse situation, as they may be involved or may filter the conversation.

Documentation Protocols: Accurate and detailed documentation is vital. A golden rule in healthcare is “if you didn’t document it, it didn’t happen”​med.unc.edu. Courts and protective services heavily rely on medical records in abuse cases, so write objectively and thoroughly. Use the patient’s own words as much as possible, especially for subjective statements about how an injury occurred or what was said by the perpetrator – put these in quotes. For example: Patient states, “My husband punched me in the eye after I talked back.” Document the time and day of the exam and any statements like patient denies pain or patient reluctant to answer when asked about cause of injury. Avoid judgmental language or implying disbelief (do not write “patient claims she was hit” – simply write “patient reports….”). For physical findings, document size, location, shape, color of each injury with great precision​med.unc.edu​med.unc.edu. Use body diagrams to mark injury locations – most hospital charts have body map forms for this purpose. If your setting allows, photographs of injuries can be extremely helpful (follow institutional policy – typically written patient consent is needed for photography). Note any incongruity between the injury and the explanation (e.g., “Explained mechanism (fell off bed) is not consistent with pattern of injuries observed.”). Remember to include evidence of neglect if noted: e.g. “Patient’s clothing soiled, strong odor of urine, diaper saturated” or “pressure ulcer on sacrum measuring 5×5 cm with foul odor, no treatment in place.” In cases of sexual assault, document findings from the forensic exam (if done) and patient statements about the assault with as much detail as possible. Maintain confidentiality in documentation but also fulfill reporting obligations: for instance, if you made a report to Child Protective Services (CPS) or Adult Protective Services (APS), document that you did so (including date, time, and to whom the report was made). Good documentation not only supports patient care and legal efforts, it also helps communicate to other providers the serious nature of the situation (flagging the chart for safety concerns)​med.unc.edu​med.unc.edu.

Validated Screening Tools: Healthcare settings increasingly use brief screening questionnaires to detect abuse early, especially IPV in adult patients. The U.S. Preventive Services Task Force recommends routine IPV screening for women of reproductive age​aafp.org, and there are several tools available. Common IPV screening tools include: the HITS (Hurt, Insult, Threaten, Scream) – a 4-item scale asking how often a partner does each of those actions; HARK (Humiliation, Afraid, Rape, Kick); the WAST (Woman Abuse Screening Tool); and the PVS (Partner Violence Screen)​aafp.org. These tools are typically self-report or clinician-administered questionnaires that can be completed quickly and have validated cutoff scores indicating abuse. For example, HITS asks the patient to rate from 1 (never) to 5 (frequently) how often their partner physically hurts them, insults them, threatens harm, or screams/curses at them – a total score of >10 suggests IPV​cebc4cw.org​cebc4cw.org. In the primary care or ED setting, even a single direct question like “Have you been hit, kicked, or otherwise hurt by someone in the past year?” combined with “Are you afraid of your partner?” (the Abuse Assessment Screen) has been shown to be effective. For elder abuse and child abuse, there is not a universally adopted screening tool like HITS, largely because these rely on third-party reports. However, some instruments exist, such as the Elder Abuse Suspicion Index (EASI) for elders, which is a set of questions for patients and physicians to flag possible abuse. Note that the USPSTF found insufficient evidence to recommend routine screening of asymptomatic elders for abuse​aafp.org​aafp.org – instead, clinicians remain vigilant for signs or risk factors. Pediatric settings don’t use formal “abuse questionnaires” on children, but pediatricians do incorporate screening of caregivers (e.g. asking about stress, substance use, use of discipline methods) and look for indicators of household violence. In any setting, ensure that screening is done in private and that if a patient screens positive, you have a protocol for response (such as a social work consult or safety assessment). Also, incorporate trauma-informed screening – meaning explain to the patient why you are asking these questions, and give them control (they can choose not to answer if they feel uncomfortable). Always prioritize immediate safety if a screening reveals active danger.

Trauma-Informed Care: A trauma-informed approach means recognizing that patients who have experienced abuse have been traumatized, and the care environment should not re-traumatize them. The SAMHSA’s six guiding principles include: Safety, Trustworthiness (transparency), Peer support, Collaboration, Empowerment, and acknowledging Cultural/Historical/Gender issues​samhsa.gov. Practically for nurses, this means: create a private and safe space for the patient; explain what you are doing before you do it (for example, before touching the patient during exam, ask permission and explain why it’s necessary); give the patient choices whenever possible to return a sense of control (e.g., “Would you like a female chaperone present?” or “We can take a break if you need a moment.”). Ensure confidentiality to build trust – let them know their info is private except in situations of mandatory reporting. Listen actively and validate their feelings: say things like “I’m sorry this happened to you” and “You are brave to share this with me.” Avoid unnecessary repetition of the story (coordinate with the team so the patient isn’t made to recount the abuse over and over). Use a gentle, assuring tone and be mindful of your body language. Trauma-informed care also extends to the environment – e.g., if the patient is a sexual assault survivor, providing a calm, quiet room and offering access to an advocate from a rape crisis center can help them feel safer. When documenting or making referrals, use empowering language. The goal is that every interaction conveys respect, empathy, and a focus on the patient’s strengths and autonomy (empowerment), not on their “victimhood.” By doing so, nurses help traumatized patients feel safe and supported, which improves honest disclosure and engagement in care​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov.

Additional Assessments: During your evaluation, remember to assess for associated conditions. Screen for depression, anxiety, PTSD symptoms, suicidal ideation – abuse survivors have higher rates of mental health needs. Inquire about substance use, as some victims use alcohol or drugs to cope. Check for signs of old fractures or injuries (e.g., ask, “Have you ever had an injury like this before?”). In children, assess growth parameters and development – chronic abuse/neglect may cause failure to thrive or developmental delays. In elders, assess cognitive function and decision-making capacity; untreated medical issues due to neglect (like uncontrolled diabetes or bedsores) should be evaluated. A comprehensive head-to-toe exam is warranted if abuse is suspected, even if the patient came in for a specific injury, because there may be other injuries they didn’t volunteer (for example, hidden bruises under clothing). Use trauma-informed physical exam techniques: be thorough but sensitive, especially around areas that may have been assaulted.

Finally, an important aspect of assessment is determining immediate safety. If you suspect the patient (or child/elder dependent) will return to a dangerous environment, this affects your intervention plan (covered in Section 6). Thus, part of your assessment is asking questions like “What do you need to be safe tonight?” or “Are there firearms in the home?” or in the case of a child, “Who takes care of you at home? Do you ever feel afraid of anyone there?” These assessment findings directly inform whether protective services or emergency authorities need to be involved right away.

5. Mandatory Reporting Laws for Nurses in the U.S.

Nurses in the United States have legal obligations to report certain types of abuse and neglect. Mandatory reporting laws vary by state, but all states require reporting of suspected child abuse or neglect, and most require reporting of abuse of vulnerable adults (including elders and dependent adults)​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. It’s critical for nurses to know their state’s specific requirements, but some general principles apply across the country:

What to Do if You Need to Report: Follow your institution’s policy. Typically, you would call the state’s abuse hotline or local CPS/APS. Provide identifying info and factual details. You do not have to inform the family or suspected perpetrator that you are making the report – in fact, it’s often recommended not to inform them, to protect your safety and the patient’s. However, with the patient (if a competent adult victim), it can be good to tell them you are required to report and offer to support them through the process. For instance, with a coherent elder: “I am really concerned for your safety. By law I have to notify Adult Protective Services. Their role is to help you – perhaps by getting you more support at home. We can talk about what that means.” In child cases, you typically do not inform the parents if you suspect them – leave that to CPS. Document that the report was made, including date/time and the agency/person who took the report​ncbi.nlm.nih.gov. Often, CPS/APS will want follow-up information or may send a caseworker to the hospital – coordinate with them as needed.

In summary, nurses are legally and ethically bound to report vulnerable populations’ abuse. Knowing these laws and your role can protect your patients and also protect you from legal repercussions. When in doubt, consult your charge nurse, social worker, or risk management, but do not delay too long if a child or dependent’s safety is at stake. Remember the motto: It’s better to report and be wrong than to not report and later find out harm continued. Your report can activate social systems to investigate and intervene. As a final note, the duty to warn (Tarasoff rule) – if a patient confides an intention to seriously harm someone, or if you believe someone (like a child) is in grave danger, there are provisions to break confidentiality and notify authorities​ncbi.nlm.nih.gov. This is tangential to mandated reporting but relevant in cases where an abuser threatens a victim even within the clinical setting; hospital security and police might need to be alerted for safety.

6. Immediate Nursing Interventions and Long-Term Support Planning

When abuse or neglect is identified or strongly suspected, nursing care extends beyond assessment and reporting. We must intervene to ensure the immediate safety of the patient (and any dependents) and lay the groundwork for long-term recovery and support. Our interventions occur on two timelines: immediate/acute (during the healthcare encounter and directly after) and long-term planning (referrals and follow-up to support the patient’s ongoing safety and healing).

Immediate Interventions:

Long-Term Support Planning:

Before the patient leaves your care, it’s vital to connect them with the resources and follow-up services that can help break the cycle of abuse and address its consequences. Long-term planning includes both referrals to support services and follow-up healthcare for ongoing needs:

In summary, immediate interventions focus on safety, acute treatment, and reporting, whereas long-term planning focuses on support, rehabilitation, and prevention of recurrence. Both are essential – rescuing someone from an abusive situation without follow-up often leads to the cycle starting again. Nurses play a central role in both domains: we treat injuries and save lives in the moment, and we plant seeds for recovery and empowerment, coordinating the network of resources that patients need to truly break free and heal.

7. Impact on Nurses: Emotional Responses, Burnout Risks, and Self-Care

Caring for patients who have been abused or neglected is deeply emotional and can be challenging for nurses. We may feel anger at the perpetrator, sorrow for the victim, or even helplessness when seeing repeated abuse cases. It’s normal to have strong reactions – but we must be aware of them to maintain professional, compassionate care and to protect our own well-being. This section addresses common nurse emotional responses, the risk of burnout and compassion fatigue, and strategies for self-care and seeking support.

Emotional Responses of Nurses: It is not unusual to feel a range of emotions when encountering abuse cases. You might feel anger or disgust towards the abuser – for example, many providers feel rage internally when treating a shaken baby or a raped patient. You might also feel frustration if the victim doesn’t follow what seems like “logical” advice (like leaving an abusive partner); it’s important to recognize that frustration but channel it productively (understand the cycle of violence and the patient’s perspective). Empathy overload can occur – you may personally feel the fear or pain that the patient went through, especially if you identify with them (for instance, if you have children, seeing an abused child might hit you extremely hard). Some nurses experience secondary traumatic stress, meaning they exhibit symptoms similar to PTSD from hearing about and witnessing trauma second-hand​pmc.ncbi.nlm.nih.gov​pmc.ncbi.nlm.nih.gov. It’s also common to worry “Did I do enough? Did I do the right thing?” – particularly after the fact, second-guessing whether you should have spotted signs sooner or intervened differently​pediatricnursing.org​e-chnr.org. Moral distress can arise if you want to do more but are constrained (like if an adult victim refuses help and you fear harm will continue). On the flip side, success cases can bring immense satisfaction – knowing you helped save someone from a dangerous situation is one of the most rewarding experiences in nursing. Being aware of your feelings and discussing them with colleagues or mentors is healthy. It’s important to remember that feeling emotional does not mean you are unprofessional – it means you care. The key is to process those emotions so they don’t accumulate negatively.

Burnout and Compassion Fatigue Risks: Chronic exposure to trauma and suffering can take a toll on healthcare providers. Compassion fatigue is a state of physical, emotional, and mental exhaustion combined with a reduced ability to empathize or feel compassion for others, often described as the “cost of caring” for others in pain​chcm.com​ojin.nursingworld.org. Nurses dealing frequently with abuse cases are at risk. Signs of compassion fatigue and burnout include: feeling emotionally numb or overly cynical about patients’ situations, reduced job satisfaction, irritability or impatience with patients (e.g., “Why won’t she ever learn?” – a thought indicating empathy depletion), and even physical symptoms like fatigue, headaches, or poor sleep. If you find yourself dreading work or feeling indifferent to a patient’s trauma, these could be warning signs. Past personal trauma can amplify these reactions; a nurse who has her own history of abuse might be especially triggered (it’s important for such nurses to be mindful of their limits and seek support). Burnout is also fueled by systemic factors – high workload, lack of support, etc. Acknowledging these risks is the first step to addressing them. It’s crucial to remember that you cannot pour from an empty cup – to care effectively for patients, you must care for yourself. Healthcare organizations are increasingly recognizing the need to support staff mental health, but it often falls on individual nurses and teams to be proactive.

Self-Care Strategies for Nurses: Self-care is not a luxury; it’s an ethical imperative when working with trauma survivors. Here are strategies:

By implementing these self-care and support strategies, nurses can sustain their ability to provide compassionate care without sacrificing their own well-being. As a nurse, you are a precious resource – taking care of yourself is not selfish, it’s essential. It models to colleagues and even to patients that wellness matters. In fact, some patients might blame themselves for burdening you; showing them that you have coping strategies can indirectly help them see the importance of caring for oneself. In summary, acknowledge the impact this work has on you, prioritize self-care, and seek support just as you encourage your patients to do. Doing so will help you maintain the empathy and strength needed to keep making a difference in the lives of those affected by abuse and neglect.

8. Community and Institutional Referral Pathways

Effective care for abuse and neglect survivors extends beyond the walls of the hospital or clinic. Nurses play a key role in linking patients to community and institutional resources that can address the multifaceted needs that arise from abuse. Below are recommended referral pathways and resources at both the community level and within healthcare institutions:

Community Resources and Referrals:

Institutional Referral Pathways (within Healthcare):

In essence, the nurse acts as a navigator for patients through a complex web of services. No single professional or agency can handle all aspects of the aftermath of abuse – it truly takes a village. The nurse’s role is to know that village (or know how to access it) and guide the patient and family to it. Often, providing a simple written list of contacts or a brochure is not enough – whenever possible, facilitate a warm handoff: for instance, with the patient’s permission, call the shelter to confirm bed availability, or schedule the follow-up appointment while the patient is present. This increases the likelihood they will actually connect with the resource. Before ending your encounter, ask the patient if they have any questions about the plan and whom to contact. It can be overwhelming, so prioritize and summarize: “After you leave here, remember you have an appointment at the clinic Tuesday. Jane (the social worker) will call you tomorrow to check in. If you feel unsafe, you can call 911 or the hotline number I gave you. You’re not alone – there are people ready to help.”

By tapping into community and institutional networks, nurses help construct a safety net for abuse survivors. Our referrals can empower patients to move from crisis to stability, from victimization to survivorship. Each referral is a thread in the net – together, they support the patient’s journey to a life free from abuse.

9. Visual Aids and Documentation Samples

Visual tools can be invaluable in both understanding and teaching about abuse and neglect. In clinical practice, they also assist with assessment and documentation. This module includes several visual aids to reinforce key concepts:

The “Power and Control Wheel” is a visual tool that outlines the pervasive tactics used by abusers. It emphasizes that while physical and sexual violence are the most visible forms, the underlying control is maintained through intimidation, emotional abuse, isolation, minimizing/blaming, using children, asserting male privilege, economic abuse, and coercion/threats【77†】. This wheel, and the cycle diagram, are often displayed in clinical settings (like exam rooms or staff areas) to remind both patients and providers of the dynamics of IPV. For broader contexts, there are similar wheels (e.g., for child abuse or elder abuse dynamics) that illustrate how abusers exert control.

Example of key documentation points for intimate partner violence in a tip sheet. Documentation Tip Excerpt. This sample emphasizes avoiding terms that cast doubt (like “claims” or “alleges”) and the importance of including detailed observations and patient quotes​med.unc.edu​med.unc.edu. It also reminds providers of the legal uses of these records and concludes with the mantra, “If you don't document it, it didn’t happen.” Nurses should use such tip sheets as checklists when writing their notes to ensure completeness and objectivity.

In using visual aids, sensitivity is key. Don’t show graphic images of injuries to patients unnecessarily (you wouldn’t, for instance, show a child pictures of other abused children – that’s not appropriate). But you might show a parent the “Period of PURPLE Crying” graphic to prevent shaken baby syndrome, or show an elder (or their family) a flyer from NCEA on elder abuse signs for education. With staff, reviewing case studies with body map sketches or going over the power and control wheel can enhance understanding and retention.

Summary: Nurses should leverage visual tools – injury pattern charts sharpen our assessment, cycle diagrams deepen our understanding of IPV dynamics, documentation samples improve our recording accuracy, and referral charts ensure no resource is overlooked. These aids complement our clinical skills, enabling clearer communication and education for both the healthcare team and the patients we aim to empower and protect.

Sources: (All sources are high-quality and authoritative, numbered [800+] per textbook convention)

[800] Centers for Disease Control and Prevention. What are child abuse and neglect? – Defines types of child abuse (physical, sexual, emotional, neglect) and gives examples​cdc.gov​cdc.gov.

[801] Wisconsin Dept. of Health Services (2016). Abuse, Neglect, and Exploitation: What to Look For – Describes definitions and detailed signs of physical, emotional abuse and neglect across populations​dhs.wisconsin.gov​dhs.wisconsin.gov.

[802] Open RN Nursing Textbook (Ernstmeyer & Christman, 2022). Nursing: Mental Health and Community Concepts – Abuse and Neglect – Provides signs of abuse/neglect in children and elders, including injury patterns and behaviors​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov.

[803] Texas DFPS. Recognize the Signs of Child Abuse – Lists behavioral and physical indicators of child abuse by type (physical, sexual, emotional, neglect)​dfps.texas.gov​dfps.texas.gov.

[804] Cleveland Clinic Consult QD (Reali-Sorrell & Rivchun, 2023). Spotting Hidden Signs of Domestic Violence – Highlights subtle and overt clinical clues of IPV (injuries, delays in care, controlling partner behavior, psychosomatic complaints)​consultqd.clevelandclinic.org​consultqd.clevelandclinic.org.

[805] CDC – National Center for Injury Prevention (2024). About Abuse of Older Persons – Defines elder abuse types (physical, sexual, emotional, neglect, financial) and notes common signs​cdc.gov​cdc.gov.

[806] Nursing Made Incredibly Easy (Hackenberg et al., 2023). IPV and Cycle of Violence – Explains Lenore Walker’s Cycle of Violence phases and their implications​nursing.ceconnection.com​nursing.ceconnection.com.

[807] NursingCenter CE Article (Taylor, 2022). Child Abuse: Recognition, Reporting, and Response – Emphasizes nurse’s duty in identifying and reporting, and addresses emotional toll and need for self-care​nursingcenter.com​nursingcenter.com.

[808] StatPearls (Thomas & Reeves, 2023). Mandatory Reporting Laws – Summarizes U.S. mandatory reporting obligations for children, elders, and some IPV; notes state variations and legal protections​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov.

[809] American Academy of Family Physicians/USPSTF (2019). Screening for IPV, Elder Abuse – Recommendation Statement – Recommends IPV screening in women, lists validated screening tools (HARK, HITS, WAST, etc.) and notes insufficient evidence for elder screening​aafp.org​aafp.org.

[810] UNC Health Beacon Program (2020). Tips for Documenting Domestic Violence – Advises on proper chart language and thorough documentation; includes the axiom “If you don’t document it, it didn’t happen.”​med.unc.edu​med.unc.edu.

[811] National Domestic Violence Hotline. Power and Control Wheel – Visual depiction of abusive tactics used in IPV relationships, developed by Domestic Abuse Intervention Programs (Duluth)​thehotline.org​thehotline.org.

[812] National Institute on Aging (2018). Spotting Signs of Elder Abuse Infographic – Highlights key physical signs of elder abuse/neglect (weight loss, missing aids, injuries, poor hygiene, unattended needs)【105†】.

[813] Child Welfare Information Gateway (HHS Children’s Bureau, 2019). Recognizing Child Abuse and Neglect – Outlines common signs by abuse type, used as basis for many educational materials​orangecountygov.com​orangecountygov.com.

[814] Substance Abuse and Mental Health Services Administration (SAMHSA, 2014). Trauma-Informed Care: Six Principles – Describes the core principles (Safety, Trust, Peer Support, Collaboration, Empowerment, Cultural Issues) guiding trauma-informed approaches​samhsa.gov.

[815] The National Child Traumatic Stress Network. Child Advocacy Centers – Explains role of CACs in coordinating medical, legal, and therapeutic services for child abuse victims (implied best practice for referrals)​ncbi.nlm.nih.gov.

[816] National Domestic Violence Hotline. Get Help – Provides 24/7 crisis intervention, safety planning, and referrals for IPV victims (hotline number 1-800-799-7233).

[817] HHS Office on Women’s Health. State Mandatory Reporting Laws for Domestic Violence – Overview indicating that a minority of states require HCPs to report IPV injuries (e.g., CA, KY)​findlaw.com​nursingoutlook.org.

[818] World Health Organization (2016). Elder Abuse Fact Sheet – Global perspective on elder abuse signs and risk factors (mirrors U.S. understanding that isolation, poor health, dependency increase risk)​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov.

[819] MedlinePlus (NIH). Intimate Partner Violence – Patient Instructions – Provides patient-friendly guidance on safety planning and resources (suitable for nurse to give patients as handout)​consultqd.clevelandclinic.org​consultqd.clevelandclinic.org.

[820] ChildHelp. National Child Abuse Hotline (1-800-422-4453) – 24/7 resource for reporting or discussing child abuse concerns, can direct callers to local CPS and support services​ncbi.nlm.nih.gov.