3. Battered Child
1. Assessment - clues to the identification of a battered child*
1. Clues in the history
1. Significant delay in seeking medical care.
2. Major discrepancies in the history:
1. Discrepancy between different people’s versions of the story.
2. Discrepancy between the history and the observed injuries.
3. Discrepancy between the history and the child’s developmental capabilities.
3. History of multiple emergency department visits for various injuries.
4. A story that is vague and contradictory.
2. Clues in the physical examination
1. Child who seems withdrawn, apathetic, and does not cry despite his or her injuries.
2. Child who does not turn to parents for comfort; or unusual desire to please parent; unusual fear of parent(s).
3. Child who is poorly nourished and poorly cared for.
4. The presence of bruises: multiple bruises, welts, and abrasions, especially around the trunk and buttocks; old bruises in addition to fresh ones.
5. The presence of suspicious burns:
1. Cigarette burns.
2. Scalds without splash marks or involving the buttocks, hands, or feet but sparing skinfolds.
3. Rope marks.
6. Clues in parent behavior - exaggerate care and concern.
2. Analysis/nursing diagnosis:
1. Same as for battered woman.
2. Altered parenting related to poor role model/identity, unrealistic expectations, presence of stressors and lack of support.
3. Low self-esteem related to deprivation and negative feedback.
3. Nursing care plan/implementation:
1. Same as for battered woman.
2. Report suspected child abuse to appropriate source.
3. Conduct assessment interview in private, with child and parent separated.
4. Be supportive and nonjudgmental.
4. Evaluation/outcome criteria:
1. Same as battered woman.
2. Child safety has been ensured.
3. Parent(s) or caregivers have agreed to seek help.


4. Sexual Abuse of Children
1. Assessment - characteristic behaviors:
1. Relationship of offender to victim: many filling paternal role (uncle, grandfather, cousin) with repeated, unquestioned access to the child.
2. Methods of pressuring victim into sexual activity: offering material goods, misrepresenting moral standards (“it’s OK”), exploiting need for human contact and warmth.
3. Method of pressuring victim to secrecy (to conceal the act) is inducing fear of punishment, not being believed, rejection, being blamed for the activity, abandonment.
4. Disclosure of sexual activity via:
1. Direct visual or verbal confrontation and observation by others.
2. Verbalization of act by victim.
3. Visible clues: excess money and candy, new clothes, pictures, notes.
4. Signs and symptoms: bed-wetting, excessive bathing, tears, avoiding school, somatic distress (GI and urinary tract pains).
5. Overly solicitous parental attitude toward child.
2. Analysis/nursing diagnosis:
1. Altered protection related to inflicted pain.
2. Risk for injury related to neglect, abuse.
3. Personal identity disturbance related to abuse as child and feeling guilty and responsible for being a victim.
4. Ineffective individual coping related to high stress level.
5. Sleep pattern disturbance related to traumatic sexual experiences.
6. Ineffective family coping.
7. Altered family processes related to use of violence.
8. Altered parenting related to violence.
9. Powerlessness related to feelings of being dependent on abuser.
10. Social isolation/withdrawal related to shame about family violence.
11. Risk for altered abuse response patterns.
3. Nursing care plan/implementation:
1. Establish safe environment and the termination of trauma.
2. Encourage child to verbalize feelings about incident to dispel tension built up by secrecy.
3. Ask child to draw a picture or use dolls and toys to show what happened.
4. Observe for symptoms over a period of time.
1. Phobic reactions when seeing or hearing offender’s name.
2. Sleep pattern changes, recurrent dreams, nightmares.
5. Look for silent reaction to being an accessory to sex (i.e., child keeping burden of the secret activity within self); help deal with unresolved issues.
6. Establish therapeutic alliance with abusive parent.
7. Health teaching:
1. Teach child that his (her) body is private and to inform a responsible adult when someone violates privacy without consent.
2. Teach adults in family to respond to victim with sensitivity, support, and concern.
4. Evaluation/outcome criteria:
1. Child’s needs for affection, attention, personal recognition, or love met without sexual exploitation.
2. Perpetrator accepts therapy.
3. Conspiracy of silence is broken.

Estimation of Time at Which Soft Tissue Injury Occurred