Intimate Partner Violence and Human Trafficking Assessment

**For educational purposes only.***

Hello, this week we cover a very heavy topic, intimate partner violence (formerly domestic violence) and human trafficking. Please take care while listening. 

These topics are difficult to face when working in healthcare, however these are real life things we can come across as you work with a variety of patient populations. 

Here we learn different types of assessment tools and what their interpretations mean. 

You can follow me @professorpoole on TikTok and at Rosie the Riveting RN on Instagram as well!

If you have any topics you would like for me to cover, you can contact me at rosietherivetingrn@yahoo.com

I do offer tutoring which can be found at superprof.com, just search Brianne Poole and you can set up a time!

Transcript

SPEAKER_00: 0:09

Hello, and welcome to this episode of Rosie the Riveting RN. I am Professor Poole, and I am here today to help you make those really hard concepts that are taught in health assessment and piece it together. So today what we're going to be talking about is a very difficult topic. So I ask you to listen with care. It is family violence and human trafficking. So we're going to just go in and dive in on into it. Domestic violence, the term has actually been changed recently to IPV, which is intimate partner violence. So just know that IPV, intimate partner violence is the same thing as domestic violence. There are four main categories of IPV. It's physical, sexual, stalking, and psychosocial aggression. So that physical category is going to be a force causing injury, disability, or death and sexual is attempted or completed nonconsensual sexual acts. This can be rape exposure or unwanted contact. Stalking is repeated unwanted attention that causes fear. And then psychosocial aggression is that emotional abuse with verbal or nonverbal communication. Now there also is something called elder abuse, which unfortunately you are probably going to come cross as you start practicing as a registered nurse. So elder abuse, it is intentional and failure to act with any good intentions for the patient. Like all your intentions are not with the benefit of the patient in mind. They are self-serving for only yours. Now, the categories and components for elderly abuse is going to be physical, which is assaulted, threatened with a weapon or inappropriately restraint of the patient, sexual abuse or sexual contact that is against the patient's will or the person is unable to consent. Unfortunately, this does happen to our elderly patients who can't speak up for themselves or they don't even understand what's happening. Psychological or emotional abuse can occur and that is when there are verbal and nonverbal ways to cause distress Fear. humiliation, isolation, or even control of the elderly patient. Neglect is the failure of the caregiver to provide any of the basic needs of the patient, whether that is hygiene, medical care, that can be medicine, compliance, food, stuff like that. Financial abuse or exploitation. Unfortunately, this does happen. This is when there is unauthorized use or improper use or unauthorized authorized use or control of finances while the person who is committing this financial abuse is completely benefiting from this. now there's also something called human trafficking and what is that so basically this is your modern day slavery this can happen by convincing a person to perform acts of labor or maybe even services this could be sexual this could be not sexual it's not always going to be sexual every single time usually the um The victim is going to be promised some type of protection or a better way of life. Basically, oh, you're going to get more money or we're going to go places and all that stuff. And trafficking, it's not necessarily moving a person to very different locations, to a different country, state or city. There have been incidences where the victim is actually found blocks away from the family and the family had absolutely no idea This can be in various industries, this can be in hospitality, this can be in the adult industry, this can be in agriculture, this can be in a number of things. And unfortunately, human trafficking, it does cause severe mental illness and it can be very difficult for us as healthcare providers to really catch. This can be because the patient is terrified to say anything. Maybe the trafficker is around, making sure the patient doesn't say anything, or maybe the trafficker is truly brainwashed and they don't believe that they are trafficked. So it can be very difficult. Now there are some effects that can happen with violence, right? So an immediate effect of violence would be trauma or injuries to the patient. Now that can be bruises, lacerations, you name it. But then there are also chronic effects of physical or any type of abuse, right? And that can be cardiovascular disease. Your endocrine system can be affected. This can cause immune issues. You're more susceptible to being sick, GI issues, and then women who are pregnant are at a higher risk. Now, let me go back and explain that chronic. Why is cardiovascular, endocrine, and immune, and GI issues prevalent in patients with any type of violence. The reason why is because you want to remember this. Dis-ease causes disease. You're in a heightened state of fear and stress. And stress totally wreaks havoc on your body. On your cardiovascular disease, you're at a higher risk of hypertension, CAD, PAD, DVTs, strokes. Heart attacks, heart failure, you name it. Your endocrine system can be off. Your hormones can be totally off. Stress can induce some other illnesses as well. I mean, your cortisol is elevated. That's affected by the endocrine system. GI issues as well. And then... And so that's how chronic illnesses can actually be tied to violence. Now, substance abuse is pretty prevalent in those who have experienced violence or even sex trafficking, or well, any human trafficking, I should say. This can actually cause low birth weights if you're being abused or experiencing violence and you are pregnant. While you're pregnant and you are experiencing violence or abuse, you can actually experience early deliveries, stillborns, miscarriages, and then unfortunately your child is also at a very high risk of experiencing child abuse as well. The cycle tends to continue. There are something called societal stressors, and these are contributes that delay struggles. So this can be poverty, racism, fear of discrimination. These are societal stressors and patients who do experience this do have a higher incidence of cardiovascular disease and so forth. These patients are also gonna be at a higher risk of not having access to appropriate healthcare or have good health literacy or there may be some other things going on and all these patients are at a higher risk of some type of violence or even human trafficking. Now the legal status of the patient can actually play a role as well. So women may not know legal rights or resources, especially if they're not born and raised here in the United States. they may not know that there's opportunities for help that there's shelters that they could go to or if they're an illegal immigrant they may be terrified to ask for help because they're afraid of what's going to happen to them if they come forward and so forth plus they may not know our culture either or even speak our language very well so then there's that whole aspect too and what feels familiar is their home but unfortunately that's more than likely where that abuse is going to be experienced we can also as as health care providers we may not be culturally competent in their specific culture and understand what their needs are and so we can give like really poor cultural care for those patients Now, patients of the LBGTQ community, they unfortunately are also at a very high risk of abuse and being trafficked. And so there's also that whole aspect that you need to worry about as well. Now, I've gone over the down and dirty of LBGTQ. intimate partner violence, elderly abuse, as well as human trafficking. But now what do you do with documentation? If you have a patient of these populations in front of you, okay, well now what do you do? How do you document this? Really, you document everything verbatim, absolutely verbatim. If a patient says something, you chart it, you put it in a quotation, and you write down exactly what that patient said. Even if the alleged abuser is in there, you also, you write everything down. Everything you see, everything you observe, you write it down. Your charting cannot be biased. Whether or not you believe the person, that does not matter. Absolutely doesn't matter. You don't need to believe anybody in order to document anything appropriately. All you need to do is document verbatim. You document everything as it happened. It is factual. You have everything that is detailed. All notes are detailed. You can do injury mapping, like you can look at different injuries. And do they make sense? Do they not make sense? Are they of different healing phases? That can be a sign of abuse. Now, as nurses, we do tend to understand different phases of healing for bruises, but we do not document what the phase is. And what I mean when I say that is we don't document, oh, an old wound or an old injury. old bruise, right? We document the location. We document how big it is, shape, and then the color. That is what we document. We don't document if we believe that it's a brand new bruise. We don't document if we believe it's a week old. We don't do that. A doctor can do that. Other things that we can do for very, very, very accurate charting is photography. So we can actually take pictures of the injuries, but make sure prior to doing this, you get the patient's consent signed. You have to get a patient's consent to take any pictures, even though those pictures are going into the patient's chart. You want to make sure that that consent is in the chart prior to doing any type of pictures. Now, Who needs to be screened for any type of abuse? Now, since women, especially women of childbearing age, are at a higher risk of intimate partner violence, they need to be screened. So patients with the ages of 14 to 46 should all be screened. And when do you report abuse? When abuse is actually suspected. You don't need hardcore evidence. You don't need the patient's consent to report it. You as a registered nurse are a mandated reporter and you have a duty to actually report that. So the key thing with any type of abuse, you want to hopefully report catch it early on, and that way we decrease long-term risks and effects. Now, those would be like those chronic side effects like cardiovascular disease, endocrine disease, immune, as well as GI distress, but it can also be saving a patient's life as well, or the children's life, right? there is an assessments tool that we can do. It's called HITS, H-I-T-S, and that stands for Hurt, Insults, Threaten, Screams. Now, this is a four-question screening tool. Each question is scored zero to five, zero being never, five being always and basically what you're asking is does your partner hurt you does your partner insult you like questions like that threaten you scream and so forth and then the patient scores it like oh one zero whatever they want to score it and then if a patient scores above a 10 that is indicative of abuse right and then remember you are a mandated reporter you need to report that so Then what we need to do after this screening is ask those open-ended questions. And the reason why you don't want to ask those closed-ended questions, those yes or no questions, is because you need as much information as possible from that patient. So that's why you need those open-ended questions. Now, for elderly abuse, you really need to think about financial abuse. Unfortunately, that That very, very commonly happens. So we can use a tool and it is called the Elder Abuse Suspicion Index. This basically is going to assess for any signs of abuse. This can be poor eye contact, malnutrition, poor hygiene, any type of injuries, neglect, poor medication compliance, forcing to sign documents, psychosocial and sexual abuse. However, the patient does need to be cognitively sound, meaning they can't have any type of delirium or dementia or any type of mental distress, right? They have to be cognitively sound to get an accurate response. Otherwise, you can't do this screening, unfortunately. Now for human trafficking, there is absolutely no standard screening tool that is used throughout the country. There's little to no training on recognition or any type of interventions for human trafficking really. Victims can routinely see doctors and doctors might not have any idea that this patient is being human trafficked in any way, shape, or form. It is very hard to catch. Some providers may use what's called the HEAL protocol, H-E-A-L. heel protocol, or they may use something called the adult human trafficking screening tool and guide. But again, a lot of providers these days, they don't really know that that is available and they don't know what to do with it. And then, okay, so what if it comes out positive, but then what? The patient's an adult, they can make their own decisions to go back. What do you, I mean, what do you do? So it makes it really, really difficult. So that's kind of your subjective data. So your objective data, the key thing is that great head-to-toe assessment. This is why a head-to-toe, all your assessment skills are so important. So doing a really, really good assessment is gonna be really helpful for these patients. You do wanna know what their baseline measurements are, like their vital signs and their labs. You may wanna collect labs as well, especially if you're expecting, suspecting any type of malnutrition or substance abuse or something. You want to know any medications that they may be taking as well as comorbidities as well, because sometimes there are comorbidities or even medications that can cause bruising of various stages. And so that can be like blood thinners or even coagulation issues, right? Like if you have thrombocytopenia, like you have low platelets or prolonged bleeding times, you can bruise very easily. So then you always want to wrap around and find a reason why does this patient have a lot of bruising do you fall a lot do you bump into things or you know do you they look like that they are um like cigarette burns? Does it look like they got burned by something else? Or are they like fingerprints and stuff like that? So those are things that you would look out for. Anybody who is suspected of sexual abuse should be tested for any STI. Now, remember for HIV testing, you actually do need the patient's consent. That is one that you do need a consent for. Those of childbearing age, they will need to be checked for pregnancy tests. Now, once again, with bruises, you're gonna want to document the color, size, shape, pattern, but do not try to determine the timing of the injury or like based off the appearance, like, oh, this looks like this has been one week. That's not good charting, just straight up. What is the size, color, shape, pattern? And you don't want to just assume what this could have caused. You can't do that. As a nurse, you cannot do that. So you just do the size, shape, color, and then the location of the bruise. Now, there are some key words. So bruise can be used interchangeably with contusion. Those can be one of the same. A laceration is related to an avulsion. Echemosis is related to senile purpa. Now remember, there are elderly people who do bruise very easily and you can't see that on the back of their hands. So you also want to take the patient's age into consideration when you're looking at any type of bruises. Petechiae. Petechiae is those little red spots that you may see and those are signs of like little capillaries bursting. And there's also perpa. Perpa is where those petechiae start to connect and it's a little bit bigger. Petechiae behind the ear, that can be a sign of abuse and some type of hitting on that ear. And that can be very painful in the patient. Rug burns is better documented as a friction abrasion. It's more accurate than just saying rug burn in your documentation. So when you're documenting any type of injury that looks like a friction abrasion, that's the term you want to go with. You don't want to go with rug burn because you don't know if they were actually dragged on a rug. Incision can be used interchangeably with a cut. That is safe charting. And then a cut can also be used interchangeably with any sharp injury. Stab wounds, of course, those are going to be deep penetrating sharp injuries. And then a hematoma is a collection of blood that is often but not always caused by blunt force trauma. So there's a couple different key terms to know. Now, we do know that with bruises, they do change color. They do often progress from purple-blue to bluish-green, greenish-brown to brownish-yellow. However, once again, you only document the color, size, shape, and location. It is not up to you. The registered nurse determine the lifeline, like how long that patient has had that bruising. Other medications that can cause increased bruising or bleeding can not only be those anticoagulants, but also NSAIDs as well. Also ginkgo and garlic can cause progressed bleeding times. And then any type of like chemotherapy can decrease your platelet count and that can actually cause you to have increased bleeding as well. So We do know that there are a lot of issues and risks that come along with abuse, any type of abuse. And unfortunately, homicide, that is a huge risk. So to assess the chances of homicide, we're going to use what is called the danger assessment. And it is a yes or no questionnaire. And basically it is a 20 question questionnaire. And then you count how many yeses, right? So basically you use a calendar. you present a calendar to the patient. And then you say, please mark the appropriate dates that, or all the dates where you experienced some type of abuse by your partner or ex-partner or whatever. This can be slapping, pushing, no injuries. This can be pain, no pain, punching, kicking, verbal abuse, anything. And one through 20, again, It is a yes or no. And then you add up all of the yeses. There is no particular cutoff amount of X amount of yeses mean, yeah, you're being abused. No, you're not being abused, right? There's no cutoff. Basically what this is, this is to help open the patient's eyes because with a calendar, they can actually look at how frequently they are experiencing abuse. And it might be more than they They really realize. And also, the more yeses there are tells us how bad the abuse is. And then what we can do is that we can basically set them up with resources and information and shelters and so forth that can help them, one, stay alive, and then two, get to safety. Now, whether or not they follow through with those recommendations, I feel like that's more of the hard part. I mean, you can offer these resources, but ultimately this is an adult and they can make the decision to go back. You just want to document absolutely everything that you did with this person. Now, unfortunately, more than 70% of murder-suicide cases are related to intimate partner violence. And the majority of that, about 94% of that, those victims are female. And if there is any type of gun present in the home, that risk of homicide increases by 500%. Those who are of minorities, they are at a very, very high risk of experiencing homicide with abuse. And then failure to routinely assess for intimate partner violence, that is absolutely a disservice to the patient. And then where we could have possibly done a screening, like the danger assessment, and we could have allowed the patient to have an opportunity for an eye-opening moment and possibly save their life. So there's that. I know this is not like a fun lecture, so I'm sorry. So human trafficking, what are your risk factors for human trafficking? It's those who are homeless, like they're kind of down on their luck. They have nowhere to go. They're a runaway youth. Those of the LBGTQ community are at a very high risk of human trafficking. Those who have no financial means and support. lack of legal status right you're an illegal immigrant you're more likely to be human trafficked unfortunately and those who are minority those who have a history of abuse any type of lack of family support you're at a higher risk of human trafficking and those who have any type of substance abuse regardless if that's drugs or alcohol or if there's some mental health um issues you are at a higher risk of human trafficking And some signs of human trafficking could be, no, key word is could be. This is not like a given thing because this can be a number of things too. But signs that could indicate human trafficking is if the patient delays medical care, their stories are absolutely inconsistent with the injuries and how they are presenting to the doctor or whatever. There's bruises of various types of or other injuries of various phases of healing. The patient is completely withdrawn. There is some type of self-mutilation. There also could be branding like tattoo branding or even like brand like you know like that burning of like the the cows and stuff like that can happen as well they can be a hyper sexualized that can also be a sign of human trafficking they can be malnourished unaware of really where they are what time it is um not be aware of the date Poor hygiene is also something that we can see as well, or even be hesitant to answer any type of questions. If a patient seems to have a rehearsed answer or response, this can be a indication of either human trafficking or either any type of abuse, whether it's physical, emotional, all that stuff. So those are some of the signs that can indicate that the patient is not safe. And what you would want to do is get that patient away from their alleged abuser. If they did come in with somebody into the ER, hospital, whatever, the best thing to do is really separate them from whoever the other person is so that we can get all the details that we need and hopefully we can follow through with what this patient needs to be safe, right? So this is your human trafficking, episode. I'm sorry, I know it's a pretty Debbie Downer episode, I know, but these are very, very important things to be very aware of. You can definitely see this in your patients, and it's important to know what your resources are and what your scope of practice is so that you can safely help these patients. So I hope you guys have a great day. I hope you were able to take something away with you today. Please let me know if you have any topics that you want me to cover. Please like, rate, subscribe, and comment. That really does help. And please share this with your other nursing friends, whether they're in the same school or a different school. I would greatly appreciate it. And I hope you have a great day. Bye-bye.