nursing care in child abuse

 child abuse

Definition

 Child abuse or wrong treatment of children is defined as any child abuse or adolens by parents, guardians, or others who sought to preserve, maintain, and care for them.Child abuse is an act or acts of negligence parents or carers of children who lead children to become mentally or physically impaired, emotional development, and child development in general.While according to the U.S. Department of Health, Education and Child abuse Wolfare definition as a physical or mental violence, sexual violence and neglect against children under the age of 18 made by people who should be responsible for the welfare of children, so safety and welfare of children is threatened.
ClassificationThere are two major categories, namely:In familiesPhysical abuse, non Accidental "injury" ranging from mild "Bruiser laceration" to the severe neurological trauma and death. Physical injury as a result of corporal punishment out of bounds, giving cruelty or toxins.Penelantantaran child / neglect, namely: direct an activity or behavior that may cause deleterious effects on children's physical condition and psychological development. Negligence can be:v Maintenance inadequate. Cause failure to thrive, children feel the loss of affection, psychiatric disorders, developmental delayv Inadequate Supervision. Cause the child fail at risk for the occurrence of physical and mental trauma.v Failure to get treatmentv Failure in treating children wellv Negligence in education, including a failure to educate children to be able to interact with its environment, or have failed to send their children to earn a living for the family that the child was forced to drop out of school.
Emotional maltreatmentMarked by fire / words that are degrading the child, does not recognize as a child. Persecution like this are almost always followed by other forms of persecution.Sexual abuse to use a persuasive approach. Coercion on the person taking the child to behave / conduct a real sexual activity, so that depict activities such as: sexual activity (oral-genital, genital, anal, or sodomy), including incest.OutdoorsIn institutions / agencies, in workplaces, on the road, on the battlefield.

Etiology 

There are several factors that cause children experiencing violence. Both physical violence and psychological violence, including:Stress stemming from the child.
a. Physically different, is physically different is the physical condition of children is different from other children. Examples can be seen is the child has a physical disability. Children have physical abnormalities and different from other children who have perfect physical.
b. Mentally different, that is mentally retarded child so the child has developmental problems and difficulty interacting with the surrounding environment. 
c. Different temperament, a child with a weak temperament tend to experience a lot of violence when compared with children who have a strong temperament. This is because the child who has a hard temperament tend to fight when compared to the weak-tempered child. 
d. Behave differently, ie the child has a behavior that is not reasonable and different from other children. For example a child behaving and acting strangely in the family and the neighborhood. 
e. Adopted children, adopted children tend to get rough treatment because parents assume that the adopted child is not the baby of the marriage itself, so instinctively there is no strong emotional ties between foster children and parents.

Family stress.
a. Poverty and unemployment, both of these factors are the strongest factors that cause violence in children, because these two factors strongly associated with survival. So anything will be done by parents, especially for the sake of earning his living, including having to sacrifice family.
b. Mobility, isolation, and inadequate housing, these three factors also greatly affect the occurrence of child abuse, because the environment sekitarlah the biggest factor in shaping personality and behavior of children. 
c. Divorce, divorce cause stress in children, because children will lose the affection of both parents.d. Children are not expected, this will also result in the emergence of violent behavior in children, because children do not correspond with what is desired by parents, for example lack of physical, mental weakness, and so on.
3. Stress comes from the parents, namely: 
a. Low self-esteem, children with low self-esteem will often get violent, because the child always feels useless and always disappointing others. 
b. As a child gets abuse, parents who experienced abuse in childhood will melakuakan the same thing to other people or their children as a form of impingement of the incident had ever experienced. 
c. Expectations on children that are not realistic, unrealistic expectations will make weight so that parents experience stress when unable to meet the needs of children, parents tend to make the child as an outlet for his frustration with violence.

Clinical Manifestations 

Due to the child's physicala. Abrasions, hematoma, bite wounds, burns, fractures, bleeding from 
a. subdural hematoma retinaakibat and the presence of damage in other organs. 
b. Sequel / disabled as a result of trauma, such as scarring, nerve damage, hearing loss, eye damage and other disabilities. 
c. Death.Due to the development of the child.

Growth and development of children who suffered abuse, are generally slower than normal children, namely: 
a. Physical growth of children in general less than peers who did not mendaapat anak2 mistreatment. 
b. Psychological development is also impaired, namely: 

§. Intelligence- Various studies have reported delays in cognitive development, language, reading, and motor.- Mental Retardation may result from direct trauma to the head, as well as malnutrition.- In some cases this delay is reinforced by the absence of adequate stimulation or because of emotional disorders. 
§. Emotions- There is emotional disturbance on: the development of positive self kosnep, or hostile in dealing with aggression, the development of social relationships with others, including the ability to confidently.- There was pseudomaturitas emotion. Some children become aggressive or hostile with adults, while others become withdrawn / away from the association. Children like bedwetting, hyperactivity, bizarre behavior, learning difficulties, school failure, difficulty sleeping, tempretantrum, etc..  
§ Self-conceptChildren who treated one felt ugly, unloved, unwanted, sad, and unhappy, incapable of enjoying the activity and some even attempted suicide. 
§. AggressiveChildren who receive physical mistreatment, more agresifterhadap peers. Often these actions egresif imitate their parents' actions or divert aggressive feelings to his peers as a result of poor self-concept. 
§. Social relationsIn this anak2 often less able to get along with peers or with adults. They have few friends and like to interfere with adults, for example by throwing stones or other criminal perbuatan2.As a result of sexual abuseSexual Tanda2 penganiayaan among others:Sign of trauma or local infection, such as perianal pain, vaginal secretions, and rectal bleeding.Signs of emotional disturbance, such as reduced concentration, enuresis, enkopresis, anorexia, or changes in behavior.Sexual behavior or knowledge of children who are not in accordance with age. Examination of genitalia dilakuak with respect to the vulva, hymen, and the child's anus.Munchausen SyndromePicture of this syndrome consists of symptoms:Symptoms are unusual / non-specificSymptoms appear only if there are parentsGetting treatment by her parents remarkableExcessive parental behavior.

Diagnostic Evaluation 

Diagnostic mistreatment can be enforced based on disease history, a thorough physical examination, documentation of a complete psychological history, and laboratory.Medical history and physical examinationPhysical abuseSigns patogomonik result of child abuse can be:Bruises, especially in the face, lips, mouth, ears, head, or back.Patogomonik burns and common: smoking, dipping an accomplice in hot water, or circular burns on the buttocks. Burns caused by electricity such as ovens or irons.Head trauma, such as skull fracture, intracranial trauma, retinal hemorrhages, and multiple long bone fractures with different levels of healing.Abdominal and thoracic trauma less frequently than the head trauma and bone on child abuse. Physical abuse is more dominant in children over age 2 years.NeglectNeglect of non-organic failure to Thrive, a condition that resulted in failure to follow the pattern of growth and development of children who should be, but responds well to the fulfillment of food and emotional needs of children.Medical neglect, which did not receive adequate treatment in children with chronic illness because the parent denies the child suffering from chronic diseases. Not able to immunization and other health care. Deliberate failure by the parents also include the failure to oral health care for children so that the damaged tooth.Sexual abuseTnda and symptoms of sexual abuse consists of:Painful vagina, anus, and penis as well as the presence of bleeding or secretions in the vagina.Chronic dysuria, enuresis, constipation or encopresis.Premature puberty in femalesSpecific behaviors: sexual activity with peers, animals, or a particular object. Not according to the age of the child's sexual knowledge and behavior that excites.Non-specific behavior: suicide attempts, feelings of fear in adults, nightmares, sleep disturbances, withdrawal, low self-esteem, depression, post-traumatic stress disorder, prostitution, eating disorders, etc..LaboratoryIf found bruises, bleeding need dilakuak screening. On sexual abuse, examination:Swab for analysis of acid phosphatase, spermatozoa within 72 hours after sexual abuse.Culture specimens from the oral, anal, and vaginal for genokokusTests for syphilis, HIV, and hepatitis BAnalysis of pubic hairRadiologyThere are two role of radiology in the diagnosis of abuse in children, namely to:a. Identifiaksi focus of the lesionb. Documentation
Radiological examinations in children under age 2 should be conducted to examine the bones, whereas in children over 4-5 years old need only be done if there is bone pain, limitation of movement during physical examination. The existence of multiple fractures with a cure rate of physical persecution.CT-scan is more sensitive and specific for acute and chronic cerebral lesions, only indicated in pengniayaan child or an infant who suffered severe head trauma.MRI (Magnetic Resonance Imaging) is more sensitive at the subacute and chronic lesions such as subdural and sub-arachnoid haemorrhage.Ultrasound is used to diagnose the presence of visceral lesionsColposcopy examination to evaluate children who suffered sexual abuse.

Management

Prevention and control of abuse and violence in children is through:Health servicesHealth services can perform a variety of activities and programs aimed at individuals, families, and communities.Primary prevention-goals: the promotion of parental and family welfare.Individual- Family life education in schools, places of worship, and community- Education for children about conflict resolution- Sexual education in adolescents at risk- Baby care education for adolescents who care for infants- A reference service life care- Training of professionals for early detection of violent behavior.Family- Class preparation parenting in hospitals, schools, institutions in society- Facilitate the fabric of affection on the new parent- Refer new parents at the health center nurse for follow-up (follow up)- Social services for familiesCommunity- Health education on family violence- Reduce the media containing the violence- Develop community support services, such as crisis services, shelters children / families / elderly / women who are abused- Control of holders of firearms and sharp 
§. Prevention of secondary objectives: diagnosis and action for families who stress- Individuals- Complete assessment of each incident of violence in the family in each health service- Plan of escape for victims adequately- Knowledge of sentence to ask for help and protection- Place of care or "Foster home" for the victims
§. Family- Community service for individuals and families- Refer to support groups in the community (self-help-group). For example: a group of prosperous families observer- Refer to the agency / institution in the community that provide services to victims 
§. Community- All healthcare professionals skilled at providing services to victims with a standard procedure in helping victims- Units and unit emergency services 24 hours to respond, report, service cases, coordination with law enforcement / social services for immediate service.- Tim coroner due to accidents / injuries, especially infants and children.- The role of government: police, courts, and local government- Epidemiological approach to the evaluation- Control of holders of firearms and sharpTertiary prevention-goals: redukasi and rehabilitation of families with violence 
§. Individuals- Recovery strategy strength and confidence to the victims- Professional counseling to individuals- Family- Re-education parents in the upbringing of children- Professional counseling for families- Self-help-group (group care) 
§. Community- "Foster home", a refuge- The role of the government- "Follow up" in cases of abuse and violence- Control of holders of firearms and sharpEducationThe school has the privilege of teaching a very private body part, namely the penis, vagina, anus, mammary in biology class. It should be emphasized that the part is very personal and harud maintained so as not to be disturbed others. Schools also need to improve the safety of children in school. Attitude or way of educating children also need attention in order to avoid emotional mayhem. Teachers also can help detect tanda2 physical persecution and neglect in child care.Law enforcement and securityLaw no.4 should yrs, 1979, regarding the welfare of children quickly enforced consistently. This will protect the child from all forms of abuse and violence. Chapter II, Article 2 states that "children are entitled to protection of the environment that may harm or hinder the growth and development of natural causes.Mass mediaCoverage of persecution and violence in children should be followed by artikel2 prevention and mitigation. The impact on children both short and long term prevention programs reported to be more emphasized.

Assessment

The focus of the overall assessment to establish the nursing diagnoses related to child abuse, among others:Psychosocial1) self neglect (neglect), clothes and hair dirty, smelly2) Failure to thrive3) Delays in the development of the cognitive, psychomotor, and psychosocial4) With drawl (secede) from adult orang2Musculoskeletal1) Fracture2) Dislocation3) Sprain (sprains)Genito urinary1) Urinary tract infections2) bleeding per vagina3) Injury to the vagina / penis4) Painful micturition time5) laceration to the external genetalia organs, vagina, and anus.Integumentary1) circulation lesions (usually in cases of burns due to smoking)2) burns the skin, bruising and abrasion3) The existence of a human bite tanda2 unexplained4) Swelling.

Nursing Dx 

a. Damage parenting b.d. young age, especially adolescents, lack of knowledge regarding the fulfillment of children's health and child care arrangements ketidakadekuatan. 
b. Adaptive capacity: a decrease in intracranial brain injury bd 
c. Imbalance nutrition less than body requirements include the inability bd, digest and absorb food due to psychological factors. 
d. The risk of developmental delay was caused by damage bd violence.

Intervention 

Dx I: Damage parenting b.d. young age, especially adolescents, lack of knowledge regarding the fulfillment of children's health and child care arrangements ketidakadekuatan.NOC: After nursing care then parents will be addressed in a constructive discipline, to identify effective ways to express anger or frustration that does not harm the child, and actively participate in counseling or parenting classes.
Intervention:- Support the disclosure of feelings- Help parents identify deficits or changes in parenting- Provide opportunities for interaction that is often a parent or child- Role models of parenting skills.
 
Dx II: adaptive capacity: a decrease in intracranial brain injury bdNOC: After nursing care then the client will show an increase in intracranial adaptive capacity is shown with fluid balance, electrolyte balance and acid-base. Neurological status, and neurological status: consciousness. 
Intervention:- Monitor the intracranial pressure and cerebral perfusion pressure- Monitor neurological status at regular intervals- Consider the events that stimulate a change in the wave of ICT- Determine the baseline vital signs and cardiac rhythm and monitor changes during and after activity- Teach caregivers about tanda2 indicating increased ICP (eg: increased seizure activity)- Teach caregivers about specific situations that stimulate the ICT on the client (eg, pain and anxiety); discuss appropriate interventions. 

Dx III: The imbalance nutrition less than body requirements bd inability to incorporate, digest, and absorb food due to psychological factors.NOC: After nursing care then the client will show the status gizia; intake of food, fluids, and nutrition, characterized by the following indicators (the range of values ​​1-5: inadequate, mild, moderate, strong, or adequate total).Oral diet, feeding through the tube, or total parenteral nutrition.Intake of fluids orally or IV
Intervention:- Identify faktor2 that can affect the patient's loss of appetite- Monitor laboratory values, particularly transferrin, albumin and electrolytes- Management of nutrition: to know the client's favorite food, monitor the nutritional and caloric intake on a mold, weigh the client at appropriate intervals- Teach a method for planning meals- Teach client / family about nutritious food and not expensive- Management of nutrition: give precise information about the nutritional needs and how to fulfill it.

Dx IV: The risk of developmental delay bd damage was caused by violence.