Child Abuse: The Role of the Nurse

When asked about their most difficult cases, nurses will often put victims of child abuse at the top of their list. Though no one wants to see another person suffer, there is something profoundly tragic about the suffering of a child that impacts nurses severely. Watching people cope with a cancer diagnosis or learn that a loved one’s organs are failing is most certainly difficult for any nurse no matter how seasoned. We are hardwired to save lives, and when we can’t, the loss is felt deeply. But the maltreatment of a child takes a far more emotional toll on nurses. Pediatric nurses often find it necessary to be counseled after having witnessed the effects of child abuse.

The Physically Abused Infant

It is common knowledge that toddlers are accident-prone and will lose their balance, trip over objects, and find all sorts of ways to collect bumps and bruises. But bruises on a non-ambulatory child (a child who cannot yet walk) are a red flag for healthcare workers. We ask the guardian to explain the injuries, and when they cannot, we have to gain more information about the family, like daily activities. We know that infants are not as mobile as toddlers, so if we see bruises on the earlobe, neck or truck we become suspicious, which can create a lot of stress on healthcare workers. Shaken baby syndrome is just one aspect of brain trauma inflicted on infants. An infant who presents to the emergency room with an obvious head injury and is not responsive is likely a clear-cut abuse base. But one whose symptoms are vague can require more detective work. For instance, babies who are taken to the emergency room with vomiting, lethargy, and irritability are often quickly diagnosed with viral or respiratory illnesses. And often it is the case that the infant is simply sick. But these symptoms can also exist in a baby with a head injury. Testing should be considered for any infant presenting with these symptoms and is accompanied by parents/guardians who are acting “funny”.

Child Sexual Abuse

Child sexual abuse cases are very hard to swallow as well. It’s hard for us to rule out these findings as kids often don’t report it immediately, giving injuries time to heal. Some acts such as fondling and oral sex do not cause physical damage, and 80% of these reported cases often come back negative. Lack of physical evidence does not mean that abuse did not occur. In such cases, it is imperative that a thorough history and forensic interview take place.

Burn Injuries

I spent my first 10 years of nursing working in a pediatric burn ICU. During that decade, I learned firsthand how calculated child abuse could be. As stated above, pediatric nursing takes a harsh emotional toll on nurses every day. But there is something profoundly disturbing about an adult who could inflict a burn injury on a child. During my time in the burn unit, I quickly learned to recognize the signs of abuse. For any nurses who may be working in burn units or pediatric emergency rooms, there are specific injuries that should raise suspicion.

First, circumferential burns go all the way around a body part. Most of the time the mechanism of injury can rule out the possibility of abuse. For example, was this a teenager trapped in a burning car? If so, the injury makes sense. Or are the parents trying to say that a toddler pulled a hot cup of coffee off a table? If so, does this story explain why both legs have circumferential burns?

Second, are lines of clear demarcation, which we call “sock burns,” a distinct line between burned skin and unaffected skin. It looks as though the burned feet/lower legs have “socks” on. This is usually what happens with young children intentionally scalded in bathtubs. A young child held in scalding water will present with a sock-like appearance to both legs.

Reporting Child Abuse

Nurses are a vital link in child safety as dedicated, diligent, responsible reporters of abuse. As mandated reporters, nurses must act in situations where abuse is suspected, and always think about the child discharged from their care and possibly sent back home with an abuser. Failure to act on behalf of the victim could result in serious bodily injury to the child. Each state has an abuse hotline to report suspected abuse and neglect. Many hotlines respect a person’s wishes to remain anonymous. Report what you see, report what you hear, be a voice for these chronically silenced patients.

Child Abuse Reporting Numbers by State:

https://www.childwelfare.gov/organizations/?CWIGFunctionsaction=rols:main.dspList&rolType=Custom&RS_ID=5

Carolyn P. Flynn, RN

Beautiful Broken Vessels Nurse Writer