Sexual Assault Nursing Care Plan

Nursing Care Plans

The nursing care plan for clients experiencing sexual assault should include assisting the victim to seek medical attention, encouraging verbalization of the assault, informing the significant others in the victim’s life, providing safety, providing support at certain times of stress, especially during police investigations or court proceedings, and planning for follow-up contact with a crisis counselor.

Here is nursing care plans (NCP) and nursing diagnosis for sexual assault:

Rape-Trauma Syndrome

Rape trauma syndrome is a psychological response that can occur after a person experiences sexual assault. It is characterized by a range of symptoms, such as anxiety, depression, flashbacks, and difficulty sleeping. These symptoms can result from the trauma of the assault itself, as well as from societal attitudes towards sexual assault victims, which can lead to feelings of shame, guilt, and self-blame.

Nursing Diagnosis

Rape-Trauma Syndrome

May be related to

Sexual assault

Possibly evidenced by

Aggression; muscle tension
Change in relationships
Denial
Depression, anxiety
Disorganization
Dissociative disorders
Feelings of revenge
Guilt, humiliation, embarrassment
Hyperalertness
Inability to make decisions
Loss of self-esteem
Mood swings
Nightmare and sleep disturbances
Phobias
Physical trauma (e.g., bruising, tissue irritation)
Self-blame
Sexual dysfunction
Shame, shock, fear
Substance abuse
Suicide attempts
Vulnerability, helplessness

Desired Outcomes

The survivor will experience hopefulness and confidence in going ahead with life plans.
The survivor will have a resolution of anger, guilt, fear, depression, and low self-esteem.
The survivor will acknowledge the right to disclose and discuss abusive situations.
The survivor will list common physical, emotional, and social reactions that often follow a sexual assault before leaving the emergency department or crisis center.
The survivor will state the results of the physical examination completed in the emergency department or crisis center.
The survivor will speak to a community-based rape victim advocate in the emergency department or crisis center.
The survivor will have access to information on obtaining competent legal counsel.
The survivor will begin to express reactions and feelings about the assault before leaving the emergency department or crisis center.
The survivor will have a short-term plan for handling immediate situational needs before leaving the emergency department or crisis center.
The survivor will verbalize the details of the abuse.
The survivor will state that the physical symptoms (e.g., sleep disturbances, poor appetite, and physical trauma) have subsided within 3 to 5 months.
The survivor will state that the acuteness of the memory of the rape subsides with time and is less vivid and less frightening within 3 to 5 months.
The survivor will discuss the need for follow-up crisis counseling and other support.

Nursing Assessment and Rationales

Forensic Examination and Issues:

1. Assess the signs and symptoms of physical trauma.
More common injuries are to the face, head, and neck extremities.

2. Make a body map to identify the size, color, and location of injuries. Ask permission to take photos.
Accurate records and photos can be used as medicolegal evidence in the future.

3. Ensure the following data are carefully documented:
Accurate and detailed communication is crucial legal evidence.

All lab tests should be noted.
Detailed observations of physical trauma.
Detailed observations of emotional status.
Results from the physical examination.
Verbatim statements.

4. Assess the patient’s level of distress, coping strategies, and support system.
This information can also help nurses anticipate and address potential issues related to the patient’s recovery and healing process.

5. Inform the client that the following will be used for the identification and prosecution of the rapist, such as blood samples, combing pubic hairs, semen samples, and skin from underneath nails.
Collecting body fluids and swabs is essential (DNA) for identifying the rapist.

Nursing Interventions and Rationales

1. Establish trust and rapport.
Since the victim may misinterpret any statements unrelated to the immediate situation as blaming or rejecting, the nurse should delay asking questions until the therapeutic nature is established.

2. Provide strict confidentiality.
The client’s situation is not to be talked over with anyone other than the medical staff involved unless the client gives consent to it.

3. Approach the client in a nonjudgmental manner.
Nurses’ attitudes can have an important therapeutic impact. Displays of shock, horror, disgust, or disbelief are not appropriate.

4. Never use judgmental language. Rather use the following language:
Using judgmental language towards a patient who has experienced rape trauma syndrome can be harmful and re-traumatizing. It can make the patient feel ashamed, blamed, or invalidated, which can further exacerbate their trauma symptoms and delay the healing process.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses is reviewed and approved by NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.