Sexual Assault Nursing Care Plan

October 11, 2016

Sexual assault is defined as a sexual contact or behavior that occurs against the will of the person. It is a form of a sexual violence that includes rape (a non-consensual vaginal, anal, oral penetration, done by force or threat of bodily harm), forced kissing, groping, child sexual abuse, or drug-facilitated sex.

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: Sustained maladaptive response to a forced, violent, sexual penetration against the victim’s will and consent.

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

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

Nursing Interventions	Rationale
Establish trust and rapport.	Since the victim may misinterpret any statements unrelated to her immediate situation as blaming or rejecting, the nurse should delay asking questions until the therapeutic nature is established.
Provide strict confidentiality.	The client’s situation is not to be talked over with anyone other than medical staff involved unless the client gives consent to it.
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.
Never use judgmental language.	Use the following: Reported not alleged. Declined not refused. Penetration not intercourse.
Have someone stay with the client (friend, neighbor, or staff member) while he or she waiting to be treated.	People in high levels of anxiety needs to feel physical safety by providing someone by his/her side until anxiety level is down to moderate.
Stress that they did the right thing to save their life.	Rape victims might feel guilt and shame. Reinforcing that they did what they had to do to stay alive can reduce guilt and maintain self-esteem.
Encourage verbalization.	When people feel understood, they feel more in control of their situations.
Explain to the client signs and symptoms that many people experience during the long-term phase, for example: Anxiety, depression. Insomnia. Nightmares. Phobias. Somatic symptoms.	Many individuals think they are going crazy as time goes on and are not aware that this is a process that many people in their situation have experienced.
*Forensic Examination and Issues:*
Assess the signs and symptoms of physical trauma.	More common injuries are to face, head, neck extremities.
Make a body map to identify size, color, and location of injuries. Ask permission to take photos.	Accurate records and photos that can be used as medicolegal evidence for the future.
Carefully explain all procedures before doing them (e.g., “I will perform a vaginal examination and do a swab. Have you had a vaginal examination before?” [rectal examination in case of a male who has been raped]).	The individual is experiencing high levels of anxiety. Matter-of-fact explaining what you plan to do and why you are doing it can help reduce fear and anxiety.
Explain the forensic specimens you plan to collect; inform client that they can be used for identification and prosecution of the rapist, for example: Blood. Combing pubic hairs. Semen samples. Skin from underneath nails.	Collecting body fluids and swabs is essential (DNA) for identifying the rapist.
Encourage the client to consider treatment and evaluation for sexually transmitted diseases before leaving the emergency department.	Many survivors are lost to follow-up after being seen in the emergency department or crisis center and will not otherwise get protection.
Many clinics offer prophylaxis to pregnancy with norgestrel (Ovral).	Approximately 3% to 5% of women who are raped become pregnant.
All data must be carefully documented: All lab tests should be noted. Detailed observations of physical trauma. Detailed observations of emotional status. Results from the physical examination. Verbatim statements.	Accurate and detailed communication is crucial legal evidence.
Arrange for support follow-up: Crisis counseling. Group therapy. Individual therapy. Rape counselor. Support group.	Many individuals carry with them constant emotional distress and trauma. Depression and suicidal ideation are frequent sequelae of rape. As soon as the intervention is carried out, the less complicated the recovery may be.