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A nurse is planning to document a conversation with a client who is preparing for a surgical

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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.

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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

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

  • 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 InterventionsRationale
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:
  1. Anxiety, depression.
  2. Insomnia.
  3. Nightmares.
  4. Phobias.
  5. 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:
  1. Blood.
  2. Combing pubic hairs.
  3. Semen samples.
  4. 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:
  1. All lab tests should be noted.
  2. Detailed observations of physical trauma.
  3. Detailed observations of emotional status.
  4. Results from the physical examination.
  5. Verbatim statements.
Accurate and detailed communication is crucial legal evidence.
Arrange for support follow-up:
  1. Crisis counseling.
  2. Group therapy.
  3. Individual therapy.
  4. Rape counselor.
  5. 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.

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Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

  • Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
    An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
  • Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
    A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
  • NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
    The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
  • Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
    Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
  • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
    Useful for creating nursing care plans related to mental health and psychiatric nursing.
  • Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
    Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
  • Maternal Newborn Nursing Care Plans (3rd Edition)
    If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
  • Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
    An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
  • All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
    Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

See also

Other recommended site resources for this nursing care plan:

  • Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
    Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
  • Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
    Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

Other care plans for mental health and psychiatric nursing:

  • Alcohol Withdrawal | 5 Care Plans
  • Anxiety and Panic Disorders | 7 Care Plans
  • Bipolar Disorders | 6 Care Plans
  • Major Depression | 9 Care Plans
  • Personality Disorders | 4 Care Plans
  • Schizophrenia | 6 Care Plans
  • Sexual Assault | 1 Care Plan
  • Substance Dependence and Abuse | 8 Care Plans
  • Suicide Behaviors | 3 Care Plans

Paul Martin is a registered nurse with a bachelor of science in nursing since 2007. Having worked as a medical-surgical nurse for five years, he handled different kinds of patients and learned how to provide individualized care to them. Now, his experiences working in the hospital is carried over to his writings to help aspiring students achieve their goals. He is currently working as a nursing instructor and have a particular interest in nursing management, emergency care, critical care, infection control, and public health. As a writer at Nurseslabs, his goal is to impart his clinical knowledge and skills to students and nurses helping them become the best version of themselves and ultimately make an impact in uplifting the nursing profession.

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nurse planning document conversation client preparing surgical

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