Assessment

Diagnosis

Inference

Planning

Interventions

Rationale

Evaluation

Subjective:

Rape trauma
syndrome

Traumatic event
(rape)

After 1 week of
nursing
interventions, the
patient will be
able to:

Assess for
statements of
guilt or self-blame
or own survival

The person may

feel responsible
for event. The
persons religious
or cultural
heritage may
support feelings of
guilt or shame
related to
behavior during
the traumatic
event.

After 1 week of
nursing
interventions, goal
met. Patient was
able to experience
decreased
symptoms of
anxiety; express
feelings
concerning the
assault and the
treatment and
build a support
system.

I always have
flashbacks of what
happened, I feel
like its happening
again and again,
as verbalized by
the patient

Objectives:

Response of
victim to rape
(psychological
trauma)

signs of sufferings
(symptoms)

difficulty in
sleeping
Loss of
appetite
Crying more
than usual
Restlessness

disruptions to
normal physical,
emotional,
cognitive, and
interpersonal
behavior

Experience
decreased
symptoms of
anxiety
Express
feelings
concerning the
assault and the
treatment

Identify fearful
reactions or hyper
vigilance to
ordinary objects
or situations

Identify
members of
support and
utilize them
appropriately

symptoms are
grouped as a
pattern over time

Assess the
presence and
degree of suicidal
ideation including
a plan, means,
past attempts,

Ordinary objects
and situations
may cause the
person to
experience
feelings from the
original traumatic
event. The person
may startle easily
or respond
aggressively in
response to these
situations

Feelings of guilt,
self-worth as a
survivor, or

rape trauma
syndrome

family history, and

ability to agree to
a contract for
safety

Assess
effectiveness of
relationships with
family, friends and
co-workers

Monitor sleep
patterns and vital
signs routinely

depression may
lead to thoughts
of suicide. A
thorough
assessment
results in early
identification and
intervention to
prevent self-harm

A person who has

experienced
trauma is more
likely to react
aggressively with
family members,
leading to
domestic violence.
Family members,
friends and coworkers may not
know how to
effectively provide
support. They
may be overly
attentive or
withdrawn. Either
type of reaction is
not supportive to
the person
experiencing
trauma.

Establish trust by
being
nonjudgmental
and hones; offer
empathy and
support; allow
person to feel a
sense of control

Assure patient
that her feelings
and behaviors are
typical following a
traumatic event

Maintain safety for

the patient and
his or her
environment

Sleep disturbance
is a common
manifestation of a
rape trauma
victim. Increased
temperature,
heart rate,
respirations and
blood pressure
can indicate
increase in
feelings of anxiety

Developing trust
following trauma
may be difficult
for patients

Patients often
believe they are
guilt for the event
and that they are
going crazy. The
person needs to
understand that
her feelings are a
normal response

to an
extraordinary
event
Encourage
adaptive coping
behaviors based
on past successes

Encourage the
establishment or
reestablishment of
healthy
relationships

Monitor
adherence to
prescribed
medication
regimen

Teach anxiety
reducing
strategies
(mindful
meditation, slow

A patients
anxiety can
escalate to panic,
and she can
become suicidal
or outwardly
violent

Patients are often

guilty about past
behaviors and
judgments toward
themselves

Relationships may
have been
negatively
affected by
patients feelings
of detachment

Adherence to
prescribed
medications can
prevent or lessen

deep breathing
exercise,
progressive
relaxation, visual
imagery etc)

exacerbation of
symptoms

These activities
assist in lessening
anxiety and its
related
components.
Knowledge and
use of them
increases the
patients control
over the disorder.