Assessment Diagnosis Inference Planning Interventions Rationale Evaluation
Subjective: Rape trauma Traumatic event (rape) After 1 week of Assess for statements The person may feel After 1 week of nursing
syndrome nursing interventions, of guilt or self-blame responsible for event. interventions, goal
“I always have
the patient will be able or own survival The person’s religious met. Patient was able
flashbacks of what
Response of victim to to: or cultural heritage to experience
happened, I feel like
rape (psychological may support feelings decreased symptoms
it’s happening again Experience
trauma) of guilt or shame of anxiety; express
and again,” as decreased
related to behavior feelings concerning the
verbalized by the symptoms of
during the traumatic assault and the
patient anxiety
signs of sufferings event. treatment and build a
(symptoms) Express feelings support system.
Identify fearful Ordinary objects and
concerning the
Objectives: reactions or hyper situations may cause
assault and the
vigilance to ordinary the person to
difficulty in treatment
experience feelings
objects or situations
sleeping
disruptions to normal Identify members from the original
Loss of appetite physical, emotional, of support and traumatic event. The
cognitive, and utilize them person may startle
Crying more than appropriately easily or respond
interpersonal behavior
usual aggressively in
Restlessness response to these
situations
symptoms are grouped
Assess the presence
as a pattern over time Feelings of guilt, self-
and degree of suicidal
worth as a survivor, or
ideation including a
depression may lead
plan, means, past
rape trauma syndrome to thoughts of suicide.
attempts, family
A thorough
history, and ability to
assessment results in
agree to a contract for
safety early identification and
intervention to
prevent self-harm
Assess effectiveness of
A person who has
relationships with
experienced trauma is
family, friends and co-
more likely to react
workers
aggressively with
family members,
leading to domestic
violence. Family
members, friends and
co-workers 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withdrawn.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.
Monitor sleep patterns
Sleep disturbance is a
and vital signs
common
routinely
manifestation of a
rape trauma victim.
Increased
temperature, heart
rate, respirations and
blood pressure can
indicate increase in
feelings of anxiety
Establish trust by being
Developing trust
nonjudgmental and
following trauma may
hones; offer empathy
be difficult for patients
and support; allow
person to feel a sense
of control
Assure patient that her
Patients often believe
feelings and behaviors
they are guilt for the
are typical following a
event and that they
traumatic event
are going crazy. The
person needs to
understand that her
feelings are a normal
response to an
extraordinary event
Maintain safety for the
patient and his or her A patient’s anxiety can
environment escalate to panic, and
she can become
suicidal or outwardly
violent
Encourage adaptive Patients are often
coping behaviors guilty about past
based on past behaviors and
successes judgments toward
themselves
Encourage the
establishment or Relationships may
reestablishment of have been negatively
healthy relationships affected by patient’s
feelings of detachment
Monitor adherence to
prescribed medication Adherence to
regimen prescribed
medications can
prevent or lessen
exacerbation of
symptoms
Teach anxiety reducing
strategies (mindful These activities assist
meditation, slow deep in lessening anxiety
breathing exercise, and its related
progressive relaxation, components.
visual imagery etc) Knowledge and use of
them increases the
patient’s control over
the disorder.
