Sexual Assault Nursing Care Plan

Sexual assault is any sexual contact or behavior that happens against a person's will. It covers rape (non-consensual vaginal, anal, or oral penetration by force or threat), forced kissing, groping, child sexual abuse, and drug-facilitated assault.

Nursing Care Plans and Management

Your job with a survivor runs on several tracks at once: get them medical attention, keep them physically safe, let them talk through the assault on their terms, support them through high-stress moments like police interviews and court, and set up followup with a crisis counselor before they leave.

Nursing Problem Priorities

1. Physical safety and medical care. Treat injuries and secure the patient's immediate physical wellbeing.
2. Trauma-informed emotional support. Build a safe space for disclosure without pressure.
3. Forensic evidence collection. Gather and document evidence carefully so it holds up in court.
4. Risk assessment and safety planning. Address the risk of further harm or re-victimization.
5. Referral to support services. Connect the survivor to counseling, crisis hotlines, support groups, and legal advocacy.

Nursing Assessment

See the assessment cues under Nursing Interventions and Actions.

Nursing Diagnosis

Form the diagnosis from your assessment and clinical judgment. The label matters less than matching care to what this patient in front of you actually needs.

Nursing Goals

Goals and expected outcomes may include:

• The survivor expresses hope and confidence about moving forward with life plans.
• The survivor works toward resolving anger, guilt, fear, depression, and low self-esteem.
• The survivor acknowledges the right to disclose and discuss the assault.
• Before leaving the emergency department or crisis center, the survivor can list common physical, emotional, and social reactions that follow an assault, states the results of the physical exam, speaks with a community-based rape victim advocate, begins expressing feelings about the assault, and has a short-term plan for immediate needs.
• The survivor has access to information on competent legal counsel.
• The survivor verbalizes the details of the abuse.
• The survivor states that physical symptoms (sleep disturbance, poor appetite, physical trauma) subside within 3 to 5 months.
• The survivor states that the memory of the assault grows less vivid and less frightening within 3 to 5 months.
• The survivor discusses the need for followup crisis counseling and other support.

Nursing Interventions and Actions

1. Assess for physical trauma. The most common injuries are to the face, head, neck, and extremities.

2. Make a body map of injuries (size, color, location) and ask permission before taking photos. Accurate records and photos serve as medicolegal evidence later.

3. Document carefully. This is legal evidence. Note all lab tests, detailed observations of physical trauma and emotional status, results from the physical exam, and the patient's verbatim statements.

4. Assess the patient's distress level, coping strategies, and support system. This helps you anticipate problems in recovery and healing.

5. Explain how evidence will be used to identify and prosecute the assailant. Blood samples, combed pubic hair, semen samples, and skin from under the nails provide DNA for identification.

6. Establish trust and rapport before asking questions. A survivor may read any unrelated comment as blame or rejection, so hold questions until you have a therapeutic relationship.

7. Keep strict confidentiality. Do not discuss the patient's situation with anyone outside the medical staff involved unless the patient consents.

8. Approach the patient without judgment. Your attitude carries therapeutic weight. Shock, horror, disgust, or disbelief have no place here.

9. Use neutral language, never judgmental terms. Judgmental wording shames and re-traumatizes. Say reported, not alleged; declined, not refused; penetration, not intercourse.

10. Keep someone with the patient (friend, neighbor, or staff) while they wait for treatment. A patient with high anxiety needs the physical presence of another person until anxiety drops to a moderate level.

11. Tell the patient they did the right thing to stay alive. Survivors often carry guilt and shame. Reinforcing that they did what they had to do reduces guilt and protects self-esteem.

12. Encourage verbalization. Feeling understood helps the patient feel more in control.

13. Explain the long-term reactions many survivors experience. Anxiety, depression, insomnia, nightmares, phobias, and somatic symptoms are common. Many survivors fear they are going crazy and do not realize this is a process others in their situation have lived through.

14. Explain every procedure before you do it. For example: "I am going to do a vaginal exam and a swab. Have you had a vaginal exam before?" (rectal exam for a male survivor). The patient's anxiety is high, and a matter-of-fact explanation of what you are doing and why reduces fear.

15. Encourage testing and treatment for sexually transmitted infections before discharge. Many survivors are lost to followup after the emergency department or crisis center and will not get protection otherwise.

16. Anticipate prophylaxis against pregnancy, such as norgestrel (Ovral). About 3% to 5% of women who are raped become pregnant.

17. Arrange followup support: crisis counseling, group therapy, individual therapy, a rape crisis center, and a support group. Many survivors carry ongoing emotional distress and trauma. Depression and suicidal ideation are frequent sequelae of rape.