ch. 27 Behavioral Health

Expressed Style of Coping

****crying, withdrawing, smoking, wanting to talk about event, acting hysterical confused, disoriented or incoherent, even laughing or joking.

Support System

Assess for availability, size, and utility of a survivor. Often partners or family do not understand rape and may not be good supports. be alert to victims nonverbal communication about strength of social network.

Psychological Effects of Sexual Assault

Long term; depression, suicide, anxiety, fear, difficulties with daily functioning, sexual dysfunction, somatic complaints. history of sexual abuse in psych pts is associated with a characteristic patter of these symptoms.

Goals for Long-Term Reorganization Phase

Pt will discuss need for follow up crisis counseling and other support, will state that the acuteness of memory of rape is less vivid and less frightening by 3 to 5 months, will state that physical symptoms have subsided within 3-5 months

Date Rape Drugs

ROHYPNOL (roofies, forget me pill, club drug, roachies, R2, and rophies) GHB (G, georgia home boy, liquid ecstasy, salty water and scoop) Ketamine (black hole, bump, K, kit kat, purple, and special K) Make victim unable to ward off attackers and unable to remember details as a witness

Nursing Diagnosis

Rape Trauma Syndrome

Fear

Rape engulfs its victims in

rape-trauma syndrome

a variant of PTSD and consists of two phases, each with separate symptoms

Cultural Definitions

affect decision to come to hospital. hispanic females, acculturated in marianismo (ennoblement of female chasity) may view themselves as tainted by rape. African American women may find support groups more helpful than individual therapy.

sexual assault (rape)

an act of violence and nonconsensual sex is the weapon used by the perpetrator

Self Asessment

analyze one's own thoughts and feelings regarding the myths about rape and its impact on survivors. A nurse's attitude, belief in myths about rape, and preconceived judgement can influence the care given to rape victims. Nurses must examine their feelings about abortion**** b/c a pt might choose to abort a fetus produced as a result of rape.

Emotional Style of Coping

anxiety, shock, humiliation, embarrassment, self blame, low self esteem, shame, guilt, anger.

Rape-Trauma Syndrome: silent reaction

apparent when the individual is unable to describe or discuss the rape but manifests other behaviors such as change in relationships with men, nightmares, phobic reactions, or marked changes in sexual behavior.

Profile of Sexual Perpetrators

are almost always men and tend to be young: 30% under age 21 and 23% under age 30. 43% under influence of alcohol or drugs at time of offense. 61%-victim is acquainted with perpetrator. when race is known white victims are more commonly identified in assaults by white perpetrators than by african american perpetrators.

Assessment Guidelines: Sexual Assault

assess psychological trauma, and document pt's verbatim statements. Assess level of anxiety. If in a severe to panic level of anxiety, the pt will not be able to problem solve or process info. Assess physical trauma. Use a preprinted body map and ask permission to take photos. Assess available support system. Often partners or family members do not understand trauma of rape and may not be best supports to draw on at this time. Identify community supports that work in the area of sexual assault. Encourage pt to talk about experience but do not press pt to tell.

Intervention and Support for Survivor

can help prevent anxiety, depression, suicide, difficulties with daily functioning, interpersonal relationships, sexual dysfunction, and somatic complaints

Case management

caring for survivors needs to include physical and psychological care. survivors may seek help from medical professionals rather than from mental health professionals b/c med treatment is more socially acceptable. Outpatient nurses can make a more focused assessment and referral if they are aware of the stigma patients may feel. reassessment should take place in person or by phone within 24-48 hrs. follow up visits for assessment and necessary treatment should occur at 2, 4, and 6 wks after initial eval. pts should be assessed for psych progress as well as presence of STD and pregnancy

assessment of physical trauma

extreme care is to be taken during assessment to avoid victim feeling traumatized again during exams. Explanations should be given along with support and reassurance. be sure to follow agency protocols to preserve evidence. HIV testing may be advised. Pregnancy prophylaxis and STD prevention may be undertaken.

Promotion of Self Care Activities

give referral info and follow up instructions verbally and in writing. Anxiety is likely to affect amount of verbal info the pt can retain.

Date Rape

has increased though the use of drugs in conjunction with alcohol given to victim.

Rape-Trauma Syndrome: Compound reaction

includes reliance on alcohol or other drugs or reactivated symptoms of previous physical or psychiatric illness

S/S of physical trauma

injuries to face, head, neck and extremities, which shoul be documented on a body map.

Gynecological History

last menstrual period, likelihood of current pregnancy, hx of STD's

Assessment

level of pt anxiety, coping mechanisms used, availability of support systems, s/s of emotional trauma, s/s of physical trauma

Survivors

likely to benefit from individual therapy, group therapy, support group to alleviate emotional trauma such as fears, phobias, nightmares, or flashback. some are susceptible to psychotic episodes or emotional disturbances so severe that hospitalization is necessary. depression and suicidal ideation are frequent sequelae.

Interventions to Lower Anxiety with victim of rape

maintain a calm manner, always remain w/ person experiencing acute severe to panic level of anxiety, minimize environmental stimulie, use clear and simple statements and repetition, use a low pitched voice, speak slowly, reinforce reality if distortions occur, listen for themes in communication, attend to physical and safety needs, excercise, assess need for meds. relaxation techniques, breathing exercises.

Controlled Style of Coping

masked faces, calm, subdued appearance or shocked, numb, confused appearance, distractibility, indecisiveness

Male rape

more likely to have physical trauma and to have been victimized by several assailants than is a female

Medicolegal Evidence

must be collected and preserved. DNA samples taken to try and identify rapist

Consent forms

must be signed before pics taken, pelvic exam, and collection of body fluids for DNA testing, and the like

General assessment

nurse should gather data from the survivor, family, friends, and police. nurse then must analyze findings to formulate nsg diagnoses

Phase 1: Acute Phase of Rape-Trauma Syndrome

occurs immediately following the assault and may last for 2 wks. Symptoms: shock, numbness, disbelief, disorganization in lifestyle, cognitive impairment w/ confusion, poor concentration, poor decision making, somatic symptoms. Hysteria, restlessness, crying, smiling may be noted. denial after assault is a protective action to give person time to prepare for reality.

Sexual Assault Nurse Examiner (SANE)

or forensic nurse specialist may perform these activities: holds an RN license , holds a SANE credential issued by KBN, is trained in forensic exam of individuals 14 years or older who have been victim of sexual assault, collects and preserves evidence and testifies in legal proceedings in accordance w/ Kentucky law.

Phase 2: Long- Term Reorganization Phase of Rape-Trauma Syndrome

phase occurs 2 or more weeks after rape. nurse should be alert for reactions to event such as intrusive thoughts, increased activity and increased emotional lability as manifested by anger & violence toward perpetrator, flashbacks, dreams, insomnia, increased motor activity, anxiety, mood swings, development of fears and phobias.

Nurse Attitudes

provide nonjudgmental care and maximum emotional support. Confidentiality is crucial. Listen and let victim talk, feeling understood allows pt to feel more in control of situation. help pt separate issues of vulnerability from blame. focusing on one's behavior which is controllable allows survivor to believe that similar experiences can be avoided in the future

Short Term Survivor Goals

pt will begin to express feelings about assault before leaving emergency department, will speak to community based rape victim advocate before leaving emergency dept., will keep follow up appt.

Level of Anxiety

pts in sever to panic level will be unable to problem solve or process info. Nursing intervention should focus on lowering pt anxiety **** to moderate or below where goals can be set and info assimilated.

Implementation

rape is considered an acute adventitious crisis. a return to previous level of functioning requires mourning losses, experiencing anger, and working through fears.

coping mechanisms

same skills that have helped pt before will be used in adjusting to the ape. New ways may also be developed. if the nurse can help pt verbalize thoughts, understanding of pt's cognitive coping mechanisms can be gained. (What do you think might help? What can I do to help you in this difficult time?)

Theory

sexual distress as a sequela is more common among women who have been attacked by intimates, whereas fear and anxiety are more common in those assaulted by strangers. Depression is common to both.

Pelvic Examination

should be explained, understanding that the pt may see it as another body violation

Planning

since individuals are mainly treated in ER, treatment must include follow up support and care.

Types of Rape

stranger rape (least common), spousal or marital rape, acquaintance or date rape

Counseling

survivor may be too traumatized, ashamed, or afraid to come to hospital and may use a telephone hotline instead. If survivor consents, involve her support systems and discuss with her the nature and trauma of sexual assault and delayed reactions that may occur. Social support moderates somatic symptoms

Evaluation

survivors are recovered if they have an absence of s/s of PTSD , sleep well, with only a very few instances of nightmares, eat according to pre rape pattern, are calm, relaxed , or only mildly suspicious, fearful or restless. show minimal or no strain in relationships w/ family and friends. are generally positive about selves. are free from somatic reactions.

S/s of emotional trauma

the extent of may not be readily apparent from behavior, especially if the person uses controlled style of coping during acute phase of rape trauma. Conduct a nursing history, allow pt to talk at a comfortable pace, pose questions in nonjudgemental descriptive terms. Avoid why questions. If suicidal thoughts are expressed, assess what precautions are needed by asking DIRECT ?'s

Perpetrators

therapy is essential for behavioral change to occur, but few acknowledge the need, and no single method or program has been found to be totally effective

Immediate Interventions durring assessment

treatment and documentation of injuries, treatment for sexually transmitted disease, pregnancy risk evaluation and prevention, crisis intervention and arrangements for follow up counseling, collection of medicolegal evidence while maintaining proper chain of evidence

Post Rape

victim often carries the additional burden of shame, guilt, fear, anger, distrust, and embarrassment