Question

1. Identify three areas to assess when working with a person who has been sexually assaulted. 2. Formulate two long-term outcomes and two short-term goals for the nursing diagnosis posttrauma syndrome.

Answer 1

1) Three areas to assess when working with a person who has been sexually assaulted are :-

- support system

- level of anxiety and fear

- signs of sexual assault

2) Nursing Diagnosis:

Post-Trauma Syndrome

r/t: distressing even consider to be outside the range of usual human experience

evidence by: flashbacks, nightmares, numbness, disassociation, amnesia

Short-term goals:

-client will begin healthy grief resolution

-client will demonstrate ability to deal with emotional reactions

Long-term goals:

-the client will integrate the traumatic experience into his or her persona

-renew significant relationships

-establish meaningful goals for the future

Nursing Interventions:

1. assign the same staff (client may be suspicious of others)

2. friendly approach

3. be consistent

4. stay with client during periods of flashback or nightmares

5. obtain history of trauma from significant others

6. encourage client to discuss trauma at own pace

7. discuss coping strategies

8. assist in trying to comprehend trauma

Outcomes:

-client will discuss trauma w/o panic

-client has fewer flashbacks/nightmares

-client can sleep w/o medication