Question

Kim is a 27-year-old woman who recently moved from a small town in Texas to work in the city of Dallas as a reporter for one

of the major newspapers. She is 5’6” tall and weighs 115 lb. To keep in shape she likes to jog, which she did regularly in her

hometown. She doesn’t know anyone in Dallas and has been lonely for her family since arriving. But she has moved into a

small apartment in a quiet neighborhood and hopes to meet young people soon though her work and church. On the first Saturday morning after she moved into her new apartment, Kim decided to get up early and go jogging. It was still dark out, but Kim was not afraid. She had been jogging alone in the dark many times in her hometown. She donned her jogging clothes and headed down the quiet street toward a nearby park. As she entered the park, an individual came out from a dense clump of bushes, put a knife to her throat, and ordered her to the ground. She was raped and beaten unconscious. She remained in that condition until sunrise when she was found by another jogger who called emergency services, and Kim was taken to the nearest emergency department. Upon regaining consciousness, Kim was hysterical, but a sexual assault nurse examiner (SANE) was called to the scene, and Kim was assigned to a quiet area of the hospital, where the post-rape examination was initiated.

Answer the following questions related to Kim:

1. What are the initial nursing interventions for Kim?

2. What treatments must the nurse ensure that Kim is aware

are available for her?

3. What nursing diagnosis would the nurse expect to focus on

with Kim in follow-up care?

Answer 1

Initial nursing interventions for Kim

• A top to toe physical examination.
• A detailed genito-anal examination.
• Recording and classifying injuries
• Collection of indicated medical specimen for diagnostic purposes.

Treatments the nurse must ensure :

• Appropriate medical examination and laboratory tests to ensure health safety .
• Information and actions concerning the possibility of infection, sexually transmitted diseases and pregnancy resulting from sexual assault.
• Information and actions concerning accepted medical procedures, medications, and possible contraindications of such medication available for the prevention or treatment of infection or diseases resulting from sexual assault.
• An initial dose of HIV prophylaxis.

Nursing diagnosis:

1. Rape trauma syndrome r/t sexual assault as manifested by depression and anxiety.