Sexual Assault and 1 Sexual Assault Nursing Care Plan.

Sexual Assault and 1 Sexual Assault Nursing Care Plan.

This study guide is about sexual assault and 1 sexual assault nursing care plan. Use it to create educational nursing care plans for sexual assault.

Sexual Assault

What is sexual assault?

Sexual Assault and 1 Sexual Assault Nursing Care Plan.
Sexual Assault

Sexual assault is any type of sexual activity or contact, including rape, that happens without your consent. Sexual assault can include non-contact activities, such as someone “flashing” you (exposing themselves to you) or forcing you to look at sexual images.

Sexual assault is also called sexual violence or abuse. Legal definitions of sexual assault and other crimes of sexual violence can vary slightly from state to state. If you’ve been assaulted, it is never your fault.

What does sexual assault include?

Sexual assault can include:

  • Any type of sexual contact with someone who cannot consent, such as someone who is underage (as defined by state laws), has an intellectual disability, or is passed out (such as from drugs or alcohol) or unable to respond (such as from sleeping)
  • Any type of sexual contact with someone who does not consent
  • Rape
  • Attempted rape
  • Sexual coercion
  • Sexual contact with a child
  • Fondling or unwanted touching above or under clothes

Sexual assault can also be verbal, visual, or non-contact. It is anything that forces a person to join in unwanted sexual activities or attention. Other examples can include:

  • Voyeurism, or peeping (when someone watches private sexual acts without consent)
  • Exhibitionism (when someone exposes himself or herself in public)
  • Sexual harassment or threats
  • Forcing someone to pose for sexual pictures
  • Sending someone unwanted texts or “sexts” (texting sexual photos or messages)

What does “consent” mean?

Consent is a clear “yes” to sexual activity. Not saying “no” does not mean you have given consent. Sexual contact without consent is sexual assault or rape.

Your consent means:

  • You know and understand what is going on (you are not unconscious, blacked out, asleep, underage, or have an intellectual disability).
  • You know what you want to do.
  • You are able to say what you want to do or don’t want to do.
  • You are aware that you are giving consent (and are not impaired by alcohol or drugs).

Sometimes you cannot give legal consent to sexual activity or contact — for example, if you are:

  • Threatened, forced, coerced, or manipulated into agreeing
  • Not physically able to (you are drunk, high, drugged, passed out, or asleep)
  • Not mentally able to (due to illness or disability)
  • Under the age of legal consent, which varies by state


  • Consent is an ongoing process, not a one-time question. If you consent to sexual activity, you can change your mind and choose to stop at any time, even after sexual activity has started.
  • Past consent does not mean future consent. Giving consent in the past to sexual activity does not mean your past consent applies now or in the future.
  • Saying “yes” to sexual activity is not consent for all types of sexual activity. If you consent to sexual activity, it is only for types of sexual activities that you are comfortable with at that time with that partner. For example, giving consent for kissing does not mean you are giving consent for someone to remove your clothes.

What is NOT considered consent in sexual activity?

  • Silence. Just because someone does not say “no” doesn’t mean she is saying “yes.”
  • Having consented before. Just because someone said “yes” in the past does not mean she is saying “yes” now. Consent must be part of every sexual activity, every time.
  • Being in a relationship. Being married, dating, or having sexual contact with someone before does not mean that there is consent now.
  • Being drunk or high. Read more about alcohol, drugs, and sexual assault.
  • Not fighting back. Not putting up a physical fight does not mean that there is consent.
  • Sexy clothing, dancing, or flirting. What a woman or girl wears or how she behaves does not show consent for sexual activity. Only a verbal “yes” means “yes” to sexual activity.

Who commits sexual assault?

Sexual assault is most often committed by someone the victim knows. This may be a friend, an acquaintance, an ex, a relative, a date, or a partner. Less often, a stranger commits sexual assault.

Women and men commit sexual assault, but more than 90% of people who commit sexual violence against women are men.

What is the average age a woman is sexually assaulted?

Four of every five women who are raped are raped before age 25. About 40% of women who have been raped, or two in every five, were assaulted before age 18.

Can I be sexually assaulted by my partner or spouse?

Yes. Sexual assault is any sexual activity you do not consent to — no matter whom it is with.

Sexual assault by an intimate partner (someone you have a sexual or romantic relationship with) is common. Nearly half of female rape victims were raped by a current or former partner.

Does sexual assault have long-term health effects?

Sexual Assault and 1 Sexual Assault Nursing Care Plan.
Does sexual assault have long-term health effects?

Yes, sexual assault can have long-term health effects. People who have experienced sexual violence or stalking by any person or physical violence by an intimate partner are more likely to report:

  • Headaches
  • Long-term pain
  • Trouble sleeping
  • Poor physical and mental health
  • Asthma
  • Irritable bowel syndrome

Other health effects can include:

  • Severe anxietystress, or fear
  • Abuse of alcohol or drugs
  • Depression
  • Eating disorders
  • Sexually transmitted infections
  • Pregnancy
  • Self-injury or suicide

Is there a link between alcohol and drugs and sexual assault?

Yes. Research shows that up to three out of four attackers had been drinking alcohol when they sexually assaulted someone.

Research also shows that about half of sexual assault victims had been drinking. However, this does not mean that drinking causes sexual assault or that the violence is the victim’s fault. Many attackers use alcohol as a way to make you drunk and unable to consent, understand what is happening, or remember the assault. They may take advantage of a victim who has already been drinking or encourage her to drink more than she might normally drink. If someone sexually assaulted you while you were drunk or passed out, they have committed a crime, no matter how much you had to drink or how old you are.

Some attackers also use drugs called date rape drugs. These drugs are put into drinks — even nonalcoholic drinks — or food without the victim’s knowledge. The drugs can cause memory loss, so victims may not know what happened. Some attackers also use other drugs, such as ecstasy, marijuana, or prescription pills. They may give drugs to someone who takes them willingly or may drug someone without her knowledge.

Someone who is drunk, drugged, or high on drugs cannot give consent. Without consent, any sexual activity is sexual assault.

What do I do if I’ve been sexually assaulted?

If you are in danger or need medical care, call 911. If you can, get away from the person who assaulted you and get to a safe place as fast as you can.

What do I do if I’ve been raped?

  • Get to a safe place. Call 911 if you can. The most important thing after rape is your safety.
  • Don’t wash or clean your body. If you shower, bathe or wash after an assault, you might wash away important evidence. Don’t brush, comb, or clean any part of your body, including your teeth. Don’t change clothes, if possible. Don’t touch or change anything at the scene of the assault. That way, the local police will have physical evidence from the person who assaulted you.
  • Get medical care. Call 911 or go to your nearest hospital emergency room. You need to be examined and treated for injuries. The doctor or nurse may give you medicine to prevent HIV and some other sexually transmitted infections (STIs) and emergency contraception to prevent pregnancy. Ask for a sexual assault forensic examiner (SAFE) or a sexual assault nurse examiner (SANE). A doctor or nurse will use a rape kit to collect evidence. This might be fibers, hairs, saliva, semen, or clothing left behind by the attacker. You do not have to decide whether to press charges while at the hospital. You do not need to press charges in order to have evidence collected with a rape kit.
  • If you think you were drugged, talk to the hospital staff about testing for date rape drugs, such as Rohypnol and GHB (gamma-hydroxybutyric acid). Date rape drugs pass through the body quickly and may not be detectable by the time you get tested.
  • Reach out for help. The hospital staff can connect you with the local rape crisis center. The staff there can help you make choices about reporting the sexual assault and getting help through counseling and support groups. You can also call a friend or family member you trust to call a crisis center or hotline for you. Crisis centers and hotlines have trained volunteers and other professionals (such as mental health professionals) who can help you find support and resources near you.
  • Report the sexual assault to the police. If you want to report the assault to the police, hospital workers can help you contact the local police. If you are in immediate danger, call 911. If you want to report sexual assault that happened in the past, call your local police non-emergency number or make a report in person at the police station.
  • Talk to someone about reporting the assault to the police. An advocate or counselor can help you understand how to report the crime. Even though these calls are free, they may appear on your phone bill. If you think that the person who sexually assaulted you may check your phone bill, try to call from a friend’s phone or a public phone.
  • If the person who assaulted you was a stranger, write down as many details as you can remember about the person and what happened. This will help you make a clear statement to police and medical providers about the sexual assault. With good information, they will be better able to help you and find the person who assaulted you.

What steps can I take to be safer in social situations?

If you are assaulted, or if you find yourself in a situation that feels unsafe, it is not your fault. Sexual assault is never the victim’s fault, no matter what she was wearing, drinking, or doing at the time of the assault. You can’t prevent sexual assault, but you can take steps to be safer around others:

  • Go to parties or gatherings with friends. Arrive together, check-in with each other, and leave together. Talk about your plans for the evening so that everyone knows what to expect.
  • Meet first dates or new people in a public place.
  • Listen to your instincts or “gut feelings.” Many women who are sexually assaulted know the abuser. If you find yourself alone with someone you don’t trust, leave. Don’t worry about hurting someone’s feelings or being disliked. If you feel uncomfortable in any situation for any reason, leave. If the person is preventing you from leaving, try to get someone else’s attention who can help you get to safety. You are the only person who gets to say whether you feel safe.
  • Look out for your friends, and ask them to look out for you. You can play a powerful role in preventing sexual assault of other people. If a friend seems out of it, seems much too drunk for the amount of alcohol she drank, is acting out of character, or seems too drunk to stay safe in general, get her to a safe place. Ask your friends to do the same for you. Learn more about how you can help prevent sexual assault as a bystander.
  • Have a code word with your family and friends that means “Come get me; I need help” or “Call me with a fake emergency.” Call or text them and use the code word to let them know you need help.
  • Download an app on your phone. Search in your phone’s app store for free women’s safety apps you can download and use if you feel unsafe or are threatened. Some apps share your location with your friends or the police if you need help. You can also set up an app to send you texts throughout the night to make sure you’re safe. If you don’t respond, the app will notify the police.
  • Be aware of how much you drink. Research shows that about half of sexual assault victims had been drinking when the attack happened. Drinking alcohol does not make the attack your fault, but alcohol — and drugs — can make it more likely that you will be drunk or high later on. If you are drunk or high, you cannot consent to sexual activity or you may not understand what is happening.
  • Keep control of your own drink, because someone could add alcohol or date rape drugs to it.
  • Get help or leave right away if you feel drunk and haven’t drunk any alcohol or if the effects of alcohol feel stronger than usual. This can happen if someone puts a date rape drug or any kind of drug into your drink. Many drugs have no smell or taste and can cause you to pass out and not remember what happened.
  • Be aware of your surroundings. If you’re walking alone, don’t wear headphones so you can hear what’s happening around you. Also, as much as you can, stay in busy, well-lit areas, especially at night. Have a plan to get home. If you plan to use a ride share service from an app, make sure your phone is charged or bring a charger. It can help to have a credit card or cash on hand if you need to leave quickly.

1 Sexual Assault Nursing Care Plan 

Sexual Assault and 1 Sexual Assault Nursing Care Plan.
1 Sexual Assault Nursing Care Plan.

The nursing care plan for clients experiencing sexual assault should include assisting the victim to seek medical attention, encouraging verbalization of the assault, informing the significant others in the victim’s life, providing safety, providing support at certain times of stress, especially during police investigations or court proceedings, and planning for follow-up contact with a crisis counselor.

Rape-Trauma Syndrome

Nursing Diagnosis

  • Rape-Trauma Syndrome

May be related to

  • Sexual assault.

Possibly evidenced by

  • Aggression; muscle tension.
  • Change in relationships.
  • Denial.
  • Depression, anxiety.
  • Disorganization.
  • Dissociative disorders.
  • Feelings of revenge.
  • Guilt, humiliation, embarrassment.
  • Hyperalertness.
  • Inability to make decisions.
  • Loss of self-esteem.
  • Mood swings.
  • Nightmare and sleep disturbances.
  • Phobias.
  • Physical trauma (e.g., bruising, tissue irritation).
  • Self-blame.
  • Sexual dysfunction.
  • Shame, shock, fear.
  • Substance abuse.
  • Suicide attempts.
  • Vulnerability, helplessness.

Desired Outcomes

  • Survivor will experience hopefulness and confidence in going ahead with life plans.
  • Survivor will have a resolution of anger, guilt, fear, depression, low self-esteem.
  • Survivor will acknowledge the right to disclose and discuss abusive situations.
  • Survivor will list common physical, emotional, and social reactions that often follow a sexual assault before leaving the emergency department or crisis center.
  • Survivor will state the results of the physical examination completed in the emergency department or crisis center.
  • Survivor will speak to a community-based rape victim advocate in the emergency department or crisis center.
  • Survivor will have access to information on obtaining competent legal counsel.
  • Survivor will begin to express reactions and feelings about the assault before leaving the emergency department or crisis center.
  • Survivor will have a short-term plan for handling immediate situational needs before leaving the emergency department or crisis center.
  • Survivor will verbalize the details of the abuse.
  • Survivor will state that the physical symptoms (e.g., sleep disturbances, poor appetite, and physical trauma) have subsided within 3 to 5 months.
  • Survivor will state that the acuteness of the memory of the rape subsides with time and is less vivid and less frightening within 3 to 5 months.
  • Survivor will discuss the need for follow-up crisis counseling and other supports.
Nursing Interventions Rationale
Establish trust and rapport. Since the victim may misinterpret any statements unrelated to her immediate situation as blaming or rejecting, the nurse should delay asking questions until the therapeutic nature is established.
Provide strict confidentiality. The client’s situation is not to be talked over with anyone other than the medical staff involved unless the client gives consent to it.
Approach the client in a nonjudgmental manner. Nurses’ attitudes can have an important therapeutic impact. Displays of shock, horror, disgust, or disbelief are not appropriate.
Never use judgmental language. Use the following: 

  • Reported not alleged.
  • Declined not refused.
  • Penetration, not intercourse.
Have someone stay with the client (friend, neighbor, or staff member) while he or she waiting to be treated. People with high levels of anxiety need to feel physical safety by providing someone by his/her side until the anxiety level is down to moderate.
Stress that they did the right thing to save their life. Rape victims might feel guilt and shame. Reinforcing that they did what they had to do to stay alive can reduce guilt and maintain self-esteem.
Encourage verbalization. When people feel understood, they feel more in control of their situations.
Explain to the client signs and symptoms that many people experience during the long-term phase, for example: 

  1. Anxiety, depression.
  2. Insomnia.
  3. Nightmares.
  4. Phobias.
  5. Somatic symptoms.
Many individuals think they are going crazy as time goes on and are not aware that this is a process that many people in their situation have experienced.
Forensic Examination and Issues:
Assess the signs and symptoms of physical trauma. More common injuries are to the face, head, neck extremities.
Make a body map to identify the size, color, and location of injuries. Ask permission to take photos. Accurate records and photos can be used as medicolegal evidence for the future.
Carefully explain all procedures before doing them (e.g., “I will perform a vaginal examination and do a swab. Have you had a vaginal examination before?” [rectal examination in case of a male who has been raped]). The individual is experiencing high levels of anxiety. Matter-of-fact explaining what you plan to do and why you are doing it can help reduce fear and anxiety.
Explain the forensic specimens you plan to collect; inform the client that they can be used for identification and prosecution of the rapist, for example: 

  1. Blood.
  2. Combing pubic hairs.
  3. Semen samples.
  4. Skin from underneath nails.
Collecting body fluids and swabs is essential (DNA) for identifying the rapist.
Encourage the client to consider treatment and evaluation for sexually transmitted diseases before leaving the emergency department. Many survivors are lost to follow-up after being seen in the emergency department or crisis center and will not otherwise get protection.
Many clinics offer prophylaxis to pregnancy with norgestrel (Ovral). Approximately 3% to 5% of women who are raped become pregnant.
All data must be carefully documented: 

  1. All lab tests should be noted.
  2. Detailed observations of physical trauma.
  3. Detailed observations of emotional status.
  4. Results from the physical examination.
  5. Verbatim statements.
Accurate and detailed communication is crucial legal evidence.
Arrange for support follow-up: 

  1. Crisis counseling.
  2. Group therapy.
  3. Individual therapy.
  4. Rape counselor.
  5. Support group.
Many individuals carry with them constant emotional distress and trauma. Depression and suicidal ideation are frequent sequelae of rape. As soon as the intervention is carried out, the less complicated the recovery may be.


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