Nurse's Pocket Guide

DRUG THERAPIES, TREATMENTS, AND DISEASE CONCERNS: Would include
ineffective tissue perfusion, activity intolerance; cardiovascular, respiratory,
and elimination concerns; risk for infection, fluid volume
imbalances, impaired skin/tissue integrity, impaired liver function;
pain, nutritional problems, fatigue/sleep deprivation, ineffective
therapeutic regimen management; and emotional responses (e.g.,
anxiety, sorrow/grief, coping, etc.). It is suggested that the user refer
to specific NDs based on identified related factors and individual
concerns for this client to find appropriate outcomes and interventions,
and Documentation Focus.
SAMPLE NURSING OUTCOMES & INTERVENTIONS
CLASSIFICATIONS (NOC/NIC)
NOC/NICs also depend on the specifics of the client’s
situation such as:
NOC—Blood Coagulation; Immune Status; Neurological Status:
Consciousness
NIC—Bleeding Precautions; Infection Protection; Postanesthesia
Care
Rape-Trauma Syndrome
[Specify]
Taxonomy II: Coping/Stress Tolerance—Class 1 Post-
Trauma Responses (see A, B, C, following)
[Diagnostic Division: Ego Integrity]
Submitted 1980; Nursing Diagnosis Extension and
Classification (NDEC) Revision 1998
Definition: Sustained maladaptive response to a forced,
violent sexual penetration against the victim’s will and
consent. [Rape is not a sexual crime, but a crime of
violence and identified as sexual assault. Although
attacks are most often directed toward women, men
also may be victims.]
NOTE: This syndrome includes the following three subcomponents:
[A] Rape-Trauma; [B] Compound Reaction; and [C] Silent Reaction
[A] RAPE-TRAUMA—(00142)
Related Factors
Rape [actual/attempted forced sexual penetration]
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 549
RAPE-TRAUMA SYNDROME