General practice and applied ethics
Effective management of rape requires a three-pronged approach that entails provision of comprehensive medical, psychological and social care. Careful immediate and on-going assessments of the patient are required to identify the physical, physiological and psychological stressors as well as the patient’s response to therapy. The potential physiological and psychological stressors for Anne, an 18 year old rape victim will be identified, the nursing strategies for reducing or alleviating these stressors and nursing interventions that will promote healing explored.
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The fear of contracting sexually transmitted diseases (STIs) like HIV and becoming pregnant may cause emotional distress to Anne. The medical and legal procedures performed on rape victims may also prove unnerving for the patient. Pelvic examinations are particularly distressing because they may remind the patient of the rape experience. Rape –related cognitive distortions are some of the other psychological stressors Anne may experience. Owens and Chard (2006 as cited in Brown, Testa and Messman-Moore, 2009) observed that traumatic experiences tend to disrupt emotional and cognitive responses of the victims. In particular, interpersonal victimizations such as rape disrupt previously held beliefs about oneself, others and the world in general. These trauma-related alterations in cognitive responses include perceptions of low self esteem, self-blame, self-criticism, feelings of hopelessness and helplessness and a preoccupation with danger. Although they are distortions in perception, they cause considerable psychological distress to rape victims. Other psychological distressing psychological responses that Anne may experience include nightmares, recurring intrusive thoughts, phobias, depression, anger, anxiety and denial. Negative social reactions towards rape are another potential source of psychological distress for Anne (Ahrens, 2006). Studies have established that the society tends to stigmatize rape victims denying them of the social support they are in so much need of. Negative social reactions encompass overtly negative reactions like blaming, condemning or doubting of the victims as well as support efforts perceived negatively by victims such as patronizing behaviors and encouragement of secrecy.
Potential physiological stressors for the patient include pain due to cellular injuries to the reproductive tract, pelvic examination and the lacerations made on her body (Smeltzer, Bare, Hinkle and Cheever 2008, p. 88). Besides pain, the patient may exhibit a constellation of distressing somatic responses such as gastrointestinal irritability, rectal and genitourinary discomfort, skeletal muscle tension, bruising and edema of the reproductive tract, vaginal discharge, fatigue, anorexia, headaches and itching (Carpenito-Moyet 2008, pp. 482-483).
Nursing strategies for reducing or alleviating the aforementioned stressors encompass explaining the medical and legal procedures to the patient beforehand and when they are being performed, promoting a trusting relationship with the patient, providing counseling as soon as possible especially within one hour of rape, ensuring that specimens, tests and appropriate prophylaxis and/or treatments for sexually transmitted infections and pregnancy are provided, enhancement of the patients coping mechanisms, implementation of interventions aimed at reducing the distress due to the somatic responses and ensuring follow-up after discharge.
Explanations of the care being provided as well as the procedures being performed as well as seeking their consent before conducting procedures will give Anne the sense of being in control. This aspect of care is critical because sexual assault violates the patient’s right to deny or consent. When explaining the medical procedures to Anne, the nurse must ensure to elaborate clearly every detail, for instance, the position and instruments used during pelvic examinations, the risk for STIs and pregnancy and the prophylaxis and treatments available. The pelvic examination may remind Anne of the rape experience hence there is a need for the nurse to explain its relevance and importance. On the legal procedures, the nurse should apprise Anne of the need to collect specimens and to report the incidence to the police as well as the kind of questions she will be required to answer if she permits a police interview. Reporting of the rape experience to the police will enhance Anne’s sense of control in addition to helping her come to terms with the reality of the crime (Carpenito-Moyet 2008, p.460).To reduce anxiety, the nurse needs to remain with Anne during the police interview and to negotiate to have the interview at a time convenient for Anne (Carpenito-Moyet 2008, p.480).
The issues relating to the rape patient that need to be addressed during the acute stage are the fear of being left alone, need to establish their sense of being in control and having someone to listen to them. As such, to promote a trusting relationship, it is imperative for the nurse to offer Anne emotional support whilst maintaining a non-judgmental attitude (Pera & Tonder, 2006, p.73) and to display an unhurried attitude when dealing with her and her family. This is because the patient is at this stage the patient is emotionally vulnerable since her normal defense mechanisms have been weakened. She is thus vulnerable to statements that she might construe to be blaming her for the incidence. Being empathetic on the other hand will help validate Anne’s sense of self-worth while provision of support will enhance her safety and provide some sense of stability. Other measures useful in promoting a mutually trusting relationship with the patient include explaining all the medical and legal procedures in advance, assisting the patient in meeting personal needs such as bathing, listening actively to the requests made by the patient, supporting the patients belief and value system (Pera & Tonder, 2006, pp. 72-73) and never leaving the patient alone. The presence of the nurse will help to reduce Anne’s level of anxiety. Furthermore, provision of immediate and on-going psychological support will prepare the patient for referral for more aggressive psychological counseling.
Crisis counseling empowers rape victims; empowerment is construed to be the primary antidote for rape-associated trauma. In providing counseling to the patient, the nurse should seek the patient’s permission before contacting the rape crisis counselor, tailor the counseling as per the patients needs, encourage the patient to verbalize their thoughts, feelings and perceptions about the event, express empathy, explore and discuss with the patient her previous coping mechanisms, strengths and weaknesses and the available support system. Other interventions during counseling include providing reassurance to the patient that the feelings she is experiencing are normal for rape victims, assessing the patients stress tolerance, convey confidence in the patient’s ability to cope appropriately with the situation, assist to restore the patient’s dignity by exploring with her the causes of her feelings of inadequacy and promotion of problem solving and decision making by involving the patient in the planning of their own care. The nurse also needs to ensure that the patient’s rights are respected and she has privacy by restricting the number of visitors and the number of people she has to narrate the rape ordeal to because repeated explanations increase the patient’s anxiety and feelings of shame. Lastly, it is necessary to reassure Anne that the rape ordeal will disrupt her life and the feelings she is experiencing might recur later. Of further importance though is the need to encourage Anne to heal at her own pace. The people who comprise Anne’s informal support system should also be counseled on Anne’s needs for love and support and encouraged to share their feelings with her (Carpenito-Moyet 2008, pp. 480-481).
Nursing interventions for reducing or eliminating somatic responses include providing small, attractive and frequent meals and giving prescribed antiemetics for gastrointestinal irritability, assessing the quality and duration of pain, inspecting the external genitalia and urine for bleeding, listening actively to the patient’s description of pain and giving prescribed analgesics. The vaginal discharge needs to be assessed in terms of its color, amount and odor and the patient should be allowed to wash and change after the preliminary examinations have been completed. To deal with itching, Anne should be advised to bath in cool water, avoid the use of detergent soaps as well as touching the areas of discomfort. To minimize skeletal muscle tension, the patient should be instructed not to change positions abruptly and to utilize previously learnt pain reducing measures as well be taught new ones. Slight elevation of the bed will also help to lower muscle tension. Finally, the nurse needs to discuss with the patient and identify the causes of insomnia as well as the interventions for reducing or eliminating them.
Nursing care for the lacerations on the arms, legs and abdomen entails observing aseptic technique when caring for the lacerations, suturing where it is indicated, applying prescribed antibiotic ointments and administering the prescribed antibiotics. To prevent infection, proper hand hygiene should be observed before and after caring for the patient and the bed linens should be clean and dry. To promote comfort, the nurse needs to measure the level of discomfort using a pain scale, administer prescribed analgesics and to help the patient to a position of comfort (Carpenito-Moyet 2008, p.482). The nurse also needs to ensure that the patient gets prophylaxis against tetanus.
For the blow to her head, the nurse needs to obtain an in-depth history on whether Anne lost consciousness after the blow and if so for how long. Further, Anne’s vital signs and level of consciousness need to be monitored regularly. The skull should be palpated for tenderness or hematomas. It is also imperative for neurological and radiologic examinations to rule out any abnormalities such as fractures or hematomas be done. Suturing and/or wound dressing should be done in case of any open wounds. If the patient had only suffered a concussion, monitoring over a few hours and educating the family and significant others on danger signs to look for such as alterations in the size of the pupil and a decrease in the level of consciousness would be appropriate. However, if the blow caused a cerebral contusion, the patient must be put on strict bed rest with the head elevated by about 300 to decrease ICP. The patient’s vital signs need to be monitored after every 15 minutes. The patient’s neurological status, level of consciousness and orientation would also need to be monitored frequently. Patient education in this case would focus on teaching the patient activities that increase the intracranial pressure such as sneezing, signs of infection and on the need to observe for drainage of CSF (Lippincott, Williams and Wilkins 2002, p. 1392).
Enhancement of coping strategies simply refers to helping the patient adapt appropriately to perceived stressors (Smeltzer, Bare, Hinkle and Cheever 2008, p. 94). This augmentation can be achieved by building on the client’s current coping mechanisms or by teaching her new techniques for coping. Although these coping mechanisms have been mentioned in the previous sections, they are going to be discussed in detail due to the vital role they play in promoting patient healing. Evidence-based strategies for coping with stressors include using social support and spiritual resources, being optimistic about the outcome, maintenance of control over one’s feelings and the situation, acceptance of the situation, encouraging one-self through self-talk and seeking information from others. The role of relaxation techniques, education of the patient, enhancement of social support and referral to support and therapy groups in promoting patient healing will be explored in details. Relaxation techniques are learnt responses used to relive stress. They counter the stress response by adjusting hypothalamic actions which in turn decreases the activity of the peripheral nervous system (PNS); the sympathetic and the parasympathetic nervous systems. The decrease in the activity of the PNS reduces the physiological signs and symptoms of stress and psychological distress. Music therapy, progressive muscle relaxation, relaxation with guided imagery, biofeedback and breathing exercises are potential relaxation techniques that can be taught to the patient (Smeltzer, Bare, Hinkle and Cheever 2008, p. 94).
In educating the patient, the nurse should provide both sensory and procedural information. Information on the sensations the patient is likely to experience as well as the steps during a procedure helps to counter stress and improve the patients coping. This is because provision of information alters the patient-environment relationship for instance by helping the patient perceive things previously thought as harmful or threatening in a more positive manner. Additionally, it mitigates the emotional response enabling the patient to cope and solve problems objectively (Smeltzer, Bare, Hinkle and Cheever 2008, pp. 95-96).
Social networks help to alleviate or reduce stress by providing individuals with emotional information and support. The patient will thus get relief and gain mastery over the situation from sharing the emotions and feelings associated with the stressor. Emotional information from the social support will boost the patient’s self-esteem and self-worth by making her feel she is loved, valued and cared for. In addition, it will help moderate the stress by availing goods and services to the patient on demand. Although the nurse can provide emotional support, it is recommended that the patient’s social support networks be identified and she is encouraged to use them after the acute stage. Social support also helps the patient gain new perspectives on how to cope from others. This is especially critical because the physiological and psychological responses to the rape may alter the patients cognitive processes as previously discussed (Ricci and Kyle 2009, p. 256).
In addition to the counseling therapies, the patient needs to be referred to support groups for rape victims. Group therapy sessions for people with similar problems are therapeutic in that the patient will be able to learn effective coping strategies, gain hope from seeing others recover, achieve satisfaction from watching others and learn to express herself openly (Smeltzer, Bare, Hinkle and Cheever 2008, p. 96).
Upon discharge, Anne needs to be provided with documented information on all follow-up appointments, the names and contact numbers of for the local crisis and counseling centers because she may be unable to assimilate all this information at the time. She should also be referred to a psychotherapist, mental health specialist, pastoral or legal counseling as appropriate. The nurse should also plan for a home visit or telephone follow-up. Follow-up counseling has been shown to provide the much needed support for rape victims over time and to lessen the physical and psychological impact of rape (Carpenito-Moyet 2008, p. 481).
Conclusion
In summary therefore, the potential psychological stressors for Anne include the fear of contracting STIs, becoming pregnant, negative social reactions, preoccupation with danger, anxiety about the medical and legal procedures and rape-related distortions in cognition such as recurring intrusive thoughts, feelings of self-blame, guilt, hopelessness and helplessness. Physiological stressors on the other hand encompass a range of somatic responses to the rape ordeal such as headaches, gastrointestinal irritability, itching, anorexia, sleeplessness and genital-urinary discomfort. Explanation of the medical and legal procedures and examinations in advance, provision of counseling within the shortest time possible, treatment and provision of prophylaxis against pregnancy and STIs, establishment of a mutually trusting relationship, enhancement of coping strategies and provision of follow up after discharge are some of the nursing strategies that can be explored to reduce or ameliorate the physiological and psychological stressors. A myriad of nursing interventions are crucial in the achievement of treatment goals for the patient. They encompass simple measures as never leaving the patient alone during the acute stage, listening to the patient actively, helping her meet her physical needs and educating the patient to complex and involving ones like in-depth counseling. These measures are amongst other goals geared towards enhancing the patient’s sense of safety, control, promoting problem-solving and decision making. The latter aspects promote patient healing.
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