00142 Postviolation Trauma Syndrome

Domain 9: coping/stress tolerance
Class 1: posttraumatic responses
Diagnostic Code: 00142
Nanda label: postviolation trauma syndrome
Diagnostic focus: postviolation trauma syndrome
Approved 1980 • Revised 1998, 2017

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « postviolation trauma syndrome is defined as: persistence of an unbalanced response to a forced, violent sexual relationship, against the will of the victim and without its consent. < /p>

Definite characteristics

  • Aggressive behaviors
  • Alteration in interpersonal relationships
  • Ira behaviors
  • Anxiety (00146)
  • Cardiogenic shock
  • Confusion
  • denial
  • Depressive symptoms
  • Difficulty in decision making
  • Disorderly thought
  • Express anger
  • Express shame
  • Express dishonor
  • Fear (00148)
  • Hypervigilance
  • Loss of independence
  • Low self -esteem
  • mood lability
  • Muscle spasm
  • Muscle voltage
  • Nightmares
  • Paranoia
  • Vulnerability perception
  • Phobic disorders
  • Physical trauma
  • Impotence (00125)
  • Psychomotor agitation
  • Express alteration of the sleep-vigilia cycle
  • Report feel guilty
  • Autoculpabilization
  • Sexual dysfunction (00059)
  • Inappropriate use of substances
  • Revenge thoughts

Related factors

  • To develop

Risk population

  • People who experience violation
  • People with a history of suicide attempt

Associated problems

  • Depression
  • Dissociative identity disorder

NOC Results

  • Sexual functioning: integration of physical, socio -emotional and intellectual aspects, of sexual expression and performance
  • Protection against abuse: protection of itself and other people dependent against abuse
  • Abuse recovery: emotional: scope of the healing of psychological injuries due to abuse
  • Abuse recovery: Physical: Scope of the healing of physical injuries due to abuse
  • Abuse recovery: sexual: scope of healing of physical and psychological injuries due to sexual abuse or exploitation

Evaluation objectives and criteria

  • • Demonstrates a recovery of abuse: sexual, as manifested by the following indicators (specify from 1 to 5: extensive, substantial, moderate, limited or none):
    • Verbal expression of abuse details
    • Verbal expression of the feelings caused by abuse
    • Verbal expression of feelings of guilt
    • Sleep alteration
  • • Demonstrates abuse recovery: sexual, as manifested by the following indicators (specify from 1 to 5: none, limited, moderate, substantial or extensive):
    • Verbal expression of precise information about sexual functioning
    • Expressions of the right to have been protected against abuse
    • Expressions of hope
    • Evidence of relationships without abuse with people of the same sex and the opposite sex
  • Other examples

    The patient will be able to:

    • • Identify and use effective coping strategies
    • • Manifest the cessation of sexual abuse
    • • Participate in positive interpersonal relationships
    • • Solve feelings of depression
    • • Show an appropriate affection to the situation
    • • Obtain treatment for, and solve, emotional and behavior problems caused by the traumatic situation
    • • Control negative or destructive impulses

    NIC Interventions

    • Support in protection against abuse: identification of acts and high -risk dependence relationships, to prevent physical or emotional damage from being inflicted
    • Support in protection against abuse: Elder: identification of acts and high -risk dependence relationships in older people, to prevent possible, or older, physical, sexual or emotional damage; Lack of attention to the basic needs of life or exploitation
    • Support in protection against abuse: Child: identification of child high -risk dependency relationships, as well as actions to prevent it from being inflicted or continuing to inflict physical, sexual or emotional damage, or that there is lack of attention to basic vital needs
    • Support in protection against abuse: domestic couple: identification of actions and high -risk dependent relationships in the home, to avoid possible or greater physical, sexual or emotional damage, or the exploitation of a domestic couple
    • Psychological advice: Application of an interactive process of help focused on the needs, problems or feelings of the patient and their loved ones, to improve or strengthen the coping, solution of problems and interpersonal relationships
    • Sexual psychological advice: application of an interactive help process that focuses on the need to make adjustments to sexual practices, or improve the coping of an event or sexual disorder
    • Health check: detection of health risks or problems through history, medical exploration and other procedures
    • Risk identification: Analysis of possible risk factors, determination of health risks and prioritization of risk reduction strategies for a person or group
    • Behavior management: sexual: description and prevention of socially unacceptable sexual behaviors
    • Group therapy: application of psychotherapeutic techniques to a group, which includes interaction between its members
    • Therapy for traumatic situations: Child: use of an interactive help process to solve the traumatic experience of a child
    • Treatment of rape trauma: emotional and physical support, immediately provided after the violation report

    Nursing Activities


    • • Determine if the patient represents a risk for their own safety or that of others
    • • (NIC) Treatment of rape trauma:
      • Document if the patient has shower, washed or bathed, from the incident
      • Document the mental state, the physical state (clothing, dirt and remains), the incident story, the evidence of violence and, above all, the gynecological history
      • Determine the presence of cuts, bruises, hemorrhages, lacerations or other signs of physical injuries

    Patient and family education

    • • Support and inform the closest people; Comment on the therapeutic response of the victim and the possible changes in their behavior
    • • (NIC) Treatment of rape trauma:
      • Inform the HIV test patient, as required
      • Provide clear and written instructions on the use of medicines, support services for crisis situations and legal advice
      • Explain to the patient the available legal procedures

    Collaboration activities

    • • (NIC) Treatment of rape trauma:
      • Channel to the patient to a legal advice program for rape cases
      • Offer medications to avoid pregnancy, as required
      • Offer prophylactic antibiotics against sexually transmitted diseases


    • • treat the patient without judging him and showing support
    • • Allow a reasonable time for the patient to answer even simple questions
    • • To advise the closest family member, to the spouse or the couple, to maintain a close relationship with the victim, paying special attention to the fact that there are no feelings of guilt (in themselves or projected)
    • • Encourage the patient and relatives to verbally express their feelings
    • • (NIC) Treatment of rape trauma:
      • Contract a support person to remain with the patient
      • Apply the rape protocol (such as labeling and saving dirty clothes, vaginal secretions and pubic hair obtained)
      • Implement the psychological advice of crisis intervention

    At home

    • • Some of the above nursing activities can be used at home
    • • Facilitate the development of a long -term support system
    • • Explain to the family that recovery can be slow (up to several years)
    • • Recommend the patient to visit your head doctor to get pregnant tests and sexually transmitted infections

    Babies and Children

    • • Be aware that most likely the child has been raped by an acquaintance, and at home or in his neighborhood
    • • Evaluate the possibility of suicide, especially when the victim is a teenage male
    • • Adapt communication to the child’s development stage
    • • Use games to facilitate the expression of feelings and the description of the event
    • • Help parents understand the child’s reactions after rape
    • • Correct any erroneous conclusion that the child has reached about the traumatic situation (for example, feeling of guilt)
    • • Emphasize parents the need to restore the sense of security in the child’s life

    Older people

    • • Evaluate the presence of depression, helplessness and impotence, which are more common in older people of rape
    • • If there are symptoms, monitor the possible abuse of elders in institutions (for example, in long -term care centers); These patients are very vulnerable and could even be reluctant to denounce abuse