RAPE-TRAUMA SYNDROME
The term rape refers to nonconsensual sexual intercourse. Rape inflicts varying degrees of physical and psychological trauma. Rape-trauma syndrome typically occurs during the period following the rape or attempted rape. It refers to the victim’s short- and long-term reactions and the methods used to cope with the trauma. Traditionally, the victim of rape is a woman, and the abuser is a man. However, rape does occur between persons of the same sex. Additionally, women may also be rapists. Children are often victims of rape; most of the time, these cases involve manual, oral, or genital contact with the child’s genitalia. Commonly the rapist is a member of the child’s family.
The prognosis is promising if the rape victim receives physical and emotional support and counseling to help deal with feelings. Patients who articulate feelings can cope with fears, interact with others, and return to normal routines faster than those who do not. Objective and precise documentation of care for a patient who has been raped may be important if the notes are used as evidence in cases where the rapist is charged and brought to trial.
Essential Documentation
The nurse needs to:
Record the patient’s statements, using the patient’s own words, in quotes.
Also, document objective information provided by others.
Include the time that the patient arrived at the facility, the date and time of the alleged rape, and the time of examinations performed.
Ask the patient about recent illnesses (especially sexually transmitted disease) and allergies to medications.
Ask a female patient about the possibility of pregnancy before the attack, the date of her last menstrual period, and details of her obstetric and gynecologic history.
Describe the patient’s emotional state and behaviors.
Make sure the health care provider has obtained the patient’s informed consent for treatment.
Note whether she douched, bathed, or washed before coming to the facility.
If the case comes to trial, specimens will be used for evidence, so accuracy is essential. Most emergency departments have special kits for rape victims, with containers for specimens. During the examination, it is important for the nurse to:
Make sure all specimens collected (including fingernail scrapings, pubic hair combings, semen, and gonorrhea culture) are labeled carefully with the patient’s name, health care provider’s name, and location from which the specimen was obtained.
Place all the patient’s clothing in paper, not plastic, bags. If clothing is placed in plastic bags, secretions and seminal stains will become moldy, destroying valuable evidence.
Label each bag and its contents. List all specimens in the note, and record to whom these specimens were given.
Follow agency protocol regarding the sealing of all evidence bags and containers.
Document whether photographs were taken and by whom.
This examination is typically very distressing for the rape victim, so (a) provide reassurance, and (b) allow control of the interaction as appropriate. The victim may need to have periods of time out during the examination. If the patient wishes, a counselor may be asked to remain in the room throughout the examination. The nurse should:
Document the names of witnesses to the examination.
Counseling helps the patient identify coping mechanisms. The gender of the counselor may be of concern to the victim. Rapport may be easier to establish if the counselor is of the same sex.
If the patient is wearing a tampon, remove it, wrap it, and label it as evidence.
List all medications administered (e.g., antibiotics and birth control prophylaxis, such as morning-after pills) on the medication administration record.
Explain possible adverse effects, what to expect of the medication, and signs and symptoms to report.
Document all teaching administered, and provide the patient with written instructions before discharge.
Record care given to such injuries as lacerations, cuts, or areas of swelling.
Document whether the patient was offered and received testing for human immunodeficiency virus (HIV) or hepatitis B and C.
Include whether prophylaxis for hepatitis was given.
Chart that the nurse told the patient the importance of follow-up testing in 5 to 6 days for gonorrhea and syphilis.
Record the names and telephone numbers of contact persons for local resources, including rape crisis centers, victims’ rights advocates, and local law enforcement.
Chart any other education and support given to the patient.
REFUSAL OF TREATMENT
Any mentally competent adult can refuse treatment. In most cases, the health care personnel responsible for the patient’s care can remain free from legal jeopardy as long as they fully inform the patient about the medical condition, the proposed testing or treatment, and the likely consequences of refusing treatment. The courts recognize a competent adult’s right to refuse medical treatment, even when that refusal will clearly lead to death. (See
Respecting a patient’s right to refuse care, below.)
When treatment is refused, it is important to inform the patient of the risks involved in making such a decision. If possible, inform in writing. If refusal of treatment continues, the nurse should notify the health care provider, who will choose the most appropriate plan of action. If the patient has a language barrier, a translator should be provided per facility policy.
Essential Documentation
The nurse needs to:
Record the date and time of the patient’s refusal of treatment.
Be sure to document the patient’s exact words in the chart as well as a neurologic assessment that describes the patient’s mental status.
Document that the prescribed treatment was not provided because the patient refused it. This action is necessary to protect the nurse legally.
Ask the patient to sign a refusal-of-treatment release form. If the patient refuses to sign the release form, document this refusal in the progress notes along with the reason for refusal of treatment, if known. For additional protection, the facility’s policy may require the nurse to ask the patient’s spouse or closest relative to sign another refusal-of-treatment release form. If an interpreter is used, document the name of the translator, such as AT&T phone services.
LEGAL CASEBOOK
