R
Rape-Trauma Syndrome
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Share feelings, concerns, and fears
• Recognize that the rape or attempt was not client’s own fault
• State that, no matter what the situation, no one has the right to assault another
• Describe medical/legal treatment procedures and reasons for treatment
• Report absence of physical complications or pain
• Identify support resources and attend psychotherapy/group assistance in coping with the trauma and effects of the traumatic experience
• Function at same level as before crisis, including sexual functioning
• Recognize that it is normal for full recovery to take a minimum of 1 year
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Escort the client to a treatment room immediately on arrival to the emergency department. Avoid interruptions during contact with the client. Stay with (or have a trusted person stay with) the client initially. EBN: In many medical facilities, sexual assault victims meet with long waits and trauma-insensitive care that might be considered a “second assault” (Keller & Lechner, 2010). Persons who have endured a sexual assault often feel traumatized by the care received in hospital emergency departments (Fehler-Capral, Campbell, & Patterson, 2011).
• Provide a sexual assault response team (SART), if available, that includes a sexual assault nurse examiner (SANE), rape counseling advocate, and representative of law enforcement for best possible outcomes. EB: A need for a comprehensive management approach to sexual assault is evident and should include prescriptive guidelines; workforce training and development; equitable access to services; and community education (Jancey, Meuleners, & Phillips, 2011). EBN: A study of the available literature demonstrates that SANE/SART programs provide emotional and mental support that allows a victim of sexual assault to take control over her/his options and choices and also assists the client in navigating the criminal justice system and accessing health services (Henry & Force, 2011; Lewis-O’Connor et al, 2010).
• Observe for signs of physical injury. EBN: Assessment and documentation of injuries and physical findings are all-important, both in furnishing a baseline for determining intervention priorities and for any possible legal action (Carter-Snell, 2011).
• Ask the client if she/he is in pain. If further clarification is needed, ask the client to point to areas that were injured or touched. EBN: Description of the appearance, distribution, and combination of genital injuries is imperative to evidence-based practice (Keller & Lechner, 2010).
• Document the client’s chief complaint and request an event history of the sexual assault in her/his own words. EB: It is agreed that awareness of the client’s sexual victimization history is invaluable in personalizing cases and determining treatment interventions (Probst, Turchek, & Zimak, 2011). EBN: The manner in which the client’s descriptions of the event are documented is up to the health care professional in accordance with policy (quotes, phrases of the victim’s description of the event, etc.). However it is done, the history should be documented as it is stated (Spears & Faugno, 2009).
• Monitor the client’s verbal and nonverbal affect. Encourage the client to verbalize his/her feelings. EB: There is widely accepted documentation that early intervention in cases of trauma significantly lessens the risk of anxiety, depression, self-harm, addiction issues, eating disorders, and suicide (Marshall, 2012). Individuals at risk for developing long-term problems after an assault should be identified during the initial assessment (Campbell, 2008).
• Explain everything you are doing. EBN: Clarify the medical aspects of the forensic examination for the victim and obtain consent, but ensure that the client is aware that although he has given consent for the exam, he can stop it at any point (Learner, 2012). EB: Ensure that a forensic examination is performed with an appreciation of the victim’s wishes and needs at all times (McGregor et al, 2009).
• Explain to the client that all or some of the client’s clothing may be kept for evidential purposes and photographs may be taken (with consent) to document the client’s injuries. EBN: For the victims of sexual assault, the forensic examination is the inaugural step in the advancement of justice. Assessment and treatment of victims, as well as the precise collection and documentation of evidence, are critical for a solid case (Fitzpatrick et al, 2012).
• If a law enforcement interview is permitted, provide support by staying with the client on her/his request. EB: By keeping the victim of sexual assault calm and comfortable, the nurse’s actions at the bedside may benefit the legal investigation and leave the victim less traumatized and better able to give a complete report of the assault (Campbell, Greeson, & Patterson, 2011).
• Utilize the sexual assault evidence collection kits that have been reviewed by the SART members and provided by your state to collect adequate and accurate evidence for analysis by a forensic laboratory. EB: Standardized evidence-collection kits usually contain forms for documentation to assist examiners. Evidence collection requires the victim’s permission during each of the necessary steps, and the client should be given the opportunity to set the tempo of the exam and to be aware that she/he may decline any part of the examination (Linden, 2011). EB: Proper evidence collection and quality laboratory services are the keys to obtaining the full value of collected DNA in sexual assault cases (Burg, Kahn, & Welch, 2011).
• Discuss the possibility of pregnancy and sexually transmitted infections (STIs) and the treatments available. EB: Immediate care for victims of sexual assault should include the treatment of injuries, prophylaxis for sexually transmitted infections, the possible administration of emergency contraception to prevent pregnancy, and the sensitive management of psychological issues (Luce, Schrager, & Gilchrist, 2010).
• Encourage the client to report the rape to a law enforcement agency. EB: Rape survivors’ decisions to assist in legal actions are influenced by three social groups: family/friends, service providers, and police (Anders & Christopher, 2011). EB: This study suggests that shame is a barrier for not reporting a sexual assault to law enforcement and was also associated with physical injury, victimization by a relative, and self-blame (Wolitsky-Taylor et al, 2011; Zinzow & Thompson, 2011). EBN: Victims may display postdecisional regret after reporting a sexual assault (Marchetti, 2012).
• Involve the support system if appropriate and if the client grants permission. EB: Research strongly suggests the kind of reactions survivors of sexual assault receive from others in their social circle (family, friends, and partners) may have a profound effect on their health and well-being; the results appear to depend on the caliber of the relationship before the sexual assault (Ahrens & Albana, 2012).
• For those interested in a spiritual connection, make the appropriate recommendation. EB: An increasing body of literature documents the benefits that religious coping provides for the victim of sexual assault, including higher levels of psychological well-being and lower levels of depression (Ahrens et al, 2010).
• Stress the necessity of follow-up care with a mental health professional to recognize and intervene with problems associated with the effects of rape-trauma. EB: In the aftermath of rape, victims often experience evidence of depression, anxiety, post-traumatic stress disorder (PTSD), self-harm, and increased risk of suicide (Marshall, 2012).
• Stress the importance of awareness throughout the community of the scope and severity of the effects of sexual abuse as a means of additional healing empowerment. EB: This study suggests that given characteristic societal victim-blaming following rape, self-blame is expected to be considerably more intense among survivors of rape than in other victims and prognostic of elevated post-trauma symptoms (Moor & Farchi, 2011). EB: Rape myth acceptance (RMA) was associated with offensive attitudes and behaviors toward women, but it was also found that RMA correlated with other “isms,” such as racism, heterosexism, classism, and ageism; consequently, it would seem that rape prevention programs could be broadened to add interventions to address other myths concurrent with RMA (Jordan, 2011; Suarez & Gadalla. 2010).
Geriatric:• Build a trusting relationship with the client. EBN: Trust begins by acting with integrity and caring, which then conveys investment in another’s welfare (Laskowski-Jones, 2011).
• All examinations should be done on the elderly as they would be done on any adult client after sexual assault with modifications for comfort if necessary. EB: The clinician has the responsibility to the client to document a competent history and perform an appropriate forensic examination, interpret the findings, and recognize patterns of harm (Fox, 2012). EBN: Sexual abuse in the elderly can present with symptoms of a sexually transmitted disease (STD) and/or reddened, swollen, bruised, or bleeding genitalia/breasts (Caple & Schub, 2011).
• Assess for mobility limitations and cognitive impairment. EB: Studies suggest that adults with possible mild cognitive impairment (MCI) display declines in everyday functioning. These results suggest that mobility declines could be features of MCI, and changes in mobility may be particularly important (O’Connor et al, 2010).
• Explain and encourage the client to report sexual abuse. EB: In this study, it was found that the caseworker and the elderly victims might hold contradictory views regarding the perpetrators’ motivations for abuse and what would be the likely outcomes of reporting it; this was most likely to occur when the perpetrator was a family member. Adjusting these differences can raise the likelihood of effective interventions (Jackson & Hafemeister, 2011). EBN: The extent of the problem of sexual abuse in the elderly is difficult to evaluate due to underreporting and the vulnerability and reluctance of the elderly to discuss the issue with health care providers, which may be due to the fact that perpetrators are frequently family members with the resulting issues of dependency, family loyalty, and fear of the consequences (Joubert & Posenelli, 2009).
• Observe for psychosocial distress. EBN: Changes in behavior, such as becoming more withdrawn, depressed, confused, fearful, or agitated, may be the consequences of sexual abuse in the elderly (Nazarko, 2011).
• Consider arrangements for temporary housing. EB: Practical implications—collaboration and an integrated community response are vital to enhancing the safety and quality of life of the older victim of abuse (Brandl & Dawson, 2011). EBN: Nurses need to consider the circumstance of an older person’s social well-being and the general risk factors for abuse (Ebutt, 2009).
Male Rape
• Encourage men who are raped to report the assault. EB: Sexual assault among males, compared with females, has not been extensively studied and may also be significantly underreported (Choudhary et al, 2012). EB: This study indicates that all things being equal in sexual assault between men and women’s experiences, men who had been penetrated had significantly lower likelihood of seeking counseling (Monk-Turner & Light, 2010). EB: This study suggests that male victims of sexual assault are more likely to be depressed and consider suicide, but less likely to seek health services; efforts should be made to reach these victims (Masho & Anderson, 2009).
Multicultural:• Assess for the influence of cultural beliefs, norms, and values on the client’s ability to cope with the trauma of the rape experience. EBN: It is suggested that divergences among minority women in the frequency of rape, reports of rape, and use of available resources will vary based on ethnicity, race, cultural standards, help-seeking behaviors, and availability of accessible services (Lawson, 2011). Assess to determine if physically abused women are also victims of sexual assault. EB: Care for those victims of sexual assault and domestic violence should include crisis services—legal advocacy, medical advocacy, counseling, support group, and shelter (Macy et al, 2011). EB: Sexual assault is experienced by most physically abused women and associated with significantly higher levels of PTSD compared with women physically abused only. The risk of re-assault is decreased if contact is made with health or justice agencies (Moreland et al, 2007).
• Assure the client of confidentiality. EB: It is suggested that not all criminal justice and medical professionals understand the statutory provision of privilege to communications between rape victim advocates and victims (Cole, 2011).
Home Care:• Some of the interventions described previously may be adapted for home care use.
• Corroborate the client’s feelings of self-worth. This study proposes that the feeling of self-worth moderates the effects of violence—especially violent loss—on PTSD and depression (Mancini, Prati, & Black, 2011).
• Assist the client with realistically assessing the home setting for safety and/or selecting a safe environment in which to live. EBN: The protection or safeguarding of vulnerable adults must be an integral part of everyday nursing practice (Straughair, 2011).
Ensure that the client has systems in place for long-term support. EB: Survivors of abuse noted that a cooperative model of health care, particularly between mental health and physical health professionals, was an asset to their recovery (Dunleavy & Slowik, 2012).
Design a practical discharge plan to include a safe shelter if needed, follow-up care for physical injury and follow-up referral for psychological support. EB: Safety, medical, and psychological plans for discharge are critical to the victim of sexual assault (Linden, 2011).
Assess for other client vulnerabilities such as mental health issues or addiction and refer client to social agencies for implementation of a therapeutic regimen. EB: Client support should be in response to the whole person; the assault should be addressed in both its social and cultural elements, with sensitivity to the client’s distinct needs and by sharing information with other social services, if so allowed by the client (Marshall, 2012).
Client/Family Teaching and Discharge Planning:
Discuss the need for prophylactic antibiotic therapy, hepatitis B vaccination, tetanus prophylaxis, and emergency contraception as needed. EB: The CDC has noted that there is poor compliance for follow-up visits among survivors of sexual assault; therefore, routine preventive therapy should be encouraged (CDC, 2010). EB: This study suggests that female sexual assault victims seen in the emergency department are often not offered comprehensive care including prophylaxis against pregnancy (Bakhru, Malinger, & Fox, 2010).
• Emphasize the client’s needs for safety and to decrease the opportunities for repeat attacks. EBN: The client should be made aware that the results of continued abuse may include more abuse, chronic pain, physical and emotional illness, and even death (Symes, 2011). EB: Safety and support programs have been shown to reduce sexual assaults (Luce, Schrager, & Gilchrist, 2010). EB: This study suggests that victims who have suffered sexual and/or physical assault identified the real supports of food, housing, financial assistance, and religious and spiritual counseling as most helpful to them (Postmus et al, 2009).
• Recognize the vulnerability of the client. EB: Conceptualizations of present control over the recovery process were related to lower levels of psychological distress (Walsh & Bruce, 2011). EB: Sexual assault could result in long-term mental and physical health problems, which may include self-destructive behaviors, chronic pelvic pain, and difficulty with pelvic exams (Luce et al, 2010).
References
Ahrens, C., Albana, E. The ties that bind: understanding sexual assault disclosures on survivors’ relationships with friends, family and partners. J Trauma Dissoc. 2012;13(2):226–243.
Ahrens, C., et al. Spirituality and well being: the relationship between religious coping and recovery from sexual assault. J Interpers Violence. 2010;25(7):1242–1263.
Anders, M., Christopher, F. A socioecological model of rape survivors’ decisions to aid in case prosecution. Psychol Women Q. 2011;35(1):92–106.
Bakhru, A., Malinger, J., Fox, M. Postexposure prophylaxis for victims of sexual assault: treatments and attitudes of emergency department physicians. Contraception. 2010;82(2):168–173.
Brandl, B., Dawson, L. Responding to victims of abuse in later life in the United States. J Adult Protect. 2011;13(6):315–322.
Burg, A., Kahn, R., Welch, K. DNA testing of sexual assault evidence: the laboratory perspective. J Forensic Nurs. 2011;7(3):145–152.
Campbell, R. The psychological impact of rape victims. Am Psychol. 2008;63(8):702–717.
Campbell, R., Greeson, M., Patterson, D. Defining the boundaries: how sexual assault nurse examiners (SANEs) balance patient care and law enforcement collaboration. J Forensic Nurs. 2011;7(1):17–26.
Caple, C., Schub, T., Pravikoff, D. Elder abuse. CINAHL Information Systems. 2p, Dec 23, 2011.
Carter-Snell, C. Injury documentation: using the BALD STEP mnemonic and the RCMP sexual assault kit. Outlook. 2011;34(1):15–20.
Centers for Disease Control and Prevention (CDC), Sexually transmitted diseases: treatment guidelines, 2010 Retrieved Feb 6, 2012, from http://www.cdc.gov/std/treatment/2010/sexual-assault.htm
Choudhary, E., et al. Epidemiological characteristics of male sexual assault in a criminological database. J Interpers Violence. 2012;27(3):523–546.
Cole, J. Victim confidentiality on sexual assault response teams (SART). J Interpers Violence. 2011;26(2):360–376.
Dunleavy, K., Slowik, A. Emergence of delayed posttraumatic stress disorder symptoms related to sexual trauma: patient-centered and trauma-cognizant management by physical therapists. Phys Ther. 2012;95(2):339–351.
Ebutt, A. Abuse of older people. Nurs Stand. 2009;24(8):59.
Fehler-Capral, G., Campbell, R., Patterson, D. Adult sexual assault survivors’ experiences with sexual assault nurse examiners (SANEs). J Interpers Violence. 2011;26(18):3618–3639.
Fitzpatrick, M., et al. Sexual assault forensic examiners’ training and assessment using simulation technology. J Emerg Nurs. 2012;38(1):85–90.
Fox, A.W. Elder abuse. Med Sci Law. 2012;52(3):128–136.
Henry, D., Force, L. From our readers. Strategies for implementing an effective sexual assault nurse examiners program (SANE). Am Nurse Today. 2011;6(8):3.
Jackson, S., Hafemeister, T. Lessons learned from APS caseworkers and elderly victims they serve. Victimization Elderly Disabled. 2011;14(1):1–15.
Jancey, J., Meuleners, L., Phillips, M. Health professionals’ perceptions of sexual assault management: a Delphi Study. Health Educ. 2011;70(3):249–259.
Jordan, J. Here we go round the review-go-round: rape investigation and prosecution-are things getting worse not better? J Sex Aggression. 2011;17(3):234–249.
Joubert, L., Posenelli, S. Responding to a “window of opportunity”: the detection and management of aged abuse in an acute and subacute health care setting. Soc Work Health Care. 2009;48(7):702–714.
Keller, P., Lechner, M. Injuries to the cervix in sexual assault victims. J Forensic Nurs. 2012;6(4):196–202.
Laskowski-Jones, L. Building a foundation of trust. Nursing. 2011;41(9):6.
Lawson, S. Sexual assault: disparities within health care and the criminal justice system for minority women. Hispanic Health Care Int. 2011;9(2):58–60.
Learner, S. Compassion in time of crisis. Nurs Stand. 2012;27(18):22–30.
Lewis-O’Connor, A. The evolution of SANE/SART―are there differences? Sexual Assault Nurse Examiner/Sexual Assault Response Team. J Forensic Nursing. 2010;6(1):53.
Linden, J. Care of the adult patient after sexual assault. N Engl J Med. 2011;365(9):834–841.
Luce, H., Schrager, S., Gilchrist, V. Sexual assault of women. Am Fam Physician. 2010;81(4):489–495.
Macy, R., et al. Domestic violence and sexual assault service goal priorities. J Interpers Violence. 2011;26(16):3361–3382.
Mancini, A., Prati, G., Black, S. Self worth mediates the effects of violent loss on PTSD symptoms. J Trauma Stress. 2011;24(1):116–120.
Marchetti, C. Regret and police reporting among individuals who have experienced sexual assault. J Am Psychiatr Nurs. 2012;18(1):32–39.
Marshall, D. Twenty-four-hour sexual assault care—incorporating courtesy, dignity, privacy and respect. Healthcare Counsel Psychotherapy Journal. 2012;2(1):15–20.
Masho, S., Anderson, L. Sexual assault in men: a population-based study in Virginia. Violence Victims. 2009;24(1):98–110.
McGregor, J., et al. Examination for sexual assault: evaluating the literature for indicators of women-centered care. Health Care Women Int. 2009;30(3):22–40.
Monk-Turner, E., Light, D. Male sexual assault and rape: who seeks counseling? Sex Abuse. 2010;22(3):255–265.
Moor, A., Farchi, M. Is rape-related self blame distinct from other post traumatic attributions of blame? A comparison of severity and implications for treatment. Women Ther. 2011;34(4):447–460.
Moreland, L., et al. Posttraumatic stress disorder and pregnancy health: preliminary update and implications. Psychosomatics. 2007;48:304–308.
Nazarko, L. Nursing & Residential Care. 2011;13(6):264–268.
O’Connor, M., et al. Changes in mobility among older adults with psychometrically defined mild cognitive impairment. J Gerontol B Psychol Sci Soc Sci. 2010;65B(3):306–316.
Postmus, J., et al. Women’s experiences of violence and seeking help. Violence Against Women. 2009;15(7):852–868.
Probst, D., Turchek, J., Zimak, E. Assessment of sexual assault in clinical practice: available screening tools for use with different adult populations. J Aggression Maltreat Trauma. 2011;20(2):199–226.
Spears, T., Faugno, D. Tips of the trade. On Edge. 2009;15(3):2.
Straughair, C. Safeguarding vulnerable adults: the role of the registered nurse. Nurs Stand. 2011;25(45):49–56.
Suarez, E., Gadalla, T. Stop blaming the victim: a meta-analysis on rape myths. J Interpers Violence. 2010;25(11):2010–2035.
Symes, L. Abuse across the lifespan: prevalence, risk, and protective factors. Nurs Clin North Am. 2011;46(4):391–411.
Walsh, R., Bruce, S. The relationships between perceived levels of control, psychological distress, and legal system variables in a sample of sexual assault survivors. Violence Against Women. 2011;22(3):603–618.
Wolitsky-Taylor, K., et al. Is reporting of rape on the rise? A comparison of women with reported versus unreported rape experiences in the National Women’s Study—replication. J Interpers Violence. 2011;26(4):804–832.
Zinzow, H., Thompson, M. Barriers to reporting sexual victimization: prevalence and correlates among undergraduate women. J Aggression Maltreat Trauma. 2011;20(7):711–725.
Readiness for enhanced Relationship
NANDA-I
A pattern of mutual partnership that is sufficient to provide for each other’s needs and can be strengthened
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
Assess for signs of depression in the family when one partner is depressed, and make appropriate referrals. EB: Depressive symptoms affect functioning of the whole family (Hinton et al, 2009).
• Support “relationship talk” between couples (talking with a partner about the relationship, what one needs from one’s partner, and/or the relationship implications of a shared stressor). Such discussions in couples with lung cancer have been shown to help partners better define their relationships and repair relationships that are functioning poorly (Badr, Acitelli, & Taylor, 2008). EB: These discussions may help alleviate the negative impact that sexual problems have on prostate cancer patients’ and their partners’ marital adjustment (Badr & Taylor, 2009).
• Encourage couples to participate and share in exciting and satisfying leisure activities and to share stories. EB: This study demonstrated that couples feel connected with their partners and more satisfied with their relationships when they engage in these types of activities (Graham, 2008). When stories are used as a way to understand the lives of couples, they have the potential for enhancing individual and relational growth (Skerrett, 2010).
• Assist couples in establishing boundaries between work and home. This study demonstrates that for both men and women, job demands foster their own work-family conflict (WFC), which in turn contributes to their partners’ home demands, family-work conflict (FWC), and exhaustion. In addition, social undermining mediates the relationship between individuals’ WFC and their partners’ home demands (Bakker, Demerouti, & Dollard, 2008).
• Assist couples in regulating negative emotions. EB: The results of this study of newlyweds support theories suggesting that the ability to regulate negative emotions may help intimates avoid perpetrating intimate partner violence (IPV), particularly when faced with a partner’s IPV perpetration (McNulty & Hellmuth, 2008).
• Assist couples in dealing with anger and communication when the diagnosis is cancer. EB: The anger-expression styles of both clients and their partners seem to modify the family atmosphere, and together, they are important determinants of the long-term quality of life of the cancer clients. Interventions for couples facing cancer should include a focus on ways of dealing with anger and thereby support dyadic coping with cancer (Julkunen, Gustavsson-Lilius, & Hietanen, 2009). Couples who are survivors of prostate cancer are faced with interruptions in their intimate relationships, communication, and overall quality of life. They need recommendations for appropriate resources (Galbraith, Fink, & Wilkins, 2011).
• Refer to care plans Readiness for enhanced Family Processes and Readiness for enhanced family Coping.
Pediatric:• Provide guidance and information on communication techniques for teenagers, especially those involved in intimate relationships. EBN: The findings of this study suggest that many female adolescents desired the love of a male partner and were willing to concede to his request of practicing unprotected sex. Findings support the urgent need for interventions that will promote skill-building techniques to negotiate safer sex behaviors among youth who are most likely to be exposed to STIs through risky behaviors (Bralock & Koniak-Griffin, 2009).
• Encourage supportive relationships among parents and teenagers EB: This study suggests that parenting may be associated with multiple benefits to teenagers’ sexual relationships including delayed intercourse and greater condom use (Parkes et al, 2011).
Geriatric:
Assess for spousal depression when one partner has cardiovascular disease, and make appropriate referrals. EB: Exposure to spousal suffering is an independent and unique source of distress in married couples that contributes to psychiatric and physical morbidity (Schulz et al, 2009).
Assess for depression and anxiety and make appropriate referrals for “prewidows” caring for spouses with chronic life-limiting conditions. EB: In this study health deficits associated with spousal bereavement may be evident earlier in the marital transition than previously thought, warranting attention to the health of elderly persons whose spouses have chronic/life-limiting conditions (Williams et al, 2008).
• Support older couples’ positive collaborative communication. EB: In this study of older couples, the couples displayed a unique blend of warmth and control during collaborative communication, suggesting that a greater focus on emotional and social concerns during problem solving is important (Smith et al, 2009).
• Encourage collaborative coping (i.e., spouses pooling resources and problem solving jointly) among older adults. EB: This study of older adults whose husbands had prostate cancer suggested that collaborative coping may be associated with better daily mood and greater marital satisfaction because of heightened perceptions of efficacy in coping with stressful events and problems surrounding illness (Berg et al, 2008).
Multicultural:• Provide culturally tailored community-level interventions to raise awareness about HIV and bisexuality, and decrease HIV and sexual orientation stigma. EB: Culturally tailored interventions may increase African American and Latino MSMW’s (men who have sex with men and women) comfort in communicating with their female partners about sexuality, HIV, and condoms (Mutchler et al, 2008). Sociocultural factors and HIV-related misinformation contribute to the increasing number of Chilean women living with HIV. Future HIV prevention should stress partner communication, empowerment, and improving the education of women vulnerable to HIV (Cianelli, Ferrer, & McElmurry, 2008).
Home Care:• Provide home-based psychoeducation to assist new parent couples with parenting and their couple relationship. EB: The best outcomes for psychoeducational interventions for effective parenting of infants and sustaining a mutually satisfying couple relationship seem to be achieved when programs are accessible by couples at home, when skill training is provided, and possibly when programs target couples at high risk of maladjustment to parenthood (Petch & Halford, 2008).
Client/Family Teaching and Discharge Planning:
• Encourage clients and spouses to participate together in interventions to lower low-density lipoprotein cholesterol (LDL-C). Teach spouses how to provide emotional and instrumental support, allow clients to decide which component of the intervention they would like to receive, and have clients determine their own goals and action plans. Provide telephone calls to clients and spouses separately. During each client telephone call, client progress is reviewed, and clients create goals and action plans for the upcoming month. During spouse telephone calls, which occur within 1 week of client calls, spouses are informed of clients’ goals and action plans and devise strategies to increase emotional and instrumental support. EB: The behaviors required to lower LDL-C levels may be difficult to adhere to if they are inconsistent with spouses’ health practices, and, alternatively, may be enhanced by enlisting support from the spouse. Interventions that teach spouses to provide instrumental and emotional support may help clients initiate and adhere to behaviors that lower their LDL-C levels. Moreover, allowing clients to retain autonomy by deciding which behaviors they would like to change and how may improve adherence and clinical outcomes (Voils et al, 2009). Interventions to reduce cardiovascular risk factors should be addressed jointly to both members of a marital couple (Di Castelnuovo et al, 2009).
References
Badr, H., Acitelli, L.K., Taylor, C.L. Does talking about their relationship affect couples’ marital and psychological adjustment to lung cancer? J Cancer Surviv. 2008;2(1):53–64.
Badr, H., Taylor, C.L. Sexual dysfunction and spousal communication in couples coping with prostate cancer. Psycho-Oncology. 2009;18(7):735–746.
Bakker, A.B., Demerouti, E., Dollard, M.F. How job demands affect partners’ experience of exhaustion: integrating work-family conflict and crossover theory. J Appl Psychol. 2008;93(4):901–911.
Berg, C.A., et al. Collaborative coping and daily mood in couples dealing with prostate cancer. Psychol Aging. 2008;23(3):505–516.
Bralock, A., Koniak-Griffin, D. What do sexually active adolescent females say about relationship issues? J Pediatr Nurs. 2009;24(2):131–140.
Cianelli, R., Ferrer, L., McElmurry, B.J. HIV prevention and low-income Chilean women: machismo, marianismo and HIV misconceptions. Cult Health Sex. 2008;10(3):297–306.
Di Castelnuovo, A., et al. Spousal concordance for major coronary risk factors: a systematic review and meta-analysis. Am J Epidemiol. 2009;169(1):1–8.
Galbraith, M.E., Fink, R., Wilkins, G.G. Couples surviving prostate cancer: challenges in their lives and relationships. Semin Oncol Nurs. 2011;27(4):300–308.
Graham, J.M. Self-expansion and flow in couples’ momentary experiences: an experience sampling study. J Pers Soc Psychol. 2008;95(3):679–694.
Hinton, L., et al. Longitudinal influences of partner depression on cognitive functioning in Latino spousal pairs. Dement Geriatr Cogn Disord. 2009;27(6):491–500.
Julkunen, J., Gustavsson-Lilius, M., Hietanen, P. Anger expression, partner support, and quality of life in cancer patients. J Psychosom Res. 2009;66(3):235–244.
McNulty, J.K., Hellmuth, J.C. Emotion regulation and intimate partner violence in newlyweds. J Fam Psychol. 2008;22(5):794–797.
Mutchler, M.G., et al. Psychosocial correlates of unprotected sex without disclosure of HIV-positivity among African-American, Latino, and white men who have sex with men and women. Arch Sex Behav. 2008;37(5):736–747.
Parkes, A., et al. Is parenting associated with teenagers’ early sexual risk-taking, autonomy and relationship with sexual partners? Perspect Sexual Reproduct Health. 2011;43(1):30–40.
Petch, J., Halford, W.K. Psycho-education to enhance couples’ transition to parenthood. Clin Psychol Rev. 2008;28(7):1125–1137.
Schulz, R., et al. Spousal suffering and partner’s depression and cardiovascular disease: the Cardiovascular Health Study. Am J Geriatr Psychiatry. 2009;17(3):246–254.
Skerrett, K. “Good Enough Stories”: Helping couples invest in one another’s growth. Fam Process. 2010;49(4):503–516.
Smith, T.W., et al. Conflict and collaboration in middle-aged and older couples: I. Age differences in agency and communion during marital interaction. Psychol Aging. 2009;24(2):259–273.
Voils, C.I., et al. Study protocol: couples partnering for lipid enhancing strategies (CouPLES)—a randomized, controlled trial. Trials. 2009;6(10):10.
Williams, B.R., et al. Marital status and health: exploring pre-widowhood. J Palliat Med. 2008;11(6):848–856.
Risk for ineffective Relationship
Impaired Religiosity
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Express satisfaction with the ability to express religious practices
• Express satisfaction with access to religious materials and rituals
• Demonstrate balance between religious practices and healthy lifestyles
• Avoid high-risk, controlling religious relationships that inflict physical, sexual, or emotional harm and/or exploitation
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Recognize when clients integrate religious practices in their life. EB: In a cross-sectional descriptive study of 85 individuals with visual impairment, religious well-being predicted 7% of coping behaviors (Yampolsky et al, 2008). In patients with traumatic brain injury, religious well-being (personal connection to a Higher Power) predicted life satisfaction, whereas public religious practice did not (Waldron-Perrine et al, 2011).
• Encourage and/or coordinate the use of and participation in usual religious rituals or practices that support coping. EB: In a cross-sectional descriptive study of 85 individuals with visual impairment, religious well-being predicted 7% of coping behaviors (Yampolsky et al, 2008). In a prospective study of antepartal women, participating in organized religious activities was associated with less postpartum depression (Mann et al, 2008).
• Encourage the use of prayer or meditation as appropriate. CEB: A controlled study of 84 college students revealed that those who participated in a religious spiritual meditation exercise experienced significantly less anxiety and more positive mood, spiritual health, and spiritual experiences and higher pain tolerance (Wachholtz & Pargament, 2005).
• Promote family coping using religious practices to help cope with loss, as appropriate. EB: In a cross-sectional, retrospective survey of parents of children who have died, participants identified spirituality and religion as shaping their perspective of the grief process (Arnold & Gemma, 2008).
Refer to religious leader, professional counseling, or support group as needed. EBN: In a grounded theory study, it was found that chaplains promoted spirituality, which was validated in a psychometric study (Burkhart & Hogan, 2008; Burkhart, Schmidt, & Hogan, 2011).
Geriatric:
Multicultural:Promote religious practices that are culturally appropriate:
African American. EBN: In a sample of 203 African American professional women, 69% rated attending church as a coping mechanism to deal with stress (Bacchus, 2008).
Hawaiian women. EBN: In a semistructured interview with Hawaiian women in churches, integrating religious and spiritual practices in health promotion was viewed as important in promoting breast cancer screening (Ka’opua, 2008).
African. EBN: In a phenomenological study, Nigerian-born immigrants treated depression with spirituality and religion, rather than health care professionals (Ezeobele et al, 2009). EB: In Uganda, 85% of African women with HIV/AIDS use spirituality as a coping mechanism, including support from other believers, prayer, and trusting in God (Hodge & Roby, 2010).
Aborigine. EB: Within Aboriginal communities, using traditional healers and elders can effectively address domestic violence victims (Puchala et al, 2010).
References
Arnold, J., Gemma, P.B. The continuing process of parental grief. Death Stud. 2008;32:658–673.
Bacchus, D.N. Coping with work-related stress: a study of the use of coping resources among professional black women. J Ethnic Cultur Divers Soc Work. 2008;17(1):60–81.
Burkhart, L., Hogan, N. An experiential theory of spiritual care in nursing practice. Qual Health Res. 2008;18(7):928–938.
Burkhart, L., Schmidt, L., Hogan, N. Development and psychometric testing of the spiritual care inventory instrument. J Adv Nurs. 2011;67(11):2463–2472.
Daaleman, T.P., Dobbs, D. Religiosity, spirituality, and death attitudes in chronically ill older adults. Res Aging. 2010;32(2):224–243.
Ezeobele, I., et al. Depression and Nigerian-born immigrant women in the United States: a phenomenological study. J Psychol Ment Health Nurs. 2009;17:193–201.
Hodge, D.R., Roby, J. Sub-Sahara African women living with HIV/AIDS: an exploration of general and spiritual coping strategies. Soc Work. 2010;55(1):27–37.
Ka’opua, L.S. Developing a culturally responsive breast cancer screening promotion with native Hawaiian women in churches. Health Soc Work. 2008;33(3):169–177.
Mann, J.R., et al. Do antenatal religious and spiritual factors impact the risk of postpartum depressive symptoms? J Womens Health. 2008;17(5):745–755.
Puchala, C., et al. Using traditional spirituality to reduce domestic violence within Aboriginal communities. J Alt Compl Med. 2010;16(1):89–96.
Wachholtz, A.B., Pargament, K.I. Is spirituality a critical ingredient of meditation? Comparing the effects of spiritual meditation, secular meditation, and relaxation on spiritual, psychological, cardiac, and pain outcomes. J Behav Med. 2005;28(4):367–384.
Waldron-Perrine, B., et al. Religion and spirituality in rehabilitation outcomes among individuals with traumatic brain injury. Rehab Psychol. 2011;56(2):107–116.
Yampolsky, M.A., et al. The role of spirituality in coping with visual impairment. J Vis Impair Blind. 2008;102(1):28–39.
Readiness for enhanced Religiosity
Pediatric:• Provide spiritual care for children based on developmental level. CEB: When nurses are comfortable providing spiritual care, they can implement numerous spiritual care activities and interventions to meet the spiritual needs of the child and family. After determining the child’s spiritual beliefs and spiritual needs, a plan of care is developed based on the child’s developmental age (Burkhart, 2011; Elkins & Cavendish, 2004; Fowler, 1981, 1987).
Infants: Have the same nurse care for the child on a daily basis. Encourage holding, cuddling, rocking, playing with, and singing to the infant. Continuity of care will promote the establishment of trust because nurses provide much of the needed ongoing support. The infant who is ill or dying still needs to be sung to, talked to, played with, held, cuddled, and rocked (Elkins & Cavendish, 2004).
Toddlers: Provide consistency in care and familiar toys, music, stories, clothing blankets, pillows, and any other individual object of contentment. Schedule home religious routines into the plan of care, and support home routines regarding good and bad behavior. The importance of consistency in care and routine with this age group cannot be overemphasized. The nurse should support parents’ home routines during hospitalization as much as possible and encourage them to continue to have the same expectations regarding good and bad behavior. If particular religious routines are carried out at certain times of the day, the nurse should schedule them in the care plan (Elkins & Cavendish, 2004).
School-age children and adolescents: Encourage both groups to express their feelings regarding spirituality. Ask them, “Do you wish to pray, and what do want to pray about?” Offer age-appropriate complementary therapies such as music, art, videos, and connectedness with peers through cards, letters, and visits. School-age children and adolescents should be encouraged to express their feelings, concerns, and needs regarding spirituality. For adolescents, nurses need to accept their beliefs and wishes even if they are different from their caregiver’s. The nurse needs to facilitate the child’s participation in religious rituals and spiritual practices. Referrals to clergy and other spiritual support may be necessary (Elkins & Cavendish, 2004). In a literature review, reflection and storytelling with adolescents helps find meaning in bereavement therapy and can lead to spiritual growth (Leighton, 2008).
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