Forensic Nursing Chronicles

I mentioned in a past discussion that nurses are already forensic nurses: Anything we document can be used as evidence in a court of law. Good documentation will help defend ourselves in a malpractice lawsuit; it can also keep out court in the first place.

According to “8 Common Charting Mistakes To Avoid” (July 1992) Marianne DeMilliano, BSN, JD, http://www.nso.com/newsletters/features/common.php

1. Failing to record pertinent health or drug information.
2. Failing to record nursing actions.
3. Failing to record that medications have been given
4. Recording on the wrong chart.
5. Failing to document a discontinued medication.
6. Failing to record drug reactions or changes in the patient’s condition.
7. Transcribing orders improperly or transcribing improper orders
8. Writing illegible or incomplete records.

A long time ago, while I was working in a hospital, I was concerned about how much time I should spend documenting. One of the nurses there was documenting every detail about her patient on the chart. I wondered whether she didn’t miss out on some of the nursing process and perhaps some action she should be performing. It took her such a long time to do such detailed documentation. I know that many nurses complain that there is no time to document. It is important to know how and what to document.

We should chart patient care at the time we provide it, but many times the charts are completed long after the care has been given. Community nurses (Public health nurse) have an easier time documenting at the time care is provided than hospital nurses, because of the patient ratio or acuteness..etc. Still, most of the current charting does not meet the demands of laws and regulations.

Recently, computer-based environments are replacing or being used in conjunction with paperless charting. The jury is out on the total effectiveness yet, but there are obvious advantages and disadvantages to computer-based documentation. I believe that computer-based charting and documenting is a little easier because often a box can be checked instead of writing every item. I hope this will end up giving us more accuracy, decrease mistakes, and provide a record that can be used as good evidence.

When monitoring patients on pain medications, such as morphine, dilaudid, and demerol; it is important to make sure that certain side effects do not occur. It is very important to monitor the respiratory status because decreased respiratory status is one of the main side effects that can happen from giving pain medications.

Narcan is another medication that it is important to be aware of. In one case, a patient was having apneic spells for about 30 seconds at a time and I had to administer narcan two times within a half an hour. I had my doubts about narcan through my readings, but seeing it personally really made me a believer. A simple medication can reverse respiratory depression and help the patient have a normal respiratory status.

It is also important to educate patients about pain management at home. When patients are taking pain medications at home, there is not a nurse or a physician there that can help if something goes wrong.

The main area that needs to be covered before discharge is side effects that need to be reported and the right dosage amounts that can be taken at certain times. Make sure that the patient is very knowledgeable about the medications they are taking and that they know when to call a physician or nurse when something is not right.

Pain medications are a wonderful thing, but can have their side effects that are not so good. However, by keeping a good eye on your patients and making sure that their vital signs are stable you will help the patient have a quicker and less painful hospital stay. Also, make sure that patients know what medications they are taking and what side effects may happen as a result of the medications before leaving the hospital.

In the U.S., many ER’s are ill-equiped to properly take care of a sexually assaulted women. With untrained ER staff, they are not giving the appropriate care that a victim might need. This is due to untrained and unexperienced doctor and nursing staff. Less than half of the sexually assaulted victims are receiving emergency contraceptives or treated for a sexually transmitted disease. Even though hospitals are improving the situation, it is a slow process.

A New Jersey committee is planning to create a standard rape kit. Some things included are test tubes, saline and sample collecting materials, data collection forms and questions to ask the victim, and a diagram to help record location of injuries. Like all hospitals, SANE’s will have to get a consent from the victim. It is the victims right to decide to press charges and the evidence will be kept untill they make that decision.

SANE’s are more than evidence collectors. They are also there to support the victim physically and emotionally. They also educate the community on sexual assault. But this takes a lot of grants and other fundings. A lot of hospitals do not have SANE 24 hours a day. Many are run on volunteers and qualified ones are hard to find.

SANE has only been around for a little bit over a decade. Before, victims were retraumatized when they would come to the hospital to get medical care and for evidence collection. The nation has opened its eyes to the importance of these nurses and now more hospitals have SANE’s to improve care and evidence collection.

The National Academy of Science’s Institute of Medicine estimates that preventable medication errors cost hospitals and extended care facilities over $5 billion annually, and account in over 7000 hospital deaths.

The majority of these medication errors occur in the ordering and administration stage. It is crucial that health care professionals take extra care in ordering and handling medications.

For example, the Institute for Safe Medication Practices (ISMP) has issued warnings about potential confusion over the following drugs: Lantus and Lente insulin both diabetes drugs; the antidepressant Serzone and the antipsychotic Seroquel, and the oral diabetes drug Avandia and the anticoagulant Coumadin.

Over a dozen mistakes have been reported involving Seroquel and Serzone. The names are very similar. Mistakes involving Lantus and Lente insulin have also been reported.

In 1991 the Institute of Medicine called for the elimination of paper-based record keeping. Since that time a computerized physician order entry (CPOE) system has been developed. The real goal in implementing this type of system is to reduce medication errors. This system checks for potential drug interactions, appropriateness of drug and the dosage ordered, and it integrates the ordering system with the pharmacy, laboratory’s and the nurses station.

Hopefully in future all hospitals will have the ability to implement this new system, and the lives and money saved will be immense. Until then it is vital that every health care professional involved in prescribing, preparing, and/or administering medications of any kind to compare the exact spelling and concentration of the medication ordered with the patient’s medication card, and read the label three times before the drug is removed from the shelf or unit dose cart, before preparation, and before opening the drug for administration.

Depressive illness in children and teens is defined when the feelings of depression persist and interfere with a child’s or adolescent’s ability to function. Many depressions are left untreated because people fail to recognize the symptoms.

While I was working at the college health center, I saw many students who were depressed. It was not only major symptoms of depression that I observed. I saw the students having other symptoms like: frequent headache, stomach ache, nausea, alcohol or drug abuse, increased irritability, anger, and change in mood.

It is important to know these symptoms, so we can distinguish depression from occasional normal sadness or moodiness. “It is important to remember that the behavior of depressed children and teenagers may differ from the behavior of depressed adults”. “Teen Depression”, Focus Adolescent services, http://www.focusas.com/Depression.html

Signs of depressive disorders in young people often are viewed simply as normal mood swings, typical of a particular developmental stage.

The majority of youth depression can be helped with treatment; most teen or college students with mental health problems do not get this help unfortunately. We need to educate the youth that it is important to get help immediately. We also have to know other early symptoms of depression and reach out to the students. We have to create a supportive environment for the youth or the student. Depressed teens become even more depressed with every supposed rejection.

At the community level we should educate our health professionals, teachers, parents, and young students. Our community has to offer counseling and assist with more information about depression. Screening can take place in schools, doctors’ offices, clinics, youth groups, shelters, and other youth-serving organizations and settings. In the Unites States, Youth Suicide Prevention programs are mental health check-ups available for all American teens.

Depressed children and teens are at increased risk for committing suicide. I have seen a couple students saying “I want to kill myself,” or “I don’t care about myself”. We have to take this seriously and put them under further evaluation.

After a professional evaluation most youths do not realistically harm themselves, but many have depressive behaviors. However, asking whether he or she is aware of what is happening can help the depressed think better about his or her situation. It is in bringing out their thoughts that such questions will provide assurance that somebody cares and will give the young person the chance to talk about problems.

I read the article A Statement of APHA Public Health Nursing Section (1996) “The Role of Public Health Nursing”

The role of the public health nursing practice is affected by biological, cultural, environmental, economic, social, and political factors. As part of the health care system public health nursing practice reacts to these factors through working with the community to promote health and prevent disease, injury and disability.

The health needs of people in the U.S. are changing, both on a local and nationwide basis. The Healthy People 2000 program focused on problems that affected the nation: cancer, obesity, etc. The local public health nursing practice had to be aware of these, and properly educate their community.

The ‘Healthy People 2000’ objectives had the Nation’s best interest in hand. It was one of the major accomplishments, including surpassing the target for reducing deaths from coronary heart disease and cancer.

Healthy People 2010 continue its initiatives, and will no doubt increase quality and years of healthy life, and hopefully eliminate health disparities.

Forensic nursing encompasses providing care to victims of crime, collecting evidence, and providing health care services within the prison system. “Dead or alive, patients need nurses to advocate for them, and never more so than in forensic cases. Contrary to common belief, forensic means establishing the facts in any legal case, not just those involving a death.” CRACKING THE CASE: Your role in FORENSIC NURSING (Nov 2004), Serita Stevens

In reality, nurses are already forensic nurses: Anything we document can be used as evidence in a court of law. Our forensic skills come into play any time a patient’s injuries become the basis for a criminal action or a lawsuit. As a nurse, we are the patient’s first line of defense.

Evidence nurses collect and document can be used in cases involving domestic violence, medical malpractice, traumatic injury, murder or manslaughter, suicide, drug overdose, or sexual assault. While I was working as community based nurse, my documentation went to court, and used as evidence.

I thought that forensic nursing and public health nursing are two totally different practices.
As part of the health care system, public health nurses practice by working with the community to promote health and prevent disease, injury and disability. In the same vein forensic nurses are working with the community to promote health and prevent disease, injury and disability.

What would happen if hospitals (doctors, nurses, etc) started advising their patients to take more herbal medicines?

I suppose there is a reason why we don’t see more of that. These supplements have not been approved by the FDA. If doctors advised or prescribed these herbal medications and there was an adverse effect or some time of side-effect or carcinogenic effect in the medicines than those prescribing doctors could be sued for their advising patients to take them.

It would be great if the FDA was able to do more research on these products because maybe it would open up the door for doctors to prescribe these medications and then maybe we wouldn’t have to rely quite as much on antibiotics or heavy-duty medications.

Another perspective from a forensic standpoint relating to criminal justice and legal matters is that I am surprised that we don’t have more court cases in which people are suing some of these herbal medicine companies for the claims they make.

They make such outlandish claims and I am sure that there have been many people who have become sick due to taking those medications. It seems that there should be more accountability there.

But there is really no way to govern it because the herbal medication/dietary supplement industry has become so huge. I do think though that from a forensic nursing standpoint there could be more effort put into this situation. Maybe by more health professionals leading the charge.

The Herbal and dietary supplements market is booming. I know I have taken a one or two of these substances hoping and feeling that they have helped me. Of these substances, I have taken Echinacea the most. As one book says it is supposed to help the immune system fight off the common cold/flu symptoms. I have felt this to be true.

Whether it has just been the placebo effect or if it really does help, I don’t know. The product I take is called “Green Magma”. It is a mixture of many different substances that are supposed to boost the immune system such as echinacea, powdered barley grass, and others.

Because of the fact that none of these products on this market are backed by the FDA (there are way too many of them for the FDA to keep up with anyways) we never know exactly how safe they are. I am looking forward to continued research on these products to test their actual scientific effect on the immune system.