Forensic Nursing Chronicles

Forensic nursing and assessing musculoskeletal injuries.

When performing assessment of musculoskeletal system be aware of other causes of injuries. In today’s society injuries can be of accidental cause but a nurse needs to be aware of clues to look for when assessing patient’s injuries, especially in children. Assess for injuries in various stages of healing. If a child has bruises or fractures in various stages of healing refer for further assessment. Also be suspicious of injuries that do not correspond to the nature of the injury, such as broken bone in a child that does not walk or climb yet. Injuries that are in shape of objects such as, belt buckles, hangers, etc. In assessing musculoskeletal status pay attention to difficulties in walking or sitting, lags in physical development, failure to thrive. Since child abuse
continues to be a problem and cases go unreported due to the privacy of the family unit, nurses both in acute and school settings need to be vigilante in detecting child abuse.

Forensic nursing was traditionally associated with death and homicide. Today forensic nursing can be defined as the application of nursing as it overlaps with the legal system. Nurses have been taught how to perform a health assessment with history and physical examination. This includes subjective and objective findings. Good assessment skills by the nurse are important to detect both physical and emotional abuse. This is accomplished with the first interaction the nurse has with the patient.
Accurate documentation is imperative. Record direct quotes as often as possible. Avoid using medical terminology, correcting the patient’s grammar or paraphrasing the patient’s descriptions.
A unique concept of forensic assessment is alternate interviewing techniques. One such method is the “forensic genogram”. This is expanded from the traditional genogram, and includes information about the transmission of family patterns, including violence. Understanding family influences assists in understanding events that may have led to the abusive behavior.

When we do our assessments of patients as they come in for a nurse visit, we not only look at their potential physical ailments and causes but also their psychological issues. Although most of the time, we do not have the extra time to really dig deeper into their mental health issues during these short visit. There is a middle-aged woman who comes in monthly for her Vitamin B-12 injections and she will talk about losing her son around the holidays (her teen aged son had committed suicide a couple of years ago) and one will quickly notice that she has a definite flat affect as she talks.

Assessment of the physical as well as the mental health of a patient is all part of the nursing assessment we perform daily as we care for our patients. We even apply this skill to those we meet and talk to on a daily basis. A very good friend of mine has a grandson who lives with her on a Native American Reservation in Montana. He is only 22 years old but has tried to commit suicide twice in the last year. Did anyone see this coming? No. Fortunately, he always called his grandmother before it was too late. This young male unfortunately falls into one of the ever-increasing statistics of Native American males between the ages of 15 to 24 who are committing suicide (In the Know Zone, 2005).

According to a recent article by Becky Shay of the Billings Gazette (April, 2005), the Bureau of Indian Affairs (BIA) in Montana has stepped up to the plate and started addressing the high incidence of suicide among Native American teens in Montana. Additionally, on the “In the Know” World Wide Web site (2005), information was presented on teen suicide and it noted that, “Native Americans account for a relatively small percentage of the suicide totals, but have a disproportionately high rate of suicide – 1.5 times the national average.

The suicide profile among American Indians and Alaska Natives also skews toward youth. Males age 15 to 24 account for 64 percent of Native American suicides. There is a significant variation in suicide among the various Native American tribes. In some, the rate is five times the national average.
Source:
In the Know Zone

Assessing mental health should be part of any nurse’s routine assessment when evaluating patients.

Tags:
suicide
suicide prevention
forensic nurse

It is important to assess a young child for evidence of bruising that may be inconsistent with the child’s developmental level or in an unusual area. Most common bruising is on elbows, lower legs and knees. As the child increases his mobility, this type of bruising is not uncommon.

Everyone who works with children knows the criteria that may set off warning flags that a child has been abused. A bruise on the middle of the face, for example, is deemed suspicious. Bruises on the buttocks and the thighs could be suspect of abuse.

The forensic nurse has the potential to prevent an increase in child abuse. His/her early detection of signs or symptoms of child abuse can lead to the removal of the child from a dangerous situation and referral to child protective services. To gain information about this vulnerable population, the nurse needs to rely on the adult caregivers.

The nurse must avoid alienating or intimidating the adults. And contrary to some stereotypical misconceptions, child abuse is not primarily inflicted on poor children. It is untrue that its all one race or class. Child abuse spans all types.

Tags:
child abuse
child-abuse
forensic nurse
abuse detection

What is postpartum depression? According to American Association for Marriage and Family Therapy (2002), “Postpartum depression is a biological illness caused by changes in brain chemistry that can occur following childbirth. During pregnancy, hormonal levels increase considerably, particularly progesterone and estrogen, and fall rapidly within hours to days after childbirth. Also, the amount of endorphins, the feel-good hormones that are produced by the placenta during pregnancy, drop significantly after delivery. Even the thyroid gland can be affected by the enormous hormonal changes that are associated with pregnancy and childbirth, leaving women more at risk for depression.” Additionally, AAMFT (2002) states, that “for 10 to 15% of those women, the period following childbirth becomes a nightmare as they experience sleeplessness, confusion, memory loss, and anxiety during the already stressful adjustment to motherhood.”
Source:
American Association for Family and Marriage

What comes to mind is the Andrea Yates case in which she murdered her children. A very notable forensic case that has been in the headline in the past but has recently come to light again as the Andrea Yates murder trial begins. In which she has claimed postpartum depression as the major reason she murdered her children. World Wide Web CNN- July 12, 2006, “Yates, 42, is being retried because her 2002 conviction was overturned by an appeals court that ruled erroneous testimony might have influenced the jury. She has again pleaded innocent by reason of insanity. Her attorneys say she suffered from severe postpartum psychosis and did not know that killing the children was wrong.” (www.cnn.com) this is a fascinating case, in the aspect that Yates had been in and out of psychiatric facilities for mental illness and depression prior to the murder of her children, so why did the psychiatrist not see this coming?

Today, with the many publicized murder trials of women who have murdered their children supposedly due to postpartum depression as the potential root cause, have encourage healthcare providers, nurses, and even new mom’s to look for the possible signs of this mental health condition. As a nurse, it is part of our nursing assessment skills in looking for potential signs that might indicate a new mom might need further assessment to rule out postpartum depression.

A great example was the other day a new mom of 4 months called the physicians office asking if there was a blood test to test if one might have postpartum depression. The woman claimed that she has noticed recently that she was having a few “sad days” and did not think she needed psychoanalysis but just wanted a blood test to check her hormone levels. When consulting with her physician, he stated that there is no specific blood test to find out if someone’s hormone levels are abnormal that would indicate postpartum depression and the only way to determine if the patient was truly having postpartum depression was an in-person evaluation, which a series of questions and lab work might be obtained. When the patient was advised of the physicians response to her questions, she agreed to a next day appointment but not before the nurse assessed if she was in any danger of hurting herself or anyone else.

Tags:
postpartum depression
postpartum-depression
depression
Family

Assessing the clients with skin problems include obtaining a detailed history as this may provide clues to forensic nursing diagnosis, with careful observation.

The general examination of the skin considers normal variants and general changes in the skin.
General changes can alter color (jaundice, cyanosis, pallor), turgor, thickness, temperature, and vascularity (purpura, petechiae, flushing).

Specific terminology is used to describe the characteristics of skin lesions (color, configuration, distribution, type of lesion, and the lesion pattern), which can then be documented

Begin a patient history using the patient’s own words regarding his/her own condition. This gives the nurse a sense of direction as to which triage questions to ask.

Examinations should be done in an orderly manner to insure important diagnostic clues are not missed. Don’t overlook hair, nails, and mouth.

Primary lesions are caused directly by the disease process. Pay attention to the shape, morphology, distribution, and quality of the lesion(s).

Some common descriptive terms of primary lesions are macule, papule, nodule, plaque, wheal, vesicle, bulla, pustule, cyst, comedo, and burrow.

Secondary lesions are the patient’s response to a disease process.

Some common descriptive terms of primary lesions are scale, crust, fissures, lichenification, erosion, ulcer, excoriation, scar, and atrophy.

Evaluate the distribution, shape, arrangement, and color of the lesion(s).

Tags:
Skin Problems
Skin Care
Forensic Diagnosis
Forensic Nurse
Diagnostic Advice

Forensic Nursing is an important part of society due to in part by today’s violence in society. Forensic nursing is a growing concept and is playing a larger role in trauma related cases. Nurses encounter various levels of abuse in their daily practice from neglect, child abuse and other types of violent assaults.

Nursing requires advance assessment skills to recognize those clues provided by the clients’ statements and physical clues. For example a nurse must establish the proper trust and confidence to provide a therapeutic relationship during the inteview phase of the health history. This is most important in cases where a client has suffered a traumatic event.

The nurse must take into consideration the setting for the inteview. The interview should be conducted in a quiet and private setting for a free exchange of information. The appearance of the nurse must be professional not only in dress but behavior. The dress apparel should be modest, and the demeanor one of interest and warmth.

The way a question is asked can offer more information. It is best to ask open ended questions unless you need to redirect the client. The nurse must be an active listener and pay attention to the information being offered in order to prevent loss of information or miscommunication. Above all a nurse must not judge the client during the interviewing phase.

Avoid making those non verbal cues such as being startled, surprised,or grimacing. A nurse must hone their interviewing skills in order to assist the client convey the infomation needed to fully evaluate the client’s needs.

Tags:
Forensic Nursing
Nursing
Nurses
Healthcare
Health Care
health-care
Education

Forensic nursing has its foundation based on theories of nursing, forensic science, criminal justice, police science and legal studies. The assessment process then is to detect, and look for clues as to what is happening to the body.

The nurse then processes the evidence and applies forensic science. As a patient advocate forensic nursing plays an important role in providing medical and legal resolutions for the client.In such cases nurses need to be aware of normal and abnormal finding’s.

For instance a nurse needs to know what to look for in a child’s nutritional status. This could be height and weight, a child who falls under 5th percentile may be at risk for malnutrtion. Other factors to take into consideration when evaluating nutrtional status in children include; General observation of prominent cheek and clavicle bones, or wasted appearance.

A child may appear disoriented or have a flat affect. The skin can offer other clues to nutrition; such as bruising can indicate vitamin deficiencies; dry skin and poor turgor could mean dehydration. Other areas of the body that offer signs of nutrition status can be hair and nails for texture and color; the eyes and teeth condition .the upper and lower extremities for symmetry, size , and shape. The nurse during Examination must be able to distinguish abnormal and normal findings to be able to provide the proper plan of action.

Tags:
Forensic Nursing
Nursing
Forensic Medicine
Forensics
School
Forensic Training
Nursing Courses