Forensic Nursing Chronicles

The subject of toxoplasmosis infection shines a light on a very important group of patients in nursing pharmacology: pregnant women. Special attention needs to be given to pregnancy/breast feeding status when administering medication. Many medications that are appropriate for the non-pregnant patient may have negative side effects for the pregnant or nursing mother. Even substances such as herbal remedies that are often used without much thought to side effect potential may be harmful for the pregnant mother or the unborn baby. An example is the herbal remedy goldenseal, which is often used for its antiseptic and anti-inflammatory properties. It may cause uterine stimulation when taken in high doses causing problems for a pregnant patient.

Many medications have not been tested for their efficacy in pregnant women and should be avoided if possible during pregnancy due to potential fetal injury. Many chemotherapeutic agents, some anti-seizure medications and certain antidepressants are known to potentially cause fetal injury and should only be used under the direct recommendation and supervision of the health care provider.

I have always been interested in forensic pathology. I don’t know if it is because I believe that many people have a curiosity about death. I once watched a documentary about forensic medicine and found out a very cleaver way to identify people. The forensic officer found a dehydrated corpse. The person had been dead for about a month in the heat and was partially mummified. He was able to get a fingerprint by injecting the tip of the fingers with saline and taking a fingerprint.

One of the goals of Healthy People 2010 is “to increase quality and years of healthy life”. The home-health nurse can be instrumental in assisting to meet this objective. With an increasing aging population whose preference is to remain in their home, increasing institutional health care costs and changes in the nuclear family, a large proportion of home care cliental are single elderly individuals with no or limited support system. A population with age-related changes that result in many types of wounds such as decubitus ulcers, skin cancers, injuries, and diabetic or circulatory related ulcers.

I found it interesting to read that United States spends about 10 to 15 billion annually (Canadian $ are comparable) in treating chronic wounds, with many of these being treated in a homecare setting. With this in mind, it is Important for health care professionals to provide these two crucial elements 1) initial and ongoing wound assessment and 2) accurate documentation. Quality documentation is important for medical, legal and reimbursement reasons, as well as serves as a communication tool to all team members.

Health care professionals should have access to methods of documentation that are quick, easy, specific and precise, and should include a) Wound Assessment, b) Photo documentation c) Pain Assessment and d) a Care Plan.

Wound Assessment: There are a number of useful wound assessment tools available. Two that I found very comprehensive were the Wound Assessment Parameter Scoring Tool (WAPST) and the other was the Wound Assessment Chart Guidelines (WACG). Both offered clear and concise parameters for ongoing documentation of the wound; however the WACG offers a chart for wounds in various anatomical locations and specific assessments for specific areas. For example, the Leg Ulcer Assessment Chart included documentation for tibial and pedal pulses. These assessment charts were very good for describing the wound appearance; however the health care team must be knowledgeable in use of the terminology such: necrotic, slough, granulation, overgranulation, and epithelialisation. The definitions of these terms are provided with the WACG system.

Photo Documentation: Proponents of photo documentation suggest that photos are the most reliable and accurate means of documentation. Photos are taken upon admission or during the initial assessment; with these serving as a reference for future images. They provide a clear, visual image of either the healing or deterioration of the skin integrity. All photos should include a wound measurement guide strip or a measurement grid. Photos may be sent electronically to the attending physician. When well done, a picture can greatly reduce the amount of written description necessary for accurate documentation and avoid confusing anecdotal records.
Conversely, some feel that photo documentation has limited uses in our homecare system due to the sometimes poor quality of the images as a result of lighting, positioning of camera etc, generally due to user inexperience, and that they are an added expense. However, newer technologies such as the Polaroid Light Lock Close-up Lens ™ have reduced these user errors. Photo documentation does require that all nurses be trained in use of the camera, along with ongoing in-services to ensure that staff remains updated.

Pain Assessment: Wound pain is a relatively new consideration in wound care. Research related to wound pain indicated that individuals with pressure ulcers experienced moderate pain about 80% of the time. It was determined that pain is related to patient well-being and is always subjective. “Pain is whatever the experiencing person says it is, existing whenever the person says it does” (McCaffery, 1968). Two common pain assessment tools are the Pain Intensity Scale and the Paces Pain Rating Scale. All clients should be assessed for pain at each visit and measures taken to eliminate or to control the pain.

Care Plan: Wound Assessment, Photo Documentation and Pain Assessment are all key components in evaluating the wound status, on which changes in the care plan are based. Past treatments, and changes in product usage should be noted in the event of staff changes so products or treatments that did not produce the desired effect are not repeated.

Wound and pain assessment and documentation should be factual, comprehensive and timely. An accurate depiction of the wound is an important legal protection. Ambiguity can be risky as documentation is legal evidence of the quality of wound care that has been provided. As the saying goes, “If you didn’t document it, you didn’t do it.”

By definition, forensic nursing is the application of nursing, when it overlaps with the legal system, but the fit is not always a smooth one.” Forensics is sometimes the collision between law and medicine.” Physicians might be reluctant to welcome law enforcement officials onto their turf and law enforcement can grow equally frustrated and impatient with hospital practices. The nurse is in an ideal position to bridge these worlds. Her physical assessment skills and knowledge of body systems and functioning enables her to identify what impact physical violence has on the human body. It could be disastrous if an individual was accused of neglect of an elderly patient based on initial findings. One such case was documented in JHN Magazine Spring 2003. An Oregon couple had been suspected of negligence after an elderly family member died at home and was discovered to have gross discolorations on one side of her body. The local police believed the markings were the symptoms of abuse, but the forensic nurse came to a different conclusion after reviewing the evidence, upon physical examination of the body and obtaining a health history. With the exception of the bedsore-like wounds, there were no signs of neglect: the woman’s hair was clean and her fingernails were neatly trimmed. A little research revealed that the dying woman was suffering from peripheral vascular disease, an arterial ailment that caused the suspicious looking discolorations. The peripheral vascular system is composed of arteries, capillaries, and veins. The tough and tensile arteries and their smaller branches, the arterioles are subjected to remarkable pressure generated from the myocardial contraction.

In 1997 forensic nursing was defined as the “application of forensic science combined with the bio psychological education of the registered nurse, in the scientific investigation, evidence collection and preservation, analysis, prevention and treatment of trauma and death related medical legal issues. That definition was expanded in 1998 as follows: “Forensic Nursing is the application of nursing science to public and legal proceedings: the application of forensic aspects of health care combined with the bio-psychological education of the registered nurse in the scientific investigation and treatment of trauma and death of victims and perpetrators of abuse, violence, criminal activity and traumatic accidents”. The SANE Program is especially Forensic nurse examiners that provide evaluation services to victims of sexual violence, sexual assault or abuse when needed. The SANE program offers documentation of any physical findings or injuries, history documentation of the assault, abuse or violence, evaluation and treatment of sexually transmitted infections, crisis intervention and arrangement for follow-up counseling services, medical, legal and social services referrals as needed, collection of medical and legal evidence for possible use by the judicial system, pregnancy risk evaluation and preventive medicines if appropriate. All services provided by the SANE program are free to the victim and their families.

The death of Jobenet was very controversial. There are lots of reasons why. The first is that the scene, which was the house, was not sealed off as soon as the parents showed the ransom note to the police. Therefore a lot of well wishers were entering and exiting the house all the time.

The house was not checked as the ransom note put the police off and they never stuck to routine procedures.

Due to the fact the scene was not sealed off. There were false remarks made like there were footprints up to the house. There was no snow at the time, therefore no footprints were visible. No forced entry, but there was a window opened at the basement, which no one noticed. The evidence is fast becoming sketchy.

The intruder if there was one, could have easily entered through the basement window, so there would not be any forced entry.

This case was obviously trialed and witnessed by the media, and the important issues of this case were overlooked.

Physical exams pertaining to female reproductive systems in regards to possible sexual assaults one must take special precautions to prevent destroying crucial evidence. Statistics indicate that each year women are the victims of more than 4.5 million violent crimes, including more than 500,000 rape and other sexual assaults. The Forensic nurse specialist would be important in taking a proactive stance in treating victims of these crimes. Nurses in general must pay particular attention to the physical and verbal cues presented by the client. Nurses should key into specific findings such as: edema, erythema, contusions, and hemorrhage. If these indicators are present then a rape kit might be warranted or at least further assessed. In these instances it is best to have someone that has special training to assist the victim through this process. The care provided could make the difference on how the victims assimilate the incidence.