Archive for February, 2007

Forensic Artist

February 28, 2007

I read an interesting article on the web entitled “ Little Known Highly Effective”
It’s an article about the Forensic Artist and what the forensic artist has to offer to law enforcement agencies. What I learned is that the forensic artist does more that just composite drawings, they are utilized in a wide variety of services , such as, three dimensional facial reconstruction , hand drawn or computerized crime scene sketching , computerized and hand drawn age- progression, image enhancement, video enhancement, as well as art related duties. This field that little is known about has helped solve a number of cases.

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Focus assessment of injury in a long-term forensic hospital setting

February 27, 2007

Keeping patients from harm is paramount to professionals in health care. In Psychiatric Mental Health Nursing, patients causing self-harm is the usual, but in a long-term care facility there are far more injuries sustained than those of self-harm. The facility where I work has a very active Recreational Therapy department including activities of basketball, volleyball, ropes course, weight training to mention a few. In addition to this the campus is sprawling across approximately 10 acres with some of the patient living areas (cottages) lying quite a distance from the main building where most of the programming and meals occur. This setting and therapies set the stage for many diverse injuries than for those of self-harm including sprains, bumps, bruises, falls during inclement weather and the like.
Nurses in this setting must have great competence in assessing for musculoskeletal injuries. Performing problem-focused assessments are a reality in this setting. The nurse must have skills in assessing each and every joint, skin lesions, edema. This is compounded by assessment for chief complaints of syncope episodes, and a whole inventory of other complaints.
The psychiatric patients (some with co-morbid mental retardation) are not always reliable in their reports, or are unable to describe their signs and or symptoms. With this being said it is imperative that Psychiatric Mental Health Nurses remain competent in their assessment skills, whether it is a comprehensive admission health history and physical assessment or a problem-focused assessment.
I challenge administrators in psychiatric facilities to offer continuing education to their Registered Professional Nurses in an on-going fashion to keep their skills current. I would be interested to learn how other facilities maintain the competence of their nurses.

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Sexual Assault Nurse Examiners

February 22, 2007

SANE nurse’s are sexual assault nurse examiners and provide a very specialized area of forensic nursing. These nurses must have specialized training for competently collecting evidence, while providing both physical and emotional support to the patient. The need for SANE nurses to be readily available in the ED setting is vast. It is not uncommon for a patient to be forced to wait in the ED from four to eight hours for a practioner to exam them. Many ED’s are implementing SANE programs in order to more quickly and efficiently take care of this population of clients. The SANE nurses have a legal obligation to offer the patient post-coital emergency contraception as well as HIV/ Hepatitis/STD testing and treatment. Some of these interventions may be ethically controversial for the nurse, and they should consider this before entering the disciplinary of forensics concerning sexual assault victims.
SANE nurses are extremely beneficial to the patient providing quick and efficient care to the clients. They establish a liaison between the regular staff or hospital and patient. They will serve as a witness in a legal trial concerning the incident or evidence. They also provide assistance to the legal system serving as a liaison between hospital and local authorities. There are currently 280 SANE programs in the US. There is a proven benefit to have these programs available in the community. They also provide a great opportunity to the RN who is seeking a rewarding and challenging career.

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Forensic Nurse Response Team

February 22, 2007

The article entitled Forensic Nurse Response Team is about a forensic nursing unit and the quick comprehendible process of evaluation within a timely manner. This is a four step process that includes step 1 triage nurse determines patients visit, medical history and documents the findings. If a situation where police needs to be involved the nurse will also contact police at this time. Step 2 involves a physician, NP or PA providing screenings and medical exams before patients medical needs are taken care of. Step 3 includes basic information in order to register patient, as example DOB, Height, Weight ext. Step 4 entails a forensic nurse collecting evidence for the processing of law enforcement. At this time the client will also be receiving referral number or social services consults. This article was interesting in the fact that it gave a quick and easy way to understand the complete goal of forensic nursing; while explaining the importance of each individual task involved. The article also discussed who was billing for the procedures and how personal insurance would and would not cover procedures depending on the incident. Forensic nursing is a multidisciplinary nursing field and will only be successful if each discipline provides correct/useful information.

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Ethnic and cultural considerations in Forensic Nursing

February 21, 2007

I read about cultural sensitivity and becoming culturally competent, and having worked in a very culturally diverse setting I studied assessment skills of special populations a lot. I tried diligently to not stereotype, to utilize interpreters, and to plan care based upon the values of the person and their health seeking behaviors/needs.

Now, I am in a predominately forensic setting (long-term care state psychiatric hospital) with many cultures and ethnicities present. Some attitudinal issues perplex me; be cautions around this patient, not only is he Hispanic but he murdered his Mother. Watch this person, he is African American and is a repeat offender, you know he is antisocial. Oh, this guy is willing to be deported because he is so kind and he thinks life will be better if he returns to Ethiopia.

I challenge the mindset of stereotyping by culture/ethnicity and by crime. I challenge the mindset of stereotyping based upon Axis II disorders. I wonder, is it complacency or is it overt familiarity with the long-term care patient that develops this thinking in the staff.

I find it exciting to conduct thorough and comprehensive assessment in collaboration with the patient and the interdisciplinary team to move toward planning that will optimize positive outcomes in the patient. Is that naivety on my part or is that our job?

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Medication Errors, comment

February 20, 2007

Not only do medication errors affect patients they also affect nurses, doctors, and the hospital in which it happened. It is not only in our best interest, but in the interest of the patient to figure out to avoid and fix the problems that currently lead to medication errors. It has been noted that three main reasons for medication errors include human errors, system failures, and communication failures. Communication failures being the number one reason for medication errors. We can prevent errors by improving the systems that guide health care practice.
Communication errors occur most often because we talk a lot! We can be rushing around at work and a physician comes in and gives a verbal order. For me I need to write it down immediately and then I repeat it back to them to make sure I heard them correctly. Other times, if I am busy or in the middle of something I tell the physician that I will do it as soon as they write it as an order. By asking them to write it down not only makes them accountable for the order, but if I have a question about it I can run it by another nurse for clarification. There also seems to be an increase in foreign doctors, especially where I work. If I am taking a verbal order, I always repeat what they have said to me back to them and ask if that is correct. We also have to sign our orders stating “read back and confirmed”. What they said very often is not what I heard. In the end if I write an incorrect order it falls back on me because I am the one who wrote it. I am very anal when it comes to orders and have many times annoyed physicians by asking them to repeat what they said or to have them spell it for me. As long as I have the patient’s best interest in my mind, I don’t care that they are annoyed with me! I am not there to appease them, I am there working for the best interest of my patient.
Systems failures include poorly developed prescription, transcription, delivery, and administration, protocols and a lack of checks and balances. Automatic checks and balances help decrease human failures and alert clinicians to errors so they can be corrected before they reach the patient. My hospital is working on implementing a new medication delivery system that includes an improved method of checks and balances. In the future will have to have all orders go through pharmacy via computer and will not be allowed to receive any meds until all checks have been done correctly. Currently, if a new order is written the charge nurse takes it off and puts it on the patient’s MAR. After doing this it is up to the nurse caring for that patient to make sure they get the correct med. By implementing the new computer system, all orders will have to go through pharmacy, via computer, in order for them to be taken off the chart. The perfect example of this is an error that occurred last year. A coworker of mine had an order to transfuse her patient with a unit of PRBC’s. Before administering the blood the patient was to receive Tylenol and Benadryl. The orders were handwritten on the MAR by the charge nurse and my coworker was informed of the order. We stock Tylenol and Benadryl on our carts so the nurse went ahead and gave them to the patient, instead of waiting for them to arrive from pharmacy. After the meds had been given, pharmacy got the order and called the floor and asked why the physician had ordered Benadryl for the patient because she was allergic to it. In this case, who is to blame? The physician who ordered the med, the charge nurse who took the order off, or the nurse who gave the med? Everyone wanted to blame the next person in line and no one wanted to step up and say they were wrong for not checking the client’s allergies. The patient ended up making it through okay and my coworker got written up for it. Chalk it to another lesson learned by all involved.
After reading several articles on the subject a common theme seemed to be that younger nurses, who have been in the field less than five years, said that human errors were the most important source of errors. To me this means that we all need more education on the matter. One way to educate is to share with others the mistakes you have made, and how they affected you and how you learned from them. I tell my students about the med error I made the first year I was on my own. It makes them see me as human and lets them know that everyone can, and usually will at least once in their career, make a medication error. It is what we do after the error that will guide our future care.
There are many other reasons medication errors occur. Understaffing, penmanship of those writing orders, verbal orders, and use of abbreviations are just a few. When a facility realizes they have a problem it is what they do to try to fix it that really matters most. Not only is my hospital going to an all computerized medication delivery system soon, but we have other checks in place. Administration has an approved list of abbreviations for us to use. If physicians use one that is not approved the order does not get filled until they come and clarify it. We are also, in the near future, going to establish a system that is all electronic. The MAR’s, medications themselves and patient name bracelet’s will all have to be scanned, all prior to being administered. These are all attempts to further reduce the amount of medication errors that actually happen and are reported. I believe that my hospital is on the right track to the future and reducing medication errors.

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GI problems and the psychiatric mental health patient

February 20, 2007

I am going to illustrate a specific example and then request advice as to how to improve communication of assessment data to the attending.

The patient is a 45 year old African American male with an Axis I diagnosis of Schizophrenia, Chronic Paranoid and Axis III of Cerebral Palsy (CP), hypertension, gastritis, and urinary hesitancy.

Mr. M. is quite debilitated from his CP compounded by extra pyramidal side effects from his psychotropic medication. He is, quite to his embarrassment, incontinent of bowel and bladder. Very recently he began having tarry stools and his H&H; dropped significantly. Even though his stools were negative for blood it was obvious he was loosing blood. This is when he was worked up for and diagnosed with the gastritis. He was prescribed medication for the gastritis, his H&H; improved, but he continued to have frequent diarrhea stools.

Nursing staff vigilantly assessed volume and visualized the color and consistency of the stools. Auscultation of the abdomen found hyperactive bowel sounds, but little else. As the days went by skin integrity became a legitimate concern. Daily, and sometimes multiple times, during the day nursing reported frequency of bowel movements to the attending psychiatrist and to the onsite internist. The problem seemed to be that the local consulting gastroenterologist had little patience or desire to work with the mentally ill and dismissed the patient. As the problem grew worse finally a successful appointment occurred and the patient was diagnosed with Crohn’s disease and treatment was prescribed.

How could the nurses have better articulated the distress that this patient was enduring?

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Nursing Process implementation in long-term forensic nursing care

February 16, 2007

I have cared for “criminally insane” patients during my 28 years as a psychiatric mental health nurse in the acute care setting. Those patients with impending revocation of a conditional release, pre-trial evaluations, incompetent to proceed, and NGRI, but now I am working in a long-term care state hospital that is greater that 90% forensic. Of those about 43% are shorter stay patients that are incompetent to proceed. In this population regaining competence is touted to be the primary focus of care and treatment.
My professional dilemma is implementation of the nursing process at this organization. My observations show less than adequate assessment, absent planning, fairly good intervention/implementation, and non-existent evaluation.
As an administrator I see opportunity to make dramatic change in this department. I see opportunity to elevate the nursing professional practice to a level that could be the benchmark. I see an opportunity to introduced evidenced based practice into this interdisciplinary yet medically driven organization.
My charge is to create, implement, educate, and mentor the advancement in nursing practice in this organization. My quandary is and my question posed is; Does anyone have input into methods or approaches that will expedite and facilitate this paradigm shift?

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Pain assessment in the forensic population

February 14, 2007

I recall one time a Psychiatrist told me; “trust and believe in the psychiatric patient until that trust is broken”. That is very much paraphrased from the actual content of that conversation that occurred oh so many years but that has been a motto that I have used throughout my nursing career. To me this mean to treat the patient with respect, dignity and to value where they are at that moment.
That preamble leads me to pain assessment. JCAHO implemented their pain standards in early 2000 for multiple reasons two of which are; 1. customer satisfaction & 2. healthcare was doing a very bad job at assessing, and providing intervention for pain. My posture is; that in caring for the forensic mental health population we continue to not meet the basic premises of pain management. We judgmentally scoff that the patient is “drug seeking”, we discount that this recovering mentally ill person with co-morbid substance usage issues could ever legitimately have pain. On the flip side of that we dole out acetaminophen without the blink of an eye.
On one hand the “drug-seeking” patient no doubt has not been adequately assessed for acute or chronic pain and the acetaminophen-ingesting patient is probably just trying to obtain some attention.
I have a desire to make change in pain assessment and implementation of interventions at this organization where I work. I am a firm believer that health promotion and health maintenance are vital in the area of pain management and all too often we either ignore the patient or far to readily administer medication. I seek suggestions for the promotion of non-pharmacologic interventions, solid assessment techniques that are tried and proven, and any other insight into being a change agent in this area.

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Forensic assessment in the emergency department

February 13, 2007

Aside from the show CSI I am unaware of nursing roles in conjunction with forensic nursing. One of the articles that caught my attention was one concerning forensic assessment in the emergency department. This was interesting to me as I have spent the last 4 years of my nursing career in a very busy ED in southern California. We are exposed to many cases of physical and sexual assault; many times the patients are simply dropped off outside of the ED doors unconscious making the case a challenge from the beginning. My current knowledge and general attitude in the ED is to establish patient care first then let the police worry about the investigatory work. After reading about forensic nursing I am now aware that we play a huge role in how easily or affective the authorities can collect data. It is exciting to know that the ED staff is a part of the investigation and what we do medically to the patient can effect the entire situation.
Another interesting concept I discovered is how occupational injuries are also within the scope of practice for forensic nursing. My hospital gets 100’s of workman’s comp cases a week. I will now be more aware of this during my assessments and charting to those workman’s compensations cases.

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