Archive for July, 2009

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ABDOMINAL TRAUMA IN FORENSIC NURSING

July 31, 2009

  The primary components of health assessment are the health history and the physical examination. Since forensic nurses may need to perform specific exams related to each individual case, abdominal assessments may be indicated where there is some nature of trauma involved. Subjective and objective data are utilized in order to obtain data required for the specific case involved. Just as nursing assessment are used in hospitals, the same assessment is utilized in forensic nursing assessments.

  Forensic nursing assessment as with general nursing assessment is initiated by observing the client’s general behavior and position. The nurse assesses the client for any marked restlessness, rigid posture or knees drawn up. Facial grimacing and rapid, uneven or grunting respirations are also noted.

  The abdomen is observed to detect any erythema or bruises. The nurse also documents any signs of abdominal distention, tautness, scars, lacerations or open wounds. Auscultation is then performed to assess if bowel sounds are present or absent. Percussion of the abdomen, liver and spleen are indicated in order to assess the level of trauma sustained. Palpation of the abdomen, umbilicus, liver, gallbladder, spleen and kidneys are noted to assess any tenderness, hypersensitivity or rigidity. The client may respond to pain by using muscle guarding, facial grimaces or pulling away from the nurse. Spleen and kidney tenderness may indicate trauma.

  The nurse should use a pain scale in order to assess the degree of pain the client exhibits. Examples of pain scales can include descriptive or numeric pain intensity scale. The McGill Pain Questionnaire is another resource to indicate pain quality descriptors using 4 major groups ie: descriptive, affective, evaluative and miscellaneous which aids clients in describing their pain.  These groups are then totaled in order to indicate the description of pain the client is experiencing.

  Although all assessments of abdominal trauma are useful in determining the degree of trauma sustained, the nurse should be aware that findings detected during an exam may warrant the use of additional tests. The client may need to be transported to the nearest hospital for further evaluation.

  Abdominal assessments regardless of injury should be performed in a setting that is conducive to the client’s safety, privacy and dignity.

  Abdominal assessment techniques utilized in Chapter 20 of Health Assessment for Nursing Practice, Wilson & Giddens is an excellent resource for any nurse to familiarize themselves with the proper sequence of assessments.

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Pediatric medication errors in the PACU (Post Anesthesia Care Unit)

July 30, 2009

When we, as nurses perform assessments on our patients, in this case, a pediatric patient that will be going for any surgery, we often forget the word beneficence (principal of doing well for our patients) or take it for granted.  We go though the assessment form with the patient and most often the parent assisting, sometimes taking aspects of it as routine or perform a ‘run of the mill assessment’. 

The patient, now has his or her surgery and moves through to the PACU.  We always believe that we will always act in the best interest of our patient, the principal of ‘doing good’.  We always plan on never doing harm to our patients- to do no harm-provide the principal of nonmaleficence. 

‘Medication errors involving pediatric patients in the PACU, may occur as frequently as one in 20 medication orders and more likely to cause harm when compared to medication errors overall.’(AORN 2007, vol 85 page 731)  There have been many instances of late with pediatric medication errors, but the one that is foremost in everyone’s mind is the much published case of the newborn twins of actor Dennis Quaid. A medication(heparin) was administered and the dosage was incorrect.   We as nurses have long been educated and re-educated on the ‘5 rights’ of medication administration.  If we would just take the time to check and re-check the medications, there perhaps would be a decreased number of errors.  Pediatric medication dosages are based on the child’s age, weight and condition. A higher percentage of errors were found of pediatric patients where calculations involving decimals, dosage forms and math related as we have to calculate the proper dosage. Hospitals, pharmacists and nurses are continually trialing and attempting to establish standardized policies, procedures and educating our nurses in the proper handling of our pediatric populations, so errors don’t occur.  Do I think we have the problem solved…no.  But we are well aware of this problem and we have begun the journey to rectify the problems.   I certainly do not want any of our pediatric patients to become statistics and our nurses go through the immense pain and suffering if a negative outcome happens. There are many regulatory bodies that could  get involved.  Not to mention, the family and their worries and concerns for their child, and yes, the lawsuit that may prevail. We must all be very cognizant of not only our pediatric patients, but all our patients.  

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Living Forensics

July 28, 2009

Living Forensic is a part of forensic science that focus on living victims of abuse or trauma. Nurses in general are often exposed to the aftermath of many of these forensic matters. Unfortunately a lot of these cases do go unnoticed due to lack of training in the field of forensic. For this reason alone, I think that all nurses should undergo some form of forensic training. Having knowledge of the forensic principles and guidelines will assist nurses in upholding the rights of the patient by being able to recognize and protect evidence that can be used in determining verdict or cause.

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The Passing of Michael Jackson and the Investigation, Part 3

July 28, 2009

According to Lehne (2007) pharmacodynamics is defined as the study of the biochemical and physiologic effects of drugs and the molecular mechanisms by which those effects are produced (Pg. 46). For any medication to be therapeutically effective, variables such as maximal efficacy, relative potency, affinity, age, body weight and composition, must be considered. One would think that Michael Jackson’s transformed appearance, frail body, saddened eyes, behavioral patterns and reported dependency on pain killers would have triggered enough red flags to bring attention to his deteriorating condition. The question, however, remains, "Did his fame and fortune contribute to and/or encourage unethical medical decisions?" Potency is defined by Lehne (2007) as the amount of drug given to elicit an effect, a factor that might have been ultimately responsible for Michael Jackson’s sudden death (Pg. 48). Lehne (2007) also reported that "It is important to note that the potency of a drug implies nothing about its maximal efficacy which refers to the largest effect that a medication can produce" (Pg. 46). With multiple medications prescribed for Michael Jackson, likely through different sources, the potency as well as the maximal efficacy could have resulted in alarming side-effects that, if diagnosed and evaluated on a timely basis by his personal doctor, might have prevented his demise. As this investigation continues, nursing forensics might be able to determine the cause and effect possibilities by evaluating the interaction of the drugs taken and their positive or negative therapeutic effects. Lehne (2007) stated, "When a patient is taking two medications, one drug may intensify the effects of the other" (Pg. 58). This suggests that all risks must be evaluated and discussed with a patient when more than one medication is prescribed. In Michael Jackson’s case, monitoring his diet was likely necessary in order to evaluate whether or not nutrients were properly ingested daily. Given his estimated height of 5′ 8" to 5′ 10" and weight of 112 pounds at death, this analysis might conclude that the type and degree of medications absorbed, coinciding with the lack of a balanced diet, were also contributing factors. Lehne (2007) defined toxicity as an adverse drug reaction caused by excessive dosing (Pg. 65). The media’s public disclosure of toxicology reports for this celebrity should bring greater focus on the potential effects of drug dependency, as well as the specific drugs used, providing both doctors and nurses with increased awareness on abusive habits, particularly when physical characteristics become negatively visible. Sociological traits, such as Jackson not leaving his home for long periods of time particularly with three children in his household, should also be questioned and evaluated. When reflecting on this case, it appears that medication remains a serious problem that requires further research and analysis. Lehne (2007) noted, "Medication error is a preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the healthcare professional, patient or consumer" (Pg. 70). Lehne (2007) noted that included among the reasons medication errors exist are: the wrong patient receiving it, the wrong drug applied, the wrong route, the wrong time, the wrong dose (overdose, underdose, extra dose), an omitted dose, the wrong dosage form, the wrong diluent, the wrong strength/concentration, the wrong infusion rate, the wrong technique or the wrong duration of treatment (Pg. 70). Communications among patient, nurse and doctor can also be a factor in the forensic nursing evaluation process. Understanding exactly what was said and done that lead to a fatal outcome is essential for future drug administration. Instead of Michael Jackson retaining one or more private doctors, he may be alive today if he had assembled a team of specialized nurses, personal trainers, a nutritionist to assist his chef and therapists trained in abusive lifestyles to oversee his daily struggles. It is my opinion that high profiled wealthy individuals, should be counseled to secure more than one physiological and psychological specialist so that opinions can be collaborated for that person’s overall well-being. References Lehne, R. A. (2007). Pharmacology for Nursing Care (Sixth Edition). Pgs. 46-70.

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Medication errors

July 27, 2009

Nurses are the last defense to ensuring medication safety, we are held accountable and responsible for their actions. Taking a few extra minutes to ensure accuracy is a preventative measure. For example, review of the 5 rights, nurses must be knowledgeable of the med being administered, we must enpower/educate our patients on their scheduled meds and then latter assess their recall of previous med teaching to make sure that the patient has full understanding of medications. Also avoid trying to interpret illegible writing, simply just call the prescriber for clarification, and always repeat telephone orders. Studies have shown that med errors are preventable and taking shortcuts when administering meds have proven to be costly and fatal.

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Opioids, more than just for addicts

July 23, 2009

Addiction is a large problem with opioids, another problem with them is that doctors and nurses tend to distrust a patients need for the opioids. There are many patients who need the relief they offer for their suffering. In the Boston Collaborative Drug Study it was found that when 12,00 patients were prescribed opioids only 4 became abusers. This shows that the drugs can do more good than the general public knows. It is very easy for the public to hear the story about a man addicted to codeine and oxycodone, but often we are not told of the person who was save tremendous pain of surgery by taking morphine. As a nurse I need to not only give my patients the best care, but also teach them about their care. Maybe if more time is put on the teaching before administering the opioids there would be fewer problems with patients becoming abused. Also if the patient understands the opioids better, they may be less inclined to mix them with other medications and the side effects will not be as dramatic.

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Bioterrorism

July 22, 2009

I had no idea until taking this pharmacology class taught by Dr. Johnson how easy bioterrorism could be. It is frightening to consider the possibility of some sick mind infecting millions with ricin or anthrax. It would appear that diagnosis would be difficult, at least initially, with the first couple of cases. The symptoms of coughing, tightness in the chest, difficulty breathing, nausea, fever, and weakness mimic many other common illnesses such as flu, pneumonia, and many other respiratory illnesses. In smaller community hospitals I would believe that bioterrorism is not the first thought when a patient presents with these symptoms. The key would have to be the volume of patients presenting with like symptoms. It is a very scary thought as to the ease with which these weapons could be obtained and I hope that we are ready if/when such an attack should occur.

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The Passing of Michael Jackson, Part 2

July 21, 2009

During Michael Jackson’s 50-year lifetime, so much has evolved and changed in drug administration and management. According to Lehne (2007), the laws and amendments were updated relevant to any misuse or tragic side effect that became uncovered, i.e, thalidomide and its outcome on infants born with phocomelia (a defect without arms and legs) (Pg. 15). In order for new drugs to enter the market, a “Randomized Controlled Trial” was utilized for the safety of those about to administer a new alternative to a person’s diagnosis, i.e., when treating AIDS. With the progression of drug research, monitoring the introduction of new medications has become crucial to the learning process for nursing. When evaluating Michael Jackson’s drug treatment following his injury-related and cosmetic surgeries, were the possible addictive side effects properly scrutinized? With addition to the investigation of his highly publicized case, it appears why many other famous people have become innocent victims of prescribed drug addictions? Because of such circumstances, forensic nursing should become a more accepted specialized field that assists in providing necessary guidelines for upgrading drug regulations, as well as understanding the dimensions of abusive lifestyles. Reports in the media have stated that Jackson was using pseudonyms to obtain sleeping medications. If such drugs were prescribed, why is it not necessary to physically see a patient when these medications are requested? According to California state law, it is illegal to use pseudonyms for any medical purpose. More research would be required to understand whether such laws are consistent throughout the United States, as well as in other places of the world in which he toured or vacationed. If it is not illegal somewhere, it is conceivable that Jackson might have found a loophole to feed his drug habit given his substantial wealth. Discovering which generic drugs would soothe his sleep or pain issues would likely require minimal effort if he paid someone off. In addition, the Internet might also have served as a resource for ordering potentially harmful prescribed drugs. Lehne (2007) outlined in pharmacokinetics that there are four basic processes that affect the human body which are absorption, distribution, metabolism and excretion (Pg. 25). If Michael Jackson was monitored on a regularly basis for drugs, his blood levels could have been easily documented and served as early indicators of his serious problem. Determining which drugs stayed in his bloodstream for how long and how they were administered are also crucial factors in this case. According to Lehne (2007), “The term blood-brain barrier (BBB) refers to the unique anatomy of capillaries in the CNS. Only drugs that are lipid soluble or have a transport system can cross the BBB to a significant degree” (Pg. 36). Furthermore, Lehne (2007) noted, “Multiple dosing leads to drug accumulation” (Pg. 42). It appears that regularly monitoring the therapeutic range of Michael Jackson’s drug usage might have saved his life. With this said, the investigation will hopefully be helpful to the medical community in the treatment of other celebrities with chronic dependencies. Nurses can also play a significant role when evaluating such patients if properly trained and understanding the rollercoaster effects of an abusive lifestyle…debilitating to any and all income brackets and ethnicity. References Lehne, R. A. (2007). Pharmacology for Nursing Care (Sixth Edition). Pgs. 15-36.

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Accidental injury or neglect

July 20, 2009

I am dealing with a 5 year old child that has had a BKA due to traumatic amputation of right calcaneus and rupture of tendons and muscle posterior calf. This child was run over by a lawnmower as his father mowed the backyard. The child was allowed to help push the mower and slid under it when the mower slipped on the hill. I am certain that dad never intended injury but the complete lack of judgement on his part has now impacted the child with a disability for the rest of his life. Yes it was an accident, but certainly a preventable one. When addressing parents about safety issues with their young children, it behooves us to encourage them to think about how to avoid possible injury – in other words, think about the worst case scenario and then have the parent ask themselves if it is worth the risk should the worst case happen. Parents need to be defensive, look for possibilities of disaster and work hard to avoid exposing their children to them. It may not be intentional neglect, but it is certainly neglect.

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The Specialty of Forensic Nursing

July 20, 2009

Personally, I think that Forensic Nursing course should be incorporated into all nursing program curriculums, because in most of all healthcare settings nurses are faced dealing with some type of forensic matter; such as abuse/neglect, med errors or injuries. Sometimes these matters do become legal issues. This specialized training equip nurses with knowledge and skills in dealing with different cases that require protecting valuable evidence. Also these nurses are able to clue in on behavior responses or physical changes that may be indicative of some form of abuse/neclect.

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