Archive for January, 2010

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Mental Health

January 28, 2010

Mental health is one of my favorite subjects. Maybe because we are all at risk for a psychological breakdown. Maybe because I have seen and experienced many mental health problems in my own environment. Friends and family have been afflicted with chemical dependency, depression, bi-polar and risk for suicide. I find it curious, though, that the designer condition, among my friends’ children, especially teen girls, seems to be bipolar or borderline. These girls all know the terms and almost seem to enjoy "schlepping around" (hanging around) the psych unit in their PJs. I wonder about some of these privileged girls and if psych care and diagnosis makes them even more coddled?

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Posted in Psychiatric Forensic Nursing | Comments Off on Mental Health

Stings Sweeling, and facial recognition

January 25, 2010

I wonder if inflammation from a bite or sting affects the facial recognition. For example, say someone is hiking in the woods and is stung by a swarm of bees, causing them to pass away. The face and body would have extensive swelling due to the venom in the bee sting. It would seem the basic structure of the face and body would remain unchanged because no bones were broken and no body structure damaged (unless a fall or something took place alongside the stings). I would imagine the same would be true of a food allergy, like peanuts. When someone eats something they are allergic too, their windpipe closes restricting the air flow. That would attest to the sudden, otherwise unharmed body. But their face and bodies swell too. Would that swelling cause someone not to recognize them?

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Mental retardation and abuse

January 25, 2010

I have always had a passion for individuals with a developmental delay. It makes me shudder at the thought that certain individuals may abuse, neglect or even kill them. Understandably, diseases like Turners Syndrome, Downs Syndrome, and other disorders are horrible. Those individuals will never have the potential that someone without these disorders will. But that is not to say that those individuals will have an input on the world. For example, my mother’s best friend has a son with Downs Syndrome. With his disorder and personal development, it will be hard for him to live alone, so he still lives at home. His mother has been diagnosed with MS and is confined to a wheelchair. Without the help of her son, she would be completely alone. It is not our place to mistreat individuals because we get frustrated or don’t grasp their existence. But on a forensic level, it must be very very hard to understand the causes of death in these individual if cause by abuse and neglect – with their facial deformations and bodily dysfunctions. This is all the more reason for us as individuals with typical development to stand up for these people and advocate for them.

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Posted in Child Abuse & Neglect, Domestic Abuse & Neglect | 2 Comments »

Livor, Rigor, and Algor Mortis and Inflammation

January 25, 2010

One item of interest that I have been reading on is inflammation and its role in identifying a body after death. The website of Forensic Pathology talks about the time of death and the ways to tell when that happened. It speaks on livor mortis, rigor mortis, and algor mortis. Livor mortis, being the discoloration of the body due to blood settling, and the rigor mortis, the stiffening of the body, would be the areas of mortis that would promote inflammation. As I have never seen a dead body, I have never seen how these two types change the body after death. I have only seen a dead body in a funeral home, so I’ve only seen one after the funeral director and staff has done their jobs, which I am sure has some kind of draining.

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Clinical Scene Investigation and Assessment Skills, comment

January 11, 2010

Police are taught to gather evidence and reconstruct crime scenes, and attorneys are taught to defend or prosecute the parties involved. Neither of these groups, however, can complete their assignments without the help of someone putting the pieces of the client together. This is where the role of the forensic nurse is crucial. Nurses are trained to assess clients from head to toe- critically analyzing every inch of the client. In addition, through comprehensive health histories, we are also able to gather vital information about the client and family members. This information, when coupled with the physical assessment, presents a “whole” picture of not only the client but also possible events leading up to the incident. We are able, when correctly assessing the client, to see causes and effects of lifestyle choices, genetics, and unplanned conditions. This ability and knowledge separates us in many ways from other personnel involved in CSI.

Original Post
November 17, 2009
Title: Clinical Scene Investigation and Assessment Skills
In the same vein as TV’s Crime Scene Investigation show, health care organizations are turning to specially trained teams to investigate severe patient incidents. These teams, titled Clinical Scene Investigators (CSI) are responsible for investigating events that result in permanent patient harm or even death. The investigators gather details about the event from the participants and patient charts and may even sequester equipment as the situation warrants. They look at all the details which lead up to the incident, how the situation occurred and then look for opportunities for process improvement. In situations like these, thorough documentation on the healthcare workers part is paramount. Was the caregiver aware of the pending situation and were appropriate actions taken? In addition, the CSI team members must have superior assessment skills, solid investigatory abilities and excellent communication skills. They must be able to paint a picture in order to determine if more investigation is required.

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Suicide, comment

January 11, 2010

Over 90 percent of the people who die by suicide have a mental illness at the time of their death. Examples of the mental illnesses include depression, schizophrenia, and bipolar disorder. Unfortunately, most of these mental illnesses are undiagnosed. Untreated depression is the number one mental illness associated with suicide. Also, people with genetic disposition to depression may manifest no signs or symptoms of depression, but may still commit suicide. The question, tragically, is why were these illnesses undiagnosed? Where were the comprehensive health assessments? We are taught our first semester in nursing school to always obtain a comprehensive assessment at the client’s initial visit. This includes a family history, personal history, and social history. The family history section identifies illnesses of genetic, familial, or environmental nature that may affect the client’s current or future health. History of mental illness is one of the questions in this assessment. The personal history section asks the client for a general statement of feelings about themselves, and the family and social section asks about general satisfaction with interpersonal relationships, including significant others, other people in the house hold, etc. Questions are asked about diet and nutrition and changes in eating habits. Mental health questions are asked to assess stress, depression, irritability, etc. As an adult, I have no recollection of ever answering questions of these types for any doctor/clinic/medical facility I have visited.  If a comprehensive health history had been correctly administered to the over 90 percent, would they have remained alive? We as healthcare providers need to remember that the information we are taught in classroom settings is not intended for regurgitation on an exam. It is designed to be a tool in increasing the wellness of our clients – even to the point of saving their lives.

Original Post
July 14, 2009
Title: Suicide, comment
Suicide is known to be associated with mental disorder. It may be in form of major depression or some sudden trigger which causes an individual to act irrationally. The ideation of suicide can be very subtle especially when nurses do not detect the signs. some patients are very crafty and may disguise very professionally as well. So the duty is on the nurses to pry deeply on the patients when assessing life stressors which may likely make patients to contemplate suicide. Often, known patients with mental illnesses are protected by HIPPA except cases that are already committed to psychiatric settings. For adolescents, they often display their emotions which helps nurses to quickly act on the information observed or stated but when it becomes a case of prolonged ideation for which the patient has had a means and time to do the act then nurses must still be vigilant. One cannot overemphasis the pivotal importance of detailed assessment and constant reevaluation of any event or attitude which may suggest that a patient is in danger of committing suicide. Once at a psychiatric hospital, a room mate committed suicide suddenly. Nurses were surprised because the patient most have acted within the spur of the moment while disguising the traits associated with suicide ideation. Quality and risk analysis in hospital settings are still open to these investigations. Nurses can also use support groups as well.

Original Post:
June 5, 2009
Title: Suicide
Suicidal ideation is more common than completed suicide. Most persons who commit suicide have a psychiatric disorder at the time of death. Because many clients with psychiatric disorders are seen by family physicians and other primary care practitioners rather than by psychiatrists, it is important that these practitioners recognize the signs and symptoms of the psychiatric disorders (particularly alcohol abuse and major depression) that are associated with suicide. Although most patients with suicidal ideation do not ultimately commit suicide, the extent of suicidal ideation must be determined, including the presence of a suicide plan and the patient’s means to commit suicide.
Many clients who commit suicide have seen their primary care physician within several months before their death and many of these physicians were unaware of the clients’ intentions or that the clients had previously attempted suicide.
The best way to prevent suicide is to ask clients with symptoms of these disorders more specific questions about recent stressors and their thoughts about suicide, excellent history taking is essential to help diagnose clients with suicidal ideation. Reviewing the clients medical history for chronic illness, obtain a drug history and ask the client about family…listen for clues!

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Medication Errors, comment

January 11, 2010

Medication errors include prescribing the wrong medication, administering the wrong medication or using the wrong route, interval, or doses, and failing to administer a medication. As a result, critical care in error prevention rests in a large part with the nurse. Nurses play a major role in medication preparation and administration, medication teaching, and evaluating clients’ responses to medications. As a result, they are required to have knowledge about the actions and effects of the medications being taken by their clients. We, as nursing students, are trained to take several steps to prevent errors. First we have the six patient rights of administering meds: right medication, right dose, right client, right route, right time, and right documentation. We are also taught to check the labels at least three times, to use at least two client identifiers, and to double-check all calculations with verification by another nurse. If we cannot read handwriting, we are not to guess, but to immediately verify the medication order with the prescriber. We are taught to question unusually large or small doses and to document all medications as soon as they are given. When available, nurses should also attend any in-service programs that focus on the medications commonly administered. If these steps are followed and distractions during the preparation and administration of medications are not allowed, the incidences of medication errors will be dramatically reduced.

Original Post
December 17, 2009
Title: Reduction in Medication Errors, comment
Recent research indicates that there is an increase in medication errors with nurses working on the night shift. It is noted that sleep deprivation interferes with concentration and increases distractibility. Assumptions can be drawn that the lack of concentration and distractibility may also affect other aspects of the night nurses care, including assessments, charting accuracy and critical thinking skills. To compound these issues, many new nurses work night shifts as it is often where the open positions are available. What can be done to address these issues? Organizations may want to explore resources to aid nurses with acclimation to the night shift. Education on circadian rhythms and how best to facilitate a healthy life style while working on nights is a great place to begin. Offering resources such as written materials, and formal classes may be of benefit. In addition, encouraging a culture that promotes power naps, healthy eating and exercise during breaks is recommended. Tracking changes in incident reports that relate to night shift medication errors and reckless behaviors may prove beneficial to support a culture of addressing night shift needs.

Original Post
November 6, 2009
Title: Reduction in Medication Errors-comment
In addition to medication administration practice for student and graduate nurses, there should also be continuous education on Pharmacology updates and practices for staff nurses. There is a wide variety of resources available, including monthly ISMP news letters providing insight into medication errors – not only showing nursing errors in judgement, but also shedding light on system errors as well. Electronic medication administration records and Physician order entry applications are also computerized tools that can be utilized by organizations to decrease the incidence and cost of medication errors.

Original Post
November 3, 2009
Title: Reduction in medication errors
It has become obvious to me in my practice as a nurse administrator that medication errors are a major liability to a health care facility. Efforts to reduce them are paramount to quality standards of practice.. A combination of education and interdisciplinary approach to error reduction is crucial. By "humanizing" medication directions i.e. at bedtime instead of hs the potential for the wrong med at the wrong time at the wrong dose is minimized. By educating new nursing students to the need for safe practice and insisting on that practice prior to graduating nurses, medication errors as well as quality of care will improve. By utilizing pharmacy consultants to review MD orders for correct utilization of meds the potential for error is again reduced.

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Abuse and Neglect of the Elderly

January 8, 2010

I work as a charge nurse in a long term care facility with 100 residents. Assessing and reporting neglect and abuse are part of my job duties. Documentation and investigation are essential elements of elder abuse, with reporting to the Ombudsmen. We use forms for documenting abuse and neglect. These are what the Ombudsmen receive and are not part of the medical record. Quality improvement review these documents as they are initiated, ensuring thoroughness and making changes to the care plans. I have found it difficult, at times, to distinguish self-inflicted injuries from those committed by staff. Skin of the elderly is so thin that a resident can easily inflict scratches and bruises on themselves. Determining whether the injuries are self-inflicted becomes a function of the investigative process by the nurse, along with reporting. An objective view must be maintained during the assessment. The nurse’s judgment has little baring. I have found this course in Advanced Health Assessment to be an invaluable tool in good assessment skills.

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Screening for Abuse in a Correctional Facility

January 8, 2010

I work as a charge nurse in a long term care facility with a small correctional facility that is a separate building on the campus. I pass meds to an average of 25 inmates. My responsibilities, also, include health assessment, injury care, psychological screening, and abuse assessment. I address, at a minimum, 4-5 inmate-to-inmate abuse incidents per week, ranging from superficial abrasions and mild bruising to severe assaults, encompassing head trauma and deep lacerations. EMS is always called for severe injuries, but the initial triage and investigation falls to the examining nurse. I find that one never gets the truth, in regards to the assault, from the inmates involved. Fortunately, cameras are everywhere. The saying, "a picture is worth a thousand words," always seems to clarify the incident. I have had to go to court multiple times, as the on-site medical officer, offering my recollection of events during my assessment. Good and thorough documentation is essential, as well as adequate injury care. Getting the guards to corroborate the nurse’s findings is necessary to preventing unnecessary law suits. The physician, on call, oversees the triage and care. He is the nurse’s ally. Most of the abuse incidents stem from the inmates being cooped up with other inmates in a closed environment. Frustration, anxiety, and anger are all thrown into the volatile mix. This is what I find difficult to come to terms with. There is very little psychological counseling done on these inmates. They have no valid coping mechanisms taught to them. This makes it frustrating for the nurse, with little psyche training. I am cognizant of the lack of funding for psyche intervention programs, but feel that a more intense and complete psychological screening assessment tool should be incorporated into correctional nursing than just a form, with questions asked of each inmate. There should, also, be ongoing evaluations done on the inmates, as environmental factors seem to have a substantial impact on the mental health of incarcerated individuals.

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Screening for abuse, comment

January 6, 2010

I agree with reporting any suspected abuse as being our obligation. We should report any sign of possible abuse whether we are definite or not to be efficient in the care of our patients. I did a little research on signs of child abuse that are not so obvious. One sign that I found to be consistent is the inability of the child to concentrate. We tend to recognize the physical aspects of abuse, but do not put as much emphases on the emotion effects.

Original Post
October 12, 2009
Title: Screening for abuse, comment
As I read through the various postings, many readers have voiced the same concern – the need for doctors and in particular nurses, to be further educated in the screening and assessing of suspected victims of abuse. I agree with the theory that the medical profession has an obligation to reach out to this patient population -whether they are willing or not to admit they are in an abusive relationship. I have a lot of mixed emotions on this topic – I think what is needed is a bit more than assessing our patients. I think it has to start with us, the nurses – taking a look at ourselves and our own relationships. In the past week I had to take my daughter to a wake and two funerals. One of her best friends had to bury both her parents, separately. The mother died a violent death – the victim of domestic violence, the father then took his own life. The mother was not only a truly loving and special person, she was a smart, educated professional. A nurse. I think as nurses, doctors – "healers" – we sometimes overlook the very things that we are trained to look for. Most of us enter this profession to "help" others, to make a difference, to not allow our patients to give up, but rather to be strong and overcome. I think it is in most of our nature to root for the underdog, take on the stray – we can help and change those who can’t help themselves. This young woman saw the signs, began to live in fear for the safety of not only herself, but for her children as well. She tried to help her husband deal with his emotions and his behaviors. She tried to help and be supportive. Tragically, the very day she took legal steps to protect her family, was the day she died. I think as healthcare professionals we not only hold an obligation to help those we provide care for, but we must also recognize the obligation to help ourselves. To reach out to our peers and our co-workers. I think that sometimes we are just blinded by the need to make things better.

Original Post
September 28, 2009
Title: Screening for abuse, comment
I think that all nurses and doctors should receive additional training in screening for abuse depending on their specialty area. Patients will present differently depending on whom they are being interviewed by. Many times in the situation of children they are with their abuser when they present and it is difficult to separate the two. The abuser does not want you to have words alone with their child. I worked many years as a school nurse and suspected many cases of abuse that were reported to the appropriate authorities only to find that the child was disbelieved and then years later found to be telling the truth. Adults are very savvy at making a child look like a liar but seldom do these children have the capabilities to make up the horrendous story I heard. Unfortunately the investigators seem to want to believe the abuser. These children were also ones with poor grades (not sleeping at night due to the abuse), behavioral issues (they just wanted someone to listen) and many times documented storytellers (the only way to get attention) so it was very easy for the abuser to discredit them. If we are all trained to look for something other than physical marks we may start to diminish abuse against our children. Part of the assessment should not include where the parents reside in society. Several times the investigators simply found out what the parents did for a living and that in itself ended the investigation.

Original Post:
September 8, 2009
Title: Screening for abuse
Thank you for this important message. It is absolutely imperative that ALL providers know the signs and symptoms of physical, emotional and sexual abuse. Furthermore, it is absolutely necessary that ALL providers screen every patient at EVERY patient encounter for abuse. Providers should incorporate screening for abuse into their health assessment. It is very easy to do. Providers can accomplish this important task by 1. Printing the screening question on the pre-assessment paperwork, 2. Asking the patient during the assessment, "Do you feel safe at home?" 3. Knowing the s/sx and incorporating screening into every pt encounter. So very important.

Original Post
September 2, 2009
Title: Abuse
Child and elder abuse continue to be very under reported making it imperative that doctors and nurses have education on signs of abuse. Nursing home abuse is also very under reported since nursing home pts. are lacking in visitors and seen as demented. Nurses also need to know who to contact should abuse be suspected.

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