Posts Tagged ‘Forensic Nursing Assessment’

Documentation

February 24, 2012

Documentation is critically important in obtaining any type of encounter in the ED, but yesterday I had the opportunity to apply what I have learned in the coursework to the fullest. My patient was a fifteen month old who was accompanied by her mother. The child was brought in for head injury. Her behavior was appropriate for a toddler, smiling and interacting with both mom, and me and very active. She was cooperative with the triage. Mom was concerned about the abrasion over her left eye and ecchymotic area under that eye which she stated had happened 2 days prior when the child had fallen off the couch and hit her head on the coffee table. She denied LOC, vomiting or lethargy and stated her activity level had been the usual state. On further exam, I noted a three cm ecchymotic area over the left sphenoid which could be consistent with the fall, but it troubled me that she also had ecchymosis lateral to the right eye, petechial contusions to the inner auricle of the right ear but none on the pinna and also noted pinpoint abrasions to the right occiput. This did not seem consistent with the story. I asked mom about these and she stated that “She is just learning to walk and falls a lot.” A fifteen month old is usually walking fairly well, and running unless developmentally delayed, which she seemed to be bright and happy, so this troubled me. However, since triage was busy and it is not the function of triage to document all findings but just identify them, I marked her as urgent and notated my suspicions of abuse due to the inconsistency. Later, when I got off triage, I took over this patient and got to interact with the police investigator and county child protective worker who had been called. The doctor felt that the findings were consistent with abuse and a report was filed with immediate action taken. I measured all the areas and took photographs and logged them as well as documenting all the individuals and actions we had taken. The child was CT’d which thankfully was negative. The mother had admitted that she had left the child alone with her significant other on a number of occasions. The investigator felt he had enough evidence to make an arrest. The child was released to the custody of the mother and her parents. This story had a happy outcome but I still feel troubled by it. How can a person abuse a sweet innocent toddler? How can the mother allow this? Aside from that, she was so benign about the whole matter and practically lied to me about it in triage. As a mother and patient advocate, this boils my blood. I fear for this child’s safety now and suspect will see more of her in the future. References Lynch, Virginia A. and Duval, Janet Barber. (2006). Forensic Nursing. St. Louis: Elsevier Mosby.

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Lowering the Risk in Suicide

December 30, 2008

Much has been said about assessment for suicidal tendencies. However, there is an upside in all the chaos. During the evaluation, one must also consider positive enforcements that actually help lower the risk of suicide. They are as follows: a. Family and friend support system b. Significant relationships (marital and non-marital) c. Children under the age of 18 living at home d. Employment e. Religious beliefs, culture, ethnicity f. Physical health g. Hopefulness, problem-solving, coping skills, cognitive flexibility h. Plans for the future i. Constructive use of leisure time j. Treatment and medication possibilities k. The propensity to seek treatment and maintain it when needed; the stigma of mental health help is not as great now as it was ten years ago. References Lynch, Virginia A. and Duval, Janet Barber. (2006). Forensic Nursing. St. Louis: Elsevier Mosby

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Medical Jurisprudence

December 16, 2008

Besides a happy policy as to civil government, it is necessary to institute a system of law and jurisprudence founded in justice, equity, and public right. (Quote by Ezra Stiles)
About two weeks ago my grandmother fell in her assisted living facility breaking her shoulder and her leg. To someone my age this is not that big of a deal, but when you are 90 years old that is a different story. I began to wonder, how did she really manage to fall? Other questions began to pop in my head such as:
• Why was she sent to the hospital by herself with no one from the assisted living riding along with her in the ambulance?
• Why could they not wait 5 minutes for my mother to get there who works right around the corner?
• Why has no one returned any of the phone calls to my mother who simply wants to know what happened?
Although, they seem to petty questions, wait until it happens to you.
I began to give the matter a great deal of thought, and as she went into the hospital it really started to bother me. Where are people when we need them to be there to support us? Where is the support for people who sometimes can’t mentally or physically care for themselves? I began to really wonder about the other people in society who are constantly in need of care. Children, mentally challenged, and elderly are just a few to start with.
As I began research on the topics, I found many articles in which people were not getting the support that they needed, whether from parents, caregivers, or fellow professionals. To begin with, what is ethics? According to our text, jurisprudence is the study of legal ethics. These ethics include the ethics of power, justice, customs, norms of conduct, civilization, reality, and utility. Lets take it a bit further. What exactly is medical jurisprudence? In my opinion you could define medical jurisprudence as the study of legal ethics in how it pertains to persons receiving, performing, or interpreting anything related to the medical field. This would entail all leagues of medicine including mental, physical, and emotionally health.
At some point in our lifetime we will have to care for someone. Many times it will not be a family member or friend. It may be a stranger. Let’s look at my grandmother. Say that my mother could not have been there for her and she was just delivered to the hospital. What is a 90 years woman suppose to do? I found a great article in NURSING2004, where it explains how come nurses are leading the way in helping others.
The article “CRACKING THE CASE: Your role in FORENSIC NURSING,” outlines they way in which nurses should think as a patient comes into your emergency room or doctors office. The point that forensic means establishing the facts in any legal case was one of the key points in the beginning of the article. The article focuses on what nurses should do as they examine someone in order to present testimony either for or against them. These cases include domestic violence to sexual assault. As I read through this article, I feel that all nurses should pay special attention to what is listed, because they may not know it, but they could be the only person who could ever help someone out in an abusive situation.
The article goes through and lists specific things that the nurses should look for. I feel that it is important to take at look at these steps, not just for a nurse but also for any concerned citizen. Like I said, even outside of doctor’s offices, it is our responsibility to look out for fellow human beings, and see if they are in need.
1) Be Suspicious-don’t be nosy, but pay attention to what people are saying and doing around you
2) Document your Findings- keep clear documentation and a visual record
3) If need be gather physical evidence
4) Preserve the Evidence
5) Protect the chain of custody
6) If need be testify in court or report it to the proper authorities
If we just simply look over these situations we are guilty in my book of negligence.
Does this mean that this is strictly used for physical circumstances only? NO. Not only as citizens or medical professionals are we responsible for the physical care of society, but the mental care as well. As a nurse we have the skills to do a good physical and emotional assessment to understand the evidence surrounding a situation.

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Focused Health Assessment

December 3, 2008

Trauma one Pediatric Emergency Department! Trauma one Pediatric Emergency Department responding over! Rescue Unit 29 transporting a 12 year-old boy, named Mike, hit by a car while riding his bicycle. This is a hit and run accident, but other motorists called a rescue unit. The child was not wearing a helmet. Facial bleeding is under control, but he suffered facial and head trauma. There appeared to be no facture of the extremities. Presently he is awake and semi-alert. Vitals signs: BP 120/56, Pulse 120, Oxygen saturation on room air 90%, Respiratory rate, 24. He is mobilized with a cervical collar on a gurney. Rescue 29 over! Emergency department preparing for arrival over! As a nurse working in the Pediatric Emergency Department, the writer recognized that rapid assessment and evaluation is essential for a positive outcome in head trauma victims. According to the Neurological Disabilities Center, “every 11 minutes one child in the United States has a brain injury which results in permanent disabilities (30,000 children per year).” The article goes on to say “Only one percent of the children admitted to trauma units after a bicycle injury were wearing helmets” (National Disabilities center, 2001). This writer also notes that the mortality rate of head injury is high and can lead to physiological, cognitive, and physical impairment lasting a life time. With this in mind, initial observation, assessment, diagnosis and management is crucial to the outcome in a head trauma patient. For any patient entering the emergency department, a proper history taking is essential to their care and subsequent treatment. Observations at the scene (using forensic nursing assessment skills) may provide valuable information, which maybe gathered from the paramedics or bystanders. Pertinent information about the speed of the vehicle, how big was the vehicle, the height of the fall, any loss of consciousness at the site, and bleeding may be critical in determining the course of treatment. Focused health assessment for injuries also asks questions similar to forensic nursing. Rapid initial assessment would be airway, work of breathing, circulation for life-threatening hemorrhage, and level of consciousness. In an emergency situation, it is imperative that a focus assessment be the top priority. This will allow the nurse and the physician to focus on any immediate life threatening symptoms. Observation of the patient should always be done before touching. A quick observation should include the child’s behavior and activity, skin color, breathing, and positioning. Gaining the cooperation and confidence of the pediatric patient is of utmost importance, even in the presence of the parent. In this case, the child needs to be reassured that his parents are on their way. Use simple terms and do not make promises that cannot be done. They should always be told what is happening and the outcome. The nurse should remain calm and talk in a quiet voice. Trauma patients are prone to hypothermia, especially in pediatrics due to their body surface. In assessing the child exposed only the body part needed, traumatic children are very susceptible to hypothermia. Once the child has been stabilized, initial vital signs should be noted and recorded. A priority in head trauma is neurological screening to evaluate the degree of injury to the head. The involvement of other body systems should also be the focus of this assessment. According to the Canadian medical association journal “children are more predisposed than adults to head injury because of their head. A child’s body ratio is greater, their brains are less myelinated, and thus prone to injury, and their cranial bones are thinner.” (Canadian Medical Association Journal.2002, p.948 (9). Careful examination of the head is necessary to identify any tenderness or deformity of the skull, skull fontanels, and facial bones for facture. While the child is awake and semi-alert, questions such as “where did you hit your head?” or what part of your head hurts?” should be asked. This will give the examiner an indication of the area of injury and which part of the brain that may be affected. The child’s response will help the nurse to evaluate his neurological state such as level of alertness, orientation, speech and comprehension. Using the Glasgow coma scale (GCS) will provide in depth incite to his neurological state. The score is calculated from best eye opening response (1to 4), verbal response (1 to 5), and motor response (1 to 6). A score of 15 is good while 3-8 is considered serious. According to Gilligan “patients with GCS less than 9 usually required intubations via the oral route” (Gilligan, 2006. p.277). The Glasgow coma scale should be used when the patient is initially evaluated and after each intervention. Pupillary response is critical for the head trauma patient. The child should be asked if he/she has any difficulty seeing or blurry vision. Pupil size, shape, reaction to light and symmetry of both eyes should be checked to detect any cranial nerve involvement. Jarvis states, “in a brain-injured person, a sudden; unilateral; dilated; and non-reactive pupil is ominous. Cranial nerve II runs parallel to the brain stem. When an increase in intracranial pressure pushes the brain stem down (uncal herniation), it puts pressure on cranial nerve III and causes pupil dilatation” (Jarvis, 2002. p.702). Around the eye should be examined for ecchymosis and the ears and nose for bleeding or watery discharge, which may indicate spinal fluid. In the book clinical manual of emergency pediatrics the Cain and Gershel state, “spinal cord injury is sometimes overlooked during the initial evaluation of the severe brain injury patient” (Crain & Gershel, 2004. p.642). The head in humans is connected to the neck bone, therefore injury to the cervical spine should be ruled out. To evaluate this, ask the child if any numbness or tingling in any body part or does it feel like pins or needles. The toes or sole of the feet should be touched to detect sensation then ask, “can you feel your toes being touched.” “Paresthesia is an abnormal sensation,” says Jarvis (2002. p.670). The goal is to detect any spinal cord injury. If there are any indications of a suspected traumatic brain injury a CAT scan of the brain should be done as long as no spinal injury is detected. The nurse should continually be alert to the signs and symptoms of increases in intracranial pressure, such as restlessness, nausea and vomiting, altered mental status, and changes in vital signs. Monitor closely for seizure activity. The child that was riding a bicycle and was struck by a vehicle is more prone to injuries to the head, spine and the abdomen. According to Cook, Schweer, Shebesta, Kaaren& Falcone “The flexible skeletal structure in young children may allow traumatic forces to extend to deeper structures, creating injury without fracture.” (Society of trauma Nurses, 2006. p 58) The child’s chest should be examined for any broken ribs, tenderness or instability of the chest wall while asking him/her “does your chest hurt when you breathe?” This is done to ensure there is no cardiac involvement or ribs facture. Observation of the thorax says Gilligan “may reveal the ‘see-saw’ respiratory pattern of a high spinal injury or upper airway obstruction, or a paradoxical segment (‘flail chest’), usually due to the mechanical instability of extensive rib-cage injury” (Gilligan, 2006. p.279). The child’s abdomen should be evaluated for internal bleeding. Asked questions like “is there any tenderness when your abdomen is touched?” Palpate abdomen while monitoring facial grimace for signs of pain. Once the life threatening assessment is completed and the patient is stabilized; and there is no physical evidence of fracture, the child should be log rolled to assess the spine and back for any injuries. Pertinent scans, x-rays, abdominal sonograms, and any labs can be completed. Risk factors related to the brain injured child’s condition can be numerous, depending on the severity of the injury and the organs involved. Paralyses from spinal cord injury can
be an unfavorable outcome in head trauma patients. Seizures are also very common in patients with head injury. Bleeding in the brain is also a major risk factor. Small children can revert to an earlier stage of development, while others suffered memory loss. The parents or care-giver should be involved in the care of the child. Education of the child and parents to the importance of helmet while riding a bicycle must be emphasized. The parents or caregiver should also be educated on the care of the child to ensure continuation of care after leaving the hospital. Managing patients with head injury can be complex and can result in post traumatic disability and death. Proper diagnosis, treatment, and management can aid in alleviating some of the long-term complications associated with head trauma in children. Many traumatic injuries could be from abuse at home, but blamed on a fall. A good nurse will use her health assessment skills to assess the patient but also questions about the circumstances of the injury. References (2002, January). Management of children with head trauma. Canadian Medical association journal, 142, 949. Retrieved December 14 2006, from htt://www.caps.ca?english/statements/EP/ep90-01.htm Cook, R.; Schweer, L. Kaaren, F.; & Richard, A. (2006, April-June). Mild traumatic brain injury in children just another bump on the head. Retrieved December 14, 2006 from Health reference center, from http://find.galegroup.com Crain, E.Gershel, J. (2004, November). Retrieved December 12, 2006 from http://www.edu.pitt.edu/neurotrauma/thebook/chap15.pdf Gilligan, J. (2006, October). From accident site to the Trauma Center, p.279. Retrieved December13, 2006, from http:/www.edc.pitt.edu/neurotrauma/the book/book.html Jarvis, C. (2002). Physical Examination & health assessment (4th ed). Elsevier Philad

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Inflammation

November 25, 2008

Inflammation could relate to forensic nursing in that forensic nurses sometimes take tissue samples from the bodies they are performing autopsies on or patients they are working on that may be criminals or victims for evidence of a crime that has been committed. If the mechanism of injury or death was from trauma, there may be lasting evidence of acute inflammation in the tissues. Some signs of acute inflammation are swelling, redness, pain, heat, and loss of function. Obviously if someone is dead, they would probably no longer have those signs I just mentioned. They may however have increased neutrophil or eosinophil levels and possibly an increased amount of macrophages out of the venules and into the interstitial tissues. If there is evidence of MBP (major basic protein) present, that could serve as evidence that the person’s body was trying to fight off a parasite.

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Community health nursing and forensic nursing

November 24, 2008

Community health nursing coincides with forensic nursing in the area of assessment. Assessment is one of the core functions of the public health system. Forensic nursing requires effective assessment competence. Community and public health assessment refers to systematic data collection on the population, monitoring of the population’s health status, and making available information on the health of the community. The role of a forensic nurse would also require the assessment along with clinical investigation skills. (Stanhope: Community and Public Nursing Chapter 1)

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Good Skin Assessment Skills

November 5, 2008

When someone is a victim of a crime and presents in the emergency department, a thorough skin assessment is critical. The primary nurse plays a key role in helping law enforcement assess and collect evidence. The exam should be begin with the inspection of skin, then palpation. In some cases a woods lamp or alternate light source may be needed for inspection. Keeping in mind patients with darker skin color may present different. Lesion or wounds should be documented including the location, size, color, pattern, and characteristics. For bruises consider the location, appearance, and pattern and the type of mark made. One can determine the age of a bruise by its appearance. Bruises associated with abuse may be caused by objects that leave distinctive patterns. Bite marks are a common injury associated with abuse. The size of the bite mark is important to note to determine the age of the person who left the mark. The most common type of burn is immersion. This appears by a “glove” or “stocking” pattern. Another is a contact burn; they leave a “branded pattern” on the skin. Depending on the nurse’s role in the investigation she/he may also be take photo documentation of findings. A body diagram may also be of use in explaining location of injury. Nurses must be thorough and descriptive during a skin assessment. – “Health Assessment for Nursing Practice” third edition, Wilson Giddens

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Pandemic influenza (H5N1)

September 25, 2008

I work in Alaska on the Aleutian island occasionally.
Recently a village had a ‘dry run’ to practice giving immunizations incase the pandemic flu strikes here. Alaska is a threat because of migration of birds. It is felt that Alaska will be one of the first hit with the avian flu.
This small village was able to immunize 68 people in 4 hours.
The staff was eight people but they probably could have done it with six because they used two people to evaluate and work on spousal and child abuse issues with the ‘dry run’
One person was an intake at the door of the community center to guide the people through and help fill out forms.
Two people took vital signs and screened to make sure the person receiving the immunization had never been allergic to other flu shots or allergic to eggs.
Two people gave the vaccines; one person helped the person go out of the clinic and answered any other questions.
The village thought this ‘dry run ‘ was a success.

Original Post:
November 29, 2007
If/when a pandemic takes place, clinical nurses will need to use advanced assessment skills to recognize those who have been infected as well as those at risk. The symptoms of H5N1 have been shown to mimic the pandemic flu of 1918. Early symptoms of H5N1 mimic that of regular seasonal flu. However, the disease process of the H5N1 appears to be more inflammatory in nature leading to a mortality rate >50% affecting those with healthy immune systems. There is no rapid method to test for H5N1 and no vaccine. A person with seasonal flu or a regular cold has upper respiratory symptoms and an increased WBC count. A person with H5N1 has upper respiratory symptoms and a low WBC count. Could these clinical markers be used as an effective screening tool to triage and disperse available treatments (anti-virals, ventilators, etc.) in the throws of a full blown pandemic? If/When H5N1 mutates to develop human-to-human transmission initiating the pandemic, could the virulence decrease?

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Verbal cues for evidence collection

September 24, 2008

The process of collecting data for evidence in regards to abuse must be a daunting task. We as Nurses are well trained in assessing physical clues but what about verbal cues. As I progress through each chapter of “Forensic Nursing” by Lynch I am reminded to constantly be alert to what the client is trying to tell you. This past week I had a client in my clinic for routine immunization, I performed a TB test and 48 hrs later when she returned she was angry, became upset with me because I pronounced her name wrong. I have seen this particular client on several occasions and she is usually happy and positive and actually seems timid at times, I was quite shocked by her outburst. Without going into particulars I found out later that day after discussing the situation with one of the Drs. that this particular individual had reported domestic violence to our social worker earlier that morning. I knew her behavior was out of the ordinary so it prompted me to investigate further. We can either choose to get angry with the client ourselves or look further into the change in behavior. I am glad I chose the right way.

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Rape is serious

September 23, 2008

Our American society takes rape seriously. Third world countries do not. The female anatomy and examination can be crucial to trial proceedings and the definition of innocence or guilt in a rape trial. The nursing assessment and collection of evidence is often performed by an emergency department nurse. Omission of an important feature can win or lose a case. In my organization, only specially trained Emergency Department RNs are allowed to utilize what we call the “Rape Kit.” This assures proper collection and assessment is performed to protect the client.

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