Posts Tagged ‘Forensic Nursing Mental Assessment’

Risk Assessment In Forensic Nursing

October 9, 2008

Forensic nurses work with mental ill patients, many with a criminal background. As nurses work with patients who have a high probability of displaying violent behavior, the need for a risk assessment increases. Risk assessment is the process of assessing the individual patient against his or her specific risk factors as well as against other general risk factors, such as substance abuse. The Royal College of Nursing (1998) suggests that the aims of risk assessment are to: identify the hazards, identify who is at risk, evaluate the risks, make a record of the findings, and review and revise the assessment. A thorough mental health and mental status assessment is also key. As a nurse we need to be aware of the many factors that influence mental health, which can aid in our risk assessment skills. Individuals have different stress management abilities, spiritual and belief systems, genetic factors and interpersonal relationships. Assessment and management of risk are necessary in mental health nursing; they protect the welfare of consumers of mental health services and the community, and also play a role in protecting nurses against potential litigation. – Health Assessment for Nursing Practice, 3rd edition, Wilson-Giddens -Violence


Postpartum Depression, comment

April 29, 2008

I agree that a postpartum psychiatric evaluation is an important part of the postpartum patient assessment. Nurses should be looking for signs in the patient of potential problems of postpartum depression as opposed to postpartum blues. As a nurse that works on L & D and postpartum, I watch for things such as: 1) inability of mother to bond with infant or not wanting to hold infant after delivery, 2) Name calling of infant, 3) Just not showing interest in feeding or holding infant. I have witnessed all of these events in my department. Mothers who have a history of postpartum depression with prior deliveries should definitely be referred for a psychiatric evaluation and perhaps follow up visits after discharge, if necessary. Although postpartum depression is a real problem for some women, it is not excuse for child abuse or murder. It can be treated. As health care providers, we need to step in and refer these women by doing a thorough assessment and involve psychiatrics and/or social services in their care.

Original Post:
February 7, 2007
In response to the article “Postpartum Depression” from 9-16-06, I feel that after delivering the baby, a new mother must have a psych assessment done before going home with her baby and maybe they should have a home health nurse or some sort of social worker check in with the new mother at 1-2 weeks postpartum. I feel that these mothers such as Andrea Yates, sometimes claim postpartum depression as a cover up for something they definitely know they did wrong. I do agree that some mothers may have some depression after giving birth because of the hormone levels changing, but I do not believe they don’t know what they are doing at the time, such as murdering their children or drowning them. They sure know enough to be able to tell the police “I was crazy at the time and depressed.” So then they go for the “not guilty by reason of insanity” plea. I believe most of it is to get attention. Most of them also have no remorse.

Original Post:
September 16, 2006
What is postpartum depression? According to American Association for Marriage and Family Therapy (2002), “Postpartum depression is a biological illness caused by changes in brain chemistry that can occur following childbirth. During pregnancy, hormonal levels increase considerably, particularly progesterone and estrogen, and fall rapidly within hours to days after childbirth. Also, the amount of endorphins, the feel-good hormones that are produced by the placenta during pregnancy, drop significantly after delivery. Even the thyroid gland can be affected by the enormous hormonal changes that are associated with pregnancy and childbirth, leaving women more at risk for depression.” Additionally, AAMFT (2002) states, that “for 10 to 15% of those women, the period following childbirth becomes a nightmare as they experience sleeplessness, confusion, memory loss, and anxiety during the already stressful adjustment to motherhood.”
American Association for Family and Marriage

What comes to mind is the Andrea Yates case in which she murdered her children. A very notable forensic case that has been in the headline in the past but has recently come to light again as the Andrea Yates murder trial begins. In which she has claimed postpartum depression as the major reason she murdered her children. World Wide Web CNN- July 12, 2006, “Yates, 42, is being retried because her 2002 conviction was overturned by an appeals court that ruled erroneous testimony might have influenced the jury. She has again pleaded innocent by reason of insanity. Her attorneys say she suffered from severe postpartum psychosis and did not know that killing the children was wrong.” ( this is a fascinating case, in the aspect that Yates had been in and out of psychiatric facilities for mental illness and depression prior to the murder of her children, so why did the psychiatrist not see this coming?

Today, with the many publicized murder trials of women who have murdered their children supposedly due to postpartum depression as the potential root cause, have encourage healthcare providers, nurses, and even new mom’s to look for the possible signs of this mental health condition. As a nurse, it is part of our nursing assessment skills in looking for potential signs that might indicate a new mom might need further assessment to rule out postpartum depression.

A great example was the other day a new mom of 4 months called the physicians office asking if there was a blood test to test if one might have postpartum depression. The woman claimed that she has noticed recently that she was having a few “sad days” and did not think she needed psychoanalysis but just wanted a blood test to check her hormone levels. When consulting with her physician, he stated that there is no specific blood test to find out if someone’s hormone levels are abnormal that would indicate postpartum depression and the only way to determine if the patient was truly having postpartum depression was an in-person evaluation, which a series of questions and lab work might be obtained. When the patient was advised of the physicians response to her questions, she agreed to a next day appointment but not before the nurse assessed if she was in any danger of hurting herself or anyone else.


Psychiatric Mental Health Nursing Assessment and the Electronic Medical Record

October 25, 2007

I am in agreement that the electronic medical record is not always ideal for charting a patient assessment. It takes thought to actually write down notes whereas sometimes in computer documentation you can get away with pointing and clicking. There is not always the correct symptom or description to fit what you are wanting to say. Today I assisted with a patient on my unit (in for a dislocated hip) but was apparently withdrawing from something. There was nothing in the computer to describe what this patient was exhibiting. She was screaming that someone was murdering her family, the next minute she was in church having revival. I am interested in looking tomorrow at what the nurse charted. We are also on electronic documentation. I think it is worse for nursing. The doctors at least have to write a progress note. The physical therapy notes include a lot of annotations. Computerized charting may be quicker, but I am not convinced it gives an accurate picture.


Post Partum Depression comments from 9/16/06

October 1, 2007

One of my nursing school classmates recently suffered a severe case of post partum depression after her delivery 6 months ago. Her depression was so severe she considered filing for divorce, quitting nursing school, and leaving a good job. Her Ob/Gyn’s Nurse Practitioner suggested a psych consultation and complete hormone evaluation. Lo and behold, her hormone levels were anything but normal. With professional medical intervention and psychological therapy, she is doing well. Thank God she had a great nurse who was truly a patient advocate and with her problem solving/forensic skills training, knew what to look for in post partum depression. Unfortunately, many new mothers don’t get the proper help they need.


The Amish Country Killing, comment

September 4, 2007

Wow, what a story. I do not agree with that sentence at all. Just because you are Amish does not mean you are above the law. The Amish believe in no violence so this Amish man must have extremely mentally unstable and probably should have never been let out. Then to have no regard for doing it in front of your children, he obviously has no regard or respect for human life.

The forensic nursing assessment would be to put the pieces together of what occurred. To keep your own judgments at bay. You must be aware of the culture. The children would be the living victims. They would need continued follow up after witnessing such a traumatic event. The approach to these children would need to be extremely gentle. A full psychological and mental evaluation would need to be done. The follow up would be long term for them. Forensic nurses would have to build a rapport with the children and have a lot of patience with them in order to do the assessments. Their emotional and mental health would be at stake. The children would probably be reliving this every day for the rest of their lives. One would have to decide at what point do you stop and try to move past it.

When this guy is released from prison, probably mandatory follow up should for him. He should not be let out without him checking in with a mental health facility on a regular basis for continued psychological and mental assessment.


Forensic Nursing Assessment in Mood Disorders

August 18, 2007

Nursing assessments are the initial subjective and objective statements and observations that help determine a patient’s nursing diagnosis, goal and treatment within the nursing process.

Nurses in hospital settings plan their care based on the nursing process. Forensic Nurses plan their investigations based on their assessments of the individual involved. When dealing with patients who are in some way involved in the criminal justice system, Forensic Nurses need to be well developed in their assessment skills. When assessing patients with mood disorders such as depression or a bipolar disorder, a Forensic nursing assessment needs to include a history of the patient’s mood disorder, their basic mental status, interpersonal relationships, mood and affect, clarity of thought and thoughts of death. These assessment areas are used as well by nurses in the hospital setting in order to determine the pharmacological need for appropriate medication for a patient’s specific mood disorder.

The Forensic Nurse needs to obtain a history of the individual’s mood disorder by determining the length of time the person has had the disorder as well as if the disorder is of a depressive nature or are there both manic and depressive phases in their illness. What factors (physiological or environmental) contribute to the mood of the patient? How long does the mood persist? Has the patient been treated previously with medications for this disorder? Have they experienced any adverse effects from these medications? Is alcohol or drug abuse an issue? Is the patient on any medications at present? What is the length of time that they have been on these medications? Are they adhering to their medication protocol?

Assessment of basic mental status includes noting the general appearance and posture (erect, stooped, or slumped) of the patient as well as if the patient is alert and oriented to person, place and time.

The Forensic Nurse will also need to assess the patient’s relationship with family, friends and coworkers. Is there a support system in place? Is there a past history of abuse from a family member? Have there been any conflicts among friends and coworkers?

The patient’s mood and affect during assessment can suddenly change. The Forensic Nurse needs to ensure a quiet environment conducive to patient assessment. The nurse needs to remain calm; to ask concise, simple questions and to use active listening. The patient may be in a manic phase of their disorder during the nurse’s assessment and may become quite talkative or argumentative. A direct, firm but kind manner of conversation needs to be used. Assess the patient’s behavior for irritability, joy, sadness, anger or tearful expressions. Are the verbal and nonverbal actions consistent with the circumstances the patient is discussing?

Is there clarity in the patient’s thought processes? Is the nurse able to identify any delusional or hallucinating thoughts? Is there any flight of ideas or paranoia exhibited by the patient?

Is the patient verbalizing any thoughts of death towards themselves or others? Does the patient have any plans formulated for suicide? Assess for any direct or indirect statements regarding death.

Nursing assessment, regardless of the different roles nurses play in their profession is the primary aspect of the nursing process. Subjective and objective assessments give Forensic Nurses the data relevant to their investigations as well as possible causes of the criminal activity of the patient.


Postpartum Depression, comment to 9/16/2006 post

May 24, 2007

As a nurse, mom, and someone who has experience premenopausal symptoms I can say that the hormonal changes are unbelievably weird. This is coming from someone who has always been mentally stable. I do agree there should be follow up in the community or at your follow up appointment with your doctor. In Andrea Yate’s case she was probably mentally unstable to some degree to begin with. Maybe this should be assessed prior to and throughout the pregnancy.


The Amish Country Killing

May 10, 2007

Edward Gingerich killed his wife Katie, on March 18, 1993. It was a cold gray Tuesday at dusk preceded by several days of snow.

The 28-year-old Amish man attacked his spouse, Katie, in front of two of their children who witnessed the scene in stunned amazement and horror. In the kitchen of their western Pennsylvania farmhouse, he knocked her down to the ground, crushed her skull by stomping on her face, ripped off her clothes, and then opened up her stomach with a kitchen knife. After he open up her stomach, he relentlessly removed her heart, spleen, lungs, liver, ovaries, and intestines through the seven inch gash from the knife, stacking them one by one in a neat pile next to her dead body. Within an hour, volunteer ambulance personnel from a nearby village stared at the bloody body without organs nude on the kitchen floor and at the knife plunged into the dripping mounds of organs.

Edward Gingerich a tall, pale skinned, lumber mill operator was arrested by the Pennsylvania state Police at a dirt road intersection near his farmhouse. When arrested by the police officers he was covered in blood, was wide-eyed and virtually incoherent. The Amish man continued to mumble biblical passages and made vague remarks to and about the devil.

The killing of his wife amazed Gingerich’s non-Amish neighbors. The told reporters and police investigators that he did indeed suffer from a mental illness, but had never exhibited any tendencies or reaction toward violence.

For the first time in American history, an Amish man stood accused of homicide, raising a host of bewildering questioning. What had driven this quiet, easy going man to commit such a crime so ghastly as to defy description? Questions were raised very easily and very fast. Who was Edward Gingerich? What was or what is he? How would his family, the Amish community and Pennsylvania’s criminal justice system deal with this unique and definitely disturbing case? In the end, Edward Gingerich was found guilty of involuntary manslaughter and sentenced to imprisonment at the State Correctional Institution in Pittsburgh, Pennsylvania for only a minimum of two and a half years to a maximum of five years. I do not understand this sentence.
I have Amish relatives from Pennsylvania. When I spoke with my Uncle, the thoughts still haunt the Amish community to this day. Edward Gingerich, his name is not spoken of easily. Knowing what he put his wife through, his kids through, and definitely the Amish community.

As a forensic nurse it would most likely be psychologically devastating. Children were involved. Was he on some type of medication or illegal drugs? Was an urinalysis or blood sample taken? Does he have a history of psychological problems? Did he have any marks on him, from a struggle from his wife? What were the kids doing? What type of knife did he use? Did it match the type of cutting wounds that were on his wife? Did he cut her anywhere else? What exactly happened to make him do this? A forensic nurse needs to find the answers to these questions. Maybe nobody really identified these issues, and that’s why he only got a short term. Did anyone do any of these things listed? What was actually presented in front of the judge, to make him only get a short time?


Memory loss and the law

March 14, 2007

A forensic nurse will be quick to determine a genuine case of memory loss and a fake one. This helps in fast tracking cases. Someone involved in an accident might have a temporary loss of memory and the police officers might think it is a fake and punish him while they are worsening the case.
During the health assessment phase the forensic nurse quickly determines the mental status of the victim without compromising the evidence needed for the case.
With more forensic nurses with good health assessment capabilities things would be much better for attorneys and doctors.


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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