Posts Tagged ‘Forensic Nursing’

Forensic Nursing Science

September 27, 2017

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Importance of Skin Assessment in Elderly and Child Abuse, comment

October 18, 2010

Skin assessment is a more valuable tool than we give it credit or time for. There are so many clues to a long list of health issues; from the varience in color, turgor, texture, temperature and thickness, to hair distribution, and condition of the nails.  All of these variances from norm could be linked to some health issue.  Issues like nutritional deficiency, allergy, local or systemic disease; such as melanoma or systemic lupus erythematosus; or they could be signs or the ‘remnants’ of abuse.

Unfortunately, I don’t think the nurse on the floor routinely gives skin assessment the time or attention needed to pick up on these clues.  The most opportune time to find these signs would be on admission, during the initial assessment. What I see on the floor, is short staffing more often than not, trying to care for more patients than can be fully cared for during their shift, and bed shortages, requiring ‘quick’ turnover.  I am also afraid that the gains in my staffing numbers over the past year are in jeopardy with the reforms and cuts in reimbursement that I think are coming. Thorough assessments are an essential part of health care, of preventative medicine, and all of our professional practices; so I truly hope there will be the time and ability going forward to complete this valuable task.

Original Post

May 26, 2009

Title: Importance of Skin Assessment in Elderly and Child Abuse

In studying skin assessment, one cannot help feeling overwhelmed. Without a desire to pursue dermatology, the unlimited amount of skin lesions, pustules, macules and papules can lead one to skim over information out of the pure necessity for mental sanity. The mind can only hold so many pictures at once. However, I do see the need to ensure the memorization and ability to recognize and diagnose normal skin variations. In reading articles and working with children and the elderly, one unfortunately sees the reality firsthand of physical abuse and neglect. This can often be recognized by assessing the skin. Breakdown, malnutrition, physical abuse, bruises, injuries at different stages of healing can all be noted by a thorogh assessment of the skin. As follow up care and the big picture should always be a part of our thought process in nursing assessment, the ability to note whether a skin assessment finding is simply normal or abnormal is vital to our practice.

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“Critical Incident” Stress in the Workplace, comment

October 4, 2010

In the thirty-five years of my professional career as a Registered Nurse, I have been involved in a wide variety of ‘critical incidents’; from the birth of an anacephalic baby, to MVCs with amputated limbs, to the loss of a patient to whom I had grown attached, to the death of someone too young, on our procedure table, that may not have happened if we had been able to care for him sooner.

 This last incident was the only time I had the privilege of a defusing and formal debriefing.  The hospital where I worked at the time, didn’t have a formal program.  We were given the chance to talk to our Child Advisor (I’m not sure of her exact title) when we, the cath lab staff, were so distraught over losing this patient during an angioplasty, on the table.  When I look back at this, I recognize it was very rudimentary, but it definitely helped us better than nothing at all. 

I’m thinking this is something I need to pursue for the facility where I work now.  There have been and always will be incidents that cause our professional staff emotional and/or physical ‘trauma’.  To provide a program that gives support for staff when they experience an untoward event with one of their patients, is only right when we ask them to provide Relationship Based Care. 

Original Post
April 4, 2004
Title: “Critical Incident” Stress in the Workplace

Many health care professionals at one time or another have experienced a “critical incident’ that has caused them strong emotional or physical reaction. The critical incidents vary from threats / assault, suicide, accidents, deaths or injury. These experiences may impair their ability to work safely and effectively in their care of patients for weeks or even months after the incident has occurred.

Nurses and other health care professionals are often expected to carry on after these incidents by simply relying on their own coping skills. However the use of formal debriefing in the workplace has been found to be a key component of recovery. Debriefing has produced many positive side effects for staff and their employers including:
• increase in team cohesiveness and mutual support.
• reduced sick time
• increased awareness of critical incidents and their impact
• decrease in staff turnover

Many hospitals and health care facilities have incorporated a formal model, the “Critical Incident Stress Management” (CISM) program that includes:
1. Defusing – a chance for to talk immediately after the incident, 45 to 60 minutes to restore order in a chaotic situation.
2. Formal Debriefing – longer, structured meeting including other professionals – chaplains, social or mental health workers.
3. Follow-up – possible long-term therapy to be arranged.

The best remedy for a nurse who has suffered this kind of reaction is often to get back to work as soon as possible; “to accelerate normal recovery in normal people with normal reactions to abnormal events.”

Should these programs not be adequate in reducing the after-effects, individuals and their co-workers should be aware of reaction symptoms that may occur. The following symptoms may be displayed:

Physical: nausea, rapid heart rate, dizziness, thirst, chills & headaches
Cognitive: poor concentration, disorientation, nightmares, memory
Emotional: grief, guilt, fear, depression, anger, exaggerated responses
Behavioural: withdrawn, loss of appetite, sleep disturbances,

Being aware of these symptoms when they occur and responding ethically and professionally will ensure that safe and effective patient care is maintained.

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CISM, comment

August 16, 2010

When reading through the blog I stumbled across the post ‘Critical Stress’. I am so pleased to see that someone not only has posted about this, but that it struck a chord in others as well. As an RN in a cardiac ICU I care for patients with chronic cardiac illnesses. Many of these patients stay with us for weeks and even months. Our most chronic patients tend to be those with end stage heart failure. In January of this year one of my patients that I had cared for over many months, passed away. This was a different sort of trauma than that of those who work in the ED or EMS experience. It wasn’t grusome, bloody, and no children were involved. I don’t think I gave the event enough justice because it wasn’t a blatant traumatic experience. Over the next two weeks following his passing, I began having terrible mood swings, I had sleep disturbances, and I began resenting my career as a nurse. Luckily I have an insightful and compassionate nurse manage who recommended bringing in the Critical Incident Stress Management team. When she first mentioned it to me I had no idea what it involved. A week later a group of nurses from my unit gathered for a meeting with the CISM team that they called a “debriefing”. It was a series of open ended questions that started a conversation amongst the group. In the end there were tears, confessions of fear and anger, frustrations, and sadness. Just to have permission to talk about our lives as critical care nurses and the amount of death that we see, we all felt more balanced afterward. It is important for health care workers to care for themselves and be able to recognize the effects of long term stresses related to caring for chronically ill patients. Thank you for posting a passage about stress management for those in the health care industry.

Original Post
December 30, 2008
Title: Critical Stress
I personally feel this is an important issue that is frequently swept aside in many critical incident situations. I have been both an EMT and an RN for many years, but have had very few debriefing sessions. Several occasions were warranted, such as a when an entire family perished in an MVC on Christmas Day, co-workers who were killed on their way into work, a colleague who successfully overdosed; to name just a few. The emotional and behavioral keynotes were especially noteworthy. It is no wonder that so many of my colleagues have turned to substance abuse and psychotropics to seek refuge. As for myself and a few others, we have turned to a higher power; after all there has to be more and a “better place.” I pray that is not a hollow promise. I and my co-workers have experienced many of the emotional stress responses: a. Agitation b. Anger c. Anxiety d. Apprehension e. Depression f. Fear g. Feeling abandoned h. Feeling isolated i. Feeling lost j. Feeling numb k. Feeling overwhelmed l. Greif m. Guilt n. Irritability o. Limiting contact with others (I found I withdrew and cuddled up with my Lab and quilting) p. Panic (what if I can’t make it through this shift?) q. Sadness r. Shock s. Startled t. Suspiciousness u. Uncertainty (constantly checking and rechecking your work, documentation, etc.) v. Wanting to hide (that never happened to me) w. Worry about others (BIG TIME!!). References Lynch, Virginia A. and Duval, Janet Barber. (2006). Forensic Nursing. St. Louis: Elsevier Mosby

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August 2, 2010

Not a week goes by when we do not receive an elderly patient on our floor who is covered by bruises. But what is the cause? Should we jumped to the conclusion that there has been abuse, or ignore what we are seeing? Knowing the sign and symptoms of abuse is extremely important, although most of the screening takes place in the emergency room, floor nurses also need to be aware.
Older patients are often on medications that can cause them to bruise more easily, their skin is also more fragile and tears easily, a client’s mental state may also be impaired. Continuing education is imperative so advanced assessment can be used to be able to distinguish between abuse and the symptoms that occur from medication or the normal aging process.

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August 2, 2010

It is an easy thing to look down upon someone who is a drug abuser, we live in a society that has very little compassion, and or understanding for these individuals. I have heard it time and again “They have done this to themselves!” But have they, what moves a person to become an addict?
The history of an individual tells us a great deal. Family history may reveal that someone is predisposed to addictive behavior, and then coupled with a severe injury that needed long term pain medication can be a recipe for disaster. Families are turned upside down, and torn apart, some never recover.
These individuals may be incapable of stopping on their own, there are many programs and institutions that specialize in helping those who have this disease, the only prerequisite is that they want the help. If someone does not want help there is no program or individual that can help them.
As caregivers showing empathy for those in these situations rather than being judgmental can be the difference in someone’s life.

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August 2, 2010

On any given week at the hospital that I am employed by there are a number of clients on suicide watch. Many of these clients are also drug abusers, a very small minority have actually attempted suicide.
What brings so many to the hospital is the fact that everyone has to be taken seriously when they say they want to kill themselves. Whether it is the first or twentieth time they have said this.
Recently we had a young drug user hospitalized for stating she wanted to die, she had been cleared by the psychologist and was ready for discharge, when she found out she was not going to be discharged to the facility for rehab she had wanted, and was not going to be given the medication she had wanted once discharged she began crying and said she would jump off the roof. Once again she was given a 1:1 sitter to keep watch on her and the psychologist was re-consulted.
All patients whether we believe they are serious or using suicide as a manipulation, follow the same policy and procedure to assure the safety of those who may want to actually harm themselves. Even though this may be frustrating for all involved it is something that needs to be, if even just for that one client who may truly be in need.

200,000 Americans Killed Each Year in Hospitals by Medical Error (comment)

July 26, 2010

Errors in medication administration can be fatal to patients. It is extremely important for nursing staff to have the training and experience to administer medication but they also need to pay attention to detail. Not just using the 5 rights when administering medication but using them accurately and correctly. A nurse can go through the motions of the 5 rights but if they are not vigilant in their medication administration they are likely to make an error. Of course an error in medication administration is not the only error that can be made within the hospital that can be harmful to patients.
Another error that is possible to be harmful to patients is negligence. If a nursing assessment is not performed as it should be then a change in patient’s condition could be easily overlooked. Or the onset of something like a bed sore could go unnoticed and undocumented casing harm to the patient because it wasn’t caught early enough. Or the signs of a DVT could be overlooked and the DVT could be come fatal all because the assessment was lacking in care and awareness.
Hospitals are not the only place where an error could bring harm to patients. For example pharmacies are a place that can make easy careless mistakes that lead to harm patients. Working as an RN in family physicians office I have had patients call and say their pharmacy gave them the wrong medication or the wrong dosage. As an RN in a doctors office I must be vigilant in my duties as much as if I worked in a hospital, if I don’t pay attention to detail an error I made could have the potential to be life threatening to a patient I am caring for.
It may lie within the duty of the forensic nurse to participate in the legal side of medication error after it has happened. A forensic nurse may need to testify on what happened leading up to the error or even to what may have cause it. A forensic nurse or any other line of nursing it is imperative to be very oriented to every detail in caring for patients.

Original Post
July 7, 2010
Title: 200,000 Americans Killed Each Year in Hospitals by Medical Error, comment
The advent of medication distribution machines may give health care providers a false sense of security when administering medications to patients. As health care providers, we need to recognize that human error is still a potential part of this new medication administration process. The orders are entered by a human, then checked by a human. As nurses we need to review the 5 rights each and every time we administer a medication to a patient. If we become relaxed because the information is coming from a computer, or the medication pops out of a machine, then we are opening ourselves up to “high-risk” nursing practice. Each and every medication you administer to a patient needs to be considered independently. Medication errors should be reviewed monthly by nursing staff in a “morbidity and mortality conference” type of review meeting in order to educate ourselves and learn from others mistakes rather than shame ourselves with a discreet incident report. This may further bring to light the fact that we are human and we make errors, but accountability is key for us to reduce the numbers and make it a safer environment for providers as well as patients. Using machines and computers as tools, not as a replacement of our own cognitive skills, is the balance we need to embrace to reduce medication errors.

Original Post

March 31, 2010

Title: 200,000 Americans killed each year in hospitals by medical errors, comment

I definitely think this is a drastic number and being on the front lines, I can see how this happens. Especially in today’s ever changing healthcare field. First, you have EMR which has completely changed our world. There have been so many changes recently that it is very hard to keep up with it all. Not only they way we chart things, but how we administer medications. Caremobile, the pt scanning device, is supposed to help catch errors. But with the Electronic charting, the charts and orders are not getting checked like they were because it is too difficult to do and navigate around. Not to mention that there are alot of issues with connectivity, timeliness of entering meds by pharmacy, etc. That by the time the med could be given, alot of unnecessary time has passed, so you may just do a work around to get the task accomplished which defeats the purpose of using Caremobile to begin with! Throw long hours, after hours “catch-up”, high acuity, understaffing, and a whole slew of other issues that are dealt with daily, it is easy to see how these unfortunate things could take place. I definitely think that issues that are causing unnecessary deaths should take precedence over anything else. And fix what is the current problem before you add something else into the mix.

Original Post
March 29, 2010
Title: 200,000 Americans killed each year in hospitals by medical errors, comment
There is no simple answer to why medication errors occur. People die every year from preventable medical errors; wrong limbs are amputated, wrong organs removed, people receive the wrong medications, orders are incorrectly transcribed, medication reconciliation is often flawed, the list could go on forever. Errors are a result of human nature. While every effort is made to minimize and prevent errors, they still occur. Nursing education, annual and ongoing review of the Joint Commission National Patient Safety Goals, time outs prior to surgical procedures, are all great ways to work to prevent errors from occurring. Responses to errors should not be punitive; they are situations from which we learn. Errors result because processes fail.

Original Post
March 4, 2010
Title: “200,000 Americans Killed Each Year in Hospitals by Medical Error”
Listed in the above are common causes of medication errors: lack of sleep in caregivers, poor communication, illegible handwriting, poor staffing. These problems are encountered in all areas of patient care. There are never enough nurses, nurses have too many patients, work too many hours, and in reality are often rushed . Home medications are often not reported accurately and many physicians (who are also often rushed) write poorly. Several of the 2010 National Patient Safety Goals focus on medication administration as a result of reported medication errors. How do we change this? Change begins with education. Nurses must continue to learn about new medications and review old ones, never hesitating to consult resources if unsure about any aspect of a medication. As the last line of defense between the patient and a medication error, nurses must be dedicated to practicing the 5 Rights and the nursing process as it relates to medication administration, providing thorough assessments and evaluations even when rushed. Patients must be educated as well, and taught to ask and know about their medications, to report untoward effects and to learn about lifestyle changes which could reduce or eliminate the need for some medications. As nurses, we must continue to promote better nurse to patient ratio in all areas of care. We must exhibit professional and safe medication administration in our own practice and in mentoring new nurses just beginning their profession. The amount of reported medication errors is a sobering fact which should incite a call to all nurses and facilities to performance improvement in this area.

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Screening for abuse, comment

July 20, 2010

Screening for abuse is a very important element of the nursing assessment.  While screening for abuse should be included in every nursing assessment abuse is seen more frequently within certain patient populations; such as the very young and the very old.  Those patients who are very young or very young are more vulnerable to abuse by their caretakers.  This screening can sometimes be difficult to perform.  There needs to be attention to detail during the interview for any inconsistencies with information given and findings during the assessment.

The nurse assessment of the skin and musculoskeletal systems hold great importance when screening for abuse.  It is during these advanced assessments there may be evidence of abuse may be found.  Any suspicious bruising, welts, or marks that are found should be taken into consideration when screening for abuse.

When a nurse is functioning in the field of forensics their assessments and screenings for abuse may be called into use during a proceeding in court; the nurse may have to testify to their assessment findings.  Forensic nurses will also have to rely on their experience in advanced assessment to accurately screen possible victims for abuse.

Forensic nurse or any other area of nursing this screening for abuse is a vital part of the nursing assessment.  A nurse is responsible for advocating for the patient to their best ability.  Especially in circumstances when the caretaker of the patient is overpowering and does not cooperate with the patient being assessed without them present.

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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Effective Measures Toward Pain Management, comment

July 12, 2010

Nursing assessment plays a significant role in the management of pain in caring for a patient.  Pain being a very subjective area to measure you can not only take the subjective level of pain you must also take into account the objective level of pain observed.  The level of pain is a grey area; it is not as simple as being in pain or not being in pain.  There are different levels to the pain and this varies from patient to patient.  Each patient has their own level of pain tolerance.  For example; in the practice I work in now we use a NIBP to measure the patients’ blood pressure in which most patients are not affected by this instrument.  However there are some patients that cannot tolerate the NIBP, it is too painful for them to use to measure their blood pressure; these patients have a lower threshold for pain.  They experience pain in a different way, however their pain is real.  As a nurse you need to be alert and conscious of each patient’s pain threshold.

An accurate pain assessment holds such an imperative function of a nurses advanced health assessment when caring for their patients.  When a nurse is functioning in the role of some area of forensic nursing their experience and knowledge of pain assessment may be called upon to use in their responsibility as a forensic nurse.  For example; if a forensic nurse is being called upon in the court of law to provide testimony in a legal matter they may have to incorporate this experience and knowledge of assessing pain to give an honest and accurate testimony.  Another example of pain assessment being incorporated into forensic nursing would be when a forensic nurse is assessing a possible victim of abuse; the victim may downplay their pain.  As a victim they may try to hide their pain and the forensic nurse will be required to be able to observe accurately any objective signs of pain to give the victim the care they need.

Original Post

September 2, 2009

Title: Effective Measures Toward Pain Management

Pain is an alteration in ones comfort level, which can significantly impact the physical, emotional, and psychological well-being. Pain is a subjective experience that can only be explained by the patient. Cultural and ethnicity are a few factors that influences patients response to pain, to improve outcomes nurses must be able to understand pain from a cultural perceptive. People respond to and view pain differently. Among various groups for various reasons emotions may or may not accompany pain it is viewed by some as an act of punishment or as a spiritual test. Having knowledge of patient’s views and how they define pain is very valuable in that it can assist the nurse in achieving positive outcomes by incorporating this information in the plan of care. Nurses who ignore or refuse to develop cultural sensitivity not only do they violate patients’ rights but also a chance of having a trustful relationship and without this you can expect poor outcomes. Pain is often poorly assessed and poorly managed due to reasons like misconceptions and nurses lack knowledge. This usually leads to under medications and poor outcomes, such as the post-op abdominal surgery patient that develop pneumonia because is unable to perform cough and deep breath exercises every 2hrs secondary to pain because of the nurses’ misconceptions about administering pain medication to a patient with history substance abuse. To achieve goals of effective pain management nurses must first be aware of their values and personal beliefs concerning pain and the behaviors associated with it, this will assist in developing an awareness and sensitivity to the patient’s need. Nurses must be knowledgeable and skilled in collection of both subjective and objective data (by accepting the patients’ assessment of pain by using pain assessment tools and observation of emotional behaviors such as crying or moaning), which will assist in identifying the intensity of patients’ pain and promote better outcomes. Misconceptions must be explored and addressed because these also impact outcomes, such as administering pain med on regular basis will lead to addiction or those who abuse drugs usually over exaggerate their pain, by acknowledging these misconceptions nurses will be able address patients’ pain related issues more professionally and improve steps toward effective pain management.

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