multidisciplinary and collaborative approaches: bringing it all together working as a team daniel j....
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Multidisciplinary and Collaborative Approaches:
Bringing it All Together Working as a Team
Daniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAANAssociate Professor, Johns Hopkins University School of NursingForensic Clinical Nurse Specialist
4N6 RN
Forensic Nurse Forensic = Pertaining to the Law
International Association of Forensic Nursing www.iafn.org 1-410-626-7805
UNDERSTANDING THE PROFESSION
Nurse’s Aide – continuing education course and/or on the job training
MA’s Medical assistants (report to MDs)– One to two months of training (HS-GED)
CNA’s Certified nursing assistants (report to LPN/LVN/RN)– Licensed by Board of Nursing– One or two months training
UNDERSTANDING THE PROFESSIONVocational-Practical Nurse
LVN’s Licensed vocational nurse– Licensed by the Board of Nursing– One year professional school– Must work under supervision of a RN or medical provider
LPN’s Licensed practical nurse– One-year professional school – Licensed by the Board of Nursing– Must work under supervision of a RN or medical provider
Staff Nurse
Experience varies
Few clinics or physician offices employ Registered Nurses – too expensive
UNDERSTANDING THE PROFESSION – Registered Nurse
RN Registered nurse– Diploma– Two-year associates degree (AD)– Bachelors degree (BSN) traditional/accelerated
Generic entry Master’s degree in Nursing– must have a previous degree + pre-reqs (Clinical
Nurse Leader) (knowledge of a new graduate)
All must take NCLEX exam – – Licensed by the Board of Nursing
UNDERSTANDING THE PROFESSIONAdvanced Practice Registered Nurses
– NPs Nurse practitioner (independent v MD) Prescriptive privileges
– CNS Clinical nurse specialist (hospital)– CRNA Certified registered nurse anesthetist– Master’s prepared clinicians
(two years post bachelors) but by 2015 must have clinical doctoral preparation
– DNP Doctorate of Nursing Practice (practice three years post bachelors)
– PhD Doctorate of Philosophy (research – average 5 years post master’s)
Clinical Nurse Specialist versus Nurse Practitioner
NP can prescribe medications. CNS cannot (CNS)
NP can diagnose and treat illness.
CNS serves as an expert resource to everybody
CNS Role
Expert in clinical area(s) Educator Consultant Patient, family, staff, administrators, APS,
surveyors, ombudsman, police
Legal Nurse Consultant
LNC = Legal nurse consultant (certified versus trained– Can be any level of registered nurse– May or may not have any real expertise– Clinical competencies– Plus education– Plus experiences
UNDERSTANDING THE PROFESSIONPhysician’s Assistant
PA’s Physician’s Assistant– Most Master’s prepared clinicians– Military trained– Supervised by a physician
UNDERSTANDING THE PROFESSION Physicians
Bachelor’s degree
Medical School – four years
Residency – minimum 3 years
Fellowship – minimum 1 year
What is Nursing?Be able to discuss the Nursing Process
A - assessment D – nursing diagnosis P - plan I - intervention E - evaluation
Forensic Nursing
It’s the collision between the law and medicine
It’s a lot more than Quincy or Diagnosis Murder!
It’s not as dramatic as CSI Coroner versus Medical Examiner ???
What is Forensic Nursing
Forensic nursing is the application of the nursing process to public or legal proceedings: the application of the forensic aspects of health care to the scientific investigation of trauma.
(IAFN Website)
Clinical Forensic Nursing
The application of clinical nursing practice to trauma survivors or to those whose death is pronounced in the clinical environs, involving the identification of unrecognized, unidentified injuries and the proper processing of forensic evidence.(IAFN Website)
Common Patient/Client Groups
Treatment of patients (victims) (survivors) of – abuse– violence– criminal activity– Vehicle crashes
History of Forensic Nursing
1975 - John C. Butt, MD Alberta Canada– Hired and trained RNs as medical examiner
investigators– Know medical terminology/pharmacology– Empathy/public relations– Over 60% of death investigator cases involve natural
death– Fostered better police/health care roles– Based on England’s Police Surgeon Concept
Early Nursing Leaders
Mid-1970’s Ann Burgess, DNSc, RN – Rape Trauma Syndrome
Mid - 1970s Rape Victim Advocates - RVA Forensic Sexual Assault Exams -
– nurses training MDs, retrain, retrain…. Late 1970’s - 1980’s Domestic violence
– Barbara Parker, PhD, RN - 1977– Ginnie Drake, PhD, RN - 1982– Jackie Campell, PhD, RN - 1979
Early Nursing Leaders
1981 - Domestic Violence Homicides – Ohio, New York– Jackie Campbell, PhD, RN
1986 -Family Violence Program, RPSLMC, Chicago– Daniel J. Sheridan, MS, RN
1987 - Death Investigations– Virginia Lynch, MS, RN, Georgia
International Association of Forensic Nurses
1992 - 74 nurses, mostly SANE formed IAFN 1993 - First Annual Scientific Assembly in Sacramento,
CA 160 members – (My Member # 251)
1995 - Formally recognized by the ANA as a specialty of nursing
2009 - Over 3,000 members with next conference in Atlanta
Forensic Nurse Provides
Consultation services to:– Nursing, medical, law-related agencies
Expert court testimony:– regarding interpersonal violence, trauma, death
investigations, unexplained injuries Adequacy of health services “Translation” or background information on routine
medical care
Can you read this? Need a translator??
85 y/o w/female w/h/o HTN, IDDM, CAD, PVD, MI x 2, multiple TIAs
s/p TAH-BSO, CABG x 2, R-AKA MMSE 15/30 Presents with +LOC, 0 x 1
Or do you want a nurse to translate to this……..
85 year old white female with a history of hypertension (high blood pressure), insulin dependent diabetes mellitus, coronary artery disease, peripheral vascular disease, and multiple transient ischemic attacks
Status post (History of) total abdominal hysterectomy and bilateral salpingo-oophorectomy (removal of her uterus, tubes and ovaries), coronary artery bypass grafts x 2 and a right above the knee amputation
Mini- Mental status test indicate possible dementia 15/30 Presents with + loss of consciousness, is oriented only to her
name
Types of Forensic Nurses
SANE/SAFE/FNE/SART Interpersonal Violence
– CA/CN– DV/FV– EA & DD Abuse Investigator– Stranger to Stranger
Death Investigators -Deputy Medical Examiners - Coroners
Correctional Nursing - Prisons/Jails Psychiatric Forensic Nursing - Criminally Insane,
Malingerers in Workman’s Comp.
Today’s USA Today p. 3A
Types of Forensic Nurses
Crime Labs Criminalists - Scene Investigators Expert Witnesses RN to Police Officer RN to FBI Academy RN to JD to Assistant Attorney General
Medicaid Fraud Prosecution Unit in DC
Role Differences – Forensic RN v LNC
Topic Forensic RN LNC Wound ID + - ? Bed sores + + Standards of care + + Translation + + Neglect of care + + Capacity - -
Role Differences - 2
Topic Forensic RN LNC Photo document + - ? Evidence collection + - ? Family violence + - DV Grown older + - Sex Assault issues + - SANE + -
Working with medical personnel
So how can we work together?
Physician’s who “get it” are rare.– If you have one, nurture that role
Develop a cadre of nurse experts
Working with medical personnel
What kind of information does the APS case worker need?
Who can give that information
How can this information be obtained
Information needed
DO NOT ASK FOR A “CAPACITY ASSESSMENT” OF YOUR CLIENT
– In most cases you will not get it
Information needed
What are the medical issues– Ex. high blood pressure, diabetes
Are they controlled?– If not, why not?
Ex. unable to afford medications, unknown
Is the client compliant with the medical plan– If not: why not ?
Ex. memory problems, no transportation, unknown
Complete copy of records from the most recent hospitalization(s) including:– EMS-EMT-Paramedic transport forms– ED physician and nurses notes hand-written and
typed– Any photographs taken by hospital staff/wound
specialists/surgeons– Admission History and Physical– All progress notes including RN & social work
notes
All dictated consultant notes All radiology reports & summaries
– Actual x-rays/scans may be needed later
All laboratory results Medication Administration Records Discharge summaries
Information needed
Does the client have to take medication for his medical issues?
– If yes, which ones ? Ex. lisinopril for high blood pressure
– If not, why not? Ex. diabetes controlled with diet
Is the client able to obtain the medication(s)– If not, why not?
Ex. unable to afford medication, unknown
Information needed
Does the client keep clinic appointments– If not, why not?
Ex. forgetful, no transportation, unknown
What is the date of the last visit?– Ex. 10 month ago
Does the clinician have any concerns?– If yes, explain:
Ex. noticed disheveled appearance at the last visit
Who can give the information
Can be obtained from:– Secretary– Office assistant– Nurse– Clinician (MD, NP, PA)
– HIPAA: – Health Insurance Portability
and Accountability Act of 1996
Get a signed release of information from:– The client/patient/victim– Medical power of attorney– Guardian
Court order – subpoena
How to get the information
Call the office and ask for:– the fax number– name of the nurse/MA/CNA
Fax your request– Ask for permission to talk with the nurse
How to get the information
Leave a number where you can be reached at all times (you might only get 1 phone call)
– Cell phone number
Best time to call:– Early morning
“Court” is Part of the Role
Levels of Proof Preponderance
– > 50.1%
Clear and Convincing– > 75.1%
Beyond Reasonable Doubt– > 99%
Discuss my neck tie…….
Documentation PearlsDocumentation Pearls
If you did not chart it………If you did not chart it……… You did not do it!!!!!You did not do it!!!!! Avoid personal opinionAvoid personal opinion Avoid charting arguments with co-workersAvoid charting arguments with co-workers Avoid derogatory remarks about client, Avoid derogatory remarks about client,
family, or other providersfamily, or other providers Write legibly, legibly, legibly, legiblyWrite legibly, legibly, legibly, legibly
Forensic DocumentationForensic Documentation
As verbatim as possibleAs verbatim as possible Do not sanitizeDo not sanitize Do not “medicalize”Do not “medicalize” Avoid pejorative documentationAvoid pejorative documentation Document excited utterancesDocument excited utterances Document medical exceptions to hearsayDocument medical exceptions to hearsay
Avoid pejorative documentationAvoid pejorative documentation
Stop charting “refused”Stop charting “refused” Stop charting “uncooperative”Stop charting “uncooperative” Stop charting “non-compliant”Stop charting “non-compliant” Stop charting “alleged” and “allegedly”Stop charting “alleged” and “allegedly” Stop charting your feelingsStop charting your feelings Stop charting your angerStop charting your anger
An Oregon case…
The importance of documentation!!
Decubitus Ulcers
Are they a sign of neglect?
Decubitus Ulcer
Bedsores Decubiti (plural) Decubitus ulcer Pressure sore – ulceration of tissue deprived
of adequate blood supply by prolonged pressure.
Bedsores, Decubitus ulcers, Decubiti, Pressure ulcers, & Pressure sores
Caused by ischemia due to pressure, shearing, and friction, from contact between the patient and an underlying surface.
The physiology:
Pressure exceeds normal capillary-filled pressure of 32mm Hg -> blood flow is obstructed
Pressure continues 2hrs, oxygen depleted & build-up of metabolic products
-> irreversible tissue damage
Risk factors for Pressure Ulcers & Neglect:
Intrinsic Acute illness CVD Decreased sensation Cognitive impairment Malnutrition Paralysis PVD Failure of vasomotor
reflexes Incontinence Decrease mobility Fractures/Surgery Diabetes
Extrinsic (Modifiable) Long periods on
stretchers, hard beds, chairs, & OR
Restraint use Inappropriate
compression stockings Shearing forces of bed
clothes or sheets
Locations of Pressure Ulcers
Bony Prominence
95% on lower half of body
Sacral area most common.
http://www.health.nsw.gov.au/hospitalinfo/pressure.html
Risk Factor Scales:
Braden Scale (1987)– Activity– Mobility– Sensory
Perception– Nutrition– Moisture– Friction/Shear
Adjunct to clinical assessment
Assessment and Documentation
Measure (2 lengths) Depth (sterile Q-tip) Stage estimate Involved skin/tissue layers Location Odor Drainage Presence or absence of
granulation or eschar
Staging Pressure Ulcers
National Pressure Ulcer Advisory Panel 1989 Skin, tissue layers, & depth Helps keep consistent the assessment between
observers Certain concerns with use Use as guide in addition to proper
documentation.
Stage 1
Intact skin, Erythema Change in skin temperature Tissue Consistency (Firm or
Boggy) Sensation(Pain/Itching) coa.kumc.edu/gec/images/ PressureUlcer/Ulcer1.jpg
www.afmc.org
Stage 2
Partial-thickness skin loss (epidermis and/or dermis)
Superficial Blister or crater Painful
coa.
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u/ge
c/im
ages
/ P
ress
ure
Ulc
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www.afmc.org
Stage 3
Full Thickness Damage or Necrosis of Subcutaneous
Tissue, not through fascia Deep Crater with possibly undermining
coa.
kum
c.ed
u/ge
c/im
ages
/ P
ress
ure
Ulc
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www.afmc.org
Stage 4
Full-thickness with extensive destruction
Necrosis or damage to muscle & bone
Tunneling
coa.
kum
c.ed
u/ge
c/im
ages
/ P
ress
ure
Ulc
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www.afmc.org
Stage 5 – Cannot stage (covered with dead skin)
Location: Hand/Wrist
www.worldwidewounds.com
Location: Ear
www.worldwidewounds.com
Is it neglect? - The Great Debate
Risk factors assessed? Prevention strategies
initiated? Skin properly assessed? Findings properly
documented?
Proper referral for findings? Initiation of proper treatment
strategies? Proper reassessment of skin?
Take Home Points
ALL Pressure ulcers are NOT preventable, but many are preventable…..
ALL Pressure ulcers are NOT curable, but many are curable.…
HOWEVER…. ALL PRESSURE ULCERS ARE
TREATABLE !!!!!!!!!!!!!!!!
Screening Questions
If at anytime a patient answers YES say,
1. Thank you for sharing.
2. Can you give me an example?
3. When was the last time?
Why Forensic Nurses?
18,000 violent crimes are committed or attempted each day in the US
Those crime scenes travel to the health care setting
Meets minimal standards of care– CMS – Centers for Medicaid & Medicare Services– Joint Commission
Why Forensic Nurses?
Recognizes the evolution of nursing care within complex medical-legal systems
Forensic nursing provides much needed, specialized nursing care to vulnerable populations
In conclusion: What your client wants to Hear from You
That you believe her or him That he or she is not crazy That no one deserves to be beaten That he or she is not alone That abuse is a crime That there is hope the abuse can end That there is help in the community –There is
a TEAM – Continue to Build your TEAM
Questions ?????
Daniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAAN
– Johns Hopkins University– School of Nursing, Room 467– 525 N. Wolfe St– Baltimore, MD 21205
– 410 – 614 - 5301– 410 - 955 - 7463 fax– Pager 1-888-390-8420– dsheridan@son.jhmi.edu
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