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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, FAAN Associate Professor,

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Presentation on theme: "Multidisciplinary and Collaborative Approaches: Bringing it All Together Working as a Team Daniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAAN Associate Professor,"— Presentation transcript:

1 Multidisciplinary and Collaborative Approaches: Bringing it All Together Working as a Team Daniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAAN Associate Professor, Johns Hopkins University School of Nursing Forensic Clinical Nurse Specialist

2 4N6 RN Forensic Nurse Forensic = Pertaining to the Law International Association of Forensic Nursing

3 UNDERSTANDING THE PROFESSION Nurses Aide – continuing education course and/or on the job training MAsMedical assistants (report to MDs) – One to two months of training (HS-GED) CNAsCertified nursing assistants (report to LPN/LVN/RN) – Licensed by Board of Nursing – One or two months training

4 UNDERSTANDING THE PROFESSION Vocational-Practical Nurse LVNsLicensed vocational nurse – Licensed by the Board of Nursing – One year professional school – Must work under supervision of a RN or medical provider LPNsLicensed practical nurse – One-year professional school – Licensed by the Board of Nursing – Must work under supervision of a RN or medical provider

5 Staff Nurse Experience varies Few clinics or physician offices employ Registered Nurses – too expensive

6 UNDERSTANDING THE PROFESSION – Registered Nurse RNRegistered nurse – Diploma – Two-year associates degree (AD) – Bachelors degree (BSN) traditional/accelerated Generic entry Masters 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

7 UNDERSTANDING THE PROFESSION Advanced Practice Registered Nurses – NPsNurse practitioner (independent v MD) Prescriptive privileges – CNSClinical nurse specialist (hospital) – CRNA Certified registered nurse anesthetist – Masters prepared clinicians (two years post bachelors) but by 2015 must have clinical doctoral preparation – DNPDoctorate of Nursing Practice (practice three years post bachelors) – PhDDoctorate of Philosophy (research – average 5 years post masters)

8 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

9 CNS Role Expert in clinical area(s) Educator Consultant Patient, family, staff, administrators, APS, surveyors, ombudsman, police

10 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

11 UNDERSTANDING THE PROFESSION Physicians Assistant PAsPhysicians Assistant – Most Masters prepared clinicians – Military trained – Supervised by a physician

12 UNDERSTANDING THE PROFESSION Physicians Bachelors degree Medical School – four years Residency – minimum 3 years Fellowship – minimum 1 year

13 What is Nursing? Be able to discuss the Nursing Process A - assessment D – nursing diagnosis P - plan I - intervention E - evaluation

14 Forensic Nursing Its the collision between the law and medicine Its a lot more than Quincy or Diagnosis Murder! Its not as dramatic as CSI Coroner versus Medical Examiner ???

15 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)

16 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)

17 Common Patient/Client Groups Treatment of patients (victims) (survivors) of – abuse – violence – criminal activity – Vehicle crashes

18 History of Forensic Nursing 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 Englands Police Surgeon Concept

19 Early Nursing Leaders Mid-1970s Ann Burgess, DNSc, RN – Rape Trauma Syndrome Mid s Rape Victim Advocates - RVA Forensic Sexual Assault Exams - – nurses training MDs, retrain, retrain…. Late 1970s s Domestic violence – Barbara Parker, PhD, RN – Ginnie Drake, PhD, RN – Jackie Campell, PhD, RN

20 Early Nursing Leaders Domestic Violence Homicides – Ohio, New York – Jackie Campbell, PhD, RN Family Violence Program, RPSLMC, Chicago – Daniel J. Sheridan, MS, RN Death Investigations – Virginia Lynch, MS, RN, Georgia

21 International Association of Forensic Nurses nurses, mostly SANE formed IAFN First Annual Scientific Assembly in Sacramento, CA 160 members – (My Member # 251) Formally recognized by the ANA as a specialty of nursing Over 3,000 members with next conference in Atlanta

22 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

23 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

24 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

25 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 Workmans Comp.

26 Todays USA Today p. 3A

27 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

28 Role Differences – Forensic RN v LNC TopicForensic RNLNC Wound ID+- ? Bed sores++ Standards of care++ Translation++ Neglect of care++ Capacity--

29 Role Differences - 2 TopicForensic RNLNC Photo document+- ? Evidence collection+- ? Family violence+- DV Grown older+- Sex Assault issues+- SANE+-

30 Working with medical personnel So how can we work together? Physicians who get it are rare. – If you have one, nurture that role Develop a cadre of nurse experts

31 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

32 Information needed DO NOT ASK FOR A CAPACITY ASSESSMENT OF YOUR CLIENT – In most cases you will not get it

33 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

34 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

35 All dictated consultant notes All radiology reports & summaries – Actual x-rays/scans may be needed later All laboratory results Medication Administration Records Discharge summaries

36 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

37 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

38 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

39 Get a signed release of information from: – The client/patient/victim – Medical power of attorney – Guardian Court order – subpoena

40 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

41 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

42 Court is Part of the Role Levels of Proof Preponderance – > 50.1% Clear and Convincing – > 75.1% Beyond Reasonable Doubt – > 99%

43 Discuss my neck tie…….

44 Documentation 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 opinion Avoid personal opinion Avoid charting arguments with co-workers Avoid charting arguments with co-workers Avoid derogatory remarks about client, family, or other providers Avoid derogatory remarks about client, family, or other providers Write legibly, legibly, legibly, legibly Write legibly, legibly, legibly, legibly

45 Forensic Documentation As verbatim as possible As verbatim as possible Do not sanitize Do not sanitize Do not medicalize Do not medicalize Avoid pejorative documentation Avoid pejorative documentation Document excited utterances Document excited utterances Document medical exceptions to hearsay Document medical exceptions to hearsay

46 Avoid 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 feelings Stop charting your feelings Stop charting your anger Stop charting your anger

47 An Oregon case… The importance of documentation!!

48 Decubitus Ulcers Are they a sign of neglect?

49 Decubitus Ulcer Bedsores Decubiti (plural) Decubitus ulcer Pressure sore – ulceration of tissue deprived of adequate blood supply by prolonged pressure.

50 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.

51 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

52 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

53 Locations of Pressure Ulcers Bony Prominence 95% on lower half of body Sacral area most common.

54 Risk Factor Scales: Braden Scale (1987) – Activity – Mobility – Sensory Perception – Nutrition – Moisture – Friction/Shear Adjunct to clinical assessment

55 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

56 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.

57 Stage 1 Intact skin, Erythema Change in skin temperature Tissue Consistency (Firm or Boggy) Sensation(Pain/Itching) PressureUlcer/Ulcer1.jpg

58 Stage 2 Partial-thickness skin loss (epidermis and/or dermis) Superficial Blister or crater Painful PressureUlcer/Ulcer1.jpg

59 Stage 3 Full Thickness Damage or Necrosis of Subcutaneous Tissue, not through fascia Deep Crater with possibly undermining PressureUlcer/Ulcer1.jpg

60 Stage 4 Full-thickness with extensive destruction Necrosis or damage to muscle & bone Tunneling PressureUlcer/Ulcer1.jpg

61 Stage 5 – Cannot stage (covered with dead skin)

62 Location: Hand/Wrist

63 Location: Ear

64 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?

65 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 !!!!!!!!!!!!!!!!

66 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?

67 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

68 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

69 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

70 Questions ?????

71 Daniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAAN – Johns Hopkins University – School of Nursing, Room 467 – 525 N. Wolfe St – Baltimore, MD – 410 – – fax – Pager –

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