Presentation on theme: "When Injuries Speak: Forensic Wound Identification & Documentation of Suspected Abuse & Neglect Daniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAAN Associate."— Presentation transcript:
1When Injuries Speak:Forensic Wound Identification & Documentation of Suspected Abuse & NeglectDaniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAANAssociate Professor, Johns Hopkins University,School of NursingForensic Clinical Nurse Specialist
24N6 RN Forensic Nurse Forensic = Pertaining to the Law International Association of Forensic Nursing
3Objectives In this session participants will learn: Correct forensic terminology related to abuse, neglectDifferentiate physical indicators of intentional versus accidental traumaIdentify patterned injuries and patterns of injury to help differentiate accidental from intentional injuryDiscuss the role of medications in injury presentationDemonstrate the ability to document in writing using correct forensic terminology and photographically violence-related findings in medical recordsApply principles of forensic evidence collection
4Forensic TerminologyIn order to accurately assess, document, and investigate suspected abuse, one needs to learn the correct use of many common forensic terms.In the following session forensic definitions will be presented along with photographic samples of the defined injury.
5AbrasionA wound caused by rubbing or scraping the skin or mucous membrane.
6Sample – clarify fell versus found down Mrs. J. Jones reportedly found on tiled bathroom floor at 2315 hours by direct care staff, R. Gilbert and J. Gentile.Mrs. J. Jones reportedly fell at 2315 hours witnessed by direct care staff, R. Gilbert and J. Gentile.
7AbrasionAbrasions are common injuries incurred from accidental falls, however, certain types of abrasions are consistent with intentional mechanism of injury.For example, if a person is laying supine and is dragged by her feet along any rough surface (carpet, sidewalk, street) you would expect to see an abrasion along the mid- spine.If a person is dragged supine by his feet with any sort of back and forth movement, the abrasion would cover much of the mid-back from side to side as previously pictured.
8AvulsionThe tearing away of a structure or part. Often seen as a partial avulsion.
10AvulsionSkin tears (partial avulsions) to the elderly most often occur to the arms and hands. For the skin to tear there must have been blunt and/or shearing force energies.Skin tears in patients who are total care must have been inflicted by another person.One needs to assess if the partial avulsion was truly accidental, the result of excessive force, or abuse by a caregiver.
11BruiseBlunt force trauma that results in a superficial discoloration due to hemorrhage into the tissue from ruptured blood vessels from beneath the skin surface without the skin itself being broken:also called a contusion.
12ContusionA bruise:Traumatic injury of tissue without breakage of skin; blood accumulates in the surrounding tissue producing pain, swelling, tenderness, and discoloration.
14EcchymosisA hemorrhagic spot or blotch, larger than petechia, in the skin or mucous membrane forming a non-elevated, rounded, or irregular blue or purplish purpuric patch.Ecchymosis is not injury from blunt force trauma. It is NOT a bruise or contusion.Ecchymosis is purpura usually in the skin or mucous membranes.
15EcchymosisEcchymosis in the elderly is often to the arms and/or hands.Blunt force trauma to the mid face often results in the development of bilateral periorbital ecchymoses (raccoon eyes).Discoloration from a bruise can be pulled by gravity downward. The downward discoloration is called ecchymosis while the discoloration at the point of blunt impact is called a bruise.
17HematomaHematoma:A localized collection of blood from a broken blood vessel (s).Hematoma is not a synonym for a bruise or a contusion.
18HematomaMany health professionals mistakenly call a bruise a hematoma and vice-versa.While a hematoma may be imbedded within a bruise as a palpable mass, hematomas can be caused by non- traumatic means ie., a spontaneous blood clot to the brain.
19HemorrhageThe escape of blood from a ruptured vessel. It can be internal, external, or into the skin or other tissue.
20Incision An Incision = A cut. A cut that is deeper than it is wide is a stab woundA wound made by a sharp instrument or object (a sharp injury).Scalpel, knife, razor, paper
21LacerationThe act of tearing or splitting. A wound produced by the tearing or splitting of body tissue often from blunt impact, usually over a bony surface, that is distinguished from a cut or incision.
22IncisionThe inside edges of a sharp wound (cut, incision) are relatively smooth and equidistance in depth.If a serrated knife is used, the inside edges may have a more scalloped appearance.
23LacerationLacerations to the skin are usually jagged or stellate (star-shaped) in appearance.The depth of lacerations is variable and often tunnels under the skin.
24LesionAny pathological or traumatic discontinuity of tissue or loss of function of a part.Broad term, including wounds, sores, ulcers, tumors, or other tissue damage.
25Patterned InjuryAn injury where one is reasonably certain an object caused the injury, or certain which object caused the injury and/or by what mechanism an injury was caused.
27Pattern of InjuryInjuries in various stages of healing, including new and old scars, contusions, fractures, wounds.
28PetechiaMinute, pin-point, non-raised, perfectly round, purplish-red purpuric spots caused by intradermal or sub-mucous hemorrhage, which later turns blue and yellow.
29PetechiaPetechia are caused by the rupture of capillaries. When blood is not allowed to leave the head/face because of occlusion or compression of the jugular veins, capillaries will burst in and around the eyes and face.
34Unexplained InjuryIt is relatively common, especially for institutionalized elderly to hear from caregivers that they have no idea how the patient received her/his injuries.All significant unexplained injuries to vulnerable patients should raise one’s suspicions of possible abuse or neglect.
35WoundA bodily injury caused by physical means, with disruption of the normal structurescontused w. - one which skin is unbrokenincised w. - one caused by cutting instrumentlacerated w. - one in which tissues are tornopen w. - one having free outward openingpenetrating w. - one caused by a sharp, slender object that passes through the skin into tissue
36Documentation Pearls If you did not chart it……… You did not do it!!!!! Avoid personal opinionAvoid charting arguments with co-workersAvoid derogatory remarks about client, family, or other providersWrite legibly, legibly, legibly, legibly
37Forensic Documentation As verbatim as possibleDo not sanitizeDo not “medicalize”Avoid pejorative documentationDocument excited utterancesDocument medical exceptions to hearsay
38Avoid pejorative documentation Stop charting “refused”Stop charting “uncooperative”Stop charting “non-compliant”Stop charting “alleged” and “allegedly”Stop charting your feelingsStop charting your anger
39Forensic Photography - 1 35 mm vs Polaroid vs DigitalISO ISO 400Film is least expensive part of the investigationFrontal ID shotRule of thirdsUse different lighting
41Forensic Photography - 2 Photograph the environment - measure the room/furniture/equipmentColor slides/tape measures/stick-umsUse a scale - ruler/coin/pencilOne roll per client/patient - 12 exposureMatch injury to object if possible
42Standard Rulers Lightning Powder Company 1-800-852-0300 - Free Catalog
43Forensic Photography - 3 Make duplicate or triplicate printsLabel all printsClient/patient nameClient numberDate of BirthDate/time of photoName of photographerPhysical location and body part location
44Daniel J. Sheridan, RN, PhD Home Office 6210 Fairbourne Ct.Hanover, MDfaxJohns Hopkins UniversitySchool of Nursing, Room 467525 N. Wolfe StBaltimore, MDfax