1. When Injuries Speak:
Forensic Wound Identification & Documentation of Suspected Abuse & Neglect
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. Objectives In this session participants will learn:
Correct forensic terminology related to abuse, neglect
Differentiate physical indicators of intentional versus accidental trauma
Identify patterned injuries and patterns of injury to help differentiate accidental from intentional injury
Discuss the role of medications in injury presentation
Demonstrate the ability to document in writing using correct forensic terminology and photographically violence-related findings in medical records
Apply principles of forensic evidence collection

4. Forensic Terminology
In 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.

5. Abrasion
A wound caused by rubbing or scraping the skin or mucous membrane.

6. Sample – 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.

7. Abrasion
Abrasions 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.

8. Avulsion
The tearing away of a structure or part. Often seen as a partial avulsion.

9. Avulsion Avulsion: Often seen as a partial avulsion
The complete tearing away of structure or part.
Often seen as a partial avulsion
A skin tear
Photos © Used with permission of Daniel J. Sheridan, PhD, RN. Do not reproduce photographs without permission.

10. Avulsion
Skin 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.

11. Bruise
Blunt 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.

12. Contusion
A bruise:
Traumatic injury of tissue without breakage of skin; blood accumulates in the surrounding tissue producing pain, swelling, tenderness, and discoloration.

13. Cut
See incision.

14. Ecchymosis
A 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.

15. Ecchymosis
Ecchymosis 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.

16. Hematoma
A localized collection of blood

17. Hematoma
Hematoma:
A localized collection of blood from a broken blood vessel (s).
Hematoma is not a synonym for a bruise or a contusion.

18. Hematoma
Many 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.

19. Hemorrhage
The escape of blood from a ruptured vessel. It can be internal, external, or into the skin or other tissue.

20. Incision An Incision = A cut.
A cut that is deeper than it is wide is a stab wound
A wound made by a sharp instrument or object (a sharp injury).
Scalpel, knife, razor, paper

21. Laceration
The 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.

22. Incision
The 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.

23. Laceration
Lacerations to the skin are usually jagged or stellate (star-shaped) in appearance.
The depth of lacerations is variable and often tunnels under the skin.

24. Lesion
Any pathological or traumatic discontinuity of tissue or loss of function of a part.
Broad term, including wounds, sores, ulcers, tumors, or other tissue damage.

25. Patterned Injury
An 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.

26. Coining & Cupping

27. Pattern of Injury
Injuries in various stages of healing, including new and old scars, contusions, fractures, wounds.

28. Petechia
Minute, pin-point, non-raised, perfectly round, purplish-red purpuric spots caused by intradermal or sub-mucous hemorrhage, which later turns blue and yellow.

29. Petechia
Petechia 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.

30. Pressure Ulcers – Closing Session

31. Puncture
The act of piercing or penetrating with a pointed object or instrument.

32. Purpura
Purpura is a hemorrhagic rash with leakage of blood into the tissue.
Often associated with bleeding or clotting disorders. Ecchymosis and petechia are forms of purpura.

33. Skin Tear Skin tear: See Avulsion
Photos © Used with permission of Daniel J. Sheridan, PhD, RN. Do not reproduce photographs without permission.

34. Unexplained Injury
It 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.

35. Wound
A bodily injury caused by physical means, with disruption of the normal structures
contused w. - one which skin is unbroken
incised w. - one caused by cutting instrument
lacerated w. - one in which tissues are torn
open w. - one having free outward opening
penetrating w. - one caused by a sharp, slender object that passes through the skin into tissue

36. Documentation Pearls If you did not chart it……… You did not do it!!!!!
Avoid personal opinion
Avoid charting arguments with co-workers
Avoid derogatory remarks about client, family, or other providers
Write legibly, legibly, legibly, legibly

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

38. Avoid pejorative documentation
Stop charting “refused”
Stop charting “uncooperative”
Stop charting “non-compliant”
Stop charting “alleged” and “allegedly”
Stop charting your feelings
Stop charting your anger

39. Forensic Photography - 1
35 mm vs Polaroid vs Digital
ISO ISO 400
Film is least expensive part of the investigation
Frontal ID shot
Rule of thirds
Use different lighting

40. Serial Photography

41. Forensic Photography - 2
Photograph the environment - measure the room/furniture/equipment
Color slides/tape measures/stick-ums
Use a scale - ruler/coin/pencil
One roll per client/patient - 12 exposure
Match injury to object if possible

42. Standard Rulers Lightning Powder Company 1-800-852-0300 - Free Catalog

43. Forensic Photography - 3
Make duplicate or triplicate prints
Label all prints
Client/patient name
Client number
Date of Birth
Date/time of photo
Name of photographer
Physical location and body part location

44. Daniel J. Sheridan, RN, PhD
Home Office 6210 Fairbourne Ct.
Hanover, MD
fax
Johns Hopkins University
School of Nursing, Room 467
525 N. Wolfe St
Baltimore, MD
fax