Forensic Nursing combines nursing science with the investigation of injuries or deaths that involve accidents, abuse, violence or criminal activity. Sexual Assault Nurse Examiners (SANE nurses) are one of the most recognized types of forensic nurses, but they have special training in one type of injury. Forensic nursing programs typically involve a broader set of skills, encompassing some or all of the following:
- Interpersonal violence, including domestic violence, child and elder abuse/neglect, psychological abuse
- Forensic mental health
- Correctional nursing
- Legal nurse consulting
- Emergency/trauma services, including auto and pedestrian accidents, traumatic injuries, suicide attempts, work-related injuries, disasters
- Patient care facility issues, including accidents/injuries/neglect, inappropriate treatments & meds
- Public health and safety, including environmental hazards, alcohol and drug abuse, food and drug tampering, illegal abortion practices, epidemiology, and organ donation
- Death investigation, including homicides, suicides, suspicious or accidental deaths, and mass disasters
Forensic nurses find that their additional training improves their basic nursing skills, and allows them to derive greater career satisfaction from helping patient in another rather unique way.
Approximately 37 training programs exist, ranging from certificate programs that require a specific number of hours of training, to degree programs (typically Masters level programs). Many of the certificate programs are available as online training.
Source: International Association of Forensic Nurses (http://www.iafn.org/)
Fatigue is a major problem for many healthcare providers, from prehospital those working in post-discharge institutions. Some interesting and underappreciated statistics about work-related injuries and shift work:
- Work related injuries increase on off-shifts. Compared to day shift, 15% more injuries occur on evenings and 28% more on nights.
- When working long shifts, there is a 13% increase in injuries after 10 hours, and a 30% increase after 12 hours.
- When working consecutive nursing shifts, there is an 8% increase in injury risk the 2nd night, a 38% increase the 3rd night, and a 70% increase the 4th night.
We know sleep deprivation and fatigue are bad. The laundry list of adverse effects is lengthy and includes confusion, memory problems, depression, weight gain, headache, diabetes, cardiovascular disease, and as we’ve discussed all week, serious performance problems.
What can be done about it? The key is to raise awareness, along with acceptance of the remedies. Many hospital workplaces are doing something about it. Here are some successful interventions that reduce workplace fatigue:
- Authorize a real break system. A break is a 30 minute period which is ideally away from the immediate work setting, where there are no disturbances (phone, pager)
- Ensure effective “handoffs” between co-workers when taking breaks
- Encourage workers to identify fatigue in their co-workers and find ways to decrease it
- Modify schedules to adhere to the Institute of Medicine’s standards
* No more than 20 hours of overtime a week
* Limit the number of 12 hours shifts
* No double shifts
Some workplaces are unfortunately not as progressive, and the work culture takes pride in showing how individuals can “power through” even when tired. Just remember, this is bad for you and bad for your patients. As you grow older, it becomes even more difficult and dangerous. It’s only a matter of time before someone, somewhere goes too far, and they or their patient will end up “dead tired.”
Trauma surgeons frequently place some type of drain in their patients, whether it be a chest tube, a damage control system, or a bulb suction drain near the pancreas. On occasion, nursing may become concerned with the character of the output, wondering if the patient is bleeding significantly. How can you tell if the output is too bloody?
First, most drains are in place to drain serous fluid which may have a little blood in it. Drainage that is mostly bloody is very uncommon from these drains, which are typically placed after orthopedic, spine or abdominal surgery. However, some drains are placed in areas where unexpected bleeding may occur, such as:
- Damage control drain systems – as patients warm up, arterial sources that were not surgically controlled may open up
- Pericardial drains – more common in cardiac surgery, not trauma
- Chest tubes in patients with penetrating trauma
What should you do if you have concerns about your patient’s drain output?
- Familiarize yourself with what kind of drain it is and what it should be draining
- Look at the volume of output – it takes 500cc of pure blood to drop the patient’s hemoglobin by about 1 gram. Low outputs are not dangerous, even if it is pure blood.
- Look at the change in output– if it is increasing significantly or changes color, call the physician to evaluate.
- Look at the color of the output – most drainage ranges from clear to something like cranberry juice and appears to be partially transparent. Look carefully if it appears to be darker or more opaque, and compare it to the blood that you would see in a blood collection tube. Even the darkest drain output usually looks a little watery compared to whole blood. Bright red output needs to be evaluated by a physician.
- If in doubt, check the fluid’s hematocrit. Whole blood has a hematocrit of 30% or more. Most bloody-looking drain output maxes out at about 5%. If the value is closer to whole blood, have a physician evaluate the patient.
The following is a sample nursing policy for c-spine immobilization.
To outline the procedure for applying immobilizing the upper spine, including application of a cervical collar and “boarding” the patient.
Application of a cervical collar and placing the patient on a backboard may be indicated for trauma patients with mechanisms of injury that place the patient at risk for spinal injury. This will not be necessary for patients with all of the following:
- no posterior midline cervical tenderness
- no evidence of intoxication
- normal level of alertness (GCS 15)
- no focal neurological deficit
- no painful distracting injuries
- The MD or RN will maintain manual stabilization of the cervical spine until cervical collar is applied and patient is placed on backboard.
* talk to the patient and tell them what you are doing- and not to move their head and neck
- Place hands on both sides of patient’s head with thumbs along mandible and fingers holding back of head.
- Assistants will help with the rest of the application of the cervical collar and backboard.
- Perform a baseline CMS assessment of the extremities.
- Remove jewelry from the neck and ears.
- Choose an appropriately sized collar by measuring the distance (with fingers) between the top of the shoulder where the collar will rest and the chin. This same number of fingers will fit between the fastener on the collar and the bottom edge of the rigid plastic of the collar.
- Cervical collar is assembled by snapping the fastener into the hole on the side of the collar
- Adjustable rigid cervical collars are measured from the bottom edge of the rigid plastic to the red circle denoting the size of the collar (red circle will move up or down as size of the collar is adjusted)
- Slide the back of the collar behind the right side of the neck until the Velcro tab is visible on the left side of the neck.
- Slide the chin portion up the chest until the chin fits in the collar.
- Secure the Velcro when the collar is on straight (nose, circle on chin portion of collar, and umbilicus are in alignment).
- Place the patient on a slide board with all team members working in a smooth fashion which moves the patient’s spine as little as possible. Patients already in bed will be log rolled and slider board inserted.
* Do not obtain a rectal temperature while the patient is turned unless the MD specifically requests this.
- Recheck CMS.
- The MD or RN can now remove hands from head.
- Document both CMS checks and procedure in patient’s record.
Nurses have a complementary role with physicians in caring for children with orthopedic injuries. Typically, the child will have been evaluated and had some sort of fracture management implemented. In children, nursing management is easer than in adults since a child is less likely to need an invasive surgical procedure. Many fractures can be dealt with using casts and splints alone.
Here are a few tips for providing the best care for you pediatric patients:
- Ensure adequate splinting / casting. You will have an opportunity to see the child at their usual level of activity. If it appears likely that their activity may defeat the purpose of the cast or splint, inform the surgeon or extender so they can apply a better one.
- Focus on pain control. Nothing aggravates parents more than seeing their child in pain! Make sure acetominophen or ibuprofen is available prn if pain is very mild, or scheduled if more significant. Ensure that mild narcotics are available if pain levels are higher. Remember, stool softeners are mandatory if narcotics are given.
- Monitor compartments frequently. If a cast is used, check the distal part of the extremity for pain, unwillingness to move, numbness or swelling. If any are present, call the physician or extender and expect prompt attention to the problem.
- Always think about the possibility of abuse. Fractures are rarely seen in children under 3, and almost never if less than 1 year old. If you have concerns about the physical findings or parent interactions, let the physician and social workers know immediately.