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When Injuries Speak:
Forensic Wound Identification &
Documentation of Suspected Abuse & Neglect
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
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
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.
http://www.cmstraining.info/pubs/provider_training.aspx
Forensic Terminology
Abrasion
A wound caused by rubbing or scraping the skin or mucous membrane.
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.
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.
Avulsion
The tearing away of a structure or part. Often seen as a partial avulsion.
Avulsion
Avulsion:– The complete tearing
away of structure or part.
Often seen as a partial avulsion
– A skin tear
Photos © 2006. Used with permission of Daniel J. Sheridan, PhD, RN. Do not reproduce photographs without permission.
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.
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.
Contusion
A bruise:
Traumatic injury of tissue without breakage of skin; blood accumulates in the surrounding tissue producing pain, swelling, tenderness, and discoloration.
Cut
See incision.
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.
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.
Hematoma
A localized collection of blood
Hematoma
Hematoma:– A localized collection of
blood from a broken blood vessel (s).
Hematoma is not a synonym for a bruise or a contusion.
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.
Hemorrhage
The escape of blood from a ruptured vessel. It can be internal, external, or into the skin or other tissue.
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
Incision
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.
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.
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.
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.
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.
Coining & Cupping
Pattern of Injury
Injuries in various stages of healing, including new and old scars, contusions, fractures, wounds.
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.
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.
Pressure Ulcers – Closing Session
Puncture
The act of piercing or penetrating with a pointed object or instrument.
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.
Purpura
Skin Tear
Skin tear:– See Avulsion
Photos © 2006. Used with permission of Daniel J. Sheridan, PhD, RN. Do not reproduce photographs without permission.
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.
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
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
Forensic Photography - 1Forensic Photography - 1
35 mm vs Polaroid vs Digital35 mm vs Polaroid vs Digital ISO 200 - ISO 400ISO 200 - ISO 400 Film is least expensive part of the Film is least expensive part of the
investigationinvestigation Frontal ID shotFrontal ID shot Rule of thirdsRule of thirds Use different lightingUse different lighting
Serial Photography
Forensic Photography - 2Forensic Photography - 2
Photograph the environment - measure the Photograph the environment - measure the room/furniture/equipmentroom/furniture/equipment
Color slides/tape measures/stick-umsColor slides/tape measures/stick-ums Use a scale - ruler/coin/pencilUse a scale - ruler/coin/pencil One roll per client/patient - 12 exposureOne roll per client/patient - 12 exposure Match injury to object if possibleMatch injury to object if possible
Standard Rulers Standard Rulers
Lightning Powder CompanyLightning Powder Company 1-800-852-0300 1-800-852-0300 - Free Catalog- Free Catalog
www.redwop.comwww.redwop.com
Forensic Photography - 3Forensic Photography - 3
Make duplicate or triplicate printsMake duplicate or triplicate prints Label all printsLabel all prints
– Client/patient nameClient/patient name– Client numberClient number– Date of BirthDate of Birth– Date/time of photoDate/time of photo– Name of photographerName of photographer– Physical location and body part locationPhysical location and body part location
Daniel J. Sheridan, RN, PhD
[email protected]– Home Office 6210 Fairbourne Ct.– Hanover, MD 21076– 410-379-8577 410-379-8572 fax
– Johns Hopkins University– School of Nursing, Room 467– 525 N. Wolfe St– Baltimore, MD 21205 410-614-5301– 410 - 955 - 7463 fax [email protected]
