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Welcome to this learning module, supporting the quality improvement project "Use of Telemedicine to Decrease Time to Care for Post-Sexual Assault Survivors".

The principal investigator is Siobhan Bell. She can be contacted at sbell85@my.gcu.edu or 1-647-388-0051.

Project Site: Thunder Bay Regional Health Sciences Center - Sexual Assault/Domestic Violence Treatment Center Team led by Lorena Beaulieu. She can be reached by 1-807-684-6751 or lorena.beaulieu@tbh.net.

As a nurse, working in an area that cares for clients who have been sexually assaulted, it is understandable, that you want to provide all the care they need without having to send them hours away from their home community. Clients also wish to see their care provided closer to home.  To do this, this quality improvement project is seeking to use telehealth through the Ontario Telemedicine Network to provide you with the expert consultation of forensic nurses, in order to walk you and your patient through the specialty acute care needed by these clients at that moment.  To do this, you will need to know a little bit about what we do as forensic nurses and alot about this client population.

The following is an educational module designed by the Ontario Sexual Assault and Domestic Violence Treatment Centers to support Emergency Department Nurses in helping to provide this care, when a forensic nurse is not on site. This module combined with the direct guidance from the forensic nurse via telehealth will provide you and the client with the support needed to successfully navigate this process and meet the standard of care for these patients as laid out in the Ontario Network Sexual Assault Domestic Violence Treatment Centers Standards of Care (ONSADVTC) Client Standards II Acute (Emergency) Service.

Standards of Care (2019) can be found here: https://www.sadvtreatmentcentres.ca/assets/resource_library/public/Standards%20of%20Care%20-%202019.pdf 

The following infographic shows a sample of how this visit process should work:

To begin the Emergency Department Staff Training Module Click Here: https://www.sadvtreatmentcentres.ca/assets/courses/care2019/story_html5.html

The following video is from the TeleSAFE program in the United States of America. It was put together to support telehealth forensic nursing for their TeleSAFE program which has demonstrated a great deal of success in decreasing time to care for post-sexual assault patients.

This video will help you to understand what to expect in a consultation with a forensic nurse.  Please be advised, that this is a US-based video and as such, the some of the healthcare context, language and processes will not be the same.

Ultimately, your forensic nurse examiner, the client and you will work as a team to ensure safe and effective client-centred care in your encounters.

The video can't be viewed inside this module, but you can click on the video to view it in VIMEO.

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Ciao!

As nurses, we care for people. We care for our patients and our peers. It is what we are trained to do. Forensic Nurses and all of our peers who care for patients of violent or extreme circumstances are at even higher risk of experiencing compassion fatigue and vicarious violence. COVID-19 has only added another layer to this challenge. Hopefully, with the support of each other, we can meet and uplift those most impacted.

After completing the following learning, you will have met the following learning objectives:

1. Examined the risk of vicarious trauma in your work.
2. Utilized reflective analysis to identify your current level of stress and work related trauma.
3. Examined mindfulness as a way to de-stress.
4. Created a plan to support your mental-health in the upcoming year.

"Helping forensic nurses recognize the situations that lead to moral distress is the first step in helping them to relieve their distress, reduce their burnout, and continue longer in practice" (Karakachian & Colbert, 2019, p.139).

Karakachian, A. & Colbert, A. (2019).  Nurses' Moral Distress, Burnout, and Intentions to Leave: An Integrative Review.  Journal of Forensic Nursing,15 (3), 133-142.  http://doi:10.1097/JFN.0000000000000249.

To read a copy click here:

https://drive.google.com/file/d/1SrISVV6Aw0NKJ0M5QpsWXVM-Vl8Vrj48/view?usp=sharing

Mindfulness can simply be defined as, "...the state of being attentive to and aware of what is taking place in the present” (Jacob & Holczer, 2016, p.33).

Jacob, C. J., & Holczer, R. (2016). The Role of Mindfulness in Reducing Trauma Counselors’ Vicarious Traumatization. Journal of the Pennsylvania Counseling Association, 15, 31–38.  http://pacounseling.org/aws/PACA/asset_manager/get_file/129164?ver=44#:….

You can download a copy at:

https://drive.google.com/file/d/1cj34FcZcAdz56upxwaCKfino_kHwXhnR/view?usp=sharing

"A Survey of Stress and Burnout in Forensic Mental Health Nursing"

https://drive.google.com/file/d/1eAe1qnHcCgOwJNT7uc4LcwG-q6yQYKWk/view?usp=sharing

"Intervening to Improve Compassion Fatigue Resiliency in Forensic Nurses"

https://drive.google.com/file/d/1QYW-3eIU7bAxJNHD2oKbfxNWVVDKQkec/view?usp=sharing

"Vicarious Trauma Among Sexual Assault Nurse Examiners"

https://drive.google.com/file/d/1U_A6tXBkkwKdxYNfLn1eGFBFMxjKcFh8/view?usp=sharing

• Sodium accounts for 90% of the extracellular cations 
• Important for electrolyte and water balance because accounts for half of the osmolarity of the ECF
• Normal serum concentration: 135-145 mEq/L
• important in generation and transmission of nerve impulses and the regulation of acid base balance
• regulated by kidneys, ADH, aldostorone

• Hypo = low (less than 135 mEq/L) 
• decreased osmolarity 
• cells are swollen: associated w ECF hypo-osmolarity from excess water. To restore balance, fluid shifts out of the ECF and into the cells, leading to cellular edema
• 

• Direct Loss of Na+
  • GI losses: diarrhea, vomiting, fistulas, NG suction
  • Renal losses: diuretics, adrenal insufficiency, Na+ wasting renal disease
  • Skin losses: burns, wound drainage
• Excess water in ECF which dilutes Na+ conc
  • SIADH: syndrome of inappropriate secretion of antidiuretic hormone (retain water)
  • Heart failure
  • Excessive hypotonic IV fluids
  • Excessive water intake (polydipsia

• irreversible neurological damage or death from brain herniation can occur
• rapid, weak thready pulse
• postural hypotension
• Brain Swelling : headache, lethargy, headache, confusion, apprehension
• nausea vomiting
• low BP

• water excess treatment: fluid restriction, for severe symptoms (seizures): small amts of IV hypertonic saline solution is admin to restore the serum sodium level while the body is returning to a normal water balance
• sodium-containing fluid loss treatment: fluid replacement w sodium-containing solutions
• oral rehydration fluids containing electrolytes may help prevent it (home setting)

Nursing 

• monitor serum sodium levels and pts response to therapy to avoid rapid correction or over correction
• record I&O

• CNS function slows down 
• Can affect different systems 
• regulates vital organs, digestion, circulation

Causes

• metabolic acidosis
• diabetic ketoacidosis
• CNS depressants: opioid overdose
• stroke, brain trauma

Symptoms

• lack of coordination
• reduced HR
• muscle weakness
• NV
• constipation
• low BP
• slow RR
• confusion

  assesses balance, coordination, the function of nerves, reflexes, mental status, motor and sensory skills 

LOC: alert? 

Eye opening, verbal response, motor response

Subjective: health hx 

• bones: trauma, ROM
• ADLs
• Self care 
• Joints: pain, stiffness
• Muscles: cramps, weakness 

Objective:

• inspect joints for size, colour, swelling, deformities
• palpate: temp, tenderness, mass
• ROM
• Muscle testing: against opposing force
• compare sides 
• Pupils: PERRLA, accommodation 
• Motor function: grip test
• Pain: sternum rub (can cause bruising)

CASE STUDY

You are working on an inpatient psychiatric unit and need to do an initial assessment of your patient Randy, who has just been admitted. He has a diagnosis of schizophrenia, paranoid type. He is 24 years old and has been attending the local college and living at home with his parents. Randy has always been a good student and participates regularly in social activities.

Last semester his grades began declining. He became very withdrawn and started to spend most of his time alone in his room. His personal self-care has deteriorated as he goes days without showering.

Prior to admission, Randy spent several weeks in seclusion. He refused to join social gatherings, isolated himself, and kept his window blinds closed.

Over the past 2 days he refused to eat, telling you, “They have contaminated the food.” As you approach Randy, you note that he appears to be talking to himself. When you talk to him, he looks around and answers in a whisper but gives you little information. He states, “They are watching me and told me not to cooperate with you.”