The Nursing Process

The Nursing Process
A. To be accepted as a nursing specialty by the American Nurses Association College of Nursing Practice, forensic nursing was required to relate the practice of forensic nursing in terms of the nursing process.
B. The forensic nursing process is an organizational tool that is used to care for the individual suffering an illness, injury, or death as a result of an act of violence, abuse, or trauma.
C. Collaboration with other nurses, physicians, law enforcement, and those within the judicial system is vital in developing an effective nursing process.

Development of a Forensic Nursing Process
1. Nursing diagnosis: The nursing diagnoses listed in this section are not all inclusive for victims of violence, trauma, or death. The North American Nursing Diagnosis Association (NANDA) International is the accepted nursing diagnosis standard and should be used as a reference in identifying a nursing diagnosis.

2. Assessment
a. Physical assessment
b. Psychological assessment
c. Scene assessment
d. Assessment of the area surrounding the scene
e. Identification of evidence

3. Planning
a. Make decisions based on each set of assessment data
b. Determine need for further investigation
c. Schedule appointments with victim, witnesses, staff
d. Determine need for family, victim, community member coping resources

4. Intervention
a. Photograph
b. Identify, collect, and preserve evidence
c. Make death notification if necessary
d. Discuss support referrals to victim, family, support system, community members
e. Protect and secure personal property

5. Evaluation: Short-term goals
a. Identification of victim
b. Examination of investigation findings
c. Review laboratory tests
d. Review medical records
e. Review postmortem information to identify cause and manner of death
f. Consider additional review of specific findings and implement interventions
g. Make investigative peer review and assessment
h. Debrief team members

6. Evaluation: Long-term goals
a. Identify perpetrator
b. Assist in the arrest of the perpetrator
c. Identify defense team
d. Identify prosecution team
e. Testify at the criminal trial
f. Assess family coping skills
g. Assess community response/coping
h. Assess for additional family or community education needs

Application of the nursing process to death investigation:
1. The major components of the forensic nurse death investigators nursing process are
a. The victim
b. The environment
c. The concept of health
d. The role of the forensic nurse
2. The object of nursing care may be
a. The decedent
b. The family
c. The witness
d. An agency official
e. Community members
3. The concept of health and health promotion in relation to the decedent is reflected in obtaining the health history prior to death.
a. The forensic nurse is able to understand and correlate the medical and surgical history of the deceased along with medication prescribed, treatments performed, and physical and mental health.
b. Nursing knowledge may establish a possible link regarding the client’s or victim’s death.

4. Patients and clients may include the survivors of the deceased.
a. Holistic care may be applicable to this population in relation to both physical and mental health needs.

Nursing process case study:
1. Assessment: Includes identification of pieces of information that will compose a whole.
a. Direct observation:
Deceased lying prone with navy blue scrub pants and top
(1) Questions to consider as part of the assessment data:
Who is the deceased?
What happened?
When did this happen?
Where did this incident happen?
Why did this individual die?
Why is the deceased not wearing a coat or jacket?
Is the deceased an employee of the hospital?
Why is the deceased wearing only a white left shoe?
Was the deceased arriving to begin a shift?
Was the deceased leaving on completion of a shift?
In what capacity did the deceased function (professional or nonprofessional)?

b. Accurate description
Dried blood along the hairline extending from the temporal region toward the back of the head, from the right nares, on anklefold of the right sock Laceration extending from the bend of the right brachial area measuring 3 inches long, 2 inches deep, 1.5 inches wide, along the posterior section of the right arm; serrated edge along right margin of incision, left margin of laceration smooth Four-inch rectangular, purplish bruise on both sides of laceration; horizontal, resembling a “t”
(1) Questions to consider as part of the assessment data:
Why is there blood only on the right side?
How long ago did the injury occur?
Did the deceased trip while tying the shoelaces on his right shoe?
Was this a deliberate attempt by another person to cause injury or was this accidental?
Did the deceased suffer from an underlying disease process?
Did the deceased take any prescription or nonprescription drugs?
Where is the object responsible for inflicting the laceration?
What type of object caused the laceration on the right arm?
What type of object has one serrated edge?
Is there an injury under the hairline that created the initial bleeding?
Is there blood under the deceased’s head?
Was the deceased pushed backward, resulting in a sudden impact to the back of the head as it hit the concrete floor of the parking garage?
c. Identification
Environmental factors: ambient temperature, humidity, wind factor, environmental exposure
Location and description of any vehicles within a 15-foot diameter of the deceased
Location and description of any materials on the clothing and any exposed body anatomy (e.g., head, neck, hands, fingers, and fingernails; anterior and posterior sections of left and right extremities) and any exposed areas relating to the torso and lower extremities (the deceased has not yet been moved to examine the anterior section of the body)
Location and description of any materials within a
12-inch radius of the body
(1) Questions to consider as part of the assessment data:
Did the deceased wear any warm outerwear, and if so, where is it?
Was there a struggle with another individual?
Did the deceased accidentally trip on a sharp object that resulted in the laceration to the right arm?
Do any of the vehicles belong to the deceased?
2. Nursing diagnosis
a. Develops from the interpretation and analysis of assessment data gathered in the death investigation.
b. NANDA has identified the domains of a nursing diagnosis as related to
(1) Physiology
(2) Behavior
(3) Family systems
(4) Health and safety systems
c. As in the death investigation example, nursing diagnosis may focus on
(1) The safety and integrity of preserving the body
(2) Maintaining a safe environment for the deceased and for those involved in the care of the deceased when
(a) Potential environmental factors may damage or destroy possible evidence.
(b) The deceased may exhibit signs of a potential communicable disease.
(c) The deceased has been exposed to toxic chemicals or gases.
(d) A natural or human-made disaster has occurred or is occurring.
(e) The deceased is located in a burning building or a building that has been burned.
(3) There is the presence of family, friends, or support individuals at the scene and evaluation of their verbal and nonverbal behavioral responses is needed.
3. Planning
a. Develop short- and long-term goals for both simple and complex activities involving the victim, deceased, perpetrator, family, support system
b. May include other nurses, several professional specialists, agencies, resources
c. Evaluate plans on regular and frequent basis to assess the response of the victim, family, perpetrator, and details regarding the deceased (evidence collection, exhumation, release of the body)
4. Intervention
a. The foundation for forensic nursing interventions may include
(1) Victimization
(2) Custody
(3) Human rights
(4) Coercion


b. Nursing care is required for the immediate care of the victim, the deceased, the perpetrator, the family, and other support systems.
c. Direct intervention may be outlined in standing orders, policies, procedures, or directives at the request of law enforcement or a judicial system representative.
d. Interventions need to be evaluated and changed based on the expected desired outcome.
e. Examples may include
(1) Collection and preservation of evidence
(2) Maintaining chain of custody
(3) Release of personal belonging
(4) Release of the body
(5) Referral to specific agency or agencies
(6) Referral to forensic specialists (e.g., pathologist, psychologist, psychiatrist, sexual assault nurse examiner, entomologist, toxicologist, anthropologist)
(7) Establishing and maintaining contact, when necessary, with family, victim, law enforcement, forensic pathologist, social service agencies, judicial system representative, and any additional persons or agency
(8) Detailed documentation of all care, treatment, evidence collection and chain of custody, response to interventions
5. Evaluation
a. Review of all aspects of the nursing process is essential:
(1) In maintaining continuity of medical care and treatment
(2) For changing or altering the nursing diagnosis, interventions, short- or long-term goals
(3) In maintaining evidence viability
(4) Regarding complete and detailed documentation of events
(5) In response to any and all interventions
(6) For determining the need for further follow-up

The Nursing Process as a Tool
A. The nursing process should be utilized at the beginning and throughout the investigation process.
B. The nursing process provides the nurse with a familiar method of organization, identification of problems, prioritization, and determination of the most appropriate intervention.
C. The nursing process addresses issues and problems related to all
individuals affected by the violent act:
1. Victim: living or deceased
2. Family, friends, support system
3. Community members
4. Forensic nurse investigator
5. Members of the investigation team
6. Health care members
7. Any individuals (professional and nonprofessional) working with the victim
D. The nursing process is incorporated in the scope and standard of nursing practice as defined by the American Nurses Association
(ANA) and remains an essential part of the standards of practice for nursing specialty groups and some forensic nursing subspecialty groups (e.g., Sexual Assault Nurse Examiner Standards of Practice, International Association of Forensic Nurses, 1996).
E. The nursing process as a standard in providing nursing care may also be used as evidence in a court of law. Nursing documentation of patient care needs to reflect patient assessment, planning, implementation, and evaluation. The nurse’s notes in the medical record duplicate a nursing process also including a nursing diagnosis.
F. The nursing process becomes a part of the victim’s medical record and should reflect all aspects of the forensic nurse’s investigation.
G. The nursing process is recognized as a standard of nursing practice in all the fields of nursing. It is recognized as a forensic nursing organizational tool to identify the care and intervention necessary for the deceased or live victim, the family or support system, the community members, and additional agency personnel during and after the investigation of a crime.