Sane-A Prep

Front 1

What STD is this?

Back 1

Candidiasis

(yeast infection

Front 2

CANDIDIASIS

Incubation

Back 2

Variable

Front 3

CANDIDIASIS

Symptoms

Back 3

Cottage-cheese like discharge
Odorless
Burning inflammation
Pruritis
Increased symptoms before or during menstrual cycle

Front 4

CANDIDIASIS

Treatment

Back 4

Diflucan (Fluconazole) 150 mg PO X 1
Clotrimazole or Miconazole Vaginal Cream
(3 or 7 day treatment)

Front 5

BACTERIAL VAGINOSIS

Mode of Transmission

Back 5

Controversial whether sexually transmitted

Front 6

BACTERIAL VAGINOSIS

Symptoms

Back 6

Foul or fishy odor (positive whiff test)
Grayish or milky discharge

Front 7

BACTERIAL VAGINOSIS

Diagnosis

Back 7

Positive clue cells on wet mount

Front 8

BACTERIAL VAGINOSIS

Treatment

Back 8

Flagyl 500mg BID for 7 days
MetroGel 0.75% 1 applicator-full BID for 7 days
*If Allergic to Flagyl-
Clindamycin 300mg TID for 7 days
Clindamycin cream 2% QHS per vagina
Augmentin 500mg TID for 7 days
*If Pregnant – Flagyl 250mg TID for 7 days

Front 9

Clue cells

What are they?

Back 9

“Clue cells” are epithelial cells that have had bacteria adhere to their surface, obscuring their borders, and imparting a stippled appearance. The presence of such clue cells is a sign that the patient has bacterial vaginosis.” CDC Website: http://phil.cdc.gov/phil/details.asp

Front 10

Which STI?

Back 10

Trich

"Strawberry cervix"

Front 11

TRICHIMONASIS

Incubation

Back 11

Incubation is 4-20 days

Front 12

TRICHIMONASIS

Symptoms

Back 12

Itching or irritation
Inflammation
Bubbly gray or yellow-green discharge
Sometimes foul odor

Front 13

TRICHIMONASIS

Treatment

Back 13

Metrodiazole (Flagyl) 2 Gm PO single dose
Metrodiazole (Flagyl) 500mg BID for 7 days

Front 14

TRICHIMONASIS

Description

Back 14

“This patient presented with a "strawberry cervix” due to a Trichomonas vaginalis infection, or trichomoniasis. The term “strawberry cervix” is used to describe the appearance of the cervix due to the presence of T. vaginalis protozoa. The cervical mucosa reveals punctate hemorrhages along with accompanying vesicles or papules.” CDC http://phil.cdc.gov/phil/details.asp

Front 15

What STI?

Back 15

Chlamydia

Front 16

CHLAMYDIA

Incubation

Back 16

Incubation
7-14 days

Front 17

CHLAMYDIA

Symptoms - Males

Back 17

Discharge from penis (purulent)
Burning with urination
Burning and itching around urethral meatus
Pain and swelling in testicles
Sometimes asymptomatic

Front 18

CHLAMYDIA

Symptoms - Females

Back 18

*Commonly asymptomatic
Mucopurlent endocervical discharge
Friable cervix
Edema
Erythema
Dysuria, Dysparunia
Lower abdominal pain

Front 19

CHLAMYDIA

Treatment

Back 19

Treatment
**Azithromycin 1 Gm PO single dose
Doxycycline 100mg PO BID for 7 days
*Erythromycin 500mg PO QID for 7 days
Ofloxcin 300mg PO BID for 7 days
*Amoxicillin 500 mg PO TID for 7 days

* Acceptable in Pregnancy
**Class B in Pregnancy

Front 20

CHLAMYDIA

Description

Back 20

This woman’s cervix has manifested signs of a erosion and erythema due to chlamydial infection. An untreated chlamydia infection can cause severe, costly reproductive and other health problems including both short- and long-term consequences, i.e. pelvic inflammatory disease (PID), infertility, and potentially fatal tubal pregnancy.” CDC http://phil.cdc.gov/phil/details.asp

Front 21

GONORRHEA

Incubation

Back 21

2-7 days


Contact with exudate from mucous membranes of infected people

Front 22

GONORRHEA

Symptoms - Male

Back 22

Purulent discharge from urethra

Front 23

GONORRHEA

Symptoms - Female

Back 23

Purulent cervical discharge
Asymptomatic

Front 24

GONORRHEA

Treatment

Back 24

Ceftriaxone (Rocephin) 125 mg or 250 mg IM single dose
Ciprofloxacin 500mg PO
Cefixime 400mg PO
Oloxacin 400mg PO
*Pregnant or Allergic to Cephalosporins/Quinolones – Spectinomycin 2Gm IM

Front 25

GONORRHEA

Incubation

Back 25

2-7 days


Contact with exudate from mucous membranes of infected people

Front 26

GONORRHEA

Symptoms - Male

Back 26

Purulent discharge from urethra

Front 27

GONORRHEA

Symptoms - Female

Back 27

Purulent cervical discharge
Asymptomatic

Front 28

GONORRHEA

Treatment

Back 28

Ceftriaxone (Rocephin) 125 mg or 250 mg IM single dose
Ciprofloxacin 500mg PO
Cefixime 400mg PO
Oloxacin 400mg PO
*Pregnant or Allergic to Cephalosporins/Quinolones – Spectinomycin 2Gm IM

Front 29

HERPES

Incubation

Back 29

2-12 days

Front 30

HERPES

Symptoms

Back 30

1) Asymptomatic
2) Pruritis with papules
3) Vesicles that ulcerate
Vesicles may be seen on vulva, vagina, cervix, penis, rectum
May have recurring symptoms
Newborn infection

Front 31

HERPES

Treatment

Back 31

Acyclovir 400 mg orally three times a day for 7–10 days    ORAcyclovir 200 mg orally five times a day for 7–10 days    ORFamciclovir 250 mg orally three times a day for 7–10 days    ORValacyclovir 1 g orally twice a day for 7–10 days* Treatment might be extended if healing is incomplete after 10 days of therapy.

Front 32

SYPHILLIS

Diagnosis

Back 32

Diagnosis – blood test VDRL, RPR

Front 33

SYPHILLIS

Symptoms

Back 33

Stage 1: Chancre (painless ulcer)Chancre may look like trauma
Stage 2: Skin rash
Stage 3: Heart, nervous system involvement

Front 34

SYPHILLIS

Treatment

Back 34

Benzathine Penicillin G 2.4 million unites IM
*Allergy – Doxycycline 100mg PO BID for 14 days

Front 35

Describe the immediate psychological response to sexual assault.

Back 35

 Shock/denial
 Irritability/anger
 Depression
 Social withdrawal
 Numbing/apathy (detachment, loss of caring)
 Restricted affect (reduced ability to express emotions)
 Nightmares/flashbacks
 Difficulty concentrating
 Diminished interest in activities or sex
 Loss of self-esteem
 Loss of security/loss of trust in others
 Guilt/shame/embarrassment
 Impaired memory
 Loss of appetite
 Suicidal ideation (thoughts of suicide and death)
 Substance Abuse
 Psychological disorders

Front 36

Describe risk factors/symptoms of post-traumatic stress disorder (PTSD).

Back 36

People with PTSD re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects reminiscent of the trauma. Anniversaries of the event can also trigger symptoms. People with PTSD also experience emotional numbness and sleep disturbances, depression, anxiety, and irritability or outbursts of anger. Feelings of intense guilt are also common. Most people with PTSD try to avoid any reminders or thoughts of the ordeal. PTSD is diagnosed when symptoms last more than one month.
Risk factors are parents who have been abused as children or who have had other previous traumatic experiences.

Front 37

PTSD acute

Back 37

symptoms less than 3 months.

Front 38

PTSD chronic

Back 38

symptoms 3 months or longer.

Front 39

PTSD delayed

Back 39

symptoms begin after six months.

Front 40

Rape Trauma Syndrome (RTS)

Back 40

Rape Trauma Syndrome (RTS) similar to PTSD. Same symptoms and clinical manifestations. RTS has acute and long-term phase. Pt may experience both RTS and PTSD simultaneously.

Front 41

Recognize the social ramifications of pt reporting sexual assault.

Back 41

• Lack of faith in police and the justice system
• The fear they won't be believed
• Fear of coping with the medical and legal procedures
• Fear of reprisals
• They don't want family and friends to know
• Humiliation and shame
• Prevalent social attitudes, which blame the victim for sexual assault.

Front 42

Identify the dynamics of drug facilitated sexual assault.

Back 42

Administration of an anesthesia-type drug to render a victim physically incapacitated or helpless and thus incapable of giving or withholding consent. Victims may be unconscious during all or parts of the sexual assault and, upon regaining consciousness, may experience anterograde amnesia--the inability to recall events that occurred while under the influence of the drug.

Front 43

GHB

Back 43

GHB, a Schedule I drug under the Controlled Substances Act, is a powerful central nervous system depressant used illicitly for its euphoric and sedative effects

Front 44

Rohypnol

Back 44

Rohypnol is a powerful benzodiazepine--up to 10 times stronger than Valium

Front 45

Ketamine

Back 45

Ketamine hydrochloride, a Schedule III drug under the Controlled Substances Act, is a dissociative anesthetic that has a combination of stimulant, depressant, hallucinogenic, and analgesic properties.

Front 46

Soma

Back 46

Soma, a commonly known trade name of the drug carisoprodol, is a prescription muscle relaxant and central nervous system depressant

Front 47

Recognize offender issues, dynamics, and characteristics.

Back 47

Rapists according to four primary motivations: opportunistic, pervasively angry, sexually motivated, or vindictive. The majority of adult sex offenders are in their teens, 20’s or early 30’s. They usually have a varied criminal background including such crimes as breaking and entering, theft, and physical assault and they usually began their career at an early age. The offenders who sexually assault significantly older victims are predominantly young, white single males. Offenders are usually known to the victim. Generally family members, neighbors, co-workers, classmates, or friends. Strangers make up a small portion or assailants. Most offenders generally rape those of their own racial background. Attack victims that are easy targets and will offer little or no resistance during an attack.

Front 48

Disorganized Asocial Offender

Back 48

This type of offender is a male who is completely disorganized with everything. According to the FBI's data, he tends to be a non assertive, white male, with a low average IQ, often a high school drop out. He usually exhibits poor hygiene and his home and car [if he has one] are sloppy as well. He has a socially inept, introverted personality with little or no social life. Because of his lack of organizational, social, and intellectual skills, he usually doesn't have the ability to carefully plan his attacks, so they tend to be spontaneous.

Front 49

Organized Nonsocial Offender

Back 49

This type of offender is the complete opposite of the disorganized offender. He has very organized even compulsive, thinking processes and behaviors, which tend to show in his appearance, lifestyle, car, and employment. This type of offender is organized in everything he does. They are nonsocial because they choose to be so. They are loners because they have an enormous ego and feel no one else measures up to them. These types of offenders are usually very bright, have attended at least some college, are socially competent and have sex partners. They usually come from a middle class background, are very sociable and are able to con people easily. They tend to hold good jobs but often have a history of drug and alcohol abuse, especially while committing the crimes.

Front 50

Power Reassurance

Back 50

least violent. This is the guy who will pick a victim or "date" to fall in love with - if only temporary. He is inept and suffers from a very low self-esteem. His psychosocial background will usually include a single parent home, a 10th grade educational level, and a menial job. He's quiet, passive, usually lives with an aggressive, controlling mother or alone; has no friends and no girlfriend. He is a loner and considers himself a loser. He often spends time in adult bookstores, can be your local peeping Tom, or a transvestite. His first crime will usually be within walking distance of work or home. He'll stalk his victims; watch them through their windows, then enter through those windows at a later time. He will usually attack in the victim's home when she is alone or with a small child.

Front 51

Power Assertive

Back 51

An extreme sense of superiority and entitlement. He will rape women simply because he can it is a way of validating his masculinity. This is what men do, according to him. He is the opposite of the passive Power Reassurance type of rapist. He is usually athletic, exercises often, likes a sense of style; dresses flashy and drives a flashy car, and is loud and boisterous. He likes the macho image. "Man's man". His psycho-social background will usually include a history of domestic problems/multiple divorces. He will probably work in a male dominated field like construction or police work. Will haunt the singles bars where he can have plenty of females to pick from. He will use the con approach, getting to know his victim, then offering to give her a ride home or walking her to her car. He will usually rape away from where he lives or works. His fists will be his weapon. He will use a moderate level of force, if the victim resists, and will assault the same victim repeatedly. He could care less about the comfort and well being of his victim. He may assault the victim vaginally, then anally, and then force her to perform fellatio. He will attack with both verbal and physical violence, committing a very brutal attack, although he doesn't intend to kill. He may slap, hit, curse, and tear clothes. He will attack most often in the early evening hours, between 7; 00pm and 1:00am, and tends to commit the rapes in a 20-25 day pattern. He picks women of his own race and age group. His motive is control and domination of "the weaker sex". He's very arrogant and doesn't try to hide his identity. There is no apology afterwards, nor will he attempt to contact the victim later.

Front 52

Anger-Retaliatory

Back 52

This guy is out to hurt someone. He blames women for all the injustices he has suffered in his life. His hate and anger are out of control. He wants to punish, hurt and degrade them. His psycho-social background includes physical and emotional abuse (more than 56%) from one or both parents. About 80% had divorced parents, many were adopted, and over half spent time in foster care. His relationships with significant females are extremely poor growing up which created very hostile feelings towards the opposite sex. He sees himself as very masculine, is usually athletic, and often works in a fast-moving male dominated field or sport. He's usually married and often has extramarital flings. He has a quick temper and his rapes usually occur after some negative event involving one of the women in his life. His urge is almost uncontrollable, as it's the result of a built up of rage and anger. He will use both verbal (excessive profanity) and physical assault, even murder. His attacks are very sudden, with little forethought. This is not a sexual act. This is rage. He intends to hurt and degrade his victim. He's the type to "beat the living crap" out of his victim, assaulting her with his fists, feet, and weapons of choice. He will pick women of his own race and age, or slightly older and will usually stalk them while driving close to home. His pattern of raping is usually every 6 months to a year. This victim will often have a lot of physical and genital injuries. In my experience, the few who have been assaulted this way, have come in with significant facial injuries at times - injured eye and cheek, with petechial hemorrhages, swollen cheek often with red marks; split lip, broken teeth, body bruises and cuts, (+) defensive injuries, and broken fingernails. If wearing a necklace, the victim will often have a necklace imprint bruise; (+) oral, vaginal, and /or anal injuries, etc. This is a very dangerous man.

Front 53

Anger Excitation (Sadistic) rapist

Back 53

This is your killer. But first, he's going to beat and torture his victims. His intent is to degrade, torture, and kill. It's the only way he can get sexual satisfaction. His psycho-social background will include being raised in a single parent household and suffering from physical abuse and sexual deviance. This type of child often shows aggressive and sexual promiscuity tendencies early on. As an adult, he's often about 30-39, married with a family, and lives in a middle class, low crime area. He's intelligent, educated, and usually has no arrest record. He's very good at not getting caught. This type of rapist puts a great deal of planning and fore-thought into his attacks. He stalks his victims by car, driving out of his area. He often carries a "rape kit". He will usually take his victims to a secluded area where he can have complete control. He may keep them bound up for days or weeks, torturing and raping them. He will tell his victims what he plans to do to them in order to increase their fear. It's not the injury to the victim which excites him. The fear the victim is feeling is what he needs. He's very ritualistic, planning every detail of the abduction, torture, rape, murder, and disposal of the body, if he has become a killer at this point. Everything has to go according to script down to the last detail, including having the victim say specific things to him in order for him to obtain sexual satisfaction. This victim will be lucky to get away with her life.

Front 54

Recognize urgent/emergent problems requiring medical TX prior to SANE exam.

Back 54

Unstable vital signs, altered consciousness, and peritoneal pain or bleeding. If injuries are life threatening or require immediate medical treatment prior to the arrival of the SANE, the physician or clinical staff should maintain forensic principles when documenting injuries in the medical record. If pt is stable await arrival of SANE, if pt is going to operating room evidence collection can occur while pt is being prepared for surgery.

Front 55

Obtain a pertinent health history.

Back 55

Pt identifying information. Allergies, current pregnancy status, menstrual cycle and current medications. Current complaints of pain. Pre-existing injuries/conditions

Front 56

Obtain history of the reported criminal act.

Back 56

Identifying info about perpetrator
Detailed description of physical/sexual contact including orifices assaulted.
Sequence and duration of events
Post-assault hygiene (shower, brushed teeth, voided)
Physical positions during assault
ETOH/drugs used by victim or suspect
Prior history of victimization

Front 57

Separate medical and forensic data.

Back 57

During the forensic exam, the examiner methodically documents the physical findings and facilitates the collection of evidence from the pt’s body and clothing. These findings in the exam and the collected evidence often provide information to help reconstruct the details about the events in question in an objective and subjective manner. Document physical findings associated with assault from tenderness to trauma. Recover evidence which confirms sexual contact and may link victim and suspect/scene. During the medical exam document any injuries. Obtain history regarding pre-existing anal-genital injuries, surgeries, diagnostic procedures, medical treatments that may affect the interpretation of physical finding.

Front 58

Use a systematic method of evidence collection to protect the integrity of evidence.

Back 58

Establish a routine—prepare, interview, examine.
Plan evidence collection and follow established protocol for evidence collection.
Maintain chain of custody. Oral swabs, fingernail clippings, blood draw from pt, urine for drug-facilitated assault, pubic combings, rectal and vaginal swabs.

Front 59

Assess patient for general physical trauma.

Back 59

Head, chest or abdominal trauma. Pain or obvious deformity to extremity. Any uncontrolled bleeding. Lacerations that may require immediate intervention or suturing. Areas of bruising.

Front 60

Take measures to maintain/protect the integrity of evidence and the chain of custody.

Back 60

Evidence should be kept in an area less than 75 degrees Fahrenheit and blood should not be frozen. Storage in an air conditioned room is sufficient for short-term storage. Chain of custody is essential and must include the signature of everyone who had possession of the evidence from the individual who collected the evidence to the individual bringing it into the courtroom.

Front 61

Issues related to variations in examination technique (age, pain, cultural, mental).

Back 61

Exams are never done against a person’s will. The SANE is balancing two very important ethical values: protecting and promoting the individual’s well-being and respecting the individual’s self-determination. A first consideration is whether or not the person is her or his own guardian and whether she or he functions independently in the community. In cases where the person has been deemed legally unable to provide informed consent to do an evidentiary exam. If a legal guardian is not available, the SANE proceeds with evidence collection, acting in what she perceives to be the victim’s best interest and informs the legal guardian as soon as possible. In the elderly, a Pedersen speculum, which is longer and thinner than the grave speculum should be used during the pelvic exam. In some elderly women just insert the swabs vaginally to avoid the trauma of inserting a speculum. If there are external tears in the introitus internal injuries must also be considered. Additionally frequent breaks during the exam and perhaps change of position should be considered.

Front 62

Issues of timing in collection of evidence/specimens.

Back 62

While a complete exam including all of the above components is usually only done during the first 36 hours after a sexual assault, an abbreviated exam is completed for up to 72 hours after a sexual assault and, for some jurisdictions, up to 96 hours. If pt presents after a specific time consider medical-forensic exam if known ejaculation, visible injuries, special request of pt or current complaints of pain or bleeding.

Front 63

Assess involved orifices for trauma. Include special pops who can’t describe event.

Back 63

Those who can’t recall events or are disabled. All orifices should be swabbed for potential evidence.

Front 64

Collect and record biological specimens from involved orifices areas of contact.

Back 64

All swabs taken from pt’s body/orifices should be labeled and time/dated. Include oral, anal, vaginal swabs.

Front 65

Collect pubic hair combings for foreign hairs and trace evidence.

Back 65

Pubic hair combings should be done prior to the pelvic exam in a downward motion with a drape under the patient. The comb should be included back in the sealed evidence kit. Trace evidence may include sand/gravel/soil, fibers, hairs or foreign matter.

Front 66

Collect standard samples for DNA.

Back 66

Evidence can be obtained by collecting any available blood evidence that could have come from the assailant and remained on the skin or clothing of the victim... Fingernail scraping from the victim. Fingernail clippings are preferred. DNA from semen can also be obtained by swabbing the involved orifices. Any dried or liquid foreign matter on the body/clothing should be collected for DNA.

Front 67

Assess patient for indicators of drug facilitated sexual assault.
Warning Signs - when the drugs are taking effect:

Back 67

• appearance of being heavily intoxicated, often out of proportion to how much the victim has actually had to drink;
• feelings of intoxication that come on very quickly;
• nausea, dizziness, disorientation, and decreased inhibition;
• heaviness or paralysis in the arms and legs;
• Tunnel vision.

Front 68

Assess patient for indicators of drug facilitated sexual assault.

Warning Signs - when the effects of drugs are wearing/have worn off:

Back 68

• feeling sick, similar to an extreme hangover;
• loss of memory of what happened just before waking up;
• amnesia - no memory of anything that happened after taking a drink;
• Signs of possibly having been assaulted - waking up with clothes put on differently, in a strange place, etc.

Front 69

Collect and record collection of clothing and its condition.

Back 69

Pt should disrobe while nurse provides as much draping as possible. Pt should stand on a clean sheet and place each item of clothing separately. Nurse should note stains/tears in documentation. Each item of clothing should be individually bagged and sealed. Alternate light source should be used to detect stains. Shoe, coats, and belts should only be collected if pertinent to evidence collection. Package clothing without cross contamination. Recognize the fragility of biological matter and maintain integrity of specific evidence (cuts/blood spatter/holes). Label, time/date, and initials. Record a list of clothing collected.

Front 70

Distinguish trauma from disease and normal variations in physiology throughout the life cycle.

Back 70

Evaluate injury. Generalized or localized? Evaluate the possibility of a pre-existing condition. Take a thorough history from the patient. A follow-up exam 10-14 days later to determine healing process. Consider consulting a specialist. Consider alternate causes of injury.

Front 71

Bruise=Contusion

Back 71

usually results in swelling and pain

Front 72

Ecchymosis

Back 72

Is not a contusion. It is non painful patch. Blood has leaked into the skin and is bigger than petechia (<3mm)

Front 73

Laceration/tear

Back 73

has jagged edges and crushed margins

Front 74

Incision/cut

Back 74

Clean edges, longer than depth

Front 75

Stab puncture

Back 75

Deeper than depth. Appearance of margins wound shape affected by instrument and location of injury.

Front 76

Describe reasons for application of specific exam techniques

ALS

Back 76

Scan area with alternate light source and document any fluorescent areas. Swab moist secretions with dry swab to avoid dilution, label and airy dry before packaging. Swab dried stains and ALS positive areas with a swab moistened with sterile water. Label and dry swab before packaging.

Front 77

Describe reasons for application of specific exam techniques

Toluidine Blue

Back 77

Toluidine blue dye is a nuclear stain that attacks to broken skin absorbs and should be considered as trauma. Because injuries could otherwise be attributed to improper handling of an examination speculum or the improper insertion of the examining finger, the toluidine blue test should be performed prior to any digital or speculum examination and thus prior to the collection of forensic evidence.

Front 78

Describe reasons for application of specific exam techniques

Foley Catheter

Back 78

Foley catheter (14 Fr) is inserted through the hymen orifice and inflated using 40 ml of air. Gentle pulling toward the orifice resulted in stretching of the hymenal tissues over the balloon surface of the catheter. After photo documentation of the anatomy of the hymen edges, the balloon is deflated and removed

Front 79

Throughout the exam provide explanation, elicit feedback, and provide feedback regarding findings.

Back 79

Involve pt in every aspect of exam. Explain reasons behind collecting clothes and procedure for obtaining clothes back from law enforcement. Interpret findings for pt in terms they understand.

Front 80

Permit pt to control/consent to all or parts of the exam.

Back 80

Obtain consent before proceeding with each part of the exam. If a patient says “no” the exam stops. Explain the rationale behind collecting evidence in a certain manner.

Front 81

Identify exceptions to usual exam procedure and document reasons for exception.

Back 81

Primary area of variation include: amount of documentation, prophylactic treatment for STD’s vs. culturing, collection of additional blood or urine specimens for drug/alcohol analysis, clothing collected as evidence, required number of head and pubic hairs is collected routinely, and utilization of colposcope and light staining microscope.

Front 82

Document pt’s injuries by photos, written description, and body diagrams.

Back 82

Document exam and findings on specific form for SANE program. Use body map diagrams and photography. Use legible handwriting. Use proper anatomical and forensic terms. No pejorative terms (use probable not alleged).

Front 83

Interpret injury presentation (patterned injury, pattern of injury, genital injury).

Back 83

Evaluate consentience of injuries with time line given. Document location, color, and size. Photograph injuries.

Front 84

Stages of healing*

Acute stage

Healing is influenced by wound location/depth, age, chronic disease, and wound infection and healing patterns in the individual.

Back 84

immediately following trauma. Bleeding and swelling begins.

Front 85

Stages of healing*

Sub-acute stage

Healing is influenced by wound location/depth, age, chronic disease, and wound infection and healing patterns in the individual.

Back 85

Bleeding stops, pain and swelling continues. Serous fluid oozes and dries over wound. Keratinocytes migrate to close wound. Open wounds begin to epithelialize from endothelial cells within minutes.

Front 86

Stages of healing*

Chronic Stage

Healing is influenced by wound location/depth, age, chronic disease, and wound infection and healing patterns in the individual.

Back 86

Skin’s layered structure formed. “Proud” smooth flesh is firm and vascular. May appear before scab entirely gone. Pain syndromes develop.

Front 87

Stages of healing*

Old chronic stage—

Healing is influenced by wound location/depth, age, chronic disease, and wound infection and healing patterns in the individual.

Back 87

Remodeling continues for years. Scar avascular (white) and may blend with other tissue.

Front 88

Assess pt’s level of development-physical, psychological, cognitive.

Back 88

Adolescent should be scaled on Tanner physical development. All pts should be evaluated on their psychological and cognitive level so that they understand all aspects of exam and follow up care.

Front 89

Provide crisis intervention.

Back 89

Continued fear and anxiety resulting from the rape can significantly affect the victim’s life, including work, school, and relationships with others far into the future. Sometime of follow up counseling should be initiated before the victim leaves the ED.

Front 90

Ensure safety of patient and SANE during and after the evaluation.

Back 90

Pts should be kept in secured and isolated room within the ED. Visitors and staff that have contact with patient should be minimal. Patients need to be discharged to a safe place or have emergency options available if they return home.

Front 91

Offer/provide prophylactic medication to prevent STD’s and recommend follow-up.

Back 91

There is no rationale for obtaining cultures other than to establish a baseline. There is also evidence that STD cultures for gonorrhea obtained at the initial exam immediately after the assault may indicate a pre-existing condition. Also culture has no forensic value. Rocephin 250mg IM (gonorrhea) Zithromax 1gm PO (chlamydia) Flagyl 500mg PO (Trichamonas) should be given if not contraindicated. Recommend GYN follow-up for testing in 2-3 weeks from initial exam. Or Doxycycline 100mg BID for 7 days.

Front 92

Explain safe sex practices to avoid spread of sexually transmitted disease.

Back 92

Back up method should be used such as condom. Especially if patient is prescribed antibiotics and is using birth control pills.

Front 93

Assess pt’s hepatitis B status and offer immunizations, if appropriate.

Back 93

Given in 3 injections (initial, 3months, and 6 months). If gap in time the series must start over. Most adults have received injects during their college or school careers.

Front 94

Assess risk of HIV infection.

Back 94

The risk of HIV infection is less than 1 percent. The risk of exposure after sexual contact overall is reported to be less than other routes of exposures.

Front 95

Inform pt of risk of HIV infection and provide info regarding prophylaxis.

Back 95

Post exposure prophylaxis is recommended for high-risk exposures. Antiretroviral treatment is not recommended when the HIV status of the assailant is unknown due to the cost and potential toxicity of zidovudine. When it is recommended the health status of the victim and her ability to withstand the potential side effects must be taken into consideration along with the severity of risk

Front 96

Assess risk for pregnancy and counsel pt about emergency contraception meds.

Back 96

Patient should be offered emergency contraception if they present within 72 hours of the rape and have a negative pregnancy test in the ED. Also need pt education and informed consent. Need to assess pertinent pt history, LMP, and GYN surgeries.

Front 97

Emergency contraception

Yupze Method

Back 97

Yupze Method uses 100mcg ethinylo estradiol and 0.5 mg levonorgestral. First dose given within 72 hours of the assault and second dose given 12 hrs later. Known as Ovral or Preven. This method is 60-90% effective. Should be given with anti-emetic. Side effects include nausea/vomiting and fatigue. Irregular menstruation following treatment. Next period may be 1 week early or late.

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Emergency contraception

Progestin only aka Plan B

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Progestin only method uses levonorgestral PO only. First dose is 0.75 mg given within 72 hrs of assault. Second dose is given 12 hrs later. More recent research suggests equivalent efficacy for 1.5mg dose up to 5 days post assault. Known as Plan B. 85-95% effective within 72 hrs and 75% effective up to 5 days later. Side effects include nausea/vomiting and fatigue. Irregular menstruation following treatment. Next period may be 1 week early or late.

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Offer or refer for tetanus immunization, if needed.

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Tetanus prophylaxis should be given when the evidentiary exam identifies any break in the skin or mucosa.

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Describe medical interactions of various prophylactic drugs.

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Pregnancy prophylaxis usually causes nausea and vomiting. May cause mentral period to be 1 week early or late. Antibiotics can cause nausea, vomiting, or diarrhea. Yeast infections are also common. If patient is on oral contraceptives use back up method of birth control.

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Criminal cases

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Criminal cases are those in which a defendant is accused of a serious crime, such as robbery, theft, drug possession or murder. In a criminal case, a prosecutor tries to prove that the defendant committed a crime. The prosecutor is an attorney who represents the State of New Jersey, and the defense attorney represents the defendant. The judge oversees the proceedings and ensures that they are conducted according to the law and the rules of court. Most criminal trials are decided by a jury consisting of 12 citizens. The jury represents the community in which the crime occurred. The jury's role is to hear the evidence presented by the prosecutor and the defense attorney. Evidence is presented to the jury by witnesses who testify. After all the evidence has been presented, the jury discusses the case in private. If all the jurors believe the evidence proves the defendant committed the crime, the jury convicts the defendant by returning a guilty verdict. After a defendant is convicted, the judge imposes a sentence, such as a term in prison. If the jurors do not believe the evidence proves the defendant committed the crime, then the jury acquits the defendant by returning a verdict of not guilty. If the jurors are unable to decide between conviction and acquittal, the judge can declare a mistrial, and a new trial can be held with different jurors. Not every criminal case is decided by a trial. Many cases are resolved through a plea bargain. In a plea bargain, the defendant agrees to plead guilty by admitting that he or she committed a crime. In return, the prosecutor asks the judge to impose a sentence that is less severe than if the defendant had gone to trial and been convicted. The judge, however, is not required to agree to the recommendation and may choose to ignore it. A plea bargain ensures that a guilty defendant is punished. Plea bargains can be entered either before or even during the trial.

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Civil lawsuits

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Civil lawsuits are cases in which a plaintiff claims that he or she has been injured by the actions of the defendant. In jury is a legal term meaning any harm done to a person's body, property, reputation or rights. In some civil cases, the plaintiff seeks damages, or money, from the defendant as compensation for injuries allegedly caused by the defendant. Examples are cases involving car accidents; age, race or gender discrimination in the workplace; medical malpractice; defective products; differences over the terms of contracts, and disputes between landlords and tenants. Civil juries consist of six members. Not all civil cases, however, involve attempts to receive compensation for injuries. People also file lawsuits to enforce their rights. In New Jersey, these kinds of non-monetary lawsuits are called General Equity cases. A General Equity case may involve a terminally ill person s right to refuse life-sustaining medical treatment, or a dispute between labor and management over rights in the workplace, or even a company s ability to protect its trade secrets, such as how it makes or markets a product. Instead of money, the plaintiff in a General Equity case may ask the court to order the defendant to do something: remove a feeding tube, for instance, or end a strike and return to work. General Equity cases are decided by judges instead of juries. As in criminal cases, the parties in civil cases often agree to settle their disputes without a trial. Settlements may occur before a trial starts or even during a trial. A settlement allows each side to resolve the dispute satisfactorily rather than risk losing at a trial.

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Family Cases

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Family Cases--Civil cases in which the disputes involve children, spouses or domestic partners. Examples of family cases are those involving divorce, adoption, juvenile delinquency, child abuse, child support, and domestic violence. Most cases in the Family Court are decided by a judge instead of a jury. To protect the privacy of children, judges are permitted to close some types of Family Court cases to the public.

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Distinguish between factual witness and expert witness testimony.

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Factual witnesses testify to what they personally saw or heard. Expert witnesses testify to their opinion. They can be based on your own exam or an exam performed by someone else.
Anyone with more than the average knowledge about the matter at hand.

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Testify regarding integrity of chain of custody of evidence.

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Helps identify an article of evidence and tracks a piece of evidence. Includes initials, time/date collected. Includes initials, time/date when the piece was transferred to another person. Shows every person who has handled evidence. Either fact or expert witnesses may need to testify about the techniques used to collect, package, document evidence, as well as the chain of custody.

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Respond effectively to aggressive/condescending questions.

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Inappropriate questions should be directed to the judge for clarification.

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Identify qualifications/characteristics of expert witnesses.

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Most states use federal rules to define an expert. Anyone with more than the average knowledge about the matter at hand. You do not have to have a specific degree. You may be asked your opinion and the basis for your opinion.

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Recognize implications of discovery process in terms of evidence collected and records kept.

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A legal process whereby each side may discover evidence the opposing side holds. Rules of discovery may vary from state to state. Each side has certain rights to information from the opposing side.

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Respond appropriately to subpoenas.

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A summons to appear in court or produce other evidence, such as documents or photos. You must respond to a subpoena or be held in contempt of court. Either side may issue subpoena. If you receive a subpoena you should discuss it with the attorney calling you as witness. A subpoena is "a command to appear at a certain time and place to give testimony upon a certain matter." A subpoena is used to compel the testimony of witnesses in a trial or other adversarial proceeding. Subpoenas are issued by the clerk of the court in the name of the judge presiding over the case in which the witness is to testify.

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Identify implications of hearsay exceptions (excited utterance, outcry, past recollection recorded, medical exception, and learned treatise).

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Hearsay evidence is anything not directly observed by the witness. Most hearsay is inadmissible the exception is statements made by the pt, as part of a medical examination. If hearsay is an issue, the judge will issue a ruling. An excited utterance, medical exception or learned treatise can be admissible.

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Recognize purpose of rape shield laws.

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Rape shield laws are statutes or court rules that limit the introduction of evidence about a victim's sexual history, reputation or past conduct. Every state and the District of Columbia have a rape shield law that applies in criminal cases; only a few extend such laws to civil cases. Rape shield laws commonly bar the introduction of opinion and reputation evidence about the sexual history of the victim. They also typically provide that evidence of specific sexual conduct of the victim is presumed irrelevant unless it is direct evidence of the source of injury, semen, pregnancy, or disease that may be at issue in the case, or relates to specific sexual conduct with the defendant. Some rape shield laws also prohibit evidence of the victim's manner of dress.

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Define concepts of age of consent and capacity to consent.

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The age of consent is the age when the law says you can agree to have sex. In most countries it means until you reach this age you cannot legally have sex with anyone, regardless of their age old. In the United States and Canada this is the same situation. Sometimes the law is different if you are female or male. Consent is crucial in deciding whether a particular sexual relationship or act is abusive. What needs to be decided is: whether consent was able to be given, and whether it was given by the individual. There are some individuals with a learning disability who would be considered as being unable to give consent and lack capacity (the ability to make informed choice). This is a complex decision and workers should seek guidance. Incapable adults who are defined as being: incapable of acting, making decisions, communicating decisions, understanding decisions, by reason of mental disorder or physical disability

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Identify core SART members—medical (SANE)

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Performs physical assessment. Collects and documents forensic evidence. Makes appropriate referrals and conducts patient education. May testify in court.

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Identify core SART members— advocacy

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Provides non-judgmental support to victim and may follow then through the legal process. Make referrals to support agencies. Typically from a rape crisis center.

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Identify core SART members— law enforcement

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Ensures safety of victim and scene. Conducts a criminal investigation and arrests suspect. Writes a report that goes to the prosecuting attorney.

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Identify core SART members— prosecutor.

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charged with bringing people’s case to court. Makes filing and charging decisions. Vertical prosecution—the same attorney handles the case from start to finish.

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Recognize appropriate roles and boundaries of the SART members.

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Nursing practice is not determined by advocates or law enforcement officers. Nurses cannot be supervised by non-nurses.

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Identify other resource personnel as potential SART members.

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Child/Adult protective services, domestic violence advocates, crime lab personnel, social service providers, clergy, counselors, judges, and defense attorneys.