TAASA handout version 2.pptx
Transcription
TAASA handout version 2.pptx
3/5/14 The ABC’s of Pedi SAEs Sarah Keymer RN, BSN, CA/CP SANE, SANE-P & Kara Faletto MA, CCLS Learning Objectives • Understand key aspects of different developmental age groups as they pertain to challenges encountered during pediatric sexual assault examinations. • Explore proper technique in conducting age sensitive sexual assault examinations in the pediatric population. • Recognize normal anatomical variants to anogenital areas as seen in the pediatric population during sexual assault examinations. Page 1 Page 1 xxx00.#####.ppt 3/5/14 3:05 PM One Size Does Not Fit All • Developmentally appropriate exams allow SANE to: ‐ Establish trust with patient and family ‐ Reduce additional trauma for patient and family ‐ Perform thorough, safe exams Page 2 Page 2 xxx00.#####.ppt 3/5/14 3:05 PM 1 3/5/14 Door to Discharge Timeline • Check in/registration • Quick Triage • SANE and social worker interview with parent/patient separately depending on age • Involve Child Life if appropriate while SANE preps exam room • Exam – including photos, evidence collection and medication administration • Patient/Parental education and discharge home Page 3 Page 3 xxx00.#####.ppt 3/5/14 3:05 PM Overview Breakdown of each step in the process for developmental age group Toddlers 1-3 years old Preschool 3-5 years old School Aged Children 6-11 years old Adolescents/Teenagers 12+ years old Page 4 Page 4 xxx00.#####.ppt 3/5/14 3:05 PM The Interview Overview • Purpose of the interview is to obtain necessary information to decide plan of care for patient. • Social worker and SANE perform interview together • Patient and caregiver interviewed separately. Page 5 Page 5 xxx00.#####.ppt 3/5/14 3:05 PM 2 3/5/14 Developmentally appropriate Interviews: Toddlers and Preschool Age • We interview patient >5 years old • For younger children, we obtain history from caregiver Page 6 Page 6 xxx00.#####.ppt 3/5/14 3:05 PM Developmentally appropriate Interviews School Aged Children: Establish Rapport and Asses verbal/cognitive abilities, comforts, attention What’s your name? How old are you? Do you have any pets? What grade are you in? Ask about home, daily living, relationships Where do you live? Who lives with you? Where do you sleep? Where do mommy/daddy sleep? Establish difference between truth and lie If I said that your shirt is green, is that a truth or a lie? (Remind child to only tell the truth) Identify hair, eyes, mouth, belly button etc. Ask to identify body parts What part of your body should nobody touch? including names for genitalia What do you call those parts? Do you know why your mom brought you to the hospital today? Has anyone ever touched those parts that nobody should touch? Can you tell me about that? Open ended questions Page 7 Page 7 xxx00.#####.ppt 3/5/14 3:05 PM Developmentally appropriate Interviews Adolescents/Teenagers: Establish trust and informed consent at the beginning What is said in this room, stays in this room… UNLESS you tell me that someone has hurt you or you want to hurt yourself. Establish Rapport and Asses verbal/cognitive abilities, comforts, attention What’s your name? What grade are you in? What school do you go to? Do you like school? What’s your favorite subject? Do you have any hobbies? Ask about home, daily living, relationships, especially friendship Where do you live? Who lives with you? Do you have friends at school? Do you have a boyfriend/girlfriend? Ask to identify body parts including names for genitalia Allow patient to use terms he/she uses with peers for body parts, no judgment Open ended questions Do you know why your parents brought you to the hospital? …And then what happened? …What happened next? Page 8 Page 8 xxx00.#####.ppt 3/5/14 3:05 PM 3 3/5/14 The Interview • Use of body diagrams or dolls for demonstration • Outcry in form of a written note Page 9 Page 9 xxx00.#####.ppt 3/5/14 3:05 PM The Exam Overview • Patient brought to exam room • Placed in gown – clothing evidence collected • Use of Bluemaxx fluorescent light • MD and SANE perform head to toe physical exam and body surface photos if indicated • Oral swabs • Anogenital exam, swabs for evidence and testing, colposcope photos • Blood specimen obtained • POPSICLES!!!!! • Patient redressed and returned to ER room prior to discharge Page 10 Page 10 xxx00.#####.ppt 3/5/14 3:05 PM Child Life 4 3/5/14 Child Life Specialist’s Role ! Provide developmentally appropriate education prior to exam ! Allow patient to see and manipulate medical equipment that will be used during exam ! Provide distraction, education and emotional support during exam Page 12 Page 12 xxx00.#####.ppt 3/5/14 3:05 PM Preparation • Provide Patient with developmentally appropriate language and education about the exam. ‐ “The Dr./Nurse wants to check your body to make sure you are healthy” ‐ “The Nurse will look at your body from your head all the way to your toes” Page 13 Page 13 xxx00.#####.ppt 3/5/14 3:05 PM Preparation cont. • Explain using sensory information, what the patient will see, hear, feel, and smell. ‐ Show patient medical equipment and materials that will be used during exam. ‐ “Some kids say it feels like…” ‐ Provide pictures of exam room/ materials ‐ Explain positioning and allow patient to practice “cannonball” “butterfly” “cat” Page 14 Page 14 xxx00.#####.ppt 3/5/14 3:05 PM 5 3/5/14 Developmentally Appropriate Exams: Toddlers • Explore surroundings • Show the around the exam room • Seek adult companionship • Fear separation from primary caregiver • Parent at bedside • Position patient in parent’s lap during exam • Assert independence • Allow patient to participate • Fear of pain • Begin exam with something familiar • Listening to their heart/lungs • Allow patient to touch swabs Page 15 Page 15 xxx00.#####.ppt 3/5/14 3:05 PM Developmentally Appropriate Exams: Preschool: • Physically active, enjoy games • Distraction with iPad, games, etc. • Sometimes misunderstand words, misconceptions common • Use concrete examples • Fear the unknown • Explain process in simple steps • May see medical procedure as a punishment • Explain reason for the exam Page 16 Page 16 xxx00.#####.ppt 3/5/14 3:05 PM Developmentally Appropriate Exams: School Aged Children: • Able to reason and think logically • Explain purpose of exam concretely • Have an awareness of body and function • Give patient a job during exam • Fear body mutilation, pain, death • Check for misunderstanding/concern Page 17 Page 17 xxx00.#####.ppt 3/5/14 3:05 PM 6 3/5/14 Developmentally Appropriate Exams: Adolescents/Teenagers: • Concerned with peer acceptance • Build rapport with patient • Concerned with body image • Preserve patient’s modesty • Changes in body and sexuality are important • Assure them that their body is “normal” • Self centered • “It can’t happen to me” attitude • Post-exam safety education • Allow patient to ask questions • Fear loss of independence and invasion of privacy • Maintain confidentiality • Allow them to decide who accompanies them to exam room Page 18 Page 18 xxx00.#####.ppt 3/5/14 3:05 PM Distraction/Coping During Exam Toddler • Bubbles, light up toys • Parent and/or CCLS presence for calming • Relate exam to diaper change Preschool • Books, bubbles, singing, counting • Parent and/or CCLS presence for comfort Teenage • Music, iPad, movie • Parent presence vs. CCLS support vs. no support for privacy School Age • Books, games, videos • Parent and/or CCLS presence for support Page 19 Page 19 xxx00.#####.ppt 3/5/14 3:05 PM Case Reviews Pediatric Sexual Assault Exams 7 3/5/14 Patient #1 Page 21 Page 21 xxx00.#####.ppt 3/5/14 3:05 PM History • 12 year old Caucasian female • Parents are separated/divorced, have joint custody • Outcry to Mother the day after she was picked up from father’s house Page 22 Page 22 xxx00.#####.ppt 3/5/14 3:05 PM Interview with Patient • Patient stated that while visiting her father, he started inappropriately touching her which led to her being fully undressed and finally oral/vaginal contact • “I thought it was weird… But he is my dad… So I did.” • “He told me not to tell anyone… But that’s not something you should keep inside!” Page 23 Page 23 xxx00.#####.ppt 3/5/14 3:05 PM 8 3/5/14 Type of Contact • Fondling • Oral/vaginal contact Page 24 Page 24 xxx00.#####.ppt 3/5/14 3:05 PM Plan of Care • Detailed head to toe and genitourinary exam • Photo Documentation • STI/Pregnancy Testing – Results were negative • Evidence collection Page 25 Page 25 xxx00.#####.ppt 3/5/14 3:05 PM Exam • Menstrual blood present • Septate hymen with no signs of acute trauma Page 26 Page 26 xxx00.#####.ppt 3/5/14 3:05 PM 9 3/5/14 Septate Hymen • The hymen is a thin membrane that partially covers the opening of the vagina • A septate hymen is when this membrane has a band of extra tissue in the middle that creates two small vaginal openings instead of one • Congenital disorder = Present at birth • Diagnosis can be made through a physical exam • Treatment may include minor surgery to remove the extra band of tissue to create a single, normal-sized vaginal opening Page 27 Page 27 xxx00.#####.ppt 3/5/14 3:05 PM Disposition • The patient was discharged home in the care of her mother • CPS/PD involved and will follow-up in home • Discharge instructions were given to have the patient followup with GYN clinic for further evaluation and possible treatment of a septate hymen Page 28 Page 28 xxx00.#####.ppt 3/5/14 3:05 PM Patient #2 Page 29 Page 29 xxx00.#####.ppt 3/5/14 3:05 PM 10 3/5/14 History • 6yo female brought in by mother with concerns r/t vaginal bleeding/lesion on vaginal area • Mother concerned because patient was with father (divorced) 9 days prior, unknown etiology of lesion • Patient seen by OSH and PCP prior to arrival, on Bactrim for diagnosed UTI • Patient with recent history of constipation Page 30 Page 30 xxx00.#####.ppt 3/5/14 3:05 PM Interview with Patient • Patient able to identify private parts • No outcry for sexual abuse at this time. Page 31 Page 31 xxx00.#####.ppt 3/5/14 3:05 PM Type of Contact • None known/unknown Page 32 Page 32 xxx00.#####.ppt 3/5/14 3:05 PM 11 3/5/14 Plan of Care • Anogential exam • Pediatric Gynecology consult Page 33 Page 33 xxx00.#####.ppt 3/5/14 3:05 PM Exam • Dark brown mole lateral to right labia majora • No trauma to any areas • Mass of dark pink tissue attached at 12:00 and moveable during exam, no active bleeding, consistent with urethral prolapse. • Gynecology at bedside during exam Page 34 Page 34 xxx00.#####.ppt 3/5/14 3:05 PM Urethral Prolapse • Often confused with genital trauma • Most commonly seen between 5 and 8 years old • May present with bleeding • Treat with topical estrogens and sitz baths Page 35 Page 35 xxx00.#####.ppt 3/5/14 3:05 PM 12 3/5/14 Follow up • CPS notified due to mom’s concerns • Discharged home with Premarin cream BID until gynecology clinic appointment. • Plan for 2-3 week gynecology follow up. Page 36 Page 36 xxx00.#####.ppt 3/5/14 3:05 PM Patient #3 Page 37 Page 37 xxx00.#####.ppt 3/5/14 3:05 PM History • 5 year old Hispanic female • Vaginal pain • Burning when voiding and defecating • Severe pruritus • Clinic personnel where concerned for abuse sent the patient to ER – mother did not have concern for abuse. Page 38 Page 38 xxx00.#####.ppt 3/5/14 3:05 PM 13 3/5/14 Interview with Patient • The patient denied being touched inappropriately • No outcry for sexual abuse Page 39 Page 39 xxx00.#####.ppt 3/5/14 3:05 PM Type of Contact • Unknown Page 40 Page 40 xxx00.#####.ppt 3/5/14 3:05 PM Plan of Care • A voided urine was collected – Results were normal • A genitourinary exam • Photo documentation Page 41 Page 41 xxx00.#####.ppt 3/5/14 3:05 PM 14 3/5/14 Exam • Hypopigmentation in a figure-8 pattern to external genitalia, including the labia majora and perineum • Excoriation with bruised and irritated areas • Noted tenderness and discomfort • Pruritus • Hymen with no signs of trauma Page 42 Page 42 xxx00.#####.ppt 3/5/14 3:05 PM Lichen Sclerosis • Exam results consistent with lichen sclerosis • Most often in 3 to 7 year olds • Lesions appear shiny, white, well-circumscribed patches • “figure-eight” distribution - involving vulva and perianal skin • Pathogenesis is unknown Page 43 Page 43 xxx00.#####.ppt 3/5/14 3:05 PM Disposition • The patient was discharged home in the care of her mother • Discharge instructions were given to have the patient follow-up in the gynecology clinic for continued care of Lichen Sclerosis Page 44 Page 44 xxx00.#####.ppt 3/5/14 3:05 PM 15 3/5/14 Other Normal Variant Findings Page 45 Page 45 xxx00.#####.ppt 3/5/14 3:05 PM Labial Adhesions • Common finding – occur in up to 1 in 3 girls • Most common under 2 years of age • Emphasize good hygiene • Extensive adhesions treated with estrogen cream. Page 46 Page 46 xxx00.#####.ppt 3/5/14 3:05 PM Labial Adhesions Page 47 Page 47 xxx00.#####.ppt 3/5/14 3:05 PM 16 3/5/14 Poor Hygiene • Common Finding ‐ Parents sometimes mistake for discharge Page 48 Page 48 xxx00.#####.ppt 3/5/14 3:05 PM Works Cited • Adams, J. A. (2011). Medical evaluation of suspected child sexual abuse: 2011 update. Journal of Child Sexual Abuse, 20(5), 588-605. Retrieved February 21, 2013, from http://dx.doi.org/ 10.1080/10538712.2011.60 • Adams, J. A., Kaplan, R. A., Starling, S. P., Mehta, N. H., Finkel, M. A., Botash, A. S., et al. (2007). Guidelines for Medical Care of Children Who May Have Been Sexually Abused. Journal of Pediatric and Adolescent Gynecology, 20(3), 163-172. • U.S. Department of Justice Office on Violence Against Women. (2013, April). A National Protocol for Sexual Assault Medical Forensic Examinations Adults/Adolescents (2nd ed.). Washington, DC: Author. • Jenny, C. (2011). Child abuse and neglect diagnosis, treatment, and evidence. St. Louis, Mo.: Saunders/ Elsevier. • Finkel, M., & Giardino, A. P. (2002). Medical evaluation of child sexual abuse: a practical guide (2nd ed.). Thousand Oaks, Calif.: Sage Publications. • Berk, L.E. (1999). Infants and Adolescents. Needham Heights, MA: Allyn and Bacon. Page 49 Page 49 xxx00.#####.ppt 3/5/14 3:05 PM Questions? Page 50 Page 50 xxx00.#####.ppt 3/5/14 3:05 PM 17 3/5/14 Thank you! Sarah Keymer - [email protected] Kara Faletto - [email protected] Page 51 Page 51 xxx00.#####.ppt 3/5/14 3:05 PM 18