Question

1. 73 year old woman presents as a new patient in a primary care setting, registered to NP. She has been taking lorazepam for anxiety/poor sleep since husband’s death 10 years ago. Normally on 1mg hs, but increased poor sleep x 2-3 months, self-increased dose to 2mg. sometimes takes during the day for anxiety with glass of scotch. Other drugs – candesartan and paroxetine (depression).

She reveals a recent ED visit after a motor vehicle accident – crashed car into tree driving home. Fall at home 3 weeks ago which she tripped on scatter mat taking out garbage – sprained wrist, taking ibuprofen, wants Tylenol with codene (T3). NP attempts to open discussion of benzo use and falls/accidents. She is surprised and says “this has never been an issue, no one discussed this before”.

Questions

Best practices regarding use of benzodiazepines and fall risk in older adults

Approaches to counselling the older adult client regarding goal, risk/benefit, proper use and potential side effect

2. ABOUT FORENSIC NURSING IN THE COMMUNITY

Amanda J. is a forensic nurse who has been trained as a sexual assault nurse examiner (SANE). Amanda works part-time in the emergency room, where she occasionally examines victims of rape and sexual assault. Amanda also works part-time as a consultant for a local domestic-violence shelter for women and children. Every year Nurse Amanda helps to organize a Walk to Prevent Domestic Violence in her community. Proceeds raised from the walk go toward the domestic-violence shelter. Nurse Amanda provides literature about domestic violence at the walk as well as at other organizations in town.

Questions

1. What are the most common types of trace evidence of victims of violence, including those who are raped?

2. The concepts in forensic nursing theory include, but are not confined to, safety, injury, presence, perceptivity, victimization, and justice. How might Nurse Amanda address these concepts in her nursing practice?

Answer 1

Greetings of the day!

Answer:

1.

Best practices regarding use of benzodiazepines and fall risk in older adults:

DISCUSS WITH A PATIENT THEIR USE OF BENZODIAZEPINES WHEN THE PATIENT:

• Is 65 or over
• Comes in for a preventative health examination
• Comes in for a prescription renewal or refill
• Has had a recent hospitalization
• Is admitted to long-term care
• Has had a recent fall
• Presents with new cognitive concerns or early onset dementia
• Reports driving difficulty or their family, caregivers or friends reports concerns
• Demonstrates rapid escalation of medication use
• Has an active substance use disorder that could trigger inappropriate or problematic use of benzodiazepines
• Has a potential benzodiazepine use disorder

1. Use validated assessment tools such as: Set EMR reminders or patient record flags as a reminder to review a patient’s benzodiazepine use during their next appointment.
2. Encourage patients to bring up their use of benzodiazepines during their next appointment: mail or hand-out patient material to rostered patients ages 65 or over, put waiting room patient posters up or provide screening questions while patients wait for their appointments. This type of patient material is available from the Centre for Effective Practice and the Canadian Deprescribing Network.

POSSIBLE INDICATIONS OF BENZODIAZEPINE USE DISORDER

• Deteriorating function despite increasing dose

• Dishonesty with respect to prescriptions (e.g. frequent reports of loss or theft of medications and/or routine early refill requests)

• Involvement with law-enforcement

• Non-oral route of administration

• Active misuse of another substance

• Diversion or other substance-dealing behaviour If patient presents with possible indications of a benzodiazepine use disorder, diagnose the patient using the DSM-5 criteria for Sedative, Hypnotic, or Anxiolytic Use Disorder.

Prescribing considerations Before initiating a course of benzodiazepine treatment, the following should be considered:

• Do not prescribe benzodiazepines to patients already taking opioids, as this is associated with increased risk of fatal overdose.

• Concurrent use of marijuana and benzodiazepines is not recommended.

• Explicitly advise the patient regarding the duration of treatment. Use of benzodiazepines beyond 2 weeks is not recommended.

• Use the lowest dose for the shortest time.

• Review with the patient the risks and side effects, including the risk of dependence. Keep in mind that some patients will have difficulty discontinuing the medication at the end of acute treatment.

• Discuss exit strategies, such as tapering and/or transition to alternative treatments.

• Discuss alternative treatments, which may include: o Antidepressant medications (e.g., SSRIs, SNRIs, tricyclic antidepressants)

o Psychotherapy (e.g., cognitive behavioral therapy)

o Serotonergic agents for anxiety (e.g., buspirone) o Anticonvulsant medications for restless legs syndrome (e.g., pramipexole, ropinirole, gabapentin)

• The patient and health care provider should agree on one provider to be the benzodiazepine prescriber for that patient. This designated prescriber should also be responsible for prescribing other medications with abuse potential, specifically central nervous system (CNS) stimulants and narcotics; otherwise the prescriber of benzodiazepines should closely coordinate care with those who are prescribing other controlled substance medications.

• For patients who are prescribed chronic benzodiazepines for anxiety at a dose exceeding the maximum dose ,, consultation with a psychiatrist is recommended.

for patients aged 65 years and over

• If prescribing for patients who are frail or aged 65 and older, consider initiating the medication at half the adult dose.

• Individuals aged 65 and older are especially vulnerable to the adverse effects of hypnotic drugs, as metabolic capacities and rates decline with age. Patients in this age group are:

o More susceptible to CNS depression and cognitive impairment, and may develop confusion states and ataxia, leading to falls and hip fractures.

o At risk of drug interaction with other medications.

o At risk of permanent cognitive impairment when using high doses of benzodiazepines (e.g., diazepam 30 mg or equivalent) on a regular basis.

Psychotropics increase falls in older people by up to 47 percent (Landi et al 2005)

• Hypnotics and sedatives (eg, benzodiazepines such as diazepam, lorazepam, triazolam; zopiclone), used to treat anxiety or insomnia, increase the risk of a fall, especially in older people with cognitive impairment or who have fallen previously (Gallagher et al 2008).

• Both long-acting and short-acting agents increase the risk of falling (Landi et al 2005).

• Hypnotics have only a small and limited positive effect in improving sleep (Glass et al 2005).Certain medicines are associated with an increased risk of falls and increased harm . This means we should do four things when an older person is prescribed these medicines (Landi et al 2005).

ways to avoid risk of falls:

1. Regularly review the reasons for prescribing the medicine and continuing its use. Consider de-prescribing medicines (Klotz 2009).

2. Educate the older person and all those involved in their care (family/whānau, caregivers and staff ) about the risks associated with these medicines, particularly when the older person starts taking the medicines or increases the dose.

3. Ensure strategies to prevent the older person from falling are appropriate and individualised to them. For example, assess the older person’s environment and make it as safe as possible. Also make sure appropriate intervention strategies have addressed any risk factors identified in a full assessment of the older person.

4. Tell the older person, their family and/or their caregivers about the importance of seeking medical attention and assessment after even a minor fall to check whether any medicines they are taking contributed to the fall.

How modifying medicine use might reduce falls and related harm:

A medicines optimisation review is a process designed to optimise the benefits of medicines and help prevent a person being harmed. The review complements medicines reconciliation, which aims to communicate a correct and current list of a person’s medicines. This is particularly important at transitions in the person’s care. How the medicines optimisation review process works The medicines optimisation review process involves assessing a person’s medicines to:

• consider appropriateness to the person’s goals of therapy and self-management (Geurts et al 2012) • identify risks that the medicines may pose for the older person to prevent harm occurring

• identify and reduce or stop inappropriate medicines: de-prescribing is a planned process of stopping medicines that may no longer be of benefit or may be causing harm

• identify medicines (or non-pharmacological alternatives) that would be beneficial

• ensure the person is being appropriately monitored (such as checking blood pressure and arranging laboratory tests) and act on the results of that monitoring

• use medicines optimisation review in conjunction with asking the person if they have slipped, tripped or fallen lately. A useful tool is Screening Tool of Older Persons Prescriptions (STOPP) START Screening Tool to Alert Doctors to Right Treatment criteria (O’Mahony et al 2014). Another source that lists potentially inappropriate medication in older people is the updated American Geriatrics Society Beers Criteria (American Geriatrics Society 2015 Beers Criteria Update Expert Panel 2015). Best Practice Advocacy Centre New Zealand (bpacnz) gives guidance on the practicalities of stopping medicines in older people.

How reviewing and modifying medicine use can help to reduce falls:

Reviewing and modifying medicines can reduce the older person’s chance of suffering harm and inappropriate prescribing (Patterson et al 2012). The review process is part of good care for older people (Gillespie et al 2012; Huang et al 2012). Examples are noted below.

• Medicines optimisation review for older people living in the community reduces the use of prescription of medicines that increase the risk of falls (Blalock et al 2010; Weber et al 2008).

• A medicines optimisation review programme significantly reduced the number of falls by older people living in the community. In such a programme, GPs received one-on-one education from clinical pharmacists (Pit et al 2007). Gradually stopping people from taking psychotropic medication regularly also reduced falls (Campbell et al 1999).

• Medicines optimisation review by clinical pharmacists, which involved the older person and their carer, reduced the rate of falls in aged residential care facilities (Zermansky et al 2006).

• The rate of falls per patient was found to be lower following medicines optimisation review in a meta-analysis of randomised controlled trials (Huiskes et al 2017).

• Importantly, variations in how medicines optimisation review (using the STOPP/START screening tool) is implemented may determine its effectiveness. Only one of three randomised control trials showed a reduction in falls in one meta-analysis (Hill-Taylor et al 2016). In this study a physician applied the criteria directly. In other studies the physician received the recommendations from others. It may be that clear communication practices could improve the results.

Approaches to counselling the older adult client regarding goal, risk/benefit, proper use and potential side effect:

In addition to abuse and dependence, other major risks associated with benzodiazepine use include the following:

• Cognitive impairment. Benzodiazepines cause acute adverse effects: drowsiness, increased reaction time, ataxia, motor incoordination, and anterograde amnesia. Additionally, a meta-analysis of studies looking at withdrawal from an average of 17 mg per day of diazepam (Valium) found that long-term use led to substantial cognitive decline that did not resolve three months after discontinuation.

• Motor vehicle crashes. The risk of driving while on benzodiazepines is about the same as the risk of driving with a blood alcohol level between 0.050% and 0.079% (an alcohol level greater than 0.08% is illegal in all states).

• Hip fracture. Benzodiazepines increase the risk of hip fracture in older persons by at least 50%.9 In a study of 43,343 persons, zolpidem increased the risk of hip fracture by 2.55 times in those older than 65 years.

ADVERSE DRUG REACTIONS

GENERAL

• Most benzodiazepines can cause these side effects due to their inhibitory effects on brain neurotransmission:
  • Anterograde amnesia
  • Confusion
  • Dizziness
  • Depression
  • Sedation
• Withdrawal symptoms from benzodiazepines (seizures, hallucinations, agitation, tremors) are most common when using benzodiazepines with shorter half-lives

COMMON

• Alprazolam: Changes in appetite (decrease or increase), weight gain, reduced mucosal production leading to xerostomia and constipation, confusion, sedation, cognitive impairment, memory impairment, irritability
• Chlordiazepoxide: Edema, constipation, nausea, confusion, sedation, cognitive impairment, memory impairment, irritability
• Clonazepam: Depression, ataxia, dizziness, confusion, sedation, cognitive impairment, memory impairment, irritability, upper respiratory infection, respiratory depression
• Diazepam: Hypotension, ataxia, dizziness, confusion, sedation, cognitive impairment
• Lorazepam: Depression, ataxia, dizziness, confusion, sedation, cognitive impairment
• Oxazepam: Dizziness, headache, sedation

OCCASIONAL

• Alprazolam: Decreased libido
• Chlordiazepoxide: Irregular menses, decreased libido
• Clonazepam: Suicidal ideation
• Diazepam: Muscle weakness, respiratory depression; rash and diarrhea can occur with rectal gel use
• Lorazepam: Delirium (especially in elderly patients), weakness

RARE

• Alprazolam: Stevens-Johnson Syndrome, liver failure
• Chlordiazepoxide: Agranulocytosis, liver failure
• Diazepam: Neutropenia
• Lorazepam: Acidosis

Benefits

• Despite these risks, benzodiazepines are often very helpful, many individuals benefit from them and use them safely for prolonged periods.
• Many treatment guidelines recommend judicious use of benzodiazepines based on their efficacy and individuals who successfully receive long-term benzodiazepine therapy with no associated problems should not necessarily be taken off the medication, according to the Jains.
• There are several positives associated with benzodiazepines, including low cost, availability, rapid symptom relief, and efficacy for many individuals.
• “The goal of this presentation is not to create fear-mongering among us clinicians,” Saundra Jain said.
• She asserted that framing any conversation on benzodiazepines as “good” or “bad” is fundamentally flawed.

EDUCATE PATIENTS USING INDIVIDUAL AND FAMILY COUNSELLING:

• It is important and effective to educate patients on the risks and benefits of benzodiazepines before prescribing them, according to the Jains.
• The McGill Experience study indicated the power of educating patients.
• In the study, researchers sent a mailer that identified risks, explained the tapering schedule and encouraged patients to initiate a conversation with their clinician.
• Overall, 62% of the cohort initiated a conversation about benzodiazepine therapy cessation with a physician or pharmacist.
• At 6-month follow-up, 27% of participants who received the mailer discontinued benzodiazepines, while 5% of the control group discontinued.
• Dose reduction occurred among 11% of participants.
• A JAMA Internal Medicine study published in 2014 showed all patient populations benefited from psychoeducation and a slow taper.
• A Canadian Medical Association Journal study published in 2003 indicated adding cognitive-behavioral therapy to withdrawing or tapering improved outcomes among individuals with chronic insomnia.
• At 3 months, discontinuation occurred in 77% of participants who received CBT compared with 38% of those who did not received CBT.
• At 12 months, discontinuation occurred in 70% of participants who received CBT compared with 24% of those who did not receive CBT.

2.

most common types of trace evidence of victims of violence, including those who are raped

Violence and Sexual assault are considered a serious offense all around the world due to the impact it has on the victims, their relatives, and society in general. The investigation of violence and sex crimes requires a group of multidisciplinary forensic professionals focused on the identification, recovery, packing, and analysis of evidence.

The trace evidence/garments collected (from the victim, corpse, aggressor, and crime scene) are inspected in the laboratory in order to perform a search for blood, semen, hair, saliva, sweat, tissues, fibers, and other elements. One of the first interventions is the macroscopic analysis that consists of evaluating evidence through meticulous and sequential observation, evaluating and establishing strategies to find biological spots. When biological evidence is not visible to the naked eye, it is then necessary to use technological help: the forensic light sources with specific wavelengths for its detection

concepts in forensic nursing theory include, but are not confined to, safety, injury, presence, perceptivity, victimization, and justice. This is how might Nurse Amanda address these concepts in her nursing practice:

The Science of Forensic Nursing,

-Virginia A. Lynch

Among scientific disciplines, forensic nursing represents a departure from the traditional foundations of nursing practice while adding a new dimension to the forensic sciences. Forensic nursing science has evolved in response to the needs of a world in crisis. This emerging discipline should be viewed as an integral member of the multisectorial structures that make up a field of inquiry that applies clinical and scientific knowledge to questions of law in both civil and criminal investigations.

The science of forensic nursing has two foci:

1. The legal principles. This focus relates to evidence collection and reliability, chain of custody and security, and the healthcare provider role in judicial processes.

2. The establishment of the manner of injury and cause thereof. This element includes death, health system documentation, investigation of trauma, care of detainees, and rehabilitation of those who have suffered violence.

Science is defined as an accumulating body of knowledge. A scientist is one learned in science, especially one active in some particular field of investigation (Dorland’s Medical Dictionary, 2005). The forensic sciences refer to any aspect of science as it relates to law. Forensic nursing science is consistent with these other disciplines. The primary area of practice and research inquiry for the forensic nurse scientist is human trauma, both physical and psychological. The incorporation of existing bodies of knowledge with new scientific discoveries has provided a sound foundation for evidence-based forensic nursing practice.

Among other sciences incorporated in the study of forensic nursing are human anatomy and physiology, physical sciences, engineering, social and behavioral sciences, and biomedical sciences including chemistry and physics. Forensic nursing is a theory-guided and ethics-guided practice that requires an intellectual endeavor within its own distinctive knowledge base, experiences, purposes, and values. Contemporary social conditions involving human violence and abuse have shaped the evolution of forensic nursing education, holistic practice, and scientific research to provide a unique framework for the investigation of issues concerning healthcare and the law.

Violence-related trauma is central to the role of the forensic specialist in nursing (Lynch, 1990). Whether physical, sexual, or psychological, violence remains the single greatest source of loss of life and function worldwide (Reiss & Roth, 1993). Forensic nursing assumes a mutual responsibility with the forensic medical sciences and the criminal justice systems in concern for the loss of life and function because of human violence and liability-related issues.

The forensic nurse, as a clinical investigator, represents one member of an alliance of healthcare providers, law enforcement agencies, and forensic scientists involved in establishing a holistic approach to the evaluation and treatment of crime-related trauma. Forensic nurse investigators address relevant areas in the assessment of criminal violence, abuse, and data collection for establishing hypotheses about the interrelationship between healthcare and the law. Forensic nurses fill voids by accomplishing selected forensic tasks concurrently with other health and justice professionals and by establishing themselves as uniquely qualified clinicians who blend biomedical knowledge with the basic principles of law and human behavior (Lynch, 1991).

Theoretical Components of Forensic Nursing

The theoretical support for forensic nursing care involves the biological, psychological, social, spiritual, and legal dimensions of the nursing practice. Forensic nursing is holistic in nature, addressing these concepts individually and collectively. The science of forensic nursing has been recognized by the professional bodies of nursing that direct the development of nursing education, research, and practice. Forensic nursing theory identifies interconnectedness with theories of the legal and physical sciences, which is reflected in The Joint Commission (TJC) guidelines that provide regulatory direction for healthcare practitioners (TJC, 2009).

These guidelines regard the identification of crime victims and the recovery and documentation of evidence, as well as the procedures for reporting abuse or suspicious patient behavior to a legal agency, as the foundations of forensic nursing practice. The legal sciences define and delineate the parameters of the law responsible for the behaviors of the nursing professional. Forensic nursing behaviors involve, among others, the identification of crime-related injury, the collection of evidence, the reporting suspicion of illegal acts to a legal agent, and the abuse or death of patients in custody or that of incarcerated or institutionalized persons. It is, then, the respective dimensions of the health and justice disciplines that integrate a variety of multidimensional theories into nursing practices and define the distinctive conjectures of forensic nursing science.

The following components are typically addressed in any theoretical concept of nursing practice:

(1) role clarification,

(2) role behavior, and

(3) role expectation.

• Role clarification identifies shared knowledge and skills. It establishes explicit expectations and boundaries between the role of the self and that of others, and it delineates goals as well as costs and rewards associated with enacting them. Role clarification also demonstrates the extent to which significant others reinforce or validate role behavior via complementary and counter roles.
• Role behavior is the performance or enactment of differentiated behavior relevant to a specific position. Role expectation is the obligation or demands placed on the individual in a role position. It encompasses the specific norms associated with the attitudes, behaviors, and cognition required and anticipated for a role occupant.
• A major component of the integrated model for forensic nursing is interactionism. The focus of interactionism concerns specific links or associations among persons, environment, concern for persons, social integration, development of meaning, and the integration of persons in a social context, as well as processes engaging persons. Not all social systems generate a sense of community, but those that do create a shared culture and social order among their members. Patient advocacy recognizes healthcare as a primary source of physical and emotional stability to the physically or psychologically traumatized patient. Patient advocacy, an aspect of social behavior that protects and provides patients with an emotionally supportive community, serves as one platform for the forensic nurse examiner role. The understanding and explanation of social order as community is the goal of social sciences. This includes the understanding and explanation of criminal behavior and human violence. It focuses on individuals involved in a reciprocal social interaction as they actively construct and create their environment through a symbiotic interaction. The main focus of this perspective reinforces the need for social order and interdisciplinary coordination in healthcare delivery and the social justice sciences.
• Problematic social situations, such as the escalation of trends in criminal violence, demand new interpretations and new lines of action, which reinforce the need to continually redefine the role of the forensic nurse. This parallels the major focus of forensic nursing as it deals with change, dynamics, and the processes by which individuals creatively adapt to a society in flux. The ongoing problems in society and rapid social change place new demands on public service providers. Their role behaviors, in turn, quickly generate new and valid concepts that contribute to safe, effective patient care.
• A dynamic role of the forensic nurse examiner has evolved in clinical and community nursing practice; it facilitates specialized and unique behaviors in forensic nursing. This role helps nursing, medical, social, and legal systems to clarify questioned issues in response to the epidemiology and query of murder, suicide, sexual assault, abuse, neglect, intentional trauma, communicable disease, and violent criminal acts that threaten lives. The principle of reciprocal social interaction represents the multifaceted relationships among patient, clinician, and multidisciplinary team members that involve law enforcement agencies, social services, legislative authorities, judicial systems, and healthcare operatives. The reciprocal interaction of interagency coordination and cooperation works to improve the structural and functional management, delivery, and effectiveness of services offered by health and justice institutions.

Assumptions of the theory

This theoretical framework makes the following assumptions:

• Clinical forensic nursing is a relatively new science, and there is limited awareness of this specialty on behalf of health professionals, law enforcement agencies, and forensic science practitioners, as well as healthcare consumers.

• Evolving healthcare systems ultimately require changes in the role of the professional nurse.

• The conception and perception of the clinical forensic nurse is currently evolving and developing and at times is poorly defined.

• The application of clinical forensic science is appropriate for the practice of nursing.

• The registered nurse, qualified by education and experience in a broad range of nursing specialties, is capable of identifying role behaviors of the clinical forensic specialist.

• Human rights are a priority for most members of society.

• Forensic nursing care encompasses a sensitivity to differences among culturally and ethnically diverse populations.

• Truth is the central goal of forensic investigative analysis, which involves patient history, assessment of forensic implications, and correlation with the conditions and circumstances of injury, illness, or death.

• Forensic patients hold equal rights in terms of law and ethics, whether victim, accused, or offender.

Propositions

Propositions are ideas brought forward for consideration, acceptance, or adoption. The basic propositions considered in the formation of forensic nursing theory include truth, presence, perceptivity, and regeneration. These propositions are explained as follows:

• Truth. The central force in the resolution of questioned issues that involve the physical, psychological, and social health or ills of a human population; includes past and future truths.

• Presence. The invisible quality that commands and comforts while directing attention away from one’s self and into the being of another, instilling confidence and respect in the self of that being.

• Perceptivity. The investigative tool of one who explores human behavior, awareness of the elements of one’s environment, and sensory phenomena interpreted in light of lived experiences that guide intuitiveness.

• Regeneration. A value and a goal of the advanced forensic praxis in patient healing that affects a victim or offender who has experienced the deepest wounds of the soul; becoming once again as before.

Application of propositions by Ms. Amanda J:

Care that incorporates the nursing process—assessment, planning, intervention, and evaluation, to restore and promote health in the patient throughout the forensic process—is essential. The concepts of truth, presence, perceptivity, and regeneration will guide the forensic practitioner in the ways of knowing, patterns of being, and shared intuition between patient and practitioner.

Best Practice

Forensic nurses should augment their usual nursing assessments and objective documentation with preservation and collection of evidence and steps to prevent the psychophysical, psychosocial, and psychosexual health risks associated with trauma and violence.

The objectives of forensic nursing intervention are injury/illness/death assessment, objective documentation, the collection and preservation of forensic data and evidence, and the prevention of potential psychophysical/psychosocial/psychosexual health risks. Patient empowerment is also a significant issue, consequential to the criminal trauma, healthcare interventions, and the acceptance or rejection by society regarding the circumstances of the criminal act involved, regardless of the patient’s legal status.

Experts recommend the SANE explain each of the steps to the victim before they occur.
The general procedure is as follows:

• Complete the treatment authorization forms for the evidence to be collected and released to law enforcement. Also, fill out the sexual assault data form as required by individual state mandates.
• Collect outer clothes and place them into the provided paper bag. If the victim changed clothes prior to the examination, law enforcement should be notified to collect the evidence.
• Collect the underpants worn at the time of and after the assault. The underpants should be placed in a separate paper bag.
• Swab the victim’s oral cavity using the four provided cotton swabs.
• Place a towel under the victim’s buttock and comb the victim’s pubic hair in downward strokes to collect any of the assailant’s pubic hairs.
• Remove pubic hairs from the victim for comparison.
• Obtain swabs of the victim’s cervix, vaginal or penile areas using 4 cotton swabs.
• Obtain swabs of the victim’s rectum area using 4 cotton swabs.
• Note any areas of injury including bruising, bite marks, and scratches.
• Remove head hairs from the victim from various areas of the scalp for comparison.
• Take a DNA sample from the victim’s inner cheek using a cotton swab.
• Take a blood sample from the victim.
• Collect a urine sample from the victim for drug testing, also called toxicology.
• Coordinate follow-up care with counseling services and victim-compensation programs.
• Complete the victim’s medical history forms.
• Complete the evidence-collection checklist.

The examination also typically includes immediate preventative treatment of sexually transmitted diseases and, possibly, emergency contraception. Some jurisdictions also request photographic evidence to be included.

Once the examination is completed, all of the evidence must be packaged and sealed. The SANE must ensure the kit follows the chain of custody, or the chronological documentation that outlines how the evidence was handled and preserved. A reliable chain of custody is essential to any legal proceedings.

After the kit is completed and given to the proper authorities, the nurse examiner may be called into court to testify on the evidence provided.