Issues and challenges for nurses

Body piercing: issues and challenges for nurses

Kym A. Halliday

To provide safe and effective care for patients with body piercings, nurses must become more knowledgeable about this increasingly common practice. Competent nursing care is more than simply noting the presence or absence of body piercings, but includes accurate assessment, cultural sensitivity, and related patient education. Body piercings can create treatment challenges during trauma or post-assault care. An increased awareness of the history of body piercing, the piercing process, care of piercings, (including related wound care), and issues related to patient education, can enhance comprehensive nursing care.

Key words: Body modification, body piercing, forensic nursing, emergency care, nursing interventions, cultural competence

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The current popularity of body piercings is unprecedented in modern society. Body piercing is both a public and a private statement of the individual (Stirn, 2003). Health care providers must acknowledge this increase in body modification practices to provide holistic and culturally-sensitive care (Larkin, 2004). By learning about body piercing, nurses are better able to counsel patients, provide care related to any complications, and maximize the ability to collect and record potential evidence.

According to the American Museum of Natural History (1999), every world culture practices some form of body modification. These changes may be temporary, such as shaving, applying hair coloring or make-up, and even dressing in certain styles. However, more permanent changes can be achieved through binding or stretching to change the shape of areas of the body, cosmetic surgery, or tattooing.

Body piercing is a semi-permanent form of modification, as jewelry can be removed and the piercing can then become less noticeable (Martel & Anderson, 2002).

Body modifications in the form of piercings have been documented throughout history. As the language of body modification is unique to each individual, motivations, representations, symbolism, and meanings vary.

Many Asian artifacts display stretched earlobes (Davis, 2001). Ivory and wood labrets, made for stretched lip piercings, are common in Alaskan and African cultures (University of Pennsylvania, n.d.). The Old Testament mentions ear piercing to identify slaves in Exodus 21:5-6 (New American Standard Bible, 1977). Male genital piercings are discussed in the Kama Sutra, an ancient text estimated to have been compiled around 250 A.D.

People of various socio-economic and cultural backgrounds currently choose to obtain body piercings in America, where formerly uncommon modifications are now considered mainstream (Larkin, 2004; Stirn, 2003). Piercings can be found on faces, ears, necks, arms, legs, torsos, navels, and genitals. Studies report the prevalence of body piercing to be between 17%-51% of the county’s population (Schnirring, 2003). The majority of individuals who choose body piercings are between 18 and 24 years of age (Larkin, 2003).

Body piercing is an act of individualized self-expression and often an outward display of personal identity (Stirn, 2003). Reasons given for body piercing include fashion, to demarcate an important life event, as a symbolic reclamation of “self” after traumatic or painful events, as a method to break away from family expectations, to minimize self-perceived flaws, to seek social cohesiveness, and to enhance sexual stimulation (Cartwright, 2000; Larkin, 2004; Stirn, 2003). The majority of pierced individuals consider themselves adventurous (Cartwright, 2000). Reasons for piercings, as well as their meanings, are individualized and related to the process as well as the result (Stirn, 2003).

General Information about Body Piercing

Piercing Process. The body piercing procedure is relatively quick and simple. Body piercing artists, not medical providers, perform body piercing; therefore local anesthetic use is contraindicated. Anesthesia is not considered useful during body piercing, as the pain from the puncture is similar to that felt during intravenous access or an injection. Some individuals find the act of piercing pain-free, others feel only momentary discomfort during the puncture.

Piercing is best performed with a sterile, single use, hollow-bore needle under asceptic conditions (Armstrong, 2004; Association of Professional Piercers [APP], 2002). Common methods of self-piercing include safety pins, sewing needles, piercing guns, or other sharp implements. Because of potential wound contamination and improper placement, self-piercing is not recommended (Armstrong, 1996).

Highly mobile body parts such as the tongue and nipple require the use of ring forceps for stabilization during piercing. The forceps also act as a local anesthetic through the pinching action of the clamp. An additional benefit of clamping is the decrease of blood flow to the immediate area, which diminishes the risk of excessive bleeding during the piercing process. Less mobile body parts, such as the ear cartilage or the nare, are stabilized by hand during the puncture.

The piercer marks the intended site with ink, and verifies the location with the consumer. Needles may range in size from 12-18 gauge. After cleansing the area with a topical antiseptic, the large gauge, hollow bore needle is passed through the targeted body location. The jewelry is placed inside the blunt end of the needle, and put into place while pulling the needle through the piercing. The jewelry is then secured. A residual of blood, tissue, or serosanguinous fluid may require removal, and the area is cleansed again (APP, 2002).

These puncture wounds are kept patent by use of jewelry, and as a result of the healing process become fistulas. Healing times vary, but until fully healed, these wounds have the potential to manifest various complications. Because an inflammatory response is anticipated, jewelry is placed that can accommodate expected swelling. Some locations, such as the tongue, start with longer jewelry to allow for swelling. These long jewelry items will require replacement after the initial inflammation subsides, as the length is usually too long for daily use (APP, 2002; Armstrong, 1996). Since piercing interrupts the integrity of the integument, infection is a risk (Stirn, 2003). Rejection, migration, scarring and other complications with long-term ramifications are possible (Armstrong, 2004; Stirn, 2003). Allergic responses to jewelry occur, but can be minimized by using the recommended hypoallergenic materials (Jappi, Bonnekoh & Gollnik, 1999).

Body Jewelry. Body jewelry is measured both by gauge and by diameter or length. The gauge refers to the thickness of the jewelry, and is the same system used for gauging needles in the health care setting. The diameter refers to the inside diameter of a ring while the length refers to the length of a barbell or curved barbell between balls (APP, 2002).

Recommended jewelry materials are considered hypoallergenic and bio-compatible. Most starter jewelry is nickel-free and composed of surgical implant grade stainless steel or titanium, solid white or yellow gold, niobium, tantalum, or platinum. Healed piercings can be maintained by use of the above jewelry materials, or with tempered glass, special hardwood organic products, or plastics. Jewelry components to avoid include gold-filled or plated, silver, alternate stainless steel grades, or aluminum (APP, 2000).

Body jewelry, also known as hardware, has a different appearance than traditional earrings. Traditional earrings have a straight post, with a curved clasp that locks onto the post using tension. Unless manually relocated, the clasp remains in the same location on the post throughout wearing. This diminished post length impinges upon tissue during the inflammatory phase and hinders healing. Additionally, the clasp has the potential to collect a large amount of cellular debris, and is difficult to clean adequately without removal. Body jewelry is manufactured–to decrease the potential collection of debris at the piercing site. In addition, the shape of the body jewelry allows adequate tissue expansion during healing (APP, 2002). Body jewelry styles vary but are based on two basic types: the barbell and the captive bead (also known as the tension hoop) (APP, 2002).

The barbell is a post with balls on both ends. Depending on the manufacturer, one or both balls unscrew from the post. Another manufacturing variance is whether the threading extends from the ball (internally threaded), or from the post (externally threaded). The post can be straight, curved, L-shaped, or semi-circular. The shape chosen is usually related to the natural shape of the body part and consumer preference (APP, 2002).

Captive bead hardware looks like a simple hoop earring with a decorative bead. Actually, this type of jewelry comprises two separate parts: an incomplete circle of metal and a bead. The opposing ends of this circular jewelry hold the bead in place by pressure. Newer variations of this type of hardware include oblong and triangular shapes. This type of jewelry can be removed by “popping out” the bead. Popping can be accomplished by placing specially designed jewelry removal pliers at the inner aspect of the hoop, and gently placing tension on the hoop to separate the ends slightly; this releases the tension on the bead and allows it to fall out of place. Pliers can be used if necessary but may limit the operator’s ability to finesse the amount of tension needed to release the bead. Care must be taken to catch the bead as it is released. The hoop can then be threaded out of the piercing (APP, 2002).

Typical Piercing Locations

Ear Piercings (see Table 1). Ear piercings can be accomplished at multiple sites of the lobe and pinna. Cartilaginous piercings have the tendency to heal more slowly, and to develop more complications than simple lobe piercings (Stirn, 2003). A complication common to cartilaginous piercings of the ear is known as hypertrophic scarring that occurs in some individuals because of a chronic inflammatory process. In this condition, excessive scar tissue forms around the healing fistula. In addition to normal wound care: some practitioners recommend adding hydrogen peroxide to the cleaning regimen. Hydrogen peroxide is known to be damaging to forming epithelial cells, and can inhibit continued anomalous scar formation (D. Munro, personal communication, November 2, 2004).

A common variant for all types of ear piercings is known as gauging. This is the process of stretching an established piercing so that the site can accommodate larger hardware. The hardware may be solid or tunnel style. Although slow gauging is recommended, some individuals chose to seek unlicensed individuals who will scalpel the larger hardware into place to speed the process. Gauging can be as small as a 1/4 inch (00 gauge), or greater than 3-inches in diameter.

Facial Piercings (see Table 2). Miscellaneous facial piercings can include the eyebrow, nares, nasal septum, and the nasal bridge (also known as the earl). Eyebrow piercings tend to lie along the natural hairline of the brow. A variant known as the anti-brow, is located along the lower orbital ridge, or may be placed at the temple. The temple location is not recommended due its proximity to the temporal branch of the trigeminal nerve. The initial temple piercing should not interfere with nerve conduction: however, excessive swelling or infection can cause permanent damage to the underlying nerve tissue in this region (J. Morehouse, personal communication, December 12, 2003).

Earl piercings are located at the nasal bridge, between the eyebrows. This soft tissue piercing is prone to a phenomenon called migration. Migration occurs when frequent irritation or movement of piercing hardware, causes the forming fistula to shift. This can lead to an asymmetrical, or tilted, piercing appearance when healed. The incidence of migration is decreased by the use of high-density, low-porosity, non-toxic plastic barbell shafts (C. Shull, personal communication, January 15, 2004).

Nasal piercings can occur at either nare, or centrally at the nasal septum. Traditional earrings should never be worn at these sites as they enhance scarring and granuloma formation. Detachable clasp style jewelry also increases the risk of foreign body aspiration. An additional risk is for the embedding of jewelry into the subcutaneous tissue during swelling that is impeded by the immovable clasp (Cronin, 2001; Stirn, 2003). Piercings of the nares are usually maintained with a captive bead hoop or a post variant known as the nostril screw. The nostril screw is a straight metallic post that has a unique series of bends along its length to secure this hardware into place, and still allow for ease of removal. Nostril screws lie flat against the nasal mucosa to decrease the risk of secondary trauma to the nare. The shape of the nostril screw also provides room for tissue expansion during the inflammatory process.

Though piercings of the nares are cartilaginous, nasal septum piercings pass only through soft tissue. The nasal septum piercing is initially maintained with a U-shaped device. This device can be turned upward so that the ends reside inside of the nostrils. This decreases the risk of traumatic movement during the healing process. This type of hardware is known as the septum retainer. Once healing has completed, this piercing can be maintained with semi-circular barbells, captive bead hoops, or other devices.

Oral Piercings (see Table 3). Cheek, lip, and tongue piercings are of similar categories, as they all enter the oral cavity. The American Dental Association (ADA) takes a strong position against all oral-piercing styles (2002). Concerns include dental trauma, speech impediments, changes in salivary flow, interference with oral vascular perfusion patterns, and risk of secondary infection.

Cheek piercings are named according to their location on the face and maintained with a variant of barbell jewelry. Instead of two balls on either end of the barbell, there is one ball on the external surface, and a flat disk on the interior surface. These barbell variants are known by the term flat backed labret (see Figure 1). In a patient with poor oral hygiene or poorly fitted hardware, there is risk of gingival irritation, erosion, or infection (ADA, 2002).

Tongue piercings are maintained with straight barbells, and are initiated anterior to the lingual frenulum at the midline. Extreme swelling can occur as part of the inflammatory response, so longer bars are placed initially. After the initial swelling has subsided, this bar should be replaced with one shorter and more appropriate in length for the individual. Due to the tongue’s highly vascular nature, location in the upper airway region, and proximity to the central nervous system, this piercing has the highest risk of complications (Stirn, 2003).

Torso Piercings (see Table 4). Navel piercings are becoming quite common (Armstrong, 2004). Healing times vary according to personal anatomy, hygiene, and clothing styles (Stirn, 2003). This piercing can accommodate either a captive bead or curved barbell. Circular captive bead hardware extends beyond the body surface and receives more friction during normal wear, which can delay the healing process. Curved barbells tend to sit flush with the skin surface during wear, receive less friction, and tend to heal more rapidly.

Rejection is a common occurrence with poorly placed navel piercings (C. Shull, personal communication, January 15, 2004). This process can occur at any highly mobile, fairly flat piercing site. Rejection is related to a chronic inflammatory process during which several stages of attempted healing occur simultaneously. The offending object, in this case the piercing hardware, is walled off from the body with necrotic tissue. The hardware is then pushed out of the body laterally. New scar tissue is formed as this process progresses. Once initiated, this is a slow and inevitable process.

Nipple piercings are popular with both men and women. This piercing crosses the nipple base, but not through the areola (see Figures 2a & 2b). The fistula can be placed horizontally, vertically, or diagonally (APP, 2002). Many find this piercing pleasurable; others find this piercing simply ornamental (C. Shull, personal communication, January 15, 2004). Newer ornamentation includes a device known as a nipple shield. This decorative metal disk is held in place over the areola by use of barbell jewelry through the nipple piercing. Important potential complications include mastitis, spontaneous milk production in females, and localized infection (Stirn, 2003).

Surface Piercings (see Table 4). The term “surface piercing” includes a wide range of locations. This term is used to identify the piercing of anatomically flat locations. Flat piercing sites are difficult to retain with metal hardware and are best maintained with high-density, low-porosity, non-toxic plastics. Recommended materials include Tygon (S-54-HL) and PTFE (polytetrafluoroethylene) (APP, 2000). These materials are hollow tubes, which can accommodate threaded balls that would normally be attached to internally threaded barbell style jewelry (APP. 2002). Surface piercings can be found on the nape of the neck, chest wall, forearms, pubis, sternal notch, and other locations.

Genital Piercings (see Tables 5 and 6). Genital piercings have been documented throughout human history. It has been reported that the majority of individuals who choose genital modifications are over the age of 30 (Larkin, 2004). Men with genital piercings are found in both the heterosexual and homosexual communities (Stirn, 2003). Many men find these piercings attractive and find urethral stimulation arousing (Perforations, n.d.). Men may choose these piercings for simple ornamentation or for their partner’s pleasure (C. Shull, personal communication, September 16, 2003).

Stirn (2003) notes a study that reports female genital piercing is strongly related to overcoming past trauma and is often a therapeutic action toward healing. Some women choose genital modifications after dysfunctional sexual relationships (Stirn, 2003). Like men, some women chose these piercings simply as ornamentation (C. Shull, personal communication. September 16, 2003).

Male Genital Piercings (see Table 5). During the Victorian era. tailors performed a penile piercing–known as a dressing ring–to allow men to secure their penis to their clothing and provide a smoother appearance while wearing tight trousers (Larkin. 2004; Stirn, 2003). This is the accepted origin of the most common male genital piercing, the Prince Albert, or the PA (see Figure 3). This piercing enters the penile urethra and exits the inferior surface of the penis at the frenulum. Depending on the gender of the receiving partner and sexual position used, this transurethral piercing can stimulate the male partner’s prostate, or female partner’s G-spot. The reverse PA (Figure 4) also enters the male urethral orifice, but exits the superior surface of the penile glans. When compared to the PA, healing times tend to be longer for this variant, as there is more tissue between the urethra and the exit site. The apadravya (see Figure 5) can be considered a blend of the PA and reverse PA. Frequently individuals who want this piercing will begin with a PA, then obtain a reverse PA, and later change the jewelry to allow these separate piercings to become an apadravya. Since each of these piercings transect the urethra, diversion of urinary and seminal flow is a common occurrence (Stirn, 2003).

The ampallang (see Figure 6) is a horizontal transcoronal piercing. Depending on the consumer’s preference, and piercer’s skill, this piercing may or may not cross the urethra.

Jewelry sizing is an important concern with all piercings that transect the penile glans and is highly individualized. Care must be taken to size jewelry so that there is minimal extension of the hardware while the penis is flaccid and for the jewelry to not impinge on the penis when in the erect state.

The prince’s wand is a unique male genital piercing. This piercing initially appears to be a PA, however, upon inspection, the jewelry is actually T-shaped, and has an extension that resides within the urethra. This extension is a hollow metal tube and can extend into the urethra by 3-6 inches. It is held in place by the exit piercing at frenulum. The prince’s wand decreases the urinary and seminal diversion that is so common with the PA and reverse PA. This device can also act as an interior splint during intercourse with a semi-erect penis.

Female Genital Piercings (see Table 6). The most common female genital piercing is to the clitoral hood. By piercing the tissue that covers the clitoris, additional stimulation can be provided to this sensory organ. Not all women find this piercing pleasurable, and response to clitoral hood piercings is highly individualized. The deep clitoral, or triangle piercing, is placed below the clitoral nerve bundle and initially is one of the more painful female genital piercings. Capture bead or semi-circular barbell hardware is usually chosen to encircle the clitoris. (C. Shull, personal communication, June 28, 2004).

The Princess Albertina is a female variant of the male PA. This piercing enters the female urethra. The exit site is anatomically dependent, and can occur above, or just inside, the vaginal orifice.

Communication Issues

Cultural competence is imperative when providing care to individuals who practice body modification. Since most health care providers have significant knowledge deficits regarding body modifications in general, the risk for provider bias is high when working these clients. Health care providers must not only possess the knowledge necessary to care for patients with body piercings, but must also possess the ability to communicate with these patients in a culturally-sensitive manner. Empathy is an important component to therapeutic communication practice and helps open communication channels. Using a judgmental approach when interacting with a patient can create a defensive response (Sears, 1996). An expression of disgust or surprise toward body modifications found during patient care is a speedy manner in which to alienate the patient and inhibit communication.

Cultural competence is not a discreet event but is a continual, multistep process. Campinha-Bacote (2003) developed a cultural competence model for health care that is described as the ability of individual health care professionals to work within the cultural context of an individual client, his/her family, and the community. Although people who practice body modification come from various socioeconomic and ethnic groups in every community, the risk for stereotyping does indicate the need to practice cultural competence with individuals who choose this method of self-expression.

According in Campinha-Bacote (2003), the first step toward cultural competence is cultural awareness and includes self-examination for bias within the individual provider and in the health care delivery system. Cultural knowledge is the process in which the health care provider learns new information about various cultures and the impact of this information on that culture’s health.

Cultural skill includes the ability to collect relevant health care data while respecting the individual client’s beliefs. These steps are necessary to properly engage a patient during the health care encounter. Health care providers must frequently ask seemingly intrusive questions during the course of patient care. Most nurses have developed individualized communication techniques that are used to develop a therapeutic relationship with patients when discussing sensitive subjects. It is important to remain open and non-judgmental during patient care to encourage further disclosure of pertinent information. Treating body modifications as a normal part of the patient’s physical assessment is important to maintaining the therapeutic relationship.

Medical Implications of Body Piercing

Regulations. It is important to be aware of who is performing body piercings in the community and under what conditions (Armstrong, 1996). Many jurisdictions do not regulate body modification practices. Depending on local policies, body-piercing services may be obtained from tattoo studios, flea markets, dedicated piercing studios, and in personal residences (Armstrong, 2004).

Nurses have many patient care opportunities in which to educate consumers on safe piercing environments. Clean, well-lit facilities are one indication of good infection control practices. The employees should exhibit good hygiene, and hand-washing facilities should be easily accessible. Glove use, with frequent changes as indicated, is also important to infection control. The piercing artist should be willing and able to explain the infection control procedures used in the studio (APP, 2002; Cartwright, 2000).

Basic Wound Care. Basic wound care techniques used for body piercings are usually called “aftercare.” Aftercare techniques are not only used for the fresh piercing; these techniques should be re-initiated whenever the piercing fistula has become disrupted through injury or exhibits signs of infection/renewed inflammation (C. Shull, personal communication, June 28, 2004).

As with any wound, piercing sites should only be handled with freshly cleansed hands to decrease the risk of contamination. Recommended aftercare techniques vary slightly according to the piercing artist and local policies. Serous exudate is a normal part of the healing process. Jewelry, and the exterior piercing site, should be thoroughly cleansed of all crust and debris. Basic care includes saline soaks and use of soap and water cleansing a minimum of two times a day (APP. 2002; Cartwright, 2000). Warm compresses made of sea salt and warm water are recommended during healing (APP, 2002). This same sea salt solution can be used to irrigate the piercing to ensure removal of residual cleansing agents. Jewelry should then be gently rotated to ensure free movement within the healing fistula. At this time, barbell hardware should be tightened (Armstrong, 2004). There is no literature available on the risks or benefits of plain soap versus antibacterial soaps related to piercing care.

Facial piercings that enter the oral cavity require general and specific aftercare. Oral piercing aftercare includes the use of ice chips for swelling (Cartwright, 2000). Alcohol-free, antiseptic mouthwash is recommended after every oral intake that is not simple water. Oral tobacco use inhibits the healing process (Cartwright, 2000).

Fresh piercings are open wounds and can be conduits of infection. The risk of site infection tends to increase with poor aftercare (Armstrong. 2004), or poor piercing artist technique (Stirn, 2003). Jewelry is left in place during treatment of localized infection (Cartwright, 2000). After appropriate cleansing, 1/4 inch gauze can be placed around the post at the piercing site. Ends of gauze should be short enough to inhibit entanglement during normal activities, but long enough to allow wicking of infectious exudate. Patient education on proper wound care, follow up, and nutrition should be provided. Systemic antibiotics may be indicated if the infection is severe or if there are signs of cellulitis extending from the original site. (D. Munro, personal communication, September 15, 2003).

Organisms implicated in piercing-related infections tend to be related to the location of the piercing. Pseudomonas has been reported at ear and cartilaginous piercings (Armstrong, 2004; Hanif, Frosh, Ghufoor, Rivron, & Sandhu, 2001; Stirn, 2003; Watson, Cambell, & Pahor, 1987). Haemophilus has caused life-threatening complications after oral piercings (Akhondi & Rahimi, 2002; Armstrong, 2004).

Staphylococcus aureus and group A streptococcus have been cultured from all piercing sites (Fisman, 1999). Increased viral transmission of condlyomas and hepatitis has been reported (Fisman, 1999; Stirn, 2003). Additional documented risks include HIV from lack of procedural asepsis and the increased potential for viral transmission through the wound of a fresh piercing (Stirn, 2003).

Airway compromise has also been reported (Hardee, Mallya, & Hutchinson, 2000). This is especially significant during physical or sexual assault when loss of all or part of hardware into air passages can lead to foreign body aspiration (Girgis, 2000; Miller, 2003). Other risks include swelling of the upper airway that can occur as part of the healing process, or in response to infection (Koenig & Carnes, 1999; Miller, 2003; Stirn, 2003). Jewelry aspiration by infants can also occur during breastfeeding if part of the mother’s hardware dislodges during latch-on and suckling (Stirn, 2003).

Emergency Medical Care. Body jewelry can interfere with emergent medical care. Common procedures that can be subsequently delayed or inhibited as a result of body jewelry and related piercings are intubation, positive-pressure-ventilation (PPV), electrical therapy, radiological imaging studies, urinary catheterization, use of anti-shock trousers, and spinal immobilization (Armstrong, 2004).

Attempts at airway management can be inhibited by some piercings. Some facial piercings can interfere with effective PPV mask placement. Numerous or large oral piercings can interfere with attempts at oral airway placement. Use of traditional earrings at nasal piercing sites can cause the affected nare to become impassable. Oral jewelry can become loose, detach, and place the wearer at risk for hardware aspiration. Airway management accommodations need to be made until the jewelry can be removed and the airway secured. These airway management modifications are provider- and patient-dependent. Nasal intubation can be provided if airway management is hindered by oral hardware. In extreme cases, cricothyrotomy can be performed.

Electrical therapies, such as defibrillation or electrocautery, can also have diminished or unexpected effects with some piercings. Metal body piercings can divert electrical current from the intended target. This can decrease defibrillation effectiveness. Additionally, burn injuries can occur if the electrical current is attracted to the conductive piercing (Armstrong, 2004; Larkin, 2004; Stirn; 2003).

Most simple radiographs are not affected by body piercings. Some oral, nape, and facial piercings can interfere with odontoid visualization during attempts at cervical spine clearance (Koenig & Carnes, 2003). Body jewelry can interfere with soft tissue imaging (Armstrong, 2004). When the patient wishes to maintain a piercing, large diameter suture can be placed to maintain patency of the fistula. In nonemergent situations, patients can contact their piercing artist for temporary, radiolucent hardware (Larkin, 2004).

Transurethral piercings can interfere with usual urinary catheterization procedures (Armstrong, 2004). If it is not possible to safely remove the piercing, a pediatric feeding tube can be used to bypass or enter the piercing jewelry to allow catheterization. Since there is no retention balloon on feeding tubes, care should be taken to maintain catheter placement during patient movement.

Though anti-shock trousers are being used less frequently in emergency medicine, abdominal or genital piercings can render these devices inoperable. When inflated, these devices exert significant pressure on the lower extremities, genitals, and the lower half of the abdomen. There is the risk that damaged metal body jewelry can puncture these inflatable devices and render them unable to maintain adequate pressure (Armstrong, 2004).

Anterior and posterior neck surface piercings are becoming more common. During cervical spine immobilization, these body piercings can interfere with cervical collar placement (Armstrong, 2004).

Forensic Implications of Body Piercing

Locard’s exchange principle states that whenever two objects come into contact, there is transference of material between them. This principle is the basis for swab collection during forensic medical exams (Geberth, 2003). It is possible for the fistula of a piercing to be a reservoir for transferred material on either the perpetrator or the victim. During evidence collection, swabs can be taken from around and under the piercing in an attempt to collect foreign DNA samples (S. Early, personal communication, February 16, 2004).

Patterned injuries can occur when forceful contact creates marks on body surfaces. The outline of piercing hardware can be transferred onto the contact surface in the form of abrasions, bruises, or target lesions. Asking if the victim noticed body piercings on the assailant can aid the examiner in searching for patterned injuries during the exam process. Body positioning during the assault and location of the piercing on the assailant determine where to search for patterned injuries (C. Caruso, personal communication, February 16, 2004).

Forceful contact can also lead to secondary trauma to either the victim or the perpetrator. This type of trauma can result from accidental injury or from assault. The jewelry itself can become lodged in neighboring structures and cause injury to surrounding tissues. Secondary trauma can occur if the hardware is pulled or torn from the fistula. Bleeding, hematoma formation, and edema can occur with trauma to any piercing site (Koenig & Carnes, 2003; Stirn, 2003). These complications are usually localized to the affected piercing site, but blood loss can be significant in highly vascular regions (Hardee et al., 2000; Koenig & Carnes, 2003).

Call for Research

There are many areas of nursing and forensic science that can benefit from increased knowledge of body piercing as well as other body modification practices. Secondary trauma from body piercing requires more study, as does the potential for piercing hardware and fistulas as possible locations for foreign DNA. In addition, more knowledge is needed regarding reasons individuals choose body modifications.

Conclusion

Nurses encounter patients after traumatic events, particularly when they are most physically and emotionally vulnerable. As body piercings become more common in the general population, interactions with people who possess these modifications will also increase. Knowledge needed for comprehensive and effective practice includes legislation regarding piercing, hardware issues, aftercare techniques, psychosocial motivators, secondary trauma, patterned injuries, infection, and the potential of piercing hardware and fistulas as reservoirs of foreign DNA.

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Kym A. Halliday, BSN, RN, CCRN, SANE-A, is a Sexual Assault Nurse Examiner and Critical Care Float Nurse, Albequerque, NM, and a recent graduate of the University of New Mexico College of Nursing in Albuquerque.

Acknowledgments: The author would like to thank Robin Miller, MSN, RN, and Paul Clements, PhD, APRN, BC, DF-IAFN, of the University of New Mexico College of Nursing, for their mentorship during the development of this paper. The following individuals also deserve thanks for providing the author with their assistance, experience, and encouragement with this project: Jeff Morehouse, MD, of Lovelace Medical Center Cosmetic Surgery Department; Dustin Munro, FNP, of Presbyterian Medical Group Urgent Care; Patricia Crane, MSN, RNC, NP, of Duquesne University; and Crystal Sims, Chrissy Shull, and Noah Babcock of Evolution Body Piercing in Albuquerque.

Table 1. Ear Piercings

Healing

Name Type Risks Times

Lobe Earlobe Infection 4-6 weeks

Gauged Lobe Stretched Earlobe Split lobe, infection Varies

Tragus Cartilage Infection, hypertrophic 2-3 months

scarring

Helix Cartilage, high Granulomas, infection, 2-3 months

pinna hypertrophic scarring

Gauged Cartilage Stretched Cracked Cartilage, Varies

Cartilage infection

Table 2. Facial Piercings

Healing

Name Type Risks Times

Brow Eyebrow (above eye) Infection 6-8 weeks

Anti-brow Lateral or inferior to Trigeminal nerve 6-8 weeks

eye and brow involvement,

infection, migration

Earl Mid-brow Migration, infection, 2-3 months

rejection

Nostril Lateral nares Granuloma, infection 2-3 months

Septum Nasal septum Site trauma, infection 4-6 weeks

Table 3. Oral Piercings

Healing

Name Type Risks Times

Monroe Cheek Infection, gingival 4-6 months

recession

Medusa Philtrum (above the See above 6-8 weeks

upper lip)

Labret Below the Lower Lip See above 6-8 weeks

Tongue Tongue See above + dental 4-6 weeks

trauma, circulatory

interference within

oral cavity, systemic

infection,

endocarditis,

meningitis

Frenulum (oral) Lingual or labial Infection, 4-6 weeks

frenulum interference with oral

cavity circulation

Table 4. Generic Body Piercings

Healing

Name Type Risks Times

Nipple Nipple base, Mastitis, migration, 2-3 months

above areola rejection, secondary (barbell);

trauma 6-9 months (ring)

Nape Posterior or Infection, interference 6-9 months

lateral neck w/radiological imaging,

C-collar placement

difficulties

Madison Anterior neck at Bleeding, infection, 6-9 months

sternal notch migration, infection

Navel Upper or lower Infection, migration, 4-6 months

lip of umbilicus rejection (curved barbell);

6-9 months (ring)

Surface Flat body surface Infection, migration, 6-9 months

piercings rejection

Table 5. Male Genital Piercings

Healing

Name Type Risks Times

Prince Albert Transurethral Infection, Urinary leakage 4-6 weeks

(AKA: PA)

Reverse Prince Transurethral Healing delays, see PA 4-6 months

Albert

Apadravya Transcoronal See PA and Reverse PA 4-6 months

Ampallang Penile Head Infection 4-6 months

Prince’s Wand Transurethral Urethral Trauma, infection 4-6 months

Guiche Surface, Infection, rejection 4-6 months

perineal

Hafada Scrotal Rejection, secondary trauma 2-3 months

Table 6. Female Genital Piercings

Healing

Name Type Risks Times

Clitoral Hood Upper labia minora, Clitoral 6-8 weeks

clitoral hood desensitization, (horizontal);

infection 4-6 weeks

(vertical)

Triangle Deep clitoral See above 4-6 weeks

Labial Inner or outer labia Secondary trauma, 4-6 weeks

infection (inner);

2-3 months

(outer)

Fourchette Inferior labial Secondary trauma, 6-8 weeks

juncture infection

Christina Superior labial Secondary trauma, 6-8 weeks

uncture infection

Princess Transurethral (can UTIs, secondary 4-6 months

Albertina also be transvaginal) trauma

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