An overview of medication management in correctional settings

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The roles and responsibilities of correctional nurses for medication management are broader in scope than other practice settings. In health care settings many other professional and support personnel contribute to delivery of patient care.  However in correctional facilities nurses are relied upon to deliver care without the availability of these other types of personnel. The result is that correctional nurses often work in professional isolation and may feel like they are in a foreign country (Muse, 2012). I think traveling in a foreign country is a good analogy for correctional nursing. Doing this well involves preparation by learning something about the sights to see, building skill using a little of the language, familiarizing yourself with the rules, particularly which side of the road people drive on and finding out how to avoid being robbed or harmed in some way. The thrill of correctional nursing, like the thrill of foreign travel, comes when you realize how much you are enjoying it, especially the independence of professional nursing practice in this field. This post is the first part of a guidebook for your journey managing medication in correctional settings.

State law, rule and regulation

State law serves as the basis for nearly all of the practices and procedures involved in medication management. Most nurses are familiar with the nurse practice act in their state. If not, this is the place to start by reviewing it for definitions and references to medication. The nurse practice act will be especially helpful in describing the training and supervision requirements if non-licensed personnel, such as nursing assistants, administer medication at the correctional facility.

The pharmacy practice act is the most important resource to review. These laws will define how to obtain, store, dispense and account for medication which are often the responsibility of nurses when there is no pharmacist on site.  Even if there is a pharmacist at the facility, being familiar with the law that governs their practice is helpful in understanding the recommendations pharmacists make about drug storage, packaging of medications and accountability.

The medical practice act provides important information about how a physician’s order for medication is lawfully carried out. The medical practice act also has information about how medical assistants and paramedics work as well as the requirements for training and supervision which need to be followed if these personnel are involved in medication management.

This is not interesting reading but it does provide information that nurses can use in determining the responsibilities of personnel for medication management. It also provides definitions and terminology to accurately communicate with the pharmacy that provides medication to the facility and with providers about implementation of orders. Finally it provides nurses a basis to knowledgably resist inappropriate requests from custody and other personnel not familiar with health care laws to carry out tasks that are inconsistent with state law.

Accreditation standards

The National Commission on Correctional Health Care (NCCHC) and the American Correctional Association (ACA) are organizations which accredit correctional facilities for providing services and programs consistent with national standards. The standards are also used by most correctional facilities in developing policy and practices even if accreditation is not sought. Both organizations have standards related to medication management which are summarized in Figure 1. This list is a handy description of all the moving parts and pieces of medication management in correctional settings and nurses are involved in all of these components. This list can be used to review how medication management is handled at a facility and identify areas that may need attention.

Figure 1:   Standards for medication management in correctional facilities
NCCHC ACA
Applicable standards C-05, D-01, D-02 4-4378, 4-4379
1. Facility operates in compliance with state and federal laws regarding medications. Similar
2. There is a formulary and method to obtain non-formulary medication. Similar
3. Policy and procedures address how to procure, receive and account, dispense, distribute, store, administer and dispose medication. Similar
4. Medications are under control of appropriate staff and accounted for. Secure storage and perpetual inventory of controlled substances, syringes and needles.
5. Medication is only prescribed as clinically indicated after provider evaluation. Similar
6. Providers are notified of medication needing renewal prior to expiration. Similar
7. Staff are properly trained to administer or distribute medication. Similar
8. Inmates do not prepare, dispense, or administer medications. Self-carry medication programs are allowed.
9. There are no outdated, discontinued, or recalled medications at the facility.
10. If there is no on-site pharmacist, a consulting pharmacist is available for advice and makes inspections of the facility’s medication program at least quarterly.

Nursing standards

The American Nurses Association (ANA) has recognized correctional nursing as a specialized field of practice since 1995. The ANA publishes a reference that describes the scope and sets standards for the practice of correctional nurses. With regard to medication management the role and responsibility of correctional nurses is as follows:

  1. To be knowledgeable of medications administered, including dosages, side effects, contraindications and food and drug allergies.
  2. Practices with regard to medication management in the correctional setting meet the same standards as in the community. To do so nurses must be knowledgeable about state practice acts (as suggested earlier in this chapter).
  3. Ensure that patients know what medications they are taking, the correct dosage and potential side effects.
  4. If patients are expected to take medications without supervision the nurse evaluates the patient’s competence to self-manage and takes steps to protect those who are not competent to do so.
  5. Work with custody staff so that patients receive medication in a timely and safe manner (ANA, 2013).

This overview makes me reflect on my first experience with medication management in correctional nursing. I was being oriented to administer medications on the evening shift at a maximum custody men’s prison. A technician rolled a grocery cart filled with stock bottles of all kinds of medication out to me. The cart was full. In giving me the cart he said “You roll this along the tier and stop at every cell. Ask the inmates what meds they want. When you give them the medication then you record it on one of these index cards that has the medication listed at the top.” I remember being shocked and asked the technician why they did it that way. He shrugged his shoulders and went on with his tasks. While this experience is pretty extreme you might use it to review against the ANA nursing standards of practice, the accreditation standards and state law that were reviewed in this post and identify the inconsistencies. Being knowledgeable about the standards and requirements for medication management prevents erosion of professional practice and ultimately protects patients from harm.

Going back to the travel analogy, knowing state law, the national standards for correctional facilities as well as the standards of practice for correctional nurses is like having a guidebook to review the sights to see in place you have selected to travel to. These become a reference point to plan so you can make the most of your time as well as an expectation for what will take place while on your journey.

Is medication management a troublesome area where you practice correctional nursing? Have you looked at the problem through the lens of applicable state law, corrections standards and the nursing practice standards? If so, what have you identified as the problem areas? Please comment by responding in the comments section of this post.

For more about the opportunities and challenges in correctional nursing order a copy of our book, Essentials of Correctional Nursing directly from the publisher or from Amazon today!

 

References

ANA (2013). Correctional Nursing: Scope and Standards of Practice. Silver Springs: American Nurses Association.

Muse, M. (2012). Professional role and responsibility. In C. Schoenly L. & Knox, Essentials of Correctional Nursing (pp. 364-377). New York: Springer.

National Commission on Correctional Health Care. (2014). Standards for Health Services. Chicago: National Commission on Correctional Health Care.

American Correctional Association. Performance Based Standards for Correctional Health Care. Retrieved August 19, 2015 from http://www.aca.org/standards/healthcare/

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Baby on Board: Substance Withdrawal and Pregnancy

Baby on Board: Substance Withdrawal and Pregnancy

With the majority of female inmates of childbearing age, drug and alcohol withdrawal during pregnancy is a fact of life in most jails and prisons. This is definitely a risky business as many substances affect fetal growth and development. Therefore, correctional nurses need to know the pregnancy status of female inmate starting at booking and have a clear understanding of the potential for drug or alcohol withdrawal while in custody.

Finding the Baby

Pregnancy evaluation at intake is recommended by the American College of Obstetricians and Gynecologists (ACOG) as well as the National Commission on Correctional Health Care (NCCHC E-02, G-09). Pregnancy risk can be assessed through screening questions about:

  • Menstrual history
  • Sexual activity
  • Contraceptive Use

Urine pregnancy testing is inexpensive and some settings opt to perform pregnancy testing on all females of childbearing age. Once identified, pregnancy should initiate various activities such as evaluation of gestational age and enrollment in an obstetric program.

Finding the Substance

Many pregnancies in this patient population are high risk due poor lifestyle habits of the mother and lack of medical services.  Female inmates have higher rates of smoking, alcohol use, and illegal drug use than the general population. All of these substances have detrimental effects on an unborn child. Identifying substance use at booking will determine any special considerations and interventions for a pregnant patient.

If a female inmate is found to be pregnant or likely to be pregnant, special attention should be given to determining the level of drug or alcohol use. Several screening tools are advocated for this purpose such as AUDIT, CAGE-AD, or SSISA. The important point is to screen for substances so that proper withdrawal intervention can be initiated.

Planning for Two

Substance withdrawal for the pregnant inmate means thinking about both the mother and the child. In fact, some withdrawals, like opiates, are too risky for the unborn child. Here is a quick breakdown on what to do for key substance withdrawals. The recommendations below come from the Principles of Addiction Medicine, Chapter 81: Alcohol and Other Drug Use During Pregnancy  unless otherwise indicated.

Alcohol: The Federal Bureau of Prisons recommends that alcohol withdrawal of pregnant women be managed in an inpatient setting. This may be the safest route to take but is not always possible. The NYS Office of Alcoholism and Substance Abuse Services recommends the use of a benzodiazepine taper and careful, frequent evaluation of withdrawal symptoms for pregnant alcohol-involved patients.

Benzodiazepines: Benzodiazepines and other sedatives/hypnotics can be withdrawn during pregnancy with careful management as abrupt withdrawal can lead to spontaneous abortion or premature labor. The second trimester is the optimum time for this withdrawal to reduce either of these outcomes.

Opiates: Opiate withdrawal has a high likelihood of miscarriage and premature labor. Therefore, pregnant opiate users (including those using methadone and buprenorphine) should be carefully managed by a specialist and may be maintained on the drug through pregnancy.

Stimulants: Stimulant use, such as cocaine and methamphetamine, during pregnancy can lead to preterm labor, placental abruption and intrauterine growth restriction. However, stimulant withdrawal does not cause significant physiologic consequence to the unborn and can be managed according to protocol with careful management.

In all cases, a pregnant substance-involved patient needs specialized obstetric medical care and close observation during the withdrawal period to have a healthy outcome.

How are you managing alcohol and drug withdrawal for your pregnant patients? Share your thoughts in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing.

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Stimulant Withdrawal: All Wound Up!

Stimulant WithdrawalPrimary concerns in substance withdrawal are alcohol and opiates; and rightly so. Withdrawal of these two drugs of abuse can cause serious health concern. Stimulants such as cocaine, methamphetamine, crack, and amphetamines are also popular among the inmate patient population and can cause significant effects when abruptly withdrawn upon incarceration. Fortunately, stimulant withdrawal, while uncomfortable, is rarely life threatening.

Case of the Jitters

Stimulant intoxication may well be the initiating circumstance landing your patient in booking. Cocaine and meth are used  for a heightened sense of well-being and euphoria. However, they can also lead to aggressive and violent behaviors. Here is a list of common negative effects of stimulant over-use:

  • Emotional instability
  • Agitation, restlessness, irritability
  • Impaired judgment
  • Poor impulse control
  • Aggression

Charges for domestic violence, aggressive driving, or property destruction may result when things get out of hand. Besides the above behavioral observations, other signs of stimulant intoxication that might be noted on booking include:

  • Rapid heart rate
  • Elevated blood pressure
  • Dilated pupils
  • Increased temperature

If a patient presents with these indications of stimulant over-use, probe further into their drug-taking behaviors and usual withdrawal symptoms.  This information will help in developing a plan to manage their withdrawal while incarcerated.

Stimulant Withdrawal Effects

Coming off stimulant use results in irritating then depressing the nervous system. The patient can expect to first experience agitation, intense drug cravings, and insomnia. Farther into withdrawal this changes to lethargy, fatigue, and dulled senses causing excessive sleepiness.

Stimulant Withdrawal Management

Stimulant withdrawal usually doesn’t require medical management and protocols rarely include medications. For example the Federal Bureau of Prisons Withdrawal Protocols recommends symptom management only. However, cardiac complications can be seen, especially in compromised individuals like the elderly or those with cardiac or respiratory disease. A baseline EKG and follow-up may be warrented.

Stimulant withdrawal behind bars is basically a self-managed event requiring the inmate to initiate health care contact for symptom relief. Therefore, it is important to provide instruction on how to access the medical unit and when to seek out treatment. Explore ways the person has managed periods without the drug in the past and provide options within available processes during incarceration.

Stimulant Withdrawal and Self-harm

Although stimulant withdrawal may not be life-threatening, coming down off uppers can lead to severe depression and suicide ideation. This ‘crash’ may happen quickly with rapidly metabolizing drugs like cocaine or more slowly with longer-acting stimulants like methamphetamine.  Conclusion of withdrawal symptoms follows the same progression with acute cocaine withdrawal lasting from 3-4 days while methamphetamine can last 1-2 weeks. Unfortunately, drug craving can last much, much longer.

Engage available mental health treatment for this patient. Suicide evaluation, drug treatment programs, and group therapy are all beneficial.

Mixed Withdrawal Alert

Like so many of our patients, stimulant users will self-medicate with other substances to smooth out uncomfortable symptoms of their drug of choice. So, be aware that cocaine and methamphetamine users are likely to also use alcohol, benzodiazepines, or opiates to mellow out between fixes or after binges. Specifically ask about what your patient uses to even out their stimulant highs and be prepared to manage possible withdrawal from these substances, as well.

Are stimulants like cocaine, methamphetamine, crack, or amphetamines popular with your patient population? Share your withdrawal tips in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing.

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Benzodiazepine Withdrawal: Monitoring and Treatment

Benzodiazepines are frequently prescribed for anxiety and sleep disorders. They are also popular for self-medicating or abuse purposes; providing peace and euphoria for troubled individuals. They are rarely abused alone and often combined with alcohol or opiates. Those who abuse cocaine or methamphetamines may use benzodiazepines to ‘level off’ a high.  An earlier post discusses the hidden nature of benzodiazepine misuse and the high potential for late withdrawal in many of our patients, especially women. Once identified, successful benzodiazepine withdrawal requires monitoring and management.

Signs of Impending Troubles

The symptoms and duration of withdrawal can be hard to nail down and are based on length of use, type (short-acting vs. long-acting), and underlying psychopathology. Symptoms can be as mild as some irritability and insomnia to as intense as seizures, panic attacks, and hallucinations. General body discomforts such as bloating, muscle aches, and restlessness are also common. The Federal Bureau of Prisons Detoxification Guidelines provide a helpful staging guide:

  • Early Withdrawal: Increased pulse and blood pressure, anxiety, panic attacks, restlessness, and gastrointestinal upset.
  • Mid Withdrawal: Progressing to include tremor, fever, diaphoresis, insomnia, anorexia, and diarrhea.
  • Late Withdrawal: If left untreated, a delirium may develop with hallucinations, changes in consciousness, profound agitation, autonomic instability, seizures, and death

Monitoring and Protocols

Unfortunately, an extensively evaluated monitoring scale does not yet exist for benzodiazepine withdrawal. A scale modeled after the well-validated CIWA-Ar (for alcohol withdrawal) is currently being tested for widespread use. The CIWA-B is a 22-item instrument that monitors type and severity of benzodiazepine withdrawal symptoms such as irritability, fatigue, appetite, and sleeplessness. Objective assessment of sweating, restlessness (pacing), and tremor are also documented. A tally of points based on responses and observation can be used to determine treatment.

Another withdrawal monitoring option with some validation is the Benzodiazepine Withdrawal Symptom Questionnaire (BWSQ). This tool is a 20-item self-report questionnaire that does not include scoring categories for level of treatment.

Because tools like the CIWA-B and BWSQ have had little validation, as yet, the FBOP recommends general evaluation of symptoms based on the withdrawal table above with vital signs at least every 8 hours for the first three days of therapy.

Medical Treatment

A tapered schedule of long-acting benzodiazepines to ease withdrawal is advocated. Under medical supervision, detoxification can be accomplished using clonazepam (Klonopin) or chlordiazepoxide (Librium). Some experts prefer the long-acting barbiturate phenobarbital for safe benzodiazepine withdrawal.

Unfortunately, benzodiazepine withdrawal is complicated by symptom reemergence and rebound. The anxiety and insomnia that caused the original drug use can return with greater intensity. Withdrawal can take many weeks or months to successfully accomplish and requires continued monitoring and attention.

What tools are you using to monitor and treat barbiturate withdrawal? Share your practices in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing.

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Benzodiazepine Withdrawal: Hidden Troubles

Officers in the women’s wing of a large urban jail call down to medical asking for assistance with an out-of-control inmate. The 22-year-old woman was booked in 10 days ago and was successfully withdrawn from alcohol during the first week. Now the officers describe her as totally out of control, hearing voices, and bouncing off the walls. As preparations are underway to do a cell-side evaluation, a Man-Down is called for the same wing. The emergency bag is pulled and the designated emergency nurse asks a second nurse to accompany her to the floor. They find the woman unconscious on the floor of her cell. The officers state that just after they phoned medical, the woman began to shake, her eyes rolled back, and she collapsed on the floor.

Delayed Benzodiazepine Withdrawal

Health care staff at this jail did a good job of withdrawing this woman from alcohol. They used a standard withdrawal protocol based on the Federal Bureau of Prisons Guidelines that included scheduled evaluations using the CIWA-Ar and administration of lorazepam (Ativan) based on scoring. Within 4 days she was symptom free and CIWA evaluations ended on Day 7.

However, intake screening questions missed this patient’s heavy dependence on diazepam (Valium) along with her alcohol intake. The benzodiazepine treatment for alcohol withdrawal held off drug withdrawal symptoms until later in her stay. Benzodiazepines are rarely misused alone. As in this case, they can be combined with alcohol abuse. In other situations they may be used in conjunction with opiates or cocaine. Women are twice as likely to misuse benzodiazepines as men.

Long-acting sedatives like diazepam may take longer for withdrawal symptoms to emerge, as indicated by this graph.

benzo

What’s in a Name?

Depending on your geographic region, you will hear many names for street drugs. Keeping up with the lingo is an important part of assessing for benzodiazepine dependence or misuse. Here are some common street terms for this drug class. Do any of these sound familiar?

  • Benzos
  • BZDs
  • Stupefy
  • Tranx
  • Qual
  • Heavenly Blues
  • Valley Girl
  • Goofballs
  • Moggies
  • Candy
  • Z Bars
  • Sleepers
  • School Bus
  • Dead Flower Powers

Seeing the Big Picture

Benzodiazepines have a calming effect and are often taken to reduce anxiety or to help sleep. The correctional patient population is less likely to frequent the health care system for these conditions and may obtain relief by self-medicating using street drugs. Asking questions about treatments used for anxiety or insomnia may reveal a need for benzodiazepine withdrawal monitoring. If regular use of a benzodiazepine is identified during intake, answers to the following questions will determine withdrawal treatment options:

  • Type of medication
  • Length of time used
  • Amount used
  • Reasons for use
  • Symptoms that occur when doses are missed
  • Date and amount of last dose

Benzodiazepine withdrawal is a hidden trouble that is often mixed with other drug and alcohol withdrawal issues. Be particularly alert for this potential with female patients in combination with other primary concerns such as alcohol and opiates.

What are you using to screen and assess for benzodiazepine dependence? Share your thoughts in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing.

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Answers to the Quiz on Hypertension

A person drawing and pointing at a Knowledge Empowers You Chalk Illustration

Last week we posted a case example followed by eight questions designed to test knowledge of the most recent guidelines for management of hypertension as well as the unique challenges managing this disease in the correctional setting. Each of the test questions are listed below with the correct answer underlined followed by an explanation of the correct answer. The references are listed at the end of the post so you can access the material that was used to prepare this quiz.

Case example: The case example involved an inmate being seen in nurse sick call for complaints of nasal allergies and a recent back strain. His blood pressure is 148/90 mm Hg. At intake, a month ago, his blood pressure was 154/92 mm Hg.

Question

1. Based upon the reading today, this patient is at what stage of hypertension?

    1. Prehypertension
    2. Stage 1 hypertension
    3. Stage 2 hypertension
    4. Hypertensive crisis

Explanation: Hypertension stages are unchanged from the JNC 7 report. These stages are defined as:

Stage Systolic blood pressure Diastolic blood pressure
Prehypertension 120 to 139 mm Hg 80 to 89 mm Hg
Stage 1 hypertension 140 to 159 mm Hg 90 to 99 mm Hg
Stage 2 hypertension Equal or higher than 160 mm Hg 100 mm Hg or higher
Hypertensive crisis Above 120 mm Hg

2. Which of the following is not a risk factor for hypertension?

  1. Race
  2. Family history
  3. Sexual orientation
  4. Alcohol use

Explanation: Gender is a risk factor but not sexual orientation. Men are more likely than women to have high blood pressure until about age 45. The rates of disease are similar between men and women from age 45 to 64 but after that women are at much higher risk (American Heart Association). Subgroups within an incarcerated population at higher risk of hypertension include youth, African American men and young women (Arries & Maposa 2013).

3. What lifestyle changes will you suggest to the patient?

  1. Weight loss
  2. Reduce salt
  3. Increase activity
  4. All of the above

Explanation: Lifestyle changes are a first line recommendation in the treatment of hypertension. Systolic blood pressure reduces 1 mm Hg for every pound of weight loss, reducing sodium intake to 1,500 – 2,300 mg/day decreases blood pressure by as much as 8 mm Hg, and 30 minutes of activity five days a week reduces systolic blood pressure by as much as 9 mm Hg (Townsend & Anderson 2015). Educating patients about the contribution of these lifestyle changes to reducing blood pressure, giving them the tools to account for these changes and the opportunity to see the change in blood pressure is a powerful means to engage patients in their own care. Several studies have shown that lifestyle change interventions are effective with incarcerated populations (Arries & Maposa 2013).

4. A patient with hypertension should be seen monthly until…

  1. Blood pressure reaches the target goal
  2. Lab work is within normal limits
  3. Blood pressure readings stabilize
  4. The provider determines another interval

Explanation: An important feature of the JNC recommendations are the target goals for blood pressure. A significant change in the JNC 8 was to ease the target goals for patients with diabetes and chronic kidney disease (James, Oparil, Carter et al 2014). The main purpose of hypertension treatment is to achieve and maintain blood pressure within the target range listed in the table below.

Population Goal for systolic BP Goal for diastolic BP
Aged 60 years or older 150 mm Hg and below 90 mm Hg and below
All others including diabetics and chronic kidney disease 140 mm Hg and below 90 mm Hg and below

When a patient does not meet the target, treatment needs modification by increasing dosages, adding another medication or both until the goal is achieved (Townsend & Anderson 2015, Mahajan 2014). The interval between provider visits can be increased once the goal is achieved. Treatment adherence can be compromised by the patients’ experience of drug side effects, lack of motivation and insufficient knowledge. Nurse led clinics to coach and monitor adherence is a keystone in managing inmate/patients who are being treated for hypertension (Voermans 2013, Arries & Maposa 2013).

5. If lifestyle changes are not sufficient to lower this patient’s blood pressure, medication should be considered unless he…

  1. Is a diabetic
  2. Has liver disease
  3. Is over 60 years of age
  4. Has blurry vision

Explanation: The patient in the case example has a blood pressure of 148/90 mm Hg. A previous blood pressure reading was 154/92 mm Hg. According to the JNC 8 guidelines a target blood pressure of 150/90 mm Hg is recommended for persons 60 and older, without diabetes or chronic kidney disease (James, Oparil, Carter et al 2014). If he is 60 years of age or older he should still be followed so that he can be referred for drug treatment when his blood pressure exceeds 150/90 mm Hg. In the meantime continued assessment and coaching about lifestyle changes is recommended.

6. Initial medication orders for treatment of hypertension are likely to include any of the following except…

  1. ACE inhibitors
  2. Beta blockers
  3. Calcium channel blockers
  4. Thiazide type diuretic

Explanation: The JNC 8 guidelines expanded the number of medications that can be considered as first line therapy to include calcium channel blockers, ACE inhibitors and ARBs. The previous guidelines (JNC 7) gave preference to thiazide type diuretics for initial therapy. The JNC 8 also include specific recommendations for medications for African Americans based upon the evidence for prevention of other cardiovascular conditions (James, Oparil, Carter et al 2014, The Pharmacists Letter 2014).

7. The patient is placed on a low dose of lisinopril and hydrochlorothiazide. What lab work should be ordered to monitor this patient?

  1. BUN & GFR
  2. Albumin & bilirubin
  3. HgA1c & LDL
  4. Creatinine & potassium

Explanation: Lisinopril is an ACE inhibitor. ACE inhibitors frequently cause an elevation in creatinine which can give rise to hyperkalemia. Both of these should monitored and dosage adjusted or drug regime changed if levels rise (Townsend & Anderson 2015). Nurses can counsel patients about what side effects to expect, how to care of various side effects and what conditions should cause the patient to request health care attention. Nurses should always consider the medications a patient is taking during a sick call encounter. The problem being experienced may be a side effect that can be addressed so that adherence with prescribed treatment continues or it may be an adverse effect that needs prompt medical attention (Smith 2013).

8. What lifestyle change will be most difficult to accomplish while incarcerated?

  1. Increased exercise
  2. Lower sodium intake
  3. Smoking cessation
  4. Limiting alcohol use

Explanation: Incarceration for the most part limits access to alcohol. Smoking cessation is a fait accompli in those facilities which are smoke free. Aerobic exercise does not require any special equipment and blood pressure reduction can be accomplished as simply as brisk walking for 40 minutes three or four days a week (American Heart Association 2014). What inmates have the least control over are meals, both the calories and sodium content. Foods high in sodium which are frequently on the menu in correctional facilities are processed meat, baked goods, and processed cheese. When inmates try to obtain a healthier diet (medical diets or religious diets) the alternatives served are often monotonous and unpalatable. Inmates often supplement institution meals with food purchased from the canteen which also is likely to be high in calories and sodium. For this reason lowering sodium intake is the most difficult lifestyle change for patients to accomplish while incarcerated. Some facilities have found that by adopting a “heart healthy” diet as endorsed by the American Heart Association and offering a selection of healthier snacks through the canteen has been cost effective because most medical diets and waste from uneaten special meals are eliminated (Voermans 2013).

For more on the correctional nurses’ role managing patients with chronic conditions like hypertension, cardiovascular disease, asthma, arthritis, diabetes, and seizure disorders see Chapter 6 of our book, Essentials of Correctional Nursing. Order your copy directly from the publisher or from Amazon today!

References:

American Heart Association (2014) Understand your risk for high blood pressure. Retrieved July 1, 2015 at http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/UnderstandYourRiskforHighBloodPressure/Understand-Your-Risk-for-High-Blood-Pressure_UCM_002052_Article.jsp

Arries, E. J. & Maposa, S. (2013). Cardiovascular risk factors among prisoners. Journal of Forensic Nursing 9 (1): 52

Binswanger I.A., Krueger, P.M., & Steiner, J.F. (2009). Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population. Journal of Epidemiology and Community Health 63 (11): 912

James, P.A., Oparil, S., Carter, B.L., et al. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Journal of the American Medical Association 311 (17): 1809

Mahajan, R. (2014). Joint National Committee 8 report: How it differs from JNC 7. International Journal of Applied Basic Medical Research 4 (2): 61

Noonan, M. E. & Ginder, S. (2014) Mortality in Local Jails and State Prisons, 2000-2012- Statistical Tables. Bureau of Justice Statistics. Retrieved July 1 at http://www.bjs.gov/content/pub/pdf/mljsp0012st.pdf

The Pharmacists Letter (2014) Treatment of hypertension: JNC 8 and more. Therapeutic Research Center. PL Detail – Document #300201. Retrieved July 1 at www.PharmacistsLetter.com

Smith, S. (2013) Sick Call. In Schoenly, L. & Knox, C. Essentials of Correctional Nursing. Springer. NY.

Townsend, T., & Anderson, P. (2015). What goes up must come down: Hypertension and the JNC-8 guidelines. American Nurse Today 10 (6)

Voermans, P. (2013) Chronic Conditions. In Schoenly, L. & Knox, C. Essentials of Correctional Nursing. Springer. NY.

Wang, E.A., Pletcher, M., Lin, F., et al. (2009). Incarceration, incident hypertension, and access to health care. Archives of Internal Medicine 169 (7): 687

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Test your knowledge: Hypertension

A person drawing and pointing at a Knowledge Empowers You Chalk Illustration

Hypertension is the most common reason for a visit to see a primary care provider and antihypertensive drugs are the most frequently prescribed medication in the community (Townsend & Anderson 2015). Hypertension is more prevalent among incarcerated persons than in the general community and a significant contributor to death, among inmates and former inmates, from cardiovascular disease (Binswanger, Krueger & Steiner 2009; Wang, et al 2009; Noon & Ginder 2014). Correctional nurses have a key role in screening, assessment and management of hypertension and other cardiovascular risk factors (Arries & Maposa 2013).

Revised guidelines for management of high blood pressure were released last year by the Eighth Joint National Committee. These are referred to as the JNC 8 (James, et al. 2014). These guidelines simplify the decision to treat hypertension, increase the options for initial drug treatment and ease the criteria defining good control (Mahajan 2014). Using the case example below, test your knowledge about treatment of hypertension in the correctional setting .

Case example: The patient you are seeing in nurse sick call has a blood pressure of 148/90 mm Hg. At intake, a month ago, his blood pressure was 154/92. He is being seen today for complaints of nasal allergies and a recent back strain.

  1. Based upon the reading today, this patient is at what stage of hypertension?
    1. Prehypertension
    2. Stage 1 hypertension
    3. Stage 2 hypertension
    4. Hypertensive crisis
  2. Which of the following is not a risk factor for hypertension?
    1. Race
    2. Family history
    3. Sexual orientation
    4. Alcohol use
  3. What lifestyle changes will you suggest to the patient?
    1. Weight loss
    2. Reduce salt
    3. Increase activity
    4. All of the above
  4. Patients with hypertension are seen monthly until…
    1. Blood pressure reaches the target goal
    2. Lab work is within normal limits
    3. Blood pressure readings stabilize
    4. The provider determines another interval
  5. If lifestyle changes are not sufficient to lower blood pressure, medication should be considered unless the patient…
    1. Is a diabetic
    2. Has liver disease
    3. Is over 60 years of age
    4. Has blurry vision
  6. Initial medication orders for treatment of hypertension are likely to include any of the following except…
    1. ACE inhibitors
    2. Beta blockers
    3. Calcium channel blockers
    4. Thiazide type diuretic
  7. The patient is placed on a low dose of lisinopril and hydrochlorothiazide. What lab work should be ordered to monitor this patient?
    1. BUN & GFR
    2. Albumin & bilirubin
    3. HgA1c & LDL
    4. Creatinine & potassium
  8. What lifestyle change are the most difficult to accomplish while incarcerated?
    1. Increased exercise
    2. Lower sodium intake
    3. Smoking cessation
    4. Limiting alcohol use

Next week we will review the answers to these questions. In the meantime, enjoy the Fourth of July holiday and stay safe!

For more on the correctional nurses’ role managing patients with chronic conditions like hypertension, cardiovascular disease, asthma, arthritis, diabetes, and seizure disorders see Chapter 6 of our book, Essentials of Correctional Nursing. Order your copy directly from the publisher or from Amazon today!

References:

Arries, E. J. & Maposa, S. (2013). Cardiovascular risk factors among prisoners. Journal of Forensic Nursing 9 (1): 52

Binswanger I.A., Krueger, P.M., & Steiner, J.F. (2009). Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population. Journal of Epidemiology and Community Health 63 (11): 912

James, P.A., Oparil, S., Carter, B.L., et al. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Journal of the American Medical Association 311 (17): 1809

Mahajan, R. (2014). Joint National Committee 8 report: How it differs from JNC 7. International Journal of Applied Basic Medical Research 4 (2): 61

Noonan, M. E. & Ginder, S. (2014) Mortality in Local Jails and State Prisons, 2000-2012- Statistical Tables. Bureau of Justice Statistics. Retrieved July 1 at http://www.bjs.gov/content/pub/pdf/mljsp0012st.pdf

Townsend, T., & Anderson, P. (2015). What goes up must come down: Hypertension and the JNC-8 guidelines. American Nurse Today 10 (6)

Wang, E.A., Pletcher, M., Lin, F., et al. (2009). Incarceration, incident hypertension, and access to health care. Archives of Internal Medicine 169 (7): 687

 

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