Drug Withdrawal: Opiate Monitoring and Treatment

Drug syringe and cooked heroin on spoonOpiate use is on the rise. Whether heroin or pills, opiate addiction is an increasing problem among the incarcerated patient population. Correctional nurses must know and understand the signs of opiate addiction and the concerns during opiate withdrawal. An earlier post discusses screening for opiate addiction when patients enter the criminal justice system. There should be a high index of concern for this potential. Once identified, withdrawing patients need continuous monitoring and treatment of symptoms.

While opiate withdrawal is frequently described as non-life-threatening, a quick search of the net located instances where county jail inmates died of complications of opiate withdrawal in Kentucky, Eastern Pennsylvania, and Western Pennsylvania. Untreated severe opiate withdrawal can lead to dehydration and renal failure; particularly in unhealthy or compromised individuals. Those with long addiction habits are often under nourished with untreated medical conditions.

Signs of Impending Troubles

The signs and symptoms of opiate withdrawal are basically the reverse of opiate addiction. The body, removed of the ‘downers’ now hyper-accelerates like a foot slamming down on the gas pedal after being restrained for a long time.  Symptoms to look for include:

  • Extreme agitation and anxiety
  • Sleeplessness
  • Gastric distress: abdominal cramping, diarrhea, vomiting
  • Muscle and joint pain
  • Elevated vital signs: Hypertension, tachycardia, and fever

Monitoring and Protocols

The effects of opiate withdrawal can last up to 1 week for heroin and 2 weeks for long-acting prescription opiates like oxycodone. Onset usually corresponds to the time of the next habitual drug dose. Intensity of withdrawal is related to the amount and frequency of current addiction level.

The Clinical Opiate Withdrawal Scale (COWS) is a validated evaluation tool to objectively monitor the progression of withdrawal symptoms. The scale rates the severity of 11 symptoms:

  • Resting pulse
  • Sweating
  • Restlessness
  • Pupil Size
  • Bone or joint aches
  • Runny nose or tearing
  • GI upset
  • Tremor
  • Yawning
  • Anxiety or irritability
  • Gooseflesh skin

The resulting scores are tallied for a total that can then be used to determine treatment or need for medical attention.

  • Mild: 5-12
  • Moderate: 25-36
  • Severe: over 36

Nurses may have medically-approved protocols to guide treatment based on withdrawal severity. For example, mild withdrawal may only warrant continued monitoring while moderate or severe withdrawal may indicate a need for medication to reduce the severity of symptoms.

Medical Treatment

Federal Bureau of Prisons Guidelines recommend the following side effect treatment options:

  • Pain and Fever: Non-steroidal anti-inflammatories (aspirin, ibuprophen)
  • Gastrointestinal Symptoms: antidiarrheals (such as loperamide) and antiemetics (such as proclorperazine)
  • Insomina and restlessness: benzodiazepines (such as Xanax)
  • Anxiety: Buspirone (Buspar)

Moderate to severe opiate withdrawal may also require tapering doses of a substatute narcotic such as methadone or buprenorphine (Suboxone). As these medications require licensing and close stock monitoring, many correctional settings rely on the use of clonidine in combination with symptom relief. Clonidine is an antihypertensive that has been used as a nonnarcotic agent for opiate withdrawal for decades.

CAUTION: Death May Be Preferable

Although your patients may not die of opiate withdrawal, they may die because of it, especially if they have gone through the agony before. Withdrawal can lead to depression and increased chances of suicide, as this news account portrays. Keep a close watch for signs of depression or suicide ideation. Any indication in this area should result in a mental health consult.

What tools are you using to monitor and treat opiate 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. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

Photo Credit: © fotomaximum – Fotolia.com

Drug Withdrawal: Opiate Screening at Intake

Drug syringe and spoon with white powderThe CDC has published an alarming report showing heroin overdose deaths are sky-rocketing. Between 2010 and 2012 heroin overdose deaths have doubled in the 28 states that were studied. The Substance Abuse and Mental Health Services Administration (SAMSA)  is also reporting rapidly rising heroin use. This is attributed to an epidemic of prescription opiate addiction that operates as a gateway drug for heroin. Whether through prescription drug abuse or IV heroin, opiate addiction is on the increase. With 75% of crimes being drug related and more than 2/3rds of the incarcerated being substance involved, many individuals will enter the criminal justice system opiate addicted and suffer through withdrawal while incarcerated. Correctional nurses need to be aware of the high potential for opiate abuse in their patient population. This starts with screening and assessment during intake into the system.

Asking the Right Questions

Although there are several screening tools available for determining drug involvement, one tool recommended for alcohol screening and later modified to include drug screening shows promise for the correctional setting as it is short and simple to apply.

CAGE –AID Questionnaire

The original 4-question CAGE screening was exclusive to alcohol addiction. Each question had a primary concept relating to one of the letters in the word. Later editions added on drug use and was retitled CAGE-AID (adapted to include drugs). Here are the 4 quick questions to ask:

  • Have you ever felt you ought to Cut down on your drinking or drug use?
  • Have people Annoyed you by criticizing your drinking or drug use?
  • Have you ever felt bad or Guilty about your drinking or drug use?
  • Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye‐opener)?

One or more “yes” responses constitute a positive screening test.

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 opiate addiction. Here are some common street terms for this drug class. Do any of these sound familiar?

  • CODIENE: Captain Cody, Cody, schoolboy
  • DILAUDID; juice, smack, D, footballs, dillies
  • FENTANYL: Apache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8, TNT, Tango and Cash
  • HEROIN – china white, fix, horse, smack, whack, mother pearl, H. junk
  • MORPHINE: M, Miss Emma, monkey, white stuff
  • OXYCODONE – Hillbilly heroin, Blues, Kickers, OC, Oxy, OX, Oxycotton, 40 (specifically for 40-milligram pills), 80 (specifically for 80-milligram pills)
  • VICODIN: Vike, Watson-387

Seeing the Big Picture

Assessment findings combine with the screening responses and patient history to provide a complete picture of drug use. Opiates are sometimes called downers for good reason. The body’s main response to opioid substances is sedation. Here are some common assessment findings:

Subjective: calmness, euphoria, sedation, drowsiness, weakness, dizziness, nausea, confusion, dry mouth, itching, constipation

Objective: impaired coordination, sweating, clammy skin, bradycardia, hypotension, hypothermia, pinpoint pupils, slow movement, slurred speech

When screening and assessment finding indicate opiate involvement the patient should be placed on a protocol for ongoing withdrawal monitoring and treatment.

What are you using to screen and assess for opiate addiction? 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. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

Photo Credit: © arska n – Fotolia.com

A Salute to Our Veterans: Even Those Behind Bars

MemorialSeveral times a year Americans pause to thank our soldiers for defending our freedom and protecting us from harm. We acknowledge the sacrifices made by past and present American soldiers to keep us free this Veteran’s Day.  Many of those same soldiers who put themselves in harm’s way are now our patients in jails and prisons across this country.

I was surprised to discover the extent of veterans behind bars. A Special Report by the Bureau of Justice lists around 140,000 veterans in our nation’s prisons in 2004 (the most recent available). Are any of them your patients? 1 in 10 prison inmates is a veteran, so it is very likely that some of your patients have military history. A significant proportion of inmate patients have served in the armed forces and participated in defending our freedom.

According to the BJS report, veteran inmates are more highly educated than nonveterans and have shorter criminal histories. One in 5 had actual combat duty. Some of the findings of the report bust typical conclusions we might have about soldiers. For example, veteran inmates are not more likely to abuse alcohol or have mental health conditions than their nonveteran peers. In addition, they are slightly less likely to be using drugs at the time of arrest.  These numbers do not vary based on whether they had combat or noncombat duty while serving our country.

Post Traumatic Stress Disorder (PTSD) is implicated in many of the convictions of military veterans. It has been said that the soldier can leave the war but the war may not leave the soldier. This was apparent to me in watching the HBO documentary – Prison Terminal: The Last Days of Private Jack Hall. The primary goal of the documentary was to chronical prison hospice services provided to Mr. Hall as he was dying in the Iowa State Penitentiary. However, during the film, Jack shared his back story; the events that led to his conviction for murder.  He talked about the nightmares and flashbacks of his time in a German Prison during World War II duty. He had become an alcoholic after discharge; finally killing a man thought to be his son’s drug dealer. PTSD did not emerge as a specific diagnosis until the 1980’s, but its symptoms abounded among returning WWII vets like Private Hall. These soldiers were said to have traumatic war neurosis, combat exhaustion, or operational fatigue. What they were experiencing, though, were symptoms of PTSD.

Responses to Traumatic Stress

The common pattern of human response to traumatization provide the three key components to a diagnosis of PTSD.

  • Intrusive Recollection: The event is persistently re-experienced through recurrent and intrusive distressing recollections, images, thoughts, or dreams.
  • Avoidance/Numbing: Avoiding thoughts, feelings, or conversations associated with the trauma. Avoiding activities, places, or people that arouse recollections of the trauma.
  • Hyper-arousal: Difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, and an exaggerated startle response.

Helping the PTSD Patient

Veterans are not the only inmate-patients likely to have PTSD. Many in our patient population carry with them violent and abusive histories. Therefore, correctional nurses need to know how to respond to a patient who exhibit acute PTSD symptoms during a medical procedure or health care interaction. Here are some tips from Veteran’s Affairs:

  • Speak in a calm, matter-of-fact voice and avoid sudden movements.
  • Reassure your patient that everything is okay.
  • Continue to explain what you are doing.
  • If at all possible, stop the procedure.
  • Ask (or remind) the patient where he or she is right now.
  • Re-ground the patient: Remind him or her that you are in a medical unit, that he or she is safe and that he or she is having a medical procedure.
  • Offer the patient a drink of water, an extra gown, or a warm or cold wash cloth for the face – anything that will make the patient feel more like his or her usual self.
  • Provide a change of environment (moving to a different room)

On this day of gratitude for those who help keep us free, maybe that inmate in pill line or sick call is someone who served…..and they deserve our gratitude, as well as our best nursing care.

To read more about characteristics of the incarcerated patient population  see Chapter 1 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

Photo Credit: © Sly-Fotolia

Nurses Role in Managing Inmates on Hunger Strike

Prison interior with light shining through a barred window

Hunger strike is a situation every correctional nurse will encounter at least once during their career. It is also one of the unique features of correctional nursing practice and not experienced by nurses in other specialties. Usually the first thoughts that come to mind when the subject of hunger strike comes up are the ethical conflicts; supporting an inmate during their hunger strike (an individual’s right to autonomy) and whether to intervene with life saving measures, such as force feeding (health care professional’s obligation to use their skills and knowledge to benefit the patient). These ethical issues were discussed in this month’s American Journal of Nursing with regard to the hunger strikers at Guantanamo Bay.

In my thirty years’ experience all but one inmate on hunger strike has resumed eating well before their condition became life threatening. It was skillful, concerned nursing care, especially patient advocacy, which eliminated the need to work through the ethical issues that take up so much of the discussion about hunger strikers in correctional settings. The focus of this blog is to describe the practical steps that nurses can take when an inmate informs staff that they are on a hunger strike. These include establishing the patient’s baseline health status, advising and educating the patient, and scheduling ongoing follow-up.

Notification: The highest level officials at a correctional facility will want to be notified when an inmate is on a prolonged fast or hunger strike. They often express concern about preventing the inmate from harms and want to avoid peer pressure or enlisting other inmates in joining the hunger strike. When a nurse is informed that an inmate is on a prolonged fast or hunger strike the first step is to make the proper notifications. These should be spelled out in facility specific policy and usually stipulate the dual responsibility of the facility health authority and chief medical officer to keep the facility command structure informed about the inmate’s health status, any change in condition, and involved in supporting the general plan of care. These leaders are also responsible for ensuring that mental health professionals are actively involved in evaluating and planning for the patient’s care.

Definition: All individuals periodically fast, so it is important to distinguish when fasting is considered a hunger strike or attempt at starvation. Sometimes the inmate will notify staff that they are not eating and the reason why; other times officers notice that an inmate is refusing foods (and maybe fluids as well) and take further steps to inquire about the inmate’s behavior. Correctional systems usually define a hunger striker as an inmate who goes without food and fluid for more than 24 hours or without food (but taking fluid) for more than two consecutive days.

Time is on our side: There is no need to rush into a confrontation with the hunger striker or struggle with the question of whether to force feed for some time. For healthy persons, serious risk does not arise until after 14 days of starvation, or until the patient has a Body Mass Index (BMI) of less than 18.5, or abnormal lab values (↓serum protein and albumin, ↓bicarbonate, abnormal kidney function or electrolytes). Persons with chronic medical or mental health conditions, who are pregnant, elderly or taking certain types of medication (e.g. insulin, diuretics, antacids) risk experiencing complications earlier. Nurses and custody staff should ensure that fluids are available at all times and food is offered according to the regular meal schedule. During this early period it is important for nurses to concentrate on building a therapeutic relationship with the patient; one that demonstrates respect, supports autonomy and self-determination, and preserves dignity.

Baseline Evaluation: When health services is notified or determines that an inmate is on a hunger strike the first step is to establish a baseline against which to monitor changes in the inmate’s health status. This evaluation should be conducted within the first 24 hours of notification if the inmate is at higher risk for complications. High risk includes patients who are elderly, pregnant, on a mental health caseload or have a medical condition that requires ongoing care. Inmates with these characteristics need to be followed and monitored on a more intense and frequent schedule. Inmates who are otherwise healthy still need to have a baseline health evaluation but it can take place anytime within 72 hours to 7 days after notification of hunger strike.

The baseline evaluation should include:

  1. Interview to determine what the inmate is refusing and the reason for refusal. Recommended questions to ask are:
  • What was the last food you ate and when was it?
  • Is this a total fast or are there certain foods you are willing to eat?
  • How much fluid are you taking in?
  • Are you refusing any prescribed medications or other treatments; if so why?
  • Are you protesting something by not eating? If so what can you tell me about your protest?
  • Are you expecting to die as a result of this fast?
  • If not, how long do you intend to continue this fast?

This may not be a quick interview so plan to conduct it when you can give the patient your time and attention to the dialogue. The information that is obtained from this interview is important for the health care team to use in planning how to monitor and care for the patient over the course of the hunger strike. The nature of the encounter is the first step in establishing a relationship between the hunger striker and health care staff that is collaborative which will also be more critical over time.

      2.  Assessment of the patient’s physical and mental condition usually includes:

  • Weight and height
  • Vital signs
  • Level of hydration
  • Mental status evaluation
  • Suicide risk assessment
  • Any finding or condition that should be referred to a higher level of care.

      3.  Patient education about the adverse effects of dehydration, starvation and risk for complications. In particular patients should urged to drink fluids in order to maintain hydration, to take precautions against inadvertent injury because of weakness, dizziness, or confusion and when they are ready to resume eating to proceed cautiously. The nurse should also describe what the health care staff will do to monitor the patient while on hunger strike and attempt to solicit their agreement and cooperation. To supplement the information provided by the nurse during this initial encounter, the California Prison Health Care Service (CPHCS) has developed a one page fact sheet that can be given to inmates at the beginning of a hunger strike.

     4. Disposition or initial plan of care. The nurse will schedule the primary care provider (PCP) to review the patient’s chart or see the patient based upon clinical findings. High risk patients need to be seen promptly or at least have their chart reviewed, including the nurse’s findings from the baseline evaluation. Patients who are not high risk should been seen or at least the chart reviewed within 48 hours but not longer than 72 hours after notification. The nurse also refers or schedules the patient to be seen by behavioral or mental health staff. The urgency of the referral is based upon the patient’s condition. Emergent or immediate referrals would include patients who are suicidal or psychotic. Urgent referrals would be anyone already on a mental health caseload. These appointments should take place within the next 72 hours. Routine referrals should be evaluated by mental health before the end of the first week.

   5. Documentation of the baseline evaluation in the patient’s health record. This should always include a narrative progress note of the date and time health services was informed, most recent fluids and nourishment taken, and who was notified. Documentation also includes the findings of the interview and assessment, what was covered in patient education and their understanding, as well as the disposition. The note should list the specifics of all subsequent appointments that were scheduled. A flow sheet may be initiated for serial recording of health status (weight, vital signs, mental status, suicide assessment, hydration etc.).

Ongoing Monitoring: Once the baseline evaluation is completed nurses continue to monitor the inmate’s condition. On a daily basis the nurse checks to make sure that food and fluids have been available, monitors the patient for changes in mental status, collects information about fluid and food intake, solicits the patient’s description of bothersome signs and symptoms, provides advice to increase comfort and maintain hydration. It is also important that the nurse checks to make sure that provider appointments or referrals are taking place as scheduled, to review and act upon provider recommendations and orders.

Periodically, usually three times a week, the nurse collects supplemental information to include weight, mental status, hydration level, medication and treatment compliance. The provider may also have written orders for routine laboratory testing or labs when vital signs are abnormal. The nurse will schedule provider appointments based upon the results of monitoring or at least once a week. Each of these encounters as well as nursing actions should be documented at least in the progress notes. Use of a flow sheet to monitor changes in signs and symptoms can supplement but should not replace the narrative in the progress note.

Many facilities have adopted the use of a multidisciplinary treatment team to manage the ongoing monitoring and care of inmates while on hunger strike. Participants include medical, nursing, mental health and custody staff. It is helpful to also include the chaplain, food service personnel and anyone else who has a positive relationship with the inmate. These teams meet weekly or more often as necessary to share information, develop or revise the treatment plan and to coordinate interventions. Components of the plan should address housing, mental health needs, medical monitoring, legal advice and preparations for court intervention if necessary. Much of the discussion in developing and revising the plan of care will concern resolving the reason for not eating as well as management of medical and mental health status. Nurses should be prepared to think of this as a negotiation that preserves the patient’s health while finding a solution to the inmate’s issue that is realistic and acceptable while incarcerated.

Nurses maintain daily contact with an inmate on a hunger strike and each of these encounters is an opportunity to strengthen the nurse-patient relationship. It is important to maintain open and non-judgmental communication with the patient. Demonstrating respect for the inmate’s autonomy by providing choices and emphasizing the control they have without fasting will help dissipate the need to continue the strike. Findings ways to preserve the patient’s dignity may also help facilitate the patient’s decision to resume taking food.

Refeeding syndrome is a complication sometimes experienced by patients when they start to take nutrition again and the body doesn’t adjust to changes in glucose metabolism and electrolyte balances. Risk for refeeding syndrome increases the longer a patient has fasted, how much weight they have lost (BMI) and the presence of underlying medical or mental health conditions. Nurses monitor patients at risk of refeeding syndrome on a daily basis which may include vital signs, intake and output, collecting lab specimens, EKG monitoring, observation for fluid overload, provision of electrolyte or vitamin/mineral supplements. Even inmates at low risk still benefit from the advice start by eating and drinking small amounts and to increase portions very slowly over several days to a week.

Additional resources for nursing care of patients while on hunger strike include:

What practical advice would you give nurses about the care of inmates while on hunger strike or prolonged fasting? Add to the advice given here by responding in the comments section of this post.

For more on this subject Lorry Schoenly discusses the ethics involved in the care of patients in the correctional setting, including hunger strike in Chapter 2 of the Essentials for Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo credit: © doomu – Fotolia.com

What’s new and news

Speaker at Business Conference and Presentation.First: What is new with Ebola since the last post? Another nurse from Texas and a doctor in New York are infected. The Centers for Disease Control has held two teleconferences with nurses across the country and issued revised infection control guidelines to prevent transmission of Ebola to health care workers. Also last week the American Jail Association disseminated guidelines developed by two jails in and around Dallas where the first case in the United States originated. I hope you have reviewed and perhaps revised your communicable disease screening and identification procedures as well as the availability and use of personal protective equipment consistent with these new recommendations.

NCCHC Fall Conference: Celebrity Chef Jeff Henderson was the key note speaker at the fall conference took place in Las Vegas last week. Henderson got his GED and learned culinary skills while serving a nine year sentence in Federal prison for drug dealing. Once released he continued to develop his culinary skills, eventually becoming Executive Chef at Café Bellagio and Caesar’s Palace in Las Vegas and writing four self-help books including his autobiography, ‘Cooked’. Now he works with young people to provide alternatives to getting involved in the illegal drug trade and is a motivational speaker. He has appeared on The Oprah Winfrey Show, Good Morning America, The Montel Williams Show, CNBC, NPR’s All Things Considered, People and USA Today.

My favorite of all the stories he told was about buying all the top ramen noodles he could afford from the prison commissary. He wasn’t interested in the noodles which he passed out to everyone on the cell block who wanted some. Instead he wanted the seasoning mix that was included with the noodles. As head chef, he used these to spice up the cheese wiz to make his nachos, now famous in prison lore. Jeff Henderson was a young man in prison when he read his first book, was called “son” for the first time, and had someone acknowledge something that he did well in school. He has a great message about self-help and a convincing perspective for all of us involved in the criminal justice system.

Here is a recipe from Cooked (pages 163-164). When Jeff makes fried chicken he still uses this recipe from Friendly Womack, who was the chief inmate cook at the federal prison outside Las Vegas when Jeff was serving time there.

Friendly’s Famous Buttermilk Fried Chicken

2 tablespoons cayenne pepper                                 2 teaspoons onion powder

3 tablespoons black pepper                                        4 tablespoons kosher salt

2 cups all-purpose flour                                                 1 quart buttermilk

1 chicken cut into eight pieces

  1.  Mix all of the spices together in a bowl. Put half the seasoning mix in another bowl. Add the flour to one bowl, mix well and set aside.
  2. Rub the chicken with the reserved spice mix. Poke all the pieces with a fork a few times and set aside. (Friendly taught me to pierce the chicken pieces with a fork so the buttermilk seeps down into the bird.)
  3. Pour the buttermilk into a stainless steel bowl. Add the remaining spices and the chicken pieces. Cover the bowl with plastic wrap and refrigerate for an hour.
  4. Dip the chicken pieces into the seasoned flour, pat the pieces together and make sure they are heavily coated.
  5. Drop them into a deep fryer or in a deep pan with enough vegetable oil to cover the chicken. Turn the chicken as it browns and remove once done.

News about the doings of contributing authors: Authors who contributed to Essentials of Correctional Nursing were also prominent during the NCCHC Conference. Margaret Collatt and Sue Smith gave a presentation about a project to develop guidelines for correctional nurses in chronic care management. In addition to Margaret and Sue, the group working on this project includes:

Sue Lane, RN, ASN CCHP                              Susan Laffan, RN CCHP-A CCHP-RN

Pat Voermans, MS, RN, ANP, CCHP-RN Patricia Blair, PhD, LLM, JD, MSN, CCHP

Lorry Schoenly, PhD, RN, CCHP-RN          Sabrina McCain, RN, ASN CCHP

Lori Roscoe, PhD, ANP-C, CCHP-RN          Debbie Franzoso, LPN, CCHP

They have two guidelines in development right now. One is on management of hypertension and the other concerns seizure disorders. The presenters encouraged nurses to participate in this process by commenting on the format for the guidelines and the topics that are important to correctional nurses. Watch for more news about this important project.

Mary Muse gave two presentations that serve to inspire the practice of correctional nurses. One was from the ANA Nursing Scope and Standards of Professional Practice on two steps in nursing process: Implementation and Evaluation. She used two case examples which always help to make standards real in their application to our daily practice. She also presented a session on the Transformation of Nursing Leadership reminding us of the challenges and expectations for nurses with the change resulting from the Affordable Care Act and the report from the Institute of Medicine (IOM) on the Future of Nursing.

Margaret and Susan Laffan teamed up to give four presentations throughout the conference. These included sessions on the cardiovascular examination, understanding lab values and critical thinking as part of nursing process. As usual with these two presenters, the sessions were full of practical information, fun and door prizes as well.

Margaret and Susan joined with Sue Medley-Lane for a session on Rejuvenation of Nursing Spirit. For Susan Laffan, rejuvenation comes when she dons her pink fuzzy slippers which you will sometimes see her smoozing around the conference in. These presenters discussed the demands of life that can contribute to a loss of spirit and ways to mitigate the cumulative effect of these experiences. They asked correctional nurses to tell the stories and describe the experiences that have inspired their commitment to the field and will collect these and send the collection back out to participants. If you have a story or experience that has been your inspiration for correctional nursing send it to njjailnurse@aol.com by November 30, 2014. The story must include your name, your state and your email address. It should be no more than 300 words long and the names of any patients in the story should be changed.

If you have some ideas about what you think the guidelines for nursing management of chronic care should include or subjects that should be covered please respond in the comments section of this post. If you have an inspirational story about correctional nursing that you would like to share please send it to Susan Laffan at njjailnurse@aol.com by November 30, 2014.

For more on correctional nursing read our book, the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Ebola: Another Look at Infection Control

EbolaA colleague of mine from Dallas, Texas mentioned on a phone call last week how busy things were in the health care industry with the death of Mr. Duncan from Ebola. Now that Nina Pham, a nurse who cared for him has Ebola, I imagine things have heated up even more. Another nurse in Spain has been infected as well after caring for a patient with Ebola. I’ve also seen one report of a jail in Wisconsin that has a detainee under medical surveillance for Ebola symptoms because she recently arrived from West Africa.

People worry about infectious diseases especially when it is a new and threatening disease, even when the risk of infection seems remote. Nurses are a trusted resource and often the first person staff and inmates seek information from about an infectious disease and what can be done to protect themselves. The next several months will be an opportunity for correctional nurses to shine in providing accurate information and advice about Ebola and infection control more generally.

Health teaching and promotion is one of the American Nurses Association (ANA) practice standards for correctional nurses (2013). The competencies for health teaching and promotion include:

  • Addressing a variety of topics that reduce risk and promote health.
  • Using teaching methods appropriate to the situation and the audience.
  • Seeking feedback and evaluation of the effectiveness of teaching strategies used.
  • Using information technologies to communicate information.

Here are five tips to use in providing health information about Ebola for staff and inmates at your correctional facility.

  1. Give credible information. The Centers for Disease Control (CDC) is going to be your best resource. Here is the link to the CDC web page which includes the latest news and advice for hospitals as well as community settings. Another resource is the local health department for your area. It is not uncommon for people to bring forward concerns or information that is contrary to your information or advice. The best approach here is just to cite your sources and ask that those with opposing information cite theirs so that individuals can make up their own minds after considering the information they have received.
  2. Give concrete suggestions about what to do. People often feel helpless and vulnerable in the face of a disease that they know little about. Suggesting concrete steps that can be taken goes a long way toward reducing the fear and anxiety associated with an unknown risk. You might suggest, for example, looking up one of your references or giving people a resource site to go to. Another suggestion might be for someone to assess their knowledge and skill in hand hygiene or use of personal protective equipment.
  3. Reinforce the information already known about infection control. Ebola is spread by direct contact with infected body fluids. We know that prevention measures are to use standard, contact and droplet precautions when caring for someone with an infectious disease transmitted by direct contact. Emphasize the measures that are already in place at your facility to protect staff and other inmates from transmission by direct contact.
  4. Link new information to past efforts and successes. The concern and anxiety about a new infectious disease can be reduced if staff and inmates can see a link to other successes with infection control practices in everyday life.
  5. Look for allies to help spread the word. If you can demystify the disease, people will feel less victimized by the unknown and uncontrollable and ready to take the steps they need to in protecting themselves. When non-medical personnel at a correctional facility embrace the facts about Ebola and the steps to prevent transmission you have mastered control of the infection. Often getting an organization to this place is jump started when a member of the custody staff becomes a spokesperson about the disease. Invest time in sharing information with interested custody staff and they will help carry the message. The same is true for inmates; often peer educators are more effective than professionals in getting important health information across to others.

Two more thoughts about how as correctional nurses we can prepare for the Ebola virus:

  • Even if the possibility of the disease presenting at your facility may seem remote ask what can be learned from it about the infection control practices you have in place. For example, the nurse in Dallas is hypothesized by CDC to have become infected as a result of a breach in infection control practices. We all know how routine infection control practices are part of the daily routine so ask yourself if there are breakdowns you may not be aware of? It is a good time to audit infection control procedures to ensure that identification and prevention measures are up to date and intact.
  • Keep up with information about the disease and what is recommended in relation to infection control. Our hearts go out to the nurse, Nina Pham; and we want to learn everything we can from her experience so we can protect ourselves. The CDC is investigating the infection control practices she used and it will be important for every nurse to incorporate what we learn into our own practice.

The CDC is sponsoring a teleconference for health care professionals on preparing for Ebola October 14 and the ANA has a resource page about Ebola for nurses. What advice do you have for correctional nurses about how to respond to questions about Ebola virus? Please share your advice by responding in the comments section of this post.

For more on standard, contact and droplet precautions see Chapter 10 Infectious Diseases written by Sue Smith in the Essentials for Correctional Nursing. She also discusses the role of correctional nurses in providing information and education about infectious disease. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

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Dealing with the Difficult Patient

Stressed manLast week I attended the fall meeting of the Oregon Chapter of the American Correctional Health Services Association. I have belonged to this organization for 30 years and have received a lot of professional support over the years, especially continuing education. These are my notes from an interesting presentation by Daryl Ruthven, M.D., CCHP, Director of Psychiatry for the Oregon Department of Corrections.

Demanding, non-compliant, whining, threatening, somatizing, malingering, drug-seeking, mentally ill, frequent flyer are some of the ways difficult patients are described. Their behavior can be so obstructive that it’s possible to miss important information or data about them and compromise our clinical work. Certain personality types are more likely to take up more time when seen at sick call or in clinic. These include people with antisocial, borderline, narcissistic, histrionic, dependent or organic personality types. The first thing to remember is that the patient’s behavior is consistent with their personality type and not likely to change just because they are seeking health care. Reduce the likelihood of missing important clinical information by remaining non-judgmental about their behavior and objective during assessment and evaluation of their condition.

The Angry Patient: Unless the patient is brain damaged or intoxicated, anger is a response to fear or threat. The patient is afraid of something that either is or is not going to happen as a result of the encounter. Anger sometimes is used as a display to intimidate others. In this situation the patient may need to vent a bit first. Then try to figure out what the patient is scared or anxious about. They may not be aware that their anger is a response to threat and so it may take a bit of dialogue to identify the problem. A good question to ask is “What do you fear will happen?” or “What are you most concerned about?” The encounter should be terminated if the anger is escalating or becomes abusive rather than defusing.

The Demanding Patient: Uses confrontation as a means to force a desired result. Demands are usually accompanied by a direct or indirect threat. Demanding behavior may be a result of fear, sociopathy, or poor assertive skills training or advice. Most patients are as interested in relief of a problematic symptom as they are in a specific outcome. With this in mind, remind the patient of the responsibilities each party has in the patient/provider relationship. The patient’s responsibility is to provide information about the problem and to decide whether to follow the plan of care suggested by the provider. The provider’s responsibility is to listen to the patient, assess the problem and determine the treatment options that are most appropriate to address the problem.

The Splitting Patient: Pits staff against each other to create chaos and in the midst of the confusion achieves a goal. When a nurse (or other provider) feels confused or at odds with other health care providers about a patient’s plan of care it is a good sign that splitting is taking place. The most important action to take with a splitting patient is to bring the team together to agree on a consistent plan to manage the patient’s care. This should include developing a comprehensive treatment plan (including custody and mental health staff) and reviewing it together at regular intervals.

The Threatening Patient: The facility or health care program should have no tolerance for physical threats and train staff in how this kind of behavior is addressed. The specifics of threatening behavior should be documented thoroughly in a report of the incident. Threatening legal action is very common. Suggestions here are to know enough about the law to appreciate how poor health care must be before a finding of “deliberate indifference” and “cruel and unusual punishment” can be made. Staying up to date with the literature and competent clinically along with thorough documentation protects nurses from tort liability. Basically providing and documenting good nursing care provides sufficient protection from legal threats.

Conclusions: Finally, don’t respond unprofessionally to the difficult patient by yelling, use of sarcasm, counter threatening or reacting emotionally. These responses undermine the power of the provider in the relationship with the patient and can destroy the reputation and authority of the clinician.

Difficult patients do have health problems that need to be identified, assessed and treated. These patients also have something that they are scared of or bothering them. Asking “What are you most concerned about?” or “What do you fear will happen?” may help identify this underlying problem so it can be addressed. Set limits that are appropriate to the responsibilities of each in the provider/patient relationship. Discuss the patient’s options calmly and clearly. Seek help from others to manage difficult patients. Take care to prevent becoming jaded, desensitized or overwhelmed by difficult patients by taking regular time off and developing interests and relationships outside of work.

What tips do you have to manage an encounter with a “difficult patient”? Add to the advice given here by responding in the comments section of this post.

There is much more on this subject in the Essentials for Correctional Nursing. Lorry Schoenly discusses working with difficult patients in Chapter 4 Safety for the Nurse and the Patient. Also Roseanne Harmon describes care of patients who have personality disorders in Chapter 12 Mental Health. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

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