Considering productivity in sick call

mature female nurseNurses at a medium security male facility have asked you to help them get a handle on nurse sick call. They don’t know what is wrong but are burdened by the number of sick call requests that they get every day. There are times during the week when inmates are not seen within the facility’s definition of timeliness. The average number written requests for health care attention that the nurses receive each day is 42. Approximately half of these involve physical symptoms that require a nursing assessment no later than the next day. The nurses see on average 26 patients each day; but only half of these are nursing assessments scheduled from triage of the written request. The other half are urgent walk-ins. There is a backlog of 30 patients who have yet to be assessed by a nurse.

What do the numbers tell: What is your first impression about how nurse sick call is being handled? Looking at the average statistics a backlog can be predicted. If an average of 21 patients each day have concerns that involve physical symptoms then the nurses will need to see that many patients every day to keep up. In this example the nurses are only seeing about 13 patients scheduled from triage of the written request each day so every day eight patients are added to the backlog. To catch up the nurses need to see more than 21 patients a day until the backlog is eliminated.

Underlying principles of sick call: Nursing sick call is considered one of the signature practices defining the specialty of correctional nursing. There are two legal principles underlying nursing sick call. The first is that inmates have daily, unimpeded access to health care. The second is that inmates are entitled to a professional clinical judgment regarding their health concerns. Simply put, inmates can request health care attention every day and their concerns must be addressed in a responsive, timely and clinically appropriate manner (Smith 2013). The failure to see patients, as in the example above, is a violation of these underlying legal principles and puts patients at risk of harm.

What gets measured gets done: Sometimes the never ending onslaught of requests for health care attention can overwhelm nursing staff and becomes a morale and staff retention issue in addition to a legal or risk management problem. Having performance benchmarks for nursing sick call can be helpful in identifying when practices deviate from the norm, considering root causes and developing solutions to improve performance. Based upon your experience how many patients can a proficient nurse see in sick call in an hour? What advice would you give to a nurse who wanted to become more efficient at sick call? Please share your opinion and advice by responding in the comments section of this post.

Next week’s post will include the consensus from nursing colleagues about how many patients nurses can see in an hour of sick call as well as their advice about how to manage sick call efficiently.

There is much more on the subject of Sick Call written by Sue Smith in Chapter 15 of the Essentials for Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

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Pustules, Furuncles and Petechia, Oh My!

human skin anatomy cross sectionI just spent a week at a correctional facility and while there was privileged to observe several nurses conducting sick call. I came away from these experiences appreciating that this process has become one of the signature practices of the correctional nursing specialty. Sue Smith referred to sick call when done well as “a thing of beauty” in her chapter on the subject in the Essential of Correctional Nursing (page 304). Reflecting on the experience of being with these sick call nurses over the week it occurred to me just how many patients were seen because of skin problems. Complaints included toenail fungus, dry skin, contact dermatitis and acne. Sound familiar? Most nursing protocols for problems related to the skin almost presume a diagnosis first. Here are some examples of these types of protocols: ectoparasite infestation, urticaria, dermatitis, candidiasis infection, bacterial infection, fungal infection, boils, jock itch, warts etc. In order to select the correct protocol the nurse should perform a more general skin assessment first. A thorough assessment and objective description of the condition also should accompany any referral to a primary care provider for more definitive diagnosis and treatment of those conditions not covered by a nursing protocol or that do not respond to nursing intervention.

Subjective description: The following subjects should be covered while gathering information from the patient about a skin problem.

  •      Duration: Is the onset sudden or gradual? Previous episodes or is this the first? Has the condition been persistent or does it fluctuate over time?
  •      Location: Where is it located? Where did it start? Has it spread and if so where?
  •      Provoking or relieving factors: What brought it on, makes it worse and makes it better?
  •      Associated symptoms: Itching, tenderness, bleeding, discharge, generalized or systemic symptoms of fever, pain, malaise?
  •      Response to treatment: What treatment has the patient tried and what was the result? Be sure to include consideration of prescription, over the counter and complementary (herbal, etc.) interventions.

The patient’s medical history and family history may be relevant (chronic or immunosuppressive disease, skin cancer etc.). Other areas to consider in gathering the patient’s subjective data include environmental exposures (work, leisure activity etc.); alcohol, drug and tobacco use, allergies and recent travel. Equipment for a dermatological exam: In terms of the tools of the trade, dermatologists recommend having a magnifying glass and measuring device available. Another recommendation is to ensure adequate lighting. Natural light is best; a hard thing to come by in some correctional facilities. If relying on artificial light, a high intensity, incandescent light is best. In addition a handheld light is helpful to provide lighting from the side when assessing a lesion. Finally, you have to have sufficient privacy for the examination and since the assessment will involve palpation, the hands need to be clean and for the patient’s sake warm. It is always best to tell the patient that you are going to touch them, where and why before you do. This is especially true for patients who have a history of having been traumatized or abused. Examination: The first step is to just look at the patient; do they seem well or ill? Is there any evidence of systemic illness (vital signs, flushing, jaundice, etc.). The next steps are to visually inspect and then palpate the lesion or effected area. Inspection includes the noting the following characteristics:

  • Location – is the lesion or effected area related to sexual contact, exposure to sun or other environmental conditions (chemicals etc.); is it in an area of friction or pressure from clothing, does it involve mucous membranes or areas of perspiration.
  • Number and Distribution – How many? How are they arranged?
Terminology Description
Annular Circular pattern
Confluent Merged or run together
Discrete Separated and distinct from each other
Generalized Scattered over an area
Grouped Clustered in multiples
Linear Line or snakelike shape
Polycyclic Concentric circles like a bull’s eye
Zosteriform Along a nerve root
  •  Characteristics – Size (measure the longest side first). Describe the color and any variation in coloring, including any areas of inflammation. Note whether edges are clearly defined and if the shape is regular or irregular.

Next palpate the affected area for tenderness and warmth. Palpate the lesion to determine where it is located within the three layers of skin (epidermis, dermis, subcutaneous tissue), how thick the lesion is and its consistency (hard, soft, firm, fluctuant). When pressure is applied does the color change or does it break down or bleed easily. Examine regional lymph nodes for tenderness or inflammation. The purpose of inspection and palpation is to obtain an accurate and objective description of the skin problem. There is a vast vocabulary of terms to describe skin conditions. A few of the most common are listed here. A great glossary of dermatological terms can be found at the American Academy of Dermatology.

Type of lesion Description
Atrophic Thin, wrinkled skin
Crust, scab Dried serum, blood or pus
Excoriation Hollowed out or linear area covered by a crust. Caused by scratching, rubbing or picking.
Lichenification Skin thickening
Macule, patch Flat, circumscribed, discolored spot. Macule less than 1 cm (ex. freckle). Patch is larger than 1 cm.
Nodule, papule Solid, palpable lesion. Nodule if greater than 1 cm, papule smaller than 1 cm in diameter.
Petechia, ecchymosis, purpura Extravasation of blood into skin. Petechia are less than 2 mm, ecchymosis larger than 2 mm. Pupura are confluent lesions.
Plaque Well defined plateau above the surface of the skin. As seen in psoriasis or eczema.
Pustule Superficial, elevated lesion containing pus.
Scales Dead skin that flakes or is built up
Scar Fibrous tissue formed after a skin injury
Vesicle, bulla or blister Circumscribed, bump containing clear fluid. Vesicle less than 5mm. Bulla or blister larger than 5 mm.
Wheal Transient, irregular, elevated, indurated, changeable lesion caused by local edema.

Documentation: Once you have taken the patient’s history, collected subjective information about the chief complaint and examined the patient review your documentation of findings to ensure that it is complete. A good description of the lesion will be important in comparing whether the patient’s condition is improving or getting worse with recommended treatment. A focused assessment of a skin condition assists in clinical decisions about which nursing protocol to use and/or the urgency of a provider referral. The key parts of an assessment include:

  • Presenting symptoms
  • History of the complaint
  • Examination
    • Location and size
    • Number and distribution
    • Characteristics of the lesion
  • Documentation of findings

For more about nursing assessment and sick call in the correctional setting go to our book, Essentials for Correctional Nursing. It is the only text published about the unique experience of correctional nursing practice. Order your copy directly from the publisher. Use promotional code AF1209 to receive a $15 discount and free shipping.  By the way, the title of this post, Pustules, Furuncles and Petechia, Oh My! is a riff on the Wizard of Oz, a holiday favorite of mine. Here is a clip from the movie. Enjoy!

References and Resources:

  1. Adult Decision Support Tools: Integumentary Assessment (2014). Remote Nursing Certified Practice. CRNBC Publication 743 at https://www.crnbc.ca/Standards/CertifiedPractice/Documents/RemotePractice/743IntegumentaryAssessmentAdultDST.pdf
  2. American Academy of Dermatology at https://www.aad.org/education/basic-dermatology-curriculum
  3. Hess, C.T. (2008) Practice points: Performing a skin assessment. Advances in Skin & Wound Care: The Journal for Prevention and Healing 21(8): 392-394.
  4. Jail Medicine by Jeffrey Keller at http://www.jailmedicine.com/. Select dermatology from the categories section for several blog posts on dermatology issues in the correctional setting.
  5. Johannsen, L.L. (2005) Skin Assessment. Dermatology Nursing 17 (2): 165-166.
  6. Pullen, R.L. (2007) Assessing Skin Lesions. Nursing 2007 (8): 44-45
  7. Tidy, C. (2014) Dermatological History and Examination. PatientPlus at https://www.patient.co.uk/print/2041

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Drug Withdrawal: Watch Out for Opiate Overdose!

Young african man lying on the floor with a syringe in her handJace had a difficult time withdrawing from heroin when he entered the jail 10 days ago on a burglary charge. He was stealing to meet the demands of his 5-bag a day heroin habit. A man-down emergency was just called for his housing unit where Jace was found unconscious and barely breathing. He may have hit his head falling from the upper bunk. His cellmate was out in the TV room at the time. The housing officer reports that Jace returned from a court hearing this morning and seemed in an upbeat mood. The nurse  registers Jace’s heart rate at 36 and respirations at 9 per minute. He is unresponsive and his pupils are equal and pinpoint. What is going on?

Opiate addiction is powerful. Even after a difficult withdrawal, individuals can be overcome with desire to return to drug use.  Jace had opportunity to obtain narcotics while out at his court hearing. In some facilities like these in California and Kentucky, contraband like narcotics can be obtained from the inmate black market and even from staff members.

Overdose Suspicion

Correctional nurses need to be suspicious of narcotic overdose any time a patient presents as unconscious with slowed vital signs and pinpoint equal pupils. Although this patient may have suffered a head injury or stroke, the presentation is suspicious for drug use. Another consideration is hypoglycemia and a fingerstick BS should be obtained if the patient is diabetic. The nurse in this situation should protect the patient’s C-spine in case of traumatic fall and follow emergency protocols for reversing the opiate effects.

Overdose Indications

Once the patient is determined to be breathing and with a regular heart rate, further evaluation for drug overdose can begin. Here is the classic triad of assessment findings in a narcotic overdose situation:

  • Respiratory depression – less than 12 inspirations per minute
  • Depressed level of consciousness
  • Equal pinpoint pupils (miosis)

Overdose Treatment

Many correctional settings have medical-approved nursing protocols to provide prompt treatment of narcotic overdose. Here is an example from Oregon. Treatment for Jace would include:

  • Maintaining C-spine protection while establishing an open airway
  • Providing ventilation support with oxygen and ambu-bag
  • Establishing IV access, if possible
  • Administering Naloxone (Narcan): Check protocol but dose range is 0.4 to 2 mg IV, IM, or SQ. Repeat doses, per protocol, may be given every 3-5 minutes until an adequate response is obtained (return to consciousness and improved vital signs).
  • Duration of action of Narcan is 45 minutes and repeat doses may be necessary until the narcotic leaves the system.
  • Prepare the patient for transport to the emergency unit for definitive evaluation and stabilization.

Note about Body Packing

In a situation like the above, consideration should be given to body packing (storing contraband drugs in body orifices or in the intestines (see this news item). If the overdose was due to a burst or leaking drug packet in the intestines or rectum, further effects may develop even after successful treatment.  A packing patient is unlikely to be a good historian or implicate themselves in the illegal activity. Alert emergency personal to the potential for retained drug packet. A simple fabdominal x-ray will reveal the truth.

Have you had to manage a narcotic overdose in your correctional facility? Share your experiences 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.

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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.

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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.

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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.

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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.

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