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.

Photo Credit: © Zerbor- Fotolia.com

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

Photo credit: © kbuntu – Fotolia.com

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

 

Photo credit: © kbuntu – Fotolia.com

How punishment affects our practice

Close-up Of Brown Gavel And Medical Stethoscope

Currently I am working on understanding more about the challenges of providing culturally competent nursing care in correctional settings. The population of patients we serve are not only culturally diverse but also some racial and ethnic groups are disproportionately represented. Many will agree that the prison, jail or detention facility is a culture as well, the culture of incarceration. Culture is described by Madeline Leininger, a well-known nursing theorist as “the learned, shared, and transmitted values, beliefs, norms, and lifeways that guide thinking, decisions, and actions…” (2006).

We all know that correctional settings have their own vocabulary, rules, practices and expectations that prisoners, correctional officers, nurses, and visitors must comply with to survive in the environment. These values, beliefs, norms and ways of being arise from philosophies about punishment in our society. The culture of incarceration and our beliefs about punishment in civil society affect how individual nurses provide “care” in the correctional setting.

Today I came across a tremendous article by Sally Gadow, Professor Emerita at University of Colorado College of Nursing that describes how different philosophies about punishment are manifest in the practice of correctional nurses (2003). Ascribing to a belief about the role of punishment and incarceration in society is necessary for nurses to address the ethical conflict between care and punishment.

It has made me consider how my nursing practice is affected by my beliefs about the role of incarceration and punishment. Here is a summary of the article.

Punishment as an immediate or reflexive consequence of wrong doing: The violation of community values, morays or laws results in an automatic or reflexive consequence for a wrongful act. In this system of beliefs the punishment occurs automatically and enforcement of the law or rule is unquestioned; there is no consideration of the circumstances or characteristics of the situation. Punishment for violation of norms in this system of beliefs require practices that exile the offender, deny freedom and loss of respect for the individual.

Nursing practices that are congruent with this philosophy about punishment include those that assert the authority of the law, morale principle or norm. In other words, nursing care that extends the interest of punishment. An extreme example would be participation in an execution. Other examples are writing infractions, participating in disciplinary hearings, collecting forensic evidence and approving use of force. When nurses comply with the expectations of the correctional system uncritically, they are at risk of providing care that advances the system perhaps at the expense of the individual. The American Nurses Association provides guidance in professional practice standard 11 on Communication stating that correctional nurses must be competent in questioning the rationale of processes and decisions when they do not appear to be in the best interest of the patient (2013).

Punishment as a logical consequence of wrong doing: An emotionally detached and reasoned approach to punishment and it’s meaning in relation to wrongdoing. Punishment still serves to exile the offender, deny freedom and express loss of respect for individuals who violate society norms and laws. Included in this category are the philosophies of “just desserts” which may also be known biblically as “an eye for an eye”. This is a belief that the degree of punishment should be equal to the severity of the violation. An example of this is the death penalty sentence for murder. Another belief is that of “fair play” when the benefits for a group (society) are achieved only when all comply with the rules. When someone fails to respect the rules a debt to society is owed and punishment is necessary to repay the debt. When we say that incarceration is the punishment, not the further denial of health care or programming during incarceration, this is an example of “fair play.” The last belief in this subset is that of “deterrence” which is to establish punishment severe enough to prevent harm or to protect the community. The punishment chosen is not constrained by the concept of fairness or reciprocity. An example of this would be three strikes laws which serve to deter recidivism and to remove repeat offenders from the community.

Correctional nursing practices consistent with this set of beliefs suppress emotion, embodiment and relationships with patients. The practice of nursing is with objective detachment. By being disengaged the nurse avoids being influenced in a negative or positive way by their personal knowledge of the offender. Many nurses adopt this approach to nursing practice believing that the best way to avoid being “conned” or manipulated by a patient is to rely solely on the nurse’s objective data discounting the patient’s report. With-holding analgesia because of a patient’s history of drug abuse is an example. Delays in responding to requests for health care attention because the problem is not significantly urgent would be another example. However there are numerous competencies listed in the ANA Scope and Standards of Practice (2013) that call for nurses to do more than adopt this disengaged approach to correctional nursing practice. The ANA standards for delivery of care in the correctional setting require nurses to elicit the patient’s personal experience and preferences with regard to illness, discomfort or disability and to partner with them to evaluate their care (Standards 1, 5-7) in a manner that preserves and protects the patient’s autonomy, dignity, rights, beliefs, and values.

Engagement as a paradox of punishment: Punishment is not an essential feature of justice but instead the focus is to restore trust and engagement between the offender and society. Detention may be necessary to engage the violator in the actions that are necessary to restore trust. The offender is not objectified and exiled but is made to relate in meaningful ways with the community. Examples of these beliefs in action include strengths based programming, drug and alcohol rehabilitation, probation and community corrections, half way houses and work camps. The meaning of the experience for offenders is the product of their engagement with others rather than an absolute defined by society.

A correctional nurse under this set of beliefs accepts the contradiction between care and punishment and does not need to embrace a particular viewpoint to resolve the conflict. The nurse assumes responsibility for defining their practice in the interest of the patient and does not accept someone else’s interpretation of how their practice should conform to some moral or ethical norm. Nursing actions are designed to assist prisoners to recover their ability to participate in the community and use their relationship with the patient as the crucible for this work. Engagement is characterized as accepting the possible validity of the patient’s perspective and the potential that the nurse’s opinion can be altered by the patient’s perspective. The nurse’s opinions or beliefs can be held firmly (not to be manipulated) but they are not absolute and open to the possibility of revision based upon experience with the patient or their situation. Dignity and respect for the patient is recognized as necessary to the caring relationship. An example is when nurses individualize a patient’s plan of care rather than apply the same intervention for all patients with the same condition. Patients are regarded as individuals rather than inmates. The ANA’s Standard 13 on Collaboration is explicit in that nurses promote engagement and participate in building consensus in the context of care for the patient (2013).

Conclusions: Correctional nurses often talk about the conflict between care and custody. Custody is a manifestation of beliefs about punishment. Nurses in correctional settings are influenced by the correctional culture, affecting their relationship with patients and ultimately their practice. I was surprised at the extent to which beliefs from all three of these descriptions have affected my practice environment. It is a relief to know that it is enough to recognize the care and custody conflict in order to find my way practically in this field. It is not necessary or even recommended that the conflict be resolved in order to provide ethical nursing care.

I suggest that correctional nurses reflect on the ways in which beliefs about punishment are manifest in their nursing practice. Reflection may suggest areas of practice that warrant more review and development. There may be aspects of practice that are unintentionally harmful or conflict with an ethical premise related to the nursing imperative of care. This material has been provided in the interest of stimulating dialogue among correctional nurses not to suggest a particular standard of practice.

For more on the ethical issues in providing nursing care in the correctional setting see Chapter 2 in our book, Essentials of Correctional Nursing. Order your copy directly from the publisher or from Amazon today!

 

Photo credit: © Andrey Popov – Fotolia.com

 

 

References

American Nurses Association (2013) Correctional Nursing: Scope & Standards of Practice. Silver Springs, MD: Nursesbooks.org.

Gadow, S. (2003) Restorative nursing: toward a philosophy of postmodern justice. Nursing Philosophy. 4: 161-167.

Leininger, M. M. & McFarland, M. R. (2006) Culture care diversity and universality: A world wide nursing theory. Boston, MA: Jones and Bartlett.

Six Challenges Managing Medications that make Correctional Nursing Unique

3d illustration of a corridor

 Medication management is a primary responsibility of nurses working in correctional settings (American Nurses Association (ANA) 2013). The Bureau of Justice Statistics reported that 66% of prisoners and 40% of inmates in jail who had a chronic condition were taking prescription medication. Among inmates with mental illness 27% of those in state prisons, 19% in Federal prisons and 15% in jails reported receiving prescription medication while incarcerated (Bureau of Justice Statistics, 2006). In addition to chronic medical problems and psychiatric disorders, medications are prescribed for inmates who have acute conditions, such as urinary tract infection as well as to provide symptom relief for minor illnesses and discomfort such as headache, constipation or seasonal allergies. As much as 80% of the population at a correctional facility may be taking medication for one or more of these reasons.

Medication management is identified as one of the features of correctional nursing that distinguishes it as a specialized field. Nurses who are new to the correctional setting are often unprepared for the scope and breadth of their role and responsibilities for managing medication delivery and yet they must meet the same standards for delivery of medication as in the community (ANA 2013).These challenges define what is unique about correctional nursing practice with regard to medications.

I started making a list of the challenges correctional nurses deal with in managing medication delivery. When the list became almost a full page long I sat back and thought about what similarities there were between the items and the following groupings came together.

  1. Professional isolation: Health care delivery in correctional facilities is often a very small part of the overall operation. In many cases nurses are expected to deliver services in independently and without advice from other health care providers. Nurses recently commented on CorrectionalNurse.net, Lorry’s other website that double checking dosages of high risk medications is a challenge when there is only one health care person on duty. One solution is to have the inmate confirm that the dose corresponded with what he or she understands it should be. Dispensing, drug packaging, storage inventory and disposal of medications are all subjects governed by state pharmacy laws and regulations. Unless there is a pharmacist on staff, correctional nurses need to be familiar with and ensure their practices comply with these requirements, in addition to the nursing regulations, when managing medication in the correctional setting.
  2. Security: Maintaining security is a primary focus of correctional facilities. This includes accounting for the presence and activities of each inmate throughout the day, ensuring that only authorized persons and products enter and exit the facility, and that contraband does not enter, is not otherwise obtained or manufactured. The most obvious example of a unique responsibility for correctional nurses is counting needles and syringes and accounting for each use. Others are ensuring access to inmates when medication is due (even on lockdown) and protecting patient confidentiality (not having medication lines that serve to identify the mentally ill or those with HIV disease for ridicule or extortion by others). Sometimes a facility will determine that for security reasons, not clinical, that all medication must be floated on water or even worse, crushed, impacting patient adherence, the time it takes to administer medication and in some cases the therapeutic effectiveness of the drug. Nurses need to confer with security on an ongoing basis so that security practices that compromise the therapeutic value of prescribed treatment are not put in place.
  3. Safety: The safety of inmates, staff and the general community is the other primary focus of correctional facilities. For correctional nurses this includes ensuring the safety of themselves and patients as well. A significant aspect of medication delivery is managing inmate behavior. This includes consistent practices for patient identification (two-part identification), checking that inmates don’t cheek or palm medication, providing privacy at the medication window or cart (prevent crowding). Often an officer will be assigned to escort the nurse or mange the medication line. Nurses need to engage the cooperation and assistance of this officer and be alert to their own behavior so that medication administration is conducted in a safe and efficient manner. The patient safety aspects are ensuring the cleanliness and hygiene of the medication delivery area to prevent transmission of infectious disease and monitoring conditions so that side effects from medications that make patients heat or light sensitive are prevented.
  4. Expanded role: Unless a correctional facility is large and has a number of specialized programs the health care program is likely to be staffed pretty simply without the support services nurses are used to in other health care settings such as pharmacy technicians, IV teams, respiratory therapists, inventory clerks and so forth. Nurses in correctional facilities routinely perform these roles instead and if there is assistance the nurse is responsible for their assignments and supervision. Nurses order medication from the pharmacy, arrange for refills and renewals, check for outdated drugs, receive, inventory and store medications and arrange for medication to be returned or properly destroyed. Nurse initiate treatment for patients via nursing standardized protocols that involve providing the patient with medication to treat the illness or manage symptoms. Nurses are the primary health care professional responsible to ensure that patients do receive medication as ordered and are expected to monitor patient adherence and solve problems with medication availability. Correctional nurses also assess the patient’s ability to manage their own medication if the facility has a self-medication or “Keep on Person” (KOP) program and to provide education or other assistance to support the inmates in providing their own care.
  5. Greater volume and scope: Because correctional nurses are responsible for the health needs of the entire population housed at one or more facilities they are generalists in nursing practice not specialists. Medications may be administered by a nurse or other personnel supervised by the nurse so that the inmate is directly observed when taking medication. Inmates may also be provided with a supply of medication by a nurse to take by themselves in a KOP or self- carry program. Nurses may also take medication to administer to patients in restraints, seclusion or housed in a high security setting for disciplinary or protective reasons. Nurses may give some medication under rules that allow for involuntary administration to patients with mental illness. In some correctional facilities nurses may be expected to use PICC lines or other specialized equipment or procedures to administer medication. The volume of medication administered by a nurse in the correctional setting exceeds that in any other setting. One difference is that most patients on pill line would be responsible for taking these medications by themselves or with the assistance of family in their own home.
  6. Timeliness: Medication delivery and administration must take place in coordination with all of the other activities that compete for the time and availability of inmates. In one facility I recently visited medication administration was halted on a unit until the canteen delivery was finished. The nurse was stranded in the corridor for twenty minutes until canteen was over. When the nurse insisted that medications be administered and canteen delivery wait the inmates complained bitterly. This is just one example of the competition for time. These time pressures can affect the therapeutic effectiveness of the drug if given too close or far apart. If inmates go to work or court before nursing staff are on duty inmates may miss important doses. The volume of medication to be given can impact timeliness; if there are too many medications a nurse may feel pressure to short cut or abandon the five rights resulting in increased patient risk.

So what are your thoughts about the uniqueness of medication management in correctional nursing practice? What have I forgotten or you would describe differently? Is there anything discussed here that you disagree with because it is not unique to correctional nursing. Share your thoughts in the comments section of this post.

Are you interested in knowing more about this nursing specialty? If so, see our book, Essentials of Correctional Nursing. Order your copy directly from the publisher or from Amazon today!

 

Photo credit: © Yannis Ntousiopoulos – Fotolia.com

References:

American Nurses Association (2013) Correctional Nursing: Scope and standards of professional practice. American Nurses Association. Silver Springs, MD.

James, D.J. & Glaze, L.E. (2006) Mental Health Problems of Prison and Jail Inmates. U.S. Department of Justice, Officer of Justice Programs, Bureau of Justice Statistics. Accessed 6.16.2015 at http://www.bjs.gov/content/pub/pdf/mhppji.pdf

Maruschak, L. M., Berzofsky, M., & Unangst J (2015) Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12. U.S. Department of Justice, Officer of Justice Programs, Bureau of Justice Statistics. Accessed 6.16.2015 at http://www.bjs.gov/content/pub/pdf/mpsfpji1112.pdf

What would you do in this situation? Comparing clinical judgement.

Last week’s post was an opportunity to exercise your skill in making clinical judgments about patients who present with possible mental health issues. This week the best clinical option in each case is described along with the rationale. Compare each answer to the conclusion you drew about what to do next with the patient. If your answer is different it is important to reflect on the reasons; it may be that you perceived the symptoms differently or that you had a past experience that influenced your decision. If your answer is the same did you have the same rationale or another?

Case # 1. Willie is a 46 year old man with a history of seizures, suicide attempts and has a mental health diagnosis of “psychotic disorder, not otherwise specified”. He is followed regularly in chronic care clinics for both the seizure disorder and mental health. Dilantin and Haldol are prescribed for him to take twice daily and he is for the most part adherent in taking the medication. This evening while administering medication cell side he will not come to the door to take his medication. He is responsive to you but his conversation is making no sense. His cell is messy and there are cartons of partially eaten food strewn about on the cell floor. What action do you take?

  1. Document your observations in the medical record.
  2. Take his vital signs.
  3. Call the medical provider.
  4. Make a referral to mental health.
  5. All of the above.

Rationale: There are both medical and psychiatric concerns here. Always consider medical reasons for disordered behavior first. This is because if diagnosed and treated early the consequences of delayed treatment are avoided (permanent disability, death, adverse events and stigma). Both medical and mental health staff need to be notified so that care of the patient is coordinated. Taking vital signs and initiating periodic monitoring as well as the description of symptoms by way of observation contribute important information to the patient’s evaluation by medical and mental health staff.

Case #2. Norma is a 55 year old woman with a history of bipolar disorder. She was taken off the mental health caseload several months ago because she was doing well. Recently she displayed threatening behavior to several other inmates and as a result has been put into administrative segregation. It is early in the morning and the officers complain to you that she has been awake all night, singing and prancing about the cell. You should do all of the following except:

  1. Try to speak with her and make your own observations of her condition.
  2. Document your assessment in the medical record.
  3. Join in her song to initiate a therapeutic alliance.
  4. Make an urgent referral to Mental Health.
  5. Call the Mental Health Clinical Supervisor to report that you have made the referral.

Rationale: While Norma is not imminently a danger to self or others right now, it is unusual behavior that needs to be addressed promptly. By trying to speak with her you can assess her ability to respond to others and the extent to which she is able to communicate. Obviously you will document your assessment in the record because otherwise “it never took place”, right? Communicating directly with the mental health supervisor about the urgent referral is recommended so that he or she has an opportunity to clarify information about your observations of the patient and has the information to follow up and ensure the patient is seen timely. Joining the patient in her song may not be interpreted by the patient as therapeutic (it could be viewed as demeaning, threatening or confusing) and it serves no therapeutic purpose.

Case # 3. Geraldo is a 35 year old man with diabetes. He is followed regularly in the chronic care clinic and his diabetes has been in fair control the last six months. At today’s insulin line you notice that he appears to be upset and say something to him about it. He says that he just got an additional 20 months on another sentence. He thanks you for your concern. What should you do next?

  1. Immediately contact the on call mental health provider.
  2. Make a supportive comment and provide information about how to access mental health services.
  3. Place him on suicide watch.
  4. Give him the insulin he needs and move on to the next patient in line.
  5. Suggest that he order some Honey Buns, a favorite comfort food, from the commissary.

Rationale: The other choices range from too much to too little, to counter-therapeutic, don’t they? He isn’t expressing actively suicidal intention so there is no basis for contacting the on call mental health provider or placing him on suicide watch. But he did just get “bad news” and looks upset about it. Don’t assume that every inmate is going to know how to access mental health services; they may not remember because it wasn’t something that was important at the time of explanation. Providing information about access also indicates that it is normal to be upset about bad news and that people can benefit from “help” in coping with these challenges. Suggesting that he eat “comfort food” undermines the management of his diabetes and is counter-therapeutic.

Case # 4. Tammy is a 23 year old woman received at the jail for the first time 72 hours ago on a charge of reckless driving. The officers have contacted you this evening because “she is going crazy” and has not rested or eaten over the last 24 hours. You check her medical record and note that on intake she gave no history of mental health treatment and denied use of drugs or alcohol. On interview she doesn’t make any sense, does not respond to requests and seemed to get increasingly agitated. She also was picking at things in the air and rolling her fingers. What would you do next?

  1. Have a drug urinalysis done.
  2. Place her on medical observation.
  3. Complete a CIWA-Ar evaluation.
  4. Contact the provider for orders.
  5. Follow up with the officer later in the shift.

Rationale: Even though Tammy denied use of drugs at intake screening and gave no history of mental health treatment these certainly are possibilities now. An earlier post commented that we should expect patients to under-report at intake use of alcohol and drugs and include possibility of withdrawal in our differential diagnosis. While you most certainly will contact the provider and place her on observation, the next step is to do a more focused assessment for withdrawal. The CIWA-Ar is a standardized assessment tool that many correctional health care programs use to manage patients in withdrawal. The data collected from an assessment with this tool will provide the clinician with important information to use in determining treatment and follow up of this patient.

Case # 5. Jamie is a 17 year old brought to jail on a charge of burglary. He has a history of several other detentions as a juvenile. Currently he is in segregation for failure to follow orders. He has multiple complaints of chest pain and indigestion because of the food served with the religious diet. He is brought to the clinic because he has cut himself. He has four superficial lacerations on his left forearm. You treat each of the wounds and after a brief examination release him to return to his cell. This is his fourth cutting episode. What would you consider the best next step to be?

  1. Schedule him for a nursing visit the next day?
  2. Make a referral to the mental health staff.
  3. Ask the dietician to see him about the religious diet.
  4. Suggest an interdisciplinary meeting to discuss his care.
  5. Report the cutting episode to the next shift.

Rationale: Repeated cutting, even when not severe, is considered self-harm. Self-harm is a form of psychological distress, even in the absence of a diagnosed mental illness. Since this is his fourth episode, we can expect to see more episodes of cutting or other forms of self-harm with accidental or intentional suicide a real possibility. Since his maladaptive behavior effects everyone (security, medical, food service, religious services and mental health) an interdisciplinary plan of care is going to be the most effective. Nursing staff are in the key position to make this recommendation because we see the constellation of problems he presents (segregation, physical complaints about the diet, self-harm etc.).

Learning from case examples

Exercising good clinical judgement is one of the most essential features of correctional nursing. The right to a clinical judgment is one of the three constitutional rights that inmates have while incarcerated and nurses are most often the first health care professional to make a clinical judgement about an inmate in the correctional setting. Comparing decisions about cases is one way to increase information and build skill in making clinical judgments.

So how do your clinical judgments compare to these recommendations? In what way do they differ and why? For example if mental health services are limited only to those with the most severe symptoms you may not provide information to Geraldo in Case # 3 about accessing mental health for help coping with “bad news”. But what if he has trouble coping? Suicide is a risk resulting from “bad news” so what is an alternative clinical judgement? Schedule him for a nurse follow up visit? Are there other programs at your facility to help…such as the chaplain or a volunteer group? Examining your answers in this way may lead to identification of additional resources that you may want to use or develop further.

You may want to discuss each of these cases with other nurses at your facility to find out what others would do. If you do this as a group you may find that there are more resources than any one individual knew were available. These cases also would be great for an interdisciplinary discussion. If each member discusses what is their most important next step and why, other disciplines will know more about each program and its operation so that work with the inmate is coordinated rather than at cross purposes. These discussions will also identify opportunities to improve the management of inmates or eliminate gaps or barriers in service that are a liability risk.

We are interested in hearing your comments about what you think is the best clinical judgement in these cases. To do so please respond in the comments section of this post. To learn more about correctional nurses’ assessment of mental illness, response to suicide, self -harm and withdrawal, see our book, Essentials of Correctional Nursing. Order your copy directly from the publisher or from Amazon today!

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