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!

Photo credit: © chrisharvey – Fotolia.com

Clinical judgment resulting from the mental health assessment

Man Woman face people problem puzzle

Previous posts have described the prevalence of mental disorder among inmates in our prisons and jails today. Every correctional nurse has witnessed the incredible suffering that the mentally ill experience during incarceration. In addition to the illness itself, mentally ill inmates are more likely to be stigmatized and perhaps victimized by other inmates, housed in isolated areas to prevent harm to themselves or others, receive long segregation sentences for rule infractions, and have difficulty finding safe housing and employment once released to the community. We also know that serious medical problems can mimic psychiatric problems and that an astute nursing assessment can prevent adverse patient outcomes.

Finally just because an inmate was not identified at intake as having a mental illness does not mean that a mental health problem cannot occur at any time later during incarceration. Stressful situations that increase the risk for developing or worsening mental illness include:

  • Recent changes or loss of privileges
  • Isolated housing assignments such as disciplinary or administrative segregation or protective custody
  • Environmental changes such as a change in cell mate, transfers within the facility or transfer to another facility
  • Assault (sexual, physical, intimidation)
  • Bed news about a death in the family, unfavorable legal decision, new medical diagnosis, divorce, loss of job, etc.
  • Pain (acute or chronic)
  • Conflict within own family or among peers

Correctional nurses may be the first health professional to identify a patient in need of mental health treatment. Even when an inmate is seen regularly by mental health staff, nurses still see the patient more frequently (during sick call, medication administration and segregation rounds) and can identify changes in condition earlier resulting in a referral for additional evaluation and treatment.

How nurses assess a patient’s mental health assessment was discussed in a three part series of posts in October 2012. Briefly the process involves observing the appearance of the person and their cell, their behavior during your interaction with them, their affect, thought process and content and cognition. It is more important to give a description of the symptoms or behavior rather than use diagnostic labels. The use of a standardized assessment process and screening tools will yield more accurate clinical judgments when determining if a referral is necessary and if so to whom and by when.

The following are five case examples to test your clinical judgement in deciding the next steps to take. Make a note of what answer you think is the best next step for the nurse to take. If you think an option other than those listed is better please write it down.

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, unspecified”. 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.

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.

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.

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.

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.

Next week we will discuss the preferred next steps for each case and the rationale. If you disagree or have a better option we want to hear from you in the comments section. In the meantime to read more about mental health care in correctional nursing see Chapter 12 of our book the Essentials of Correctional Nursing. Order your copy directly from the publisher today.

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Pender’s Model Could Transform Your Chronic Care Clinic – Honest!

It might be nutty, but I’m really getting into these nursing theorists and how to use their work in the correctional nursing specialty. I recently wrote about Orem’s Self-Care Theory with Nursing Sick Call and Peplau’s Interpersonal Relations with Intake Screening. So, why not try Pender’s Health Promotion Model in a Chronic Care Clinic?  Are you with me on this? Let’s go!

Nola Pender developed the Health Promotion Model (HPM) in the early 1980’s as a framework to describe how nurses can motivate patients toward desired healthful outcomes. The model is based on nursing, human development, and social cognitive theory. Pender sees a nurse’s role as collaborating with the patient to create the most favorable conditions for optimal health and well-being. This is particularly well-positioned for chronic disease management where nurses must motivate patients to make long-term lifestyle changes to improve health.

Assume the Best

A major underpinning of the HPM is the assumption that individuals value growth and seek improvement in their health status. Self-efficacy, a belief in the ability to succeed, is an important part of the model. The nurse, as well as the patient, needs to believe that positive change is possible. Here is where correctional nurses may need some self-reflection. The inmate patient population can seem mired in a sea of poor life choices that they cannot (or will not) overcome. Bringing a negative attitude to the nurse-patient relationship can affect the patient’s willingness to try and the nurse’s desire to motivate the patient to make positive health decisions.

Here are some other propositions that are foundational to this model.

  • Patients commit to actions that they anticipate will provide benefits of high value.
  • The more positive the emotions associated with a behavior, the more likely the behavior will take place.
  • Family, peers, and health care providers are a source of influence in health decision-making.

Past Affects the Present

Of particular importance to correctional nursing may be the connection between past experience and present situation in motivating needed health behavior changes.  Prior related behavior and personal factors affect willingness to take health actions. For example, self-esteem and self-motivation are important factors, as are the patient’s perception of their health status. In addition, race, ethnicity, culture, education, and socioeconomic status influence decisions to improve health.

So, by assuming the patient is able to change and factoring in their past experiences and background, nurses can motivate patients to make the necessary, even difficult, changes to support a healthy outcome. Most definitely, this is a simplistic overview of Pender’s Model but it gives us the basic framework for application in the correctional setting. Here is a diagram of the key elements of the Health Promotion Model borrowed from NursingPlanet.com.

hpm

Applying Pender’s Health Promotion Model to Chronic Care

Could the HPM be helpful in your Chronic Care Clinic (CCC)? Let’s give it a go. Here is a common situation.

Inmate Nagy, age 45, was just diagnosed with Type II Diabetes and is in for his first CCC visit after hearing the news. He has no other chronic diseases and is a Desert Storm veteran with PTSD and brain injury symptoms. He is in a patient education session with the chronic care nurse after his appointment with the provider.

The nurse starts by explaining in simple terms what Type II Diabetes is and the effects and side effects of the new medication prescribed. Inmate Nagy is asked to share back this information to the nurse as he would if he were describing his condition and medication to a family member. Once this is successful, the nurse begins to gather information to help motivate the patient toward changing his eating habits. Based on the principles of the Health Promotion Model, these are the questions asked (modified from this resource):

Prior Behavior

  • What attempts have you made in the past to eat healthy foods?
  • What did you learn from these attempts?

Personal Influences

  • What are the personal benefits of improving your eating habits?
  • What problems (barriers) might you have trying to eat healthier foods?
  • What healthy foods do you enjoy most?

Interpersonal Influences

  • Social Norms – Do any of your family members or friends expect you to eat healthy foods? If so, who, and what do they do?
  • Social Support – Who will encourage you to eat healthy meals?
  • Role Models – Do any of your family members or friends eat healthy meals most of the time? If so, who?

Situational Influences

  • Where can you find healthy foods to eat that you enjoy?

Commitment to a Plan of Action

  • Are you ready to set goals and develop a plan to eat healthier meals?

During this discussion Inmate Nagy identified that he had attempted to eat healthy several times in his early 20’s but was only successful with a lot of effort. He doesn’t like ‘rabbit food’ and prefers a high meat diet. He has noticed in the last few years that he does not feel well on a high starch diet and occasionally tries to avoid chips and ice cream. He does like fruit; especially oranges and grapes. The only vegetable he likes is corn. His younger sister is a ‘health food nut’ and has often tried to get him to eat better.

Armed with this information the nurse asked Inmate Nagy to get in touch with his sister and share his news and ask her for some ideas for health eating. He was also asked to use a provided food list to make at least 3 healthy food substitutions when he is in the dining hall and commissary. An appointment was set for 2 weeks later to review his progress and set new goals.

So, what do you think? Would Pender’s Health Promotion Model transform your Chronic Care Clinic? Share your thoughts in the comments section of this post.

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Peplau’s Theory of Interpersonal Relations – Could This Really Work in Correctional Nursing?

Peplau’s Theory of Interpersonal Relations – Could This Really Work in Correctional Nursing?

In the last post I applied Orem’s Self-Care Theory to correctional nursing practice. It fit well in a sick call situation but doesn’t give much attention to the emotional/psychological needs of the patient. So, I have been on the search for a practical theory that might help in that sphere. Thus, I happened upon the classic nursing theory of Interpersonal Relations developed by Hildegard Peplau.

What is attractive about Peplau’s theory of nursing practice is that it focuses on the dynamics of the nurse-patient relationship and sees the nurse’s role as a therapeutic force in that relationship. She also emphasizes the importance of communication and interviewing skills in nursing practice and that nurse-patient interactions promote growth for both the patient and the nurse. Correctional nurses must often quickly develop relationship in brief patient encounters in order to determine the health concern and needed interventions so Peplau’s theory holds promise for application in the criminal justice system. Here are the high points.

Progressing Roles

The Theory of Interpersonal Relations provides a number of roles the nurse plays in a patient relationship depending on immediate needs. These roles can change overtime as the patient progresses through various stages in their health or illness. Here are a few of the common nursing roles identified in the theory.

  • Stranger – Start the relationship with an accepting attitude that will build trust
  • Teacher – Provide information related to the patient’s need or interest
  • Resource Person – Provide information that will assist in better understanding a situation or problem
  • Counselor – Assist the patient to integrate the meaning of the current situation along with guidance and encouragement to adapt to new situations
  • Surrogate – Act on the patient’s behalf as an advocate, when needed
  • Leader – Encourage the patient to take on the responsibility for meeting health care needs

Phases of the Nurse-Patient Relationship

Besides various roles, there are also natural phases that a nurse-patient relationship moves through.

  • Orientation: During this phase of the relationship the nurse identifies the health care problem of concern and moves from a stranger to one or more of the other roles depending on what is discovered.
  • Identification: Here the nurse determines the appropriate professional assistance to provide to the patient. The patient, in turn, begins to feel supported and has decreased feelings of helplessness and hopelessness.
  • Exploitation: In this phase assistance is provided and the nurse supports the patient in ‘exploiting’ all the avenues of help.
  • Resolution: In this final phase the patient leaves the relationship in a healthier emotional balance, no longer needing professional nursing services. The relationship ends.

Applying Peplau’s Theory to Correctional Practice

Will Peplau’s theory work in a correctional nursing interaction? Let’s apply it in this intake screening encounter.

A 34 year old husband and father of 2 is booking in to a small county jail on a 30 day sentence for possession and sale of a controlled substance. A nurse is performing the receiving screening and preparing to place a TST when he states, “I just want to get this over with. I figure if I mind my own business I can stay out of trouble and get on with it. They’ll leave me alone, won’t they?” He looks stiff and nervous.

How might Peplau’s Theory of Personal Interaction help in this patient situation? Let’s walk through the phases of the nurse-patient relationship.

Orientation: Using an accepting tone of voice and open body language the nurse responds, “It’s tough going to jail. Tell me about your concerns. Maybe I have some information for you.”

Identification: The patient is slow to respond but finally shares with the nurse that he has never been in jail before and he is anxious about gangs, violence, and sexual assault. He says he has seen a lot of things on television. The nurse determines that she can take on the role of teacher, resource person, and counselor to this patient.

Exploitation: The nurse acknowledges his anxiety, instructs him on how to access health care and some of the other support services available, including chaplain services. She explains that, fortunately, there is little gang activity or sexual assault in this small jail and counsels him on how to report any sexual advances.

Resolution: The patient is visibly more relaxed after this information is shared and proceeds through the rest of the health screening. At the conclusion of the encounter, the nurse makes direct eye contact with the patient and states, “You can do this. It may be one of the toughest things you have ever done, but you can make it through.” The patient nods and seems to be pondering those words as he heads back out to the booking room.

So, what do you think? Would Peplau’s Theory of Interpersonal Relations work in your setting? Share your thoughts in the comments section of this post.

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