Considering productivity in sick call

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

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

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

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

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

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

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Pustules, Furuncles and Petechia, Oh My!

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

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

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

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

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

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

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

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

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

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

References and Resources:

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

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Dealing with the Difficult Patient

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

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

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

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

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

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

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

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

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

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

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Alcohol Withdrawal: Do You Know the Signs?

AlkoholismusAlcohol withdrawal is the most serious of substance withdrawal situations. Do you know the signs of this condition? Most everyone working in a jail for even a short time is aware of the substantial use of alcohol by those detained for criminal activity or other law violations. Indeed, many of these law violations are a result of alcohol overuse such as DUI, traffic violations, and personal injury due to car crashes. As many as 85% of inmates are substance involved in some way. One study of data from the Arrestee Drug Abuse Monitoring Program (ADAM) estimates 1.2 million arrestees were alcohol dependent in 1997.

BOLO!

Be on the lookout for alcohol withdrawal in all your jail patients. Universal screening for alcohol withdrawal is recommended by the National Commission on Correctional Health Care (NCCHC) in their Alcohol Detoxification Guideline. They recommend that every intake screening include the following:

  • An explanation of why alcohol screening is taking place – to identify those who need treatment for withdrawal
  • Questions about the type, amount, frequency, duration of use, and withdrawal history
  • Immediate medical evaluation for a positive history of heavy and regular alcohol use.

NCCHC guidelines also recommend the use of a standard screening tool such as the Simple Screening Instrument for Substance Abuse (SSI-SA). This list of questions is indeed simple and less cumbersome than many alternatives. An advantage of this tool is that is can be used for either drugs or alcohol. The patient’s answers to 16 yes/no questions are then scored along a continuum of degree of risk for abuse.

Another highly-credible alcohol screening tool is CAGE, discussed in a prior blog post. CAGE is even shorter than the SSI-SA and is specific to alcohol intake. Two positive responses are considered a positive test and indicate further assessment is warranted.

The World Health Organization (WHO) recommends use of AUDIT – the Alcohol Use Disorders Identification Test. This tool was developed and extensively evaluated in a variety of settings, making it a credible screening option.

Whatever tool you use, it is important to consistently screen every incoming patient.

Expect Under-Estimation

There are many reasons your patients may under-estimate their alcohol involvement. First of all, if alcohol use could be a contributor to the activity that resulted in detainment, your patient may not want to emphasize use. Then, trust might be lacking in the nurse-patient relationship that will limit full disclosure. Finally, people generally under-estimate poor habits while over-estimating good behaviors. For all these reasons, some seasoned jail nurses mentally double the estimated drinking reported on intake. Although that might be extreme, expecting under-estimation can help you better predict withdrawal potential.

Assume It Is Present

Alcohol withdrawal should be top-of-mind when screening those entering the criminal justice system. Besides screening tool results, NCCHC guidelines also recommend that immediate medical evaluation be sought for observable symptoms of current alcohol use such as alcohol on the breath, unsteady gait, or confusion.

Withdrawal from alcohol causes increased excitability in the nervous system leading to the following manifestations:

  • Nausea and/or vomiting
  • Tremors, tremulousness, or agitation
  • Confusion
  • Unsteadiness or lack of coordination

Any of these symptoms should indicate a deeper evaluation of alcohol withdrawal potential.

How do you screen for potential alcohol withdrawal in your setting? Share your thoughts in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

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Identifying Prescription Drug Misuse and Abuse

piatto di farmaci e drogaOne of my first mentors in correctional health care described prisons and jails as functioning like a city or town with many of the same characteristics as the surrounding community. I still think that is a good description. So we can expect trends identified in the larger community to eventually transcend the walls of the correctional facility in some way. One of these trends is the growing problem of prescription drug misuse and abuse.

According to a 2010 survey done by the Substance Abuse and Mental Health Services Administration more Americans over age 12 are taking prescription medications for non-medical purposes. These medications include pain relievers, tranquilizers, stimulants, sedatives and psychotherapeutic drugs. More than half of those said that they obtained the drug from a friend or relative for no cost. More than half the teens surveyed in another study obtained prescription drugs for non-medical purposes from the family medicine cabinet (Kirchner et. al., 2014).

The Centers for Disease Control and Prevention (CDC) reports that visits to Emergency Rooms (ER) increased 114% from 2004 to 2011. The majority of this increase is due to misuse or abuse of pharmaceuticals. In 2011 half of the admissions to the ER were related to prescription drug misuse or abuse. Of these admissions, one third involved medications used to treat anxiety or insomnia and another third were opioid analgesics (2014).

Deaths by poisoning or drug overdose have been the leading cause of injury in the United States since 2008. Overdose deaths have increased five-fold since 1980 (Kirchner et. al., 2014). In 2010 among deaths related to overdose with prescription drugs 75 % involved opioid analgesics and 35 % involved benzodiazepines. The number of overdose deaths from opioid analgesics is now greater than those of deaths from heroin and cocaine combined (CDC 2014).

All of this is to say that detainees arriving at our jails and prisons are likely to have recently misused or abused prescription drugs. Thorough, routine and non-judgmental inquiry about recent drug use during reception health screening is essential to identify individuals who will need to be managed medically during withdrawal. These questions should solicit the name of the drug, the usual dose; the route used, frequency, date and time of the last dose. Other questions include previous withdrawal symptoms and whether hospitalization was necessary (Laffan 2013).

The characteristics of people who overdosed with prescription drugs include:

  • Middle age
  • Male
  • White, Native American or Alaska Native
  • Rural community
  • History of chronic pain
  • History of mental health disorder
  • History of substance abuse
  • Have multiple health care providers or inconsistent providers
  • Taking multiple prescriptions (DHHS, 2013).

These are not listed as a definitive means to diagnose prescription drug abuse but instead to point out how many of our inmates have these same characteristics and are at risk of adverse consequences from this behavior.

When inmates are identified who will need assistance with detoxification the nurse’s next step is to contact a provider. Monitoring and management of withdrawal from prescription drug abuse should be initiated by a provider according to protocols established by the facility medical director. Nurses should not be expected to use standing orders to initiate detoxification (NCCHC 2014). For more about drug withdrawal in the correctional setting read Chapter 5 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Resources:

Centers for Disease Control and Prevention. (2014) Prescription Drug Overdose in the United States: Fact Sheet. Accessed at http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html.

Kirschner, N., Ginsburg, J., Sulmasy, L. S., (2014) Prescription Drug Abuse: Executive Summary of a Policy Position from the American College of Physicians. Annals of Internal Medicine 160 (3).

Laffan, S. (2013) Alcohol and Drug Withdrawal in Schoenly, L. & Knox, C.M. (ed.) Essentials of Correctional Nursing, pp. 81- 96, (New York: Springer Publishing Company LLC).

National Commission on Correctional Health Care. (Prisons and Jails 20014). Standards for Health Services. National Commission on Correctional Health Care.

U.S. Department of Health and Human Services (DHHS), Behavioral Health Coordinating Committee, Prescription Drug Abuse Subcommittee, (2013) Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities. Accessed at http://www.cdc.gov/HomeandRecreationalSafety/overdose/hhs_rx_abuse.html.

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Clinical Communication with Patients who are Deaf or Hard of Hearing

abstract human face 3d illustrationIt is 1 o’clock Saturday morning and the police have just arrived with a middle aged man to book into jail for an assault that took place in the city an hour ago. He has abrasions on his face, neck and hands; he is observant and seems compliant with the officers’ instructions. Custody staff complete booking and he is brought to medical for intake health screening. The officer tells the nurse that the man is deaf. The nurse writes on a notepad “Can you read and write?” The detainee nods his head affirmatively. The nurse puts the intake screening form in front of the detainee and points to each question on the form. The detainee nods his head in a “no” gesture to each of the screening questions. The nurse takes vital signs, examines the abrasions, applies a bactericidal ointment and then observes the detainee while he is changing into the jail uniform. His deafness and abrasions are noted; no other problems are identified by the nurse and the detainee is given a handbook that explains how to access health care when he is released to housing.

Did this nursing encounter meet the standard of care for persons in correctional settings who are deaf or hard of hearing?

The components of receiving screening defined by the American Corrections Association (ACA) and the National Commission on Correctional Health Care (NCCHC) are that a screening form is used to inquire about the status of each detainee’s health and that reception personnel observe the detainee’s condition for signs of illness or injury before making decisions about disposition. NCCHC also states in the discussion of the standard that “Receiving screening is conducted using a form and language fully understood by the inmate, who may not speak English or may have a physical (e.g., speech, hearing, sight) or mental disability” (2014, page 72). The nurse modified how the receiving screening data was collected when the detainee indicated that he could read and write. Literally interpreted the accreditation standards were met. But were best practices used to screen for potential emergency situations, treating illness or continuing prescribed medication?

The Americans with Disabilities Act passed in 1990 establishes specific requirements that apply to persons who are deaf or hard of hearing in correctional settings. These include:

  • Giving primary consideration to providing the aid or service requested by the person with the hearing disability.
  • Communication aids and services may not be denied except when a particular aid or service would result in an undue burden or a fundamental change in the nature of the law enforcement services being provided.
  • Only the head of the agency or his or her designee can make the determination that a particular aid or service would cause an undue burden or a fundamental change in the nature of the law enforcement services being provided.
  • Not charging for communication aids or services provided.
  • Providing effective, accurate, and impartial interpreters when needed.

In this case the nurse did not inquire about the type of communication aid or service the detainee preferred but instead only asked if the detainee could read and write. Relying on writing or pointing to items is effective communication for brief and relatively simple face-to-face conversations. Having the detainee fill out the health history portion of the intake screening form may be appropriate if he is literate enough in medical terminology. While many who are deaf and hard of hearing indicate the ability to read lips nurses need to be cognizant that only about 30% of what is said can be accurately interpreted (Shuler et. al., 2013). If the detainee indicates he has any medical or mental health problems, is seeing a provider in the community or is taking medication the nurse will have to use a more interactive and accurate communication method. These include:

Sign language interpreters: There are several kinds of sign language, including American Sign Language (ASL) and Signed English. When arranging for an interpreter be sure to ask what form of sign language the detainee uses.

Oral and cued speech interpreters: Some individuals have been trained in lip reading and with assistance from an interpreter can understand spoken words fairly well.

Transcription services: Many people who are deaf or hard of hearing are not trained in either sign language or speech reading. There are several types of devices that allow a person who is deaf or hard of hearing to communicate by typing. These include Computer Assisted Real-time Transcription (CART) and text telephone (TTY or TTD).

Video services: use high speed internet and wireless connections to link a camera or videophone that transmits sign language to an interpreter who conveys the message verbally to the hearing person.

Each state defines the education and training required to be considered a qualified interpreter and may also require certification. Since the ADA requires that interpreters in correctional settings be effective, accurate, and impartial special care should be taken in arranging for interpreters. Using staff who “know sign language” or family members to interpret may not meet these criteria. Further the nurse needs to document in the detainee health record what effort was made to inquire about communication preferences, arrangements made to provide assistance and if an interpreter is used document their name, certification or qualification and contact information.

The detainee in this example was scheduled to be seen by a nurse the following day to review the intake screening information and complete the history portion of the initial health assessment. Correctional staff at booking inquired about the detainee’s communication preferences and had noted in the classification system that he used American Sign Language (ASL). The nurse was aware of this and made arrangements for the presence of a qualified interpreter at the nursing encounter the next day. The ADA does not require that the services of an interpreter be immediately available  at intake for example but that arrangements are made in a reasonable amount of time when they are necessary.

Best practices summary

• Before speaking, get the person’s attention with a wave of the hand or a gentle tap on the shoulder.

• Face the person and do not turn away while speaking.

• Try to converse in a well-lit area.

• Do not cover your mouth or chew gum.

• Minimize background noise and other distractions whenever possible.

• When you are communicating orally, speak slowly and distinctly. Use gestures and facial expressions to reinforce what you are saying.

• Use visual aids when possible, such as pointing to printed information or photos.

• When using an interpreter, look at and speak directly to the deaf person, not to the interpreter.

  • Talk at your normal rate, or slightly slower if you normally speak very fast.
  • Only one person should speak at a time.
  • Use short sentences and simple words (U.S. Department of Justice, Civil Rights Division, Disability Rights January 2006).

It is estimated that up to nine percent of the population has some degree of hearing loss, and this percentage will increase as the population ages. So as correctional nurses, we expect to come into contact with people who are deaf or hard of hearing. In your opinion was the standard of care met in the intake screening and assessment of this detainee’s health status? What are the challenges in providing nursing care for detainees who are deaf or hard of hearing? Please share your opinions and experience by responding in the comments section of this post.

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

References:

American Corrections Association. (2010). 2010 Standards Supplement. Alexandria, VA.: American Corrections Association.

National Commission on Correctional Health Care. (Prisons and Jails 20014). Standards for Health Services. National Commission on Correctional Health Care.

Shuler, G.K; Mistler, L.A.; Torrey, K.; Depukat, R. (2013). Bridging communication gaps with the deaf. Nursing 2013 43 (11): 24-30.

U.S. Department of Justice, Civil Rights Division, Disability Rights. (January 2006). Communicating with People Who Are Deaf or Hard of Hearing: ADA Guide for Law Enforcement Officers. Accessed June 16, 2014 at http://www.ada.gov/lawenfcomm.htm.

U.S. Department of Justice, Civil Rights Division, Disability Rights. (October 2003). ADA Business BRIEF: Communicating with People Who Are Deaf or Hard of Hearing in Hospital Settings. Accessed June 16, 2014 at http://www.ada.gov/hospcombr.htm.

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Happy New Year: Alcohol Withdrawal

Alkoholflasche in PapiertüteIt is New Year’s Eve and the police have just brought a middle aged man into the booking area on an arrest for drinking while driving. The man is in his 50’s, staggering but attempting to follow the booking officer’s directions. This is his first arrest so there is no history or prior information about him. The booking officer asks you to assess the man and decide if he can be accepted at the jail or if the arresting officer should take the man to the hospital for further assessment and possible treatment.

Use of alcohol is widespread among persons brought to jail.  A third of all inmates booked into jail were drinking at the time of arrest. Almost half of all jail inmates report alcohol use that met the definition for dependence or abuse (Karberg & James 2005).  Access to alcohol is disrupted by detention or incarceration and puts individuals who regularly use alcohol at risk of alcohol withdrawal syndrome. Seventy-four percent of deaths from intoxication took place within the first seven days of admission according to the Bureau of Justice Statistics (Noonan 2010). Identifying inmates at risk of alcohol withdrawal and treating these patients proactively is the most important step in preventing alcohol related death in jail. See a post on this topic at http://correctionalnurse.net/2010/03/31/alcohol-withdrawal-jail-nurse-alert/. The decision to accept this man into the jail or send him to the local hospital for further evaluation is going to depend upon two things:

  • An assessment of the patient’s condition and
  • The facility’s capacity to provide ongoing monitoring and treatment.

At the initial medical clearance any person presenting with the following should be referred to the hospital:

  • Inability to ambulate without assistance
  • Fever greater than 1010 F
  • Serious trauma or other injury
  • Profound confusion or altered sensorium
  • Tremors
  • Seizure activity
  • Autonomic dysfunction (dilated pupils, pulse greater than 120, blood pressure greater than 120, severe diaphoresis and/or flushing).

If the person does not have any of the conditions described above use of a standardized alcohol consumption assessment tool is recommended in addition to the health screening questions asked at intake (Laffan 2013, Department of Veterans Affairs 2009).  Two recommended tools are the CAGE Alcohol Abuse Assessment Tool which was discussed in a previous post and the Alcohol Use Disorders Identification Test (AUDIT-C). The AUDIT-C tool identifies individuals who are hazardous drinkers or have active alcohol use disorders.   It consists of only three questions: 1. How often do you have a drink containing alcohol?

  1. Never
  2. Monthly or less
  3. 2-4 times a month
  4. 2-3 times a week
  5. 4 or more times a week

2. How many drinks of alcohol do you have in a typical day?

  • 1 or 2
  • 3 or 4
  • 5 or 6
  • 7 to 9
  • 10 or more

3. How often do you have six or more drinks on one occasion?

  • Never
  • Less than monthly
  • Monthly
  • Weekly
  • Daily or almost daily

Each answer is scored; an answer of “a” equals zero points and an answer of “e” equals 4 points for a possible total points of 12.  Men who score 4 and women who score 3 or more are considered hazardous drinkers with active alcohol use disorders (Bush et al. 1998, Department of Veterans Affairs 2009). These individuals will likely experience withdrawal symptoms that need to be monitored and treated medically. Inmates who are pregnant, have other chronic medical problems, or give a history of delirium tremens or seizures upon withdrawal are more at risk of morbidity and mortality associated with alcohol withdrawal. A provider should be contacted immediately to initiate and manage the care of these patients during incarceration. The table below describes the symptoms and nursing care required by patients undergoing alcohol withdrawal. Facilities without the capacity to provide 24 hour monitoring and availability of on-call provider consultation should be prepared to refer detainees to the hospital for required monitoring and care. Good clinical oversight, thoughtfully prepared protocols and trained staff are sufficient to manage inmates with minor and moderate withdrawal symptoms.

Condition Symptoms Nursing actions
Minor withdrawal
  •   Nausea
  •   Sleeplessness
  •   Night sweats
  •   Anxiety
  •   Irritability
  •   BP = 140/90
  •   Mild tremor
  •   Disturbance in vision, hearing or sensation.
  •    Symptom monitoring (CIWA –AR) q 4 hours
  •   Encourage fluid intake (8-10 glasses daily)
  •   Medication for anxiety or agitation
  •   Provider ordered medications
Moderate withdrawal
  •   Inability to concentrate
  •   Forgetfulness
  •   Numbness of hands or feet,
  •   Severe agitation or anxiety
  •   Tremors
  •   Disturbance in vision, hearing or sensation
  •  Admit for inpatient care
  •   Vital signs q 4 hours
  •   CIWA-AR q 4 hours
  •   Oral fluids (10-12 glasses daily)
  •   Provider ordered medications
Severe withdrawal
  •   Hallucinations or  delusions
  •   Profound confusion or altered sensorium
  •   Autonomic dysfunction
  •   (dilated pupils, fever, pulse greater than   120, diastolic BP greater than 110, severe diaphoresis or flushing)
  •   Seizure activity
  •  CIWA-AR greater than 15
  •   Emergency transport to the hospital
  •   Notify provider immediately

The Clinical Institute Withdrawal Assessment-Alcohol Revised (CIWA-AR) is a nationally recognized tool for monitoring alcohol withdrawal (Bayard et al. 2004).  The use of a standardized tool provides a consistent basis for serial evaluations of withdrawal symptom and can serve as the source for protocols that define treatment orders and timeframes for contacting a provider or referring for offsite care (Laffan 2013). On assessment of the inmate in the case example above the nurse found that the patient was at risk of withdrawal symptoms but he did not have any complicating medical conditions and so was cleared for booking. After completing the initial screening exam the nurse put him on the facility’s alcohol withdrawal protocol that included medically supervised housing and a treatment plan concurrent with the suggestions in the table above. What do you do at your facility to recognize and treat alcohol withdrawal? Share your thoughts in the comments section of this post. For more about alcohol withdrawal read Chapter 5 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.  References Bayard, M., McIntyre, J., Hill, K.R., (2004) Alcohol withdrawal Syndrome. American Family Physician, 69 (6) 1443-1450. Bush, K., Kivlahan, D.R., McDonell, M.B., Fihn, F.B., Bradley, K.A. (1998) The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Archives of Internal Medicine 158 (16) 1789-95. Department of Veterans Affairs. (2009) Management of Substance Use Disorder. Accessed 12/230/2013 at http://www.healthquality.va.gov/Substance_Use_Disorder_SUD.asp Karberg, J.C. & James, D.J. (2005) Substance Dependence, Abuse and Treatment of Jail Inmates, 2002. Bureau of Justice Statistics, Special Report (NCJ 209588). US Department of Justice, Office of Justice Programs. Accessed 12/30/2013 at http://www.bjs.gov/content/pub/pdf/sdatji02.pdf Laffan, S. (2013) Alcohol and Drug Withdrawal in Schoenly, L. & Knox, C.M. (ed.) Essentials of Correctional Nursing, pp. 81- 96, (New York: Springer Publishing Company LLC). Noonan, M. (2010) Mortality in Local Jails, 2000-2007. Bureau of Justice Statistics, Special Report, US Department of Justice, Office of Justice Programs. Accessed 12/30/2013 at  http://www.bjs.gov/content/pub/pdf/mlj07.pdf Photo credit: © artenot -Fotolia.com