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.

Photo Credit: @ Krasimira Nevenova – Fotolia.com

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