The Challenges and Distinguishing Features of Correctional Nursing: Part 3

Tonia FaustThe last two weeks we explored two of the challenges in becoming a correctional nurse and how once mastered, the results are practices that distinguish correctional nursing from other areas of nursing practice. A final cultural challenge for nurses in the land of correctional Oz, a phrase Lorry coined for nurses new to the specialty, is to develop a caring practice, consistent with professional principles. Many correctional nurses lament “how can I be caring when the place where I work exists for the purpose of punishment?” In correctional settings, staff are cautioned against touching an offender, unless it is necessary to perform some task, such as a pat down search. Some places go as far as considering touch, an act for which staff can be disciplined.

Common expressions of caring in nursing such as therapeutic touch or an empathic disclosure of personal information are often prohibited or extremely limited in the correctional setting. These acts earn a nurse derision from other staff, particularly custody staff, and they will be taunted as a “chocolate heart”, “hug-a-thug” or “convict lover.” Correctional officers will not trust nurses who violate the facility’s expectations about maintaining boundaries, to act professionally in other encounters.

Caring however remains a central tenet of correctional nursing and is vital to the therapeutic relationship. Another distinguishing characteristic of the specialty, is that the expression of caring, emphasizes interpersonal communication rather than physical contact and use of self to convey empathy. Correctional nurses express caring when their interactions with patients convey respect, are nonjudgmental, acknowledge the validity of the patient’s subjective experience, are not rushed and are done in the genuine interest of the patient (ANA 2013).

Correctional nurses have described how, it is first, necessary to establish a professional relationship with custody staff before they can negotiate delivery of compassionate nursing care. This means having acting, behaving and speaking in a ways that are consistent with professional practice standards. The most recent version of the Scope and Standards of Practice for Correctional Nursing were published in 2013 and now are identical to those of nursing generally. So a correctional nurse practices as any nurse does; it is only the place and population served that differ.

An example of how a professional relationship with custody staff is established, is in accounting, not just for controlled substances, but for all the sharp instruments as well. This is usually done at the beginning and end of every shift. This means all of the instruments, including those in the dental clinic, those kept in the inpatient and outpatient medical areas, and the lab as well plus every needle on site…it can be an arduous task. This degree of accountability is necessary because sharps can be used as weapons, to do tattooing and to shoot drugs, all dangerous and prohibited activities in a correctional facility. Nurses count sharps because it is necessary for security, not as part of health care delivery. A missing sharp means that the whole facility will be locked down and searched until the item is found. I have experienced an entire facility being locked facility down, for hours on end, because a single insulin syringe could not be accounted for. No other work, even delivery of health care takes place, until the “sharp” is accounted for. Sometimes nurses balk at the requirement for counting or act as though it isn’t as important as patient care. However, failure to account for sharps is not only dangerous, but it undermines the professional relationship with custody staff.

The ANA standards for professional practice are also important because they help to define and protect the role of nurses in the correctional setting. We provide health care in a setting where custody staff, facility commanders and correctional administrators have little or no knowledge of the standards for nursing care, let alone much appreciation for the limits of nursing practice in state law, unlike traditional health care settings. A nurse cannot rely on the correctional facility to have practices and procedures that are compliant with state law or professional practice standards. They may be the only nurse for a small facility and have no other health care professional to provide advice, other than a part time visiting physician. Even in large correctional facilities with many nurses, including nurses in management, practice creep can occur for an individual nurse whose primary interaction during a shift is with correctional officers and inmates who don’t know or appreciate the nurse’s scope of practice. Individual nurses must therefore establish these boundaries on their own, or risk violation of the law and the potential for action on their license.

There are many examples where nurses are asked to perform work that is outside the scope of practice or not consistent with professional standards. A nurse may be asked to approve use of pepper spray or endorse the use of a restraint chair and hood; decisions which are not in the interest of the patient or their health care. For example, another friend of mine, Lynda Bronson, was threatened with insubordination for refusing a direct order from the Warden to forcibly medicate an inmate who was in segregation and screaming obscenities at the officers.

The Warden threatened Lynda three times with insubordination and yet she stood her ground and explained that she did not have a medical order that would allow her to forcibly medicate the inmate. These are tough situations to be in and correctional nurses must be experts in communication, collaboration, and problem solving, with Wardens as well as correctional officers. These skills are necessary to arrive at compromises that solve problems, like screaming obscenities and gravely disordered behavior, while keeping the patient and staff safe.

Well done, this is experienced as practice autonomy, one of the most preferred and distinguishing characteristics of correctional nursing. Nurses who are clear about the standards and boundaries of their practice in correctional settings earn the respect of custody staff and are able to negotiate better outcomes for their patients.

To sum up, correctional nurses provide health care from within the justice system, to a disparate population of prisoners with great disease burden. These features; the location and population served, along with the nurse’s independent negotiation for care, define and characterize correctional nursing.

They say that once a nurse has resolved these cultural challenges, he or she will stay in the Land of Correctional Oz forever. As Tonia Faust, the nurse from the Louisiana State Penitentiary said in The American Nurse “There is a purpose for me here”. Those that don’t survive the transition, leave, usually within the first year.

Do the challenges portrayed over the last three weeks fit the experience you had transitioning into the field of correctional nursing? Are there aspects of your practice in correctional nursing that are different from other nursing fields that have not been highlighted in this series? Please share your thoughts about these questions by responding in the comments section of this post.

If you would like to read more about caring and professional practice in correctional nursing see Chapter 2 on the ethical principles of correctional nursing and chapter that discusses the elements of professional correctional nursing practice in our book, Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

If you would like to order a copy of The Wizard of Oz Guide to Correctional Nursing go to Lorry’s website, Correctionalnurse.net to order through Amazon.

Photo credit: Jaka Vinsek, Cinematographer The American Nurse

The Challenges and Distinguishing Features of Correctional Nursing: Part 2

Illustration - Woman in jailLast week’s post described the challenge of knowing the impact of the law on the delivery of health care in the correctional setting. Knowledge of the law and prisoners’ rights is one of the distinguishing features of correctional nursing practice. This week’s post describes the second challenge correctional nurses encounter which is the patients themselves. There is no denying that our patients have been charged with or convicted of breaking the law, sometimes violently. For the most part, knowing the nature of their crime is irrelevant to the provision of their health care, but it is also true, that offenders tend to think and behave in ways that get them in trouble with the law. These criminogenic thoughts and behaviors pepper a nurse’s interaction with their patients.

This is otherwise known as “the Con”, which is defined as the purposeful effort to deceive, manipulate or take advantage of another. Convicts gain respect from others when they “con” someone else and the person who gets conned is considered “weak”. Being weak makes one vulnerable to further exploitation.

Correctional nurses describe this as being manipulated. How it often works, is that an offender requests health care attention because of, let’s say, chronic low back pain, for example. In correctional facilities the offender will always be evaluated by a nurse first, who will determine what to do about the request. It may be that with some education, the offender can take care of it themselves, or a nursing intervention may take care for the problem, or finally, the nurse may decide that the offender needs to be seen by another provider and if so will make a referral.

Sometimes the offender will ask for something for which there is no objective evidence they need. The offender’s request for a narcotic analgesic to ease the chronic pain in his back, is likely not to be supported by objective findings. The request could simply be that the offender is seeking drugs; it could also be to sell or used to pay back a loan. The offender probably will also ask for an extra mattress or pillow. This also may be used to repay a debt or it could be just an effort to stand apart from others, as having something “special”.

If there is a medical need, these may be appropriate to give the offender. But if they are not needed and the nurse acquiesces, the offender has successfully “conned” or manipulated the nurse and achieved a secondary gain. The nurse is then considered “weak” and sought out for other such requests. Correctional nurses joking refer to this dynamic when we say “you know you are a correctional nurse when your patients make up reasons to see you and then don’t want to leave until they get what they came for.”

This gives rise to another distinguishing feature of correctional nursing practice which is the emphasis on the assessment of objective signs and symptoms and the accuracy of the resulting clinical judgment. Our patients subjective complaint may be embellished and critical details may be withheld (remember the example last week about the inmates who drank printer fluid). The conditions within which our assessments are done, often are not conducive to the patient giving a full and candid account of what led up to the request for care. Erring on the side of leniency in the absence of objective findings can result in being seen as, easy to con, and as word gets around, the nurse will be bombarded with inappropriate requests thereafter.

Making the wrong decision though, can also result in harm to the patient. An error in clinical judgment can be because the nurse’s skills are poor or undeveloped, or because the nurse lacks of sufficient knowledge. It can also occur, when a nurse has become cynical about their patient’s criminality and views every request as likely to be devious or untrue. This belief will cloud a nurse’s clinical judgement and important clues to the patient’s condition missed.

While they may be manipulative and sometimes untruthful, they have legitimate health care needs as well. So knowledge about the health problems that characterize the population we care for is a critical piece in achieving more accurate clinical judgments.

According to a report issued this year by the Bureau of Justice Statistics, forty percent of the incarcerated or detained adult population are diagnosed with a chronic medical condition compared to a third in the general community. Diabetes is twice as prevalent among the correctional population compared to a matched sample in the general community and hypertension is 1 ½ times more common. In terms of communicable disease, TB infection and STDs among offenders in correctional settings are twice the rates in the general community and hepatitis is six times the community rate (Bureau of Justice Statistics 2015 Medical Problems of State and Federal Prisoners and Jail Inmates 2011-12).

The racial and ethnic disparities of the criminal justice population are substantial. More than 60 percent are considered racial or ethnic minorities in the general community. One in every three black men and one in every six Latino men will serve time in prison or jail during their lifetime, compared to one in 17 white men. The same racial and ethnic disparities exist among women; one in every 18 black women and one of every 45 Latina women will be incarcerated in their lifetime compared to one of every 111 white women (The Sentencing Project at http://www.sentencingproject.org/template/page.cfm?id=107).

There are age and gender disparities among the incarcerated population as well. The overwhelming majority are men and they are relatively young in age. While women are in a minority, representing only 9% of all incarcerated persons, their population is increasing at much faster rates than men. Incarcerated women have high rates of traumatic history, particularly child abuse and domestic violence; their convictions are usually drug or drug related and most also are responsible for raising children (Bloom, Owen & Covington 2005).

Older prisoners also are a small percentage of the total (8%) incarcerated population but their numbers are growing at much faster rates because of mandatory sentencing and increasing numbers of extremely long sentences received. In fact the population of prisoners over the age of 65 increased 63% compared to a 0.7% growth for all other ages between 2007 -2010 (Human Rights Watch (2012) Old Behind Bars at https://www.hrw.org/report/2012/01/27/old-behind-bars/aging-prison-population-united-states).

Juveniles are another small but important group, with unique health care needs. They represent less than 1% of all persons incarcerated. Although incarceration rates for youth are declining, we know that incarceration decreases the likelihood of high school graduation and increases the likelihood of subsequent incarceration as an adult (The Hamilton Project 2014 at www.hamiltonproject.org).

What these statistics mean is that correctional nurses provide population-based health care. Nurses must be knowledgeable and vigilant in their clinical judgement, in order to identify and appropriately treat the health conditions that occur more frequently within each of these population subgroups (blacks, Latinos, women, children and the elderly). This focus on the uniqueness of each individual conflicts with one of the major norms of the correctional system; that incarceration is done to deprive a person of their individuality. No one gets special treatment, no one can be singled out and the rules are applied to all, firmly, fairly and consistently.

This norm about uniformity among prisoners, conflicts with the expectation and science of patient-centered care. Yet when individualization is in the best medical interests of the patient, correctional nurses are obligated to speak up. Patient advocacy, therefore is another distinguishing feature of correctional nursing. Often the nurse will have to act alone because they are the only health care provider at the scene.

An example of nursing advocacy for the individual needs of patients is shackling. Shackling is a security measure to prevent escape when prisoners are taken outside the confines of a correctional institution. In some correctional facilities or systems this is a routine practice applied to all, even pregnant women during labor and delivery. The American Medical Association, the American Public Health Association and the American College of Obstetricians and Gynecologists have each decried this as an unsafe and potentially harmful practice. Some states have even passed legislation prohibiting the use of shackles during labor and delivery. And yet we know the practice continues, so it often is the individual nurse who must insist the shackles be removed for the sake of the patient and their care.

In addition to knowledge, vigilance and advocacy for the needs of the population served, correctional nurses must be generalists in their competency to provide all types of nursing care. Like the prisoners themselves, who are not being able to choose their provider, correctional nurses do not get to choose their patients. A friend of mine and author of one of the chapters in our Essentials text, Roseann Harmon, tells a story about one of her first experiences in correctional nursing. She had been hired at the county jail because she had mental health experience. One evening the nurse manager came to her and said “Roseann, we have a woman out in the squad car at intake and she is in active labor. I am going to need your help because we are the only ones close by. Will you go get the OB pack?” Roseann gulped and said, “But I’m the mental health nurse, not an OB nurse.” The manager responded, “Well you are a nurse and so am I. We are the only ones here right now so we have to respond and we will do it together. This woman needs us.” Well, Roseann survived this experience and still tells the story years later, reminding us not to let our general nursing expertise diminish.

The second part of the ANA’s definition of correctional nursing is that the population cared for are prisoners. To summarize our population is characterized by criminality; ethnic, racial and gender disparities and has a high burden of disease. This population has had little in the way of regular health care prior to incarceration and are illiterate about self-care and health generally. Correctional nursing is defined as being responsive to the health care needs of people during their incarceration.

What are the best ways to maintain your knowledge and competencies as a generalist in nursing practices when there are some many changes in the science and best practices of health care? Please share your thoughts and resources that you think help nurses stay current in our field by responding in the comments section of this post.

If you would like to read more about the health care challenges and characteristics of the incarcerated population, see many chapters in our book, Essentials of Correctional Nursing, devoted to the nursing care of women, juveniles, the elderly, the racial and cultural groups as well as those with chronic disease and mental illness. Order a copy directly from the publisher or from Amazon today!

 

Photo credit: © Helder Sousa – Fotolia.com

The Challenges and Distinguishing Features of Correctional Nursing: Part 1

00000001What career did you want for yourself when you graduated from nursing school? Did know you wanted to be a correctional nurse? You probably never heard of it, right? This is me back in 1973 and I had never heard of correctional nursing either. Most correctional nurses will tell you that they never planned to be in this field. The reasons they give for trying it out included:

Wanting to try something different.

It was close to home and convenient.

They knew someone else who was a correctional nurse and suggested it.

I made the change because I was bored with hospital-based psychiatric care. The opportunity to develop a health care program for offenders in state prisons came at the perfect time and I took on the challenge and have had a chance to make a difference in the lives of those who could not do so for themselves. I thought I would stay about five years and move on, but it has been 31 years now. The next several posts will explore the challenges of becoming a correctional nursing specialist, the features that distinguish the specialty and explore why nurses stay in the field.

Nurses have advocated for the health and well-being of prisoners practically since the beginning of time. These include Florence Nightingale, who did some of her best work in England’s poor houses in the mid-nineteenth century as well prisoners during the Crimean war, Clara Barton, who cared for prisoners of war in the Civil War, and Dorothea Dix who was responsible for prison reform in the 1800s. The American Nurses Association has considered correctional nursing a specialty since 1985 and publishes standards for the scope of professional practice in correctional nursing.

The Institute of Medicine report The Future of Nursing: Leading Change, Advancing Health (2010) acknowledges correctional nursing when commenting on diversity in the nursing profession, stating that nurses will be present anywhere there are people who have healthcare needs. Those of you who watched the movie, The American Nurse, met Tonia Faust, a correctional nurse, and hospice coordinator at the Louisiana State Penitentiary. Four of the 75 nurses portrayed in the book, The American Nurse, were providing health care in correctional facilities at the time they were interviewed. We don’t really know how many correctional nurses there are because many state boards of nursing don’t include this as an option when indicating your place of employment or area of practice.

My co-contributor, Lorry Schoenly, likens the transition to correctional nursing to the popular tale, The Wizard of Oz when Dorothy Gale, walks out into the Land of Oz, after her prairie home landed on the Wicked Witch of the East, following a tornado ride from Kansas. Our first experiences with correctional officers, handcuffs, sally ports, metal detectors, crossing the yard and pop counts brings to mind Dorothy’s admonition to her little dog “This isn’t Kansas anymore, Toto!” In fact Lorry, published a book by the title, The Wizard of Oz Guide to Correctional Nursing, to help nurses manage the transition to this very different setting.

Well the first cultural challenge for nurses after they have arrived in the Land of Correctional Oz is the realization and understanding that our services are secondary to enforcing the law and protecting the public. This is the primary purpose of incarceration in the United States. The people whose health we are responsible for, are being detained against their free will, as punishment. Even so, the Supreme Court has granted prisoners a constitutional right to health care under the 8th amendment. Failure to do so is considered “cruel and unusual punishment.” The court’s reasoning was that “it is but just, that the public be required to care for the prisoner, who cannot, by reason of the deprivation of his liberty, care for himself.”

This is not just a cultural challenge but one of the distinctive features of correctional nursing practice. The first part of the ANA definition of correctional nursing, is that it takes place at the intersection of an individual and their involvement with the justice system. Legal precedents have been the primary means by which the delivery of health care in the correctional system has been shaped.

The courts have established that inmates have the right to health care during incarceration which includes:

  1. Unimpeded access to care
  2. Care that is ordered must be provided
  3. Entitled to professional clinical judgment

These three rights are referred to as the three legged stool of the Eighth Amendment rights to prisoner health care and they are operative in almost every aspect of a correctional nurse’s daily practice.

Here is an example of the application of these rights to health care from my early experience in correctional nursing. In this instance, three inmates, working in the print shop, drank printing fluid, in an attempt to get high. All three became sick but they did not seek medical attention because the nursing staff would have to report them to security for stealing the printer fluid. One inmate died as a result of the delay in treatment. The courts found a violation of the eighth amendment because the inmates’ access to health care attention was impeded, due to the threat of being reported and subsequently disciplined. In this case, a correctional facility’s requirement for reporting prohibited conduct impeded access to care and resulted in a finding of “cruel and unusual punishment”.   The legal right to health care, its practical interpretation and application in the correctional setting is one of the distinguishing features of correctional nursing.

Do you have some good examples of how legal considerations impact the practice of correctional nursing? If so please share by responding in the comments section of this post.

If you would like to read more about legal considerations in correctional nursing please see Chapter 3 written by Jacqueline Moore in the Essentials of Correctional Nursing; the first and only textbook written so far about the practice of nursing in this specialized field. Order a copy directly from the publisher or from Amazon today!

If you would like to order a copy of The Wizard of Oz Guide to Correctional Nursing go to Lorry’s website, Correctionalnurse.net to order through Amazon.

 

Photo credit: © Africa Studio – Fotolia.com

Stay at home ways to build continuing education credits

Man sitting at a computer, learning at home.

I have a friend recently who was lamenting that personal circumstances did not allow her attendance at the National Conference on Correctional Health Care that took place in Dallas Texas this week. She was worried that she would not have enough continuing education hours to satisfy the requirements for recertification as a Certified Correctional Health Professional (CCHP). In addition to professional recertification, many states require evidence of continuing education when nurses renew their license. There are times when life events or circumstances make attending a conference or other educational activity just impossible and then we worry about having enough CEs. This post is written to provide information about some CE resources that can be done at home and are free or inexpensive.

CCHPs and CCHP-RNs recertify once each year. In addition to the renewal fee of $75 the applicant must attest to having obtained 18 hours of continuing education of which 6 hours are specific to correctional health care. CCHPs and CCHP-RNs should maintain a record of the continuing education that they have attested to, in case they are audited. One way to do this is to keep a CE log that includes the following information:

Your name Date Title or subject # of hours

In addition to conference attendance, continuing education credit may be obtained by attending in-service at a correctional facility, writing an article for a journal, or making a presentation at a conference. Another way to obtain CEUs that may be more practical or achievable when life becomes hectic is self-study or independent learning. The following are some self-study options:

The Journal of Correctional Health Care is provided free as one of the benefits to CCHPs and CCHP-RNs. The Journal is published four times each year and contains six to ten scholarly, peer reviewed articles that are specific to correctional health care. If you are not certified an annual subscription costs $125 so this is a tangible return on the investment in certification. You can earn 1 continuing education credit for each article if you complete a corresponding exam. Any article published by the Journal of Correctional Health Care within the previous two years is eligible for continuing education credit. All of this material would meet the requirement of CCHP for 6 hours specific to correctional health care. For more information about this resource go to this link http://www.ncchc.org/journal-of-correctional-health-care.

Medscape is another resource for continuing education credit. This site offers clinicians access to timely clinical information and educational tools to stay current in practice. There is no cost to join and you can access resources that are selected specifically for nurses. For example 0.25 contact hours can be obtained for previewing a slide show and web discussion about motivational interviewing, behavioral action and collaborative care in Strategies for Effective Communication with Patients with Major Depression. There is an easy to use CE Tracker that will keep track of the courses and credits accumulated through the year which can be saved or printed out as necessary. This last year I took two classes, one on the guidelines for prevention of bedsores and the other on prescribing antibiotics and both were easy to access, informative and the exam very simple. For more information about this website go to this link: http://www.medscape.org/

The American Nurses Association is a favorite on-line resource of mine for continuing education. You do have to belong, but an on-line membership only costs $45 a year. Membership benefits include three publications, American Nurse Today, The American Nurse, and the Online Journal of Issues in Nursing. There also is a large library of on-line courses with continuing education credit that can be accessed when it is convenient for you.  I have taken several courses from ANA this year, including a session on the new ethical guidelines for nurses, a course on preventing medication errors and another on the JNC guidelines for managing hypertension. As a member I receive announcements of upcoming Webinars that are offered with continuing education credit and at no charge. This year I took a whole series on building a healthy workplace. Go to this link to find out more about the continuing education resources through the American Nurses Association: http://www.nursingworld.org/JoinANA/E-Membership-Only.

These three resources offer thousands of continuing education hours without ever having to leave your home. Most can be obtained either free or as a benefit of being a CCHP or CCHP-RN. So when time or circumstances make it impossible to access continuing education credits at conferences or on the job, these options may be a help. In my case I’ve chosen to access continued learning through these sites even though I have been able to attend conferences and in-service programs this year.

Do you have resources for continuing education that you would like to share with other correctional nurses? If so, please tell us about them by replying in the comments section of this post.

For more about continuing education in correctional nursing see Chapters 17 Management and Leadership as well as Chapter 19 Professional Practice in the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

 

Photo credit: © ponomarenko13 – Fotolia.com

Explaining what is it like to be a correctional nurse?

Tonia FaustAll correctional nurses have the experience of explaining to another nurse what it is like to be a nurse who practices in a prison, jail, juvenile detention facility, police lock up, or customs enforcement facility. Many of our fellow nurses respond to our answer with comments or questions like…”I had no idea nurses could be found in there.” “How can you provide care for a murderer or a rapist?” or “Do you feel safe?”

I am having the same experience now as I get ready to give a presentation at the Arizona Nurses Association later this month about the cultural challenges in correctional nursing. This audience will be nurses but very few of them will be correctional nurses. The three cultural challenges for correctional nurses that I am going to describe are:

  1. Balancing the security imperative with the constitutional right to care.
  2. Diversity and disparity of the patient population.
  3. Developing a practice that embraces caring and remains true to professional principles.

In preparing, I went back to The American Nurse which I discussed in an earlier post. This book is a collection of seventy-five interviews with nurses in the United States. It was published in 2012 as part of The American Nurse Project. There were five nurses in this group who talked about their work as correctional nurses. I thought I could use their stories as a starting point to describe the tremendous opportunities in correctional nursing.

While searching through the book I found another resource, a documentary film by the same name that was produced about two years after the book was published. A correctional nurse, Tonia Faust, is one of five nurses portrayed in the film; she is responsible for the hospice program at Louisiana State Penitentiary. She is pictured at the top of this column. It turns out the film will be shown at the conference the night before my presentation, so by the time I talk about correctional nursing every nurse in attendance will have been introduced to at least one already!

In the film Ms. Faust gives a tremendous interview and we are right there with her as she dresses a wound and talks with the offenders in the infirmary. We meet one of the inmate hospice workers and observe the caring he expresses as he helps to shower an inmate. I would think any nurse could identify with the intimacy and humanity of care so apparent in the film taken from inside the penitentiary. Next time you have someone ask what you are doing as a nurse working in a correctional facility have them watch the film, An American Nurse directed by Carolyn Jones.

The best news is the website for The American Nurse Project is fabulous and this post is written to suggest that every correctional nurse visit it. You don’t have to wait because the film can be downloaded for only $9.99 and watched multiple times thereafter or it can be rented and viewed for a period of five days for only $3.99. The other four nurses portrayed in the film work in labor and delivery, home health, a nursing home and for the military. Two of the five nurses are men. The film really does a great job confronting many of the stereotypes there are about nurses and their careers. An hour and a half of CE is also available after watching the film. Finally there is also a blog that that provides more details about filming of each of these fabulous nurses.

Nurses responsible for new employee orientation or professional development should consider using the film to generate discussion about the expression of caring in the correctional environment, what it means to be non-judgmental as a nurse and what it is like to feel purposeful as a correctional nurse. There are two study guides available without cost on the website; one for the general community and one for nurses. Both provide good material for discussion and reflection on correctional nursing practice.

I watched The American Nurse last night and cried. I was so proud of the nurses portrayed in the film, but especially Tonia. I don’t think that others will ever think correctional nurses aren’t among the best the profession has after watching this film. As one commenter said “My eyes were really opened by the nurse who worked in prison. You could see how much she cared about the patients. I learned that there are more opportunities in nursing than just the traditional settings.”

Take time at least to see the film (79 minutes) and get an hour and a half of CE. Does watching the film help you answer the question when others ask you “What is it like to be a correctional nurse?” Tonia Faust talks about having a purpose for being at the Louisiana State Penitentiary and it has made me think about my purpose as a correctional nurse. What is yours? Share your thoughts about the film as well as the questions posed here by responding in the comments section of this post.

For more about the opportunities and challenges in correctional nursing order a copy of our book, Essentials of Correctional Nursing directly from the publisher or from Amazon today!

 

Photo credit: americannurseproject.com

Knowledge Resources for Medication Management

ReadingThe American Nurses Association statement on the scope of practice for correctional nurses requires that nurses be knowledgeable of the medications administered, including dosages, side effects, contraindications and allergies. Nurses also must be able to teach and coach patients so that they know what medications they are taking, the correct dose and frequency (2013). Many more drugs have been developed to effectively treat a wider variety of conditions in the last several decades and new drug formulations established which reduce treatment time, improve adherence and reduce the burden of side effects. With the proliferation of treatment choices available to prescribers today, the scope of knowledge required of nurses has expanded as well.

The types of health problems presented by our patients during incarceration is very broad therefore correctional nurses must maintain more expansive knowledge about the drugs likely to be prescribed than nurses who specialize their practice to a certain acuity (e.g., critical care) or particular health problem (e.g., kidney dialysis). It is impossible to memorize all this information so what references should a nurse use to aid their knowledge about medications these days? What are the drug references that you use?

A couple years ago another nurse and I were talking about a patient and one of the drugs that had been prescribed. I went in search of the big red text from the American Hospital Formulary Service. He turned to the computer and typed the drug’s name into Wikipedia and before I left the room he had the information we were looking for.  The problem is that anyone can contribute information to Wikipedia and so the accuracy and completeness of drug information on this site has been examined. Drug information on Wikipedia relies most heavily on news articles and commercial websites rather than evidence-based material and the information, especially that which is safety related is not reliably updated (Koppen, Phillips & Papageorgiou 2015).

Nurses in one survey in the U.S. favored using the Physician’s Drug Reference (PDR) or a text written especially for nurses like Lippincott’s Nursing Drug Handbook (Gettig 2007). In another survey nurses reported that, other than the PDR, they relied most on other colleagues in the workplace. The problem with relying on co-workers for information about drugs is that the individual may not be available or authoritative on the subject. Access to information and ease of use were the most important factors in nurses’ choice of drug information resources so that quick and concise answers could be obtained (Ndosi & Newell 2010). As drug information has become more available in electronic format it can be more quickly accessed and is becoming a more reliable reference for busy correctional nurses.

The following is a list of drug references and applications that are available on line and can be obtained for free:

National Library of Medicine has three databases that are useful for nurses in medication management. The first is the Drug Information Portal which provides information on 53,000 drugs from government agencies and scientific journals. The second is Drugs, Herbs and Supplements providing information for patients about the purpose of drugs, correct dosages, side effects and potential interactions with dietary supplements and herbal remedies. Last is a database designed for use in emergencies and developed to help identify unlabeled pills called Pillbox.

Epocrates is one of the most widely used and highly recommended drug references. In addition to drug information the basic package which is free has a dose calculator, drug-drug interaction checker which includes OTC medication and a pill identification program. For an annual fee the program can be upgraded to access medical information, diagnostic information, a medical dictionary and infectious disease guidelines.

Medscape Mobile is a combination medical reference and drug database. In addition to clinical reference for 8,000 drugs, herbals and supplements it includes a robust drug-drug interaction checker and a dosage calculator.

A final resource that should be available at every correctional facility is the telephone number for the poison control center. This is a national hotline number (1 800 222-1212) which connects to the nearest poison control center. Most poison exposures can be treated locally if contact is made with a poison control center because they are staffed 24 hours seven days a week by health care professionals with special training. The facility should also stock a supply of antidotes for various types of poison. A consensus guideline published in the Annals of Emergency Medicine (2009) recommended stocking 12 antidotes available for immediate use in treatment (2009). Since then several poison control centers have lists on-line of recommended antidotes to have on hand.

Availability of antidotes is a decision that should be made by the facility medical director in consultation with the supplying pharmacy. Usually they are stored with other emergency medications. Nurses should be familiar with each antidote stocked at the facility for use in medical emergency care. Here is a link to a list of common drugs and antidotes that nurses should know about.

Are there any knowledge resources for nurses in managing medications that are not described here and should be? Please let us know about them by responding in the comments section of this post. For more about the opportunities and challenges in correctional nursing order a copy of our book, Essentials of Correctional Nursing directly from the publisher or from Amazon today!

References

ANA (2013). Correctional Nursing: Scope and Standards of Practice. Silver Springs: American Nurses Association.

Dart, R.C., Borron, S.W., Caravati, E. M., et.al. (2009) Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care. Annals of Emergency Medicine 54 (3): 386-394.

Gettig, J.P. (2007). Drug information availability and preferences of health care professionals in Illinois: A pilot survey study. Drug Information Journal 42, 263-272.

Koppen, L., Phillips, J., Papageorgiou, R. (2015) Analysis of reference sources used in drug-related Wikipedia articles. Journal of the Medical Library Association 103 (3), 140- 144.

Ndosi, M. & Newell, R. (2010). Medicine information sources used by nurses at the point of care. Journal of Clinical Nursing 19, 2659-2661.

Photo credit: © Xuejun li – Fotolia.com

Communication and medication management

man talking on the phone but does not listen

This week’s post explores the language of medication management. The correct use of terminology enables nurses to communicate accurately and prevents misunderstanding with other nurses, providers and pharmacy staff in the delivery of patient care. Continuing the analogy that working is corrections is like foreign travel it is helpful to speak and understand enough of the local language to find the train station, grocery and rest room and not get these mixed up along the way. The same is true when dealing with medications in correctional health care.

 

Using the correct terminology

The terminology used to describe who does what in the medication delivery system is subtle and often misused. One of the most commonly misused terms I hear used in correctional settings are dispense and administer. Only pharmacists and prescribers (physician, advanced practice nurse, physicians assistant) can dispense medication. To dispense is to remove medication from a stock bottle or container, label and package it for a patient according to a written prescription (the sig). Important steps in this process are to verify that the order is safe (right drug for the problem, correct dosage and route) and to review other medications the patient may be taking to ensure that the new medication does not cause an adverse interaction. Administration of medication is to give medication to a patient as prescribed and then to evaluate or monitor the patient for intended and unintended effects. Medication administration involves correctly carrying out the order as well as assessment of the patient’s response which are fundamental steps of nursing process. Most states allow administration of medication to be delegated by a nurse to unlicensed personnel if they have been trained and are supervised.  Sometimes medication is given to inmates in correctional facilities by other types of personnel including clerical staff, medical technicians, paramedics and correctional officers. The proper term for this is distribution of medication because there is no evaluation that the medication is being given as prescribed and no evaluation of the medication’s effect.

An adequate number and variety of medications must be available at any time at a correctional facility to treat inmate/patients in a timely manner. To accomplish this a correctional facility will have an arrangement with a wholesale drug supplier or pharmacy to dispense and deliver patient specific medications that are prescribed and will keep some medication on hand to use in an emergency or to start treatment immediately. Procurement is the term used when ordering or receiving medication at a correctional facility to be available for use, as prescribed, in the treatment of patients. Medication accountability is a similar term, but broader in scope.  Both state law and the accreditation standards require that there is a system to track, document and account for all medication from the time it is received at the facility until it is administered or delivered to the patient, returned or destroyed. Nurses may be responsible for procurement and accountability of medication at the facility, especially if no pharmacy staff are on site. This is not a role nurses have in traditional health care settings but is common in corrections.

Knowing how and where patients get medication

There are a handful of terms used in correctional settings to describe how inmates receive medication. When inmates receive medication administered directly by a nurse is referred to as directly observed therapy or DOT.  When a package of medication (an envelope, blister card or bottle) is given to an inmate and they are expected to take the medication on their own is referred to as keep on person or KOP medication. Another term is self-administered medication. When inmates receive medication it may be at a “pill call” or “pill line”.  Medication may be delivered “cell side”, through the “cuff port”, at the “pill cart” or “pill window”. Sometimes the vernacular used to describe an activity or place within a correctional facility can be unprofessional or demeaning. Nurses should know what local terms are used as well as their meaning, then make a deliberate decision to use the local language or not.

Selection and availability of drugs

As mentioned in last week’s post, correctional facilities should have a formulary which is a list of the medications that providers can order. The formulary can be “open” meaning virtually any brand of drug is available. A correctional facility that uses a local retail pharmacy to supply medications is more likely to have an open formulary. A “closed” formulary narrows the choices of drugs available in each class (antibiotics, analgesics etc.).  Accreditation standards require that if a particular medication is not on the formulary that there must be a way to request it for a particular patient if needed-this is a “non-formulary” request. Correctional nurses are often involved in helping to fill out and track responses to non-formulary requests so that the medication is received by the patient in a timely manner. It also pays for nurses to be familiar with what drugs are on the formulary so that they can help providers remember what is available when writing orders.

Having a voice in drug selection

Nurses sometimes have representation on the Pharmacy and Therapeutics Committee (P & T) where decisions about what drugs are on the formulary are made. Nursing input is very important in drug selection especially to avoid decisions that result consume unnecessary time during pill line (such as pill splitting or crushing) or present safety issues in the correctional setting (potential misuse or error). If you have a chance to serve on this committee I hope you will jump on the invitation. Even if you do not have a spot on the committee be sure to voice your opinion about the selection of drugs available for treatment at your facility.

Use of generic vs. brand names

One of the most important decisions and practices in medication delivery is how particular medications are referred to. At your facility is the brand or trade name of the drug used or is the generic or chemical name used? In a comment on last week’s post a nurse said that some nurses organize medications in the cart by using the generic name and other nurses put the medication in by brand name. That means that you have to look in at least two places on the cart for a particular medication! Deciding on and then using one or the other saves a lot of time.  It really is preferable to use the generic name since the brand or trade name changes.

How medication is packaged

Various terms are used to describe how medication is packaged. Some nurses came into the profession when most medication was administered out of “bulk stock”. This refers to taking one dose for a particular patient out of a bulk container of the drug. Some correctional systems prefer to use bulk stock for psychotropic drugs because of cost, frequent prescription change and high patient turnover. To improve patient safety most state pharmacy laws prohibit medication administration systems that rely solely on “bulk stock” and have developed “patient specific packaging” that is in “unit dose”.  Patient specific packaging is a medication that has been prepared and dispensed by a pharmacist in a container or package that is labeled with the patient’s name, start and stop date, the medication dose, route and frequency, as well as prescriber and pharmacy names. Many correctional systems will provide discharge medication packaged in this way with a child proof cap. When medication is packaged in unit dose each dose of medication is packaged individually. An example of unit dose are the plastic or paper packets or aspirin or acetaminophen. Unit dose packaging may be labeled with the individual patient name as described in patient specific packaging above or it may not be labeled and used like “bulk stock” with single doses provided to multiple patients. An example of the later would be single doses of medication used for immediate treatment such as an antihistamine. Finally some correctional facilities allow inmates or their families to bring in an inmate’s medication that they were taking in the community. This is referred to as patient owned or personal medications. The medication and prescription must be verified before accepting it into the facility and accountability for proper use must be assured. Usually several types of packaging is used in correctional facilities. How many different kinds of packaging and what terms are used at your facility?

Preventing miscommunication

Even when we speak the same language communication can be misunderstood. Errors in communication occur in oral and written communication about medications sometimes resulting in adverse consequences for the patient. The Joint Commission, U.S. Food and Drug Administration (FDA) and the Institute for Safe Medication Practices (ISMP) have each promoted practices that reduce errors in medication management. One example is that QD is often misunderstood as QID resulting in four times the intended daily dose. The opposite is also true but the patient would receive a much lower dose than was intended therapeutically.   Either can have disastrous consequences. The IMSP and FDA have listed medication abbreviations that are frequently misunderstood and have developed brochures, posters, a slide set and a video about how to avoid these errors. The health care program at your facility should have a list of approved abbreviations and may also have adopted a list of error prone abbreviations to avoid using. If not the IMSP website is a recommended resource.

Have you had a funny or sobering experience with the language used in medication management at your facility? Do you have any terms unique to medication delivery in the correctional setting you would like to contribute to our glossary? Do you favor use of generic or brand names and why? Please comment by responding in the comments section of this post.

For more about the opportunities and challenges in correctional nursing order a copy of our book, Essentials of Correctional Nursing directly from the publisher or from Amazon today!

 

Photo credit: © talitha – Fotolia.com

An overview of medication management in correctional settings

Isolated, whitespace, copyspace.

The roles and responsibilities of correctional nurses for medication management are broader in scope than other practice settings. In health care settings many other professional and support personnel contribute to delivery of patient care.  However in correctional facilities nurses are relied upon to deliver care without the availability of these other types of personnel. The result is that correctional nurses often work in professional isolation and may feel like they are in a foreign country (Muse, 2012). I think traveling in a foreign country is a good analogy for correctional nursing. Doing this well involves preparation by learning something about the sights to see, building skill using a little of the language, familiarizing yourself with the rules, particularly which side of the road people drive on and finding out how to avoid being robbed or harmed in some way. The thrill of correctional nursing, like the thrill of foreign travel, comes when you realize how much you are enjoying it, especially the independence of professional nursing practice in this field. This post is the first part of a guidebook for your journey managing medication in correctional settings.

State law, rule and regulation

State law serves as the basis for nearly all of the practices and procedures involved in medication management. Most nurses are familiar with the nurse practice act in their state. If not, this is the place to start by reviewing it for definitions and references to medication. The nurse practice act will be especially helpful in describing the training and supervision requirements if non-licensed personnel, such as nursing assistants, administer medication at the correctional facility.

The pharmacy practice act is the most important resource to review. These laws will define how to obtain, store, dispense and account for medication which are often the responsibility of nurses when there is no pharmacist on site.  Even if there is a pharmacist at the facility, being familiar with the law that governs their practice is helpful in understanding the recommendations pharmacists make about drug storage, packaging of medications and accountability.

The medical practice act provides important information about how a physician’s order for medication is lawfully carried out. The medical practice act also has information about how medical assistants and paramedics work as well as the requirements for training and supervision which need to be followed if these personnel are involved in medication management.

This is not interesting reading but it does provide information that nurses can use in determining the responsibilities of personnel for medication management. It also provides definitions and terminology to accurately communicate with the pharmacy that provides medication to the facility and with providers about implementation of orders. Finally it provides nurses a basis to knowledgably resist inappropriate requests from custody and other personnel not familiar with health care laws to carry out tasks that are inconsistent with state law.

Accreditation standards

The National Commission on Correctional Health Care (NCCHC) and the American Correctional Association (ACA) are organizations which accredit correctional facilities for providing services and programs consistent with national standards. The standards are also used by most correctional facilities in developing policy and practices even if accreditation is not sought. Both organizations have standards related to medication management which are summarized in Figure 1. This list is a handy description of all the moving parts and pieces of medication management in correctional settings and nurses are involved in all of these components. This list can be used to review how medication management is handled at a facility and identify areas that may need attention.

Figure 1:   Standards for medication management in correctional facilities
NCCHC ACA
Applicable standards C-05, D-01, D-02 4-4378, 4-4379
1. Facility operates in compliance with state and federal laws regarding medications. Similar
2. There is a formulary and method to obtain non-formulary medication. Similar
3. Policy and procedures address how to procure, receive and account, dispense, distribute, store, administer and dispose medication. Similar
4. Medications are under control of appropriate staff and accounted for. Secure storage and perpetual inventory of controlled substances, syringes and needles.
5. Medication is only prescribed as clinically indicated after provider evaluation. Similar
6. Providers are notified of medication needing renewal prior to expiration. Similar
7. Staff are properly trained to administer or distribute medication. Similar
8. Inmates do not prepare, dispense, or administer medications. Self-carry medication programs are allowed.
9. There are no outdated, discontinued, or recalled medications at the facility.
10. If there is no on-site pharmacist, a consulting pharmacist is available for advice and makes inspections of the facility’s medication program at least quarterly.

Nursing standards

The American Nurses Association (ANA) has recognized correctional nursing as a specialized field of practice since 1995. The ANA publishes a reference that describes the scope and sets standards for the practice of correctional nurses. With regard to medication management the role and responsibility of correctional nurses is as follows:

  1. To be knowledgeable of medications administered, including dosages, side effects, contraindications and food and drug allergies.
  2. Practices with regard to medication management in the correctional setting meet the same standards as in the community. To do so nurses must be knowledgeable about state practice acts (as suggested earlier in this chapter).
  3. Ensure that patients know what medications they are taking, the correct dosage and potential side effects.
  4. If patients are expected to take medications without supervision the nurse evaluates the patient’s competence to self-manage and takes steps to protect those who are not competent to do so.
  5. Work with custody staff so that patients receive medication in a timely and safe manner (ANA, 2013).

This overview makes me reflect on my first experience with medication management in correctional nursing. I was being oriented to administer medications on the evening shift at a maximum custody men’s prison. A technician rolled a grocery cart filled with stock bottles of all kinds of medication out to me. The cart was full. In giving me the cart he said “You roll this along the tier and stop at every cell. Ask the inmates what meds they want. When you give them the medication then you record it on one of these index cards that has the medication listed at the top.” I remember being shocked and asked the technician why they did it that way. He shrugged his shoulders and went on with his tasks. While this experience is pretty extreme you might use it to review against the ANA nursing standards of practice, the accreditation standards and state law that were reviewed in this post and identify the inconsistencies. Being knowledgeable about the standards and requirements for medication management prevents erosion of professional practice and ultimately protects patients from harm.

Going back to the travel analogy, knowing state law, the national standards for correctional facilities as well as the standards of practice for correctional nurses is like having a guidebook to review the sights to see in place you have selected to travel to. These become a reference point to plan so you can make the most of your time as well as an expectation for what will take place while on your journey.

Is medication management a troublesome area where you practice correctional nursing? Have you looked at the problem through the lens of applicable state law, corrections standards and the nursing practice standards? If so, what have you identified as the problem areas? Please comment by responding in the comments section of this post.

For more about the opportunities and challenges in correctional nursing order a copy of our book, Essentials of Correctional Nursing directly from the publisher or from Amazon today!

 

References

ANA (2013). Correctional Nursing: Scope and Standards of Practice. Silver Springs: American Nurses Association.

Muse, M. (2012). Professional role and responsibility. In C. Schoenly L. & Knox, Essentials of Correctional Nursing (pp. 364-377). New York: Springer.

National Commission on Correctional Health Care. (2014). Standards for Health Services. Chicago: National Commission on Correctional Health Care.

American Correctional Association. Performance Based Standards for Correctional Health Care. Retrieved August 19, 2015 from http://www.aca.org/standards/healthcare/

Photo credit: © BillionPhotos.com – Fotolia.com

Answers to the Quiz on Hypertension

A person drawing and pointing at a Knowledge Empowers You Chalk Illustration

Last week we posted a case example followed by eight questions designed to test knowledge of the most recent guidelines for management of hypertension as well as the unique challenges managing this disease in the correctional setting. Each of the test questions are listed below with the correct answer underlined followed by an explanation of the correct answer. The references are listed at the end of the post so you can access the material that was used to prepare this quiz.

Case example: The case example involved an inmate being seen in nurse sick call for complaints of nasal allergies and a recent back strain. His blood pressure is 148/90 mm Hg. At intake, a month ago, his blood pressure was 154/92 mm Hg.

Question

1. Based upon the reading today, this patient is at what stage of hypertension?

    1. Prehypertension
    2. Stage 1 hypertension
    3. Stage 2 hypertension
    4. Hypertensive crisis

Explanation: Hypertension stages are unchanged from the JNC 7 report. These stages are defined as:

Stage Systolic blood pressure Diastolic blood pressure
Prehypertension 120 to 139 mm Hg 80 to 89 mm Hg
Stage 1 hypertension 140 to 159 mm Hg 90 to 99 mm Hg
Stage 2 hypertension Equal or higher than 160 mm Hg 100 mm Hg or higher
Hypertensive crisis Above 120 mm Hg

2. Which of the following is not a risk factor for hypertension?

  1. Race
  2. Family history
  3. Sexual orientation
  4. Alcohol use

Explanation: Gender is a risk factor but not sexual orientation. Men are more likely than women to have high blood pressure until about age 45. The rates of disease are similar between men and women from age 45 to 64 but after that women are at much higher risk (American Heart Association). Subgroups within an incarcerated population at higher risk of hypertension include youth, African American men and young women (Arries & Maposa 2013).

3. What lifestyle changes will you suggest to the patient?

  1. Weight loss
  2. Reduce salt
  3. Increase activity
  4. All of the above

Explanation: Lifestyle changes are a first line recommendation in the treatment of hypertension. Systolic blood pressure reduces 1 mm Hg for every pound of weight loss, reducing sodium intake to 1,500 – 2,300 mg/day decreases blood pressure by as much as 8 mm Hg, and 30 minutes of activity five days a week reduces systolic blood pressure by as much as 9 mm Hg (Townsend & Anderson 2015). Educating patients about the contribution of these lifestyle changes to reducing blood pressure, giving them the tools to account for these changes and the opportunity to see the change in blood pressure is a powerful means to engage patients in their own care. Several studies have shown that lifestyle change interventions are effective with incarcerated populations (Arries & Maposa 2013).

4. A patient with hypertension should be seen monthly until…

  1. Blood pressure reaches the target goal
  2. Lab work is within normal limits
  3. Blood pressure readings stabilize
  4. The provider determines another interval

Explanation: An important feature of the JNC recommendations are the target goals for blood pressure. A significant change in the JNC 8 was to ease the target goals for patients with diabetes and chronic kidney disease (James, Oparil, Carter et al 2014). The main purpose of hypertension treatment is to achieve and maintain blood pressure within the target range listed in the table below.

Population Goal for systolic BP Goal for diastolic BP
Aged 60 years or older 150 mm Hg and below 90 mm Hg and below
All others including diabetics and chronic kidney disease 140 mm Hg and below 90 mm Hg and below

When a patient does not meet the target, treatment needs modification by increasing dosages, adding another medication or both until the goal is achieved (Townsend & Anderson 2015, Mahajan 2014). The interval between provider visits can be increased once the goal is achieved. Treatment adherence can be compromised by the patients’ experience of drug side effects, lack of motivation and insufficient knowledge. Nurse led clinics to coach and monitor adherence is a keystone in managing inmate/patients who are being treated for hypertension (Voermans 2013, Arries & Maposa 2013).

5. If lifestyle changes are not sufficient to lower this patient’s blood pressure, medication should be considered unless he…

  1. Is a diabetic
  2. Has liver disease
  3. Is over 60 years of age
  4. Has blurry vision

Explanation: The patient in the case example has a blood pressure of 148/90 mm Hg. A previous blood pressure reading was 154/92 mm Hg. According to the JNC 8 guidelines a target blood pressure of 150/90 mm Hg is recommended for persons 60 and older, without diabetes or chronic kidney disease (James, Oparil, Carter et al 2014). If he is 60 years of age or older he should still be followed so that he can be referred for drug treatment when his blood pressure exceeds 150/90 mm Hg. In the meantime continued assessment and coaching about lifestyle changes is recommended.

6. Initial medication orders for treatment of hypertension are likely to include any of the following except…

  1. ACE inhibitors
  2. Beta blockers
  3. Calcium channel blockers
  4. Thiazide type diuretic

Explanation: The JNC 8 guidelines expanded the number of medications that can be considered as first line therapy to include calcium channel blockers, ACE inhibitors and ARBs. The previous guidelines (JNC 7) gave preference to thiazide type diuretics for initial therapy. The JNC 8 also include specific recommendations for medications for African Americans based upon the evidence for prevention of other cardiovascular conditions (James, Oparil, Carter et al 2014, The Pharmacists Letter 2014).

7. The patient is placed on a low dose of lisinopril and hydrochlorothiazide. What lab work should be ordered to monitor this patient?

  1. BUN & GFR
  2. Albumin & bilirubin
  3. HgA1c & LDL
  4. Creatinine & potassium

Explanation: Lisinopril is an ACE inhibitor. ACE inhibitors frequently cause an elevation in creatinine which can give rise to hyperkalemia. Both of these should monitored and dosage adjusted or drug regime changed if levels rise (Townsend & Anderson 2015). Nurses can counsel patients about what side effects to expect, how to care of various side effects and what conditions should cause the patient to request health care attention. Nurses should always consider the medications a patient is taking during a sick call encounter. The problem being experienced may be a side effect that can be addressed so that adherence with prescribed treatment continues or it may be an adverse effect that needs prompt medical attention (Smith 2013).

8. What lifestyle change will be most difficult to accomplish while incarcerated?

  1. Increased exercise
  2. Lower sodium intake
  3. Smoking cessation
  4. Limiting alcohol use

Explanation: Incarceration for the most part limits access to alcohol. Smoking cessation is a fait accompli in those facilities which are smoke free. Aerobic exercise does not require any special equipment and blood pressure reduction can be accomplished as simply as brisk walking for 40 minutes three or four days a week (American Heart Association 2014). What inmates have the least control over are meals, both the calories and sodium content. Foods high in sodium which are frequently on the menu in correctional facilities are processed meat, baked goods, and processed cheese. When inmates try to obtain a healthier diet (medical diets or religious diets) the alternatives served are often monotonous and unpalatable. Inmates often supplement institution meals with food purchased from the canteen which also is likely to be high in calories and sodium. For this reason lowering sodium intake is the most difficult lifestyle change for patients to accomplish while incarcerated. Some facilities have found that by adopting a “heart healthy” diet as endorsed by the American Heart Association and offering a selection of healthier snacks through the canteen has been cost effective because most medical diets and waste from uneaten special meals are eliminated (Voermans 2013).

For more on the correctional nurses’ role managing patients with chronic conditions like hypertension, cardiovascular disease, asthma, arthritis, diabetes, and seizure disorders see Chapter 6 of our book, Essentials of Correctional Nursing. Order your copy directly from the publisher or from Amazon today!

References:

American Heart Association (2014) Understand your risk for high blood pressure. Retrieved July 1, 2015 at http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/UnderstandYourRiskforHighBloodPressure/Understand-Your-Risk-for-High-Blood-Pressure_UCM_002052_Article.jsp

Arries, E. J. & Maposa, S. (2013). Cardiovascular risk factors among prisoners. Journal of Forensic Nursing 9 (1): 52

Binswanger I.A., Krueger, P.M., & Steiner, J.F. (2009). Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population. Journal of Epidemiology and Community Health 63 (11): 912

James, P.A., Oparil, S., Carter, B.L., et al. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Journal of the American Medical Association 311 (17): 1809

Mahajan, R. (2014). Joint National Committee 8 report: How it differs from JNC 7. International Journal of Applied Basic Medical Research 4 (2): 61

Noonan, M. E. & Ginder, S. (2014) Mortality in Local Jails and State Prisons, 2000-2012- Statistical Tables. Bureau of Justice Statistics. Retrieved July 1 at http://www.bjs.gov/content/pub/pdf/mljsp0012st.pdf

The Pharmacists Letter (2014) Treatment of hypertension: JNC 8 and more. Therapeutic Research Center. PL Detail – Document #300201. Retrieved July 1 at www.PharmacistsLetter.com

Smith, S. (2013) Sick Call. In Schoenly, L. & Knox, C. Essentials of Correctional Nursing. Springer. NY.

Townsend, T., & Anderson, P. (2015). What goes up must come down: Hypertension and the JNC-8 guidelines. American Nurse Today 10 (6)

Voermans, P. (2013) Chronic Conditions. In Schoenly, L. & Knox, C. Essentials of Correctional Nursing. Springer. NY.

Wang, E.A., Pletcher, M., Lin, F., et al. (2009). Incarceration, incident hypertension, and access to health care. Archives of Internal Medicine 169 (7): 687

Photo credit: © kbuntu – Fotolia.com

Test your knowledge: Hypertension

A person drawing and pointing at a Knowledge Empowers You Chalk Illustration

Hypertension is the most common reason for a visit to see a primary care provider and antihypertensive drugs are the most frequently prescribed medication in the community (Townsend & Anderson 2015). Hypertension is more prevalent among incarcerated persons than in the general community and a significant contributor to death, among inmates and former inmates, from cardiovascular disease (Binswanger, Krueger & Steiner 2009; Wang, et al 2009; Noon & Ginder 2014). Correctional nurses have a key role in screening, assessment and management of hypertension and other cardiovascular risk factors (Arries & Maposa 2013).

Revised guidelines for management of high blood pressure were released last year by the Eighth Joint National Committee. These are referred to as the JNC 8 (James, et al. 2014). These guidelines simplify the decision to treat hypertension, increase the options for initial drug treatment and ease the criteria defining good control (Mahajan 2014). Using the case example below, test your knowledge about treatment of hypertension in the correctional setting .

Case example: The patient you are seeing in nurse sick call has a blood pressure of 148/90 mm Hg. At intake, a month ago, his blood pressure was 154/92. He is being seen today for complaints of nasal allergies and a recent back strain.

  1. Based upon the reading today, this patient is at what stage of hypertension?
    1. Prehypertension
    2. Stage 1 hypertension
    3. Stage 2 hypertension
    4. Hypertensive crisis
  2. Which of the following is not a risk factor for hypertension?
    1. Race
    2. Family history
    3. Sexual orientation
    4. Alcohol use
  3. What lifestyle changes will you suggest to the patient?
    1. Weight loss
    2. Reduce salt
    3. Increase activity
    4. All of the above
  4. Patients with hypertension are seen monthly until…
    1. Blood pressure reaches the target goal
    2. Lab work is within normal limits
    3. Blood pressure readings stabilize
    4. The provider determines another interval
  5. If lifestyle changes are not sufficient to lower blood pressure, medication should be considered unless the patient…
    1. Is a diabetic
    2. Has liver disease
    3. Is over 60 years of age
    4. Has blurry vision
  6. Initial medication orders for treatment of hypertension are likely to include any of the following except…
    1. ACE inhibitors
    2. Beta blockers
    3. Calcium channel blockers
    4. Thiazide type diuretic
  7. The patient is placed on a low dose of lisinopril and hydrochlorothiazide. What lab work should be ordered to monitor this patient?
    1. BUN & GFR
    2. Albumin & bilirubin
    3. HgA1c & LDL
    4. Creatinine & potassium
  8. What lifestyle change are the most difficult to accomplish while incarcerated?
    1. Increased exercise
    2. Lower sodium intake
    3. Smoking cessation
    4. Limiting alcohol use

Next week we will review the answers to these questions. In the meantime, enjoy the Fourth of July holiday and stay safe!

For more on the correctional nurses’ role managing patients with chronic conditions like hypertension, cardiovascular disease, asthma, arthritis, diabetes, and seizure disorders see Chapter 6 of our book, Essentials of Correctional Nursing. Order your copy directly from the publisher or from Amazon today!

References:

Arries, E. J. & Maposa, S. (2013). Cardiovascular risk factors among prisoners. Journal of Forensic Nursing 9 (1): 52

Binswanger I.A., Krueger, P.M., & Steiner, J.F. (2009). Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population. Journal of Epidemiology and Community Health 63 (11): 912

James, P.A., Oparil, S., Carter, B.L., et al. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Journal of the American Medical Association 311 (17): 1809

Mahajan, R. (2014). Joint National Committee 8 report: How it differs from JNC 7. International Journal of Applied Basic Medical Research 4 (2): 61

Noonan, M. E. & Ginder, S. (2014) Mortality in Local Jails and State Prisons, 2000-2012- Statistical Tables. Bureau of Justice Statistics. Retrieved July 1 at http://www.bjs.gov/content/pub/pdf/mljsp0012st.pdf

Townsend, T., & Anderson, P. (2015). What goes up must come down: Hypertension and the JNC-8 guidelines. American Nurse Today 10 (6)

Wang, E.A., Pletcher, M., Lin, F., et al. (2009). Incarceration, incident hypertension, and access to health care. Archives of Internal Medicine 169 (7): 687

 

Photo credit: © kbuntu – Fotolia.com