Heart Disease and Women Part 4: Assessing Cardiac Risk Quiz

Portrait of young beautiful woman doctor holding red heart against gray background

We have spent the last several posts examining how women’s’ presentation in an impending cardiac event differs from men. We also looked at the emerging data that differentiates women’s cardiac risk from that of men. In this post we put our knowledge assessing cardiac risk to the test! Review the following paragraphs and identify the cardiac risk factors in each case example.

Case example 1. Ms. Falwell is a 38-year-old black woman who has been incarcerated for 10 months. She is single with three children who are living with her mother. Ms. Falwell has hypertension which has been well controlled with medication (ACE inhibitor). She is of a normal weight and her labs are unremarkable. She has a history of THC use and moderate alcohol intake but has not used tobacco. She is considered well-adjusted to prison life having been active in classes and other programs at the facility and taking part in competitive sports but also has expressed a good deal of anger and anxiety to her counselor and other inmates about the separation from her children and its impact on them.

Case example 2. Ms. Joseph is a 65-year-old white woman who is incarcerated for neglect and abuse of children in her day care. She has been an insulin dependent diabetic since she was in junior high school. She has diabetic retinopathy as well as peripheral neuropathy. Until her incarceration last year, she had been a heavy smoker since adolescence. She is housed in the special needs unit near the infirmary because she uses a wheelchair and needs assistance with all activities of daily living. She has no visitors or contact with her family and does not participate in any programs at the correctional facility.

Case example 3. Ms. Ott is 55 years old, of Malaysian descent and has just been incarcerated for manufacturing and distributing drugs. She has used drugs and tobacco daily for more than 30 years. During her admitting physical she was diagnosed with hyperlipidemia – her HDL was 35 mg/dL and LDL was 145 mg/dL. She has been prescribed a lipid lowering agent but is only partially adherent. Ms. Ott was disciplined recently for having cigarettes in her property so it is likely that she is still smoking even though this is prohibited at the facility.

Case example 4. Ms. Garcia is a 44-year-old Hispanic woman incarcerated the last two years for theft from several businesses where she and her husband were the night janitors. At 5’3” weighing 220 lbs. she is considered obese. Her provider has her on a reduced calorie diet but has gained weight since incarceration because she barters for junk food from the canteen. Her abdominal girth is substantial and the prison jumpsuit she was issued had to be altered to fit. She does not participate in any exercise programming at the facility. She does work two hours a day as the janitor on her living unit.

Case example 5. Ms. Hollister is a black woman 49 years of age and was transferred from jail to prison a few days ago to begin serving a ten-year sentence. During the admission health assessment, she gives a family history of heart disease. Upon further inquiry by the nurse Ms. Hollister’s father had an MI at age 53 and he eventually had a CABG procedure done. Her brother had a fatal MI at the age of 46. She has been receiving hormone replacement therapy for menstrual irregularity and now is in menopause. Ms. Hollister has led a sedentary lifestyle, is 35 lbs. overweight, does not exercise and has a significant history of alcohol use.

Questions:

  • Which of these five women is at greatest risk for heart disease?
  • Which of these woman is at the least risk?
  • What are the recommendations you would make in counseling each of these women?

See how your answers compare with the discussion about each of these questions in the next post. In the meantime, read more about correctional nursing in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

Photo credit: © Aleksandar Mijatovic – Fotolia.com

 

Heart Disease and Women Part 2: Traditional Cardiac Risk Factors

Heart - Female Organs - Human AnatomyWomen, as well as their healthcare providers, tend to underestimate risk of heart disease in women. The woman in the case example last week presented with six risk factors for heart disease.  Age, gender, family history and ethnic background are the only risk factors that cannot be altered; all of the others can be prevented. By midlife (40 to 50 years of age) almost all women have at least one cardiac risk factor (more than 80%) and the burden of heart disease increases synergistically with the presence of each risk factor. Among women, ages 18-39 years old, followed for an average of 31 years, those with 1 or fewer risk factors had 88% less cardiovascular mortality compared with those who had 2 or more risk factors. This is why the American Heart Association recommends that prevention of cardiovascular risk factors in women begin at an early age. The following paragraphs describe each of the risk factors traditionally associated with heart disease and their impact on women and their health.

Obesity: Incidence of obesity in the U.S. is greater than any other country with 24 states reporting rates of obesity over 30%. The prevalence of heart disease and death are the highest in these states as well. Non-Hispanic black women compared to other racial groups have the highest obesity rates (49.6%). The incidence of obesity among post-menopausal women has been reported as high as 40% and even when women do not gain additional weight, their weight is redistributed to the abdomen which is associated with higher rates of heart disease. Women who are obese have 2-3 times greater risk of an acute cardiac event compared to women who are not overweight.

Dyslipidemia: Elevated serum levels for low density lipoprotein, triglycerides, and total cholesterol as well as low levels of high density lipoprotein are all associated with heart disease in women. Data from the Nurse’s Health Study showed significantly higher risk for myocardial infarction and ischemic heart disease among women who had a higher intake of saturated fat in their diet. All of the major treatment guidelines recommend similar approaches for treatment of men and women and yet women are less likely to be prescribed lipid lowering medication or achieve recommended goals for cholesterol compared to men. This finding supports the role of nurses in informing women about risk factors and helping to advocate for treatment consistent with guideline recommendations.

Diabetes: The number of women diagnosed with diabetes has tripled since 1980 and is now more common in women than men. Women with diabetes experience more serious cardiovascular disease and have a cardiovascular mortality rate twice that of diabetic men. Women with diabetes have 6 times higher risk of cardiovascular death compared with women without diabetes. Diabetes is considered the second most significant risk factor for heart disease.

Metabolic syndrome: This refers to the clustering of obesity, dyslipidemia, diabetes, and hypertension in an individual. Women with metabolic syndrome have significantly increased prevalence of atherosclerotic disease and higher cardiovascular mortality rates than women who do not.

Physical inactivity: Among women 18 years of age and older, only about a third engage in regular physical activity. Women report lower levels of physical activity compared to men which contributes to risk for heart disease. Although the benefits of cardiac rehabilitation programs in reducing cardiovascular risk after a cardiac event are well known, women are referred by their health care provider  at lower rates than men. Those who are referred have low attendance rates compared to men and are significantly less likely to complete cardiac rehabilitation.

Hypertension: Women with hypertension have greater risk of heart disease compared to men with hypertension. Hypertensive women have three to four times the risk of heart disease compared to women with normal blood pressure. Women with hypertension are less often diagnosed than men and when diagnosed and treated, the condition is not as well controlled as in men. Furthermore, hypertension in non-Hispanic black women tends to be more severe, treated less adequately and results in significant cardiac morbidity and mortality. Pregnant women and women older than 65 years of age are also at high risk of developing hypertension.

Tobacco use: Women who smoke are at 25% greater risk of ischemic heart disease than men who smoke. Women who smoke experience significantly higher rates of fatal and non-fatal ischemic heart events compared to women who do not smoke. The largest difference in risk between smokers and non-smokers was among women less than 49 years of age. Women who smoke more than 24 cigarettes a day have a tenfold increase in risk for myocardial infarction compared to non-smokers. Smoking is considered the most preventable cardiac risk factor.

Psychosocial: Depression is a major risk factor for ischemic heart disease and this mental health disorder is twice as common in women compared to men. In addition lack of social relationships, particularly loneliness, in women is associated with greater cardiac morbidity and mortality. Also two studies have found hostility to be a significant predictor of risk for ischemic heart disease in women. Interestingly several studies failed to find a correlation between Type A personality traits and heart disease among women.

Hormones: Postmenopausal women are believed to be more vulnerable to heart disease because of the absence of estrogen. However large clinical trials of postmenopausal women receiving hormone replacement have not shown that it reduces heart disease, suggesting that the relationship between hormones and heart disease is complex and not yet well understood. Women who take oral hormonal contraceptives are at increased risk of heart disease especially in the presence of other cardiovascular risk factors.

The rate of heart disease increases with the number of traditional risk factors present. This is true of both men and women. In Ms. Locke’s case (the example in last week’s post) there were six risk factors for heart disease; which one of these was not preventable? What were the other five risk factors? What nursing interventions should be included in her chronic disease care plan?

The use of traditional risk factors alone has been criticized as underestimating heart disease risk in women, particularly those with subclinical disease. Improving risk estimation and detection of heart disease in women has led to the identification of newer or non-traditional risk factors. Next week we will look at the new or non-traditional risk factors for heart disease in relationship to women’s health.

For more about nursing care of patients in correctional settings with cardiovascular disease and other chronic diseases see Chapters 6 and 9 of the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

References:

McSweeney, J.C., et al. (2016) Preventing and experiencing ischemic heart disease as a woman: State of the Science. A scientific statement from the American Heart Association. Circulation:133.

Halm, M. A (2014) Women and Heart Disease. NetCE Course # 33221. Accessed March 2016 at http://www.netce.com/courseoverview.php?courseid=1001

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Heart Disease and Women Part 1: Symptom Presentation

17638Case Example: Ms. Locke, a 45-year-old inmate at your facility seeks medical attention today because of fatigue and shortness of breath. You look at the problem list and note that she was a smoker before incarceration and is being treated for hypertension, hyperlipidemia and diabetes. She is also obese. In your interview and assessment of Ms. Locke, she says that she feels nauseated and has a burning or soreness in her necks and upper arms. She reports experiencing these symptoms intermittently for the last month and being treated for a cold, epigastric distress and anxiety.

Does your differential diagnosis include cardiac disease, particularly ischemia or infarction? She is describing the four most common symptoms experienced by women before an acute cardiac event and there are six risk factors for heart disease in her health history.

The problem: There is still a belief that heart disease is a man’s disease and breast cancer is perceived as a greater threat for women than heart disease. And yet heart disease is the single leading cause of death among women in the United States! While ischemic heart disease is less prevalent among women compared to men; after the age of 45 the risk for women is comparable to men. Since the life expectancy of women is greater than men, as the population ages there is more heart disease among women.

The reason: In a survey of women conducted in 2012 only just over half were aware that cardiovascular disease was the leading cause of death for women and among black and Hispanic women recognition was even lower. In addition, women were not aware of the signs and symptoms of acute myocardial infarction that are more typical for women.

Research also shows that providers minimize the importance of women’s symptoms or disregard their concerns, do not order recommended diagnostic tests for heart disease and are more likely to prescribe treatments for depression or indigestion. Women also have poorer outcomes after diagnosis of ischemic heart disease than men; they are more likely to die the first year after an acute myocardial infarction, more often experience complications after cardiac intervention and have a poorer health related quality of life. While the death rate for younger men (ages 35-44) has decreased with prevention and treatment of heart disease the death rate for young women is increasing. Not knowing prodromal symptoms more typical of women and failure to asses for ischemic heart disease are thought to be the reason for this.

Typical symptom presentation: A meta-analysis of 26 studies concluded that women with acute myocardial infarction were less likely than men to present with chest pain. Women were more like likely to report fatigue, nausea, neck pain, right arm pain, jaw pain, dizziness and syncope than men. Another prospective longitudinal study showed that there were four symptoms that were significantly associated with the likelihood of a woman experiencing a cardiac event: discomfort in the jaw/teeth, unusual fatigue, discomfort in the arms and shortness of breath. Experiencing more than one of these symptoms increased the likelihood of a woman experiencing a cardiac event by four times.

Nursing implications: Here are my suggestions about what nurses should do with this information about the differences between men and women with ischemic heart disease.

  1. Review the nursing protocols at your facility that pertain to cardiac disease, especially those for emergent and urgent conditions. Do they need to be revised to include information that differentiates how ischemic heart disease typically presents in men and women? I looked at a nursing protocol today for angina and among the risk factors was “male gender”. While it is true that ischemic heart disease is more prevalent among men, women are more likely to present with angina when experiencing a worsening cardiac condition. It also doesn’t list age or menopausal status which are extremely relevant risk factors. The symptom description emphasized chest pain or pressure as intense and discounted the importance of other symptoms independent of chest pain. After the immediate problem is addressed does the nursing protocol provide guidelines for referral to a provider for a more comprehensive cardiac assessment?
  2. Educate women about the prevalence of heart disease, the risk factors and the symptoms of cardiac disease. Women tend to attribute their symptoms to non-cardiac reasons and are therefore more likely to be treated for non-cardiac disorders. A more knowledgeable patient helps to reduce delays in treatment for heart disease.
  3. Advocate for patients to receive appropriate diagnostic workups and treatment for heart disease. Unrecognized or “silent” myocardial infarction is more frequent in women and women who experience an MI have a much poorer prognosis than men. Because women are more likely to have their symptoms disregarded or minimized by providers (lack of knowledge by providers about increasing evidence of sex and gender differences in cardiac disease) nurses need to be familiar with diagnostic procedures as well as treatment interventions that are more accurate with women and advocate for these in developing the patient’s plan of care.
  4. You may be saying “Whew, just another reason why I am glad I don’t work in a women’s correctional facility”. But even at male facilities there are women correctional officers, nurses, other officials and visitors who are women. As a nurse you have the opportunity to educate these women about cardiac disease, its prevention and recognition-doing so may change their life. You may also be called to respond to one of these women in a medical emergency and it would be good to be prepared if they present with symptoms more typical of women in a cardiac event.

Next week we will review how sex and gender characteristics of women affect risk factors for heart disease. In the meantime, it would be interesting to know how the emerging information about women and heart disease might change how health care is provided at your correctional facility. Please let us know your thoughts by replying in the comments section of this post.

To read more about nursing care of women and patients in correctional settings with cardiovascular disease and other chronic diseases see Chapters 6 and 9 of the Essentials of Correctional Nursing.  Order a copy directly from the publisher or from Amazon today!

 

References:

McSweeney, J.C., et al. (2016) Preventing and experiencing ischemic heart disease as a woman: State of the Science. A scientific statement from the American Heart Association. Circulation:133.

McSweeney, J. C., et al. (2014) Predicting coronary heart disease events in women: a longitudinal cohort study. Journal of Cardiovascular Nursing: 29.

Coventry, L.L., Finn, J., Bremmer, A.P. (2011) Sex differences in symptom presentation in acute myocardial infarction: a systemic review and meta-analysis. Heart Lung: 42.

 

Photo by Linda Howard at http://www.picturequotes.com/create?quote=Women-were-always-complications,-bless-their-perverse-little-hearts

Continuity of medication and solving problems unique to the correctional setting

preso FATMany of the issues that nurses confront in the correctional setting while advocating for patients and their treatment are because health care is not the main goal, the burden of disease is great, and the population is transient with high turnover among inmates.

Problems with medications that arise from the setting: The most common problem in this category are inmates who do not show up to take medication at the prescribed time. While patients have a right not to take a medication in the correctional setting the patient must communicate this to the nurse by stating their refusal. The mere absence of a patient is not a refusal but a “no show” instead. There are many reasons why an inmate doesn’t appear to take their medication; it could be that they are at an appointment, in court or attending a program. It could also be that they have been moved to another part of the correctional facility or transferred to another institution entirely. It could be that no officer has let the inmate out of the cell or the housing unit. The nursing action to a “no show” is to follow up to find out where the inmate is and determine if the dose can be given later. Repeated instances of “no shows” need to be reported to the supervisor so that a systemic correction can be ma

Another problem is having the wrong medication delivered. Because there are so many inmates and they may have very similar names the pharmacy may dispense the wrong medication or staff may incorrectly identify the patient’s and put their medication in the wrong place in the med room or on the cart. This is one of the reasons for insisting upon two forms of identification and checking the medication against the MAR. When inmates have similar names, use of capital letters, color coding or some other way to easily distinguish one from the other is a practical solution.

Nurses who work in hospitals and other major health care settings have the advantage of quick access to the pharmacy for stat or urgent orders. Correctional nurses most often work in facilities that do not have an on-site pharmacy and in fact may use a mail order pharmacy located miles away. And yet there are times when an inmate arrives or an incident happens and a medication is needed quickly. Many of these types of situations can be anticipated (anaphylaxis, for example and medication epinephrine) and the medication stocked at the facility. Imagine though, an inmate arrives who is on the newest HIV medication and no other medication is a clinically appropriate substitution. It doesn’t make sense to stock some of every medication just in case there is a need. Instead, most facilities have made arrangements with a local pharmacy with 24 hour – seven day a week service to provide medications that cannot be obtained timely from the regular dispensing pharmacy. The nurse will be the one responsible for contacting the pharmacy and making arrangements for delivery once the provider has given the medication order. Correctional facilities without access to a backup pharmacy to fill urgent and stat orders jeopardize the health and safety of inmates.

Problems with medications arising from the burden of disease: Inmates as a population are sicker than the general community. There are many studies which have demonstrated the burden of disease among correctional populations. The majority take prescription medications, not only for one or more chronic medical diseases but often for a mental health disorder as well. Polypharmacy is a problem in correctional settings. The impact on nurses is an explosion of inmates on med line or who need KOP meds delivered, lengthy MARS that need to be transcribed and kept updated, and an increasingly complex patient care situation that can produce adverse events. Also the patients themselves, in this case, inmates, expect providers to treat conditions that many of us who live in the community would either not experience, ignore or treat ourselves without use of prescription medication. Because patients in correctional facilities see different providers, medications may be prescribed by one without being aware of what else the patient is receiving. A solution to this is to bring patients on multiple medications to the attention of the medical director or senior medical professional for review. These are patients perhaps better assigned to see one provider and for medical and mental health providers to collaborate when making treatment decisions. These are also patients whose treatment would benefit from pharmacy consultation.

Because of the presence of so many mentally ill persons in prisons and jails nurses are also likely to be involved in administration of involuntary medication to patients. State law and other aspects of law will govern the use of involuntary medication in your facility and you need to familiarize yourself with these requirements; hopefully your facility will have a policy and procedure. Many patients who have gone through the process of having an involuntary medication order put in place are very cooperative with the process. Medication may also be administered involuntarily in a psychiatric emergency; again, be familiar with your facility’s policies and practice as well as state law so that you are prepared if this becomes necessary.

Problems with medications arising from inmate movement: Missing medications are a huge problem, especially in large jails and prisons with multiple locations where medications are administered. If an inmate is moved from housing block A to D block, and a different medication cart is used for these two housing units, the nurse administering medication in block D isn’t going to have the inmate’s medication when it is time to administer it, unless the nurses are informed that the inmate has been moved before the next med administration and someone moves the medication from one cart to another. In this same scenario, if the inmate takes the medication KOP, it gets put into his property when he is moved and he cannot access it until the property is inventoried and returned to him. Solutions to this problem center on improving the timeliness of notification by custody to health care and nursing accountability to put the medication in the new location. For KOP a solution is to ensure prompt processing of property or providing a way for the inmate to bring the medication with them to the new location.

The problem of transfers is even more profound when an inmate is transferred from one correctional jurisdiction to another, from a county jail to a state prison and visa versa, from one county jail to another or one prison to another, from a jail to the Marshall’s Service to a series of jails for brief stays while being transported across country to another correctional facility. Nurses play a key role in providing a written transfer summary that includes a list of the inmate’s medical problems, the medications they are taking, recent labs and pending appointments. When this is not done it may be because the nursing staff did not receive timely notice of the transfer. If you receive an inmate from another facility who reports that they were taking medication it is best to contact the facility to verify the information and follow up until you succeed in receiving it.

Discharges is another problem area. When inmates return to the community, it is a well-established standard that they receive a supply of medication sufficient to ensure continued treatment until they are seen by a provider in the community. Again lack of timely notice that the inmate is being discharged is the culprit. Solutions to this problem are to work with classification officers to anticipate the probable discharge date. Inmates can also be good sources of information about probable discharge dates and provide information about the resources they use for health care while in the community. Some jails initiate discharge planning at the time of intake and provide inmates with information about how to obtain bridge medication until they see a community provider. Most facilities have processes in place to let inmates take the medication already dispensed, to provide a container of especially prepared discharged medication or for the inmate to go to a local pharmacy to pick up medication prescribed by the provider at the correctional facility within a couple days of discharge. The nurse’s role usually is to ensure the discharge prescription has been written, the patient has their medication upon release or has been provided with information about how to obtain the medication from a community pharmacy.

Managing and monitoring continuity of medication

One of the most important factors affecting patients’ willingness to follow the treatment plan is whether their symptoms are relieved and new ones not experienced (Ehret et al. 2013, Mills et al. 2011). If patients don’t feel better, they are not going to continue following treatment recommendations. Increasing adherence to prescribed medication has greater impact on health outcomes than any other specific form of medical treatment (Brown & Russell 2011, Sabaté 2003). Monitoring patients closely for symptom response, addressing side effects promptly and eliminating barriers and other reasons for medication discontinuity increase the likelihood of treatment success (Vellegan et al. a. & b. 2010). These three interventions are within correctional nurses’ independent scope of practice and can therefore be implemented without provider orders.

Specific steps correctional nurses can take to support the patient’s continuity of care in medication treatment are to:

  1. Notify custody staff of patients whose medication requires:
    • Dietary restrictions or a special diet for patients with diabetes or those taking MAO inhibitors for example.
    • Work restrictions such as not driving or using machinery when a patient is taking medication that causes sedation.
    • Canteen restrictions when for example a patient’s salt intake or carbohydrates must be limited.
    • Housing restrictions such as a lower bunk for a patient taking medication that causes dizziness or medically supervised housing for patients on medication that needs close monitoring (rehydration for example)
    • Environmental precautions: such as limiting exposure for patient’s taking heat or light sensitive medication.
  2. Schedule Follow up appointments with:
    • Nursing to check adherence by review of the MAR or the patient’s own medication if on KOP, to collect serial data such as blood pressure, weight, blood glucose and to find out from the patient if they are feeling better (intended effects) or experiencing side effects (unintended effects). Patients with poor adherence should be seen weekly while those with better adherence can be seen monthly or quarterly.
    • The patient’s provider(s) to review labs, discuss progress, symptom relief, side effects, adherence and adjust prescribed treatment as necessary. Provider appointments should be scheduled to coincide with the availability to lab and other monitoring measures as well in time to see the patient to re-order medication.
  3. Schedule lab and other monitoring measures to coincide with and take place in advance so that the data is available for review and discussion with the patient at provider appointments. Be familiar with common lab work recommended for medications you are responsible for providing to patients and help providers remember to order these when appropriate.

What problem areas do you experience with medication treatment that you believe are unique to the correctional setting? Do you have solutions to any of these problems that haven’t been discussed in this post? Please share your comments by replying in the comments section of this post.

For more about supporting medication treatment and continuity of care see Chapter 6 Chronic Conditions and Chapter 12 Mental Health in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

References

Brown, M. T. & Bussell, J.K. (2011) Medication adherenace: WHO cares? Mayo Clinic Proceedings 86 (4) 304-314.

Ehret, M.J., Barta, W., Maruca, A., et al. (2013) Medication adherence among female inmates with bipolar disorder: results from a randomized controlled trail. Psychological Services, 10 (1), 106-114.

Mills, A., Lathlean, J., Forrester, A., Van Veenhuyzen, W. & Gray, R. (2011) Prisoners’ experiences of antipsychotic medication: influences on adherence. The Journal of Forensic Psychiatry & Psychology, 22 (1) 110-125.

Sabaté, E., ed. (2003) Adherence to Long Term Therapies: Evidence for Action. Geneva Switzerland: World Health Organization. Accessed January 24, 2015 at http://www.who.int/chp/knowledge/publications/adherence_report/en/

Velligan, D.I., Weiden, P.J., Sajatovic, M. et al. (2010 a.) Assessment of adherence problems in patients with serious and persistent mental illness: recommendations from the Expert Consensus Guidelines. Journal of Psychiatric Practice, 16 (1) 34-45.

Velligan, D.I., Weiden, P.J., Sajatovic, M. et al. (2010 b.) Strategies for addressing adherence problems in patients with serious and persistent mental illness: recommendations from the Expert Consensus Guidelines. Journal of Psychiatric Practice, 16 (5) 306-324.

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Intake Health Screening-Making the most out of this brief encounter

Rear view of nurse assisting man while working at reception desk in hospital

 

Receiving or intake health screening is done whenever someone is brought to a jail or prison for admission. These individuals are being detained for any number of reasons including having been arrested for an alleged illegal activity, involved in an altercation or other suspicious activity that the police were called for, having been tried, found guilty and sentenced to serve a term of incarceration, having violated conditions of parole or probation, or are being deported for being in the country illegally or are being transported by the Federal Marshall.

Persons may be held in custody for only a brief time (hours) or for very long periods of time (life). The length of time people generally spend in jail is considerably less than in prison. Therefore, jails have very high rates of turnover and intake health screening is a very high volume activity. Furthermore, people admitted to jail have been in the community immediately before, perhaps living in conditions that were a risk to their health and wellbeing or they may have been injured during the arrest or while in police detention. The volume of people admitted to prisons is not as great but because they have been in custody for a while their condition may have deteriorated if it was not identified or treated at facilities which held the person previously. Because of the potential to miss identifying a serious medical or mental health condition and delay necessary treatment, intake receiving screening is also a considered a risk prone process.

Chart audit of intake health screening is one way to monitor the quality and effectiveness of the process. I just finished an audit of 25 charts using these three questions.

  1. Were conditions that warranted referral to a provider identified?
  2. Were patients seen timely by a provider when referred?
  3. Were records of previous care requested when the patient reported ongoing or recent treatment?

Several problem practices were identified that would be good to review further so that corrections can be put in place. I have seen these same problems with intake screening before and so wanted to share them with you to see if your experience is similar and if you have found ways to improve? The following paragraphs describe these findings and suggest possible corrective action.

  1. Practices that reduce the likelihood of identifying a medical or mental health condition that should be referred include:
  • Not collecting serial assessments when abnormal results are found initially. There are many things that can cause elevated blood pressure, including stress, agitation and withdrawal. The same with pulse, blood glucose and peak flow readings. Repeating tests that were abnormal at the end of the assessment or having the inmate wait a bit to reassess adds important information. Results that don’t improve or worsen need to be followed up and a nurse cannot depend on the next person down the line to pick it up. Consideration should be given to removing the barriers that get in the way of obtaining serial assessment data at intake screening.
  • Not inquiring further to yes answers or when the patient reports a medical or mental health condition. For example, if the patient says that they have seizures follow up questions should elicit a description of the type of seizure, when the last one took place, how often they happen and what treatment did the patient receive. Another example was a woman who reported in response to the social history questions that she had been forced to have sex and did not feel safe living at home. Maybe the nurse expected the social worker to pick up on this later but the absence of any additional inquiry or explanation on the part of the nurse indicated that this information was ignored in considering possible health problems. Developing question prompts may help nurses follow up on positive answers.
  • Not going further to establish rapport with patients who give minimal answers or deny obvious problems. An example I see frequently is a patient who denies alcohol or drug use when either their current condition or history of arrest suggest it is likely untrue. A follow-up question or statement to challenge the answer in a non-threatening manner may yield better information. Receiving screening is a dialogue not just rote fact finding using a standardized questionnaire. When the patient’s answer is no to every question you have to consider if language or some other barrier is effecting the patient’s disclosure. Here are some techniques that build rapport during intake screening:
      • Professional appearance of the nurse
      • Focus on the patient
      • Have a neutral or friendly facial expression
      • Allow silence so the patient can reflect and respond
      • Eye contact that is neither too much or not enough
      • Ask questions without reading verbatim
      • Avoid use of leading or biased questions
      • Avoid body language that is perceived as superior or judgmental
      • Do not be distracted, preoccupied or rushed
      • The setting provides privacy

2. Practices impacting timely referrals to providers include:

  • Not following up when nurses make urgent or priority referrals to a provider to make sure the patient is seen timely. We all get busy during the shift and it may be that something is preventing the provider from seeing the patient within the timeframe the nurse requested. Or it may be that the communication about the patient’s priority was missed. The person making the referral bears responsibility to follow-up to make sure that it is accomplished or an acceptable alternative put in place. This is the sixth step in the nursing process; evaluation and revision of the plan of care.
  • Not ensuring that patients are seen by a provider promptly when they return to the facility after diversion to the emergency room. When the ED clears an arrestee for jail it simply means that their condition is not urgent enough to require further monitoring in the ED or admission to the hospital. It does not mean the person was medically cleared and therefore intake health screening is not necessary. Instead information from the ED should be collected and reviewed by the nurse, other intake screening data collected and the patient referred promptly to a provider. If not immediately, the provider should see these patients no more than a couple hours of their return to jail and the nurse should follow up to ensure that this takes place.

3. Not requesting health records of recent or ongoing treatment at intake may delay initiation of appropriate medical or mental health care. Examples of conditions where the previous treatment record should be requested include HIV disease, seizure disorder, heart disease and other acute or chronic conditions. Nurses are in the best position to get prior records; the patient is right there and can sign the consent forms and the nurse knows how to navigate the local health community. These records can be very important to the provider’s decisions about treatment. Many times the reason given for not requesting records is that the patient will be gone before the record arrives or that the patient’s information is so vague that tracking down the provider isn’t efficient use of time. Examining barriers to requesting previous records should be explored and efforts to eliminate or develop sources to get the information made. Making specific arrangements for transfer of information with specific providers who see a majority of the same population may reduce the time it takes to get information. Examples would be the state prison system and jails, major community based providers of indigent care, and the mental health system in the state or county. With the advent of electronic records, the timeliness to request and receive information is vastly improved.

Conclusion: Intake health screening is an activity unique to jails and prisons, that involves nurses’ collection and review of information about the health of every person admitted to the facility and nursing decisions about patients’ immediate needs for medical attention, ongoing treatment and protection from harm. It is a high risk, problem-prone aspect of correctional health care and should be regularly reviewed by the Quality Improvement Program and studied to identify opportunities to improve practices. This blog post described the findings from a chart audit that used just three criteria and only took a couple hours to complete. Six areas of possible improvement in nursing practice were identified. Further study to identify and eliminate barriers to best practices is the next step to an improved intake process.

What are the most common problems you have identified when monitoring the nurses’ role in intake or receiving screening? What barriers were addressed which improved intake screening practices? Please share your answers to these two questions by replying responding in the comments section of this post.

For more about the nurse’s role in intake or receiving screening see Chapter 14 Health Screening in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Learning from case examples

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

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

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

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

Photo credit: © chrisharvey – Fotolia.com

Clinical judgment resulting from the mental health assessment

Man Woman face people problem puzzle

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Photo Credit: @ Krasimira Nevenova – Fotolia.com