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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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!

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Clinical judgment resulting from the mental health assessment

Man Woman face people problem puzzle

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Medication Adherence

Знак вопроса из медицинских таблетJessie has put in a sick call request because she is depressed and anxious.  You see her later in the day; she is worried about her children, who are under the care of their aunt while Jessie is incarcerated. She is unable to sleep, tearful and was sanctioned recently for not following orders. She is having difficulty getting along with her cellmate and prefers to stay in the corner of the dayroom.  You note in her record that Jessie has diagnoses of schizoaffective disorder, asthma and hypertension.  She takes several different medications and misses taking them about half of the time.  Jessie uses sick call frequently and has declared several medical emergencies for chest pain and shortness of breath; later diagnosed as anxiety. Jesse missed a recent mental health appointment and claimed she was not notified. She unsure about her work and program assignments and her appearance at the sick call is disheveled.

This is a classic example of a patient seen in the correctional setting; one who has a chronic mental health condition, comorbid chronic health problems and a likely history of substance abuse, who is only partially compliant with treatment. How many times have you wondered what else you might do to better support her and other patients like this to adhere to the plan of treatment?

The first step is to congratulate yourself that you identified non-adherence to treatment as a primary reason for the symptoms she is experiencing. What would Jessie’s clinical condition be like today if she were taking medication as prescribed, keeping her appointments with mental health providers and engaged in work and other program assignments? When you ask Jesse why she is not taking her medication her answer is vague. She professes to have a good relationship with the psychiatric nurse practitioner but cannot tell you what medications she is prescribed or why.

According to the World Health Organization (Sabaté 2003) approximately 50% of patients with chronic illnesses do not take medications as prescribed. Failure to take medications as prescribed is associated with poor patient outcomes, relapse, increased mortality and increased hospitalization (O’Malley 2013). Adherence is defined as the extent to which a person’s behavior corresponds with the recommendations for treatment to which the patient agreed. Adherence is complex, involving the patient’s knowledge, beliefs and attitudes, and their relationship with health care providers. Adherence also changes over time and may vary from day to day. The nature of the treatment itself, health care provider behavior and the system that provides the patient care impact adherence.

One of the most important factors affecting adherence among inmates is the patient’s experience of symptom relief (Mills et al. 2011, Ehret et al. 2013). In Jessie’s case, the anxiety and depression she is experiencing probably is because she is missing half of her medications. Several studies report good adherence rates among prisoners because of directly observed therapy (Gray et al. 2008, Westergaard et al. 2013, Saberi et al. 2012). However, even with directly observed therapy, inmates miss taking their medication because the request for refill was not made timely, the inmate was asleep or not present at the time medication was administered, the inmate forgot or was experiencing unwanted side effects (Mills et al. 2011, Ehret et al. 2013).

Viewing the patient as solely accountable for adherence is considered an uninformed and destructive model. Experts suggest instead that helping patients’ increase adherence would have a greater effect on health outcomes than any other specific medical treatment (Brown & Russell 2011, Sabaté 2003).  In an expert guideline series on adherence two first-line interventions were recommended:

1. Symptom and side effect monitoring

2. Medication monitoring and environmental supports

Listed below are specific actions that can be taken which are consistent with these two interventions. They provide guidance about how to assist our patient, Jessie.  Monitoring and support of patients to improve adherence are independent functions and within the scope of practice for registered nurses.

Symptom and side effect monitoring

Medication monitoring and environmental supports

  • Monitor closely for symptom response using a daily checklist or chart
  • Institute directly observed therapy
  • Increase frequency of contact
  • Provide reminders to take medication
  • Address side effects promptly
  • Provide reminders to get medication refills
  • Consider how distressing the side effect is for the patient
  • Target support to address barriers
  • Provide information about how to manage side effects
  • Increase visit frequency to monitor for relapse
  • Simplify the medication regime
  • Involve family or other social support
  • Consider the patient’s preference for dosing regime

(Velligan et al. 2010)

Poor adherence is due to multiple factors and requires several concurrent strategies to effect change. The goal of our interventions is not adherence, per se, but to achieve the best possible outcome for the patient. Involving the patient in the identification of the outcome she wants to achieve will provide clarity and motivation for the patient. Tailoring the medication experience, as much as possible, to the patient’s goals will improve their adherence.

The next post will describe the various factors affecting adherence among our patients and provide more strategies which have evidence to support their use to improve adherence. Until then, we invite you to tell us about the most challenging aspects of supporting patient adherence to prescribed medication in your setting?  Please share your opinions by responding in the comments section of this post.

Read more about monitoring and supporting patient compliance with prescribed medication in Chapters 6 and 12 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

References: 

Brown, M. T. & Bussell, J.K. (2011) Medication adherence: 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

Gray, R., Bressington, D., Lathlean, J. & Mills, A. (2008) Relationship between adherence, symptoms, treatment attitudes, satisfaction, and side effects in prisoners taking antipsychotic medication. The Journal of Forensic Psychiatry & Psychology, 19 (3), 335-351

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

O’Malley, P. A. (2013) Medication adherence and patient outcomes. Part 1: Why patients fail to take prescribed medications. Clinical Nurse Specialist, 227-228

Sabaté, E., ed. (2003) Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization. Accessed 11/20/2013 at http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf

Saberi, P., Caswell, N.H., Jamison, R., Estes, M. & Tulsky, J.P. (2012) Directly observed versus self-administered antiretroviral therapies: preference of HIV-positive jailed inmates in San Francisco. Journal of Urban Health 89 (5) 794-801

Velligan, D.I., Weiden, P.J. & Sajatovic, M., et al. (2010) 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

Westergaard, R.P.; Spaulding, A. C., Flanigan, T.P. (2013) HIV among persons incarcerated in the USA: a review of evolving concepts in testing, treatment and linkage to community care. Current Opinion in Infectious Disease 26 (1) 10-16

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Assessing the Mentally Ill Patient: Part 3

Last week we had just finished an assessment of a young man with agitated, restless behavior. These are some of the key findings from our assessment of the patient:

Does not respond to questions or requests in a  coherent way.

  •  Vocalizes words but they are not logically connected to express thought.
  • Increased agitation when interviewed.
  • Appearance of visual & tactile hallucinations.

The patient is not in touch with current reality and has symptoms of abnormal cognitive status. This is the definition of psychosis. Our initial nursing diagnosis is that the patient is at risk of deterioration or injury as a result of a psychotic condition.  The first step in our plan is to place the patient in the inpatient unit, for safety, additional assessment and monitoring. See Chapter 12: Mental Health for more information about the assessment of psychosis including more detail about patients experiencing hallucinations and delusions.

Delirium is characterized by:

  •     Rapid onset or mental status that fluctuates over the course of a day and
  •     Inattention, or difficulty focusing, distractibility or inability to track what is said and
  •     Disorganized thinking, incoherence or an altered level of consciousness (hyper-alert, lethargic, stuporous). 

Another piece of advice for nurses in correctional settings is to always consider medical causes as a possible explanation for psychotic symptoms. The next step is to look at the onset of symptoms and consider whether the patient is likely to be experiencing delirium rather than a psychotic disorder.  It is important to identify delirium early because the underlying medical problem can be treated and the symptoms reversed. Key findings from our patient assessment that suggest delirium are:

  • Condition has deteriorated within the last 24 hours.
  • Not responsive to questions or requests.
  • Increased agitation and hyper-vigilant.

Medical conditions that can cause delirium include:

  • Alcohol or drug withdrawal
  • Drug abuse
  • Electrolyte or other chemical imbalance including metabolic or endocrine diseases
  • Infection
  • Poisons
  • Medications
  • Surgery
  • Other conditions that deprive the brain of oxygen and other nutrients (cardiopulmonary diseases, CNS disease)

The patient denied any history of alcohol or drug use when interviewed during receiving screening. Now that it is 72 hours later, his symptoms and their onset suggest alcohol withdrawal so we further assess the patient using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar).  The results of this further evaluation lead us to conclude that this patient is in moderate to severe alcohol withdrawal.  We call the provider with our findings and request treatment orders. The focus of treatment is to prevent seizures and to address fluid and electrolyte imbalances. The plan of care also includes serial assessments to monitor the patient’s status closely and a safe environment to prevent injury.  For more information about the assessment and treatment of alcohol and drug withdrawal see Chapter 5 in the Essentials of Correctional Nursing.

Always remember that psychiatric symptoms, such as psychoses, can be caused by medical conditions.  When identified and treated these symptoms can be completely reversed.  Objective, descriptive assessment, use of standardized screening tools and attention to the possibility of both medical and psychiatric etiology contribute to accurate clinical judgments.

If you haven’t already order your copy of the Essentials of Correctional Nursing directly from the publisher at http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4

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Assessing the Mentally Ill Patient: Part 2

In last week’s post we were preparing to assess an inmate at the county jail, who the custody staff described as “going nuts”. With an accurate assessment our goal is to seek the most appropriate and immediate help for the patient. We reviewed his record and decided that the best place to interview him at this time is the cell front.

A nursing assessment of mental health is similar to the assessment of a physical status.  It consists of asking questions of the patient about their symptom and treatment experience (subjective assessment) while at the same time observing the patient’s behavior, activity and expressions (objective assessment).  The table below lists the clinical signs and symptoms that are evaluated in a mental health assessment.  It can be used as a quick reference to make sure your assessment is comprehensive. For more detail about each of these areas see Chapter 12 of the Essentials of Correctional Nursing.

Component Areas   Assessed Method
Appearance Dress &   Hygiene Observation
Behavior Expression   & Motor Activity Observation
Speech Rate, Tone,   Manner, Content Observation
Cognition Orientation,   Memory, Attention, Insight Interview
Mood Patient’s   description of how they feel Interview
Affect Expression   of emotion Observation
Thoughts Form &   Content Interview
Perception Hallucinations Interview

We arrive on the unit and check in with the correctional officer who called with concerns about the inmate and then go see the patient. After introductions we engage the patient in purposeful conversation; asking about the time of day, his activities, and how he is feeling. We may ask him to carry out a request or recall a recent event. As our interaction takes place we are listening carefully and observing the patient’s behavior noting his cognition, emotions, their expression and thought processes. We follow up on his responses to fill in detail, provide support and offer reassurance.

Nurses make significant contribution to good patient outcomes by skilled observation.  Describing a patient’s health status, especially signs and symptoms that deviate from “normal” is much more useful in determining the plan of care than use of psychiatric terminology and diagnostic labels. In the following documentation of our patient assessment we do not use elaborate or specialized psychiatric terminology.

S:  23 yo male, first incarceration, received 72 hours ago on charge of reckless driving. On intake denies ETOH and/or drug use. No history of MH treatment. At 22:00 h officers requested help w/ inmate “going nuts”.  According to custody he has not rested or eaten over the last 24 hours.

O:    Pt. appears disheveled; not having shaven or washed hair for several weeks, observed pacing the cell. Minimal eye contact, no direct response to questioning, verbalizes random words that are not connected logically to one another.  Does not comply when directed to approach the cell front or sit on bunk. Withdraws to cell corner and random hand movements increase when spoken to. Patient appears to be rolling fingers and picking at air, this activity increases in pace and emphasis during the assessment. No self-harm behavior was observed.”

Basic survival advice for correctional nurses conducting a mental health assessment is to remember that:

1. Both mental and physical health assessments are formed by the collection of subjective and objective information.

2. The mental health assessment considers the patient’s appearance, cognition, emotion and thought processes.

3. Comprehensive, descriptive information is more valuable in determining the plan of care than use of specific psychiatric terminology or labels.

Based upon the description of the patient what is your assessment and nursing diagnosis?  What is your plan for the patient? We will pick up here on the next post.

If you haven’t already order your copy of the Essentials of Correctional Nursing directly from the publisher at http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4

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Assessing the Mentally Ill Patient: Part 1

You are coming to the end of a busy evening shift at the county jail and receive a telephone call from custody staff about an inmate who is “going nuts.” The officer wants a nurse to come to the unit and “do something” about the inmate. The officer says that the inmate is a 23 year old male brought in on a charge of reckless driving the day before yesterday.  What are the next steps you will take as the nurse responding to this patient?

Last week’s post made a couple suggestions. The first is to take a deep breath and think about what needs to be accomplished for the patient and the best way to get there. Second, of the types of encounters in last week’s post, this is likely a patient who is acutely ill. The nursing action and goal is to carefully assess and document the patient’s health and mental health status so that the most clinically appropriate and immediately responsive plan of care is put into place.

Prepare yourself for this encounter by:

  • reviewing the patient’s record
  • identifying a safe, private place for the interview and
  • setting aside time to conduct the interview

Prepare the patient by:

  • identifying yourself
  • making it clear to the patient why the interview is taking place
  • listening carefully

Taking these steps increases the accuracy of the information obtained in the assessment which means more precise problem identification and more effective treatment.  People are sometimes reluctant to describe symptoms they are experiencing while incarcerated because of concerns about being victimized as mentally ill. Review of the record will provide information to the nurse about the potential this patient has for substance withdrawal as well as any history of mental health treatment. It may be that the safest place to conduct the assessment is at the cell front; just be aware of factors in the setting that effect the patient’s responses by inhibiting disclosure or creating confusion.

Setting aside the time, identifying yourself, and telling the patient why you are there, are all done to create a therapeutic relationship between the nurse and the patient. We all know what it feels like to interact with someone who conveys that they don’t have the time and don’t care about you or think you are lying. Taking the steps to establish a therapeutic relationship helps the nurse be mindful about the nature and purpose of the patient encounter in a very busy and sometimes stressful setting.  By listening carefully, the nurse can pick up on information that the patient is reluctant to disclose.  For example, the patient may deny mental health treatment but mentions the name of a counselor at the local community mental health clinic. This is probably an indicator that the patient has had some contact with the mental health system that could be followed up on. It helps to be familiar with the main contacts and places that provide mental health services in the community so that if the patient mentions something related to these you can pick up on it. The same is true of substance abuse services in the community.  Some communities have begun to share access to patient registries especially to reduce or eliminate discontinuity of treatment.

Do you have access to information from mental health agencies or substance abuse treatment programs that help identify patients who have been in treatment before admission to the correctional facility?  If so, please let us know if you think it has improved care of the mentally ill and if so how?

Read more about mental health in Essentials of Correctional Nursing. Order your copy directly from the publisher http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4

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