Alcohol Withdrawal: Keeping Tabs

AlkoholsuchtWithdrawing from alcohol may be a common experience behind bars but it can never be taken lightly. Withdrawing patients need ongoing monitoring until they are through the risky period – at least the first three to five days. So, once you have screened for alcohol withdrawal and set a treatment plan in motion, you need to regularly check-in with withdrawing inmates to assess the progression of symptoms.

Know the Score

Both the Federal Bureau of Prisons Clinical Practice Guideline for Detoxification of Chemically Dependent Inmates and the NCCHC Alcohol Detoxification Guideline recommend the use of the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) for ongoing symptom monitoring and management during alcohol withdrawal (A copy of the CIWA-Ar can be found in the FBOP Guidelines).

This quick-to-use tool has been validated in many settings and assesses vital signs and withdrawal symptoms in 10 categories:

  • Nausea/Vomiting
  • Tremors
  • Anxiety
  • Agitation
  • Paroxysmal Sweats
  • Orientation and Clouding of Sensorium
  • Tactile Disturbances
  • Auditory Disturbances
  • Visual Disturbances
  • Headache

A score is calculated by summing the scale number for each of the 10 categories. The highest obtainable score is 67 and most protocols consider a score greater than 15 to need increased attention and medical treatment. For example, the NCCHC Alcohol Detoxification Guidelines recommends this categorization of patients based on a CIWA-Ar Score:

  • Low Risk: Asymptomatic or minimal symptoms (CIWA-Ar score less than 10)
  • Moderate Risk: A history of significant alcohol withdrawal syndrome and history of medical and psychiatric conditions (CIWA-Ar 10-15)
  • High Risk: History of severe alcohol withdrawal syndrome including seizures, delirum tremens, and suicidal ideations (CISA-Ar greater than 15)

Using the Data

Using risk categories can determine the level of attention given to withdrawing patients. For example, low risk patients may be evaluated every 8 hours while moderate and high risk patients may need hourly assessments and intervention until symptoms subside.

Regularly assessing withdrawing patients along a continuum of these ten symptoms provides objective data that can be used to guide treatment with benzodiazepines. The FBOP guidelines establish a treatment protocol based on the CIWA-Ar score:

CIWA Treatment

The Assessment Challenge of CIWA-Ar

Although the CIWA-Ar rating system is practical and can be completed in a few minutes, it requires practice and consistency among raters. Let’s take the scoring for agitation as an example. Here are the directions on the Scoring Tool:

Rate on a Scale of 0-7

  • 0 = No Activity
  • 1 = Somewhat Normal Activity
  • 4 = Moderately fidgety and restless
  • 7 = Constantly paces or thrashes about

The directions indicate that you can rate this category anywhere from 0-7 and provides low, middle, and high score examples. One nurse may determine that the patient is slightly more than moderately fidgety and restless; rating the patient as a 5. The next shift nurse may see the same restlessness as slightly under moderate and rate the patient a 4. In reality, the patient may be escalating in agitation and is really on the way to a 7. With a spread of scores in both the FBOP and NCCHC guidelines of less than 10 to over 15 encompassing risk ranges, a couple points difference in nurse evaluations can mean missing increased withdrawal symptoms or overmedicating receding symptoms.

Meeting the Challenge

In the high-stakes process of managing alcohol withdrawal, assessment variability using the CIWA-Ar tool must be minimized. This can be accomplished in several ways:

  • Orient every nurse specifically to the tool including the use of case presentations to be sure the directions can be correctly applied.
  • Use actual withdrawal situations to determine inter-rater reliability of the use of the tool. Have more than one nurse independently score a withdrawing patient and then have them compare their findings.
  • Consider only using the defined scores on the tool. For example, in the agitation category the only scores possible would be 0,1,4,7. This could eliminate some of the variability among raters.
  • Consider instructing assessors to err on the side of higher scores as the greater risk is in not treating withdrawal and closer monitoring is a safer outcome.

Successful alcohol withdrawal in the criminal justice system requires a thoughtful coordinated effort involving many team members. Ongoing monitoring of withdrawing patients is a major part of this effort. How are you monitoring your withdrawing patients? If you use the CIWA-Ar Tool, how do you confirm proper use? Share your thoughts in the comments section of this post.

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

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Alcohol Withdrawal: What’s the Plan?

What is your plan ?Alcohol withdrawal is a fact of life in our patient population. You are likely screening for it on intake and hopefully using a standard evaluation tool like those described in a prior post. Once you see an incoming patient is at risk for withdrawal, what is your plan?

Location, Location, Location

Withdrawing patients need to be located where they will not get lost in the system. Some facilities have the capacity to keep potentially withdrawing patients in an Infirmary or Special Needs Unit where they are directly monitored. Other facilities only place symptomatic patients in the infirmary and keep potentially withdrawing patients in a specific housing unit. If they develop symptoms they are transferred to a higher level of observation or treatment. The key principle is to have a designated place for potentially withdrawing inmates where officers and other staff are aware of what signs and symptoms indicate alcohol withdrawal.

Get the Timing Down

If you know when your patient last had a drink or can estimate it based on entry into the facility, you can have some idea of when withdrawal symptoms will peak. Of course, timing is individualized based on many factors such as the patient’s liver health and long-term nature of the alcoholism. However, generally, withdrawal from alcohol progresses to completion over 5 days with the greatest degree of symptoms in the first 24-36 hours. Without intervention, though, withdrawal can lead to delirium tremens at about 3-5 days from the last drink. This condition is serious and can lead to hallucinations, electrolyte imbalances, unconsciousness, and death. Even ‘frequent-flyer’ alcoholics with a known history of uncomplicated withdrawals in your facility should be watched closely and treated for withdrawal. A phenomena called ‘alcohol withdrawal kindling’  can emerge where progressive withdrawal episodes increase in neurotoxic intensity. This means your ‘regular’ withdrawing patient may not progress as mildly this time around.

Maintain the Protocol

Alcohol withdrawal is both a common and risky medical condition for the inmate-patient population. Therefore, it is important to have a standard protocol for treatment. A standard protocol establishes consistent and appropriate practices for all staff members and provides a safeguard in those situations where practitioners may be unfamiliar with the standard of care. The Federal Bureau of Prisons Clinical Practice Guideline for Detoxification of Chemically Dependent Inmates is a good place to start in determining necessary elements of a plan of care. Here are some important management principles that should be a part of any correctional alcohol withdrawal protocol:

When to Seek Provider Orders: If a patient is deemed a medium or high risk of alcohol withdrawal at intake, most protocols stipulate a provider evaluation and prescriptive therapy. Low risk patients may be put on a monitoring protocol and advanced to provider oversight if symptoms emerge. Many of the protocol treatments described in this post require a provider order but can be part of a protocol list to speed treatment ordering and avoid omissions.

Patient Evaluation: Withdrawal protocols should spell out how often patient evaluations should take place, with increasing evaluation frequency if severity progresses. Low risk patients, for example, may require three-times-a-day evaluation while high risk patients may require every two hour evaluations for a specific time period.

Benzodiazepine Therapy: A cornerstone of alcohol withdrawal management is the use of benzodiazepines to reduce the excitability of the nervous system that has been shocked by the loss of alcohol. This tranquilizing effect can relieve withdrawal symptoms such as insomnia, muscle spasms, involuntary movement disorders, anxiety, and convulsions. While some correctional providers recommend long-acting options, such as Valium, as they have the ability to self-taper over time, the FBOP guidelines recommends Ativan, a shorter-acting option. The point is to have benzodiazepine therapy as part of the protocol with specific guidelines at to timing and dose. This may end up being based on the facility medical director’s preference and comfort level. Having a consistant program for benzodiazepine therapy spelled out in a protocol eliminates variability and helps both nurses and providers maintain the program.

Vitamin Therapy: Many who are alcohol dependent are poorly nourished and frequently thiamine deficient. Thiamine replacement therapy is recommended as a part of a withdrawal protocol along with a multivitamin.

Symptom Management: Common withdrawal symptoms should be addressed on the protocol with standard treatment options. Many symptoms of alcohol withdrawal are reduced through benzodiazepine administration but other common side effects such as headache, nausea, and vomiting may need additional comfort measures such as pain relievers or anti-emetics. Having these options addressed on a protocol and then prescribed by a provider at the time of protocol initiation is efficient.

Nutrition and Hydration:Don’t forget the need for quality food and water during withdrawal. This point, in itself, may indicate a need for a special housing assignment for withdrawing inmates. Most chronic alcoholics are undernourished and can become dehydrated during withdrawal. This can lead to eleyctrolyte abnormalities and hypoglycemia. Encouraging eating and drinking is important. Some settings even have electrolyte replacement drinks available for use by patients in withdrawal. Many protocols include checking fingerstick blood glucose daily on high risk patients.

Know When to Hold ‘Em – Know When to Ship Them

Many, if not most, of our patients withdrawing from alcohol can be treated safely behind the perimeter, but some can’t. Knowing when a patient needs to be moved to a higher level of care is crucial. Generally, seizures, hallucinations, or hemodynamic instability are all indications of a need for acute care monitoring and treatment. Be sure to have indications for emergency transport spelled out in your alcohol withdrawal protocol.

What is your plan for managing alcohol withdrawal in your setting? Share your tips in the comments section of this post.

Other Alcohol Withdrawal Resources

Drug and Alcohol Withdrawal Clinical Practice Guidelines – NSW

World Health Organization Management of Alcohol Withdrawal Recommendations

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

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Preventing diversion of prescription drugs in prison and jail


Last week’s post described the epidemic of prescription drug abuse in the United States and the impact on the nation’s jails and prisons. This week we return to the same subject but focus on the problem of prescription drug diversion during incarceration. There are many more medications available and appropriate to be used in treatment today than when I started in nursing 40 years ago. Just to illustrate there were an average of 13 prescriptions written in 2011 for every person in the United States. At one of the jails I am familiar with an average of 24 prescriptions per inmate are filled each month.

Most correctional facilities allow some medications to be taken by inmates on their own as directed by the provider. This is usually called a “self-carry” or “keep on person” program. Virtually all facilities also require that certain medication be administered to inmates. These medications usually have potential for misuse (narcotics) or are medication regimes that require close monitoring (TB prophylaxis). The volume of medications handled daily in correctional facilities is substantial.

Nearly 85% of incarcerated adults in the United States have a substance use disorder and four out of five crimes committed by youth involve substance abuse (National Center on Addiction and Substance Abuse 2010, 2004). Some misuse of prescription drugs takes place simply because access to illegal drugs is so greatly limited during incarceration. Incarceration also brings other discomforts such as insomnia, pain, anxiety and boredom. Inmates may request medication from health care staff; they may also simply take or trade for someone else’s medication in an effort to alleviate problems like these. As correctional health care professionals we all have experience with patients who feign an illness or symptom to get a prescription for a preferred medication. Prescription medication has a value in prison or jail that is greater than in the general community (Phillips 2014).

Diversion and misuse of prescription medication is as much a clinical problem as a custodial one. If patients are bullied or coerced into giving up needed medication their condition may deteriorate. The provider may prescribe higher doses or additional intervention to treat a condition that appears unimproved when instead the patient was not treated effectively in the first place. In addition inmates who take someone else’s medication are not monitored clinically and expose themselves to potential for adverse reaction or other injury.

Methods to prevent or mitigate diversion

  1. Formulary controls: Often the first reaction to counter diversion is to ban prescription of the drug in the first place. The problem with this approach is that once a particular drug is banned another becomes the drug of choice for misuse. Secondly there are appropriate clinical indications for these medications and not allowing their use is to deny medically necessary care. It is possible to designate a particular drug as a non-formulary item that requires additional rationale and review before it can be issued. An example of this is that many facilities have made bupropion a non-formulary anti-depressant and thus limited its use (Phillips 2012). It is also possible to designate a certain housing location with greater supervision and control for patients receiving drugs at high risk for diversion. For example some facilities require patients to be admitted to the infirmary in order to receive treatment with an opiate analgesic.
  2. Choice of preparation: Another action is to administer the drug in a way that limits the possibility of diversion. Choices include ordering the drug in a liquid, aerosol or injectable preparation or that the tablet be “crushed and floated” (Bicknell 2011). Challenges are that these methods are either more expensive or time consuming to administer. A policy to “crush and float” an entire class of drugs (i.e. psychotropics) is not advised since the effectiveness and safety of some medications may be altered. Nurses expose themselves to liability if they “crush and float” medications against manufacturer advice (Phillips 2012).
  3. Increased multidisciplinary communication: Communication between providers, nurses and custody staff about prescription drug abuse generally and the importance of each method used to minimize diversion will reinforce the roles of each (Phillips 2014). Both correctional officers and nurses have responsibilities to ensure that inmates take medications as prescribed. These include maintaining orderliness during medication administration, monitoring ingestion, observing individual inmates for intended and unintended effects of medication. Correctional officers should be invited to provide information about behavior that suggests coercion by others or diversion. Providers and nurses may ask correctional officers about their observations of an inmate’s behavior to help with diagnosis or clinical monitoring. Random cell searches by correctional staff and periodic review of adherence by nursing staff are very helpful in identifying inmates who are diverting medication. Recently a facility changed their procedure for medication administration to include checking an inmate’s hands as well as their mouth before leaving the medication area. This change was made after discussion with an inmate who was found trading medication. The provider asked the inmate how he managed to get the medication and he gladly demonstrated his sleight of hand. It was an educational experience for all the staff and improved the methods used to control diversion at the facility.
  4. Caring for patients: Proactive identification and preventive treatment of inmates withdrawing from use of illicit drugs is an important first step in reducing diversion. This includes programming and targeted education to build alternative coping skills and recovery (Phillips 2012).Indications that a patient may be “at risk” of diverting prescribed medication include:
  • Requesting a particular drug by name before describing symptoms
  • Objective data about the patient’s condition is inconsistent with the description of symptoms
  • Refusal or non-adherence with other drugs prescribed for the condition
  • Claiming allergies or side effects to other possible drugs without being able to provide specific detail
  • Not remembering or being able to pronounce drugs other than the preferred drug
  • Threatening or other signs of excessive distress when the requested drug is not prescribed (Phillips 2012, 2014).

The nurse should be observant for these behaviors when seeing patients in sick call, nurse clinics or during medication administration, document the findings in the inmate’s health record and inform the patient’s prescribing provider. This information is more helpful to the treating provider when it is descriptive rather than judgmental. Nurses should also discuss with patients the potential for victimization when taking medication, the adverse outcomes of prescription drug abuse as well as steps to protect the inmate. This discussion is most effective if it is specific to the patient, the drug and their behavior rather than more general information.

Medications with high diversion value in the correctional setting

Click on this link to a table Common Prescription Medications- Use and Misuse which lists the prescription medications that are commonly misused or abused by inmates. The table also lists the purpose each drug is usually prescribed for as well as the reason for its misuse. During administration or when working with patients to self-administer these drugs nurses should be hyper-vigilant for possible diversion. Please remember though that any prescription medication can be misused if there is a belief that the drug will produce some desired effect.


What have you learned about diversion of prescribed medications at your correctional facility that has not been discussed here? Are there methods to prevent diversion not discussed here that should be? Please share your opinions and experience by responding in the comments section of this post.

Anthony Tamburello, MD, FAPA, Statewide Associate Director of Psychiatry,  Rutgers University Correctional Health Care in New Jersey provided much of this information in a continuing education presentation for nurses and was willing to share it for use in this post. Also correctional physicians in the United Kingdom have published Safer Prescribing in Prisons: Guidance for Clinicians a thoughtful and well organized on-line resource. For more on correctional nursing read our book, the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.


Bicknell, M., Brew, I., Cooke, C., Duncall, H., Palmer, J., Robinson, J. (2011) Safer Prescribing in Prisons: Guidance for Clinicians. Royal College of General Practitioners, Secure Environments Group. Accessed at

Centers for Disease Control and Prevention. (2014) Prescription Drug Overdose in the United States: Fact Sheet. Accessed at

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

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

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

Phillips, A. (2014) Prescribing in prison: complexities and considerations. Nursing Standard 28 (21): 46-50.

Phillips, D. (2012) Wellbutrin®: Misuse and abuse by incarcerated individuals. Journal of Addiction Nursing, 23: 65-69.

Tamburello, A. (n.d.) Prescription Medication Abuse. Presentation for University Correctional Health Care. Rutgers, The State University of New Jersey. Personal correspondence dated 6/17/2014.

The National Center on Addiction and Substance Abuse at Columbia University. (2010). Behind bars II: Substance abuse and America’s prison population. New York, NY: The National Center on Addiction and Substance Abuse at Columbia University. Retrieved from

The National Center on Addiction and Substance Abuse at Columbia University. (2010). Criminal neglect: Substance abuse, juvenile justice and the children left behind. New York, NY: The National Center on Addiction and Substance Abuse at Columbia University. Retrieved from

U.S. Department of Health and Human Services (DHHS), Behavioral Health Coordinating Committee, Prescription Drug Abuse Subcommittee, (2013) Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities. Accessed at

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Identifying Prescription Drug Misuse and Abuse

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

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

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

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

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

The characteristics of people who overdosed with prescription drugs include:

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

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

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


Centers for Disease Control and Prevention. (2014) Prescription Drug Overdose in the United States: Fact Sheet. Accessed at

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

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

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

U.S. Department of Health and Human Services (DHHS), Behavioral Health Coordinating Committee, Prescription Drug Abuse Subcommittee, (2013) Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities. Accessed at

Photo credit: © 541albertod –

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

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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

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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

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