Heart Disease and Women Part 5: Answers to the Cardiac Risk Quiz

Heart disease risk

The last post gave five case examples and readers were asked to identify the cardiac risk factors in each. In addition, readers were asked which of the five had the most cardiovascular risk and which had the least. Finally, readers were asked to identify the counseling recommendations for each patient. The following are the answers to the questions and a discussion of each answer.

Which of the five women is at greatest risk for heart disease?

All five women have risk factors for heart disease however based upon what we know now about each of them, Ms. Joseph is at greatest risk. She has two of the most significant risk factors, smoking and diabetes. Ms. Joseph also has more risk factors than the others and risk accumulates with each additional risk factor. These include that she is over 65, menopausal, sedentary and has little or no social contacts. Because she has diabetic complications we may find other risk factors upon gathering additional data.

Ms. Ott and Ms. Hollister would be the next most at risk. Ms. Ott because of the significant risk factors of continued tobacco use, hyperlipidemia and poor treatment adherence. Ms. Hollister because of the cumulative number of risk factors, including family history of heart disease, menstrual irregularity and now menopause, sedentary lifestyle, being overweight and excessive intake of alcohol.

Which of these women is at the least risk?

Ms. Falwell is in the best cardiovascular health of the group. Her hypertension is well controlled. Her alcohol and drug use and emotions about the separation from her children are the only contributors to her risk of heart disease. She is of normal weight, physically and socially active. Ms. Garcia’s only risk factors are obesity and a sedentary lifestyle. Obesity, though is a significant contributor to heat disease (2-3 x risk increase) and because she is continuing to gain weight, Ms. Garcia cannot be considered at lowest risk.

What are the recommendations you would make in counseling each of these women?

Case example 1. Ms. Falwell’s counseling emphasizes three points: a. continued involvement and attention in managing her hypertension (regular monitoring and medication adherence) b. stress management and developing healthy avenues to address anger and anxiety c. limiting drug and alcohol use (perhaps participating in the facility AA or NA groups or attending classes to increase her knowledge about the effects of drug and alcohol as well as treatment options). Ms. Falwell already has several good lifestyle habits that can be leveraged to increase opportunity to control cardiac risk.

Case example 2. Ms. Joseph’s counseling is focused on achieving good control of her diabetes to prevent further complications as well as the identification and early intervention to address other cardiac risk factors, including obesity, dyslipidemia and hypertension. Most correctional facilities no longer allow smoking so Ms. Garcia has been forced into smoking cessation which will lower her cardiac risk over time but if she is to be released to the community continued smoking cessation would be an important goal for her. I would also recommend a mental health evaluation to rule out depression or another mental health disorder as an explanation for her social isolation and based upon those results try to increase her social interactions. Lastly, a program to increase her physical activity should be developed that is appropriate for her age and physical limitations.

Case example 3. Ms. Ott’s counseling is directed to smoking cessation as a first priority and second, the effectiveness of her treatment for hyperlipidemia. While smoking at the facility is prohibited Ms. Ott continues to crave cigarettes and has violated this disciplinary rule recently. She should be encouraged to participate in one or more smoking cessation programs that are available at the correctional facility and her steps to do this discussed and acknowledged during her health care appointments. Ms. Ott’s medication administration record should be monitored and she should be seen regularly to discuss adherence with the medication she is prescribed. Barriers to adherence should be identified and ways to resolve adherence problems developed with the patient. A change in medication should be considered if her lipid levels cannot be lowered with the currently prescribed medication. Her lipid levels should be monitored closely.

Case example 4. Ms. Garcia’s counseling emphasizes weight loss, proper nutrition and incorporating exercise into her daily life. She has gained weight since admission to prison and is now more than 30% overweight, a tremendous increase in cardiac risk. She already is on a heart healthy, reduced calorie medical diet but eats a lot of canteen food. She should be monitored regularly for symptoms of hypertension, dyslipidemia, and metabolic syndrome perhaps best done in a cardiovascular chronic disease program or nursing driven wellness program, she should receive education about heart disease prevention and encouraged to adopt better eating habits and to begin walking or some other form of aerobic exercise three to five times a week. Finding out what she is most motivated to change and helping her to develop plans to make small change or new behavior is the primary focus of counseling Ms. Garcia.

Case example 5. Ms. Hollister’s family history cannot be changed so her counseling focuses on the alterable risk factors of weight control, exercise, and limited alcohol use. She gave a history of significant alcohol use and should be referred for alcohol and drug counseling, and encouraged to attend AA or NA groups, if she has not already. Helping her to understand her risk of heart disease resulting from alcohol use may provide additional motivation for her to participate in treatment. Education about nutrition choices on the institution menu and canteen, counseling or problem solving to reduce caloric intake along with weight monitoring to lose some or all of the 35 extra pounds would be another counseling goal for Ms. Hollister. She also would benefit from adding aerobic exercise three to five times a week to her schedule. A group wellness or heart healthy program is a convenient way to provide information, educate and encourage adoption of lifestyle changes that increase fitness and reduce weight.

Each of these women would benefit from knowing their cardiac risk profile and participating in an earnest discussion about what can be done to limit or prevent heart disease. Any success you have with these patients not only effects their health during incarceration but far into the future. Even if you are not successful in achieving a single improvement now the information you provide makes it more likely one or more of these women will make a change in the future than if you did nothing. After suicide, heart disease was the leading cause of death among women in jails in the United States from 2000 through 2013. Except for cancer, heart disease caused the most deaths among women in prison in the United States during this same time period (2015).

You might want to identify those women at your facility who have the highest risk for cardiovascular disease and then offer a counseling, diet and activity program developed to reduce their risk. It would be interesting to see what results would be achieved at 4 weeks, 8 weeks and 12 weeks. It would be a great study especially if it was compared to a control group.

What ideas do you have about nurses’ involvement in programs to reduce heart disease and related deaths among women who are incarcerated? Please comment by responding in the comments section of this post.

The following are some excellent online resources about heart disease and women:

To read more about nursing care of women 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!

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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.


  • 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!

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Heart Disease and Women Part 3: Emerging Risk Factors

Risky Character Showing Dangerous Hazard Or Risk

The emphasis on traditional risk factors alone has been criticized for underestimating heart disease in women, especially those who are not yet manifesting symptoms. Several additional factors have been identified that may improve detection of heart disease in women. Are any of these on your clinical judgement radar when evaluating women and possible heart disease?

Periodontal disease has been linked to increased risk of heart disease for several years now. Specifically, the repeated systemic exposure of the gums to bacteria and bacterial byproducts increase levels of C-reactive protein (CRP) and fibrinogen; both of which are associated with increased likelihood of heart disease. Women with metabolic syndrome and elevated CRP levels had twice the risk of an acute cardiac event as those with metabolic syndrome but low CRP levels. It has been suggested that measuring CRP levels in women with at least intermediate risk of heart disease or metabolic syndrome may identify additional individuals who would benefit from treatment with statins.

Autoimmune disease, such as rheumatoid arthritis and systemic lupus erythematous (SLE), is associated with significantly increased risk of heart disease. Women ages 35-44 years with SLE were found to be 50 times more likely to have an acute myocardial infarction compared to women of the same age without SLE. Systemic autoimmune collagen-vascular disease was listed as a risk factor for heart disease in the Effectiveness-Based Guidelines for Prevention of Cardiovascular Disease in Women, published by the American Heart Association in 2011.

Complications of pregnancy, specifically pre-eclampsia and gestational diabetes, are associated with greater risk of subsequent heart disease. Women with pre-eclampsia, or pregnancy associated hypertension have double the risk of developing cardiovascular disease in the first five to ten years after delivery. They also are significantly greater risk of developing hypertension which is recognized as a traditional risk factor already. Women who experience gestational diabetes are at 1 ½ times greater risk of heart disease compared to those who did not. Women with gestational diabetes have double the risk of developing diabetes mellitus, which is another traditional risk factor for heart disease. Gestational diabetes was also listed as a risk factor for women in the American Heart Association’s 2011 update.

Menstrual irregularities increase the risk of ischemic heart disease in women by 50%. One of these is polycystic ovarian syndrome, a hormone imbalance that prevents normal development and release of eggs. As a result, women experience irregular menstruation (irregular, light or heavy flow) and have difficulty getting pregnant. Polycystic ovarian syndrome is associated with high levels of insulin, which contribute to development of metabolic syndrome and insulin resistance. Another is a type of amenorrhea caused by psychological stress or metabolic insult (caloric reduction or excessive exercise) which results in a hormone imbalance that contributes to risk of heart disease.

Breast cancer treatment is associated with various degrees of injury to the cardiovascular system. Radiation therapy, in particular has an established association with risk of heart disease. With other treatments it is not yet clear if the treatment itself or resulting lifestyle changes increase women’s’ risk of heart disease. Since the rate of breast cancer survival increases more women need providers who are attentive to their cardiovascular risk and prevention.

Sleep apnea is another disease more commonly associated with the male gender and yet there is increasing evidence that women with this disorder present differently and are often misdiagnosed with depression, anxiety, insomnia and fatigue instead. Women with sleep apnea have increased risk of hypertension, coronary artery disease, stroke and atrial fibrillation and have 3 1/2 times greater risk of dying from cardiovascular disease. Treatment with continuous positive pressure reduces the risk to that of women who do not have sleep apnea.

The following table summarizes the traditional as well as the newer risk factors for heart disease in women that we have reviewed the last two weeks.

Risk Factors for Heart Disease in Women
Traditional Risk Factors Emerging Risk Factors
Obesity Periodontal disease
Dyslipidemia Autoimmune disease
Diabetes Complications of pregnancy
Metabolic syndrome Menstrual irregularities
Physical inactivity Breast cancer treatment
Hypertension Sleep apnea
Tobacco use
Psychosocial (depression, loneliness, hostility)
Hormones (postmenopausal and contraceptives)

It can be challenging to convince women to make the lifestyle changes that are necessary to control or limit the risk factors listed above. This is especially so in the absence of symptoms of heart disease and the fact that the benefits of doing so are not immediately apparent. One way that is recommended to assist women to make the necessary lifestyle changes is for health care providers to engage women at a young age and on a regular basis in discussion about their own personal risk of heart disease.

Correctional nurses have the opportunity to make a real difference in the cardiac health of their female patients when completing the initial and periodic health appraisals during incarceration, during every contact with patients who have chronic disease, while caring for women during pregnancy and in any health education programs provided to the population at large. Further correctional nurses are often asked to spear head employee wellness programs which can bring this same information to female employees.

Next week’s post will provide some case examples to practice assessing cardiac risk. In the meantime, what are your thoughts about working with women while they are incarcerated to increase their recognition of cardiac risk and how to prevent heart disease? Please share your thoughts by replying in the comments section of this post.

The following are some excellent online resources about heart disease and women:

To read more about nursing care of women 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!


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

Photo credit: © Stuart Miles – 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!


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

Photo credit: © decade3d – Fotolia.com

Baby on Board: Substance Withdrawal and Pregnancy

Baby on Board: Substance Withdrawal and Pregnancy

With the majority of female inmates of childbearing age, drug and alcohol withdrawal during pregnancy is a fact of life in most jails and prisons. This is definitely a risky business as many substances affect fetal growth and development. Therefore, correctional nurses need to know the pregnancy status of female inmate starting at booking and have a clear understanding of the potential for drug or alcohol withdrawal while in custody.

Finding the Baby

Pregnancy evaluation at intake is recommended by the American College of Obstetricians and Gynecologists (ACOG) as well as the National Commission on Correctional Health Care (NCCHC E-02, G-09). Pregnancy risk can be assessed through screening questions about:

  • Menstrual history
  • Sexual activity
  • Contraceptive Use

Urine pregnancy testing is inexpensive and some settings opt to perform pregnancy testing on all females of childbearing age. Once identified, pregnancy should initiate various activities such as evaluation of gestational age and enrollment in an obstetric program.

Finding the Substance

Many pregnancies in this patient population are high risk due poor lifestyle habits of the mother and lack of medical services.  Female inmates have higher rates of smoking, alcohol use, and illegal drug use than the general population. All of these substances have detrimental effects on an unborn child. Identifying substance use at booking will determine any special considerations and interventions for a pregnant patient.

If a female inmate is found to be pregnant or likely to be pregnant, special attention should be given to determining the level of drug or alcohol use. Several screening tools are advocated for this purpose such as AUDIT, CAGE-AD, or SSISA. The important point is to screen for substances so that proper withdrawal intervention can be initiated.

Planning for Two

Substance withdrawal for the pregnant inmate means thinking about both the mother and the child. In fact, some withdrawals, like opiates, are too risky for the unborn child. Here is a quick breakdown on what to do for key substance withdrawals. The recommendations below come from the Principles of Addiction Medicine, Chapter 81: Alcohol and Other Drug Use During Pregnancy  unless otherwise indicated.

Alcohol: The Federal Bureau of Prisons recommends that alcohol withdrawal of pregnant women be managed in an inpatient setting. This may be the safest route to take but is not always possible. The NYS Office of Alcoholism and Substance Abuse Services recommends the use of a benzodiazepine taper and careful, frequent evaluation of withdrawal symptoms for pregnant alcohol-involved patients.

Benzodiazepines: Benzodiazepines and other sedatives/hypnotics can be withdrawn during pregnancy with careful management as abrupt withdrawal can lead to spontaneous abortion or premature labor. The second trimester is the optimum time for this withdrawal to reduce either of these outcomes.

Opiates: Opiate withdrawal has a high likelihood of miscarriage and premature labor. Therefore, pregnant opiate users (including those using methadone and buprenorphine) should be carefully managed by a specialist and may be maintained on the drug through pregnancy.

Stimulants: Stimulant use, such as cocaine and methamphetamine, during pregnancy can lead to preterm labor, placental abruption and intrauterine growth restriction. However, stimulant withdrawal does not cause significant physiologic consequence to the unborn and can be managed according to protocol with careful management.

In all cases, a pregnant substance-involved patient needs specialized obstetric medical care and close observation during the withdrawal period to have a healthy outcome.

How are you managing alcohol and drug withdrawal for your pregnant patients? 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.

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Caring for Women in Prison: Eating Disorders

schienaIncarcerated women have increased chances for eating disorders and they can be deadly. The in-custody death of a young anorexic woman several years ago points out the potentially fatal nature of these conditions when extreme. This case was complicated by communication issues and recent changes in facility processes, but it exemplifies the concern correctional nurses should have for screening and initiating treatment for eating disorders when working with women inmates.

Are eating disorders common among female inmates?

Eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN) are more common among young white women who are unhappy with their body size and shape. Added contributing factors include feelings of powerlessness and lack of control over life situations – common emotions during incarceration. Although the reported prevalence of eating disorders in the general population is less than 1%, one study found as many at 25% of female inmates in a British prison at risk for eating disorders. With the potential of one in four female inmates at risk for AN or BN, it is important to screen for this condition.

What should be done to identify patients with this disorder?

Be alert for eating disorders among the young females entering your facility. Loose-fitting garments may hide wasted torsos and boney appendages. Take a good look at muscle tone and skin thickness when performing a physical assessment. Bulimic women will usually maintain a low normal body weight but those with anorexia could show significant wasting.
In addition, consider adding a simple screening tool to subjectively evaluate for an eating disorder. The SCOFF Eating Disorder Questionnaire is widely advocated as an effective and rapid evaluation method. One point is assigned for every “yes”; a score greater than two (≥2) indicates a possible case of anorexia nervosa or bulimia nervosa.

SCOFF Questionnaire

S  – Do you make yourself SICK (vomit) because you feel uncomfortably full?

C  – Do you worry that you have lost CONTROL over how much you eat?

O  – Have you recently lost more than ONE stone (15 pounds) in a 3-month period?

F  – Do you believe yourself to be FAT when others say you are thin?

F  – Would you say that FOOD dominates your life?

What treatments are available of eating disorders?

If an eating disorder is suspected, a referral for mental health services is needed, in addition to a medical work-up. Women with eating disorders, especially AN, are at higher risk for suicide, osteoporosis, and electrolyte imbalances. Severe AN can cause dangerous electrolyte imbalances leading to cardiac arrhythmia. The in-custody death of the young female inmate in the story above may have been prevented with potassium supplementation.

How do you assess for and manage eating disorders in your setting? Share your thoughts in the comments section of this post.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 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.

This post originally appears in CorrectionalNurse.Net

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Caring for Women in Prison: Postpartum Depression

Mother in tears with baby childAs discussed in an earlier post, an estimated 6-10% of incarcerated women are pregnant at any time in the criminal justice system. Therefore, many of these women will give birth while behind bars and must deal with the physiologic and psychological adjustments of the postpartum period in an alien environment with little social support.

Reasons for Concern

Women who give birth behind bars are highly susceptible to postpartum depression. A review of literature on the subject found factors associated with this condition include past histories of anxiety disorders or depression, recent life stresses and poor social support. All these conditions are highly present in the female inmate population. Depression can be exacerbated by separation from the infant soon after birth. Although some progressive settings, such as this New York prison, are allowing babies to stay with mothers, most require that the child be placed with another family member, the foster care system, or given up for adoption.

Keep an Eye on Them

Correctional nurses should assess for postpartum depression in women who have recently delivered. The most common emergence of postpartum depression is in the first 4 weeks after delivery but depression can develop even a year later. Monitor for these indications of developing depression during the postpartum period:

  • Sadness and tearfulness
  • Exhaustion not relieved by sleep
  • Despair
  • Compulsive thoughts
  • Sleep difficulties
  • Loss of appetite

Use an Objective Screening Tool

The 10-question Edinburgh Postnatal Depression Scale is used in outpatient and home care settings to objectively screen for potential postpartum depression. It could easily be incorporated into a correctional setting with self-administration possible for those patients with good reading skills. Another option is for the nurse to ask the questions.

Treatment for Postpartum Depression

Although treatment options may be limited, postpartum depression must be addressed to avoid poor outcomes such as self-harm. A mental health consult is the first action to take. Management of postpartum depression is similar to any major depression and can include psychological support, cognitive therapy, and antidepressant or antianxiety medication.

How do you manage women after childbirth in your setting? Share your thoughts in the comments section of this post.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 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.

Photo Credit: © patrimonio designs – Fotolia.com

Caring for Women in Prison: Psychogenic Seizures

Brain StormCalled to a housing unit on a man-down emergency, a nurse finds a female inmate on the floor flailing about, arching her back, crying, and shaking her head side-to-side. She does not lose consciousness but is holding her eyes tightly shut. The housing officer says she is just throwing a tantrum and faking a seizure. What other diagnoses should be considered?

Seizure disorders are common in the inmate patient population.  In fact, incarcerated patients are four times more likely to have a seizure disorder than the general  population. Reasons for increase seizure activity in our patient population include frequent histories of head trauma, physical abuse, and drug or alcohol involvement. There are many causes of seizures, with the most common, epileptic seizures, being the result of spontaneous and uncontrolled electrical discharge of neurons in the brain that interrupts normal body functions.

However, what the nurse is witnessing in the case above does not appear to be an epileptic seizure as the patient seems to be in control of her actions – shaking her head and holding her eyes tightly shut. Maybe the housing officer is correct and this inmate is merely pretending to be seizing to gain attention?

Another possible diagnosis in this presentation could be Psychogenic Nonepileptic Seizure (PNS) activity; a psychiatric rather than physiologic condition. PNS results most often from severe childhood trauma and manifests during a psychologically stressful situation. Individuals with PNS are not ‘faking it’ and are not in control of when and how a seizure takes place. Instead, the seizure activity is a coping mechanism to an intense emotional event.

Three times more women are diagnosed with PNS than men.  Although the exact reason is still unknown, it is suggested that these seizures are an expression of rage, fear, and helplessness that manifests most frequently in women who have histories of abuse. More than half of patients with PNS also have concurrent psychiatric illness such as post-traumatic stress disorder, anxiety disorders, depression, or dissociation disorders.

In the case presentation above, the person needs to be treated with compassion. Observations should be carefully documented and medical treatment sought. In particular, the nurse should document the nature, timing, and context of seizure activity. Psychogenic seizures are diagnosed by their presentation and EEG-video monitoring. Once diagnosed, PNS is treated based on the underlying condition and mainly through psychiatric services. Patients may benefit from supportive psychotherapy and lifestyle changes to reduce the effect of situational stressors. Underlying anxiety or depressive disorders may respond to drug treatment. Some patients are helped through behavior modification therapy.

You can learn more about psychogenic seizures in the female inmate population by listening to this podcast interview with Gregory Famiglio, MD.

What are your experiences with inmate seizure activity? Share your thoughts in the comments section of this post.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 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 and shipping is free.

Photo Credit: © AlienCat – Fotolia.com

Caring for Women in Prison: Mental Illness and Self-Harm

The mindThe disturbing story of 19 year old Ashley Smith’s witnessed suicide in a Canadian prison highlights the complex issue of mental illness and self-harming behaviors among incarcerated women. Ashley Smith attempted self-harm over 150 times during a three year period as outlined in this report of her treatment and in-custody death. She was a very troubled young women, as so many of our patients are.

Women in the criminal justice system have higher rates of serious mental illness than male counterparts; including higher rates of depression, bipolar disorders, antisocial personality disorder, and post-traumatic stress disorder. This can be attributed to many factors including histories of childhood abuse, adult victimization, substance abuse, and traumatization.

Social problems add to emotional stress; intensifying mental and behavioral disorders. Financial hardship, parental stress, and inadequate relational support make dealing with mental illness more difficult. Higher rates of chronic illness among female inmates compound the burden of mental illness.

Deliberate Self-Harm

Some women turn their distress inward and engage in deliberate self-harm (DSH) also called self-injurious behavior (SIH). In fact, as many as 30-50% of incarcerated women may harm themselves intentionally; most often by cutting or scratching with an object. This behavior can be perplexing and frustrating for healthcare and custody staff, alike. Conflicting interpretations cloud objectivity. Healthcare staff are more likely to see self-injury as a condition in need of treatment while custody staff are more likely to see it as a behavior issue requiring control.  Although Ashley Smith received anger management interventions and participated in group activities early in her incarceration, increasingly frustrated custody staff resorted to isolation, restraint, and pepper spray to compel her to comply with security requirements.

Mental health professionals, however, see self-harm as a coping mechanism brought on by distress, like the stress of incarceration. Therefore, a therapeutic response involving a non-judgmental attitude and interventions to decrease injury events is advocated over punitive measures. Phased-in behavior management plans, for example, have been effective for self-injury reduction. In this program, individualized incentives are developed and awarded when self-injury is avoided for periods of time. Patients move into advanced phases of the program with positive behavior change or back into earlier, more restrictive, phases if self-injury returns.


Deliberate self-harm when used as a coping mechanism rarely moves to suicide. Ashley Smith, however, began attempting suicide soon after she was transferred to an adult facility at age 18. Women inmates attempt suicide more frequently than men; although men have more completed suicides. Frequent, unsuccessful suicide attempts are viewed by staff as attention-seeking behavior and can soon be disregarded. It appears that Ashley Smith was allowed to kill herself while being watched by security officers. By that time she had been transferred 17 times through 9 different institutions. She entered the system as a youth on a 30 day sentence and accrued additional time for various charges resulting in a total of 2,239 days cumulative sentence.

As noted in the ombudsman report, there is no record of a psychiatric evaluation once Ms. Smith was transferred to the adult facilities; even after beginning a string of suicide attempts. Could a concerted program of therapy and behavioral management have avoided this fatal outcome? It is hoped that something positive will come from the death of Ashley Smith. The inquest jury has made 104 recommendations for improvements in mental health care and inmate treatment. The case highlights the challenges of working with mentally ill female offenders and the need for a coordinated program of care.

What has been your experience working with incarcerated women with mental illness? Share your thoughts in the comments section.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 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 and shipping is free.

Photo Credit: © Rob hyrons – Fotolia.com

Caring for Women in Prison: Sexual Assault and Family Groups

kids girlfriends sharing a secret isolated

Cheryl is a petite inmate in her twenties who just entered a federal prison to serve out her drug trafficking sentence. She is quiet and withdrawn during her intake screening and admits to the nurse that she was sexually abused by an uncle when she was 12. Her family and friends are over 200 miles away and will be rarely able to visit. Several weeks into her stay she is seen almost exclusively in the company of an older woman who orders her around and often shouts profanity at her. The nurse wonders if this is a sexually abusive relationship.

Sexual assault is a real concern for incarcerated women. Although all inmates are at risk for sexual assault, female inmates are twice as likely as their male counterparts to be coerced by a fellow inmate according to a recently published Bureau of Justice report. The authoritarian structure of the prison system also contributes to sexual victimization by staff. Like Cheryl, a high number of women in prison have sexual abuse histories, some as children.

All forms of sexual contact are prohibited by the Prison Rape Elimination Act (PREA) of 2003. This federal mandate requires jails and prisons to prevent, detect, and respond to indications of sexual victimization within their facilities. Correctional nurses need to be aware of the prevalence of abuse histories and vigilant for sexual assault in the female patient population.

Risk factors for sexual assault: The following classes of individuals are more vulnerable for sexual assault while incarcerated.

  • Mental, physical, or developmental disability
  • Age
  • Physical build
  • Gay, lesbian, bisexual, transgender, intersex, or gender nonconforming
  • Previously experienced sexual victimization

With her slight build, young age, and past abuse history, Cheryl has a potential for sexual victimization while in the prison system.

The smaller size of the female inmate population and the special needs of this group mean there are few female prisons in the federal and state systems. Therefore, many female inmates are sent to facilities far from home with little opportunity to have contact with family and friends. The relational nature of this gender and the desire for belonging and group identity leads to the emergence of family groups within female prisons. The pseudo-family distinction in female prisons parallels gangs in male prisons. This can blur the relationship boundaries and make it difficult to determine if an intimate relationship is consensual or coerced.

How do you think a correctional nurse should respond to Cheryl’s situation? Should this nurse intervene? Would you? Share your thoughts in the comments section of this post.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1209 the price is discounted by $15 and shipping is free.

Photo Credit: © Oksana Kuzmina – Fotolia.com