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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Alcohol Withdrawal: Special Issues

Danger signEven with an effective screening process, a solid treatment plan, and regular monitoring, patients withdrawing from alcohol can be in danger. Seizures and Delirium Tremens (DTs) can derail an otherwise effective withdrawal program. That is why it is also important to consider patient safety when making management decisions.

Safe Housing

Withdrawing patients are prone to falls and injury. Decreased liver functioning from long alcohol use causes increased bleeding tendencies that lead to hematoma formation, making head injury dangerous. Hallucinations and delirium can lead to erratic behavior and friction with officers and other inmates. Officers need to be aware of any inmates they are monitoring who are withdrawing. Those with potential for confusion, agitation, seizures, or delirium should be housed in the most protective manner possible.

Complicating Circumstances

Chronic conditions and past injuries can make alcohol withdrawal even more perilous than usual. According to Federal Bureau of Prison guidelines, withdrawing patients who have any of these additional conditions should have even close monitoring and additional safety precautions.

  • Cardiac Conditions: Sympathetic hyperactivity, common as high levels of alcohol are withdrawn, can agitate a weakened heart. A slower taper of benzodiazepine therapy is recommended for this group of patients.
  • Elderly: Older alcoholics may not show the usual signs of sympathetic hyperactivity so they may progress to severe withdrawal symptoms without any warning. Higher levels of chronic diseases and greater use of prescription drugs in this patient population increases chances of co-morbid complications and drug interactions. Aging causes decreased drug metabolism that can affect the adjustment of medications during the treatment tapering process.
  • History of Traumatic Brain Injury (TBI): Past brain injury increases the likelihood of seizures or DTs.
  • Liver or Kidney Disease: Chronic liver or kidney disease leads to poor metabolism of medication that requires closer monitoring as treatments are tapered.
  • Pre-existing Psychiatric Conditions: Alcohol can ameliorate psychiatric conditions. Mental illness symptoms may re-emerge once alcohol is no longer in the system. Severe depression, in particular, can lead to attempts at self-harm and suicide. Another reason for close monitoring.
  • Pregnant Inmates: Pregnancy complicates the withdrawal process by adding a second patient. Coordination of alcohol withdrawal with an obstetrical specialist is highly recommended, especially if there is also concern about drug use. Many correctional settings are not equipped or staffed to manage complex situations so transfer to an acute care facility is often the best option.
  • Seizure Disorders: A history of seizure disorders or already being under medical management for seizures increases the potential for withdrawal seizures. This history should be considered when tapering from benzodiazepine treatment. A slower taper is recommended for these patients.

How do you handle alcohol withdrawal for patients with these additional considerations? Share your tips 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: 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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Alcohol Withdrawal: Do You Know the Signs?

AlkoholismusAlcohol withdrawal is the most serious of substance withdrawal situations. Do you know the signs of this condition? Most everyone working in a jail for even a short time is aware of the substantial use of alcohol by those detained for criminal activity or other law violations. Indeed, many of these law violations are a result of alcohol overuse such as DUI, traffic violations, and personal injury due to car crashes. As many as 85% of inmates are substance involved in some way. One study of data from the Arrestee Drug Abuse Monitoring Program (ADAM) estimates 1.2 million arrestees were alcohol dependent in 1997.


Be on the lookout for alcohol withdrawal in all your jail patients. Universal screening for alcohol withdrawal is recommended by the National Commission on Correctional Health Care (NCCHC) in their Alcohol Detoxification Guideline. They recommend that every intake screening include the following:

  • An explanation of why alcohol screening is taking place – to identify those who need treatment for withdrawal
  • Questions about the type, amount, frequency, duration of use, and withdrawal history
  • Immediate medical evaluation for a positive history of heavy and regular alcohol use.

NCCHC guidelines also recommend the use of a standard screening tool such as the Simple Screening Instrument for Substance Abuse (SSI-SA). This list of questions is indeed simple and less cumbersome than many alternatives. An advantage of this tool is that is can be used for either drugs or alcohol. The patient’s answers to 16 yes/no questions are then scored along a continuum of degree of risk for abuse.

Another highly-credible alcohol screening tool is CAGE, discussed in a prior blog post. CAGE is even shorter than the SSI-SA and is specific to alcohol intake. Two positive responses are considered a positive test and indicate further assessment is warranted.

The World Health Organization (WHO) recommends use of AUDIT – the Alcohol Use Disorders Identification Test. This tool was developed and extensively evaluated in a variety of settings, making it a credible screening option.

Whatever tool you use, it is important to consistently screen every incoming patient.

Expect Under-Estimation

There are many reasons your patients may under-estimate their alcohol involvement. First of all, if alcohol use could be a contributor to the activity that resulted in detainment, your patient may not want to emphasize use. Then, trust might be lacking in the nurse-patient relationship that will limit full disclosure. Finally, people generally under-estimate poor habits while over-estimating good behaviors. For all these reasons, some seasoned jail nurses mentally double the estimated drinking reported on intake. Although that might be extreme, expecting under-estimation can help you better predict withdrawal potential.

Assume It Is Present

Alcohol withdrawal should be top-of-mind when screening those entering the criminal justice system. Besides screening tool results, NCCHC guidelines also recommend that immediate medical evaluation be sought for observable symptoms of current alcohol use such as alcohol on the breath, unsteady gait, or confusion.

Withdrawal from alcohol causes increased excitability in the nervous system leading to the following manifestations:

  • Nausea and/or vomiting
  • Tremors, tremulousness, or agitation
  • Confusion
  • Unsteadiness or lack of coordination

Any of these symptoms should indicate a deeper evaluation of alcohol withdrawal potential.

How do you screen for potential alcohol withdrawal in your setting? 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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Happy New Year: Alcohol Withdrawal

Alkoholflasche in PapiertüteIt is New Year’s Eve and the police have just brought a middle aged man into the booking area on an arrest for drinking while driving. The man is in his 50’s, staggering but attempting to follow the booking officer’s directions. This is his first arrest so there is no history or prior information about him. The booking officer asks you to assess the man and decide if he can be accepted at the jail or if the arresting officer should take the man to the hospital for further assessment and possible treatment.

Use of alcohol is widespread among persons brought to jail.  A third of all inmates booked into jail were drinking at the time of arrest. Almost half of all jail inmates report alcohol use that met the definition for dependence or abuse (Karberg & James 2005).  Access to alcohol is disrupted by detention or incarceration and puts individuals who regularly use alcohol at risk of alcohol withdrawal syndrome. Seventy-four percent of deaths from intoxication took place within the first seven days of admission according to the Bureau of Justice Statistics (Noonan 2010). Identifying inmates at risk of alcohol withdrawal and treating these patients proactively is the most important step in preventing alcohol related death in jail. See a post on this topic at http://correctionalnurse.net/2010/03/31/alcohol-withdrawal-jail-nurse-alert/. The decision to accept this man into the jail or send him to the local hospital for further evaluation is going to depend upon two things:

  • An assessment of the patient’s condition and
  • The facility’s capacity to provide ongoing monitoring and treatment.

At the initial medical clearance any person presenting with the following should be referred to the hospital:

  • Inability to ambulate without assistance
  • Fever greater than 1010 F
  • Serious trauma or other injury
  • Profound confusion or altered sensorium
  • Tremors
  • Seizure activity
  • Autonomic dysfunction (dilated pupils, pulse greater than 120, blood pressure greater than 120, severe diaphoresis and/or flushing).

If the person does not have any of the conditions described above use of a standardized alcohol consumption assessment tool is recommended in addition to the health screening questions asked at intake (Laffan 2013, Department of Veterans Affairs 2009).  Two recommended tools are the CAGE Alcohol Abuse Assessment Tool which was discussed in a previous post and the Alcohol Use Disorders Identification Test (AUDIT-C). The AUDIT-C tool identifies individuals who are hazardous drinkers or have active alcohol use disorders.   It consists of only three questions: 1. How often do you have a drink containing alcohol?

  1. Never
  2. Monthly or less
  3. 2-4 times a month
  4. 2-3 times a week
  5. 4 or more times a week

2. How many drinks of alcohol do you have in a typical day?

  • 1 or 2
  • 3 or 4
  • 5 or 6
  • 7 to 9
  • 10 or more

3. How often do you have six or more drinks on one occasion?

  • Never
  • Less than monthly
  • Monthly
  • Weekly
  • Daily or almost daily

Each answer is scored; an answer of “a” equals zero points and an answer of “e” equals 4 points for a possible total points of 12.  Men who score 4 and women who score 3 or more are considered hazardous drinkers with active alcohol use disorders (Bush et al. 1998, Department of Veterans Affairs 2009). These individuals will likely experience withdrawal symptoms that need to be monitored and treated medically. Inmates who are pregnant, have other chronic medical problems, or give a history of delirium tremens or seizures upon withdrawal are more at risk of morbidity and mortality associated with alcohol withdrawal. A provider should be contacted immediately to initiate and manage the care of these patients during incarceration. The table below describes the symptoms and nursing care required by patients undergoing alcohol withdrawal. Facilities without the capacity to provide 24 hour monitoring and availability of on-call provider consultation should be prepared to refer detainees to the hospital for required monitoring and care. Good clinical oversight, thoughtfully prepared protocols and trained staff are sufficient to manage inmates with minor and moderate withdrawal symptoms.

Condition Symptoms Nursing actions
Minor withdrawal
  •   Nausea
  •   Sleeplessness
  •   Night sweats
  •   Anxiety
  •   Irritability
  •   BP = 140/90
  •   Mild tremor
  •   Disturbance in vision, hearing or sensation.
  •    Symptom monitoring (CIWA –AR) q 4 hours
  •   Encourage fluid intake (8-10 glasses daily)
  •   Medication for anxiety or agitation
  •   Provider ordered medications
Moderate withdrawal
  •   Inability to concentrate
  •   Forgetfulness
  •   Numbness of hands or feet,
  •   Severe agitation or anxiety
  •   Tremors
  •   Disturbance in vision, hearing or sensation
  •  Admit for inpatient care
  •   Vital signs q 4 hours
  •   CIWA-AR q 4 hours
  •   Oral fluids (10-12 glasses daily)
  •   Provider ordered medications
Severe withdrawal
  •   Hallucinations or  delusions
  •   Profound confusion or altered sensorium
  •   Autonomic dysfunction
  •   (dilated pupils, fever, pulse greater than   120, diastolic BP greater than 110, severe diaphoresis or flushing)
  •   Seizure activity
  •  CIWA-AR greater than 15
  •   Emergency transport to the hospital
  •   Notify provider immediately

The Clinical Institute Withdrawal Assessment-Alcohol Revised (CIWA-AR) is a nationally recognized tool for monitoring alcohol withdrawal (Bayard et al. 2004).  The use of a standardized tool provides a consistent basis for serial evaluations of withdrawal symptom and can serve as the source for protocols that define treatment orders and timeframes for contacting a provider or referring for offsite care (Laffan 2013). On assessment of the inmate in the case example above the nurse found that the patient was at risk of withdrawal symptoms but he did not have any complicating medical conditions and so was cleared for booking. After completing the initial screening exam the nurse put him on the facility’s alcohol withdrawal protocol that included medically supervised housing and a treatment plan concurrent with the suggestions in the table above. What do you do at your facility to recognize and treat alcohol withdrawal? Share your thoughts in the comments section of this post. For more about alcohol withdrawal 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.  References Bayard, M., McIntyre, J., Hill, K.R., (2004) Alcohol withdrawal Syndrome. American Family Physician, 69 (6) 1443-1450. Bush, K., Kivlahan, D.R., McDonell, M.B., Fihn, F.B., Bradley, K.A. (1998) The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Archives of Internal Medicine 158 (16) 1789-95. Department of Veterans Affairs. (2009) Management of Substance Use Disorder. Accessed 12/230/2013 at http://www.healthquality.va.gov/Substance_Use_Disorder_SUD.asp Karberg, J.C. & James, D.J. (2005) Substance Dependence, Abuse and Treatment of Jail Inmates, 2002. Bureau of Justice Statistics, Special Report (NCJ 209588). US Department of Justice, Office of Justice Programs. Accessed 12/30/2013 at http://www.bjs.gov/content/pub/pdf/sdatji02.pdf 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). Noonan, M. (2010) Mortality in Local Jails, 2000-2007. Bureau of Justice Statistics, Special Report, US Department of Justice, Office of Justice Programs. Accessed 12/30/2013 at  http://www.bjs.gov/content/pub/pdf/mlj07.pdf Photo credit: © artenot -Fotolia.com

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

Photo Credit: © termis1983

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

Photo Credit: © Michael Brown

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

Photo Credit: © theblackrhino

CAGE for Alcohol Withdrawal


Our patients are prone to drug and alcohol misuse so correctional nurses need heightened awareness of withdrawal potential for all who enter their facilities. According to authorities, more than 65% of inmates meet criteria for drug abuse, alcohol dependence, and addiction. There are also significant concerns about deaths while in custody related to drug and alcohol withdrawal. Of the two, alcohol withdrawal has significantly higher concerns but withdrawal from opiates and depressant drugs can also cause problems.


Intake assessment of withdrawal potential is critical for good care. CAGE is a standard evaluation of alcohol intake that can quickly determine if withdrawal is likely. Two positive responses are considered a positive test and indicate further assessment is warranted.


C – Have you ever felt you should cut down on your drinking?

A – Have people annoyed you by criticizing your drinking?

G – Have you ever felt bad or guilty about your drinking?

E – Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?


Correctional nurse and chapter author Susan Laffan has a list of other questions that should be asked during intake:

  •  Do you currently use any type of alcohol or drugs?
  • If “no”: has the individual used in the past?
  • What type?
  • alcohol: beer/wine/liquor
  • drugs: illegal vs. prescription (dosage)
  • name of each drug
  • route of drug (oral/smoke/inhaled/intravenous)
  • How much/many?
  • How often?
  • Date and time last used?
  • Have you ever had withdrawal symptoms or seizures/“shakes” when alcohol/
  • drug is stopped?
  • Have you ever been hospitalized for medical treatment of withdrawal
  • symptoms?

What do you use to evaluate for alcohol withdrawal potential? Share your tips in the comments section.

Read more about withdrawal detection and management in correctional nursing practice in Chapter 5: Alcohol and Drug Withdrawal from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4