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!

Photo credit: © alexskopje – Fotolia.com

Heart Disease and Women Part 4: Assessing Cardiac Risk Quiz

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

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

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

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

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

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

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

Questions:

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

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

Photo credit: © Aleksandar Mijatovic – Fotolia.com

 

Heart Disease and Women Part 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!

References:

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

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

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!

References:

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

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

Photo credit: © decade3d – Fotolia.com

Heart Disease and Women Part 1: Symptom Presentation

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

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

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

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

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

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

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

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

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

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

 

References:

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

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

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

 

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

The Challenges and Distinguishing Features of Correctional Nursing: Part 2

Illustration - Woman in jailLast week’s post described the challenge of knowing the impact of the law on the delivery of health care in the correctional setting. Knowledge of the law and prisoners’ rights is one of the distinguishing features of correctional nursing practice. This week’s post describes the second challenge correctional nurses encounter which is the patients themselves. There is no denying that our patients have been charged with or convicted of breaking the law, sometimes violently. For the most part, knowing the nature of their crime is irrelevant to the provision of their health care, but it is also true, that offenders tend to think and behave in ways that get them in trouble with the law. These criminogenic thoughts and behaviors pepper a nurse’s interaction with their patients.

This is otherwise known as “the Con”, which is defined as the purposeful effort to deceive, manipulate or take advantage of another. Convicts gain respect from others when they “con” someone else and the person who gets conned is considered “weak”. Being weak makes one vulnerable to further exploitation.

Correctional nurses describe this as being manipulated. How it often works, is that an offender requests health care attention because of, let’s say, chronic low back pain, for example. In correctional facilities the offender will always be evaluated by a nurse first, who will determine what to do about the request. It may be that with some education, the offender can take care of it themselves, or a nursing intervention may take care for the problem, or finally, the nurse may decide that the offender needs to be seen by another provider and if so will make a referral.

Sometimes the offender will ask for something for which there is no objective evidence they need. The offender’s request for a narcotic analgesic to ease the chronic pain in his back, is likely not to be supported by objective findings. The request could simply be that the offender is seeking drugs; it could also be to sell or used to pay back a loan. The offender probably will also ask for an extra mattress or pillow. This also may be used to repay a debt or it could be just an effort to stand apart from others, as having something “special”.

If there is a medical need, these may be appropriate to give the offender. But if they are not needed and the nurse acquiesces, the offender has successfully “conned” or manipulated the nurse and achieved a secondary gain. The nurse is then considered “weak” and sought out for other such requests. Correctional nurses joking refer to this dynamic when we say “you know you are a correctional nurse when your patients make up reasons to see you and then don’t want to leave until they get what they came for.”

This gives rise to another distinguishing feature of correctional nursing practice which is the emphasis on the assessment of objective signs and symptoms and the accuracy of the resulting clinical judgment. Our patients subjective complaint may be embellished and critical details may be withheld (remember the example last week about the inmates who drank printer fluid). The conditions within which our assessments are done, often are not conducive to the patient giving a full and candid account of what led up to the request for care. Erring on the side of leniency in the absence of objective findings can result in being seen as, easy to con, and as word gets around, the nurse will be bombarded with inappropriate requests thereafter.

Making the wrong decision though, can also result in harm to the patient. An error in clinical judgment can be because the nurse’s skills are poor or undeveloped, or because the nurse lacks of sufficient knowledge. It can also occur, when a nurse has become cynical about their patient’s criminality and views every request as likely to be devious or untrue. This belief will cloud a nurse’s clinical judgement and important clues to the patient’s condition missed.

While they may be manipulative and sometimes untruthful, they have legitimate health care needs as well. So knowledge about the health problems that characterize the population we care for is a critical piece in achieving more accurate clinical judgments.

According to a report issued this year by the Bureau of Justice Statistics, forty percent of the incarcerated or detained adult population are diagnosed with a chronic medical condition compared to a third in the general community. Diabetes is twice as prevalent among the correctional population compared to a matched sample in the general community and hypertension is 1 ½ times more common. In terms of communicable disease, TB infection and STDs among offenders in correctional settings are twice the rates in the general community and hepatitis is six times the community rate (Bureau of Justice Statistics 2015 Medical Problems of State and Federal Prisoners and Jail Inmates 2011-12).

The racial and ethnic disparities of the criminal justice population are substantial. More than 60 percent are considered racial or ethnic minorities in the general community. One in every three black men and one in every six Latino men will serve time in prison or jail during their lifetime, compared to one in 17 white men. The same racial and ethnic disparities exist among women; one in every 18 black women and one of every 45 Latina women will be incarcerated in their lifetime compared to one of every 111 white women (The Sentencing Project at http://www.sentencingproject.org/template/page.cfm?id=107).

There are age and gender disparities among the incarcerated population as well. The overwhelming majority are men and they are relatively young in age. While women are in a minority, representing only 9% of all incarcerated persons, their population is increasing at much faster rates than men. Incarcerated women have high rates of traumatic history, particularly child abuse and domestic violence; their convictions are usually drug or drug related and most also are responsible for raising children (Bloom, Owen & Covington 2005).

Older prisoners also are a small percentage of the total (8%) incarcerated population but their numbers are growing at much faster rates because of mandatory sentencing and increasing numbers of extremely long sentences received. In fact the population of prisoners over the age of 65 increased 63% compared to a 0.7% growth for all other ages between 2007 -2010 (Human Rights Watch (2012) Old Behind Bars at https://www.hrw.org/report/2012/01/27/old-behind-bars/aging-prison-population-united-states).

Juveniles are another small but important group, with unique health care needs. They represent less than 1% of all persons incarcerated. Although incarceration rates for youth are declining, we know that incarceration decreases the likelihood of high school graduation and increases the likelihood of subsequent incarceration as an adult (The Hamilton Project 2014 at www.hamiltonproject.org).

What these statistics mean is that correctional nurses provide population-based health care. Nurses must be knowledgeable and vigilant in their clinical judgement, in order to identify and appropriately treat the health conditions that occur more frequently within each of these population subgroups (blacks, Latinos, women, children and the elderly). This focus on the uniqueness of each individual conflicts with one of the major norms of the correctional system; that incarceration is done to deprive a person of their individuality. No one gets special treatment, no one can be singled out and the rules are applied to all, firmly, fairly and consistently.

This norm about uniformity among prisoners, conflicts with the expectation and science of patient-centered care. Yet when individualization is in the best medical interests of the patient, correctional nurses are obligated to speak up. Patient advocacy, therefore is another distinguishing feature of correctional nursing. Often the nurse will have to act alone because they are the only health care provider at the scene.

An example of nursing advocacy for the individual needs of patients is shackling. Shackling is a security measure to prevent escape when prisoners are taken outside the confines of a correctional institution. In some correctional facilities or systems this is a routine practice applied to all, even pregnant women during labor and delivery. The American Medical Association, the American Public Health Association and the American College of Obstetricians and Gynecologists have each decried this as an unsafe and potentially harmful practice. Some states have even passed legislation prohibiting the use of shackles during labor and delivery. And yet we know the practice continues, so it often is the individual nurse who must insist the shackles be removed for the sake of the patient and their care.

In addition to knowledge, vigilance and advocacy for the needs of the population served, correctional nurses must be generalists in their competency to provide all types of nursing care. Like the prisoners themselves, who are not being able to choose their provider, correctional nurses do not get to choose their patients. A friend of mine and author of one of the chapters in our Essentials text, Roseann Harmon, tells a story about one of her first experiences in correctional nursing. She had been hired at the county jail because she had mental health experience. One evening the nurse manager came to her and said “Roseann, we have a woman out in the squad car at intake and she is in active labor. I am going to need your help because we are the only ones close by. Will you go get the OB pack?” Roseann gulped and said, “But I’m the mental health nurse, not an OB nurse.” The manager responded, “Well you are a nurse and so am I. We are the only ones here right now so we have to respond and we will do it together. This woman needs us.” Well, Roseann survived this experience and still tells the story years later, reminding us not to let our general nursing expertise diminish.

The second part of the ANA’s definition of correctional nursing is that the population cared for are prisoners. To summarize our population is characterized by criminality; ethnic, racial and gender disparities and has a high burden of disease. This population has had little in the way of regular health care prior to incarceration and are illiterate about self-care and health generally. Correctional nursing is defined as being responsive to the health care needs of people during their incarceration.

What are the best ways to maintain your knowledge and competencies as a generalist in nursing practices when there are some many changes in the science and best practices of health care? Please share your thoughts and resources that you think help nurses stay current in our field by responding in the comments section of this post.

If you would like to read more about the health care challenges and characteristics of the incarcerated population, see many chapters in our book, Essentials of Correctional Nursing, devoted to the nursing care of women, juveniles, the elderly, the racial and cultural groups as well as those with chronic disease and mental illness. Order a copy directly from the publisher or from Amazon today!

 

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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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