Help! I’m Not a Mental Health Nurse! Part 1: A Deputy Calls with an Inmate “Going Nuts”

Funny crazy young doctorIf you work in corrections, you need to understand the basics of mental health conditions and treatments. For one thing, so many of our patients have a mental disorder. Estimates are that nearly 25% of inmates have a serious mental illness while over half report at least one mental condition. Secondly, even if you are providing nursing care for a medical condition, a co-occurring mental health condition can affect the nurse-patient relationship. Mental illness adds complexity to any symptom interpretation and additional potential for medication interactions. Correctional nurses administering medication need to know the reason for the medications they are providing to their patients, along with the effect and side effect profiles of an array of psychotropics. Finally, correctional nurses are regularly the only health care staff in the facility when a mental health crisis is identified by officers. Consider this jail scenario:

A deputy calls to say he has an inmate who is “going nuts.” He wants someone to come up and “do something” about this. The inmate is a 23 year old white male having many prior short stays in the jail without incident. This is the first time he has been held over with a charge of reckless driving. Anna, the nurse staffing the jail for this evening shift, is unfamiliar with the patient and with the deputy.

What is going on here? How should the nurse respond to this crisis? In a situation like this the first step is to gather information to rule out a treatable medical condition that might be causing this patient response. This nurse is preparing to contact a provider but she needs to first have all the necessary information to share with the on-call nurse practitioner. She collects her emergency bag and takes a couple minutes to see if there is any medical record on the patient before heading to the housing unit.

Medical Conditions that Cause a Psychiatric Response

While gathering subjective and objective data for an assessment, it is a good idea to have in mind the medical conditions that could be causing this response. There are several medical or organic causes of psychiatric symptoms – the two most notable are dementia and delirium tremens. This patient’s age and history do not support dementia but delirium from alcohol withdrawal is a consideration. In fact, psychiatric psychosis and alcohol withdrawal delirium are easily and frequently confused. Here is a helpful guide taken from an Academy of Family Physicians article that differentiates the three conditions:

Delirium

  • Rapid onset
  • Visual hallucinations, disorientation, agitation, impaired attention

Dementia

  • Chronic slow onset
  • Disorientation and agitation

Psychosis

  • Usually a slow onset
  • Usually oriented, visual hallucinations rare, auditory hallucinations more common

Another consideration when gathering assessment data is the physical condition of the patient. Patients in substance withdrawal to the point of delirium will be physically sick while dementia or psychosis will not likely present that way. The nurse needs to have all this information available to make a good clinical judgment about actions to take.

Safety Check – Always!

No matter what psychiatric condition is being evaluated, patient and staff safety is always at the forefront. Anna needs to be continually evaluating this patient’s potential for harm to self or others during the assessment process.

The SAFER Model for dealing with potentially violent patients should be part of interventions with a potentially violent patient:

  • S = Stabilize the situation by lowering stimuli, including voice.
  • A = Assess and acknowledge the crisis by validating the patient’s feelings and not minimizing them.
  • F = Facilitate the identification and activation of resources (mental health staff, officers, chaplain).
  • E = Encourage the patient to use resources and take actions in his or her best interest.
  • R = Recovery and referral – Leave the patient in care of a responsible professional.

Anna was able to use a calming voice tone and actions to obtain needed assessment findings. This patient was indeed ill, having insomnia, nausea, and diarrhea. He began hallucinating only recently and the initial screening in the chart indicated no past history of mental or chronic illness. Anna continually reoriented the patient to reality. While awaiting a call back from the nurse practitioner, with the assistance of security staff, she was able to relocate him from the noisy housing unit to an infirmary bed for closer observation and decreased stimulation.

A Medical Condition Rather than a Discipline Issue

Thankfully, the deputy in this case sought a medical solution to this inmate outburst rather than a disciplinary one. This may be due to a collegial and collaborative relationship among staff and management in both custody and health care disciplines. It makes a difference. By contacting medical for help, the correct treatment was provided. This inmate was, indeed, withdrawing from alcohol and in delirium tremens. Through the deputy’s initiation of evaluation and the nurse’s astute assessment, the patient was started on a benzodiazepine; first with a high dose to get the blood level up and then tapered to response. He successfully recovered from the delirium during a short hospital stay. He was referred to substance dependency community services on release from the jail.

Have you ever had a similar patient situation? Share your thoughts and tips in the comments section of this post.

Photo Credit: © Shmel – Fotolia.com