Nursing Care of End-Stage Liver Disease (podcast)


cnt-podcast_cover_art-1400x1400Richmond James Rada, MSN, RN, CCHP, a nurse consultant with the California Correctional Health Care Services in Sacramento, CA, talks about managing end-stage liver disease (ESLD) in a correctional setting. Richmond recently published an article on nursing care of end-stage liver disease in CorrectCare, the magazine of the National Commission on Correctional Health Care (NCCHC). Here is a link to the online issue in which his article appears. Richmond became interested in ESLD while doing death reviews for the state. He saw how important nursing management of the condition was to patient outcomes.

Although liver disease can be caused by many conditions such as chronic heart failure, obstruction, or metabolic conditions, our patient population most often develops ESLD due to chronic alcoholism and infection (especially Hepatitis C).

ESLD is not curable – liver transplant is the only cure and that is not an option for the majority of inmates. So, symptom management is the primary plan of action.

Nurses can be challenged to understand the clinical manifestations of liver pathology. Just a few of these include:

  • Upper GI Bleed due to back pressure in the vessels of the lower esophagus and upper stomach
  • Ascites due to portal hypertension causing fluid leak into the abdominal cavity
  • Ammonia build up causing confusion, disorientation, and behavior changes

Medication management is a key nursing management role. For example, lactulose is a common treatment for high ammonia build-up from a failing liver. It causes frequent bowel movements that is difficult to manage in the cell block. Nurses need to help patients develop a plan for working with the side effects of important ESLD medications.

Patient teaching is also an important nursing function. Our patient population needs information that is focused on their level of understanding. Richmond recommends that the patients bring their medications to chronic care visits and explain to the nurse how they are taking the medication, what the side effects might be, and what the medication is for.

Nurses can advocate for ESLD patients by recommending higher levels of care when deterioration is noted. This requires collaboration with medical and custody staff. Sensitivity to end-of-life wishes is vital, but talking about dying in prison is difficult. Family and friends may not be in contact or difficult to engage in this type of discussion.

Medical appointments, dietary needs, and activity restriction can cause conflict with officer peers. CO’s also need information to understand ESLD implications for security operations.

Finally, nurses are the hub for managing ELSD treatment complexities. This means coordinating outside appointments, dietary restrictions and pharmacy communication. ESLD treatment is costly. By managing symptoms and adherence to the medical regimen, correctional nurses are able to improve patient outcomes while reducing costly hospitalizations.

The Correctional Nurses’ Guide to the Code of Ethics

code of ethics in wood typeLast fall I was appointed to the American Nurses Association advisory committee to the distinguished panel of nurses who will be revising the Code of Ethics for Nurses. I am honored to represent the correctional nursing perspective and provide input to the panel as they update the 2001 version of the Code. I’d like you to come along with me on the journey as I consider how the Code of Ethics for Nurses applies to our specialty practice.

It All Started with Flo

All professions have codes of ethics that govern practice. The nursing code of ethics has a long history reaching back to the original Florence Nightingale pledge of 1893. Until researching the pledge for this post, I never realized that it wasn’t written by Florence Nightingale but, instead, was named after her when developed by a nurse training school in Michigan. Many nursing schools still use the pledge in graduation ceremonies. Did yours? I graduated from an associate degree program of a small community college in Wisconsin in 1984. We did not say the pledge that I remember. However, like the Hippocratic Oath often recited by graduating medical students, it provides an ethical basis and common foundation to guide practice.

It wasn’t until 1950 that a formal professional code of ethics was developed and approved by a large group of nurses through the American Nurses Association.  The current 2001 code is the sixth revision to the document. Most revisions involve variation in the way nurse duties to the patient and professional values are described in light of the changing social context. However, it is clear that the primary values of the profession are unchanged.

Professional Nursing Values

The values embedded in the code have stood the test of time. Within the 9 provisions are the values of

  • Altruism – concern for the welfare of others
  • Patient Autonomy – the right of self-determination
  • Human Dignity – the inherent worth of every individual
  • Integrity – consistent honesty of action
  • Social Justice – fair treatment regardless of the status of the individual

Duty to Self and Others

Although nursing practice is definitely altruistic, the code clearly identifies that nurses have a duty to themselves as well as the patient. It reminds me of the flight attendant instruction to put on your own oxygen mask first before helping others. If we do not pay attention to our own health and well-being, we are not fully able to engage in a therapeutic patient relationship.

The duty we have to others extends beyond the patient to include other team members. This duty includes respectful interactions and peer support.

Over the course of this year, I will be regularly blogging through the current Code of Ethics for Nurses using correctional nursing situations to help us apply the code to our unique environment. I hope you will join me in the dialogue and help make the nursing code practical for the work we do.

Photo Credit: © Marek –

Chronic Care: Are You Really Making Sense?

Plastic English letters isolated on white backgroundManaging chronic conditions is a major process in every correctional setting. The chronic care visit is an ideal time for patient teaching and reinforcement. Correctional nurses often provide a large part of patient teaching in a collaborative chronic care clinic. Areas of teaching include

  • The disease process
  • Lifestyle adjustments
  • Medication effects and side effects
  • Self-care activities

Unfortunately, there are few ready-made patient educational materials that suit the correctional setting. Most materials must be adapted to the restrictions of a secure facility and the limitations of diet and exercise imposed on our patients. As described in an earlier post, many of our patients have learning disabilities or little formal education. For all these reasons, correctional nurses need to be sure written materials are adapted to our environment, easy to understand, and make sense to our patients.

Even the general population has trouble understanding most patient education materials, as this Institutes of Medicine paper indicates. Therefore, we need to improve the readability of any patient handout used in our setting. Fortunately, there are free resources available to help us – like this guide created by the Centers for Disease Control.

Back to Basics

Here are some basic principles for creating clear and understandable patient education materials for low literacy patients taken from the CDC guide:

  • Include graphics and pictures to demonstrate important principles
  • Limit text to need-to-know information that uses action terms to directly tell the patient what they need to do
  • Use a  positive, friendly, and conversational writing style
  • Use simple words with limited use of medical and scientific jargon.
  • Limit statistics and use general terms, such as many or few, instead.
  • Format the teaching material for maximum understanding – font size of text should be as large as possible to improve readability – at least 12 points


Once materials are written and formatted, readability should be tested. The best test is to pilot with a sample of your patients; however, readability can also be factored using MSWord functions or online readability services. A very simple test of readability is the number of multiple-syllable words in the document. The Simple Measure of Gobbledygook (SMOG) is a quick online option.  The test counts the multiple-syllable words in three strings of 10 sentences within the document and then comparing the count to a table to determine reading level.

Culture and Language

Once you have your basic material together, check it for cultural appropriateness. Are the visuals representative of your patient population? Are there any trigger words that might be offensive to members of your patient community? Are there familiar terms that need to be added for clarity? Again, you may want to pilot test with key members of your patient groups. Also consider whether translation is needed; for example some settings have a large Spanish-speaking population.

Start with a Good Foundation

As you can see, writing patient education materials that make sense is hard work. You may want to start with some foundational materials created by experts. In that case, there are plenty of materials from national associations and government sites that can be adapted for the criminal justice setting. Here are a few links to get you started:

How do you teach patients in your setting? Share your thoughts in the comments section of this post. 

Photo Credit: © Vladimir Voronin –

Encouraging Patients to Participate in Self-Care

TrappedOne of the challenges of correctional nursing is engaging patients as full participants in their healthcare. Depending on the organizational culture, you may have limited opportunity to encourage your patients to manage their healthcare needs. Yet, the majority of our patients will be released to the community and they need to take on the responsibility for their health and well-being. Here are a few barriers we must overcome to be able to involve our inmate-patients in their healthcare.

Paternalistic Culture

Some correctional settings have a culture that devalues the patient and discourages patient input in other areas of life. A correctional culture based on order, control, and discipline could stall efforts to actively engage patients in care decisions and therapy monitoring.  A paternalistic culture can develop in a correctional setting where inmates are controlled and are not expected to make personal decisions. This hinders patient engagement in their healthcare and reduces motivation toward self-care activities.

Patient Preparation

The patient population can be ill-prepared to actively participate in their own health care. Limited English proficiency and low literacy levels can make self-care difficult. The inmate patient population is less educated than the general population and is twice as likely to have learning disabilities. It is also difficult to get an accurate evaluation of literacy from the patient’s self-report as inmates are more likely to over-estimate their reading and comprehension abilities. The patient’s unwillingness to participate in their own care can also be a barrier.

Practitioners Behaving Badly

Practitioner behaviors can also inhibit patient involvement. Involving patients in care provision involves a time-commitment that clinicians may be unwilling or unable to make. In addition, a continuing paternalistic medical culture combine with pervasive attitudes about the correctional patient population can result in an authoritarian stance toward the patient that inhibits involvement. Here are some practitioner behaviors that block patient involvement. Have you seen any of these behaviors in your setting?

  • Defending an action and blocking continued expression of concern
  • Interrupting and finishing sentences for the patient
  • Deliberately changing the subject when uncomfortable
  • Citing policy as a reason for an action
  • Minimizing patient’s concerns
  • Condescending comments about patient concerns
  • Not following through on promises

A primary role of the nursing profession is that of patient advocate. Correctional nurses can advocate for patient involvement in their healthcare. Even small changes can make a difference.

How do you involve patients in self-care in your setting? Share your thoughts in the comments section of this post. 

Photo Credit: © Stocksnapper –

Under the Influence: Impaired Nurses in Corrections

pill on a hookOne in ten doctors and nurses abuse drugs or alcohol. Is this surprising to you? It is to me. Although this number (10-15%) is equivalent to abuse rates in the general public, those of us in healthcare have a special responsibility to be able to think and act clearly as we are responsible for providing safe patient care. Drug abuse is particularly concerning in healthcare as there is increased access to addicting substances. This can be especially true in correctional healthcare, a low tech setting with fewer barriers to access. For example, very few correctional systems have electronic lockout systems such as pyxis.

Some impaired healthcare professionals gravitate to a correctional setting with the perception that the system has fewer safeguards than a traditional setting; so drug diversion is less likely to be detected. Unfortunately, this may be an accurate appraisal, especially in smaller or disorganized settings where strong narcotics security is not in place. Even well-managed settings can become lax about shift narcotics counts or double-lock systems. Here are a couple successful diversion methods from my own correctional management experience. Could any of these happen in your setting?

  • The foil backing of a bubble pack of oxycontin was slit. Pills were replaced with a similar looking over-the-counter medication and taped back in place. Bubble packs of the same medication were banded together and the middle pack was tampered with. Nurses were only counting the number of packs each shift.
  • An entire page of a narcotics ‘red book’ was sliced from the book along with the full pack of medication. Nurses were counting based on what was in the drawer rather than what was in the book index so it was unclear when the theft took place.
  • A hospice patient was on liquid morphine at fairly high doses. A sealed box of multiple bottles was double locked in the long-term inventory. When active stock was depleted, the sealed box was opened to find that it no longer contained all the original bottles. The count had been done for some time by just looking to see that the box was still in long-term inventory so it was unclear when it had been tampered with.

According to the National Council of State Boards of Nursing, there are four risk factors for narcotic diversion. How does your setting line up with these risks:

  • Access:  Relatively easy access to narcotics in the clinical area
  • Attitude: A relaxed attitude toward narcotics security in the setting
  • Stress: A high stress work environment including shift rotation and frequent short staffing
  • Lack of Education: Staff members are not regularly educated or warned of narcotic diversion concerns

One of the greatest ethical challenges you may face as a nurse is confronting a workmate who appears to be abusing substances. An atmosphere of suspicion and feelings of betrayal can poison work relationships. Many nurses would rather look the other way than deal with the after math of talking to a colleague or reporting suspicious behavior. An article from American Nurse Today has some helpful information on signs and symptoms of a substance abusing nurse:

Physical Signs

  • Tremors
  • Slurred speech
  • Watery eyes
  • Sweating
  • Unsteady gait
  • Runny nose
  • Change in grooming

Behavioral Changes

  • Frequent mood changes
  • Angry outbursts
  • Defensiveness
  • Lack of concentration
  • Blackout periods
  • Frequent lying
  • Poor judgment


  • Wearing long sleeves even when it is hot
  • Unexplained absences from the nursing unit
  • Medication errors
  • Reports of lack of pain relief from assigned patients
  • Offering to medicate co-worker patients
  • Increased narcotic sign-outs

Being aware of drug diversion or of staff members working impaired is both an ethical and legal concern. We have a responsibility to our patients and other team members to address concerns about a colleague’s substance abuse behaviors. In fact, we have a responsibility to our impaired colleague to initiate action so that they get the help they need to overcome their addition.

Have you witnessed drug diversion or impaired nurse behavior in your setting? Share your insights in the comments section of this post.

Photo Credit: © Photobank –

Planning for the New Year: December 2013 Reader Survey Results

2014 Reader Survey Graphs-Job DescriptionThanks to everyone who participated in last month’s first-ever reader’s survey. The results are in and they will help us plan a fantastic 2014.2014 Reader Survey Graphs-Work Experience

Who is Reading CorrectionalNurse.Net?

The majority of readers participating in this survey have been working in corrections for over 5 years and are either a staff nurse or a nurse manager.



Most of you visit the site weekly and you expect to continue to read the blog in 2014. You mostly read the weekly postings but the resources are also highly valued.

Most Surprising Finding

As an educator, it was delightful to see comments from several respondents about using the blog material and podcasts for staff meetings and monthly education. I hadn’t considered that use and want to encourage more of it. Corrections specific nursing content is scarce so providing content for educational purposes is a great value add.

What You Want More Of

Participants were asked to suggest topics for future posts. Here are the topics most often suggested:

  • Current legal challenges and cases
  • Ethical cases
  • Relationships with custody staff
  • Staying safe in a dangerous environment
  • Drug abuse and withdrawal
  • Documentation Pitfalls

Changes and Updates in the Year Ahead

To make this blog more useful and a good investment of your time, I am planning on the following changes and updates in 2014.

Brand New Look with More Functionality: It has been almost 2 years since the blog had a face lift. We will be upgrading the site in early 2014 with added functionality and easier mobile access.

Encourage More Interaction: One thing I learned from this survey is how much wisdom we have in our regular readers. Besides being an information source, CorrectionalNurse.Net needs to also be a place where nurses from jails and prisons around the country can come together as a community for mutual support. With this in mind, a members-only section will be started later this year with forums and additional information so we can interact and exchange information.

The CorrectionalNurse.Net CE Store: CorrectionalNurse.Net recently became accredited to provide Nursing CE through the California Board of Registered Nursing. Stay tuned for corrections-specific continuing education offerings available this year in text, audio, and video formats.

Monthly Newsletter: CorrectionalNurse.Net will offer a free monthly newsletter starting this spring. The newsletter will highlight recent blog posts and news items, while offering exclusive information not posted on the blog.

So, what do you think of the results of our first reader’s survey and the direction we are going in 2014? Share your ideas in the comments section of this post.

First Ever Reader Survey!

tyousagrupI don’t know why I didn’t think of this before. CorrectionalNurse.Net has been around since early 2009 yet I have never asked for your feedback on what you want and need from the blog. Now is your chance to help me plan for the year ahead. Please take a few minutes to let me know what you want more (and less) of in 2014 by using the link below:

CorrectionalNurse.Net Reader Survey

Have you searched the CorrectionalNurse.Net archives lately? In the last 4 years 239 posts were published on topic categories like Nursing Practice, Medical Conditions, Ethics, Legal, and Safety concerns. In that same time period 65 episodes of the Correctional Nursing Today podcast were produced. The Resource Page has links to more than 40 online documents on important correctional healthcare topics. Newslinks on the sidebar are continually updated.

Even with all these resources, we can make things better in 2014. Help decide what will be new in the year ahead by participating in the reader survey. You are just ten short questions away from being part of it all! The survey is open through December 31 and I will post survey results in early January.

How have you used the information on this blog? Share your thoughts in the comments section of this post.

Photo Credit: © july97 –

Too Tired to Think Straight: Fatigue and the Correctional Nurse

Baby schläftYears ago, when I was young with a school-aged son and in graduate school, I worked night shift in the critical care unit of our local hospital. I would work two 12 hours shifts over the weekend back-to-back. This is still very common in many clinical settings. In fact, nurses frequently work up to 3 or 4 12 hours shifts in a row before a break. Many correctional facilities rely on 12 hour shifts to provide healthcare coverage. Regularly working extended hours in a shift has been linked to increased fatigue on the job.

We know that lack of sleep is a health hazard but, did you know that being tired is also a safety hazard for your patients? During one of my 12 hour night shifts I made a significant medication error that haunts me to this day. My math was incorrect and I was a decimal point off. I gave my patient, by IV push, 10 times the amount of medication ordered by the resident. I was horrified and immediately initiated action once I discovered my error. This resident and I hovered over the patient all night and she made it through without lasting consequence…..but it could have been much worse. The literature is mounting indicating that nurse fatigue is hazardous to our patient’s health, as well as our own.

Burning that Candle at Both Ends

According to a review of healthcare worker fatigue and patient safety , among other things, fatigue leads to lapses of attention, compromised problem-solving, memory difficulties, and faulty judgment. This can be a deadly combination for our patients and for our own personal safety in the correctional setting. The diminished response time caused by fatigue can mean nurses are in physical jeopardy in some patient interactions. Those working behind bars need to be mentally alert for potential personal threat while caring for incarcerated patients.

Give Me a Break!

Correctional nurses need to have a personal fatigue management program while working to support fatigue management strategies at the workplace. Here are some personal fatigue management strategies recommended by the Emergency Nurses Association:

  • Be willing to decline extra shifts and overtime if you have not had enough rest
  • Take your breaks!
  • Get some brief exercise if you feel fatigued – take a short walk around the unit
  • Choose nutritious foods to eat during your shift to reduce blood glucose fluctuations

For our own safety and the safety of our patient, initiate fatigue management strategies at your facility.  Here are some suggestions from the Agency for Health Care Research and Quality:

  • Watch out for signs of drowsiness in yourself and others
  • Speak up when fatigue may be an issue in decision-making
  • Take your breaks and encourage your peers to do the same
  • Keep the lights bright in the work area
  • Consider allowing short naps at break time; especially on night shifts

My math error was a real wake-up call for me. I realized that I was unable to get accustomed to the sleep patterns needed to work through the night and soon after that event I moved to a day shift position.

What do you do to stay alert on your shift? Share your thoughts in the comments section of this post.

Photo Credit: © st-fotograf –

Verbal Order Safety Tips

Old-fashioned phone on white isolated backgroundDo you use verbal orders in your correctional facility? I bet you do…..and probably more frequently than traditional settings as prescribers are often less accessible in our secure environment. Orders communicated verbally are common in all clinical settings with estimates as high as 20% of all inpatient ordering.

A Verbal Order (VO) has the following characteristics:

  • communicated orally by telephone, digital device, or face-to-face
  • requires transcription by an approved individual
  • requires the prescriber to follow-up with review and signature of the transcribed order

Did I Hear That Right?

The most common VO errors involve misinterpretation of the dose or the medication name. For example VO errors reported in the literature include misinterpreting the number fifteen (15) as being fifty (50) and the number two (2) as being ten (10). Besides dosage confusion, sound-alike medications have also caused VO errors. Examples cited include mistaking azithromycin for erythromycin and Klonopin for clonidine.

Verbal information among care providers can also lead to error. Verbal communication of blood glucose readings without confirmation have resulted in administration of overdoses of insulin, as when the nurse heard a verbal report of the patient’s blood glucose reading being 353 when the reading was actually reported as 85.

Could You Repeat That?

For these reasons, patient safety experts recommend a standing policy that all verbal orders be stated back (or read back) to the prescriber before implementation. Besides verbal orders, this state-back policy should include high-risk clinical information that results in medication administration such as blood glucose levels or patient assessment information during a code.

One pediatric hospital reduced VO errors from 9% to zero by implementing this process. The read-back process requires the staff member who receives a verbal order to read-back the order information and obtain affirmation from the prescriber that the information is accurate. The read-back process includes the following components:

The receiving staff member writes down the order as it is verbalized by the prescriber.

  • The receiving staff member repeats the order back to the prescriber – reading directly from the written dictation.
  • To reduce sound-alike errors in medication and dosage, the reader spells out the medication name and dosage amount, for example, t-w-o – 2 mg.
  • A verbal affirmation is obtained from the prescriber before initiating the order.
  • A second staff member qualified to accept VOs listen in on highly risky communications such as insulin, anticoagulants, and narcotics

Who Are You?

We are surprisingly trusting when taking patient orders by phone. One study found that few smaller institutions asked for identification when prescribers called with patient orders. With the rapid turnover of staff and covering providers, it can be risky to rely on voice recognition to confirm identification. Many large academic institutions use provider identification numbers for verbal orders. Several incidents of individuals posing as providers have fooled staff into taking and implementing verbal orders for patients. The correctional setting has opportunity for nefarious use of telephone communication. Do you know who is on the other end of the line when you take verbal orders?

Know Your Limits

The high risk of error with VO’s requires limits on use. Here are some standard limits placed on VO’s that should be considered in our setting:

  • Limit VO’s to urgent patient care needs and not as a routine practice or for convenience purposes.
  • Limit the number of staff who can take verbal orders.
  • Limit the type of medication that can be ordered to formulary medications that are more likely to be familiar to staff members.
  • Do not use verbal orders for complex medication schemes such as chemotherapy.

What is your practice regarding verbal orders? Share your thoughts and tips in the comments section of this post.

Photo Credit: © Maksym Yemelyanov –

Excellence in Correctional Nursing: An Interview with Ava Chavez, RN (podcast)


cnt-podcast_cover_art-1400x1400My guest on this episode is Ava Chavez, RN, Senior Nurse with Correctional Health Services (CHS) in Orange County, CA, where she oversees the daily nursing operations in the various clinical units located within the Orange County Jail system. She created a wound care team and manages the wound care program, in addition to her role as Case Manager at CHS. Recently, Ava was chosen as a regional awardee of the 2013 CALIFORNIA Nursing Excellence in the Home, Community and Ambulatory Care category. She was honored at the Nursing Excellence GEM Awards in August. In addition, she has been chosen as the Outstanding Wound Care Certified Nurse of the Year by the National Alliance of Wound Care and was awarded the Orange County Sheriff’s Gold Star Award for accomplishments achieved January-June 2013.

We talk about her work at Orange County and the meaning of excellence in nursing. Some have found their nursing career in the correctional specialty to be devalued by others. We discuss how nurses can practice professionally in jails and prisons. Ava gives some advice on seeking excellence in correctional nursing practice and encourages nurses interested in the specialty to try it out.  She also talks about the wound care team she manages and the importance of teamwork for excellent practice.

Thoughts on Teamwork in Correctional Practice

Teamwork is an important factor in accomplishing patient goals yet most of us didn’t learn much about it in our professional training. I am currently writing a chapter on communication and teamwork for my upcoming book on Patient Safety in the Correctional Setting. More about the book in the coming months but let’s talk some about the components of teamwork. Teamwork is based on good communication and collaboration skills of all the team members. But it is more than that. A team focuses concerted effort on achieving patient-centered goals through interdependent collaboration and shared decision-making. This requires team members to understand and enact their professional roles for common health goals.

A well-working team doesn’t just happen. It takes effort. There is a need for clarity of structure, process, and expected outcomes. Without clear direction, roles, task, or authority a team can flounder in meeting patient care goals.


Winter winds are blowing here in the mountains and the holiday season is soon upon us. I have just returned from the NCCHC Fall Conference in Nashville and saw many friends and colleagues. I was also honored with the 2013 B. Jaye Anno Award of Excellence in Communication for my work in traditional and New Media communication to advance correctional health care practice. If you would like to listen to my 6 minute acceptance speech you can find it here.

I’m still pretty excited that Correctional Nursing Today is now available on Stitcher. If you already use Stitcher to listen to your favorite podcasts, add me to your list. If you’ve never tried Stitcher, head over to and download the app. It is amazingly easy to cue up a series of podcasts for listening anywhere you have internet access and your cellphone, tablet or laptop. I use mine every day to listen to podcasts while I exercise, run errands, get ready for work in the morning, or even when I’m doing yard work.

As always, you can also subscribe on iTunes or listen to past episodes from the Podcast tab on the website.

Just a reminder –  If you are new to the correctional specialty, or want to brush up on your practice, consider purchasing my book – Essentials of Correctional Nursing. You can find it on amazon or, even better, click on the tab called ‘Get the Book’ on the website and scroll down to find a promo code to get $15 off and free shipping by ordering directly from the publisher. Either way, I want to know what you think. Send me feedback at or leave a review on amazon.