What’s Bugging You? Lice Identification and Treatment

baboon grooming another closeup isolated on blackDuring a jail intake for a homeless man brought in for vagrancy, a nurse sees some tiny insects flying about his clothing and he is scratching at them as she interviews him. She is concerned that an infestation may result and initiates a protocol for lice which involves shampooing and showering with the insecticide permethrin and a special laundering process for all clothing. Was this the right action?

Correctional nurses need to be aware of various infestations as a high percentage of inmates in some locales are prone to head, body, and pubic lice. Once these little hitchhikers enter a facility they can spread by direct physical contact or through sharing of personal items like clothing, bedding, or towels. Was this patient infected with lice? Let’s look at some information about these little critters.

Do lice fly?

Lice remain on a person’s hair or clothing and wander to the skin to blood feed once or more often each day. They have tiny straw-like mouthparts – similar to those of mosquitoes – that they use to suck blood from skin capillaries. They’re unable to burrow into the skin. Lice never develop wings, so they cannot fly.  They’re also incapable of jumping. So, this patient did not have lice.

Lice cause itching

Lice may cause an allergic reaction that can cause itching. For head lice, the itching tends to be mild and temporary.  Body lice tend to cause far more itching, and even make the infested person feel ‘lousy’. Public lice tend to cause much itching in the affected area.  This patient’s itching may be caused by the insect in question but further investigation is needed.

Lice are not very common

Lice are not nearly as prevalent as is generally believed, and other creatures and objects on a person are frequently mistaken for lice.  Other insects include fleas, ticks, mites and bedbugs. None of these insects have wings, though. The homeless man in our case may merely have gnats or fruit flies about his person.

Lice are relatively tiny – as small as a poppy seed and as large as a sesame seed. A screener must have good eyesight, be close enough to see the creature, use a magnifying lens, and some expertise to identify lice; distinguishing them from other insects. In fact, other kinds of insects and even bits of debris are frequently mistaken to be lice. As in this case, misdiagnosis and unnecessary treatment can be frequent.

When in doubt – don’t treat

Treating everyone who enters a facility is not a good idea; nor is it cost effective. Treatment focused just on those infested is consistent with sound medical practice.  It can also dramatically save time and precious funds; while reducing the risk of lawsuit. The standard medications used in prisons for delousing contain the insecticides permethrin and pyrethrins. These have become less effective as resistance is becoming widespread.

When positive lice identification is confirmed, treatment can be ordered as follows:

  • Head lice can be treated with one or two 10-minute applications of a pediculicide.
  • Body lice usually require no treatment to the person. Instead, a person with body lice should bathe and change into prison-issued clothing. The infested clothing should be disinsected by proper laundering, or disposed of.  If body lice are detected on the body hairs of a person, a full-body treatment with a pediculicide is needed.
  • Pubic lice would necessitate treatment to the affected area only.

Ongoing prevention measures for lice include frequent (at least weekly) laundering of clothing and linens, and early recognition and treatment of genuine infestations.  The Federal Bureau of Prisons Lice and Scabies Protocol of March 2011 recommends the following actions:

  • Be sure laundry temperatures are set to at least 130 degrees Fahrenheit to kill lice and their eggs on linens and clothing. Use a hot cycle for drying, as well.
  • Educate inmates about lice and how to get treatment if they observe lice. The FBOP Protocol includes inmate education handouts that might be helpful.
  • Inmates should not be transferred to other facilities until 24 hours after initiation of treatment.  If moved before the 2nd treatment application (7 days), communication and continuation of treatment should be provided.

How are you managing lice, bedbugs, fleas, and ticks in your facility? Share your thoughts in the comments section of this post.

Photo Credit: © Sascha Burkard – Fotolia.com

Scope and Standards: New Definition of Correctional Nursing

ANA StandardsHow has professional nursing practice in the correctional setting changed and evolved over the last decade? When discussing any concept, the first place to start is with a definition. How has the definition of correctional nursing changed over the years?

To start with, the very name of our specialty has moved from corrections nursing to correctional nursing. This name change indicates a movement away from purely defining nursing practice based on location. Similar evolutions have taken place in such specialties as emergency nursing (no longer Emergency Room Nursing) and Perioperative Nursing (no longer Operating Room Nursing).

Definition of Corrections Nursing in 2007

Corrections nursing is the practice of nursing and the delivery of patient care within the unique and distinct environment of the criminal justice system.

As the general definition of nursing has progressed, so has the definition of correctional nursing. This edition of the Correctional Nursing Scope and Standards of Correctional Nursing unveils an expanded definition of correctional nursing which mirrors the 2010 ANA definition of nursing.

Definition of Correctional Nursing in 2013

Correctional nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, advocacy, and delivery of health care to individuals, families, communities, and populations under the jurisdiction of the criminal justice system.

Nurses practice professionally in every setting. Therefore, the core components of correctional nursing include protecting, promoting, and optimizing the health and abilities of patients. Nurses in all practice settings, including corrections, prevent illness and injury while alleviating suffering. Correctional nurses, as those in other settings, diagnose and treat the human response to illness and injury. They advocate for their patient’s health and deliver health care to individuals, families, communities, and populations.

The location of care – under the jurisdiction of the criminal justice system – does give context to the practice of nursing. The criminal justice system presents the unique environmental constraints and ethical dilemmas of our specialty. In addition, the criminal justice system creates a unique patient population for nursing care. This patient population has demographic characteristics and illness patterns that require specialized nursing knowledge. The combination of environment and patient can lead to specific patient advocacy situations for correctional nurses.

What do you think of the new definition of correctional nursing? Share your thoughts in the comment section of this post.

The full Correctional Nursing Scope and Standards of Practice, 2nd Ed. Is available through amazon.com.

Top Six Posts of 2013

six balloonsThank you for being a part of CorrectionalNurse.Net this past year! Your comments and suggestions make this blog a helpful resource for nurses new to the specialty and those interested in keeping abreast of the latest news and information important to working in jails and prisons. In fact, my goal for this blog is:

Informing, encouraging, and inspiring nurses who care for vulnerable, marginalized patients in the low resourced, ethically challenging criminal justice system.

This blog has been around for more than 4 years now and has over 250 informational posts in a variety of categories. Search by key word using the search field in the upper right or by category using the drop-down menu on the right sidebar.

Here are the six most popular posts in 2013. Check them out if you missed them when they originally aired. Stay tuned for more great information in the year ahead. I hope you visit often and include your views by commenting frequently.

#6 Confidentiality, HIPAA, and the Correctional Nurse

Concern continues for the confidentiality of patient medical information. Correctional nurses must navigate within a security system that often requires the exchange of medical information for safety and good patient care. What medical information can be shared? This post provides information directly from the HIPAA code that specifically addresses the correctional setting.

#5 Women’s Health in Prison

Women may only constitute 7-12% of the incarcerated population, but their healthcare needs can be great. Maybe increased interest this year can be attributed to the popular Netflix show “Orange is the New Black” – a portrayal of life in a female federal prison.

#4 Taser Injury – The Stunning Truth

Correctional nurses take care of an extensive variety of conditions and some that are rare in more traditional settings. Taser injury is one such unusual care situation. This post covers assessing and treating post-taser wounds as well as what conditions render persons at high risk for increased injury from being tased.

#3 8 Medication Rights – Not 5?

Just when you think you are up-to-date something changes. That is life as a practicing nurse. This post adds three new ‘rights’ to the classic 5-rights of medication administration and is actually reposted from the blog of a fellow nurse. A great review!

#2 Interview Guide: Part I   Part II

Many nurses discover this blog while looking for help in preparing for their first interview for a correctional nursing position. This 2-part series shares tips for determining if a correctional setting will be a safe work environment along with questions that may be asked during the interview.

#1 Dental Issues for Correctional Nurses

By far, dental issues were the greatest learning curve for me in entering this specialty. This post has some great pictures provided by Dr. Stephen Mitchell and is a big help for nurses who need to know what is routine and what is a possible emergency when dealing with dental conditions.

What was your favorite post of 2013? Share your thoughts in the comments below.

Photo Credit: © Kyrylo Grekov – Fotolia.com

December 2013 News Round-Up (podcast)

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cnt-podcast_cover_art-1400x1400Regular panelists Johnnie Lambert, Mari Knight, and Margaret Collatt help us close out the year with discussion of December 2013 correctional healthcare news. Let’s roll……

Story #1: Eye Care Rare Among Low Income Diabetics – Implications for Correctional Nursing?

Our first story, while not specifically about correctional healthcare has a very real connection for our consideration. A Reuter’s news story reports on a study finding that young low-income diabetics are not attending to their eyes. Our inmate population fits this profile – young, low-income and often diabetic. Are their implications for our patient care here?

Story #2: Psychiatrist Shortages in Corrections?

Our next story is from the California Prison System. California Healthline reports that the state prison hospital has had to cut services and reduce admissions due to a psychiatrist shortage.

Story #3: Orange is the New Black and Women’s Prisons Portrayal

Story #3 from the Washington Post lauds the Netflix series ‘Orange is the New Black’ as a fairly accurate portrayal of a women’s prison. Do you think having a program based on a women’s prison might be helpful in raising awareness of incarcerated women and their plight?

Story #4: Mother Antonia Passes

Our final news item is the sad report that Mother Antonia Brenner has passed on. She was dubbed the Prison Angel for her work with the poor and imprisoned in Tijuana, Mexico. She has an amazing story. Her prison worked grew from her charity work among the poor in California where she was a twice divorced mother of eight children. Eventually she moved into a cell in the Tijuana Prison to more fully experience the lives of those she served. Hers is an inspiring story of kindness and sacrifice.

What is your take on the December news? Share your thoughts in the comments section of this post.

Christmas is About the Children

Little child decorating christmas tree

With my grandson nearly 3 years old, our Christmas this year is full of toys and wonder and a reminder of the Babe long ago who brought hope to the world; whose birth we are celebrating. Christmas is definitely a time for children and a reminder of how many children have parents behind bars in our country. These young victims of their parent’s crimes suffer grave consequences, including separation from their parents during the holiday season.

According to the Bureau of Justice, 1.75 million children have a parent in a state or federal prison this Christmas. Many inmates have multiple children and the Sentencing Project estimates that 1 in every 50 children in this country has a parent behind bars. These are sobering numbers amid the lights and glitter of our holiday celebrating.

Children in this situation may be lonely and feel alienated from the season’s festivities. Even if able, visiting a parent in prison during this time of year can bring more sadness than cheer; emphasizing the obvious separation.  Distance and lack of financial resources may make visiting impossible and incarcerated parents may be unable to afford providing even a token gift for a child.

If the incarcerated parent is also the primary care provider, the child may be living in foster care. More fortunate children may have a loving extended family member willing to provide support and supervision during this period. According to an economic study of incarcerated families, children with incarcerated parents are more likely to have difficulty in school with more aggressive behavior noted among boys and an increased chance of being expelled or suspended.

Most of us will not be able to make as great an impact as 2012 Miss America, Lauren Kaeppeler, who is using her platform to bring more attention to the plight of kids of incarcerated parents. Her father was incarcerated when she was a teenager and she has first-hand experience of the effects of a parent behind bars. However, every one of us can do something. Here are just a few of the organizations that are helping our patient’s children cope with the impact of prison on their lives. This Christmas season, consider contributing to one of these charities, or another you may be aware of in your community:

Prison Fellowship: Angel Tree

Camp Spaulding – New Hampshire

Children of Promise – New York City

New Hope – Oklahoma

Does your facility do anything for inmates and their children on Christmas? Could they? Share your thoughts in the comments section of this post.

Photo Credit: © allari – Fotolia.com

Vicarious Traumatization in Correctional Nursing (podcast)

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cnt-podcast_cover_art-1400x1400Have you ever felt traumatized at the end of your work day? Maybe you have gone through periods of feeling very burned out in your nursing practice. In this episode I talk with Tanya Munger about her research into vicarious traumatization of correctional nurses. She surveyed correctional nurses from around the country about their experiences with this phenomenon. Tanya Munger, MSN, FNP-BC, CNOR, CCHP, is Clinical Instructor, Department of Health Systems Science, UI College of Nursing at Rockford, IL. She worked as a nurse practitioner with UIC College of Medicine inside of the Winnebago County Jail, the second largest county jail in the state of Illinois.

What is vicarious trauma?

Vicarious trauma is the result of taking on and absorbing disturbing aspects of the traumatic experiences of others, such as our patients. As correctional nurses we work in a harsh system among patients who often have very painful background full of violence and abuse. Regular contact can result in integration of this post-traumatic stress into our own functioning resulting in a variety of alarming symptoms such as flashbacks, nightmares, intrusive thoughts, depression, and sleeplessness.

What can you do about vicarious trauma?

What should you do if you think you are absorbing the traumatic experiences of others? First, be aware of this possibility and monitor yourself. Be sure to take care of yourself, getting enough rest, health food and activity. Traumatic stress can get you off balance and it might take conscious effort to return to a balanced lifestyle. Find ways to separate yourself from your patient. Remind yourself that this is not your pain. You may be holding it or helping with it, but it is not you. Look for small and large ways to renew yourself. Do what works – which can be different for everyone. Meditation, deep breathing, yoga, creative arts are some small regular options. Larger ways might be taking a real vacation away from your worksite to totally unplug, drain your stress, and re-center yourself. Certainly, if you are experiencing serious or debilitating symptoms, it is time to seek help through counseling or healthcare services. Read more about this condition from the resource links below.

Resources

Burnout, vicarious traumatization and its prevention

For Professionals: Vicarious Trauma

Announcements – Reader Survey

Did you know CorrectionalNurse.Net is running a first-ever reader survey for the month of December? Take the survey and give your input on what you want more of in posts and resources for 2014.

November 2013 News Round-Up: Pew Report on Prison Healthcare Spending (podcast)

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cnt-podcast_cover_art-1400x1400Our panel of nurse experts drills deep into the recently published Pew Report on Prison Healthcare Spending to discuss implications and compare their experiences with the report’s recommendations. Panelists include Johnnie Lambert, correctional nurse and Vice-President, Clinical Operations, Policy and Accreditation with Armor Correctional Health Services, Inc. ; Mari Knight, Mid-Atlantic Transition, Training and HSA Support Nurse for Conmed Healthcare Management; and Catherine Knox, correctional nurse consultant from Portland Oregon.

The Pew Report on Prison Healthcare Spending is an extensive document chronicling the rising expense of providing healthcare to our inmate patients. It identifies trends we are all too aware of with familiar causes such as aging patients with high prevalence of infectious and chronic diseases, as well as mental illness and substance abuse. The report also describes challenges we have with location, transportation, and staffing – which we don’t often see in print. Since the mid 1970’s when inmate healthcare was established as a constitutional right, correctional healthcare costs have risen almost 700%. The first part of the report lays the groundwork for why correctional healthcare costs are escalating. The later half of the report documents various state responses to increasing prison healthcare costs. Examples provided include telehealth, outsourcing care, Medicaid financing, and medical or geriatric parole. Panelists provide thoughts on the uses of telehealth described in the report and whether we have fully exploited this technology in corrections. Outsourcing is also explored and panelists agree that this is a promising cost containment strategy. The third theme of the report is Medicaid financing. In some ways this seems like cost shifting (from state to federal tax dollars) rather than cost savings, but there are ways to make it work. The final theme offered in the Pew report is the use of medical or geriatric parole. The report suggests that recidivism is low among elderly inmates but acknowledges this is a political hot potato. Correctional systems need to carefully implement this strategy to make it work.

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 – Fotolia.com

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 – Fotolia.com

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

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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 Nurse.com Nursing Excellence in the Home, Community and Ambulatory Care category. She was honored at the Nurse.com 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.

Announcements

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 stitcher.com 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 Correctionalnurse.net 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 correctionalnurse.net 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 correctionalnursingtoday@gmail.com or leave a review on amazon.