About 37 percent of incarcerated individuals in prison have a history of mental health problems, according to a 2017 report from the U.S. Department of Justice. More than 24 percent have been previously diagnosed with major depressive order, 17 percent with bipolar disorder, 13 percent with a personality disorder and 12 percent with post-traumatic stress disorder. The numbers are even higher for individuals in jail, where one-third have been previously diagnosed with major depressive disorder and almost one-quarter with bipolar disorder.

Nurses who work in corrections, therefore, must have a basic understanding of mental health conditions that they might encounter in their patients, and their treatment.  This is especially true if you are providing nursing care for a medical condition, as a co-occurring mental health condition can affect the medical treatment plan and the nurse-patient relationship. Mental illness adds complexity to any symptom interpretation, and adds a real potential for medication interactions. Correctional nurses administering medication need to know the reason for the medications they are giving to their patients, as well as 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 who has had many prior short stays in the jail without incident. This is the first time he has been held over, and currently has 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. Anna 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 for 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 are 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 the 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 provider, 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. He ultimately was sent to the emergency department, where he was an inpatient for two days before returning back to the facility. 

A Medical Condition Rather than a Discipline Issue

Appropriately, the deputy in this case sought a medical solution to this inmate outburst rather than a disciplinary one. This was due to a collegial and collaborative relationship among staff and management in both the 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 a medical evaluation and the nurse’s astute assessment, the patient was medicated, per the provider’s order, immediately with a benzodiazepine and sent to the emergency department for further evaluation and treatment. 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.

This month the discounted class at The Correctional Nurse Educator is Common Mental Health Disorders for the Correctional Nurse.