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In the correctional environment, nurses are faced with many obstacles to delivering care, so it is imperative that we fully understand the most common critical conditions our patients present with. 65% of new inmates qualify as having substance abuse disorder or addiction to drugs and/or alcohol (7). Withdrawal from alcohol and drugs is a medical condition that needs intervention from the nurse at the earliest opportunity.  Being able to deliver high-quality and effective care to this population requires appropriate assessment, treatment, referral, and communication between the multidisciplinary teams of medical, mental health, and security staff. 

Introduction

In the USA, 5.6% of the adult (>18yrs old) population suffer from alcohol use disorder (AUD) which equates to 14.1 million people. 95,000 people die annually as a result of alcohol. This makes alcohol the 3rd leading cause of preventable death in the USA – behind tobacco and poor diet and physical inactivity (1,3,4). 

In the correctional environment, nurses are faced with many obstacles to delivering care, so it is imperative that we fully understand the most common critical conditions our patients present with. 65% of new inmates qualify as having substance abuse disorder or addiction to drugs and/or alcohol (7). Withdrawal from alcohol and drugs is a medical condition that needs intervention from the nurse at the earliest opportunity.  

Delivering quality, appropriate, and effective care to this population requires many stages of assessment, treatment, referral, and communication between the multidisciplinary teams of medical, mental health, and security staff. This course will walk through alcohol use, alcohol withdrawals, and the nurses‘ role in the correctional setting in correctly identifying and appropriately treating alcohol withdrawal. 

Clinical Considerations of Alcohol

It is important to understand the clinical manifestations of alcoholism, the patient’s clinical presentation, and the risks associated with sudden alcohol withdrawal if left untreated. Alcohol is toxic to the body if consumed in excess frequency and/or amount.  

Alcohol Use Disorder (AUD) is defined as a chronic relapsing brain disease characterized by impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences. (5) 

Binge Drinking is defined as a drinking pattern that brings blood alcohol concentration (BAC) levels to 0.08g/dL. This is typically four drinks for a female and five drinks for a male within 2 hours (6). 

Once ingested, alcohol metabolism starts in the stomach, where there is some gastric ADH (alcohol dehydrogenase) – the principal enzyme that breaks down alcohol. Most of the alcohol is absorbed into the small intestine, which then joins the venous system, being pushed into the portal vein and finally into the liver. The liver creates ADH to metabolize the alcohol into waste products for excretion. (8) 

However, suppose the liver is unable to metabolize the alcohol at the rate of ingestion. In that case, the alcohol easily crosses into the bloodstream, which then becomes toxic in other tissues –for example, the neuromuscular system and the brain. This manifests itself in many ways, for example, poor balance, slurred speech, change of behaviors (whether aggressive or more affectionate), and the “drunk“ state most of us have experienced and/or seen. 

Over time, excessive alcohol use damages tissues on a more permanent basis. Seizures are a common sign of brain damage, but lesser understood is the damage to the executive function of the brain. This manifests with difficulty organizing, showing accountability, self-regulation, poor time management, and planning and setting goals. Cognitive processes are also affected, such as being able to remember and follow instructions, short term memory loss, understanding what is being said, personal awareness, and paranoia. (9) 

Alcohol is a simple molecule that affects all organs. It can damage the heart which can cause hypertension and lead to an increased risk of heart failure and strokes. It can increase the risk of certain cancers and change our biochemical and hormonal physiology. When performing a nursing assessment on a patient with a history of alcoholism, all organ systems must be considered. 

Alcohol Withdrawals

When binge drinking has taken place, most healthy people will be able to rid the system of alcohol and toxins over a 24–48-hour period. The symptoms, commonly deemed a hangover, range from mild to delirium and are the manifestation of your body experiencing withdrawal from the alcohol. Most people can manage their symptoms over time, with rest and hydration. However, alcohol withdrawals in patients that have AUD do not follow this pattern. Alcohol Withdrawal Delirium (AWD) is a serious medical condition. If AWD leads to death in 15% of untreated people (10), but with proper care and treatment, the mortality rate is 0-1% (16). 

For patients in a correctional facility, clinical features of AWD can appear within hours of the last drink. The delirium will typically peak around 2-3 days after the last drink and can last 48-72 hours (9). However, each patient is unique and must be monitored closely for signs and symptoms. 

Stages of Alcohol Withdrawal Delirium 

Stage 1 often presents with mild symptoms with vital signs remaining in normal range. 

Stage 2 presents with more intense symptoms and abnormal vital signs, commonly with increased blood pressure, temperature, and respiratory rate. 

Stage 3 is when the patient presents with severe symptoms, including DTs and/or seizures. 

If left untreated, AWD symptoms can rapidly progress from Stage 1 to Stage 2 or 3 (17). 

Knowing the patient‘s history is crucial for assessing what treatment level a patient may require while in your care. There is also evidence to show that the “kindling effect“ in AUD patients needs to be considered. The “kindling effect“ is related to the clinical symptoms of withdrawal. Every time a patient with AUD goes through treated or untreated withdrawals, the severity of symptoms increases (14) – for example, they may have one seizure during their last incarceration but may have three seizures this incarceration. Not only is there an increase in the severity of physical withdrawal symptoms, but psychiatric pathology worsens too, especially in relation to depression, anxiety, and cravings (12).  

Treatment for AWD is well established and agreed upon in the literature. The gold standard for treatment is the use of benzodiazepines. Other alternatives can be used, such as sodium oxybate, clomethiazole, and tiapride, but these are only appropriate for acute hospital stays.  

In conjunction with benzodiazepines, alpha–2 agonists, such as clonidine, beta-blockers, propranolol, and neuroleptics, such as risperidone, have also been shown to be effective in helping treat AWD. 

Anticonvulsants are not sufficient to control AWD (13). 

Much of the literature and research on AWD comes from acute hospital settings. This reinforces the most important takeaway from this educational unit:  AWD is a serious medical condition that can be fatal.  

The nurses‘ role in monitoring and assessing patients who are going through AWD in the correctional setting is crucial. Once a patient has been identified as at risk from AWD, some form of monitoring must be started immediately. Remember, detoxification can start as early as a few hours after the last drink. Using the CIWA-Ar (Clinical Institute Withdrawal Assessment – Alcohol revised) monitoring tool is the most common practice (15). This not only requires vital sign monitoring but uses a scoring system in relation to symptoms.  

Symptoms include:  

• Nausea/Vomiting 
• Tremors 
• Paroxysmal Sweating 
• Agitation 
• Tactile Disturbance 
• Anxiety 
• Headache/Fullness in Head 
• Orientation 

Each symptom is scored and added together, with a maximum score of 67. For scores of 8 and above, a provider needs to be consulted; if a score is greater than 19, this patient needs sent to the Emergency Department or seen STAT by a provider. 

These assessments should be made at least every 8 hours, but more frequently if a patient is starting to deteriorate. 

Case Studies 

The following case studies discuss the nurses’ role in advocating for patients in the correctional setting: 

Case Study 1 – Jimmy

Jimmy (55yr old man) is a regular visitor to your facility. He smells of alcohol. During your assessment, his vitals are as follows: 

• BP: 158/88 mmHg 
• P: 92 bpm 
• Temp: 98.6°F 
• RR: 12 bpm 
• SpO2: 97% 

His speech is slurred, and he is slow to respond to your questions; his answers are not always consistent with your questions. He laughs, giggles, and tries to flirt with you. When you ask him if he knows where he is, he tells you it‘s Tuesday night (it is Saturday), and you are in the bar. He is restless and when he tries to put his elbow on the table, he misses. When you try to weigh him, he is unable to stand without holding on to the wall. His mouth is dry, and his eyes are bloodshot. He tells you he has two beers every day and only had one today. 

The medical record history tells you that he had two seizures during his last incarceration eight weeks ago, had visual hallucinations, and was had become very anxious. He had received some Librium on days 3,4, and 7, was given diazepam on day eight following his 2nd seizure and had Keppra from day eight until he was released. 

What do you initially think should be done?
Are you concerned about Jimmy‘s clinical condition now?
Can you name the physiological system(s) being affected by alcohol? 

For Jimmy, we need to use our clinical assessment skills, knowledge of alcohol withdrawals, and use every opportunity to ensure he will be cared for while he is housed inside the facility. It is clear that Jimmy is not telling us the full story of his recent drinking habits. This is common, and we now understand that Jimmy‘s brain function has probably been affected by his AUD. As with any patients who we suspect of not being truthful or not able to be truthful, as in Jimmy‘s case, you must use your clinical knowledge and complete your assessment independent of Jimmy‘s story. 

Let’s break it down: 

The first things to consider are his vital signs – What do they tell us?

The vitals do not tell much, other than he is teetering on hypertension, tachycardia, and pyrexia. Respiratory rate and SpO2 are on the low side. 

Next, assess his presentation – What does that show us?

Be careful not to assume – “He‘s just drunk.” You are correct, he is drunk, but clinically – What is happening to him? What is the alcohol currently doing to him as he sits there looking at you?  

Despite what he tells you about his one beer, his presentation shows you that his neuromuscular system is being affected by the alcohol (imbalance), as well as his executive function (regulating his behavior towards you) and cognitive brain function (not answering questions appropriately). His mouth is also dry, so, physiologically, he may be dehydrated, and more than likely, his biochemistry will not be within normal limits. 

Even though Jimmy’s input doesn’t aid your assessment, his vital signs and presentation are very telling. 

Consider his history. 

With most patients, history is not always available. If you do have access to a patient’s history, take the time to understand it, especially when it comes to substance abuse, alcohol abuse, and mental health issues. Notoriously, these patients don‘t give an accurate account of their recent history. For us to provide the best care, having some past medically documented information is vital and may be the difference between life and death. 

Fortunately, there is a record of Jimmy‘s medical history. 

Remember the “kindling effect“ – do you think it is applicable here? 

Take note of the care that Jimmy received during his last incarceration. He was given no treatment until day 3, when he received some chlordiazepoxide. He had his 2nd seizure on day 8, when he received benzodiazepine and started on an anticonvulsant from there. 

Do you think his treatment was proactive?
Do you think his treatment was adequate? 

Jimmy has suffered from withdrawals in his last incarceration, so we can expect that he will have at least the same severity of withdrawal symptoms, if not more, due to the kindling effect on this occasion. 

Physiologically, he is compromised, and in a correctional setting, Jimmy is at risk. He is at risk of being harmed by others due to his incapacitated state, of harming others due to his potential mood swings and poor decision making, of potential self-harm due to mood changes, and of physical harm from AWD. 

How should you proceed with Jimmy? 

Jimmy’s plan of care at this point will depend on what level of care your facility is able to manage. If you have a hospital unit or a close observation/detox unit staffed with clinical personnel, he may be able to be housed there. However, if your facility lacks the option for Jimmy to be closely monitored, then he will likely need to be sent to the local ER. 

As the nurse assessing Jimmy, the conversation you have with your Provider will determine Jimmy’s outcome. Ensure that the information that is presented to the Provider in a clear, concise, and comprehensive manner. Jimmy could become very sick very fast, and your report must advocate for him. 

Case Study 2 – Poppy

The next patient after Jimmy comes shuffling in with vomit stains down the front of her shirt and make-up running down her face. 22yr old Poppy, first arrest and first time in jail. She is crying and tells you a long–winded story about how she was in a club, drank too much, and vomited on the way to the restroom. The security guard came to get her, and she tried to fight with him because she wanted to stay and continue having a “good time.” She scratched the security guard‘s face and bit his arm. She tells you that the last time she was drunk was 6 weeks ago at her boyfriend‘s birthday party. She has a full–time job and doesn‘t drink on a typical day. Her vitals are as follows: 

• BP: 126/80 mmHg 
• P: 86 bpm 
• Temp: 98.1°F 
• RR: 18 bpm 
• SpO2: 99% 

She denies any health issues, is alert and orientated, and is coherent, but visibly upset. She denies suicidal ideation. Her only complaint is that she claims to be getting a bit of a headache and feels very thirsty.  

What else do we need to know about Poppy before we do anything else?
Are we looking after one human being or two? 

It is best practice to conduct a pregnancy test on every female who comes into the facility. After conducting a pregnancy test, you find that Poppy is not pregnant. 

There are a few important points to consider when you think about Poppy and what kind of care she needs. It is easy to think – “She‘ll be fine, she‘ll just sleep it off.” That may be true, but we do have a responsibility to ensure that she safely “sleeps it off.” This is a difficult part correctional nursing; you have a responsibility to care for a patient, yet have very little information, cannot verify their story, and have no easy way of monitoring them closely as is possible in a hospital setting.  

What if: She had been drinking for 3 days in a row up until today?  

What if: She has MS and a congenital liver disorder? 

What if: She was taking medication for depression and had scars on her wrist from previous self-harm? 

This information will change how you manage Poppy’s care and your concern about Poppy while incarcerated. When we assess intoxicated patients at the correctional facility’s intake area, we must try to get as much information as we can from them. If they are so intoxicated that their story is inconsistent and incomplete, this alone would raise a red flag that a higher level of care may be required. Assessing and getting the information from an intoxicated patient may take longer than you would like to spend, but alcohol is a toxin and can be fatal if not appropriately managed. 

Upon further examination, you are confident that none of these “what ifs” apply to Poppy.  

Are there any clinical indicators that she needs to be monitored closely?
Are there any other factors to consider for Poppy‘s safety? 

Poppy is, like Jimmy, physiologically compromised. She is detoxifying from alcohol too and may fall victim to mood swings. She has never been in jail before, which increases her risk of being victimized.  

How should you proceed with Poppy? 

Poppy’s plan of care will require a discussion with your Provider. For Poppy’s safety, it would be prudent to also discuss her case and needs with the security staff.  

Consider the staffing ability to monitor Poppy at your facility, this will guide you and the Provider to determine the best plan of care for Poppy. She will likely be safely managed onsite without further intervention, assuming that she has no other compromising medical or mental health issue. 

Your facility’s policies and procedures concerning patients who have consumed alcohol in excess must always be followed. This not only improves the outcomes for your patients, it protects your nursing license too. 

Conclusion 

As correctional nurses, a high percentage of the patient population has substance abuse and/or alcohol problems. It is important to consider the full picture: signs, symptoms, presentation, behaviors, patient story, and history. By avoiding assumptions and completing a thorough assessment, you can ensure that your patient is receiving the best care. 

Key aspects to your role: 

Assessment of the patient involves getting a good history, vital signs, CIWA-Ar score, observing, and documenting behaviors associated with physiological compromise due to intoxication. 

Determining what level of care our patient needs and using the multidisciplinary medical and mental health teams‘ input to help support your decision. You have resources, use them! 

Communicating with security staff and implementing observation plans or protective elements to ensure the patient is kept safe in this environment. 

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