I am an LPN and worked in a level 2 correctional facility for 11
months. The Prison's doctor was a wonderfully smart man and lived by a few simple rules, Never trust the offender regarding pain level. There are too many substance abusers who cry out in pain for attention and medication. You can only trust your objective assessment data.
Chest pain was a daily complaint and between 1600 offenders,
it was always something. Thankfully, all that drama and my insistence
to pursue more nursing knowledge, nursing interventions, and perform
proper assessment skills it landed me a highly coveted LPN position at
a local Emergency Room where I see and even act as a primary nurse for
varying levels of acuity. I wish to share with you my success in a
correctional setting and tell you what I learned.
1. Perform Immediate Visual assessment
---- Look for pallor (think deathly pale) clutching at chest, gasping
for air, and extremely diaphoretic.
---- How did the offender get to the Health Services Unit?
2. Take control of the situation, this is an offender who may need
health care but simultaneously poses a safety risk to you.\
--- Tell the the Custody officer to calm down (if in a panic), to
release the offender, and not to leave you alone. If necassary ask
unneeded personal or extra officers to leave to provide you room to
---Tell the offender to stand up.
---Tell the offender to get on the gurney.
---Tell the offender to take off his shirt in preparation for EKG.
--- Above all, you must be persistent. Encourage the offender's goal
of obtaining treatment only should he comply with your stipulations.
You are in charge.
Don't help or touch the offender until you have seen and noted what
the offender is capable of. Measure his physical limitations. They may
groan and complain the entire time about how it hurts to get their arm
out from under their shirt but too bad too sad. If they can do it then
thats a check mark in the "they'll survive category". If the offender
refuses or honestly cannot, in your opinion, perform any of the above
tasks then help him and continue to the next steps.
3. Place on 2L Nasal Cannula ( if readily available- my correctional
clinic rarely had easy access to supplies due to everything being
4. Obtain Vitals.
5. Obtain an EKG
--- Familiarize yourself with a ST - elevation (STEMI) as would be
seen on a 12-lead (often the machine will tell you too)
--- Is the rhythm a regular? (If they have a pacemaker it will usually
look a mess, but you should see very small notches at regular
intervals that indicate the pacemaker is firing.)
--- Is the EKG different than past EKGs? (This usually was info that
required a bit of chart searching in the EMR, and even at times,
required me to pull the hard chart.)
6. Perform Hx with the following or similar questions:
--- Do you have any other associated symptoms? (do not offer
suggestions, but look for nausea, pain in L arm, Shortness of Breath,
--- Where is the pain?
--- When did the pain begin?
--- What does the pain feel like?
--- What were you doing when the pain started?
--- Have you ever had a heart attack previously?
--- Are you on any Medications?
--- Do you have any allergies?
--- Have you ever taken Sublingual Nitro?
7. Perform head to toe assessment.
--- a/ox3 ?
--- PERRL ?
--- Skin warm, dry, intact?
--- Respirations even and unlabored?
--- Breath sounds clear to auscultation anterior / posterior
--- S1&S2 auscultated?
--- apical pulse correlates to radial pulse?
--- bilateral extremities (lower and upper) overcome resistance?
--- grips strong?
--- capillary refill brisk?
8. Give ASA 325 mg or 2-4 BABY ASA of 81 mg / tab - make sure he chews
--- hold if allergy is present
9. Give sublingual nitro if offender has on hand and has not already taken.
--- Sublingual nitro is contraindicated for offenders who...
------ do not have their own SL nitro on hand and do not have IV access
------ have an SBP < 100, or DBP < 50 for fear of bottoming their
blood pressure out.
--- repeat up to 3 total doses 5 minutes apart and assess offender's
supposed comfort level.
Now allow me to describe a scenario for you. The exact one that
happened to me a few months ago.
The officers call HSU (Health services unit) while I'm working the clinic
alone. There are other nurses in the infirmary and one nurse in the
med room. It is a scorching, hot, weekend. The doctor is not on site nor is
management. An offender is complaining of chest pain and an CO (Correctional Officer) radios in that he'll be bringing an offender up to the clinic.
Its 1625. The peak of my insulin line. I already have 20+ offenders standing in a single file line outside of my open door waiting for their insulin. I have 30+ more offenders I am expecting to come before 1700. This is just not the time to deal with this CP (chest pain) crap. I yell back to my CO in the clinic, "How's he getting up here?" as I continue shooting my offenders with their insulin.
Officer Wise shouts back, "They're bringing him up in a wheel chair." I roll my eyes and stab another offender with his Humulin R as she continues, "I'll meet them at the entrance". Little does the officer realize she's now leaving me alone with these 20 offenders. My concerns have been voiced repeatedly for this safety issue but have always landed on deaf ears. The considerations for the nurse's safety by the CO's is atrocious.
"Hey." says an offender in front me, "While I'm here can you look up what my last A1C was?" he pleads as he towers over me as I sit at my station.
"No. I've got to get as many people done before this chest pain arrives and we're not supposed to hold up insulin line for requests." I plainly state.
"Awe, it'll not even a minute." the offender reckons.
"I'm sorry. I have to get everyone else done. You'll have to put in a health care request where we'll write you back with the information or either you'll need to wait for your next chronic care appointment."
"I don't see what the big deal is. The computer is right in front of you."
"I said no. If you do not leave so I can get the next person I will call the CO". I state in my most authoritative voice.
"Man, you used to be cool." the offender storms off muttering audible, derogatory curses under his breath.
The next offender steps in and pricks himself with a lancet. He throws it away in front of me to a sharps container. We wait a moment for his accucheck to register when I hear Officer Wise yelling, "Get out! Get out of the way!" Her high pitched voice is chilling and filled with panic. "He's having a heart attack!"
Not one, not two, not even three officers.... but FOUR officers were around this heart attack guy all trying to talk at once and explain what was going on to me, where they found him, his Hx, etc.
"Hold on! Hold on!" Their panic is very contagious. I'm feeling overwhelmed already and haven't even made contact with the patient yet. Miss Wise can you move the offenders out of the hall?" She looks at me and eagerly nods.
"OOHH! My chest. I can't breathe. I can't breathe. OH MY GOD. OH GOD. Its hurting!" The offender in the wheelchair moans. I look at the offender. He's white, in his 50's, and slim. No visible injury or trauma noted.
********* NURSING CHECK 1:
OFFENDER CAN BREATHE
as evidenced by his ability to coherently express his pain
OFFENDER IS PROFUSELY SWEATING,
is that from the awful heat outside or is he truly diaphoretic?
OFFENDER IS BADLY SUNBURNT
pallor cannot be noted at this time.
OFFENDER ARRIVED BY W/C -
gait not visualized at this time.
I take a deep breath and I hate this next part. I begin to take control of the situation by issuing orders to everyone.
"Who has this guy's ID?" I ask the three remaining officers. One of them hands it to me with the offender's DOC #. With the officer's own out of breath pants informed me, "He was in the chow line when he collapsed and began screaming for help".
"Sir," I address the offender, "I need you on this bed. We need vitals and an EKG." I state while simultaneously picking up my insulin sharps and throwing them into a random drawer. Officer Wise only cleared the offenders out of the doorway but did not take them out of the hall. My sharps are still at risk and need to be far out of the offender's reach.
The offender momentarily just sits there, hyperventilating, moaning, and grabbing his L shoulder. The officers don't bother to wait for him to move but instead grab under his arms and begin to lift him from the wheel chair.
"Wait! Wait!" I rush forward flaring my hands up to the officers. "No. I need him to do it. This is a nursing assessment
." Test? Assessment? Its all the same right? Assessment just sounds better. "I have this. Just watch him..." I purposefully fail to verbalize "In case he falls" for fear of putting ideas into the offender's head. Hopefully the overeager officers will take the hint, but I doubt it.
I look back to the offender and provide him with instruction. "Now, I need you to move to the gurney. The longer we put this off, the longer we delay treatment" I decide to tack on an enthusiastic, "and you look like you might need it, so let's get started."
With much complaining, but absolutely no difficulty, the offender leaves his wheel chair and hops onto the gurney.
"Okay, officers. Thank you so much for your help. Can you have Miss Wise come back in here and help me. You guys can go now, I'm good." The Officers grudgingly comply and are probably thinking about why I'm not calling 911 this very moment. I turn back to the offender and reach for my vital sign equipment. "This will probably be uncomfortable for you but I need you take off your shirt" The offender complies, slowly. His hyperventilation increases and the groans are still persistent.
***** NURSING CHECK 2:
OFFENDER IS AMBULATORY
OFFENDER'S GAIT IS STEADY
OFFENDER APPROPRIATELY AND READILY OBEYS COMMANDS
Now that this XXL T-shirt and jumpsuit are off of him, I notice he has a small baggy with a familiar dark glass bottle of SL nitro on him, attached by a safety pin to his pant's waistline. I inwardly groan and my level of anxiety jumps a notch. I'm starting to lean to the side that this may be real. I think it might be time for oxygen, at the very least to help his hyperventilating. I also think how odd it is that the offender is allowed a safety pin- I'd have thought such an item would be contraband. Pushing that thought aside, I reach to the cabinet, praying we have even one nasal cannula available. I open it and not to my surprise it was completely empty. I longed to be at my second job this instant in the hospital where supplies were abundant and I always had something I could use.
Turning my attention to the Offender and getting a set of Vitals on him, I request Officer Wise to retrieve the Emergency Cart from an adjacent room. The gaggle of offenders in the hall are watching with enthusiasm. Others are yelling to get my attention telling me they need their insulin or they're blood sugars would drop, which of course made no sense. An odd few even left, cursed my name, and went to eat without taking insulin.
BP: 132 / 84
HR: 124 BPM
Resp: 32 / min
Officer Wise returned with the Emergency Cart. Thankfully, it was stocked with one NC. I put the offender on 2L O2, informed he must take deeper and slower breaths by inhaling through his nose and exhaling through his mouth, and immediately began to proceed with obtaining an EKG. Oxygenation levels out at 94% on 2L NC. As I hook the offender up to the machine I try to get a Hx and quick vibe for what he's going through at this time.
************ Nursing Check 3 & 4
OFFENDER IS ON 2L OXYGEN
putting someone on Oxygen, even if they don't need it often helps the patient / offender feel more at ease, trusting, and more secure with the nurse. This is something we do in the ER to allay fears and make people "think" we're actually doing something for them
BLOOD PRESSURE IS SHOWING MILD HTN,
a BP does not provide much information when experiencing an MI, but it is good to know none-the-less.
HR IS SLIGHTLY TACHYCARDIC,
this would indicate a compensatory mechanism for lack of O2 being perfused and/or possible stress.
OXYGEN IS VERY LOW,
is this due to the heart perfusing poorly or is the offender hyperventilating so much he's just getting very little oxygen period?
RESPIRATIONS INDICATE HYPERVENTILATION,
is this due to the lungs attempting to compensate for the heart perfusing poorly or is the offender just anxious and doing this to himself?
I ask him, as I place the electrodes on his bare chest, "What does the pain feel like?"
"Its like someone is sitting on my chest. Its a horrible pressure and I can't get my breath, " he gasps. "It just keeps shooting down my arm. I don't think I can move it much."
I respond back, "Well, have you tried taking your Nitro. You're supposed to take a tab when you begin feeling this way."
"I've never taken it before. They just gave it to me over at RDC" states the offender. RDC is our sister prison that receives all new inmates and sends them to an appropriate facility for their sentencing.
"When did the pain begin?" I'm having difficulty getting the electrodes to stick to his sweaty chest. The heat outside has been absolutely horrid lately and even HSU has been without air conditioning for the better part of the summer.
"I was just standing in line for Chow when it just overtook me."
"Did you have anything to eat prior to standing in line?"
"Have you ever had a heart attack before?"
"Yeah. My first one was in September of 2009. I've had about 12 heart attacks since then."
"How long have you been in prison?" My interest is peaked
"Since Februrary of 2010."
"Are you taking any medication?"
"I'm on Coreg for my blood pressure." he says. I notice his respirations are slowing and becoming more regular. "I missed my morning dose because I slept in today".
The EKG is ready. I hit the interpret / print button.
"Do you have any allergies?" I ask.
He responds, "I'm allergic to aspirin."
The rhythm appears at even intervals. All components of the the rhythm, PQRST, are present. EKG reads, "NORMAL SINUS RHYTHM. ABNORMAL EKG." Heart rate, per EKG is now at 101 BPM.
"Are you ready to give me my insulin?" I hear a shout from the hallway, reminding me my insulin line is still waiting.
"Give me a few more minutes. I need to get this guy an IV. " Hoping those words would strike a profound sense of gravity to the waiting offenders outside. It didn't.
********** NURSING CHECK 5 & 6
OFFENDER'S PAIN IS DESCRIBED AS SOMEONE SITTING ON CHEST
as is typical with angina
OFFENDER'S ASSOCIATED S/S INCLUDE SOB AND RADIATING PAIN TO LEFT ARM
as is typical with classic male MI's
OFFENDER IS NOT DIAPHORETIC AND COLOR IS INTACT,
after seeing offender shirtless I conclude he is wet due to the raging summer heat and pigment is of normal color.
OFFENDER HAS AN EMPTY STOMACH
so this is not merely an episode of GERD
OFFENDER STATES HE HAS HAD 12 PAST MI's,
I find this highly unlikely that he's had 12 MI's and still standing here. Even more so, I wish to point out he is only on one medication, Coreg, a beta blocker for HTN. Most patients, after an MI, are put on an ACE Inhibitor and should take it every day for the rest of their life and the mortician should probably put one in their mouth after death just to be safe.
OFFENDER'S EKG READS "NORMAL SINUS RHYTHM, ABNORMAL EKG".
I really don't see what is abnormal about it, and I don't put too much investment in the computerized interpretation being that I'm 26 years old at this point and myself have an abnormal EKG with normal sinus rhythm.
OFFENDER'S HEART RATE IS SLOWING DOWN AND RESPIRATIONS ARE DECREASING TO A MORE APPROPRIATE RATE WHILE OXYGENATION HAS INCREASED TO 94%.
this is a good sign with the offender's vitals stabilizing.
OFFENDER HAS NEVER TAKEN SL NITRO BEFORE AND UNAWARE OF ITS USE
sublingual nitro can be very potent and the general population have varying sensitivities to it. Some people are so sensitive just coming in contact with it can cause a sudden and dangerous decrease in blood pressure. It is a nursing consideration and intervention to establish IV access before allowing someone to take Nitro without prior experience. Should things go badly and EMS be called, it will save valuable minutes having already established an IV.
OFFENDER IS ALLERGIC TO ASA
obviously we are not going to give it. Although, it would have been appropriate should it not have been contraindicated.
I begin a necessary head to toe assessment to establish a baseline. As I proceed the offender is talking and talking. He is asking me questions about my choice in jobs at the prison. How much experience I have. What he used to do on the streets. What his past cardiac history has been like and what Correctional Doctors and Nurse Practitioners he has seen while in prison and so on. He's talking so much I'm beginning to think he's going to be just fine. I ask him to grab my two fingers and squeeze. He lifts his arms and squeezes well. I put my hands over both of his arms and tell him to raise his arms. His L arm is not overcoming resistance. I lighten my touch to just only the mildest of contact and tell him to lift his L arm again. He is still unable to perform saying it hurts too much. He begins moaning in pain. He says its starting to hit him so hard again. An important observation has now been made. Refer to Nursing check #7 below.
"Calm down. Remember, just breathe through your nose and exhale through your mouth. That oxygen is going to help you." I calmly say to him, nodding my head.
"So are you just going to deny us our insulin. This is some ********!" I hear a familiar voice yell. A regular insulin dependent offender has stepped into the doorway. There's another, older offender behind the accuser who speaks up also. "C'mon I need to go eat. I got commissary today and I already know my blood sugar is sky high. I didn't know I was given a death sentence."
I ignore them. My temper is getting very short. I speak to Officer Wise. "Will you please escort everyone to the cage so I can open up a couple of locked drawers and start this IV without people yelling at me."
"Alright you guys," Officer Wise begins as she swings her 250 lbs around in commanding five foot two inch height. "You need to give us some room. Get back there behind the cage and wait while we get this finished."
"But Miss Wise, we need our insulin. This is some serious ****. If we leave and eat, you know the walk officers will tell us to turn around." a new diabetic to our camp says.
I can't help but chime in, "That's never stopped anyone before. You guys come up here whenever you want like those walk officers dont even exist. I'm almost finished. After I'm finished with the IV I'll start the insulin line again. Its only been 15 minutes."
Officer Wise successfully herds up the offenders into caged area, allowing me to go from room to room in search of an IV start kit, since the Emergency Cart was fresh out.
********** Nursing Check #7:
shows no difficulty answering or asking his own questions
--- Skin warm, moist, and intact. Color is normal.
nursing notes / later documentation explain cause of adjective "moist"
--- Respirations even and unlabored anterior/posterior
--- Breath sounds clear to auscultation anterior / posterior
--- Abdomen is soft, nontender, nondistended, and bowel sounds are normoactive.
--- S1&S2 auscultated
--- apical pulse correlates to radial pulse
Rhythm is regular.
--- The offender was able to raise his hands and arms without difficulty to reach up and grab my fingers to squeeze, but can no longer lift his L arm when specifically assigned that task. This tells me the offender is lying about something
--- grips strong are strong +2
-- Capillary refill is < 3 seconds.
If you are having difficulty judging perfusion on an African American, pull down their lower eyelid. If they're suffering hypoxia the inside of the eye lid will be white instead of red or bright pink.
I establish a 20 gauge in the offender's LAC. First attempt. Offender tolerated. I'm beginning to lean toward the offender suffering from anxiety rather than actual chest pain. My notes describe the offender as tolerating the IV attempt, not tolerating well. He was whooping and hollering about how much he hated IVs and how much they hurt while I was I was sticking him, more than he was about his latest recourse of chest pain.
I think to myself, this guy is faking. He's gotta be having anxiety or faking. He's talking too much and is terrified of one measly needle.
Now that I've established IV access I administer one tablet of SL Nitro to the offender. "We're going to recheck your vitals in five minutes and I'm going to resume the insulin line. I'll be right here. Just tell me if you start feeling any worse than you currently do." I raise the gurney's side rail for safety.
I restart the insulin line for five minutes. The offender suffering the chest pains is making conversation with diabetics as they enter the room. Its keeping me calm knowing that he's not bottoming out, but also irritating me because he was acting like he was dying 20 minutes ago.
I repeat the VS and NITRO two more times with minimal drop in BP and no reduced chest pain per offender, but he has since significantly calmed down. I also recheck his O2 levels without oxygen. It immediately drops to 90% or 91%. I put the offender back on 2L.
I finish insulin line before I start looking at my scattered sheets of paper with vitals on them and times. While the offender is stable, its to look through his EMR (Electronic Medical Record). I find several EKGs over the last few years that all say "Normal Sinus Rhythm. Normal EKG" in the EMR. I think that is unusual that the offender suddenly has an abnormal EKG. I look to the offender's paper chart in the Medical Records room and find the original EKGs and a few that were not entered in the EMR. Same results as the EMR. The EMR also states no further cardiac Hx beyond HTN.
I silently curse at myself. I should probably call the doctor to report the abnormal EKG and chest pain.
I page the doctor to call me back. I receive a call back within 15 minutes. I explain the situation to the Doctor; hi-lighting these things.
Situation: I have an offender complaining of chest pain starting at 1620. He has allergies to aspirin. He has his own Nitro. He has taken three supervised doses without relief.
Background: Only medical Hx includes HTN. He has no meds other than Coreg which he states he missed his AM dose today. Has several EKGs in the EMR, all of which show Normal Sinus Rhythm, Normal EKG.
Assessment: Today's EKG, in tandem with chest pain show Normal Sinus Rhythm. Abnormal EKG." Oxygen levels started out upon arrival by wheel chair at 88%. Increased to 94% with 2L. When O2 is removed they drop to 91%. Pain radiates to L arm. Describes chest pain as if someone were sitting on his chest. No physical impairment is noted at this time.
Recommendation: I'd like to send him out for further evaluation.
The doctor agreed with me and Officer called 911. I gathered as much of the offender's paperwork as I tried the best i could to gather pertinent information.
Two days later I see the offender return to the prison. He had been diagnosed with severe anxiety. He was prescribed Xanax which our doctor took away due to its ability to be sold and abused within the prison. I later went to the doctor to ask if I did the right thing. My gut had been telling me this guy was faking and this was not a heart attack. The doctor said that because of the odd oxygen level and the new abnormal EKG my choices were sound.
In the end, you must go by vital signs and lab results. Those are the things that will hold up in court. An offender has already proven themselves to be untrustworthy just by being in prison. As the doctor believes, trust only your objective data.