You are conducting nursing sick call in a local jail. Mr. Riley, your next patient, submitted a sick call slip indicating he has “right ankle pain.” You obtain the subjective information from Mr. Riley, including any report of trauma to the area and the initiation, duration, and quality of the pain, while beginning your examination of his ankle. Mr. Riley explains that he hears voices at night talking about the tracking device implanted in his ankle. When the device is turned on, he gets a sharp pain that lasts for about 20 minutes. He knows that his movements are being tracked by the government. Mr. Riley has been in the jail for five days. You review the Receiving Screening form and see that Mr. Riley stated at that time that he was not taking any medications and had no history of medical or mental health treatment. He was also deemed not suicidal upon intake. You note that his mother is listed as his emergency contact on the book-in sheet.
What Do You Do Next?
You still need to perform a thorough physical assessment and document Mr. Riley’s subjective and objective findings in the health record. Although it is very unlikely that he has a tracking device implanted in his ankle, Mr. Riley may actually be feeling pain and may have an injury. Thus, it is very important to always fully evaluate a patient’s concern. In addition, exposure to medications or drugs and medical conditions such as hepatic disease and electrolyte imbalance can cause psychotic symptoms. There is little known about Mr. Riley’s history. You question Mr. Riley further about his health history, and ask questions in multiple ways to assure that Mr. Riley understand what you are asking (“Do you take any medications every day?” “Has a provider ever told you that you should be taking medication?”) You ask Mr. Riley if there is someone outside of the jail who could help you get his health information, like a close friend or family member. He replies that his mother used to help him, but she doesn’t do that any more. He states he doesn’t know how to contact her.
Once you complete your evaluation of Mr. Riley and determine that Mr. Riley has no deficits with his ankle, you obtain permission from Mr. Riley to contact his mother, who is listed as his emergency contact. His mother shares that Mr. Riley had, indeed, been under psychiatric care in the past and had been taking Risperdal (risperidone). She also confirmed that Mr. Riley’s delusion of an ankle implanted device by the government was a common one that he has had for “many years.” She shared her concern for her son, stating that Mr. Riley left home several months ago and she was no longer able to monitor his medication adherence and encourage compliance.
You then contact the on-call provider, give a thorough report to include a description of the delusions, no physical abnormalities, vital signs that were within normal parameters, and a synopsis of the conversation with Mr. Riley’s mother. The on-call provider gives the order to start risperidone (Risperdal). Risperidone is an atypical antipsychotic agent (also called second generation) often prescribed for schizophrenia. Other drugs in this class include Clozapine (Clozaril), Olanzapine (Zyprexa), and Quetiapine (Seraquel). She also orders that Mr. Riley be seen by the provider the next day, and be enrolled in the Mental Health chronic care clinic. You requested past records from the providers Mr. Riley was seeing in the community (per his mother) through the procedures set-up at the jail. Finally, you notify custody of Mr. Riley’s underlying mental health condition so that they will notify healthcare staff immediately if his behavior changes.
Important to remember – General Tips for Working with Psychotic Patients
It can be challenging to handle a patient interaction with someone who is not in touch with reality. There are a few considerations that should be kept in mind when communicating with patients like Mr. Riley:
• Avoid touching the patient without warning. Although we avoid touching anyway in corrections, touch does happen during physical assessment and the measuring of vital signs.
• Maintain an attitude of acceptance to encourage the patient to fully share the delusion or hallucination.
• Do not reinforce the hallucination. For example, refer to an auditory hallucination as “the voices you are hearing” rather than “they.”
• If a patient is hearing the hallucination in your presence, respond truthfully in an affirming tone, like “Even though the voices are real to you, I do not hear them.”
• Do not argue or deny a false belief. Instead, present a “reasonable doubt” position such as “I understand that you believe this, but I am personally having a hard time accepting it.”
• Avoid laughing, whispering or talking quietly to other staff around the patient.
• Maintain an assertive, matter-of-fact, and genuine approach.
For more information about Psychosis and Mental Health conditions in general, check out our accredited class at The Correctional Nurse Educator entitled Mental Health Disorders for the Correctional Nurse.
Please share any experiences you have had in your practice with patients presenting with psychosis in our comments section below.
*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.