Mr. Stone is a 32 year old male who arrived at the prison about 3 months ago from the county jail, where he had been incarcerated for the past 18 months. There, he was diagnosed with hypertension and anxiety, and has been adherent to his medication regimen of amlodipine and fluoxetine. He was enrolled in the facility chronic disease clinic when he arrived, and has been seen twice for his hypertension and monthly for his mental health, with no adjustments made to his treatment plan.
Today (July) Mr. Stone participated in outside recreation time. He initially was playing basketball, but had to stop playing because of leg cramps. He did remain outside for the full hour, and when the Correctional Officer (CO) asked for help to sweep the recreation area, Mr. Stone volunteered. Ultimately he was outside for almost 2 hours. The temperature was approximately 100 ℉ per the thermometer on the recreation yard wall.
At approximately 1600 hours, about 15 minutes after Mr. Stone came in from the yard, his cellmate noted that he was breathing heavily. When he attempted to drink the water his cellmate brought to him, Mr. Stone could not hold the cup steadily due to hand tremors and arm “twitches.” A few minutes later, the COs found Mr. Stone sitting in the shower, with the water on, still wearing his clothing. When they approached him, Mr. Stone was confused and used non-sensical language. The COs called a medical emergency for “illicit drug intoxication,” and you are the nurse responding to the unit.
When you arrive two minutes later with your emergency bag, you ask the COs what drugs Mr. Stone had taken. They replied that they did not know, but this “is how it always looks” when the inmates “take drugs.” You attempt to speak with Mr. Stone, but his words are jumbled.
WHAT DO YOU DO?
Get a history, obtain vital signs and conduct a physical assessment of Mr. Stone
The other inmates insist that Mr. Stone did not take any drugs. They describe Mr. Stone during recreation as being his usual self and share that he did have to stop playing basketball because he was having terrible leg cramps. The also tell you that there was no water outside during recreation time as there usually is because the guy who was supposed to bring the cooler outside forgot, and the COs rule is that once outside, you cannot go back in unless you stay in. You obtain Mr. Stone’s vital signs, which are: blood pressure 110/60; pulse 136 beats per minute; respirations 22 breaths per minute; oxygen saturation 95%; and oral temperature 102.3℉. Your physical assessment includes the following:
- Alert, not oriented, confused white male
- Skin cold and wet (?from sitting in shower wearing clothing with water on versus diaphoresis)
- Eyes PERRLA, unable to follow commands to check neuro status further
- Lungs clear bilaterally without adventitious sounds
- Heart S1S2, tachycardic without murmur, gallops or rubs heard
- Abdomen soft, non-tender to palpation with +bowel sounds all four quadrants
- Muscles in forearm and thighs twitching
- Gait unsteady
You tell the CO to call for EMS, as you realize that Mr. Stone’s condition requires the diagnostics and treatment available at the emergency department. The COs assisted/carried Mr. Stone to the wheelchair because his gait was unsteady, and he was brought to the medical unit. He was not combative, but continued to react with confusion.
IN THE MEDICAL UNIT
Another nurse continues to monitor Mr. Stone with vital signs and physical assessment every 5 minutes, while you contact the on-call provider, who concurs with sending Mr. Stone to the emergency department, and orders an intravenous Normal Saline bolus – 1 liter, elevate legs on stretcher and keep body supine, and ice packs to the axilla and the groin.
The EMS staff arrive within 15 minutes. At that time, the nurse monitoring Mr. Stone reports that his last set of vital signs (taken seconds before they entered the medical unit) included a blood pressure of 100/56, a pulse of 148 beats per minute, respirations of 22 breaths per minute, oxygen saturation level of 95%, and an oral temperature of 103.0℉. You give report, and Mr. Stone is transported to the emergency department, where he is diagnosed with heat exhaustion progressing to heat stroke. He is treated inpatient and returns to the prison three days later with no residual problems.
SHARING YOUR LEARNINGS FROM MR. STONE
At your staff meeting the following week, you present Mr. Stone’s case to your colleagues, including the fact that the outside temperature that day was 100℉ and Mr. Stone was taking Fluoxetine (an anti-anxiety medication) and amlodipine (calcium channel blocker), two medications that contribute to the exacerbation of heat-related illnesses. Nursing staff decide to make some posters and conduct patient education in the pods for heat-related illnesses, including the medications that might increase someone’s sensitivity to higher temperatures and the importance of hydration, rest periods and shade during times of high environmental temperatures.
For more information about Heat-Related Illness, go to CorrectionalNurse.Net where this month the Correctional Nurse Clinical Update is about Heat-Related Illness.
Please share any experiences you have had in your practice with patients presenting with heat-related illness in the comments section, below.
*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.