The facility where I work recently facilitated the CIWA and COWS scale and we're just not getting it.
Firstly, it seems subjective. Patients can easily fake nausea, light sensitivity, etc....They are smart and catch onto things quickly that can score them higher doses of Subutex, Valium, etc...
Secondly, how do two nurses re-score 20 patients every two hours? They are not always available (in therapy and such) but mainly because there is just not enough time with all the other duties we have to do.
Dec 1, '11
We are a free standing detox and crisis stabilization unit we have an average census of 12 acute patients with one RN 24/7 an APN 8 hours daily and any where from 4 to 1 MHT's ( some are CNA's some are MA's, all are certified by the State as Detoxification Technicians) we do vital signs on all new patients every 4 hours for the first 24 hours then q 4 hours after that while awake. At each time we do the CIWA and COWS This is what we have learned to do: 1) the RN has to have a lot of discretion as to whether to medicate a patient or not. Ideally before each dose of Valium we would do a CIWA scale but that is not always practical. If the patient is visually tremulous and has a heart rate of 90 or above we generally medicate them.2) We educate each staff member on how to do the scales. The clients do "catch on" very quickly ; we ask them "Would you describe your bone and joint pain as...?" What they answer and how they look to you are often not at all the same. then we ask them the same question again but explaining that they do not necessarily look that uncomfortable "would you give me more information about that?" It takes time to do a good CIWA and COWS. For the non-complicated patient at least 2 minutes. We recommend 5 minutes to do a first time CIWA . 3)The RN should be able to do a scale at any time especially for the first dose of Valium or Suboxone - we must be very careful to be as accurate as possible before giving the first Suboxone dose. I always explain carefully why this is important and that the patient should not try to embellish or exaggerate their symptoms because of the dangers of giving the Suboxone too soon. I always ask them to verbalize their understanding and then document their score and their understanding.4) This is all based on good nursing assessment
. How does that client look to you? Do they look like they are in distress? do they look anxious ? I do not always medicate a patient solely on the CIWA score. Remember these are tools only. Always remember to document what you did and why you did it.
Dec 6, '11
I agree with Tom7044.
The RN must assess the objective data not just the subjective data. Yesterday, I had a pt say to me "I was gonna ask for my PRN suboxone but that motrin you gave me really helped!" In that case, the motrin was given because the clinical symptoms just weren't there. Aside from aches and pains, I couldn't score him. Vitals were WNL but slightly low and that had me concerned. The motrin was given it worked. However, you'll have those pts who fake it and "nothing" but that withdrawl med will help them. Its funny to me because it seems like those guys all say the same thing "headache, hot n' cold, anxious, nauseous..." they know what criteria needs met to be scored because they know whatever they said that one time to get the med worked so they'll use it over and over.
I'm not cynical towards pts going through withdrawl although it probably sounds like it! These are just examples of some bad apples.
Feb 17, '12
I also agree with Tom7044, but I do my CIWA every two hours for the 6 hours and then increase the time depending on what I'm seeing. The assessments are as much art as science. You will develop a sense for what is actual withdrawal over time. In the beginning just get lots of input from more experienced staff. That said I'm sure we all have a few tactics we use like doing watching patients as they interact with others, giving them an drink of water so we can watch their hands, gauging their response to alternate therapies, and assessing patients at odd times (when I first started I found a patient doing push-ups to ready himself for the assessment).
Tom RN, NRC
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