How to you use the subjective questions in CIWA?

[NewGradNurse3, BSN, RN]

I'm a new grad and am wondering how you all assess the subjective symptoms in CIWA - do you take the patient's answers at face value? I work on a med-surg floor and during orientation, one of my preceptors made me change my CIWA scoring of a patient because he scored high enough due to his subjective answers to receive ativan, but he appeared fairly calm so she felt he didn't need it.

I guess I just find it confusing that literally half of the CIWA questions are completely subjective. I read through past threads on CIWA (this one was especially helpful) and from that thread it sounds like oversedation of withdrawing patients is rare and part of the goal is to sedate the patient. But wouldn't most alcoholics kind of know how to answer the questions in order to get benzos, even if they don't need them? So won't most people just answer the subjective questions in ways that are the most likely to have them score high on CIWA, rather than answering them honestly?

I'm definitely not advocating a "tough love" approach to addiction/withdrawal at all, I believe people should get what they need to remain safe and get through the detox process. But I don't really understand how something as subjective as CIWA can give you an accurate assessment of what's going on with the patient when I'm assuming most people will just answer the questions in order to get as much ativan as they can if they're currently unable to get their drug of choice.

Also, for the serial addition question, what's an example of a math problem you would give your patient? Just wondering how simple they should be - like is it adding one digit numbers, or two digit numbers?

[TheMoonisMyLantern, ADN, LPN, RN]

So, the answer to this is unfortunately not cut and dry. The reason is that treating substance abuse disorders continues to become more complicated than what we thought it was even just 20 years ago. Standards of care are changing to where substance use and abuse is not a moral or legal issue but a healthcare issue. Add to that that chemical dependency and addiction has both a physical component and psychological component and you're looking at a medical condition that from the outside looks rather simple but in truth is very complex.

In my practice with etoh detoxers, I and most of the physicians I've worked with, had the opinion that sedation was safer for the patient physically and compassionate for the patient mentally. Without alcohol to numb the emotions and the memories and the trauma they can't cope with, the amount of psychic pain they often experience is astronomical. Anxiety doesn't begin to cover it. So providing Ativan or Librium or Valium does blunt that emotional water fall. Detox is NOT the time to teach someone how to live without alcohol, that's what rehab is for. Detox is to keep them physically and mentally stable enough to progress to some form of rehab.

Do people know how to answer the questions to get ativan? Of course, especially the ones that you see every week. For patients that are continually seeking higher doses of Ativan or trying to manipulate their scores for additional dosing, it is recommendable to talk to their physician and see if they can order their benzo on a scheduled basis, with PRN coverage with vital sign parameters. This provides boundaries to keep the patient comfortable and safe but to also help the patient focus away from just medications to cope. I've had a lot of success with this method.

Regardless of whether you think a patient is faking, I tend to heir on the side of caution and provide the medication. I would rather be manipulated into giving a drug, than to refuse and have the patient deteriorate into DT's have a seizure, violent behavior, or choose to leave AMA and abandon their path to recovery. Unfortunately I've seen all those scenarios play out because patients were undermedicated for the symptoms they were experiencing. A lot of the sections of the CIWA are subjective but quite a bit of it is based off what you can observe with your patient, a/v hallucinations for instance, isn't necessarily subjective as some presentations of a/v hallucinations the patient will be responding to internal stimuli which allows for fairly easy recognition of hallucinatory sx.

My advice to you, is to continue with what you're doing, and that is research! It will help guide your practice, make sure you are following company policy, and remember you're looking after their physical and mental well being during detox because addiction is physical and psychological. 

[NewGradNurse3, BSN, RN]

Thank you so much, this is super helpful!

[JBMmom, MSN, NP]

I think that just like pain assessments, when a patient answers questions that indicate that medication is to be given, I will give the medication. Whether a person rates their pain a "10" while eating a sandwich and talking on the phone, or they know to answer CIWA by saying that they feel like small bugs are crawling all over their skin while they're sitting there appearing completely unaffected, I will administer the medicine as ordered in the MAR based on the assessment.

While there is definitely a component of nursing judgment with administering PRNs, if a patient's score indicates a PRN should be administered, my license is covered if I administer as ordered unless it will put the patient in danger. As moon pointed out, trying to influence the course of detox with education is like spitting into the wind. Patients that are going to seek meds are going to seek meds and while they're hospitalized there is a need for acute treatment no matter what brought them there. And while your preceptor may not have felt the patient needed a PRN, it doesn't take long to get behind on a patient going through detox and then playing catch up almost never works, they will need a transfer to a higher level of care. 

The only time I will withhold a medication is when the patients are unable to answer questions and I have to use the mMINDS scoring. If a patient has visible sweat or tremors and an elevated diastolic blood pressure I'm supposed to administer a PRN, but if I'm close to the patient becoming unable to protect their airway because of oversedation I will sometimes hold a dose at that time. Fortunately, the scoring is available every 30 minutes, so if it's needed 30 minutes later when the patient is more awake, I will administer at that time. For some patients going through detox, intubation for airway protection is a nearly inevitable outcome, but I do try if at all possible to avoid that scenario because it will is so difficult to wean the detoxers from the vent once they're intubated.