Patients lying on ciwa?

[s0ad]

Just wondering how everyone handles the ciwa scale. On my floor it's typically ordered q2 if the Pt has a history of drinking. However with the last couple of patients I believe the patients lied (or at least exaggerated) symptoms to get meds. I think this then led to them becoming actually worse off... Hallucinating, violent etc. Soon after when Ativan was eventually cut back or stopped they became better off. I typically go through the questions, but just as with pain, if they tell me they have severe nausea headaches pins and needles etc I enter what they state... Which leads to a dose of medication.

I've also seen nurses who, if the Pt "looks OK" to them enter 0. I don't want to falsify documentation but it almost seems like sometimes they would be better off without the Ativan. So what do you do if you think the patient is lying?

[evastone, BSN, RN]

It has been my experience that most CIWA patients want to leave the hospital as soon as possible. They don't want some IV medication they want real booze.

That being said, there are parts of the CIWA assessments that are hard to fake. Is the patient able to hold out his arm without shaking? How much sweat is on his forehead? Is he vomiting? If the patient has any of these symptoms along with any of the fakeable ones then they are probably experiencing withdrawal. Delerium is another symptom of withdrawal-sometimes the ativan the patient gets is not enough. Or he could be experiencing hepatic encephalopathy if all that drinking is now causing his liver to fail.

Never falsify data. It will one day come back to bite you if you ever get sued. I always ask even if I think he looks ok. Better to waste a few minutes asking "redundant " questions than have a pt with DTs because he "looked " ok and I was to lazy to take the time to inquire futher.

[NewMurse1014]

Agree with PP. We have no way to tell from their subjective data, and it's not our job to judge whether the pt is lying or not. We can only document as objectively as possible. Same thing with pt with drug-seeking behaviors asking for pain meds. I would document "pt was sleeping and c/o 10/10 pain upon being waken up" and work with the PRN meds I got. Of course always use your nursing judgment before giving any meds, including ativan and pain meds. You wouldn't give those meds when the pt is visibly lethargic and has a RR of 8.

[martymoose, BSN, RN]

we seem to be getting our share of ciwa pts lately, and have yet to run into them becoming violent on the ativan. usually, they need it badly, and downplay the sx( like pp said, so they can leave and get the real stuff).If anything, we have had some that almost get out of hand ie- they should have been in icu prior, etc. have had some start w/d with 2 hours . had one guy 2 cases beer a day. another 5 pints a day . these dont belong on regular floors. the pts get scared( rightfully so) when this stuff is out of their control.Im happy to give the meds based on the score- I just get worried that some are so far in that they need to be romaziconed, but then sent to icu for a drip anyway.