Withdrawal Protocol Question

  1. I have a question for experienced psych nurses.

    I've observed, both at work and in clinicals, that nurses seem to want to assure that a client is scored based on objective signs. The withdrawal protocols I've seen, both CIWA and another one for opiate/etoh withdrawal actually ask questions that have some subjective scoring included as well as objective sign scoring.

    Why do you think it has been my experience that nurses desire to rely more on objective signs, thus resulting in a lower score?

    From what I see, the only problem with a medium high score is that the client will receive Librium or Ativan-not a large dose, either.

    What exactly are the repercussions / nursing interventions of a pt scoring high enough on the withdrawal form to require meds to alleviate withdrawal symptoms?

    I'm trying to ask, in a non-judgemental way, why it's been my experience that if I ask the pt about their symptoms, do my assessment, and it results in a high score, that my charge or clinical preceptor will repeat the assessment and arrive at a lower score?

    This has happened to me twice now, where my assessment was repeated and the score became lower.

    I only worked as charge nurse in an acute psych unit for 1 shift, so I'm thinking there's more to this than meets my eyes....

    Any thoughts, please? ๐Ÿ˜€
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    About vintagemother, CNA, LVN, RN

    Joined: Aug '09; Posts: 2,744; Likes: 3,247


  3. by   marshmallowstar
    Sometimes if patients are well known, you may known they have a history of exaggerating or extending their w/d sx to receive PRNs. For opiates, I don't much mind, we really only do sx relief and clonidine so if they want tylenol or imodium and it's time, go for it. Even the vistaril we use for anxiety management is this situation is fairly benign and I haven't really had anyone seek this too inappropriately.
    Benzo/ETHO withdrawal is where it gets a little trickier since you're typically giving them a benzo to relieve sx and prevent significant withdrawal events. I use observation skills as I'm preparing to assess the patient, how are they presenting, relaxed? fidgeting? withdrawn or engaged with peers? If the patient's presentation changes once they know I'm observing or actively assessing then I may take things with a grain of salt. It's a balance of not wanting the pt to have dangerous withdrawal events and not wanting to continue their addiction. We had a patient that was on benzo withdrawal for 2 weeks because a newer nurse had been doing meds/withdraw assessments her first week and the patient had essentially been getting 8-12mg of Ativan daily because of her subjective scores for the first week with no tapering till one of the more senior nurses realized what was happening and had the doc switch her to a scheduled taper and assisted the newer nurse with assessments.
    I also make it a conversation with the patient if the score they're reporting seems out of proportion with the behaviors I'm observing.
    You're telling me that your nausea is at a 5/7 (on CIWA) but I saw you eat all of your dinner an hour ago and the rounds (we document q15 minute checks) say you haven't been to the bathroom since. Were you able to keep it down? If they say yes but that they feel sick to their stomach then I educate them that's probably a 2 or a 3, that someone with a 6 is actively vomiting or dry heaving. Once I challenge them/educate them on the scale I tend to get more accurate numbers. Also asking them to describe their experience instead of just a number can be helpful, "How does your skin feel?" "It feels like pins and needles, like when your foot is asleep" and "I feel like I have bugs crawling on me" gives you much more information than just a number.
    It's also about developing that rapport, acknowledging that tapering/withdrawing off of meds can be an anxiety producing process and encouraging them to be proactive in acknowledging and managing the anxiety instead of feeling overwhelmed and needing the med. Of course how much they're interested in changing their behaviors and addictions plays a huge part in this too.
  4. by   vintagemother
    MarshmallowStar, I appreciate your insight. I'm just trying to make sense of it all. I am fascinated with the field of psychiatric nursing, and enjoyed working in the field. I'm now in RN clinicals doing a psych rotation and I'm learning even more. Curiosity has me wondering about all sorts of interesting things. Thanks for taking the time to respond. ๐Ÿ˜Š
  5. by   mtjoanna
    As Marshmallowstar says, we get to know our patients and have a basic idea of who is ativan-seeking and who is not. Some patients can be extremely manipulative and convincing with their s/sx, so I learned to rely on the VS and other observable signs more than the subjective. Even with the physical signs, I learned to be "sneaky." When I was working in psych and doing MSSAs/CIWAs, I'd have some of my nursing aids assist with my assessment. I'd have the aid get the VS and ask whether the pt was shaking when holding out his/her hand for the BP cuff; some of our patients cycled through the facility enough to know who the nurses were and who the aids were, so they'd shake for the nurse but not the aid, because the aid wouldn't give them ativan. I've also handed a pt a (partially full) cup of ice water or fresh coffee and watched how they transferred the cup to the table--did they shake? Did they come near spilling the coffee/water? Then I asked him/her about hand tremors and would often (not always) get a hand that was shaking so hard the wrist was about to come disconnected from the body. If they were rock-steady with the hot/cold beverage and shaking like a leaf when asked, I'd score them lower.
  6. by   RN420
    If you want to live a less stressful life I suggest completing the protocol with both subjective and objective findings, Get their vitals. And Medicate accordingly .... We are not going to change a drug addict by holding a prn dose of Ativan. It's the truth. Now if they are sedated and look like they are gonna fall over then obviously u would hold the Ativan. Same goes for vitals, if they are low I will hold it. Use your common sense and nursing judgment. Also, some pts won't know they have a prn Ativan available (I have this one dumb doctor who puts everyone on ciwa ) I won't be the one to tel them
  7. by   catebsn25
    At my hospital the protocols taper down day by day... if a patient is able to take every prn dose of whichever protocol they're on then the chances are we will need to then detox them from the Librium/Serax even longer... Also if you gave them every prn when it wasn't indicated they would most likely be snowed and unable to actively participate in treatment at all
  8. by   banana, MD
    The CIWA scale was developed as a standardized assessment requiring good interrater reliability for its assessment, meaning that all clinicians using it are trained specially for it and perform the assessment in very specific ways with numbers that are relatively the same across examiners. This rarely happens in real life.

    With that said, have you ever noticed how easy it would be for a patient to score outrageously high on a CIWA scale if the assessment was obtained by just any average joe? Iin my experience psychiatric RNs are way more privy to this vs. many medical/surgical RNs who conduct it in a rather willy-nilly fashion. If someone has a "headache" and a tremor "only apparent to physical touch" they automatically get a whopping PRN of (insert drug of abuse of choice). I personally hate the CIWA scale for its absurdly terrible specificity, though I realize it is probably the best I have as I am not around to actually lay eyes on every withdrawing pt every second of the day.

    Placing every patient on a CIWA is just dumb and for obvious reasons relating to its terrible specificity already mentioned (i.e. even non-withdrawing pts may receive plenty of PRNs)
  9. by   SouthernPsy
    Reasons I've seen psych RNs score patients conservatively/low: fear of hypotension, bradycardia, respiratory failure. Laziness (higher score = more frequent assessment and medication). Some don't want the hassle of having to call the doctor for whatever reason. Addicts sometimes exaggerate their symptoms, and some nurses are too cynical and trust no one unless their vitals are jacked up.