9.5 Substance Abuse Nursing Process

Question 1

Screening Tools

Answer 1

• Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA)
• Michigan Alcoholism Screening Test (MAST)
• CAGE questionnaire

Question 2

CAGE

Answer 2

C - Have you ever felt like you should CUT down your drinking

A - Have people ANNOYED you by criticizing your drinking

G - Have you ever felt GUILTY about your drinking

E - Have you ever had a drink early in the morning to steady your nerves (EYE-OPENER)

Question 3

Clinical Opiate Withdrawal Scale (COWS)

Answer 3

• Measures severity of opiate withdrawal

Checks
- Pulse rate
- Restlessness
- Yawning
- Tremors
- Anxiety
- Pupil Size
- Sweating

Question 4

Difference in Scales

Answer 4

CAGE - Determines suspected alcohol disorders

CIWA - Management of alcohol withdrawal

COWS - Determines opiate withdrawal

Question 5

Codependency

Answer 5

• Achieves a sense of control through fulfilling the needs of others.
• Personal identity is relinquished
• People who please for validation
• Being somewhat comfortable with being abused.
• Dysfunctional relationship with ones-self