Alcohol Withdrawal Asssment Scoring Guidelines (CIWA - Ar)
Naua/Vomiting - Rate on scale 0 - 7 Tremors - have patient extend arms & spread fingers. Rate on
scale 0 - 7.
0 - None 0 - No tremor
1 - Mild naua with no vomiting 2
3 1 - Not visible, but can be felt fingertip to fingertip 2
3
4 - Intermittent naua 5
6 4 - Moderate, with patient’s arms extended 5
6
most wanted7 - Constant naua and frequent dry heaves and vomiting 7 - vere, even w/ arms not extended Anxiety - Rate on scale 0 - 7 Agitation - Rate on scale 0 - 7
0 - no anxiety, patient at ea 0 - normal activity
1 - mildly anxious 2
3 1 - somewhat normal activity 2
3
4 - moderately anxious or guarded, so anxiety is inferred 5
6 4 - moderately fidgety and restless 5
6
7 - equivalent to acute panic states en in vere delirium
or acute schizophrenic reactions.
7 - paces back and forth, or constantly thrashes about
Paroxysmal Sweats - Rate on Scale 0 - 7.
0 - no sweats Orientation and clouding of nsorium - Ask, “What day is this? Where are you? Who am I?” Rate scale 0 - 4
1- barely perceptible sweating, palms moist 0 - Oriented
2
3
clever的意思1 – cannot do rial additions or is uncertain about date 4 - beads of sweat obvious on forehead
5
2 - disoriented to date by no more than 2 calendar days
6 3 - disoriented to date by more than 2 calendar days
7 - drenching sweats 4 - Disoriented to place and / or person
Tactile disturbances - Ask, “Have you experienced any itching, pins & needles nsation, burning or numbness, or a feeling of bugs crawling on or under your skin?” Auditory Disturbances - Ask, “Are yo
u more aware of sounds around you? Are they harsh? Do they startle you? Do you hear anything that disturbs you or that you know isn’t there?”
0 - none 0 - not prent
1 - very mild itching, pins & needles, burning, or numbness 1 - Very mild harshness or ability to startle
2 - mild itching, pins & needles, burning, or numbness 2 - mild harshness or ability to startle
3 - moderate itching, pins & needles, burning, or numbness 3 - moderate harshness or ability to startle
4 - moderate hallucinations 4 - moderate hallucinations
5 - vere hallucinations 5 - vere hallucinations
6 - extremely vere hallucinations 6 - extremely vere hallucinations
7 - continuous hallucinations 7 - continuous hallucinations
Visual disturbances - Ask, “Does the light appear to be too bright? Is its color different than normal? Does it hurt your eyes? Are you eing anything that disturbs you or that you know isn’t there?” Headache - Ask, “Does your head feel different than usual? Does it feel like there is a band around your head?” Do not rate dizziness or lightheadedness.
0 - not prent 0 - not prent
1 - very mild nsitivity 1 - very mild
2 - mild nsitivity 2 - mild
3 - moderate nsitivity 3 - moderate
4 - moderate hallucinations 4 - moderately vere
5 - vere hallucinations 5 - vere
6 - extremely vere hallucinations 6 - very vere
7 - continuous hallucinations 7 - extremely vere
Procedure:
1. Asss and rate each of the 10 criteria of the CIWA scale. Each criterion is rated on a scale from 0 to 7, except for “Orientation and clouding of
nsorium” which is rated on scale 0 to 4. Add up the scores for all ten criteria. This is the total CIWA-Ar score for the patient at that time.
Prophylactic medication should be started for any patient with a total CIWA-Ar score of 8 or greater (ie. start on withdrawal medication). If started on scheduled medication, additional PRN medication should be given for a total CIWA-Ar score of 15 or greater.
2. Document vitals and CIWA-Ar asssment on the Withdrawal Asssment Sheet. Document administration of PRN medications on the asssment
sheet as well.
3. The CIWA-Ar scale is the most nsitive tool for asssment of the patient experiencing alcohol withdrawal. Nursing asssment is vitally important.
Early intervention for CIWA-Ar score of 8 or greater provides the best means to prevent the progression of withdrawal.
Asssment Protocol
a. Vitals, Asssment Now.
b. If initial score ≥ 8 repeat q1h x 8 hrs, then if stable q2h x 8 hrs, then if stable q4h.
c. If initial score < 8, asss q4h x 72 hrs. If score < 8 for 72 hrs, d/c asssment. If score ≥ 8 at any time, go to (b) above.
d. If indicated, (e indications below)
administer prn medications as ordered and record on MAR and below.
Date Time
Pul
RR O 2 sat BP
Asss and rate each of the following (CIWA-Ar Scale): Refer to rever for detailed instructions in u of the CIWA-Ar scale.
Naua/vomiting (0 - 7)
0 - none; 1 - mild naua ,no vomiting; 4 - intermittent naua; 7 - constant naua , frequent dry heaves & vomiting.
Tremors (0 - 7)
0 - no tremor; 1 - not visible but can be felt; 4 - moderate w/ arms extended; 7 - vere, even w/ arms not extended.
Anxiety (0 - 7)
0 - none, at ea; 1 - mildly anxious; 4 - moderately anxious or guarded; 7 - equivalent to acute panic state
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Agitation (0 - 7)
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0 - normal activity; 1 - somewhat normal activity; 4 - moderately fidgety/restless; 7 - paces or constantly thrashes about
Paroxysmal Sweats (0 - 7)
0 - no sweats; 1 - barely perceptible sweating, palms moist; 4 - beads of sweat obvious on forehead; 7 - drenching sweat
Orientation (0 - 4)
0 - oriented; 1 - uncertain about date; 2 - disoriented to date by no more than 2 days; 3 - disoriented to date by > 2 days; 4 - disoriented to place and / or person
Tactile Disturbances (0 - 7)
0 - none; 1 - very mild itch, P&N, ,numbness; 2-mild itch, P&N, burning, numbness; 3 - moderate itch, P&N, burning ,numbness; 4 - moderate hallucinations; 5 - vere hallucinations;jcb是什么意思
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6 – extremely vere hallucinations;
7 - continuous hallucinations
Auditory Disturbances (0 - 7)
0 - not prent; 1 - very mild harshness/ ability to startle; 2 - mild harshness, ability to startle; 3 - moderate harshness, ability to startle; 4 - moderate hallucinations; 5 vere hallucinations;
6 - extremely vere hallucinations;
7 - continuous.hallucinations
Visual Disturbances (0 - 7)
0 - not prent; 1 - very mild nsitivity; 2 - mild nsitivity; 3 - moderate nsitivity; 4 - moderate hallucinations; 5 - vere hallucinations; 6 - extremely vere hallucinations; 7 - continuous hallucinations
Headache (0 - 7)
0 - not prent; 1 - very mild; 2 - mild; 3 - moderate; 4 - moderately vere; 5 - vere; 6 - very vere; 7 - extremely vere
Total CIWA-Ar score:
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PRN Med: (circle one) Diazepam Lorazepam Do given (mg): Route: Time of PRN medication administration:
Asssment of respon (CIWA-Ar score 30-60 minutes after medication administered)
RN Initials
Scale for Scoring: Total Score = 0 – 9: abnt or minimal withdrawal 10 – 19: mild to moderate withdrawal more than 20: vere withdrawal
Indications for PRN medication:
a. Total CIWA-AR score 8 or higher if ordered PRN only (Symptom-triggered method).
b. Total CIWA-Ar score 15 or higher if on Scheduled medication. (Scheduled + prn method)
Consider transfer to ICU for any of the following: Total score above 35, q1h asss. x more than 8hrs required, more than 4 mg/hr lorazepam x 3hr or 20 mg/hr diazepam x 3hr required, or resp. distress.super sound
Patient Identification (Addressograph)
经典英文歌词
Signature/ Title
大学生必看电影
Initials
Signature / Title
Initials
