Ciwa Assessment Pdf Details

Ciwa Ar is an artist, curator, and arts educator originally from Milwaukee, Wisconsin. She relocated to Los Angeles in 2006 and has since exhibited her work nationally and internationally. In addition to her studio practice, Ciwa is the founder of the artist-run space CH Projects. As an arts educator she has worked with various organizations including The Museum of Contemporary Art, Los Angeles (MOCA), The Hammer Museum, LACE (Los Angeles Contemporary Exhibitions), and Educational Center for the Arts (ECA). She currently lectures in the Department of Design at California Institute of the Arts (CalArts) where she also earned her MFA in 2009.

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Form NameCiwa Ar
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Avg. time to fill out30 sec
Other namesciwa scale pdf, ciwa assessment tool, ciwa pdf, ciwa assessment pdf

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Alcohol Withdrawal Assessment Scoring Guidelines (CIWA - Ar)

Nausea/Vomiting - Rate on scale 0 - 7

0 - None

1 - Mild nausea with no vomiting

2

3

4 - Intermittent nausea

5

6

7 - Constant nausea and frequent dry heaves and vomiting

Anxiety - Rate on scale 0 - 7

0 - no anxiety, patient at ease

1 - mildly anxious

2

3

4 - moderately anxious or guarded, so anxiety is inferred 5 6

7 - equivalent to acute panic states seen in severe delirium or acute schizophrenic reactions.

Paroxysmal Sweats - Rate on Scale 0 - 7.

0 - no sweats

1- barely perceptible sweating, palms moist

2

3

4 - beads of sweat obvious on forehead

5

6

7 - drenching sweats

Tactile disturbances - Ask, “Have you experienced any itching, pins & needles sensation, burning or numbness, or a feeling of bugs crawling on or under your skin?”

0 - none

1 - very mild itching, pins & needles, burning, or numbness 2 - mild itching, pins & needles, burning, or numbness

3 - moderate itching, pins & needles, burning, or numbness 4 - moderate hallucinations

5 - severe hallucinations

6 - extremely severe 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 seeing anything that disturbs you or that you know isn’t there?”

0 - not present

1 - very mild sensitivity

2 - mild sensitivity

3 - moderate sensitivity

4 - moderate hallucinations

5 - severe hallucinations

6 - extremely severe hallucinations

7 - continuous hallucinations

Tremors - have patient extend arms & spread fingers. Rate on scale 0 - 7.

0 - No tremor

1 - Not visible, but can be felt fingertip to fingertip 2 3

4 - Moderate, with patient’s arms extended

5

6

7 - severe, even w/ arms not extended

Agitation - Rate on scale 0 - 7 0 - normal activity

1 - somewhat normal activity

2

3

4 - moderately fidgety and restless

5

6

7 - paces back and forth, or constantly thrashes about

Orientation and clouding of sensorium - Ask, “What day is this? Where are you? Who am I?” Rate scale 0 - 4

0 - Oriented

1 – cannot do serial additions or is uncertain about date

2 - disoriented to date by no more than 2 calendar days

3 - disoriented to date by more than 2 calendar days 4 - Disoriented to place and / or person

Auditory Disturbances - Ask, “Are you 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 - not present

1 - Very mild harshness or ability to startle

2 - mild harshness or ability to startle

3 - moderate harshness or ability to startle

4 - moderate hallucinations

5 - severe hallucinations

6 - extremely severe hallucinations

7 - continuous hallucinations

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 present

1 - very mild

2 - mild

3 - moderate

4 - moderately severe

5 - severe

6 - very severe

7 - extremely severe

Procedure:

1.Assess 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 sensorium” 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 assessment on the Withdrawal Assessment Sheet. Document administration of PRN medications on the assessment sheet as well.

3.The CIWA-Ar scale is the most sensitive tool for assessment of the patient experiencing alcohol withdrawal. Nursing assessment is vitally important. Early intervention for CIWA-Ar score of 8 or greater provides the best means to prevent the progression of withdrawal.

 

Assessment Protocol

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Vitals, Assessment Now.

 

 

Time

 

 

 

 

 

 

 

 

 

 

 

 

 

b. If initial score 8 repeat q1h x 8 hrs, then

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

if stable q2h x 8 hrs, then if stable q4h.

 

Pulse

 

 

 

 

 

 

 

 

 

 

 

 

 

c. If initial score < 8, assess q4h x 72 hrs.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If score < 8 for 72 hrs, d/c assessment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If score 8 at any time, go to (b) above.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O2 sat

 

 

 

 

 

 

 

 

 

 

 

 

 

d. If indicated, (see indications below)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

administer prn medications as ordered and

 

BP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

record on MAR and below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assess and rate each of the following (CIWA-Ar Scale):

Refer to reverse for detailed instructions in use of the CIWA-Ar scale.

 

Nausea/vomiting (0 - 7)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0

- none; 1 - mild nausea ,no vomiting; 4 - intermittent nausea;

 

 

 

 

 

 

 

 

 

 

 

 

7

- constant nausea , frequent dry heaves & vomiting.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tremors (0 - 7)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0

- no tremor; 1 - not visible but can be felt; 4 - moderate w/ arms

 

 

 

 

 

 

 

 

 

 

 

 

 

extended; 7 - severe, even w/ arms not extended.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Anxiety (0 - 7)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0

- none, at ease; 1 - mildly anxious; 4 - moderately anxious or

 

 

 

 

 

 

 

 

 

 

 

 

 

guarded; 7 - equivalent to acute panic state

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agitation (0 - 7)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 - severe hallucinations;

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6 – extremely severe hallucinations; 7 - continuous hallucinations

 

 

 

 

 

 

 

 

 

 

 

 

 

Auditory Disturbances (0 - 7)

 

 

 

 

 

 

 

 

 

 

 

 

 

0

- not present; 1 - very mild harshness/ ability to startle; 2 - mild

 

 

 

 

 

 

 

 

 

 

 

 

 

harshness, ability to startle; 3 - moderate harshness, ability to

 

 

 

 

 

 

 

 

 

 

 

 

 

startle; 4 - moderate hallucinations; 5 severe hallucinations;

 

 

 

 

 

 

 

 

 

 

 

 

6

- extremely severe hallucinations; 7 - continuous.hallucinations

 

 

 

 

 

 

 

 

 

 

 

 

 

Visual Disturbances (0 - 7)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0

- not present;

1 - very mild sensitivity;

2 - mild sensitivity;

 

 

 

 

 

 

 

 

 

 

 

 

3

- moderate sensitivity; 4 - moderate hallucinations; 5 - severe

 

 

 

 

 

 

 

 

 

 

 

 

 

hallucinations;

6 - extremely severe hallucinations;

7 -

 

 

 

 

 

 

 

 

 

 

 

 

 

continuous hallucinations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Headache (0 - 7)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0

- not present; 1 - very mild; 2 - mild; 3 - moderate; 4 - moderately

 

 

 

 

 

 

 

 

 

 

 

 

 

severe; 5 - severe; 6 - very severe; 7 - extremely severe

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total CIWA-Ar score:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRN Med: (circle one)

 

Dose given (mg):

 

 

 

 

 

 

 

 

 

 

 

 

 

Diazepam

Lorazepam

 

 

 

Route:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time of PRN medication administration:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assessment of response (CIWA-Ar score 30-60

 

 

 

 

 

 

 

 

 

 

 

 

 

minutes after medication administered)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RN Initials

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Scale for Scoring:

Total Score =

0 – 9: absent or minimal withdrawal

10 – 19: mild to moderate withdrawal

more than 20: severe 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 assess. x more than 8hrs required, more than 4 mg/hr lorazepam x 3hr or 20 mg/hr diazepam x 3hr required, or resp. distress.

Patient Identification (Addressograph)

Signature/ Title

Initials

Signature / Title

Initials

Alcohol Withdrawal Assessment Flowsheet (revised Nov 2003)