##  TABLE 1 Nursing Alcohol Withdrawal Assessment Scale

**MEDICAL RECORD NURSING DOCUMENTATION**

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<td><strong>Date:</strong></td>
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<td><strong>Time:</strong></td>
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<td><strong>Vitals: Temperature</strong></td>
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<td><h3 id="pulse"> Pulse</h3></td>
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<td><h3 id="respirations"> Respirations</h3></td>
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<td><strong>Blood Pressure</strong></td>
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<td><h3 id="tremors">Tremors</h3></td>
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<td><h3 id="tachycardia">Tachycardia</h3></td>
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<td><h3 id="hypertension">Hypertension</h3></td>
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<td><h3 id="sweating">Sweating</h3></td>
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<td><h3 id="temperature">Temperature</h3></td>
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<td><strong>Nausea/Vomiting</strong></td>
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<td><strong>Agitation</strong></td>
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<td><strong>Orientation</strong></td>
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<td><strong>Insomnia</strong></td>
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<td><strong>Total Score:</strong></td>
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<td><strong>Hallucinations</strong></td>
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<td><strong>Convulsions</strong></td>
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<td><strong>Initials:</strong></td>
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**Symptom Severity Scale**

### TREMORS: Arms extended, fingers spread SWEATING: ORIENTATION:

1.  **Not present** O Not present 0 Oriented x4

#### Tremor felt by examiner but 1 Mild ,barely visible 1 Detached ,partially

> not visible 2 Moderate aware of examiner,

2.  Mild visible tremor 3 Marked, clothing or bedding vague on
    time/place

3.  Marked visible tremor soaked 2 Sometimes out of

contact, hyper alert

3 intermittent confusion

#####  TACHYCARDIA: NAUSEA/VOMITING and orientation

1.  Less than 80 beats/min 0 Not present **INSOMNIA:**

2.  80-100 beats/min 1 Nausea only 0 Sound asleep

3.  101-130 beats/min 2 Vomiting once or occasionally 1 Up or awake(or
    per shift )

4.  Over 130 beats/min 3 Frequent vomiting, "dry heaves" 2 Awake half
    the night

3 Awake all night

**HYPERTENSION TEMPERATURE AGITATION:**

1.  Systolic less than 150mm 0 Less than 99.5 F 0 Not present

> Diastolic less than 90 1 99.5-100.2 1 Activity increased

2.  Systolic 150 to 175 mm 2 100.3-101.3 2 Restless "fidgety"

> Diastolic 91-100 3 Greater than 101.3 F 3 Restless, pacing

3.  Systolic 176 to 200

> Diastolic 101-110 **HALLUCINATIONS:** Record presence **CONVULSIONS:**
> Record as

3 Systolic over 200mm of visual, auditory or tactile. Do not score
present. Do not score

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