**Alcohol Withdrawal Assessment Scoring Guidelines (CIWA - Ar)**

+-------------------------------+---+----------------------------------+
| **[Nau                        |   | **[Tremors -]{.underline}** have |
| sea/Vomiting]{.underline}** - |   | patient extend arms & spread     |
| Rate on scale 0 - 7           |   | fingers. Rate on scale 0 - 7.    |
+-------------------------------+---+----------------------------------+
| 0 - None                      |   | 0 - No tremor                    |
+-------------------------------+---+----------------------------------+
| 1 - Mild nausea with no       |   | 1 - Not visible, but can be felt |
| vomiting                      |   | fingertip to fingertip           |
|                               |   |                                  |
| 2                             |   | 2                                |
|                               |   |                                  |
| 3                             |   | 3                                |
+-------------------------------+---+----------------------------------+
| 4 - Intermittent nausea       |   | 4 - Moderate, with patient's     |
|                               |   | arms extended                    |
| 5                             |   |                                  |
|                               |   | 5                                |
| 6                             |   |                                  |
|                               |   | 6                                |
+-------------------------------+---+----------------------------------+
| 7 - Constant nausea and       |   | 7 - severe, even w/ arms not     |
| frequent dry heaves and       |   | extended                         |
| vomiting                      |   |                                  |
+-------------------------------+---+----------------------------------+

+-------------------------------+---+----------------------------------+
| **[Anxiety]{.underline}** -   |   | **[Agitation]{.underline}** -    |
| Rate on scale 0 - 7           |   | Rate on scale 0 - 7              |
+-------------------------------+---+----------------------------------+
| 0 - no anxiety, patient at    |   | 0 - normal activity              |
| ease                          |   |                                  |
+-------------------------------+---+----------------------------------+
| 1 - mildly anxious            |   | 1 - somewhat normal activity     |
|                               |   |                                  |
| 2                             |   | 2                                |
|                               |   |                                  |
| 3                             |   | 3                                |
+-------------------------------+---+----------------------------------+
| 4 - moderately anxious or     |   | 4 - moderately fidgety and       |
| guarded, so anxiety is        |   | restless                         |
| inferred                      |   |                                  |
|                               |   | 5                                |
| 5                             |   |                                  |
|                               |   | 6                                |
| 6                             |   |                                  |
+-------------------------------+---+----------------------------------+
| 7 - equivalent to acute panic |   | 7 - paces back and forth, or     |
| states seen in severe         |   | constantly thrashes about        |
| delirium or acute             |   |                                  |
| schizophrenic reactions.      |   |                                  |
+-------------------------------+---+----------------------------------+

+-------------------------------+---+---------------------------------+
| **[Paroxysmal                 |   | **[Orientation and clouding of  |
| Sweats]{.underline}** - Rate  |   | sensorium]{.underline}** - Ask, |
| on Scale 0 - 7.               |   | "What day is this? Where are    |
|                               |   | you? Who am I?" Rate scale [0 - |
| 0 - no sweats                 |   | 4]{.underline}                  |
+-------------------------------+---+---------------------------------+
| 1- barely perceptible         |   | 0 - Oriented                    |
| sweating, palms moist         |   |                                 |
+-------------------------------+---+---------------------------------+
| 2                             |   | 1 -- cannot do serial additions |
|                               |   | or is uncertain about date      |
| 3                             |   |                                 |
+-------------------------------+---+---------------------------------+
| 4 - beads of sweat obvious on |   | 2 - disoriented to date by no   |
| forehead                      |   | more than 2 calendar days       |
|                               |   |                                 |
| 5                             |   |                                 |
+-------------------------------+---+---------------------------------+
| 6                             |   | 3 - disoriented to date by more |
|                               |   | than 2 calendar days            |
+-------------------------------+---+---------------------------------+
| 7 - drenching sweats          |   | 4 - Disoriented to place and /  |
|                               |   | or person                       |
+-------------------------------+---+---------------------------------+

  -------------------------------- ---- ----------------------------------
  **[Tactile                            **[Auditory
  disturbances]{.underline}** -         Disturbances]{.underline}** - Ask,
  Ask, "Have you experienced any        "Are you more aware of sounds
  itching, pins & needles               around you? Are they harsh? Do
  sensation, burning or numbness,       they startle you? Do you hear
  or a feeling of bugs crawling on      anything that disturbs you or that
  or under your skin?"                  you know isn't there?"

  0 - none                              0 - not present

  1 - very mild itching, pins &         1 - Very mild harshness or ability
  needles, burning, or numbness         to startle

  2 - mild itching, pins &              2 - mild harshness or ability to
  needles, burning, or numbness         startle

  3 - moderate itching, pins &          3 - moderate harshness or ability
  needles, burning, or numbness         to startle

  4 - moderate hallucinations           4 - moderate hallucinations

  5 - severe hallucinations             5 - severe hallucinations

  6 - extremely severe                  6 - extremely severe
  hallucinations                        hallucinations

  7 - continuous hallucinations         7 - continuous hallucinations
  -------------------------------- ---- ----------------------------------

  ------------------------------- --- ------------------------------ --------
  **[Visual                           **[Headache]{.underline}** -   
  disturbances]{.underline}** -       Ask, "Does your head feel      
  Ask, "Does the light appear to      different than usual? Does it  
  be too bright? Is its color         feel like there is a band      
  different than normal? Does it      around your head?" Do not rate 
  hurt your eyes? Are you seeing      dizziness or lightheadedness.  
  anything that disturbs you or                                      
  that you know isn't there?"                                        

  0 - not present                     0 - not present                

  1 - very mild sensitivity           1 - very mild                  

  2 - mild sensitivity                2 - mild                       

  3 - moderate sensitivity            3 - moderate                   

  4 - moderate hallucinations         4 - moderately severe          

  5 - severe hallucinations           5 - severe                     

  6 - extremely severe                6 - very severe                
  hallucinations                                                     

  7 - continuous hallucinations       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]{.underline} 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.

<table>
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<tbody>
<tr class="odd">
<td colspan="2" rowspan="6"><h3
id="assessment-protocol"><strong><u>Assessment
Protocol</u></strong></h3>
<h3 id="a.-vitals-assessment-now.">a. Vitals, Assessment Now. </h3>
<h3 id="b.-if-initial-score-8-repeat-q1h-x-8-hrs-then">b. If initial
score ≥ 8 repeat q1h x 8 hrs, then</h3>
<h3 id="if-stable-q2h-x-8-hrs-then-if-stable-q4h."> if stable q2h x 8
hrs, then if stable q4h.</h3>
<h3 id="c.-if-initial-score-8-assess-q4h-x-72-hrs.">c. If initial score
&lt; 8, assess q4h x 72 hrs. </h3>
<h3 id="if-score-8-for-72-hrs-dc-assessment."> If score &lt; 8 for 72
hrs, d/c assessment.</h3>
<h3 id="if-score-8-at-any-time-go-to-b-above."> If score ≥ 8 at any
time, go to (b) above. </h3>
<h3 id="d.-if-indicated-see-indications-below">d. If indicated, (see
indications below) </h3>
<h3 id="administer-prn-medications-as-ordered-and"> administer prn
medications as ordered and </h3>
<h3 id="record-on-mar-and-below."> record on MAR and below. </h3></td>
<td><h3 id="date"><strong>Date</strong></h3></td>
<td><h3 id="section"></h3></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>Time</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><h1 id="pulse"><strong>Pulse</strong></h1></td>
<td><h1 id="section-1"></h1></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><h2 id="rr">RR</h2></td>
<td><h2 id="section-2"></h2></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><h1 id="o2-sat"><strong>O2 sat</strong></h1></td>
<td><h1 id="section-3"></h1></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><h2 id="bp">BP</h2></td>
<td><h2 id="section-4"></h2></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="15"><strong>Assess and rate each of the following (CIWA-Ar
Scale): Refer to reverse for detailed instructions in use of the CIWA-Ar
scale.</strong></td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>Nausea/vomiting</strong> (0 - 7)</p>
<p>0 - none; 1 - mild nausea ,no vomiting; 4 - intermittent nausea;</p>
<p>7 - constant nausea , frequent dry heaves &amp; vomiting.</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"><p><strong>Tremors</strong> (0 - 7)</p>
<p>0 - no tremor; 1 - not visible but can be felt; 4 - moderate w/ arms
extended; 7 - severe, even w/ arms not extended.</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>Anxiety</strong> (0 - 7)</p>
<p>0 - none, at ease; 1 - mildly anxious; 4 - moderately anxious or
guarded; 7 - equivalent to acute panic state</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"><p><strong>Agitation</strong> (0 - 7)</p>
<p>0 - normal activity; 1 - somewhat normal activity; 4 - moderately
fidgety/restless; 7 - paces or constantly thrashes about</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>Paroxysmal Sweats</strong> (0 - 7)</p>
<p>0 - no sweats; 1 - barely perceptible sweating, palms moist;</p>
<p>4 - beads of sweat obvious on forehead; 7 - drenching sweat</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"><p><strong>Orientation</strong> (0 - 4)</p>
<p>0 - oriented; 1 - uncertain about date; 2 - disoriented to date by no
more than 2 days; 3 - disoriented to date by &gt; 2 days;</p>
<p>4 - disoriented to place and / or person</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>Tactile Disturbances</strong> (0 - 7)</p>
<p>0 - none; 1 - very mild itch, P&amp;N, ,numbness; 2-mild itch,
P&amp;N, burning, numbness; 3 - moderate itch, P&amp;N, burning
,numbness; 4 - moderate hallucinations; 5 - severe hallucinations;</p>
<p>6 – extremely severe hallucinations; 7 - continuous
hallucinations</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"><p><strong>Auditory Disturbances</strong> (0 - 7)</p>
<p>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;</p>
<p>6 - extremely severe hallucinations; 7 -
continuous.hallucinations</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>Visual Disturbances</strong> (0 - 7)</p>
<p>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</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"><p><strong>Headache</strong> (0 - 7)</p>
<p>0 - not present; 1 - very mild; 2 - mild; 3 - moderate; 4 -
moderately severe; 5 - severe; 6 - very severe; 7 - extremely
severe</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3">Total CIWA-Ar score:</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td rowspan="2">PRN Med: (circle one) Diazepam Lorazepam</td>
<td colspan="2"><strong>Dose given (mg):</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"><strong>Route:</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Time</strong> of PRN medication
administration:</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3">Assessment of response (CIWA-Ar score 30-60 minutes
after medication administered)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3">RN Initials</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

+-------------------------+--------------------------------------------+
| **[Scale for            | **[Indications for PRN                     |
| Scoring:]{.underline}** | medication]{.underline}:**                 |
|                         |                                            |
| Total Score =           | a\. Total CIWA-AR score 8 or higher if     |
|                         | ordered PRN only (Symptom-triggered        |
| 0 -- 9: absent or       | method).                                   |
| minimal withdrawal      |                                            |
|                         | b\. Total CIWA-Ar score 15 or higher if on |
| 10 -- 19: mild to       | Scheduled medication. (Scheduled + prn     |
| moderate withdrawal     | method)                                    |
|                         |                                            |
| more than 20: severe    | [Consider transfer to ICU for any of the   |
| withdrawal              | following]{.underline}: 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

                                                                     

                                                                     

                                                                     

                                                                     

                                                                     
  ---------------------------- ---------- -------------------------- ----------