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.

This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. The maximum score is 67 (see instrument). Patients scoring less than 10 do not usually need additional medication for withdrawal.

Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) For each section, ask the prompts and/or observe behavior. 1. Time: 24 hour clock, midnight=00:00 __ __:__ __ 2. Pulse or heart rate, taken for one minute __ __ __ bpm 3. Blood pressure __ __ __/__ __ __ mm/Hg 4. NAUSEA AND VOMITING Do you feel sick to your stomach? Have you vomited?

EXAMPLE - ALCOHOL DETOXIFICATION PROTOCOL The following is an example of a protocol developed around the use of the CIWA – Ar in an alcohol detoxification program: 1. CIWA to be completed on admission and q 8 hours for a period of 24 hours. 2. Determine and record blood alcohol concentration (BAC) by breathalyzer on admission. 3.

Clinical Institute Withdrawal Assessment for Alcohol Scale, revised (CIWA-Ar) . Patient— Date Time— : (24 hour clock, Blood pressure: TACTILE DISTURBANCES—Ask "Have you any itching, pins and needles sensations, any burning, any numbness or do you feel bugs crawling on or under your skin?"

Alcohol Withdrawal Standing Order (CIWA) [1161] General Nursing Vital Signs [X] Vital Signs-Per unit Protocol Routine, Per unit protocol CIWA-Ar Alcohol Withdrawal Assessment Nursing [ ] Use the CIWA-Ar Alcohol Withdrawal Assessment Tool to assess the patient's need for symptom based treatment. Routine, Until discontinued, Starting S

1. Assess and rate each of the 10 criteria of the CIWA scale. Add up the scores for all ten criteria. This is the total CIWA-Ar score for the patient at that time. 2. Document CIWA-Ar assessment administration of PRN medications on the chlordiazepoxide prescription.

Cl i ni c al I ns ti tute Wi thdr awal As s e s s me nt - Al c ohol Sc al e Re vi s e d (CI WA - AR) Agi tati on 0 - Norm a l a c t i vi t y

ciwa-ar-alcohol-withdrawal) and the Short Alco-hol Withdrawal Scale (SAWS). The CIWA-Ar is a 10-item questionnaire completed by a physician that assesses the signs, symptoms, and...

Assessment of alcohol withdrawal: The Revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction, 84, 1353-1357. This scale is not copyrighted and may be used freely. ANXIETY -- Ask "Do you feel nervous?" Observation. "Does your head feel different? Does it feel like there is a band around your head?"