CIWA Basics
What does CIWA stand for
Clinical Institute Withdrawal Assessment
Patient vomited once but can tolerate sips of water. What is their score for nausea/vomiting?
2-3
What is the first nursing action after obtaining a CIWA score of 14?
Administer PRN benzodiazepine per order set.
True or False: CIWA assess alcohol withdrawal severity
True
Patient reports seeing "shadows moving." What is their visual disturbances score?
3-4
How often should CIWA assessments be done when a patient is first admitted to your unit/floor?
Q1 hour x4 if score stays below 8 then Q4 hours x48 if the score stays below 8
What score range indicates mild withdrawal
8-14
Patient has soaked through their gown with sweat. What is their paroxysmal sweat score?
7
fall precautions, seizure precautions, close monitoring
A CIWA score > _ indicates the need for medication
>8
Patient is moderately fidgety, picks at linens, cannot relax. What is their agitation score?
4-5
When should the provider be notified urgently?
Rapid CIWA increase, hallucinations, seizure activity, delirium
How many total categories are in CIWA assessment.
10
Patient believes bugs are crawling continuously under their skin. What is their tactile hallucinations score?
7
Why should nurses treat high blood pressure/ elevated heart rate during CIWA assessments?
To help prevent the patient from having dangerous hypertension, tachycardia, arrhythmias, and potential organ damage. (Also known as an adrenergic storm)