BASICS
This tool helps drive interventions and care for patients with suspected alcohol withdrawal.
What is the CIWA-Ar?
Assessed while patient's arms are extended.
What are tremors?
Patient skin is moist, with sweat dotting his face.
What is a 5 or 6?
A patient who is not a good candidate for this screening tool.
What is an unconscious patient? (or a ventilated patient)
The nurse may assess this as "mild sensitivity."
What are visual disturbances?
The patient appears to be acutely schizophrenic.
What is a 7 in the anxiety section?
These vital signs are part of the final score calculation.
What are none?
Patient c/o "ants crawling on forearms."
What is a tactile disturbance?
Patient whispers, "Whose dog is growling? Will it bite me?"
What is a 4 in auditory disturbances?
Scores less than this number equate with very mild withdrawal.
What is 8?
Except for these, all assessments require observation and asking questions.
What are tremor, agitation and paroxysmal sweats?
Patient states, "I feel lightheaded," but denies head pain or fullness.
What is a zero on the headache section?