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Ciwa Sheet

The document describes the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale for assessing alcohol withdrawal symptoms. It lists 10 categories of symptoms - nausea/vomiting, tremors, sweating, tactile disturbances, auditory disturbances, visual disturbances, headache, orientation, anxiety, and agitation. Each category is rated on a scale of 0 to 7 based on the severity of symptoms observed or reported by the patient. The scale provides a standardized way to evaluate alcohol withdrawal and monitor symptoms over time.

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Venu Reddy
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175 views2 pages

Ciwa Sheet

The document describes the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale for assessing alcohol withdrawal symptoms. It lists 10 categories of symptoms - nausea/vomiting, tremors, sweating, tactile disturbances, auditory disturbances, visual disturbances, headache, orientation, anxiety, and agitation. Each category is rated on a scale of 0 to 7 based on the severity of symptoms observed or reported by the patient. The scale provides a standardized way to evaluate alcohol withdrawal and monitor symptoms over time.

Uploaded by

Venu Reddy
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT FOR ALCOHOL (CIWA-Ar) NAUSEA AND VOMITING Ask Do you feel sick to your

r stomach? Have you vomited? Observation 0 No nausea 1 Mild nausea with no vomiting 2 3 4 Intermittent nausea with dry heaves 5 6 7 constant nausea, frequent dry heaves and vomiting TREMOR arms extended and fingers spread apart. Observation 0 No tremor 1 Not visible, but can be felt fingertip to fingertip 2 3 4 Moderate, with patients arms extended 5 6 7 severe, even with arms not extended PAROXYSMAL SWEATS Observation TACTILE DISTURBANCES Ask Have you any itching, pins and needles, any burning, or numbness or do you feel bugs crawling under your skin? 0 None 1 Very mild itching, pins and needles, burning or numbness 2 Mild itching, pins and needles, burning or numbness 3 Moderate itching, pins and needles, burning or numbness 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations AUDITORY DISTURBANCES Ask Are you more aware of sounds around you? Are they harsh? Do the frighten you? 0 Not present 1 Very mild sensitivity 2 Mild harshness or ability to frighten 3 Moderate harshness or ability to frighten 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations VISUAL DISTURBANCES Ask Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things that you know are not there? Observation 0 Not present 1 Very mild sensitivity 2 Mild sensitivity 3 Moderate sensitivity 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations HEADACHE, FULLNESS IN HEAD Ask Does your head feel different/ Does it feel like there is a band around our head? Do not rate for dizziness or light-headedness. Otherwise rate severity 0 Not present 1 very mild 2 mild 3 moderate 4 moderately severe 5 severe 6 very severe 7 extremely severe ORIENTATION AND CLOUDING OF SENSORIUM Ask What day is this/ Where are you? Who am I? 0 Orientated and can do serial additions 1 Cannot do serial additions or is uncertain about date 2 Disorientated for date by no more than two calendar days 3 Disorientated for date by more than two calendar days 4 Disorientated for place and/or person

0 No sweat visible 1 Barely perceptible sweating, palms moist 2 3 4 Beads of sweat obvious on forehead 5 6 7 Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions ANXIETY Ask Do you feel nervous? Observation

0 No anxiety 1 Mildly anxious 2 3 4 Moderately anxious, or guarded so anxiety is inferred 5 6 7 Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions AGITATION Observation 0 Normal activity 1 Somewhat more than normal activity 2 3 4 Moderately fidgety and restless 5 6 7 Paces back and forth during most of the interview, or constantly thrashes out

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