ALCOHOL WITHDRAWAL ASSESSMENT

OBSERVATIONS

Date

Time

Breath alcohol testing

Blood glucose reading

Temperature

Pulse

Respiration rate

Blood pressure

ALCOHOL WITHDRAWAL ASSESSMENT SCORE

Nausea and vomiting

Tremor

Paroxysmal sweats

Anxiety

Agitation

Tactile disturbances

Auditory disturbances

Visual disturbances

Headache, fullness in head

Orientation and clouding of sensorium

Total score

Nursing Management:
• Nurse in a quiet, evenly lit environment.
• Provide reassurance and explanation.
• Re-orientate the person if confused.
• Ensure adequate hydration.
ALCOHOL WITHDRAWAL ASSESSMENT SCALE

Nausea and vomiting Tactile disturbances

Ask “Do you feel sick in the stomach? Have you vomited?” Observation Ask “Have you any itching, pins and needles sensations, any burning, any
0 No nausea and no vomiting numbness or do you feel bugs crawling under your skin?” Observation
1 Mild nausea with no vomiting 0 None
2 1 Very mild itching, pins and needles, burning or numbness
3 2 Mild itching, pins and needles, burning or numbness
4 Intermittent nausea, with dry retching 3 Moderate itching, pins and needles, burning or numbness
5 4 Moderately severe hallucinations
6 5 Severe hallucinations
7 Constant nausea, frequent dry retching and vomiting 6 Extremely severe hallucinations
7 Continuous hallucinations
Tremor Auditory disturbances
Arms extended, elbows slightly flexed and fingers spread. Observation Ask “Are you more aware of sounds around you? Are they harsh?
0 No tremor Do they frighten you? Are you hearing anything that is disturbing to you? Are
1 Not visible, but can be felt fingertip to fingertip you hearing things you know are not there?” Observation
2 0 Not present
3 1 Very mild sensitivity
4 Moderate 2 Mild sensitivity
5 3 Moderate sensitivity
6 4 Moderately severe hallucinations
7 Severe, even with arms not extended 5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
Paroxysmal sweats Visual disturbances
Observation Ask “Does the light appear to be too bright? Is its colour different? Does it
0 No sweat visible hurt your eyes? Are you seeing things you know are not there? Observation
1 Barely perceptible sweating, palms moist 0 Not present
2 1 Very mild sensitivity
3 2 Mild sensitivity
4 Beads of sweat obvious on forehead 3 Moderate sensitivity
5 4 Moderately severe hallucinations
6 5 Severe hallucinations
7 Drenching sweats 6 Extremely severe hallucinations
7 Continuous hallucinations
Anxiety Headache, fullness in the head
Ask “Do you feel nervous?” Observation Ask “Does your head feel different? Does it feel as though there is a band
0 No anxiety, at ease around your head?” Do not rate for dizziness or light headedness.
1 Mildly anxious Otherwise rate severity.
2 0 Not present
3 1 Very mild
4 Moderately anxious or guarded so anxiety is inferred 2 Mild
5 3 Moderate
6 4 Moderately severe
7 Equivalent to acute panic states as seen in severe delirium 5 Severe
or acute schizophrenic reactions 6 Very severe
7 Extremely severe
Agitation Orientation
Observation Ask “What day is this? Where are you? Who am I?” Observation
0 Normal activity 0 Orientated and can do serial additions
1 Somewhat more than normal activity Ask person to perform serial addition of 3s up to 30 e.g 3, 6, 9…
2
1 Cannot do serial addition or is uncertain about date
3
2 Disorientated by date by no more than 2 calendar days
4 Moderately fidgety and restless
3 Disorientated for date by more that 2 calendar days
5
4 Disorientated for place and/or person
6
7 Paces back and forth during most of the interview
or constantly thrashes about

This withdrawal Assessment Scale for Alcohol (CIWA-Ar) was developed by the Addiction Research Foundation Clinical Institute, Toronto