Alcohol Withdrawal Documentation Guide for MMC Nursing Staff

Clinical Institute Withdrawal Assessment - Alcohol (CIWA)

The CIWA assessment evaluates alcohol withdrawal symptoms using a scale. Key categories and their descriptions include:

Adrenergic Hyperactivity:

• Heart Rate: Monitored in bpm.
• Blood Pressure: Monitored in mmHg.

Nausea & Vomiting:

• Options: no nausea and vomiting, mild nausea, no vomiting, intermittent nausea with dry heaves, constant nausea, frequent dry heaves & vomiting.

Tremors:

• Observation: Have patient extend arms with fingers spread apart.
• Rating: no tremor, not visible but can be felt fingertip to fingertip, moderate with patient's arms extended, severe even with arms not extended.

Sweats - CNS Excitation:

• Observation: Assesses sweating.
• Rating: no sweat visible, barely perceptible sweating (palms moist), beads of sweat obvious on forehead, drenching sweats requiring linen changes.

Anxiety:

• Question: Ask, "Do you feel nervous?"
• Rating: no anxiety (at ease), mildly anxious, moderately anxious (or guarded, so anxiety is inferred), acute panic state.

Agitation:

• Observation: Assesses activity level.
• Rating: normal activity, somewhat more than normal activity, moderately fidgety and restless, paces back and forth, or constantly thrashes about.

Headache, Fullness in Head:

• Instructions: Do not use pain scale. Do not state dizziness or light-headedness. Otherwise, rate severity. Ask, "Does your head feel different?" "Does it feel like there is a band around your head?"
• Rating: not present, very mild, mild, moderate, moderately severe, severe, very severe, extremely severe.

Tactile Disturbances:

• Question: Ask, "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?"
• Rating: none, very mild itching/pins & needles/burning/numbness, mild itching/pins & needles/burning/numbness, moderately severe hallucinations, severe hallucinations, extremely severe hallucinations.

CIWA Score of 15 or More

This section details the withdrawal regimen based on the CIWA score and provides specific instructions:

Withdrawal Regimen Options:

• No Ativan, next CIWA-Ar in 4 hours
• 2 mg Ativan, next CIWA-Ar in 1 hour
• 4 mg Ativan, next CIWA-Ar in 1 hour

CIWA Score of 15 or More Options:

• 1st time score of 15 or more and patient not in Phase 2
• 2nd consecutive score of 15 or more, patient not in Phase 2
• 3rd consecutive score of 15 or more, patient not in Phase 2
• Not applicable; patient in Phase 2

Instructions:

• First score greater than or equal to 15: If NOT already given, contact provider to order phenobarbital load (use ideal body weight for dosing) and Ativan 4mg. If blood pressure is greater than or equal to 160/90, give clonidine.
• Third consecutive score of 15 or more: Call for notification and orders for transfer to critical care unit if not already in critical care unit. Provider to consider repeat phenobarbital load (use ideal body weight for dosing). Ativan to continue per protocol. If no critical care bed is available, expect a critical care RN to come to bedside and assist with care and drug administration. DO NOT DELAY transfer. If symptoms remain uncontrolled despite above interventions, call provider to consider addition of Precedex drip or Haloperidol for refractory delirium/agitation.

? Note: When a patient reaches Phase 2, they must be moved to Critical Care.

4. Sign the PowerForm.

Viewing Resources

To view Acute Alcohol Withdrawal Reference Text and Alcohol Withdrawal Flow for Phase 1 and 2, click the Reference Text icon [Ref Text] within the Alcohol Withdrawal PowerPlans or Orders.

To view CIWA scores and status:

• Select CIWA from myPatient Views on the Menu [Menu].

CIWA View Details: