Order 1103231: Clinical Case study post op
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DarrenRobertsAlcoholWithdrawalAssessmentScoring.pdf
Support Referral to AOD Clinician Yes No Referral Made
ALCOHOL WITHDRAWAL
ASSESSMENT SCORING TOOL
(CIWA-Ar Scale)
Surname ________________________________ Given Name _____________________________ UR No _____________ DOB ________________ Address _________________________________ GP ________________ Sex _________________
Assess and rate each of the following : Refer to reverse for detailed instruction in use of the CIWA-Ar-Scale
Nause a/vomiting (0 - 7) 0 - no ne; 1 - mild na us e a , no vo miting; 4 - inte rmitte nt na us e a; 7 - c o ns ta nt na use a , f re quent dry he a ve s & vo miting
Tr e mors (0— 7) 0 - no tremor; 1 - not visible but can be felt; 4 - moderate w/ arms extended; 7 - severe, even w/arms not extended
Anxie ty (0 - 7) 0 - no ne a t e as e; 1 - mildly a nxio us; 4 - mo de ra te ly a nxio us o r gua rde d; 7 - e quiva le nt to a c ute pa nic s ta te
Ag itation (0 - 7) 0 - normal activity; 1 - somewhat normal activity; 4 - moderately fidget/restless; 7 - paces or constantly thrashes about
Par oxy smal swe ats (0 - 7) 0 - no s we a ts; 1 - ba re ly pe rc e ptible s we a ting, pa lms mo is t; 4 - be a ds o f wea rs o bvio us o n f o re he a d; 7 - dre nc hing s we a t
O r ie ntation (0 - 4) 0 - oriented; 1 - uncertain about date; 2 - disoriented to date by no more than two days; 3 - disoriented to date by > two days; 4 - disoriented to place and / or person
Tactile Distur bance s (0 - 7) 0 - none; 1 - very mid itch, P&N, numbness; 2 - mild itch, P&N, burning, numbness; 3 - moderate itch, P&N, burning, numbness; 4 - moderate hallucinations; 6 - extremely serve hallucinations ; 7 - continuous hallucinations
Auditor y Distur bances (0 — 7) 0 - not present; 1 - very mild harshness/ ability to startle; 2 - mild harshness, ability to startle; 3 - moderate harshness, ability to startle; 4 - moderate hallucinations; 5 - serve hallucinations; 6 - extremely severe hallucinations; 7 - continuous hallucinations
Visual Distur bance s (0 - 7) 0 - not present; 1 - very mild sensitivity; 2 -mild sensitivity; 3 - moderate sensitivity; 4moderate hallucinations; 5 - severe hallu- cinations; 6 - extremely severe hallucinations; 7 - continuous hallucinations
He adache (0 - 7) 0 - not present; 1 - very mild; 2 - mild; 3 - moderate; 4 - moder- ately severe; 5 - severe; 6 - very severe; 7 - extremely severe
Total CIWA-Ar score:
P R N Med : ( ci rc le one) Dose given (mg):
Diazepam Lorazepam Route:
Time of PRN medication administration:
Assessment of response (CIWA-Ar-score 30-60 minutes after medication administered )
RN Initials
Assessment Protocol: a. Vitals Assessment Now. b. If initial score ≥ 8 repeat q 1 h × 8 hrs, then if
stable q2h × 8 hrs, then if stable q4h. c. If initial score < 8 for 72 hrs, d/c assessment. If
score ≥ 8 at any time, go to (b) above. d. If indicated, (see indications below) administer
prn medication as ordered and record on MAR and below.
Date
Time
Pulse
RR
O2 Sat
BP
Scale f or Scor ing: Total Sc or e =
0 - 9: absen t or min imal wi thdr awal 10 - 19: mild to mode r ate wi thd rawal Mo re than 20: se ver e withd rawal
Indica tio ns for PRN medica tio ns: a. Total CIWA -AR sco re 8 or h igher if ord ered PRN o nly (Symptom -tr iggered
method) b. Total CIWS -Ar sco re 15 or highe r if on Sc hedu led medica ti on (Sch edul ed +
prn method) Conside r tran sfe r to ICU for any of the fo llow ing: Tota l s cor e ab o ve 35, q1h assess, x more tha n 8he s r equi re d, more than 4 mg/hr lor aze pam × 3hr or 20 mg/hr diaze pam ×3hr req ui red, or r esp. dis tr ess
Roberts Darren
075486 23/11/1968 25 Happy St, Carins
J. Smith M
5/3/ 18 0300
90R
20
96%RA
140/ 88
1
0
1
0
0
0
0
0
0
1
3 N/A
N/A
N/A
N/A
DS
Example: Diazepam withdrawal regime (Mild Dependence)
6am 12 midday 6pm 12 midnight
Day 1 10mg 10mg 10mg 10mg
Day 2 10mg 10mg 10mg 10mg
Day 3 5mg 5mg 5mg 10mg
Day 4 5mg 5mg 5mg 10mg
Day 5 5mg - - 5mg
Day 6 5mg - - 5mg
Alcohol Withdrawal Assessment Scoring Guidelines (CIWA - AR)
Na usea / vomiting - R a te o n sca le 0- 7
0 - No ne
1 - M ild na use a with no vo miting
2 -
3 -
4 - I nte rmitte nt na us ea
5 -
6 -
7 - C o ns ta nt na us ea a nd f re que nt dry he a ve s a nd vo miting
Tremors - have patient extend arms & spread fingers. Rate on scale 0
-7
0 - No tremor
1 - Not vis ible, but can be felt fingertip to fingertip
2 -
3 -
4 - Moderate, with patient’s arm extended
5 -
6 -
7 - severe, even w/ arms not extended
Anx iety - R a te o n s ca le 0 - 7
0 - No a nxie ty, pa tie nt a t e as e
1 - M ildly a nxio us
2 -
3 -
4 - Mo de ra te ly a nxio us o r gua rde d, so a nxie ty is inf e rre d
5 -
6 -
7 - e quiva le nt to a c ute pa nic s ta te s se e n in s e ve re
de lirium o r a c ute sc hiz o phre nic re ac tio ns
Ag ita tion - R a te o n s ca le 0 - 7
0 - No rma l a c tivity
1 - So me wha t no rma l a c tivity
2 -
3 -
4 - Mo de ra te ly f idge ty a nd res tle ss
5 -
6 -
7 - P ac es bac k a nd fo rth, o r c o ns ta ntly thra s he s a bo ut
Tactile disturbances - Ask, “Have you experienced any itching, pins
& needles sensation, burning or numbness, or a feeling bugs crawling
on or under your skin?”
0 - None
1 - Very mild itching, pins & needles, burning, or numbness
2 - Mild itching, pins & needles, burning, or numbness
3 - Moderate itching, pins & needles, burning, or numbness
4 - Moderate hallucinations
5 - Severe hallucinations
6 - Extremely severe hallucinations
7 - Continuous hallucinations
P a r ox ysma l Swea ts - Ra te o n sc a le 0 - 7
0 - No s we a ts
1 - Ba re ly pe rc e ptible s wea ting, pa lms mo is t
2 -
3 -
4 - Be a ds o f s wea t o bvio us o n f o re hea d
5 -
6 -
7 - D re nc hing s we a ts
Or ienta tion a nd clouding of sensor ium - As k “W ha t da y is this ?
W he re a re yo u? W ho a m I ” R a te sc a le 0 - 4
0 - Orie nte d
1 - C a nno t do se ria l a dditio ns o r is unc e rta in a bo ut da te
2 - D is o rie nte d to da te by no m or e tha n 2 ca le n da r d a ys
3 - D is o rie nte d to da te by mo r e th a n 2 ca le nd a r d a ys ?
4 - D is o rie nte d to pla ce a nd / o r pe rso n
Auditory disturbances - Ask, “Are you more aware of sounds around
you? Are they hars h? Do they startle you? Do you hear anything that
disturbs you that you know isn’t there?”
0 - Not present
1 - Very mild harshness or ability to startle
2 - Mild harshness or ability to startle
3 - Moderate harshness or ability to startle
4 - Moderate hallucinations
5 - Severe hallucinations
6 - Extremely severe hallucinations
7 - Continuous hallucinations
Visual disturbances - Ask, “Does the light appear to be too bright? It
its colour different than normal? Does it hurt your eyes? Are you
seeing anything that disturbs you or that you know isn’t there?”
0 - No present
1 - Very mild sens itivity
2 - Mild sensitivity
3 - Moderate sensitivity
4 - Moderate hallucinations
5 - Severe hallucinations
6 - Extremely severe hallucinations
7 - Continuous hallucinations
Headache - Ask, “Does your head feel different than usual? Does it
feel like there is a band around your head?” So not rate dizziness or
lightheadedness.
0 - No present
1 - Very mild sens itivity
2 - Mild sensitivity
3 - Moderate sensitivity
4 - Moderate hallucinations
5 - Severe hallucinations
6 - Extremely severe hallucinations
7 - Continuous hallucinations
P ro ce dure : 1. A ss es s a nd ra te ea c h o f the 10 c rite ria of the CI WA s ca le. Eac h c rite rio n is ra te d o n a sc a le fo rm 0 to 7, e xpec t fo r “Orie nt a tio n a nd c lo uding o f
s e nso rium” whic h is ra te d o n a s ca le f ro m 0 to 4. A dd up the s co re d fo r a ll te n c rite ria / This is the to ta l CI WA - Ar s co re fo r th e pa tie nt a t the time . P ro phylac tic me dic a tio n, s ho uld be s ta rte d fo r a ny pa tie nt with a to ta l C IW A -A r sc o re of 8 o r grea te r ( ie . S ta rt o n withdr a wa l me dic a- tio n) . If s ta rte d o n s c he dule d me dicatio n s ho uld be give n fo r a to ta l C IW A - A r s co re of 15 o r gre a te r
2. D oc ume nt vita ls a nd CI WA - A r a ss es sme nt o n the W ithdra wa l As s ess me nt S he e t. Do c ume nt a dminis tra tio n o f PR N me dic a tio ns o n the as s es s- me nt s he e t as we ll.
3. The C I WA-A r Sc a le is the mos t se ns itive to o l fo r as se ss me nt of the pa tie nt e xpe rie nc ing a lc o ho l withdra wa l. Nurs ing a ss es s me nt i s vita lly impo rta nt. Ea rly inte rve ntio n f o r C IWA - A r sco re o f 8 o r grea te r pro vides the be s t mea ns to pre ve nt the pro gres sio n of withdra wa l .
Patient Name: ______________________________________ UR Number: _________________ Darren Roberts 075486
