for NICOHWILLIAM ONLY WK 8 FINAL ASSIGNMENT new question coming to pay.

ID #: _________________________ Date: ___ ___ / ___ ___ / ___ ___ ___ ___

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{Module Name} Module

Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)

For each section, ask the prompts and/or observe behavior.

1. Time: 24 hour clock, midnight=00:00 __ __:__ __

2. Pulse or heart rate, taken for one minute

__ __ __ bpm

3. Blood pressure

__ __ __/__ __ __ mm/Hg

4. NAUSEA AND VOMITING Do you feel sick to your stomach? Have you vomited?

No nausea and no vomiting 0 Mild nausea with no vomiting 1

2 3

Intermittent nausea with dry heaves 4 5 6

Constant nausea, frequent dry heaves and vomiting 7 5. TACTILE DISTURBANCES

Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?

None 0 Very mild itching, pins and needles, burning or numbness 1

Mild itching, pins and needles, burning or numbness 2 Moderate itching, pins and needles, burning or numbness 3

Moderately severe hallucinations 4 Severe hallucinations 5

Extremely severe hallucinations 6 Continuous hallucinations 7

6. TREMOR Arms extended and fingers spread apart.

No tremor 0 Not visible, but can be felt fingertip to fingertip 1

2 3

Moderate, with patient's arms extended 4 5 6

Severe, even with arms not extended 7

Agency Name: _________________________ Site Name: _________________________

ID #: _________________________ Date: __ __ / __ __ / __ __ __ __

ID #: _________________________ Date: ___ ___ / ___ ___ / ___ ___ ___ ___

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7. AUDITORY DISTURBANCES Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?

Not present 0 Very mild harshness or ability to frighten 1

Mild harshness or ability to frighten 2 Moderate harshness or ability to frighten 3

Moderately severe hallucinations 4 Severe hallucinations 5

Extremely severe hallucinations 6 Continuous hallucinations 7

8. PAROXYSMAL SWEATS No sweat visible 0

Barely perceptible sweating, palms moist 1 2

3 Beads of sweat obvious on forehead 4

5 6

Drenching sweats 7

9. VISUAL DISTURBANCES Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?

Not present 0 Very mild sensitivity 1

Mild sensitivity 2 Moderate sensitivity 3

Moderately severe hallucinations 4 Severe hallucinations 5

Extremely severe hallucinations 6 Continuous hallucinations 7

10. ANXIETY Do you feel nervous?

No anxiety, at ease 0 Mild anxious 1

2 3

Moderately anxious, or guarded, so anxiety is inferred 4 5 6

Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions 7

ID #: _________________________ Date: ___ ___ / ___ ___ / ___ ___ ___ ___

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11. HEADACHE, FULLNESS IN HEAD Does your head feel different? Does it feel like there is a band around your head? Do not rate for dizziness or lightheadedness. Otherwise, rate severity.

Not present 0 Very mild 1

Mild 2 Moderate 3

Moderately severe 4 Severe 5

Very severe 6 Extremely severe 7

12. AGITATION Normal activity 0

Somewhat more than normal activity 1 2 3

Moderately fidgety and restless 4 5 6

Paces back and forth during most of the interview or constantly thrashes about 7

13. ORIENTATION AND CLOUDING OF SENSORIUM What day is this? Where are you? Who am I?

Oriented and can do serial additions 0 Cannot do serial additions or is uncertain about date 1

Disoriented for date by no more than 2 calendar days 2 Disoriented for date by more than 2 calendar days 3

Disoriented for place/or person 4

14. Total Score: __ __ Maximum Possible Score=67 Patients scoring less than 10 do not usually need additional medication for withdrawal.

Reference: Sullivan JT; Sykora K; Schneiderman J; Naranjo CA; Sellers EM. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-AR). Br J Addict 1989;84:1353-1357.