Search results
The CIWA-Ar is a 10-item scale that measures the severity of alcohol withdrawal symptoms and predicts the risk of complications. It is easy to use, reliable, and validated by expert ratings and clinical outcomes.
The CIWA-Ar is not copyrighted and may be reproduced freely. This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. The maximum score is 67 (see instrument). Patients scoring less than 10 do not usually need additional medication for withdrawal.
The CIWA-Ar scale is the most sensitive tool for assessment of the patient experiencing alcohol withdrawal. Nursing assessment is vitally important. Early intervention for CIWA-Ar score of 8 or greater provides the best means to prevent the progression of withdrawal.
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.
Moist skin. Beads on face and body. Profuse, whole body wet. 0. No tremor. Tremor can be felt in fingers. Visible tremor but mild. Moderate tremor, arms out. Severe, arms not extended.
The MINDS protocol is an alcohol withdrawal scoring tool which has been studied in the ICU setting. Check vitals signs and arousability (RASS score) q 4 hours or based on protocol. Other causes for delirium and agitation must always be considered (i.e. hypoxia or sepsis).
Learn how to recognize, assess, and treat alcohol withdrawal syndrome in primary care. The article includes the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised, and the Short Alcohol Withdrawal Scale as tools to measure symptoms.
