Presentation on theme: "Utilizing the Adult Alcohol Withdrawal Syndrome Order form & CIWA-Ar tool Prepared by Buffalo General Hospital Departments of Pharmacy and Clinical Education."— Presentation transcript:
Utilizing the Adult Alcohol Withdrawal Syndrome Order form & CIWA-Ar tool Prepared by Buffalo General Hospital Departments of Pharmacy and Clinical Education Utilizing the Adult Alcohol Withdrawal Syndrome Order form & CIWA-Ar tool Prepared by Buffalo General Hospital Departments of Pharmacy and Clinical Education April 2010
Alcohol Withdrawal Syndrome (AWS) Definition: discontinuation or reduction of prolonged, heavy alcohol use that results in minor or major withdrawal symptoms. Minor withdrawal symptoms include: tremor, hypertension, diaphoresis and tachycardia. Symptoms can occur within 6-12 hours from last drink. Serious withdrawal complications include: seizures and delirium tremens (DTs). Symptoms can occur within 48-96 hours from last drink. Severity of symptoms is related to amount of alcohol intake and duration of patient’s recent drinking habit.
Clinical Institute Withdrawal Assessment for Alcohol Scale, revised (CIWA-Ar) This assessment scale: Objectively assesses Objectively assesses patients for the development of acute alcohol withdrawal. well-documented Has well-documented reliability and validity. Is a 10-item scale that assesses the severity of withdrawal. basis for prescribing medication management Serves as a basis for prescribing medication management.
CIWA-Ar This 10-item scale can be located in 2 places: On the back of the order form (requires addition calculation) or by using an online CIWA-Ar calculator that can be placed on a computer desktop. The 10 items to be assessed are: Nausea & vomitingVisual disturbances Headache, fullness in head Agitation Paroxysmal sweatsTactile disturbances Auditory disturbances Tremor AnxietyOrientation & clouding of sensorium
CIWA-Ar Score Total score is a simple sum of each item score (maximum score is 67) less than 10 = very mild withdrawal 10-15 = mild withdrawal 16-20 = modest withdrawal greater than 20 = severe greater than 20 = severe withdrawal
Adult Alcohol Withdrawal Syndrome Orders Adult Alcohol Withdrawal Syndrome Orders A new form developed to incorporate the CIWA-Ar assessment scale as well as physician orders to manage the patient’s alcohol withdrawal safely
CIWA-Ar Documentation Prescriber to fill in first CIWA-Ar score in “Monitoring” section. Prescriber will check the desired protocol in the table.
CIWA-Ar Calculation and Documentation Registered Nurse must obtain all subsequent CIWA-Ar scores and document in “Alteration in Neurological Status” section of the “Adult Patient Plan of Care Record” (write in on blank line) Frequency of patient assessment and scoring is dictated by the protocol table at bottom of the order form. CIWA-Ar Score 3
CIWA-Ar Online Calculator* *Note: check your desktop on WOWs FIRST…the CIWA- Ar calculator icon may already be there! Available from “UpToDate” and can be placed on computer desktop by following these steps: Go to “Kaleidascope” home page Click on “Applications” tab Click on “UpToDate.com” then enter “UpToDate.com” button then “Accept” button Click on “Calculators” tab Click on “Primary Care Calculators” Right click on “Calculator: CIWA-Ar Clinical Institute Withdrawal Assessment for Alcohol Scale” and select “Copy Shortcut” Go to desktop and right click in blank area and select “Paste Shortcut”
Frequency of Assessing CIWA-Ar Score Frequency of score depends on current CIWA-Ar* score: 1-9q4h while awake If score is 1-9: repeat score q4h while awake, until score is less than 10 for 24 hours; then repeat score q8h for 48 hours 10-15: repeat score q2h If score is 10-15: repeat score q2h 16-20: repeat score q2h If score is 16-20: repeat score q2h greater than 20: repeat score q1h If score is greater than 20: repeat score q1h or as clinically indicated along with vital signs. * Higher Score indicates more severe symptoms, necessitating more frequent patient assessment
Duration of Order Set less than 10 for 72 hours The protocol is to be discontinued when the CIWA-Ar score has been less than 10 for 72 hours.
Scenario 1-Introduction A 47 year old male is admitted with diagnosis of cellulitis. The Adult Alcohol Withdrawal Syndrome Orders were initiated- and the Lorazepam protocol was selected based on his symptoms and history. Patient Assessment: is awake, alert & oriented X 3 complains of being a little nauseous but has not vomited has a very mild headache feels a little anxious The patient does not have: any visual, auditory or tactile disturbances; paroxysmal sweats agitation or tremors. The patient states he drinks approximately 2-3 beers/day.
Scenario 1 (continued) Use this chart to determine his CIWA-Ar Score.
Scenario 1-continued What medication should be administered? When should the CIWA-Ar score be repeated?
Scenario 1 answers What is his CIWA-Ar Score? 3 What medication should he receive? No medication necessary When should the CIWA-Ar Score be repeated? Every 4 hours while awake
Scenario 2 8 hours later the patient is still awake, alert & oriented x 3 and has the following: Intermittent nausea with dry heaves Moderate headache Sweat seen on forehead Moderately anxious Moderately fidgety Severe tremors even without arms being extended Patient does not have auditory, visual or tactile disturbances
Scenario 2-continued What is the patient’s CIWA-Ar score now?
Scenario 2-What is his CIWA-Ar Score now? Answer=26
Scenario 2-continued What medication should be administered? When should the CIWA-Ar score be repeated? Should any additional interventions be initiated?
Scenario 2 (answers) What is his CIWA-Ar Score now? 26 What medication should he receive? Lorazepam 3mg po NOW and every 1 hour as needed When should the CIWA-Ar Score be repeated? Every hour along with vital signs Should any additional interventions be initiated? Yes, contact prescriber to evaluate; document assessment and interventions in patient’s chart
Conclusion The CIWA-Ar scale is a very useful tool to: Measure severity of withdrawal symptoms Guide medication administration based on severity of symptoms Assure patient safety during withdrawal