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Utilizing the Adult Alcohol Withdrawal Syndrome Order form & CIWA-Ar tool Prepared by Buffalo General Hospital Departments of Pharmacy and Clinical Education.

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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:

1 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

2 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.

3 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.

4 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

5 On the back of the order form:

6 On line Calculator: CIWA-Ar Clinical Institute Withdrawal Assessment for Alcohol Scale  Sample sections:  Sample sections: NAUSEA AND VOMITING: Ask "Do you feel sick to your stomach? Have you vomited?" Observation. -No nausea and no vomiting (0 points) -Mild nausea with no vomiting (1 point) -Intermittent nausea with dry heaves (4 points) -Constant nausea, frequent dry heaves and vomiting (7 points) TREMOR: Arms extended and fingers spread apart. Observation -No tremor (0 points) -Not visible, but can be felt fingertip to fingertip (1 point) -Moderate, with patient's arms extended (4 points) -Severe, even with arms not extended (7 points) PAROXYSMAL SWEATS: Observation -No sweat visible (0 points) -Barely perceptible sweating, palms moist (1 point) -Beads of sweat obvious on forehead (4 points) -Drenching sweats (7 points) ANXIETY: Ask "Do you feel nervous?" Observation. -No anxiety, at ease (0 points) -Mildly anxious (1 point) -Moderately anxious, or guarded, so anxiety is inferred (4 points) -Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions (7 points) AGITATION: Observation -Normal activity (0 points) -Somewhat more than normal activity (1 point) -Moderately fidgety and restless (4 points) -Paces back and forth during most of the interview, or constantly thrashes about (7 points) It seems to us that you have your JavaScript turned off on your browser. JavaScript is required in order for our site to behave correctly. Please enable your JavaScript to continue use our site. Calculator: CIWA-Ar Clinical Institute Withdrawal Assessment for Alcohol Scale NAUSEA AND VOMITING: Ask "Do you feel sick to your stomach? Have you vomited?" Observation.No nausea and no vomiting (0 points)Mild nausea with no vomiting (1 point)Intermittent nausea with dry heaves (4 points)Constant nausea, frequent dry heaves and vomiting (7 points)TREMOR: Arms extended and fingers spread apart. ObservationNo tremor (0 points)Not visible, but can be felt fingertip to fingertip (1 point)Moderate, with patient's arms extended (4 points)Severe, even with arms not extended (7 points)PAROXYSMAL SWEATS: ObservationNo sweat visible (0 points)Barely perceptible sweating, palms moist (1 point)Beads of sweat obvious on forehead (4 points)Drenching sweats (7 points)ANXIETY: Ask "Do you feel nervous?" Observation.No anxiety, at ease (0 points)Mildly anxious (1 point)Moderately anxious, or guarded, so anxiety is inferred (4 points)Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions (7 points)AGITATION: ObservationNormal activity (0 points)Somewhat more than normal activity (1 point)Moderately fidgety and restless (4 points)Paces back and forth during most of the interview, or constantly thrashes about (7 points) TACTILE DISTURBANCES: Ask "Have you any itching, pins and needles sensations, burning sensations, numbness or do you feel bugs crawling on or under your skin?" Observation. None (0 points)Very mild itching, pins and needles, burning or numbness (1 point)Mild itching, pins and needles, burning or numbness (2 points)Moderate itching, pins and needles, burning or numbness (3 points)Moderately severe hallucinations (4 points)Severe hallucinations (5 points)Extremely severe hallucinations (6 points)Continuous hallucinations (7 points) AUDITORY DISTURBANCES: Ask "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?" Observation. Not present (0 points)Very mild harshness or ability to frighten (1 point)Mild harshness or ability to frighten (2 points)Moderate harshness or ability to frighten (3 points)Moderately severe hallucinations (4 points)Severe hallucinations (5 points)Extremely severe hallucinations (6 points)Continuous hallucinations (7 points) VISUAL DISTURBANCES: Ask "Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation. Not present (0 points)Very mild sensitivity (1 point)Mild sensitivity (2 points)Moderate sensitivity (3 points)Moderately severe hallucinations (4 points)Severe hallucinations (5 points)Extremely severe hallucinations (6 points)Continuous hallucinations (7 points) HEADACHE, FULLNESS IN HEAD: Ask "Does your head feel different? Does it feel as if there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity. Not present (0 points)Very mild (1 point)Mild (2 points)Moderate (3 points)Moderately severe (4 points)Severe (5 points)Very severe (6 points)Extremely severe (7 points)ORIENTATION AND CLOUDING OF SENSORIUM: Ask "What day is this? Where are you? Who am I? Count forward by 3Oriented and can do serial additions (0 points)Cannot do serial additions or is uncertain about date (1 point)Disoriented for date by no more than 2 calendar days (2 points)Disoriented for date by more than 2 calendar days (3 points) Disoriented for place and/or person (4 points) Total Criteria Point Count: Use of UpToDate is subject to the Subscription and License Agreement.Subscription and License Agreement Legal Notices and Disclaimer All information contained in and produced by the MedCalc 3000 system is provided for educational purposes only. This information should not be used for the diagnosis or treatment of any health problem or disease. THIS INFORMATION IS NOT INTENDED TO REPLACE CLINICAL JUDGMENT OR GUIDE INDIVIDUAL PATIENT CARE IN ANY MANNER. Click here for full notice and disclaimer.Click here for full notice and disclaimer. MedCalc 3000 is Copyright © 1998-2010 Foundation Internet Services © 2010 UpToDate, Inc. All rights reserved. | Subscription and License Agreement |Support Tag: [ecapp0602p.utd.com-199.33.173.1-B048A2E7C7-2405] Licensed to: Kaleida HlthSubscription and License Agreement ONLINE 18.1 HomeHome | Contact us | About UpToDate | Careers | HelpContact usAbout UpToDateCareersHelp New Search Patient Info What's New Calculators LOG IN FEEDBACK Calculator: CIWA-Ar clinical institute withdrawal assessment for alcohol scale F ind F ind P rint P rint Calculator: CIWA-Ar clinical institute withdrawal assessment for alcohol scale CIWA Score Interpretation References 1.Stuppaeck CH, Barnas C et al. Assessment of the alcohol withdrawal syndrome - validity and reliability of the translated and modified Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-A). Addiction. 1994; 89: 1287-1292. 2.Sullivan JT, Sykora K et al. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addiction. 1989; 89: 1353-1357.

7 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

8 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

9 Front of form

10 CIWA-Ar Documentation Prescriber to fill in first CIWA-Ar score in “Monitoring” section. Prescriber will check the desired protocol in the table.

11 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

12 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”

13 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

14 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.

15 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.

16 Scenario 1 (continued) Use this chart to determine his CIWA-Ar Score.

17 Scenario 1-What is his CIWA-Ar Score? Answer=3

18 Scenario 1-continued  What medication should be administered?  When should the CIWA-Ar score be repeated?

19 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

20 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

21 Scenario 2-continued What is the patient’s CIWA-Ar score now?

22 Scenario 2-What is his CIWA-Ar Score now? Answer=26

23 Scenario 2-continued  What medication should be administered?  When should the CIWA-Ar score be repeated?  Should any additional interventions be initiated?

24 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

25 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


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