CIWA interpretation questions

June 14, 2018

Alcohol withdrawal syndrome is a common medical problem and follows the abrupt discontinuation of, or at least the rapid decrease in intake of alcohol, the use of which has been heavy and prolonged. The syndrome usually begins within 6-8 hours of alcohol cessation or reduction, though alcohol withdrawal delirium does not usually develop for 2–3 days after stopping drinking and usually lasts for at least 48–72 hours.

If patient admission not avoided follow management plan and refer to Alcohol Withdrawal Guidelines via connect. Based on undertaking CIWA scoring it may be useful to use this scoring interpretation guideline alongside your assessment.

a) Nausea & Vomiting. Ask ‘Do you feel sick?’ ‘Have you vomited?’

b) Paroxysmal sweats. Use observation. Is the patient clammy/sweaty? Beads of sweat to forehead? Drenching sweats?

c) Anxiety. Ask ‘Do you feel nervous?’ ‘Do you feel calm inside or churned up?’ Use observation is the patient at ease?

d) Agitation. Use observation. Is the patient restless/fidgety?

e) Tremor. Use observation. View the patient from afar before approaching them. Is their tremor visible? How severe when patients arms extended. Is the tremor severe even with arms not extended?

f) Headache. Ask patient. How severe?

g) Auditory disturbances. Ask ‘Are you more aware of noise around you?’ ‘Are you hearing things you know are not there?’

h) Visual disturbances. Ask ‘Does the light appear to be too bright?’ ‘Does it hurt your eyes?’ ‘Are you seeing things which you feel may not be real?’

i) Tactile disturbances. Ask ‘Do you have any itching, pins and needles sensations, burning or numbness?’

j) Orientation. Ask ‘What day is it?’ ‘Where are you?’ ‘Who am I?’