CIWA, COWS Scale, And Drug Courts: Q’s And A’s
CIWA scale Right Ans - used by nurses to assess risk and severity of
*alcohol* withdrawal
CIWA- Scale assess for these common withdrawal symptoms Right Ans - -
nausea/vomiting
- tremors
- anxiety
- agitation
- paroxysmal sweats
- orientation and clouding of sensorium
- tactile disturbances
- auditory disturbances
- visual disturbances
- headache
CIWA procedure Right Ans - 1. Assess and rate each of the 10 criteria of the
CIWA scale. Each criterion is rated on a scale from 0 to 7, except for
"Orientation and clouding of sensorium" which is rated on scale 0 to 4. Add up
the scores for all ten criteria. This is the total CIWA-Ar score for the patient at
that time. Prophylactic medication should be started for any patient with a
total CIWA-Ar score of 8 or greater (ie. start on withdrawal medication). If
started on scheduled medication, additional PRN medication should be given
for a total CIWA-Ar score of 15 or greater.
2. Document vitals and CIWA-Ar assessment on the Withdrawal Assessment
Sheet. Document administration of PRN medications on the assessment sheet
as well.
3. 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.
when to perform vitals for CIWA Right Ans - b. If initial score greater or
equal to 8 repeat q1h x 8 hrs, then if stable q2h x 8 hrs, then if stable q4h.
, c. If initial score < 8, assess q4h x 72 hrs. If score < 8 for 72 hrs, d/c
assessment. If score greater or equal 8 at any time, go to above
Indications for PRN medication CIWA: Right Ans - a. Total CIWA-AR score 8
or higher if ordered PRN only (Symptom-triggered method).
b. Total CIWA-Ar score 15 or higher if on Scheduled medication. (Scheduled +
prn method)
Consider transfer to ICU for any of the following: Total score above 35, q1h
assess. x more than 8hrs required, more than 4 mg/hr lorazepam x 3hr or 20
mg/hr diazepam x 3hr required, or resp. distress
Scale for Scoring CIWA Right Ans - 0 - 9: absent or minimal withdrawal
10 - 19: mild to moderate withdrawal
more than 20: severe withdrawal
COWS Scale Right Ans - Clinical Opiate Withdrawal Scale
CIWA Right Ans - Clinical Institute Withdrawal Assessment
COWS scale
for buprenorphine/ naloxone induction: Right Ans - - enter scores at time
zero
- 1-2hrs after the first dose
- and at additional time that buprenorphine/naloxone is given
COWS scale
components assessed: Right Ans - - resting pulse (measured after patient is
sitting/lying for 1 minute)
- sweating (over past 1/2 hour not accounted for by room temperature or
patient activity)
CIWA scale Right Ans - used by nurses to assess risk and severity of
*alcohol* withdrawal
CIWA- Scale assess for these common withdrawal symptoms Right Ans - -
nausea/vomiting
- tremors
- anxiety
- agitation
- paroxysmal sweats
- orientation and clouding of sensorium
- tactile disturbances
- auditory disturbances
- visual disturbances
- headache
CIWA procedure Right Ans - 1. Assess and rate each of the 10 criteria of the
CIWA scale. Each criterion is rated on a scale from 0 to 7, except for
"Orientation and clouding of sensorium" which is rated on scale 0 to 4. Add up
the scores for all ten criteria. This is the total CIWA-Ar score for the patient at
that time. Prophylactic medication should be started for any patient with a
total CIWA-Ar score of 8 or greater (ie. start on withdrawal medication). If
started on scheduled medication, additional PRN medication should be given
for a total CIWA-Ar score of 15 or greater.
2. Document vitals and CIWA-Ar assessment on the Withdrawal Assessment
Sheet. Document administration of PRN medications on the assessment sheet
as well.
3. 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.
when to perform vitals for CIWA Right Ans - b. If initial score greater or
equal to 8 repeat q1h x 8 hrs, then if stable q2h x 8 hrs, then if stable q4h.
, c. If initial score < 8, assess q4h x 72 hrs. If score < 8 for 72 hrs, d/c
assessment. If score greater or equal 8 at any time, go to above
Indications for PRN medication CIWA: Right Ans - a. Total CIWA-AR score 8
or higher if ordered PRN only (Symptom-triggered method).
b. Total CIWA-Ar score 15 or higher if on Scheduled medication. (Scheduled +
prn method)
Consider transfer to ICU for any of the following: Total score above 35, q1h
assess. x more than 8hrs required, more than 4 mg/hr lorazepam x 3hr or 20
mg/hr diazepam x 3hr required, or resp. distress
Scale for Scoring CIWA Right Ans - 0 - 9: absent or minimal withdrawal
10 - 19: mild to moderate withdrawal
more than 20: severe withdrawal
COWS Scale Right Ans - Clinical Opiate Withdrawal Scale
CIWA Right Ans - Clinical Institute Withdrawal Assessment
COWS scale
for buprenorphine/ naloxone induction: Right Ans - - enter scores at time
zero
- 1-2hrs after the first dose
- and at additional time that buprenorphine/naloxone is given
COWS scale
components assessed: Right Ans - - resting pulse (measured after patient is
sitting/lying for 1 minute)
- sweating (over past 1/2 hour not accounted for by room temperature or
patient activity)
