Lippincott ® NursingCenter ® Wolters Kluwer Logo

Lippincott Nursing Pocket Card - April 2025

Alcohol Withdrawal Scale: CIWA-Ar

icon-howtouse.jpg

Clinical Institute Withdrawal Assessment of Alcohol Scale – Revised (CIWA-Ar)

The Clinical Institute Withdrawal Assessment of Alcohol Scale – Revised (CIWA-Ar) can help determine the need for medically supervised withdrawal management in patients who are able to communicate symptoms to their providers. Research has shown that use of the scale in the treatment of withdrawal reduced the total amount of benzodiazepines needed and shortened the duration of treatment (Pace, 2024). The following scale has been adopted from Sullivan et al., 1989. Add the scores from each category and determine the level of alcohol withdrawal at the end.
 

NAUSEA and VOMITING: Ask “Do you feel sick to your stomach? Have you vomited?” Observation.
   0    No nausea and no vomiting
1 Mild nausea with no vomiting
2  
3  
4 Intermittent nausea with dry heaves
5  
6  
7 Constant nausea, frequent dry heaves, and vomiting
 
PAROXYSMAL SWEATS: Observation.                                                                                                         
   0  No sweat visible
1 Barely perceptible sweating, palms moist
2  
3  
4 Beads of sweat obvious on forehead
5  
6  
7 Drenching sweats
 
ANXIETY: Ask “Do you feel nervous?” Observation.                                                                                  
     0     No anxiety, at ease
1 Mild anxiety
2  
3  
4 Moderately anxious, or guarded
5  
6  
7 Acute panic state, consistent with severe delirium or acute schizophrenia

icon-info.jpg

AGITATION: Observation.
       0       Normal activity
1 Somewhat more than normal activity
2  
3  
4 Moderately fidgety and restless
5  
6  
   7    Paces back and forth during most of the interview, or constantly thrashes about                              
 
TREMOR: Arms extended and fingers spread apart. Observation.                                                              
  0   No tremor
1 Not visible, but can be felt at fingertips
2  
3  
4  
5  
6  
7  
 
HEADACHE, FULLNESS IN HEAD: Ask “Does your head feel different? Do you feel pressure?” Do not rate for dizziness or lightheadedness. Otherwise, rate severity.
0 Not present
1 Very mild
2 Mild
3 Moderate
4 Moderately severe
5 Severe
6 Very severe
7 Extremely severe
 
AUDITORY DISTURBANCES: Ask “Are you more aware of sounds around you? Are they harsh or frightening? Do hear things that you know aren’t there?” Observation.
  0   Not present
1 Very mild harshness or ability to frighten
2 Mild harshness or ability to frighten
3 Moderate harshness or ability to frighten
4 Moderately severe hallucinations
5 Severe hallucination
6 Extremely severe hallucinations
7 Continuous hallucinations

VISUAL DISTURBANCES: Ask “Does the light appear to be too bright? Does it hurt your eyes? Are you seeing things you know aren’t there? Observation.
  0   Not present
1 Very mild photosensitivity
2 Mild photosensitivity
3 Moderate photosensitivity
4 Moderately severe visual hallucinations
5 Severe visual hallucination
6 Extremely severe visual hallucinations
7 Continuous visual hallucinations
 
TACTILE DISTURBANCES: Ask “Have you had any itching, pins and needles sensations, burning, numbness, or feel bugs crawling under your skin?” Observation.
     0      None
1 Very mild paresthesias (itching, pins and needles, burning or numbness)
2 Mild paresthesias
3 Moderate paresthesias
4 Moderately severe hallucinations
5 Severe hallucination
6 Extremely severe hallucinations
7 Continuous hallucinations
 
ORIENTATION AND CLOUDING OF SENSORIUM: Ask “What day is this? Where are you? Who am I?” Count forward by three.
    0     Oriented and can perform serial additions
1 Cannot perform serial additions or is uncertain about the date
2 Disoriented for date by no more than 2 calendar days
3 Disoriented for date by more than 2 calendar days
4 Disoriented for place and/or person

Total score is the sum of each item score (maximum score is 67)
Score:  
Less than 10 Very mild withdrawal
10 to 15 Mild withdrawal
16 to 20 Modest withdrawal
Greater than 20 Severe withdrawal
References
Pace, C. (2024, February23). Alcohol withdrawal: Epidemiology, clinical manifestations, course, assessment, and diagnosis. UpToDate. https://www.uptodate.com/contents/alcohol-withdrawal-epidemiology-clinical-manifestations-course-assessment-and-diagnosis
 
Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A., & Sellers, E. M. (1989). Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). British journal of addiction, 84(11), 1353–1357. https://doi.org/10.1111/j.1360-0443.1989.tb00737.x

Download this Tip:

CE Resources

Nursing Resources

About NursingCenter

 

© 2025 Wolters Kluwer Health, Inc. and/or its subsidiaries. All rights reserved. – Terms & Conditions – Privacy Policy – Disclaimer – Your California Privacy Choices -- v10.02.00