Psychiatric CIWA Protocols

Clinical Institute Withdrawal Assessment (CIWA ) protocols provide a quantitative assessment to guide medical treatment to safely help a patient through varying degrees of alcohol withdrawal. CIWA protocols consist of 10 evaluation categories. Each category is rated on a scale of zero to seven, except for orientation which is scored zero to four, based on severity of symptoms over two to four hours. Of the ten categories, five are involve psychological determinations. They are orientation, agitation, anxiety, auditory disturbances and visual disturbances. The higher the score, the greater the need for medical intervention.

Auditory Disturbances

• Ask during initial assessment whether the person is unusually aware of sounds and whether they are harsh, threatening, frightening or disturbing. Ask whether the patient is hearing sounds they know are not present. Points are assessed on the patient's response and nurse's observation, rating from zero for not present to six or seven for severe sounds or continuous sounds not present.

Visual Disturbances

• Evaluate sensitivity to light and color, as well as any disturbing influence they may have. Determine whether the patient is seeing things that he knows are not present. The rating scale is zero for not present to seven for extreme and continuous sensitivity, based on patient responses and nurse's observation.

Anxiety

• Nurses must determine a patients degree of nervousness. This is a judgment call based on the patient response ranging from no anxiety (zero points) to "severe delirium" or "schizophrenic reactions" (six or seven points), based upon the nurse's psychological evaluation.

Agitation

• Observation by the attending nurse determines the score for a patients degree of agitation. The scoring ranges from normal (zero points) to moderate fidgeting (four points) to pacing or thrashing about (seven points). This is purely a subjective and requires psychological evaluation on the part of the nurse.

Orientation

• Reciting numbers or letters in sequence determines part of the the orientation score. A nurse could ask a patient to count backward from 100 or to recite the alphabet starting with the letter "L," for example. This is a four point scale based on whether the patient can perform these basic serial recitations. Knowing the date and his location comprise the rest of the orientation protocol. He is rated zero points if he can perform the tasks satisfactorily, one point if he cannot perform serial recitation or is uncertain about the date, two points if he is uncertain about the date by up to two days and three points if he cannot identify the day within two days. The patient is scored four points if he is uncertain about who or where he is.

Numbers Aren't Everything

• The nurse, CIWA numbers, doctor, pre-existing medical conditions, medical testing from blood analysis and age all play a part in the overall prognosis and the degree, if any, that medical intervention is necessary to treat apparent withdrawal symptoms.