Withdrawal Assessment Tools

The Withdrawal Assessment Tool (WAT-1) is used to assess withdrawal reactions of patients detoxing from opiates, benzodiazepines or other chemical substances. Information is recorded from the first day the patient enters detox, and his reaction changes and improvement are then monitored throughout the entire withdrawal process.

Patient Information

• When patients are admitted for withdrawal or detox from chemical substances, the hospital or clinic first gathers general personal information. The chemical substance that the patient is withdrawing from should be identified. The date and time the patient enters withdrawal should also be recorded. Information on the patient's last 12 hours of activity also should be entered into the records, if possible.

Assessment Instructions

• Patients withdrawing from opiates or benzodiazepines should be assessed with the WAT-1. Assessment must be started on the first day the patient begins the process. The WAT-1 should be completed once every 12 hours. In this way, withdrawal signs can be observed and followed as they change.

Withdrawal Assessment Scoring

• Symptoms are scored according to a number system. The assessment uses a question format, which determines if the patient has loose or watery stools; is vomiting, retching or gagging; has a temperature greater than 100 degrees Fahrenheit; is experiencing tremors; is sweating; is exhibiting uncoordinated or repetitive movement; is yawning or sneezing; or is startled to the touch. The patient is also scored on how long it takes him to reach post-stimulus recovery and regain a calm state. The total score can be anywhere from 0 to 12. Questions are answered with a 0 or a 1, with 0 meaning "no" and 1 meaning "yes." For example, if the patient has watery stools, the nurse should indicate the number 1; if not, the nurse would indicate the number 0. In the case of temperature, the score is 1 if the temperature is greater than 100 degrees Fahrenheit and 0 if not. Scores are added once all categories are scored. Time to regain a calm state is assessed with a 1 or a 2. If a calm state is achieved anywhere from two to five minutes after stimulus (after administering medication for detox), the score is 1. If the calm state takes more than five minutes to achieve, the score is 2.

Alcohol Withdrawal Assessment

• When patients are withdrawing from alcohol, the withdrawal assessment is scored in a slightly different manner. Patients are assessed for nausea and vomiting, tremors, anxiety, agitation, paroxysmal sweats, orientation and clouding of perception, tactile disturbances, auditory and visual disturbances, and headache. Symptoms are rated on a scale from 0 to 7, with the exception of orientation and clouding of perception, which is rated on a scale from 0 to 4. Zero means the symptom is not present, 4 means the symptom is moderate and 7 means the symptom is severe. For assessing orientation and perception, the nurse or doctor will ask the patient if he knows today's date or who he is. Orientation and perception questions allow the doctor to understand whether the patient is disillusioned. Zero means the patient is oriented, two means the patient is mildly disoriented and four means the person does not know the date or who he is. Based on the score, health care providers will decide if prophylactic medication should be administered to correct chemical imbalances in the brain, which can be a characteristic of alcohol abuse. If the total score is more than 8, medication should be administered.