CIWA-Ar Documentation: A Nursing Guide to Alcohol Withdrawal Scoring

What CIWA-Ar Measures

The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) is a 10-item scale that assesses the severity of alcohol withdrawal. Each item scores between 0 and 7, except for orientation, which scores between 0 and 4. The total range is 0-67, although scores above 45 are rare in practice. Sullivan, Sykora, Schneiderman, Naranjo, and Sellers developed the CIWA-Ar at the Addiction Research Foundation in Toronto, publishing it in 1989. This scale replaced the original CIWA, which lacked rigorous validation. It is used in detox units, medical and psychiatric floors, emergency departments, and ICUs - anywhere a patient may experience alcohol withdrawal. The 10 items include: nausea and vomiting (0-7), tremor (0-7), paroxysmal sweats (0-7), anxiety (0-7), agitation (0-7), tactile disturbances (0-7), auditory disturbances (0-7), visual disturbances (0-7), headache/fullness in head (0-7), and orientation/clouding of sensorium (0-4).

How to score each CIWA item

Most CIWA items use a 0-7 descriptive scale where 0 means the symptom is not present and 7 means the symptom is at its most severe. Use the standardized descriptors on the scoring sheet, not your own interpretation. The following are examples of these descriptions, but it is not a comprehensive list. For tremor: 0 = no tremor, 1 = not visible but can be felt fingertip to fingertip, 4 = moderate with arms extended, 7 = severe even with arms not extended. For anxiety: 0 = no anxiety, 1 = mildly anxious, 4 = moderately anxious/guarded, 7 = equivalent to acute panic states. For tactile disturbances: 0 = none, 1 = very mild itching/pins and needles/burning/numbness, 4 = moderate hallucinations, 7 = continuous hallucinations. Scoring is subjective for many items - consistency across assessors is a known challenge. The best defense is to: document WHAT you observed alongside the score. "Tremor 4 (moderate, visible with arms extended)" is more defensible than "Tremor 4" alone.

Scoring and Documentation Workflow

The CIWA assessment follows a score-intervene-reassess workflow.

Step 1: Assess at the ordered interval. Step 2: Score each item per the standardized descriptors. Step 3: Sum the total. Step 4: Compare the total to your facility's protocol thresholds. Step 5: Administer medication if the protocol indicates and you have an active order. Step 6: Document everything - time, item scores, total, action taken, and reassessment plan. Step 7: Schedule the next assessment per the protocol. This is a loop, not a one-time event. After medication administration, reassess within 30-60 minutes (per protocol) to document the response. The reassessment is part of the loop - do not skip it.

What to Document for Each Assessment

A complete CIWA chart entry has 6 pieces of information.

1. Time of assessment (military time - CIWA is time-sensitive and protocols are interval-based). 2. Item-level scores (detailing the number value for each item, not just the total score). 3. Total score. 4. Protocol action taken (medication given, none needed, or escalated to provider). 5. Patient response (if medication was given and you have reassessed). 6. Time of next scheduled assessment. Example format: 1400 CIWA-Ar 12 (Nausea 2, Tremor 4, Sweats 3, Anxiety 2, Agit 1, Tactile 0, Auditory 0, Visual 0, Headache 0, Orient 0). Per protocol: lorazepam 2mg PO given at 1405. Next assessment 1500.

Protocol Interpretation Basics

CIWA protocols vary by institution - always use YOUR facility's protocol, not a generic one from the internet. That said, most follow a common pattern. A typical CIWA protocol might be: score <10 - no medication, monitor per schedule. Score 10-18 - PRN benzodiazepine (usually lorazepam 1-2mg or diazepam 5-10mg). Some facilities use phenobarbital. Follow your facility's guidelines. Score ≥19 - PRN medication plus provider notification. Some protocols may have fixed-schedule dosing above this threshold, or may have fixed-dose scheduling from the start. Know your protocol's re-score intervals: commonly Q1h if the score is elevated, Q2h if stable mid-range, Q4h if stable, and Q8h if stable and low.

Medication Compliance Tracking

Withdrawing patients are commonly on concurrent psychotropics, so medication compliance documentation shows up alongside CIWA scoring in the same shift.

The framework (compliant, partial, refusing) and the refusal → education → outcome documentation loop are covered in the Psychiatric Nursing Charting guide. Use the same pattern for any psychotropic given during the withdrawal protocol.