FEB 2020 U.S. DEPARTMENT OF JUSTICE
ALCOHOL WITHDRAWAL ASSESSMENT AND TREATMENT FLOWSHEET FEDERAL BUREAU OF PRISONS
a. Assess vitals and CIWA-Ar.
b. If total CIWA-Ar score > 8, repeat every hour. Once the
CIWA-Ar score < 8, then repeat every 4–8 hours until score
has remained < 8 for 24 hours.
c. If initial Total CIWA-Ar score < 8, repeat CIWA every 4–8 for
24 hours.
d. If indicated, administer PRN medications per BOP protocol.
Time
O
2
sat
Use the CIWA-Ar Scale to assess and rate each of the following 10 criteria.
Nausea/Vomiting: Rate on scale of 0–7.
0 - none; 1 - mild nausea, no vomiting; 4 - intermittent nausea; 7 - constant nausea,
frequent dry heaves and vomiting
Tremors: Have patient extend arms and spread fingers. Rate on scale of 0–7.
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
Anxiety: Rate on scale of 0–7.
0 - none, at ease; 1 - mildly anxious; 4 - moderately anxious or guarded, so anxiety
is inferred; 7 - equivalent to acute panic states, as in severe delirium or acute
Agitation: Rate on scale of 0–7.
0 - normal activity; 1 - somewhat normal activity; 4 - moderately fidgety and restless;
7 – constantly paces or thrashes about
Paroxysmal Sweats: Rate on scale of 0–7.
0 - no sweats; 1 - barely perceptible sweating, palms moist; 4 - beads of sweat
obvious on forehead; 7 - drenching sweats
Orientation & Clouding of Sensorium: Ask, “What day is this? Where are
you? Who am I?” Rate on scale of 0–4.
0 - oriented; 1 - cannot do serial additions, uncertain about date; 2 - disoriented to
date by no more than 2 days; 3 - disoriented to date by > 2 days; 4 - disoriented to
Tactile Disturbances: Ask, “Have you experienced any itching, pins and
needles sensation, burning or numbness, or a feeling of bugs crawling on or
under your skin?” Rate on scale of 0–7.
0 - none; 1 - very mild itch, P&N, burning, numbness; 2 - mild itch, P&N, burning,
numbness; 3 - moderate itch, P&N, burning, numbness; 4 - moderate hallucinations;
5 - severe hallucinations; 6 - extremely severe hallucinations; 7 - continuous
Auditory Disturbances: Ask, “Are you more aware of sounds around you?
Are they harsh? Do they startle you? Do you hear anything that disturbs you or
that you know isn’t there?” Rate on scale of 0–7.
0 - not present; 1 - very mild harshness or ability to startle; 2 - mild harshness or
ability to startle; 3 - moderate harshness or ability to startle; 4 - moderate
hallucinations; 5 - severe hallucinations; 6 - extremely severe hallucinations;
7 - continuous hallucinations
Visual Disturbances: Ask, “Does the light appear to be too bright? Is its color
different than normal? Does it hurt your eyes? Are you seeing anything that
disturbs you or that you know isn’t there?” Rate on scale of 0–7.
0 - not present; 1 - very mild sensitivity; 2 - mild sensitivity; 3 - moderate sensitivity;
4 - moderate hallucinations; 5 - severe hallucinations; 6 - extremely severe
hallucinations; 7 - continuous hallucinations
Headache: Ask, “Does your head feel different than usual? Does it feel like
there is a band around your head?” Rate on scale of 0–7. Do not rate dizziness
or lightheadedness.
0 - not present; 1 - very mild; 2 - mild; 3 - moderate; 4 - moderately severe;
5 - severe; 6 - very severe; 7 - extremely severe
(<10 = none to very mild withdrawal; 10-15 = mild withdrawal;
16-20 = moderate withdrawal; >20 = severe withdrawal)
Indications for PRN Medication: Please follow the protocol in BOP
Clinical Guidance for Treatment of Withdrawal for Inmates with Substance Use
Disorders for use of lorazepam and other medications for withdrawal. See Table 3 and Section 7, Alcohol Withdrawal .
Medication administered? (see Medication Administration Record) Yes/No:
Time of PRN medication administration:
Assessment of response:
(CIWA-Ar Score 30–60 minutes after medication administered)
Inmate Name _______________________________
Reg No. ___________________________________
Date of Birth ____/____/____
Institution _________________________________