CIWA-AR

JL
by Jennifer Leggett1 view·Updated Apr 14, 2022
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  1. Hi, my name is Kylie, registered nurse at Green Lake Mental Health.
  2. And today we're going to be reviewing where we go in the v to document our
  3. ceo scores for clients that are withdrawing from
  4. alcohol and on protocol in the crisis unit.
  5. So let me share my screen with you so we can review it.
  6. I already have a scoring system
  7. opened up an E. V.
  8. And we're going to talk about first before we get started,
  9. a couple of changes that I want you to be aware of.
  10. Um First and foremost you may notice the difference to the name, see what A. R.
  11. Is, how it's how it's titled in E. V. And they are simply means a revised version.
  12. The Sea Watch scale has been used for decades and there
  13. is there have been many revisions over that time frame,
  14. we're just moving to the most recent, most updated version of the C.
  15. Wa scale. Um And we're starting that on tv
  16. across the board,
  17. most of it looks exactly the same and you're producing a number
  18. in order to determine the severity of a client's alcohol withdrawal symptoms.
  19. And then treatment based on that score.
  20. But there are a couple of differences that I want you to be made aware of.
  21. So the first difference is um that heart rate is not one of the 10 symptoms that we're
  22. going to be assigning a score and that takes
  23. into account the severity of their withdrawal symptoms.
  24. So on the seawall that we were using on paper or last version,
  25. it was heart rate was one of the 11 symptoms that we were assigning a rating to.
  26. You will no longer use the heart rate as the rating as a rated score.
  27. And so we have our 10 symptoms that will have a rated numerical score.
  28. To give us a total,
  29. You can record the heart rate and the pulse or
  30. the heart rate and the blood pressure here for documentation,
  31. but you won't see a score associated with that heart rate.
  32. Okay.
  33. We're going to move into our 10 symptoms that look very familiar and
  34. essentially have not changed as far as what we will be assessing.
  35. So to assign a number, we select the drop down for each symptom.
  36. Okay.
  37. One change that we definitely want to talk through at
  38. this stage is that on our previous ceo scoring nausea,
  39. Tremors, anxiety, agitation and sweats gave us the ability to assign a zero,
  40. a one
  41. of four and a seven without the ability to assign a number in between those numbers
  42. and on the C.
  43. A. R.
  44. Every single symptom that we're assessing allows us to assign
  45. a number based on severity between zero and seven,
  46. for example.
  47. Um
  48. We may need to assign a two to the client's nausea.
  49. It's still mild and they're not vomiting, but it is slowly worsening.
  50. Okay? And we can move up the scale.
  51. We can use a sign a two or three to worsening mild nausea.
  52. They're not dry heaving yet, but we're seeing a worsening of symptoms.
  53. same thing between four and 7.
  54. Um At four. They're having dry heaves and nausea comes in waves. Or as intermittent.
  55. And that may be worsening to a # seven,
  56. which is constantly nauseated and having frequent vomiting.
  57. So the blank does not mean that you can't assign a
  58. score that it's not a valid number in the score.
  59. It absolutely is.
  60. And we should be using those increments to assign an appropriate score.
  61. So,
  62. we have a really clear picture about
  63. worsening or improving alcohol withdrawal symptoms.
  64. So, let's select a three.
  65. We're going to go down our symptom list here.
  66. Um 0 - seven.
  67. Some of our 027s have descriptive is with them. And we can we can select accordingly.
  68. Okay, we're going to just continue down.
  69. Here's another one that previously we only have the ability to
  70. document a zero A one of four and a seven.
  71. Now this increment just means that the symptoms are
  72. worsening and we can assign an appropriate number based on
  73. their symptoms.
  74. All of these um descriptive is and the symptoms
  75. that were assessing should look really familiar to you.
  76. So, we're just going to kind of plow through here and select
  77. our numbers
  78. based on the client's reported and
  79. assessed symptoms.
  80. All right.
  81. And once we have assigned a number to each symptom,
  82. just like on our hard copy that we are accustomed to using.
  83. We will then
  84. select save
  85. and this will auto populate an auto count a score for us.
  86. Yeah.
  87. All right.
  88. I
  89. am signing the document now so we can save it
  90. and then we can X out of here
  91. where we find the sea wa
  92. to document is in our timeline and it is under C. Y A. R. In order to create a new sequel.
  93. We would just select the plus sign.
  94. We can also look at the history here
  95. and there. We can see um The last time
  96. uh C was score was assessed as well as what observation day.
  97. So we know where we are in their protocol.
  98. And that is how you document A CIA A R N E. V.