The nurse is planning to use the Clinical Institute Withdrawal Assessment (CIWA-Ar) scale with a patient who has been recently admitted with pancreatitis. When using this measurement tool, the nurse must realize that:
1. The lower the score, the greater the patient's risk for severe withdrawal symptoms.
2. The higher the score, the lower the patient's risk for severe withdrawal symptoms.
3. Pharmacologic therapy is matched with the score to direct the level of care required.
4. Sixteen specific areas are scored and assessed with this tool.
3
Rationale 1: The higher the score, the greater the patient's risk for severe withdrawal symptoms.
Rationale 2: The higher the score, the greater the patient's risk for severe withdrawal symptoms.
Rationale 3: Best practice utilizes the CIWA-Ar to guide pharmacologic therapy and direct the level of care required. The nurse assesses and scores 10 specific symptoms: nausea and vomiting, tremor, sweating, anxiety, agitation, headache, disorientation, tactile disturbances, visual disturbances, and auditory disturbances. Concurrently vital signs including temperature and pulse oximetry are evaluated.
Rationale 4: There are 10 specific areas that are assessed in the patient at risk for developing alcohol withdrawal syndrome.
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