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CIWA – Questions & Complete Answers (Expert Verified)
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CIWA – Questions & Complete Answers (Expert Verified)
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CIWA – Questions & Complete Answers (ExpertVerified)
Heart rate for one minute Right Ans - Do you feel sick to your stomach, or
have you vomited?
Rating Right Ans - 0- no n/v
1- mild nausea, no vomiting
4- intermittent nausea with dry heaves
7- Constant nausea, frequent dry heaves and vomiting
Tremor Right Ans - Arms extended and fingers spread apart
Rating Right Ans - 0- no tremor
1- not visible, that can be felt fingertip to fingertip
4- moderate, with patients arms extended
7- severe, even with arms not extended
Anxiety Right Ans - Do you feel nervous?
Rating Right Ans - 0 - no anxiety
1 - mildly anxious
4 - moderately anxioius, guarded
7 - equivalent to acute panic states as seen in severe delirium
Paroxysmal sweats Right Ans - Observation
Rating Right Ans - 0- no visible sweat
1- barely visible sweating, palms moist
4- beads of sweat obvious on forehead
7- drenching sweats
Blood pressure Right Ans -
Tactile disturbances Right Ans - Have you had any itching, pins and
needles, burning, numbness or bugs crawling sensation?
Rating Right Ans - 0 -none
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