Alcohol Withdrawal Scale

(AWS)

<Investigations>

<Index>

 

 

 

Rationale

- Used to monitor pts w clinical Dx of EtOH Dependance for EtOH withdrawal

- Instituted by Drs, monitored by nurses

- Used to guide BZD use for withdrawals

 

Features

- May be ass w Delerium

- Make sure Diazepam is charted PRN

 

Caution

- NOT a Dx Tool!

- Excessive BZD use from AWS will increase score & worsen sedation

 

Components

- Nausea & Vomiting

-  0 = nil

-  7 = constant nausea, dry heaves, vomiting

- Tremor (extend arms & fingers)

-  0 = nil

-  7 = severe, even w arms not extended

- Paroxysmal Sweats

-  0 = nil

-  7 = drenching sweats

- Anxiety

-  0 = nil

-  7 = acute panic state

- Agitation

-  0 = normal

-  7 = Pacing, restless

- Tactile Distrbance

-  0 = nil

-  7 = hallucinations, itching, paresthesia

- Auditory Hallucinations

-  0 = nil

-  7 = continuous

- Visual Disturbance

-  0 = nil

-  7 = Continuous

- Headache/fullness

-  0 = nil

-  7 = extremely severe

- Orientation

-  0 = orientated, serial additions

-  7 = disoriented for place &/or person

 

Procedure

- EtOH Hx

- Drug Hx

- Current level of intoxication/withdrawal

- BAC

- Nursing staff monitor AWS & vitals & admin Diazepam as needed

 

 

 

EtOH