Nausea
and Vomiting - Ask "Do you feel sick to your stomach?" "Have
you vomited?" Observation.
- 0 - no nausea and no vomiting
- 1 - mild nausea with no vomiting
- 2
- 3
- 4 - intermittent nausea with dry heaves
- 5
- 6
- 7 - constant nausea, frequent dry heaves and vomiting.
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Tactile
Disturbances - Ask "Have you any itching, pins and needles sensations, any
burning, any numbness, or do you feel bugs crawling on or under your skin? Observation.
- 0 - none
- 1 - very mild itching, pins and needles, burning or numbness
- 2 - mild itching, pins and needles, burning or numbness
- 3 - moderate itching, pins and needles, burning or numbness
- 4 - moderately sever hallucinations
- 5 - severe hallucinations
- 6 - extremely severe hallucinations
- 7 - continuous hallucinations
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Tremor
- Arms extended and fingers spread apart. Observation.
- 0 - no tremor
- 1 - not visible, but can be felt fingertip to fingertip
- 2
- 3
- 4 - moderate, with patient's arms extended
- 5
- 6
- 7 - severe, even with arms not extended
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Auditory
Disturbances - Ask "Are you more aware of sounds around you? Are they harsh?
Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing
things that you know aren't there?" Observation.
- 0 - not present
- 1 - very mild harshness or ability to frighten
- 2 - mild harshness or ability to frighten
- 3 - moderate harshness or ability to frighten
- 4 - moderately severe hallucinations
- 5 - severe hallucinations
- 6 - extremely severe hallucinations
- 7 - continuous hallucinations
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Paroxysmal
Sweats - Observation.
- 0 - no sweat visible
- 1 - barely perceptible sweating, palms moist
- 2
- 3
- 4 - beads of sweat obvious on forehead
- 5
- 6
- 7 - drenching sweats
|
Visual
Disturbances - Ask " Does the light appear to be too bright? Is its color
different? Does it hurt your eyes? Are you seeing anything that is disturbing you? Are you
seeing things that you know aren't there?" Observation.
- 0 - not present
- 1 - very mild sensitivity
- 2 - mild sensitivity
- 3 - moderate sensitivity
- 4 - moderately severe hallucinations
- 5 - severe hallucinations
- 6 - extremely sever hallucinations
- 7 - continuous hallucinations
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Anxiety
- Ask "Do you feel nervous?" Observation.
- 0 - no anxiety, at ease
- 1 - mildly anxious
- 2
- 3
- 4 - moderately anxious, or guarded, so anxiety is inferred
- 5
- 6
- 7 - equivalent to acute panic states as seen in severe
delirium or acute schizophrenic reactions
|
Headache,
Fullness in Head - Ask "Does your head feel different? Does it feel like
there is a band around your head?" Do not rate dizziness or lightheadedness.
Otherwise, rate severity.
- 0 - not present
- 1 - very mild
- 2 - mild
- 3 - moderate
- 4 - moderately severe
- 5 - severe
- 6 - very severe
- 7 - extremely severe
|
Agitation
- Observation.
- 0 - normal activity
- 1 - somewhat more than normal activity
- 2
- 3
- 4 - moderately fidgety and restless
- 5
- 6
- 7 - paces back and forth during most of the interview, or
constantly thrashes about.
|
Orientation
and Clouding of Sensorium - Ask "What day is this? Where are you? Who am I?
- oriented and can fo serial additions
- cannot do serial additions or is certain about date
- disoriented for date by no more than two calendar days
- disoriented for date by more than two calendar days
- disoriented for place and/or person
|
| |
Total CIWA-A Score _____
Rater's Initials _____
Maximum Possible Score - 67 |
