CIWA-Ar Calculator

Score all ten items to grade alcohol withdrawal severity.

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Higher = more severe

10 items remaining

Nausea / Vomiting

Ask: “Do you feel sick to your stomach? Have you vomited?”

0 — No nausea, no vomiting

1 — Mild nausea with no vomiting

4 — Intermittent nausea with dry heaves

7 — Constant nausea, frequent dry heaves and vomiting

Unanchored values are clinician-judged between the published anchors.

Tremor

Observe with arms extended and fingers spread.

0 — No tremor

1 — Not visible, but can be felt fingertip to fingertip

4 — Moderate, with arms extended

7 — Severe, even with arms not extended

Unanchored values are clinician-judged between the published anchors.

Paroxysmal Sweats

Observe.

0 — No sweat visible

1 — Barely perceptible sweating; palms moist

4 — Beads of sweat obvious on forehead

7 — Drenching sweats

Unanchored values are clinician-judged between the published anchors.

Anxiety

Ask: “Do you feel nervous?” Observe.

0 — No anxiety; at ease

1 — Mildly anxious

4 — Moderately anxious or guarded, so anxiety is inferred

7 — Acute panic state, as in severe delirium or schizophrenic reactions

Unanchored values are clinician-judged between the published anchors.

Agitation

Observe.

0 — Normal activity

1 — Somewhat more activity than normal

4 — Moderately fidgety and restless

7 — Paces back and forth, or constantly thrashes about

Unanchored values are clinician-judged between the published anchors.

Tactile Disturbances

Ask: “Do you have any itching, pins and needles, burning, or numbness — or a feeling of bugs crawling on or under your skin?”

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 severe hallucinations

5 — Severe hallucinations

6 — Extremely severe hallucinations

7 — Continuous hallucinations

Auditory Disturbances

Ask: “Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that disturbs you or that you know is not there?”

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

Visual Disturbances

Ask: “Does the light appear too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that disturbs you or that you know is not there?”

0 — Not present

1 — Very mild sensitivity

2 — Mild sensitivity

3 — Moderate sensitivity

4 — Moderately severe hallucinations

5 — Severe hallucinations

6 — Extremely severe hallucinations

7 — Continuous hallucinations

Headache / Fullness in Head

Ask: “Does your head feel different? Like a band around it?” Do not rate dizziness; rate severity only.

0 — Not present

1 — Very mild

2 — Mild

3 — Moderate

4 — Moderately severe

5 — Severe

6 — Very severe

7 — Extremely severe

Orientation / Clouding of Sensorium

Ask: “What day is this? Where are you? Who am I?”

0 — Oriented; can do serial additions

1 — Cannot do serial additions or is uncertain about the date

2 — Disoriented to date by no more than 2 calendar days

3 — Disoriented to date by more than 2 calendar days

4 — Disoriented to place and/or person

Scoring notes

Score what you observe and elicit at this assessment, not the worst the patient has been. Reassessment frequency is driven by the score and your protocol — typically more often after each medication dose.

The timeline matters as much as the number: seizures cluster at 12–48 hours after the last drink and delirium tremens at 48–96 hours. A rising score trend is more alarming than any single value — and remember thiamine before glucose in every chronic drinker.

Educational use only. CIWA-Ar scoring supports assessment within a provider-ordered withdrawal protocol; medication decisions, dosing thresholds, and escalation follow facility policy and provider orders. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.

CIWA-Ar Scale ReferenceThe full scale with scoring guidance

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Alcohol Withdrawal Nursing CareThe clinical content behind the score

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Alcohol Withdrawal Timeline ChartTremor to seizures to DTs, hour by hour

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Alcohol Withdrawal NGN Case StudyApply the scale on an unfolding case

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