Alcohol Withdrawal Scale AWS - Queensland Health

1 Alcohol Withdrawal Scale AWS SW281x - 06/2012SW281 Last Alcohol Use - Date: ../ ../ .. Time: ..: .. AM / PMDateTimeBalPerspiration0. Nil1. Moist skin2. Beads on face and body3. Profuse, whole body wettremor0. No tremor1. Tremor can be felt in fingers2. Visible tremor but mild3. Moderate tremor, arms out4. Severe, arms not extendedAnxiety0. calm1. Uneasy2. Apprehensive3. Fearful, slow to calm4. Unable to calm / panicAgitation0. Able to rest1. Unsettled, fidgety2. Restless, tossing, turning3. Excitable, pacing4. constant movementtemperature0. < - - - > if:V = Visualt = tactileA = Auditory0. lucid1. infrequent, aware2. Brief, persuadable3. Frequent, distressed4. No meaningful realityorientation0. Fully oriented1.

2 Unsure of time2. Unsure time, place3. Unsure time, place, person4. disorientatedTotalBlood pressurePulsetemperaturerespirationscons cious level1. Alert, obeys, oriented2. confused, response to speech3. Stuporous, response to pain4. Semi-comatose5. comatosePupils+ reactive- No reactionB BriskS SluggishleftSizereactionRightSizereactio nMedication given?Nurse initialsSource: NSW Health Department 1999, New South Wales Detoxification Clinical Practice Guidelines, NSW Health Department, ISBN0 7347 (mm)do Not Write iN thiS BiNdiNG MArGiNDo NoT WRITE IN THIS BINDING MARGINPage 1 of 2(Affix identification label here)UrN:Family name:Given name(s):Address:date of birth: Sex: M F iAlcohol Withdrawal Scale AWSF acility.

3 Last Alcohol Use - Date: ../ ../ .. Time: ..: .. AM / PMDateTimeBalPerspiration0. Nil1. Moist skin2. Beads on face and body3. Profuse, whole body wettremor0. No tremor1. Tremor can be felt in fingers2. Visible tremor but mild3. Moderate tremor, arms out4. Severe, arms not extendedAnxiety0. calm1. Uneasy2. Apprehensive3. Fearful, slow to calm4. Unable to calm / panicAgitation0. Able to rest1. Unsettled, fidgety2. Restless, tossing, turning3. Excitable, pacing4. constant movementtemperature0. < - - - > if:V = Visualt = tactileA = Auditory0. lucid1. infrequent, aware2. Brief, persuadable3. Frequent, distressed4. No meaningful realityorientation0. Fully oriented1. Unsure of time2. Unsure time, place3. Unsure time, place, person4.

4 DisorientatedTotalBlood pressurePulsetemperaturerespirationscons cious level1. Alert, obeys, oriented2. confused, response to speech3. Stuporous, response to pain4. Semi-comatose5. comatosePupils+ reactive- No reactionB BriskS SluggishleftSizereactionRightSizereactio nMedication given?Nurse initialsSource: NSW Health Department 1999, New South Wales Detoxification Clinical Practice Guidelines, NSW Health Department, ISBN0 7347 (mm)Do Not Write iN this biNDiNg margiNDo NoT WRITE IN THIS BINDING MARGINPage 2 of 2(Affix identification label here)UrN:Family name:Given name(s):Address:date of birth: Sex: M F iAlcohol Withdrawal Scale AWS