Provider Orders
(Provider must sign all orders-check and/or fill in appropriate blanks)
Date__________Time___________________
VPH Alcohol Withdrawal / Delirium Tremens Protocol Orders
Last modified: 2009-07-21 14:25:17.0
Faculty Owners: R. Finlayson MD, P. Martin MD
Evidence Update 9/23/08
DO NOT use this order set if pt reports recent use of and/or + UDS for CNS Depressants-Use CNS
Depressant Withdrawal order set
1. CIWA INITIATION CRITERIA (@IWEB=belegost.mc.vanderbilt.edu/~starmejm/v.php?e=1646)
2. CIWA ALGORITHM (@IWEB=belegost.mc.vanderbilt.edu/~starmejm/v.php?e=1643)
3. CIWA PROTOCOL (@IWEB=belegost.mc.vanderbilt.edu/~starmejm/v.php?e=1648)
4. CIWA FREQUENTLY ASKED QUESTIONS
(@IWEB=belegost.mc.vanderbilt.edu/~starmejm/v.php?e=1645)
Care Reminders and Treatments






NURSING: c1: Complete the 1st CIWA assessment now, then follow the CIWA protocol for vital
sign frequency requirements.
NURSING: c2: Print the CIWA form from e-Docs, assess symptoms per form instructions and
document score on CIWA form. Place CIWA form in patient's chart.
NURSING: c3: IF CIWA score is 20 or higher: give 20 mg of diazepam per physician orders. Assess
CIWA score before each dose and document the score on CIWA form.
NURSING: c4: If patient is sleeping , do not wake the patient up to give Diazepam or assess the
patient's CIWA score. Assess the CIWA score when patient awakens.
NURSING: c5: if CIWA score 15 or greater, repeat CIWA in 1h. If repeat score is 15 or greater:
give 20 mg diazepam and assess pt every hour. hold diazepam if pt sleeping & complete the
CIWA when patient awakens.
NURSING: c6: If initial or repeat CIWA score 10-14: complete CIWA assessment q2h. IF CIWA
score is less than 10: assess CIWA q4h.
Date/ Time ___________________
Provider Signature _________________________ Print Name_____________________Beeper#_______
Provider Orders
(Provider must sign all orders-check and/or fill in appropriate blanks)
Date__________Time___________________
VPH Alcohol Withdrawal / Delirium Tremens Protocol Orders Continued






NURSING: c7: 1 hour after the 5th diazepam dose is given, assess CIWA score. If CIWA is 15 or
higher, call MD to reassess need to give more doses of diazepam.
NURSING: c8: If the patient is sleeping after the last dose of diazepam, do not wake the patient.
Assess CIWA when patient awakens.
NURSING: c9: Continue CIWA assessments for at least 48 hrs. Document CIWA scores on CIWA
forms and place in patient's chart.
NURSING: c10: Some patients require additional doses of diazepam beyond the 5 doses already
given. Contact the physician to assess if patient needs additional doses of diazepam.
NOTIFY HOUSE OFFICER: T>: 101 F SBP>: 160 mmHg SBP<: 90 mmHg DBP>: 112 mmHg HR>: 120
HR<: 60 RESP>: 24 RESP<: 10 seizures or if pt scores 15 or higher after 5th dose of diazepam.
SEIZURE PRECAUTIONS
Medication


6. DIAZEPAM: VALIUM 20 mg po q1h prnx48 hours (MAX 5 doses.q1h prn per CIWA score.Give
if CIWA 20 or > or CIWA 15 or higher on 2 consecutive scores. HOLD if asleep.)
NURSING: Assess CIWA score 1h after 5th dose of diazepam. If CIWA score 15 or higher, call MD
to reassess need to give more doses of diazepam.
For patients with a history of alcohol seizures:



7. diazepam: valium 20 mg po q1h x 3 doses; HOLD if pt asleep or somnolent; assess CIWA score
each hour and 1hr after 3rd dose 20 mg po q1hx3 hours now (HOLD if pt asleep or if
somnolent.assess the patient's CIWA score each hour and 1 hr after 3rd dose of valium.)
DIAZEPAM: VALIUM 20 mg po q1h prnx48 hours =+4h (MAX 5 doses.Assess CIWA q1h.Give if
CIWA 20 or >Or CIWA 15 or higher on 2 consecutive scores. Hold if pt asleep.)
NURSING: Assess CIWA score 1h after last dose of diazepam. If CIWA score 15 or higher, call MD
to reassess need to give more doses of diazepam.
Additional 3 doses of Diazepam - Second round:
8. DIAZEPAM: VALIUM 20 mg po q1h prn (MAX 3 Doses. give if CIWA 20 or higher, or if CIWA 15 or
higher on 2 consecutive scores. Score q1h. hold is pt asleep.)
Date/ Time ___________________
Provider Signature _________________________ Print Name_____________________Beeper#_______