CIWA Simulation
Date:
File Name:
Discipline:
Nursing
Expected Simulation Run Time: 20 min
Location:
Lab
Student Level: 2nd semester junior students
Guided Reflection Time:
Location for Reflection:
Admission Date:
Psychomotor Skills Required Prior to Simulation
Today’s Date:
Brief Description of Client
Name: Brett Jones
Gender: M Age: 45
DOB: 4-15-65
Race: C
Weight: 177#
Height: 5’8
Religion: Nondenominational
Major Support: Spouse
Phone: Unlisted
Allergies: NKA
Immunizations: Received flu vaccine Oct 2010
Attending Physician/Team: Dr. Clark
Past Medical History: Pancreatitis, GERD
Current Assessment of Present illness:
45 yo married male brought to ED by wife. BAC .287
g/dl, last drink was three hours prior to arriving in
ED. Relapsed several months ago following job loss
and reports drinking fifth of vodka daily for the past
two months. Longest sobriety has been several years.
Denies illicit substance use although UDS was positive
for benzodiazepines and marijuana. Patient has a
history of seizures during alcohol detox. VS: 112/86,
HR 92, R 18, 94% O sat.
Social History: Deferred
Primary Medical Diagnosis:
Axis 1: Alcohol dependency
Axis 2: Deferred
Axis 3: Pancreatitis, GERD
Axis 4: Economic, relationship
Axis 5: 35
Surgeries/Procedures & Dates: Denies
Nursing Diagnoses: (Developed on care plan)
Ability to
1. Monitor VS
2. Complete CIWA
Cognitive Activities Required prior to Simulation [i.e.
independent reading (R), video review (V), computer
simulations (CS), lecture (L)]
Reading: Nursing process for alcohol withdrawal, including
administration of medications, monitoring vital signs and
providing safe, therapeutic milieu.
Varcarolis, E. & Halter, M. (2010). Foundations of psychiatric
mental health nursing: A clinical approach (6th ed.). Philadelphia:
W. B. Saunders. CH 18, pp 411-412, 424,425.
Varcarolis, E. (2006). Manual of psychiatric nursing care plans (3rd
ed.). Saint Louis: WB Saunders. pp. 327-331.
Lab reference manual.
Computer lab to access information.
Simulation Learning Objectives
1. Develop a plan of care for the patient experiencing alcohol detoxification.
2. Appreciate risks associated with handoffs [SBAR] among providers and across transitions in care (QSEN Teamwork and
Collaboration)
3. Demonstrate use of standardized practices [CIWA] that support safety and quality, as well as use interventions to reduce risk
of harm to self or others (QSEN Safety)
4. Analyze key assessments and nursing interventions related to alcohol use and dependency.
5. Evaluate through debriefing the delivery of nursing care for the patient experiencing alcohol withdrawal.
Fidelity (choose all that apply to this simulation)
Setting/Environment
o ER
o Med-Surg
o Peds
o ICU
o OR / PACU
o Women’s Center
o Behavioral Health
o Home Health
o Pre-Hospital
o Other _________________
Simulator Manikin/s Needed: HAL
Props:
Equipment attached to manikin:
o IV tubing with primary line ___________ fluids
running at __________ cc/hr
o Secondary IV line __ running at _ cc/hr
o IV pump
o Foley catheter ________cc output
o PCA pump running
o IVPB with ___ running at ___ cc/hr
o 02 _______
o Monitor attached
o ID band _______
o Other____________________
Equipment available in room
o Bedpan/Urinal
o Foley kit
o Straight Catheter Kit
o Incentive Spirometer
o Fluids
o IV start kit
o IV tubing
o IVPB Tubing
o IV Pump
o Feeding Pump
o Pressure Bag
o 02 delivery device (type)
o Crash cart with airway devices and emergency
medications
o Defibrillator/Pacer
o Suction
o Other_________
Roles / Guidelines for Roles
o ED Nurse – writes & gives SBAR
o Primary RN – prepares pt room/calls for orders
o Orientation RN – works with primary RN
o BHA (Behavioral Health Associate)– takes VS upon
arrival
o Wife – asks nurse what to expect
o Observer/s – documents on observation sheet
o Recorder – documents on observation sheet
o Physician / Advanced Practice Nurse – gives orders
Medications and Fluids
o IV Fluids:
o
Oral Meds:
o
IVPB:
o
IV Push:
o
IM or SC:
Diagnostics Available
o Labs
o X-rays (Images)
o 12-Lead EKG
o Other__________________
Documentation Forms
o Physician Orders
o Admit Orders
o Flow sheet
o Medication Administration Record
o Kardex
o Graphic Record
o Shift Assessment
o Triage Forms
o Code Record
o Anesthesia / PACU Record
o Standing (Protocol) Orders
o Transfer Orders
o Other______________________
Recommended Mode for Simulation
programmed, etc.)
(i.e. manual,
Student Information Needed Prior to Scenario:
o Has been oriented to simulator
o Understands guidelines /expectations for scenario
o Has accomplished all pre-simulation requirements
o All participants understand their assigned roles
o Has been given time frame expectations
o Other ___________________________
Report Students Will Receive Before Simulation
Information Related to Roles
**See history of present illness**
EMERGENCY DEPARTMENT NURSE:
The nurse will give a SBAR report to receiving unit nurse and
send SBAR to the floor.
PRIMARY RN:
After receiving report, the nurse will prepare the patient room
by identifying necessary equipment. .
The primary nurse asks the orienting RN to assess the
patient for anxiety, mood and feelings related to suicidal
ideation. The assessing nurse should ask patient what has
happened in the past when he has withdrawn from
alcohol. What pertinent findings would be important for
the nurse to ask about regarding patient’s previous
history with alcohol withdrawal?
The primary nurse completes CIWA when patient arrives on
unit. RN gives report and asks for physician orders for alcohol
detoxification using SBAR format
ORIENTATION RN:
The nurse will assess HAL’s mood, anxiety, pain, etc and work
with primary RN asking questions about admission process
and how to do the CIWA. Orientation nurse will have many
questions about why certain drugs are being ordered for the
patient. Orientation RN will assist the BHA in repeating vital
signs.
Behavioral Health Assistant or Nursing Assistant:
The BHA tells the RN that he will take vital signs on the
patient. BHA takes vital signs on HAL and reports to RN that
he is having trouble getting the blood pressure because it is so
high and patient is agitated and tremulous.
WIFE:
Wife sits at bedside and asks nurse many questions about her
husband’s responses and what it means. Why is he so shaky?
What could happen that might be dangerous while
withdrawing from alcohol? How long will he be in the hospital
as she is worrying about him losing his job and having to tell
the children why daddy has been admitted to a Detox. Unit.
PHYSICIAN:
Dr. Clark gives orders for Ativan protocol on standing order
sheet and orders for Dr. Smith to see patient for history and
physical. Trazodone 50mg. Q HS prn for sleep and may repeat
in one hour if unable to sleep. Dr. Clark asks if patient was
taking any home medications and how long it has been since
HAL had his last drink?
RECORDERS/OBSERVER:
Depending on the size of the student group, there will be one
or two recorders. Please use the observation checklist to
identify learning objectives met, performance of appropriate
behaviors, and the degree to which these were achieved. Any
pertinent feedback that the students did well or failed to do
should be noted for discussion during the debriefing session.
Recorders will begin debriefing by using simulation learning
objectives for discussion.
Primary RN and Orientation RN review lab values for
abnormal findings. ( see attached)
Physician Orders: (see attached)
Significant Lab Values: **Attached**
Physician Orders: **Refer to order sheet**
References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used For This Scenario: (cite source,
author, year, and page)
Sullivan, J., Sykora, K. Schneiderman, J. Naranjo, C. & Sellers, E. (1989) Assessment of alcohol withdrawal: The revised
clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). British Journal of Addiction 84:1353-1357.
2010 NCLEX-RN Test Plan Categories and Subcategories
Choose all areas included in the simulation
Safe and Effective Care Environment
The nurse promotes achievement of client outcomes by providing and directing nursing care that enhances the care delivery
setting in order to protect clients and other health care personnel.
Management of Care – providing and directing nursing care that enhances the care delivery setting to protect clients and health
care personnel.
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Related content includes, but is not limited to:
..Advance Directives
..Advocacy
..Case Management
..Client Rights
..Collaboration with Interdisciplinary Team
..Concepts of Management
..Confidentiality/Information Security
..Consultation
..Continuity of Care
..Delegation
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..Establishing Priorities
..Ethical Practice
..Informed Consent
..Information Technology
..Legal Rights and Responsibilities
..Performance Improvement (Quality
Improvement)
..Referrals
..Supervision
Safety and Infection Control – protecting clients and health care personnel from health and environmental hazards.
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Related content includes, but is not limited to:
..Accident/Injury Prevention
 ..Reporting of Incident/Event/Irregular
Occurrence/Variance
..Emergency Response Plan
 ..Safe Use of Equipment
..Ergonomic Principles
 ..Security Plan
..Error Prevention
 ..Standard Precautions/Transmission-Based
..Handling Hazardous and Infectious
Precautions/Surgical Asepsis
Materials
 ..Use of Restraints/Safety Devices
..Home Safety
Health Promotion and Maintenance
The nurse provides and directs nursing care of the client that incorporates the knowledge of expected growth and development
principles, prevention and/or early detection of health problems, and strategies to achieve optimal health.
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Related content includes, but is not limited to:
..Aging Process
 ..Health Screening
..Ante/Intra/Postpartum & Newborn
 ..High Risk Behaviors
..Developmental Stages and Transitions
 ..Lifestyle Choices
..Health and Wellness
 ..Principles of Teaching/Learning
..Health Promotion/Disease Prevention
 ..Self-Care
 ..Techniques of Physical Assessment
Psychosocial Integrity
The nurse provides and directs nursing care that promotes and supports the emotional, mental and social well-being of the client
experiencing stressful events, as well as clients with acute or chronic mental illness.
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Related content includes, but is not limited to:
..Abuse/Neglect
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..Behavioral Interventions
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..Chemical and Other Dependencies
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..Coping Mechanisms
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..Crisis Intervention
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..Cultural Diversity
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..End of Life Care
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..Family Dynamics
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..Grief and Loss
..Mental Health Concepts
..Religious and Spiritual Influences on Health
..Sensory/Perceptual Alterations
..Stress Management
..Support Systems
..Therapeutic Communication
..Therapeutic Environment
Physiological Integrity
The nurse promotes physical health and wellness by providing care and comfort, reducing client risk potential and managing
health alterations.
Basic Care and Comfort – providing comfort and assistance in the performance of activities of daily living.
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Related content includes, but is not limited to:
..Assistive Devices
 ..Nutrition and Oral Hydration
..Elimination
 ..Personal Hygiene
..Mobility/Immobility
 ..Rest and Sleep
..Non-Pharmacological Comfort
Interventions
Pharmacological and Parenteral Therapies – providing care related to the administration of medications and parenteral
therapies.
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Related content includes, but is not limited to:
..Adverse Effects/Contraindications /Side
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Effects/Interactions
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..Blood and Blood Products
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..Central Venous Access Devices
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..Dosage Calculation
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..Expected Actions/Outcomes
..Medication Administration
..Parenteral/Intravenous Therapies
..Pharmacological Pain Management
..Total Parenteral Nutrition
Reduction of Risk Potential – reducing the likelihood that clients will develop complications or health problems related to
existing conditions, treatments or procedures.
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Related content includes, but is not limited to:
..Changes/Abnormalities in Vital Signs
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..Diagnostic Tests
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..Laboratory Values
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..Potential for Alterations in Body Systems
..Potential for Complications of Diagnostic
Tests/Treatments/Procedures
..Potential for Complications from Surgical
Procedures and Health Alterations
..System Specific Assessments
..Therapeutic Procedures
Physiological Adaptation – managing and providing care for clients with acute, chronic or life-threatening physical health
conditions.
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Related content includes, but is not limited to:
..Alterations in Body Systems
 ..Medical Emergencies
..Fluid and Electrolyte Imbalances
 ..Pathophysiology
..Hemodynamics
 ..Unexpected Response to Therapies
..Illness Management
Debriefing / Guided Reflection Questions for This Simulation
Recorder/Observers begin debriefing in regards to quality and safety initiatives:
Recorder(s) reviews the Observation Checklist.
1. Which behaviors were achieved? Partially or unachieved?
2. What did the group do well?
3. Could the nurses or primary care providers have handled any aspects of the simulation differently?
Questions to ask primary nurse & family member.
4. How did you feel throughout the simulation experience?
Questions to ask primary nurse, nurse orientee, BHA or nursing assistant
5. Did you have the knowledge and skills to meet objectives? How were you able to access information? How would it be
different if you had immediate access to information from an electronic health record at the point-of-care, or bedside?
6. Were you satisfied with your ability to work through the simulation?
7. If you were able to do this again, how could you have handled the situation differently?
8. What did the team feel were potential diagnosis?
9. What were the key assessments and interventions?
10. Review CIWA protocol
11. Is there anything else you would like to discuss?
Complexity – Simple to Complex
Suggestions for Changing the Complexity of This Scenario to Adapt to Different Levels of Learners
Observation Checklist & Notes
QSEN Competencies
Behavior
Quality
Use data to monitor
the outcomes of care
processes.

Based on patient data, how did the nurse interpret patient
data such as VS, signs/symptoms, CIWA score, and then
determine the need for intervention? What outcomes
would you anticipate for the patient?
Safety
Demonstrates
strategies to minimize
harm to patient and
providers.

What standardized practices were used to support safety?
For example,
a. bed in low position
b. assures bed wheels locked
c. pads side rails for seizure precautions
2) Was CIWA form used to assess & reduce reliance
on memory?
3) How was SBAR prepared & used for standardized
communication?
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Did the nurse implement the 6 rights of medication
administered?

Was SBAR used as an opportunity to exchange information
with nurse/ physician & ask relevant questions about
patient. What relevant questions were asked, if any?
Informatics
Use information
and technology to
communicate, manage
knowledge.

What reliable resources were used to review relevant
information for patient condition, lab, and other aspects of
the care plan?
Teamwork
Function effectively
within nursing and
inter-professional
teams, fostering open
communication,
mutual respect, and
shared decisionmaking.

How did communication occur between the nursing staff
and between the nurse and physician?
Patient Centered
Care
Recognize the
patient or designee as
the source of control
and full partner in
providing
compassionate and
coordinated care.

How was the patient/wife involved in the treatment plan?
For example, did the nurse or provider
1) ask if there were any questions?
2) respond effectively to questions?
3) assess & respond to patient’s condition?
EBP
Integrate best
current evidence with
clinical expertise and
patient/family
preferences and values
for delivery of optimal
health care:

What evidence-based guidelines were used to develop the
treatment plan and prepare for the simulation? How does
the evidence support use of these guidelines?
Notes
Patient Simulation Experience
Confidentiality Statement
Students are expected to keep all events, information and procedures related to the scenario strictly confidentiality. This includes
patient information obtained in the actual simulation experience, as well as information used for planning and debriefing.
Students must refrain from sharing information about the simulation with other students.
I have read this statement, understand it and agree to follow the above expectations. Violation of this agreement is similar to a
violation of HIPAA.
Date: ________________________________________
Student: ______________________________________
Patient Simulation Experience
Confidentiality Statement
Students are expected to keep all events, information and procedures related to the scenario strictly confidentiality. This includes
patient information obtained in the actual simulation experience, as well as information used for planning and debriefing.
Students must refrain from sharing information about the simulation with other students.
I have read this statement, understand it and agree to follow the above expectations. Violation of this agreement is similar to a
violation of HIPAA.
Date: ________________________________________
Student: ______________________________________
Patient Simulation Experience
Confidentiality Statement
Students are expected to keep all events, information and procedures related to the scenario strictly confidentiality. This includes
patient information obtained in the actual simulation experience, as well as information used for planning and debriefing.
Students must refrain from sharing information about the simulation with other students.
I have read this statement, understand it and agree to follow the above expectations. Violation of this agreement is similar to a
violation of HIPAA.
Date: ________________________________________
Student: ______________________________________
Directions for simulation
Explain to students how to prepare
1. Bring resources such as text, care plan & lab reference manual. Each student is responsible for resources, whether you
bring a personal copy or access online through Evolve text or use PDA, for example.
On simulation day
2. With the identified resources, students will contribute to development of a treatment plan for a patient who may
experience alcohol detox (care plan form attached).
Considerations for the plan of care include:
a.
b.
c.
d.
e.
f.
Comparison of Blood Alcohol Content (BAC) & behavioral manifestations of intoxication.
What are priorities for the plan of care? What are the risks if a patient does not detox safely?
What are possible medications that may be administered?
Review lab/abnormal values & interpret. Which lab values would you assess as it relates to alcohol use?
What medical conditions are often associated with alcohol abuse/dependency?
What standardized assessment tool can be used to monitor for alcohol detox?
Logon to the library resources: In order to retrieve evidence-based information to implement the CIWA, follow these steps.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
Under databases, choose EBSCO Research Databases
Click EBSCO host
Checkmark MEDLINE with full text
Click continue
Type British Journal of Addiction
Click SO Publication Name
Type Sullivan in the next box
Click AU Author
Click Search
Two results will appear, click on Assessment of alcohol withdrawal: The revised CIWA-Ar.
Click pdf Full Text and the article will open.
Note the Discussion at the end of the article, what do the authors suggest in regards to assessment and
treatment?
Once preparation is complete
3. Review roles that students will be assigned, distribute necessary forms
a.
b.
c.
d.
e.
f.
Begin scenario
ED Nurse – SBAR report form & documentation about patient history.
Primary RN – CIWA, order sheet
Orientation RN – CIWA, order sheet
BHA – VS equipment & flow sheet for VS
Recorder(s) – Observation checklist
Physician – Order sheet as prompt for orders.
Additional Notes for Staff-to-Staff Handoff Communication
1.
2.
3.
4.
Facilitates more accurate information exchange, preventing errors
Work in partnership with patients by letting them know what plan is in order to improve outcomes of care.
Provide staff opportunity for asking questions to clarify care.
When completed at bedside, provides opportunity for bedside safety checks and medication review.
Barriers t effective handoffs
1.
2.
3.
4.
5.
Lack of teamwork/respect.
Not enough time to share information about the patient.
Lack of standardized communication tools.
Inaccurate or incomplete information.
Competing priorities.
Ineffective handoffs can result in the following:
1.
2.
3.
4.
Errors leading to patient harm.
Treatment delay
Inappropriate treatment.
Increased length of stay.
DOB 4-15-65
Admission
WBC
CBC
Hemoglobin
Hematocrit
Platelet Count
7.1
L 4.26
L 13.2
L 37
282
Sodium
Potassium Chloride
CO2
Anion Gap
Glucose Level
BUNCreatinine
Calcium
GFR
Est CrCl
137
3.4
101
27
6
11
9.7
>110
99
Brett JONES
Blood Count
Chemistry Profile
Common Chemistry
Albumin
Protein Total, Serum
3.8
7.3
Alkaline Phosphatase
Amylase IU/L
Gama GT
Lipase Level
AST(SGOT)
ALT(SGPT)
126
45
H 129
13
H 47
17
Enzymes
Thyroid Function Tests
TSH
Vitamin Levels
Vitamin B-12 Level
Toxicology/Therapeutic Levels
Alcohol Blood
Lithium Level mEq/L
Urinalysis
Color Ur
Ur pH
Ur Specific Gravity
Ur Glucose
Bilirubin, Total
Ur Ketone
Ur Blood
Ur Protein
Ur Nitrite
Ur Leukocyte Esterase
Urobilinogen
Urine Other Studies
Creatinine, Urine Raw Value
Urine Toxicology
Amphetamines Level, Urine
Barbiturates, Urine
Benzodiazepine, Urine
Cocaine, Urine
Opiates Level, Urine
UR Phencyclidine
THC, Urine
1.83
197
287
L 0.4
Yellow
5.5
1.015
Neg
Neg
**Pos
Neg
Neg
Neg
Neg
Neg
71.9
Neg
Neg
**Pos
Neg
Neg
Neg
**Pos
Range