Likert Survey for Hypothermic Therapy, Questionnaire Example

The following questions should be used to assess a patient who is post cardiac arrest where therapeutic hypothermia has been decided to be part of his treatment. Each question should be rated on a scale of 0 to 5, with 0 meaning it is not applicable to the situation and 5 meaning immediate measures should be taken to counteract the assessment or procedure being implemented as the subject of the question.

Has the patient had a baseline evaluation of his height, weight, core body temperature, pertinent labs, and blood pressure immediately prior to induction of therapeutic hypothermia?

1. Not Applicable
2. No Clinical Significance
3. Little Clinical Significance
4. Normal/Average as defined by each assessment/procedure
5. Increased range in significance (Caution)
6. Measures to counteract assessment or procedure should be taken immediately

Did the patient receive proper sedation prior to induction of hypothermia and is he being evaluated routinely during this process for signs of seizure?

1. Not Applicable
2. No Clinical Significance
3. Little Clinical Significance
4. Normal/Average as defined by each assessment/procedure
5. Increased range in significance (Caution)
6. Measures to counteract assessment or procedure should be taken immediately

Is the patient being routinely monitored for hemodynamic indicators of complications (bradycardia, tachycardia, hypotension, arrhythmia, etc.)?

1. Not Applicable
2. No Clinical Significance
3. Little Clinical Significance
4. Normal/Average as defined by each assessment/procedure
5. Increased range in significance (Caution)
6. Measures to counteract assessment or procedure should be taken immediately

Are pupillary changes being monitored routinely to detect seizure activity?

1. Not Applicable
2. No Clinical Significance
3. Little Clinical Significance
4. Normal/Average as defined by each assessment/procedure
5. Increased range in significance (Caution)
6. Measures to counteract assessment or procedure should be taken immediately

Is laboratory testing (electrolytes, blood gases, coagulation markers) being conducted frequently and are these results being used to determine continuing therapy?

1. Not Applicable
2. No Clinical Significance
3. Little Clinical Significance
4. Normal/Average as defined by each assessment/procedure
5. Increased range in significance (Caution)
6. Measures to counteract assessment or procedure should be taken immediately

Is the hypothermia device’s BIS sensor readout being taken every hour and is the patient’s temperature being taken every hour?

1. Not Applicable
2. No Clinical Significance
3. Little Clinical Significance
4. Normal/Average as defined by each assessment/procedure
5. Increased range in significance (Caution)
6. Measures to counteract assessment or procedure should be taken immediately

Are the patient’s extremities being warmed to prevent permanent damage without compromising the hypothermic therapy?

1. Not Applicable
2. No Clinical Significance
3. Little Clinical Significance
4. Normal/Average as defined by each assessment/procedure
5. Increased range in significance (Caution)
6. Measures to counteract assessment or procedure should be taken immediately

Is the hypothermic device delivering water with a consistent temperature throughout the entire process?

1. Not Applicable
2. No Clinical Significance
3. Little Clinical Significance
4. Normal/Average as defined by each assessment/procedure
5. Increased range in significance (Caution)
6. Measures to counteract assessment or procedure should be taken immediately

Is a complete assessment of the patient’s skin being assessed every two hours to ensure no complications arise to cause permanent damage?

1. Not Applicable
2. No Clinical Significance
3. Little Clinical Significance
4. Normal/Average as defined by each assessment/procedure
5. Increased range in significance (Caution)
6. Measures to counteract assessment or procedure should be taken immediately

After the hypothermic cooling process is completed and the patient has been warmed to body temperature, the sedative should be given 48 hours to fully metabolize in the body. After this time, has the patient’s body and brain activity been monitored to assess any damage incurred as a result of the hypothermic therapy?

1. Not Applicable
2. No Clinical Significance
3. Little Clinical Significance
4. Normal/Average as defined by each assessment/procedure
5. Increased range in significance (Caution)
6. Measures to counteract assessment or procedure should be taken immediately

Reference

Hospital, L. V. (2007). Therapeutic hypothermia after cardiac arrest. Guide, Leigh Valley Hospital Health Network, Neuroscience Intensive Care Unit.