EXAM 3 QSENS
QSEN for Glasgow Coma Scale pg 851
● A decrease of 2 or more points in the Glasgow Coma Scale total is clinically significant and should be
communicated to the primary health care provider immediately. Other findings requiring urgent communication
with the health care provider include a new finding of abnormal flexion or extension, particularly of the upper
extremities (decerbrate or decorticate posturing); pinpoint or dilated nonreactive pupils; and sudden or subtle
changes in mental status. Remember a change in level of consciousness is the earliest sign of neurologic
deterioration. Communicate early recognition of neurologic changes to the Rapid Response Team or primary
health care provider for the best opportunity to prevent complication and preserve CNS function.
QSEN for Lumbar Puncture pg 855
● It is very important that the patient not move during a lumbar puncture. If the patient is restless or cannot
cooperate, two people may need to assist instead of one. The patient may need a sedative to reduce movement.
Consider patient needs for additional assistance or sedation before beginning the procedure.
QSEN for Pupils pg 946
● Check pupils of TBI patients for size and reaction to light, particularly if the patient is unable to follow directions,
to assess changes in level of consciousness. Report and document any changes in pupil size, shape, and
reactivity to the primary health care provider immediately because they could indicate an increase in ICP!
QSEN for TBI pg 947
● Position the TBI patient to avoid extreme flexion or extension of the neck and to maintain the head in the midline,
neutral position. Log roll him or her during turning to avoid extreme hip flexion and keep the head of the bed
elevated at least 30 degrees or as recommended by the health care provider
● Generally, HOB elevation in patients with TBI is elevated at 30-45 degrees to prevent aspiration. However, if
increasing head elevation significantly lowers systemic blood pressure, the patient does not benefit from drainage
of venous blood or CSF out of the skull from this position. If hypotension accompanies an elevated backrest
position, the patient may be harmed. Avoid sudden vertical changes of the HOB in the older patient because the
dura is tightly adhered to the skull and may pull away from the brain, leading to a subdural hematoma.
QSEN for TBI pg 949
● Teach the patient who has sustained a mild brain injury, sometimes called a concussion, that symptoms that
disturb sleep; affect enjoyment of daily activities, work performance, mood, memory, and the ability to learn new
material; and cause changes in personality require follow-up care. Provide the patient and family with education
materials that will alert them to symptoms and management options. A good source of written instructions is
available from the CDC. Information titled “ What Can I Do to Help Feel Better After a Mild Traumatic Brain
Injury?”
QSEN for Craniotomy pg 953
● Assess neurologic and vital signs every 15-30 mins for the first 4-6 hours after a craniotomy and then every hour.
If the patient is stable for 24 hours, the frequency of these checks may be decreased to every 2-4 hours, depending
on agency policy or the patient’s condition. Report immediately and document new neurologic deficits,
particularly a decreased level of consciousness, motor weakness or paralysis, aphasia (speech and/or language
problems), decreased sensation, and sluggish pupil reaction to light! Personality changes such as agitation,
aggression, or passivity can also indicate worsening neurologic status.
QSEN for Craniotomy pg 953
● After craniotomy, monitor the patient’s dressing for excessive amounts of drainage. Report a saturated head
dressing or drainage greater than 50mL/ 8 hr immediately to the surgeon! Monitor frequently for signs of
increasing ICP!
QSEN for Meningitis pg 882
● For the patient with meningitis, assess his or her neurologic status and vital signs at least every 4 hours or more
often if clinically indicated. The priority for care is to monitor for early neurologic changes that may indicate
increased ICP sch as decreased LOC. The patient is also at risk for seizure activity. Care should be provided as
discussed in interventions in the seizures and epilepsy section.
QSEN for Bacterial Meningitis pg 883
● Place the patient with bacterial meningitis that is transmitted by droplets on Droplet Precautions in addition to
standard precautions. When possible, place the patient in a private room. Stay at least 3 feet from the patient
unless wearing a mask. Patients who are transported outside of the room should wear a mask. Teach visitors about
the need for these precautions and how to follow them.
QSEN for Acute Spinal Cord Injury pg 898
● Monitor the patient with acute spinal cord injury at least hourly for:
○ Pulse oximetry <95% or symptoms of aspiration (stridor, garbled speech or inability to clear airway)
○ Symptomatic bradycardia, including reduced level of consciousness and decreased urine output
○ Hypotension with systolic blood pressure <90 or MAP <65
● Notify the PCP immediately if these symptoms occur because this problem is an emergency! Respiratory
compromise from aspiration may be treated with intubation or bronchial endoscopy. Similar to interventions for
any type of shock, neurogenic shock is treated symptomatically by providing fluids to the circulating blood
volume, adding vasopressor IV therapy, and providing care to stabilize the patient.
QSEN for Autonomic Dysreflexia pg 898
● If the patient experiences AD, raise the head of the bed immediately to help reduce the blood pressure. Notify the
PCP immediately for drug therapy to quickly reduce blood pressure as indicated. Determine the cause of AD and
treat it promptly. For example ,if the bladder is distended, catheterize the patient to relieve the urinary retention.
Check the room temperature and bed coverings and adjust as needed for patient comfort. Lack of snesory
perception may prevent the patient from noticing temperature variations.
QSEN for Halo Fixator pg 899
● Never move or turn the patient by holding or pulling on the halo device. Do not adjust the screws holding it in
place. Check the patient’s skin frequently to ensure that the jacket is not causing pressure. Pressure is avoided if
on finger can be inserted easily between the jacket and the patient’s skin. Monitor the patient’s neurologic status
for changes in movement or decreased strength. A special wrench is needed to loosen the vest in emergencies
such as cardiopulmonary arrest. Tape the wrench to the vest for easy consistent accessibility. Do not use sharp
objects to relieve itching under the vestl skin damage and infection will slow recovery.
● Common complications of the halo device are pin loosening, local infection, and scarring. More serious but less
common complications include osteomyelitis (cranial bone infection) subdural abscess ,and instability. Hospital
policy is followed for pin-site care, which may specify the use of solutions such as saline. Vaseline dressings may
also be used. Monitor vital signs for indications of possible infection and report any changes to the PCP
immediately. Discharge teaching related to halo fixator management is described in chart 43-4.
QSEN for Gullian-Barre Syndrome pg 916
● In the initial phase of Guillian-Barre syndrome, monitor the patient closely for signs of respiratory distress, such
as dyspnea, air hunger, adventitious breath sounds, decreased oxygen saturation, and cyanosis. In addition, assess
respiratory rate, rhythm, and depth every 1-2 hours. In collaboration with the respiratory therapist, check vital
capacity every 2-4 hours and auscultate the lungs at 4-hour intervals. Monitor the patient’s ability to cough and
swallow for any change. Assess cognitive status, especially in older adults; a decline in mental status indicates
hypoxia.
QSEN for Myasthenia Gravis pg 919
● Keep a bag-valve-mask setup (Ambu), equipment for oxygen administration, and suction equipment at the
bedside of the patient with MG in case of respiratory distress
QSEN for Cholinesterase Inhibitor Drugs pg 919
● Instruct the patient to eat meals 45 minutes to 1 hour after taking ChE inhibitors to avoid aspiration. This is
especially important if the patient has bulbar involvement. Drugs containing magnesium, morphine, or its
derivatives, curare, quinine, quinidine, procainamide, or hypnotics or sedatives should be avoided because they
may increase the patient’s weakness. Antibiotics such as neomycin impair transmitter release and also increase
myasthenic symptoms.
QSEN for Hypovolemic Shock pg 754
● Be aware that increased heart rate and respiratory rates or a slight increase in diastolic blood pressure may be
the only sign of this stage of shock.
QSEN for Progressive Stage/ Hypovolemic Shock pg 755
● The progressive stage of shock is a life-threatening emergency. Vital organs tolerate this situation for only a
short time before developing multiple organ dysfunction syndrome (MODS) with permanent damage. Immediate
interventions are needed to reverse the effects of this stage of shock. The patient’s life usually can be saved if
the conditions causing shock are corrected within 1 hour or less of the onset of the progressive stage.
Continuously monitor and compare with earlier findings to assess therapy effectiveness and determine when
therapy changes are needed.
QSEN for Shock pg 756
● Because changes in systolic blood pressure are not always present in the initial stage of shock, use changes in
pulse rate and quality as the main indicators of shock presence or progression
QSEN for Sepsis/SIRS pg 761
● Monitor the patient at risk for sepsis to recognize symptoms that meet the criteria for sepsis and SIRS. If any of
these are present, respond by notifying the HCP or the Rapid Response Team.
QSEN for Burns pg 490
● Monitor patient’s respiratory efforts closely to recognize possible airway involvement. For a burn patient in the
resuscitation phase who is hoarse, has a brassy cough, drools or has difficulty swallowing, or produces an audible
breath sound on exhalation, respond by immediately applying oxygen and notifying the Rapid Response Team.
QSEN for Burns pg 491
● Monitor patients’ respiratory efforts closely to recognize possible development of pulmonary edema. When signs
and symptoms of pulmonary edema are present, respond by elevating the head of the bed to at least 45 degrees,
applying oxygen, and notifying the burn team or the rapid response team.
QSEN for Paid Meds for Burns pg 496
● Give opioid drugs for pain ONLY BY THE IV ROUTE during the resuscitation phase to prevent delayed rapid
absorption leading to lethal blood levels
QSEN for Acute phase of Burn Injury pg 498
● Use aseptic techniques in caring for wounds and during invasive monitoring to prevent infection