CHAPTER 1 ABSTRACT STATEMENT OF PURPOSE- To analyse the role of nurses in rehabilitation of the brain injury patients and to develop

a model for the nurses involved in rehabilitation of TBI patients for fast recovery and increase in success rate of interventions applied both quantitatively and qualitatively. BACKGROUND KNOWLEDGE- Brain Injury patients and their families spend the majority of their rehabilitation time with rehabilitation nurses and yet, not once has the role of the rehabilitation nurse been noted in all the recent media features about recovery. Most likely this is because only those people who have been through this experience truly understand the unique role and very close relationship patients and their families develop with their rehabilitation nurse during this very difficult time. Why is this relationship so special? Soon after the onset of a disabling injury or chronic illness, the rehabilitation nurse steps into to navigate recovery from a holistic perspective. Rehabilitation nurses act as multisystem integrators and team leaders, working with physicians, therapists, and others to solve problems and promote patients' maximal independence. The goal to help patients and families achieve their greatest potential, adapt to their disabilities, and work toward productive, independent lives. METHODOLOGY- The methodology followed in the study is a mixed one that is qualitative and quantitative methodology. While qualitative methodology focus on the small matters and questions such as how and why are important rather than when quantitative methodology provides the background support to the hypothesis or assumptions. Here a qualitative approach is maintained by categorizing different nursing interventions needed for the brain injury patients first, and then three hospitals were choosen where the rehabilitation centre for the brain injury patients is visited. Then what all interventions they are doing for different category of brain injury patients are noted down, what is their approach in this regard and what is the outcome of the interventions are they sufficient enough or just manageable. This is done for three hospitals. To cross check the data or information obtained, the rehabilitation nurses of those departments were choosen and were interviewed with certain questions regarding holistic approach, their relations with patients and how they perceive there service which is provided, next to that the patients and their families were also interviewed in this regard and their satisfaction level is measured. Later findings were listed and a model is developed for the rehabilitation nurses and the current stage or status is valued accordingly. FINDINGS- Whatever data or information is obtained from the above methodology is analyzed by immersion crystallization technique so that each dimension of the issue can be addressed. The analysis team comprises experts ranging from nursing, MBBS, experts from brain injury research. The findings were written in a report format and what relation they have with themselves is also analyzed. On that basis a model is developed for the rehabilitation nurses as

well as the patients of brain injury for better interventions at right time and better positive outcomes. CONCLUSIONS- The conclusions were made from the above findings and also further research studies and recommendations are also provided so that new dimensions in this sector can be explored. Along with limitations of this study were also analyzed so that it will authentication and validity to the study. DEFINITIONS AND TERMS Glossary

aneurysm - a blood-filled sac formed by disease related stretching of an artery or blood vessel. anoxia - an absence of oxygen supply to an organ's tissues leading to cell death. aphasia - difficulty understanding and/or producing spoken and written language. ( See also nonfluent aphasia.) apoptosis - cell death that occurs naturally as part of normal development, maintenance, and renewal of tissues within an organism. arachnoid membrane - one of the three membranes that cover the brain; it is between the pia mater and the dura. Collectively, these three membranes form the meninges. brain death - an irreversible cessation of measurable brain function. Broca's aphasia - see non-fluent aphasia. cerebrospinal fluid (CSF) - the fluid that bathes and protects the brain and spinal cord. closed head injury - an injury that occurs when the head suddenly and violently hits an object but the object does not break through the skull. coma - a state of profound unconsciousness caused by disease, injury, or poison. compressive cranial neuropathies - degeneration of nerves in the brain caused by pressure on those nerves. computed tomography (CT) - a scan that creates a series of cross-sectional X-rays of the head and brain; also called computerized axial tomography or CAT scan.

concussion - injury to the brain caused by a hard blow or violent shaking, causing a sudden and temporary impairment of brain function, such as a short loss of consciousness or disturbance of vision and equilibrium. contrecoup - a contusion caused by the shaking of the brain back and forth within the confines of the skull. contusion - distinct area of swollen brain tissue mixed with blood released from broken blood vessels. CSF fistula - a tear between two of the three membranes - the dura and arachnoid membranes that encase the brain. deep vein thrombosis - formation of a blood clot deep within a vein. dementia pugilistica - brain damage caused by cumulative and repetitive head trauma; common in career boxers. depressed skull fracture - a fracture occurring when pieces of broken skull press into the tissues of the brain. diffuse axonal injury - see shearing. dysarthria - inability or difficulty articulating words due to emotional stress, brain injury, paralysis, or spasticity of the muscles needed for speech. dura - a tough, fibrous membrane lining the brain; the outermost of the three membranes collectively called the meninges. early seizures - seizures that occur within 1 week after a traumatic brain injury. epidural hematoma - bleeding into the area between the skull and the dura. erosive gastritis - inflammation and degeneration of the tissues of the stomach. fluent aphasia - a condition in which patients display little meaning in their speech even though they speak in complete sentences. Also called Wernicke's or motor aphasia. Glasgow Coma Scale - a clinical tool used to assess the degree of consciousness and neurological functioning - and therefore severity of brain injury - by testing motor responsiveness, verbal acuity, and eye opening.

global aphasia - a condition in which patients suffer severe communication disabilities as a result of extensive damage to portions of the brain responsible for language. hematoma - heavy bleeding into or around the brain caused by damage to a major blood vessel in the head. hemorrhagic stroke - stroke caused by bleeding out of one of the major arteries leading to the brain. hypermetabolism - a condition in which the body produces too much heat energy. hypothyroidism - decreased production of thyroid hormone leading to low metabolic rate, weight gain, chronic drowsiness, dry skin and hair, and/or fluid accumulation and retention in connective tissues. hypoxia - decreased oxygen levels in an organ, such as the brain; less severe than anoxia. immediate seizures - seizures that occur within 24 hours of a traumatic brain injury. intracerebral hematoma - bleeding within the brain caused by damage to a major blood vessel. intracranial pressure - buildup of pressure in the brain as a result of injury. ischemic stroke - stroke caused by the formation of a clot that blocks blood flow through an artery to the brain. locked-in syndrome - a condition in which a patient is aware and awake, but cannot move or communicate due to complete paralysis of the body. magnetic resonance imaging (MRI) - a noninvasive diagnostic technique that uses magnetic fields to detect subtle changes in brain tissue. meningitis - inflammation of the three membranes that envelop the brain and spinal cord, collectively known as the meninges; the meninges include the dura, pia mater, and arachnoid. motor aphasia - see non-fluent aphasia. neural stem cells - cells found only in adult neural tissue that can develop into several different cell types in the central nervous system. neuroexcitation - the electrical activation of cells in the brain; neuroexcitation is part of the normal functioning of the brain or can also be the result of abnormal activity related to an injury.

neuron - a nerve cell that is one of the main functional cells of the brain and nervous system. neurotransmitters -chemicals that transmit nerve signals from one neuron to another. non-fluent aphasia - a condition in which patients have trouble recalling words and speaking in complete sentences. Also called Broca's or motor aphasia. oligodendrocytes - a type of support cell in the brain that produces myelin, the fatty sheath that surrounds and insulates axons. penetrating head injury - a brain injury in which an object pierces the skull and enters the brain tissue. penetrating skull fracture - a brain injury in which an object pierces the skull and injures brain tissue. persistent vegetative state - an ongoing state of severely impaired consciousness, in which the patient is incapable of voluntary motion. plasticity - ability of the brain to adapt to deficits and injury. pneumocephalus - a condition in which air or gas is trapped within the intracranial cavity. post-concussion syndrome (PCS) - a complex, poorly understood problem that may cause headache after head injury; in most cases, patients cannot remember the event that caused the concussion and a variable period of time prior to the injury. post-traumatic amnesia (PTA) - a state of acute confusion due to a traumatic brain injury, marked by difficulty with perception, thinking, remembering, and concentration; during this acute stage, patients often cannot form new memories. post-traumatic dementia - a condition marked by mental deterioration and emotional apathy following trauma. post-traumatic epilepsy - recurrent seizures occurring more than 1 week after a traumatic brain injury. prosodic dysfunction - problems with speech intonation or inflection. pruning - process whereby an injury destroys an important neural network in children, and another less useful neural network that would have eventually died takes over the responsibilities of the damaged network.

seizures - abnormal activity of nerve cells in the brain causing strange sensations, emotions, and behavior, or sometimes convulsions, muscle spasms, and loss of consciousness. sensory aphasia - see fluent aphasia. shaken baby syndrome - a severe form of head injury that occurs when an infant or small child is shaken forcibly enough to cause the brain to bounce against the skull; the degree of brain damage depends on the extent and duration of the shaking. Minor symptoms include irritability, lethargy, tremors, or vomiting; major symptoms include seizures, coma, stupor, or death. shearing (or diffuse axonal injury) - damage to individual neurons resulting in disruption of neural networks and the breakdown of overall communication among neurons in the brain. stupor - a state of impaired consciousness in which the patient is unresponsive but can be aroused briefly by a strong stimulus. subdural hematoma - bleeding confined to the area between the dura and the arachnoid membranes. subdural hygroma - a buildup of protein rich fluid in the area between the dura and the arachnoid membranes, usually caused by a tear in the arachnoid membrane. syndrome of inappropriate secretion of antidiuretic hormone (SIADH) - a condition in which excessive secretion of antidiuretic hormone leads to a sodium deficiency in the blood and abnormally concentrated urine; symptoms include weakness, lethargy, confusion, coma, seizures, or death if left untreated. thrombosis or thrombus - the formation of a blood clot at the site of an injury. vasospasm - exaggerated, persistent contraction of the walls of a blood vessel. vegetative state - a condition in which patients are unconscious and unaware of their surroundings, but continue to have a sleep/wake cycle and can have periods of alertness. ventriculostomy - a surgical procedure that drains cerebrospinal fluid from the brain by creating an opening in one of the small cavities called ventricles. Wernicke's aphasia - see fluent aphasia.

INTRODUCTION

Brain Injury patients and their families spend the majority of their rehabilitation time with rehabilitation nurses and yet, not once has the role of the rehabilitation nurse been noted in all the recent media features about recovery. Most likely this is because only those people who have been through this experience truly understand the unique role and very close relationship patients and their families develop with their rehabilitation nurse during this very difficult time. Why is this relationship so special? Soon after the onset of a disabling injury or chronic illness, the rehabilitation nurse steps into to navigate recovery from a holistic perspective. Rehabilitation nurses act as multisystem integrators and team leaders, working with physicians, therapists, and others to solve problems and promote patients' maximal independence. The goal -- to help patients and families achieve their greatest potential, adapt to their disabilities, and work toward productive, independent lives. Each year in this country, an estimated 1.5 to 2 million people incur traumatic brain injuries, principally as a result of vehicular incidents, falls, and acts of violence or sports accidents. Traumatic brain injury is the leading cause of long term disability among children and young adults and the number of people surviving it with impairment has increased significantly in recent years. This has led to a call for nurses skilled in trauma and rehabilitation. The role of the rehabilitation nurse is vital in the acute care and treatment of brain injured patients. Nurses in this setting must have a set of skills and knowledge that exceed those required in other disciplines. In addition to being clinically sharp and able to recognize even the subtlest physical changes, nurses who treat brain injured patients must be able to effectively coordinate care with other caregivers, deal with and educate family members, and deescalate potentially dangerous. Rehabilitation/restoration nursing principles are more important to the healthcare system than ever before because it has measurable, functional outcome goals for patients, which rehabilitation nurses use in planning and evaluating the effectiveness of patient care. Rehabilitation Nurses practice in all settings including: freestanding rehabilitation facilities, hospitals (inpatient rehabilitation units), long-term subacute care facilities/skilled nursing facilities, long-term acute care facilities, comprehensive outpatient rehabilitation facilities, private practice, home healthcare agencies, clinics and day rehabilitation programs, and community and government agencies including the Veterans Administration and the Department of Defence. CHAPTER TWO 2.0- RESEARCH METHODOLOGY 2.1-INTRODUCTION

The methodology followed in the study is a mixed one that is qualitative and quantitative literature study methodology. While qualitative methodology focus on the small matters and questions such as how and why are important rather than when quantitative methodology provides the background support to the hypothesis or assumptions. Here a qualitative approach is maintained by categorizing different nursing interventions needed for the brain injury patients first, and then three hospitals were chosen where the rehabilitation centre for the brain injury patients is visited. Then what all interventions they are doing for different category of brain injury patients are noted down, what is their approach in this regard and what is the outcome of the interventions are they sufficient enough or just manageable. This is done for three hospitals. To cross check the data or information obtained, the rehabilitation nurses of those departments were chosen and were interviewed with certain questions regarding holistic approach, their relations with patients and how they perceive there service which is provided, next to that the patients and their families were also interviewed in this regard and their satisfaction level is measured. Later findings were listed and a model is developed for the rehabilitation nurses and the current stage or status is valued accordingly. 2.2-SEARCH STRATEGY Studies were sought from a wide variety of sources, including MEDLINE, PubMed, CINAHL, Cochrane databases, EBSCO research database, BioMed Central, federal reports, National Database of Nursing Quality Indicators, National Center for Health Workforce Analysis, American Nurses Association, American Academy of Nurse Practitioners, and Digital Dissertations. The search strategies for the four research questions are described in Appendix A . The same eligibility criteria, selection of studies, and analysis of studies were used to examine what types of role can be played by the nurses in case of rehabilitating the brain injured patients. The approach was different to identify studies that examined factors that influence nurse staffing policies and how it affects their role in giving proper care to the brain injured patients. As noted earlier, the question about role was not appropriate for meta-analysis. Excluded references are shown in Appendix B. All work was conducted under the guidance of a expert supervisor. Members are identified in Appendix C. The data abstraction forms are shown in Appendix D. 2.3 NUMBER OF ARTICLES IDENTIFIED,RETRIEVED AND INCLUDED We reviewed abstracts to exclude studies with ineligible target populations conducted in countries other than the UK and Australia and in long-term nursing facilities. Then we confirmed the eligibility status of the study designs, excluding secondary data analysis, reviews, letters, comments, legal cases, and editorials. The full texts of the original cohort studies were examined to define eligible independent variables (nurse staffing and strategies to maintain there role) and eligible outcomes. Then we excluded studies that did not test the associative hypotheses and did not provide adequate information on tested hypotheses (e.g., least square means, relative risk). Inclusion criteria were applied to select articles for full review. Studies needed to meet one of

the following criteria for questions Retrospective observational cohort studies and retrospective cross sectional comparisons Administrative cross-sectional survey and analyses; Randomized controlled trials with random allocation of subjects to intervention and control groups Controlled not randomized clinical trials2 The studies must evaluate the associations between role of nurses and the theoretical models for approach. outcomes/nurse quality measures among eligible target populations (patients hospitalized in acute care hospitals in the UK and Australia) and published after 1990 except conducted in 1982-1989 but frequently cited in recent publications Ecologic studies on correlations between nurse role and patients outcomes Cost-effectiveness analysis of nurse role

Studies were selected for question if the study provided implications for role of nurses in traumatic brain injury . No studies had as a primary purpose to empirically examine a specific nurse role in rehabilitation policy. The exclusion criteria included the following: Studies published before 1990 Studies conducted in countries other than UK and Australia and not published in the English language Studies with target population as outpatients and patients in long-term care facilities Studies with no information relevant to role of nurses in brain injury patients. Studies that examined the contributions of advance practice nurses (nurse practitioners, nurse clinicians, certified nurse midwives, nurse anesthetists) Studies that evaluated the association between role of nurses and ineligible outcomes Administrative reports and single hospital studies with no control comparisons that do not test an associative hypothesis The assessment of the studies quality was based on Systems to Rate the Strength of Scientific Evidence. we grouped all criteria into ten dimensions with scores for each aspect assigned a value from 0 to 5 (highest) for a total possible score of 50 for the statistical analysis of the studies quality. Given the absence of RCTs, the level of evidence for all studies was estimated using a subset of the U.K. Preventive Services Task Force criteria noted below: II-2A: Well-designed cohort (prospective) study with concurrent controls II-2B: Well-designed cohort (prospective) study with historical controls II-2C: Well-designed cohort (retrospective) study with concurrent controls II-3: Well-designed case controlled (retrospective) study

III: Large differences from comparisons between times and/or places with or without interventions (cross-sectional comparisons). An evidence table was developed for each of the nurses role variables identifying the purpose of the study, sample, design, independent and dependent variables, and findings. We used the Trim and Fill method to detect publication bias defined as the tendency to publish positive results and to predict the association when all conducted (published and unpublished) studies are analyzed. Time trends in positive results were assessed with interaction models with time of the events as continuous variables. The evaluations of the studies and the data extraction were performed manually and independently by us. The principal investigators of some studies were contacted to assess the additional and missing information when necessary. Errors in the data extractions were assessed by a comparison with the established ranges for each variable and by a comparison of the data charts with the original articles. Any discrepancies were detected and discussed. Patient populations were classified as surgical, medical, and combined samples. Adjustments for patient age, race, gender, comorbidities, socioeconomic status, provider characteristics, and clustering of patients and providers were extracted from the studies. 2.31FINDINGS The main findings of the research indicated that nurses viewed multi-professional teamwork as essential to the rehabilitation process. Another inference is that nurses engagement in multiprofessional teamwork was contingent on their interaction with the multi-professional team, which occurred mainly as formal meetings of which the patient conferences were most common. It was also dependent on nurses years of experience in rehabilitation and length of time working at the hospital. Nurses viewed their role as being as essential link in the multi-professional team, providing up-to-date pertinent information to other disciplines, because of their 24 hour presence. The main barriers identified by the nurses to multi-professional teamwork were communication, and the practice of nursing which entails shift work, and therefore not always being available nine to five like the other disciplines. A greater understanding of the philosophy and process of rehabilitation was seen by the nurses as a means of enhancing their selfconfidence in relation to their contribution as members of the multi-professional team, and team building. 3.0 LITERATURE REVIEW 3.1 INTRODUCTION Effective treatment of brain injured patients is a dynamic process that involves multiple, interrelated caregivers. Team members may include physical therapists, speech therapists, occupational therapists, and physicians, among others. The nurse is often at the core of this

circle, coordinating care and problem solving with all team members to treat patients and keep them safe. Learning to effectively deal with potentially dangerous situations is a challenge unique to treating people with brain injuries. Patients can become extremely agitated and combative, biting, yelling, shouting, hitting, and lashing out at those around them. Nurses must be familiar with different options available to help with these situations, such as special veil beds used to contain patients to bed with minimal restraint. When a person sustains a brain injury, the result is traumatic, not only for the patient but for his or her family as well. Families are often ill equipped to deal with the devastating changes brain injury can bring. It is hard for many families to accept these changes and to know what their responsibility is in the recovery process. It is the nurse's role to help family members through this difficult time. Families often find it hard to deal with the variety of complications that can result from brain injury, including loss of memory, poor judgement, loss of inhibitions and personality changes. In addition, long-standing family dynamics or feelings of guilt, anger or frustration may make the process more difficult. In treating brain injuries, nurses deal with the entire family, not just the patient. Nurses are also responsible to provide the education families need to be able to give ongoing support and care once the patient is released The families of traumatic brain injury (TBI) victims often have many questions when their loved one is transferred to a rehabilitative care center. What happens in rehabilitation? Similar to the acute care facility, the TBI patient will be cared for by a team of professionals who specialize in the care of trauma victims. Their goals are to: 1. Stabilize the medical and rehabilitation issues related to brain injury and the other injuries. 2. Prevent secondary complications. Complications could include pressure sores, pneumonia and contractures. 3. Restore lost functional abilities. Functional changes could include limited ability to move, use the bathroom, talk, eat and think. 4. The staff will also provide adaptive devices or strategies to enhance functional independence. 5. The staff will begin to analyze with the family and the patient what changes might be required when the person goes home.

Each day, the patient will participate in therapy. Initially, the patient may require staff assistance for even the most simple activities: brushing teeth, getting out of bed and eating. The patient also may require staff for safety because there is a risk of falling, eloping (trying to get out of the hospital to go home) or getting hurt. The patient may be confused and forgetful. 3.2 AIMS AND OBJECTIVES The main aim or objectives behind this study was to evaluate the role of nurses especially those of rehabilitation centers for the brain injury patients. To achieve this aim certain research questions were framed and according to that the study has been designed so that particular findings against those questions can be done and it can be analyzed in a scientific way. Research questions- a) what are the current interventions provided by the nurses to rehabilitate the brain injured patients? b) Whatever interventions are followed are they authenticated according to the biomedical ethics or not? c) What are the outcomes of those interventions and those outcomes are satisfactory or not? d) Does any model exist for this if the outcomes are not satisfactory? e) How the patients, their families perceive the current role of nurses in rehabilitation? F) is there any gap existing in between the patient care and nurses and ethics, if yes how these can be minimized? So these are some of the research questions that have to be studied in this report so that the research is accomplished. 3.3 Theme 1 3.4 CASE STUDY I This case study describes the management of a 54-year-old male who presented to the Hospital of the University of Pennsylvania (HUP) with a traumatic brain injury (TBI) after being assaulted. He underwent an emergent bifrontal decompressive hemicraniectomy for multiple, severe frontal contusions. His postoperative course included monitoring of intracranial pressure, cerebral perfusion pressure, partial pressure of brain oxygen, brain temperature, and medical management based on HUP's established TBI algorithm. This case study explores the potential benefit of combining multimodality monitoring and TBI guidelines in the management of severe TBI.

3.4 INTRODUCTION Traumatic brain injury (TBI) patients require a multidisciplinary approach among all members of the healthcare team, including physicians, nurses, respiratory therapists, speech therapists, physical/occupational therapists, and nutritionists. This case study demonstrates how a successful outcome can be achieved when a TBI patient is treated under the guidance of an algorithm designed specifically for the management of this population. Our facilty, the Hospital of the University of Pennsylvania (HUP), established a TBI algorithm based on the American Association of Neurologic Surgeons Guidelines for the Management of the Severely Brain Injured Patient (Bullock et al., 2000), which incorporates surgical management and multimodality monitoring (MMM). These guidelines help healthcare providers address patients' complex needs while executing the established standard of care. Once an initial injury to the brain has occurred, the cascade of events that follows includes altered cerebral perfusion, increased intracranial pressure, and cerebral hypoxia, which all increase the risk of ischemia. The goal of MMM is to prevent secondary injury to the fragile brain. Critical care nurses play a pivotal role in the successful management of brain-injured patients. This article presents and discusses the implementation of a TBI algorithm as a guideline for neuroscience nurses in caring for TBI patients. 3.5 EVIDENCIAL SUPPORT TBI occurs when a blow, jolt, or penetration to the head damages brain tissue. Severity can range from mild concussion to coma and death. This type of injury is a major public health problem and a common cause of death and disability in the United States. It is estimated that 1.5 million people sustain a TBI each year in the United States, and approximately 50,000 people die from TBI, accounting for one-third of all injury deaths (Centers for Disease Control [CDC], 1996). An estimated 5.3 million Americans are living with disabilities from TBI ( CDC report shows prevalence of brain injury, 1999). Impairments include cognitive, physical, and psychological disabilities. The loss of potential income, the cost of acute care, and the ongoing expenses of rehabilitation and medical care are considerable. It is estimated that TBI costs society an estimated $48.3 billion each year (Guerrero, Thurman, & Sniezek, 2000). In 2003, 929 patients were seen in the emergency department (ED) at the HUP Level I Trauma Center. Brain injuries from blunt trauma numbered 892 and there were 37 penetrating head traumas. The average patient age was 42 years. Of the 929 patients seen, 473 were admitted and the average length of stay was 8 days, of which 2 were spent in the intensive care unit (ICU). Overall, 871 patients survived and were discharged either from the ED or after inpatient hospitalization; 58 patients died 3.6 EVALUATION AND ANALYSIS

Initial Presentation A 54-year-old male was traveling with his family and was discovered by his wife in a highway service area restroom beaten; he was disoriented, walked with an unsteady gait, and had profuse bleeding from both ears. He was airlifted to the HUP Level I Trauma Center and admitted to the trauma resuscitation area. His Glasgow Coma Scale (GCS) score on admission was 15 (4 = eye opening, 5 = verbal, 6 = motor). A rigid cervical collar was placed and spinal precautions were initiated. During the emergent head computed tomography (CT), he had a generalized seizure and lost consciousness. He was returned to the trauma resuscitation area for intubation. The head CT revealed bifrontal and bitemporal contusions with associated subarachnoid hemorrhage (SAH) and left-side subdural hematoma (SDH) with a right midline shift (Fig 1). The patient was transported to the HUP Neurotrauma Surgical Intensive Care Unit (NTSICU). Figure 1. Head CT taken at admission (Enlarge Image) Upon arrival to the NTSICU, the patient's GCS score was 5 (1 = eye opening, 1 = verbal, 3 = motor) and he was becoming more bradycardic, from 45 55 beats per minute. His pupils were unequal (left was larger than right), and intermittent seizure activity was noted. Lorazepam (Ativan) and a phenytoin (Dilantin) bolus were given to control seizure activity. After 30 minutes in the ICU, his left pupil became nonreactive and he was taken for an urgent head CT, which demonstrated bifrontal and bitemporal hemorrhagic contusions with increasing hemorrhage along with increasing diffuse SAH. Left uncal herniation and descending transtentorial herniation were noted. Mannitol was given and he was taken emergently to the operating room (OR). Nursing Considerations Initial and repeated nursing assessments of patients with severe TBI are essential to detect neurological changes. Nonreactive pupils require prompt reaction by nurses to prevent impending herniation. Mannitol is an osmotic diuretic that increases plasma osmolality, causing a subsequent reduction of osmotic pressure. HUP's guideline prescribes a 0.25 1.0 g/kg intravenous (IV) bolus until intracranial pressure (ICP) <20 mm Hg or serum osmolality reaches 320 mOsm/L. The fluid and electrolyte shifts that occur can cause severe hypovolemia and arrhythmias; therefore, it is important for nurses to monitor the electrocardiogram (ECG), blood pressure, and fluid intake and urine output every hour in addition to serum sodium and potassium levels. Variables that can affect cerebral oxygen demands are fever, shivering, seizures, pain, and agitation. To control oxygen demand, seizures are treated with 4 mg of IV lorazepam over 2 5 minutes and may be repeated every 10 15 minutes as needed to a maximum dose of 8 mg (Lexi-

Comp Online, n.d.). Benzodiazepines as a class may cause respiratory depression and hypotension; the patient was already intubated and his blood pressure was tolerating the medication bolus. Per HUP procedure, a loading dose of 15 18 mg/kg of phenytoin was given to reach a therapeutic level of 10 20 mg/mL. During administration of these medications, nurses need to continuously monitor ECG, blood pressure, and respiratory effort to ensure hemodynamic and respiratory stability are maintained. Surgery and Immediate Postoperative Care Upon arrival to the OR, a report of the patient's past medical history and current medical issues was given to the perioperative nurse and anesthesia physician assigned to the case. The perioperative nurse was then responsible for proper positioning to avoid skin and tissue injury and the implementation of thromboembolic stockings and external sequential compression devices. A bifrontal craniectomy was performed for evacuation of a left SDH with subsequent alleviation of ICP. During the surgical procedure the brain was visualized to be swollen and the subfrontal regions severely contused. The dura was left open and covered with a dural closure product, Duragen (Integra LifeSciences, Plainsboro NJ). Prior to departing the OR, a triple lumen bolt that accommodates a brain tissue oxygen probe, a brain tissue temperature probe, and a fiberoptic intracranial pressure monitoring device catheter (Integra LifeSciences, Plainsboro, NJ) was inserted. After surgery, the patient was returned to the NTSICU unreversed from anesthesia and neuromuscular blockade; he remained intubated. A clinical exam was performed; the external sequential compression devices were connected and turned on, and he was placed in reverse Trendelenburg to promote cerebral venous drainage. His GCS score was 3 and pupils were 2 mm bilaterally with slight reaction to light. The brain oxygen and brain temperature (bT) probes were connected to their corresponding cables, which attached to the LICOX stand-alone bedside monitor. The partial pressure of brain oxygen (PbO2) was 21 mm Hg (normal range is 25 45 mm Hg) and ICP was 12 mm Hg. Over the next 2 hours he awoke and became agitated, withdrawing hihours he awoke and became agitated, withdrawing his right side to painful central stimuli. His Pbright PbO2 increased to 30 mm Hg. Despite the decompressive craniectomy, however, his ICP climbed and remained above 20 mm Hg. Midazolam (Versed) and sublimaze (Fentanyl) were ordered for sedation and ICP control. His serum osmolality was 320 mOsm/L and mannitol could no longer be given. His ICP continued to climb despite analgesic administration. Concerned about secondary brain injury, the team decided to administer further chemical sedation. A continuous infusion of propofol (Diprovan) and sublimaze for sedation and pain were started with a goal to lower the ICP to <20 mm Hg. Prepared for the sedation- related hypotension, his nurse had a phenylephrine (Neosynephrine) infusion ready by the bedside. As the patient became hypotensive during the initiation of sedation, the phenylephrine infusion was started with a goal to maintain a cerebral perfusion pressure (CPP) >60 mm Hg. His hydration status was assessed and he demonstrated adequate hydration with a central venous pressure of 8

mm Hg. Over the next 6 12 hours the ICP decreased from a range of 19 24 mm Hg to a range of 17 19 mm Hg. Once the ICP was controlled, he was taken for a repeat head CT that demonstrated marked improvement of the descending transtentorial herniation. He was taken back to the NTSICU where MMM was continued. Because the loading dose (1000 mg) of phenytoin had already been given, he was continued on a maintenance dose of 5 6 mg/kg/day in three divided doses. His phenytoin level was checked to maintain a therapeutic level of 10 20 mg/ml. An international normalized ratio (INR) level of 1.6 was corrected to 1.3 with two units of fresh frozen plasma. Nursing Considerations When the patient arrived from the OR the nurse connected the PbO2 and temperature probes to their respective cables. Ten to 120 minutes are required for the brain tissue to stabilize after the microtrauma of inserting the PbO2 probe into cerebral white matter. During this time the accuracy of the PbO2 is not guaranteed (Integra NeuroSciences/ GMS, 2002). If the PbO2 is <20 mm Hg and there is a question of probe accuracy, reliability, or validity the nurse performs a 100% O2 challenge on the ventilator for 2 5 minutes. If the PbO2 does not increase, a head CT is obtained to check for proper catheter placement. If the PbO2 increases with the O2 challenge, the nurse refers to the Brain Hypoxia Module (Fig 2) within the TBI algorithm to determine the cause and systematically manage the patient with the neurosurgical team. ( Table 1 explains the components of the Brain Hypoxia Module.) Because propofol was started, the nurse monitored its effects on blood pressure and CPP. Continuing to follow the TBI guidelines, a phenylephrine drip was initiated to maintain CPP >60 mm Hg. Phenylephrine must be administered via a central line to prevent extravasation and skin necrosis. Figure 2. Brain hypoxia module from the University of Pennsylvania Medical Center Severe Traumatic Brain Injury algorithm. Authored by the TBI Multidisciplinary Committee, Hospital of the University of Pennsylvania. (Used with permission.)

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The nurse also recognized that the patient was at risk for deep vein thrombosis (DVT) and continued the use of antiembolism stockings and external sequential compression devices. When the head CT Results showed the areas of hemorrhage were stable, subcutaneous heparin was added. Venous thromboembolism is a common, life-threatening complication in critically ill patients and those undergoing neurosurgery procedures. Mechanical and pharmacologic Methods have been shown to significantly reduce the risk of thromboembolism. Forty-Eight Hours Later

Propofol infusion was stopped daily at 5 am for a neurological assessment. During 6 am team rounds, the patient did not follow commands; his GCS score was 3; and his ICP was >20 mm Hg. During these 48 hours, the PbO2 began to desaturate to 21 2 mm Hg and ICP remained <20 mm Hg on propofol and sublimaze infusions. His PaO2 was 169 mm Hg on 30% FiO2 and hemoglobin was 11.6mg/mL. Frequent hypotensive events caused a decrease in CPP and consequently a decrease of oxygen supply to the patient's brain. During these periods of PbO2 desaturation, his CPP was 50 3 mm Hg requiring a titration of his phenylephrine infusion to maintain a CPP >60 mm Hg. With titration, the PbO2 increased to 30 mm Hg. A head CT at this time showed extensive hemorrhagic contusions in the frontal and temporal lobes bilaterally, with an overall increase in mass effect with increased compression of the frontal horns of the lateral ventricles and narrowing of the basilar cisterns. It also showed an evolving infarct in the medial left temporo-occipital region. Nursing Considerations During PbO2 desaturation the nurse immediately and systematically must determine its cause by following the HUP Brain Oxygen Algorithm for brain tissue oxygen <20 mm Hg (Fig 3 explains low Pb < PbO2 and Fig 4 explains high PbO2). Inadequate PbO2 is affected by either an increased O2 demand by the brain or a decreased O2 supply to the brain. The four factors that cause a decrease in O2 supply are anemia, hypovolemia, hypoxia, and hypotension. The patient's hemoglobin was 11.6 mg/ mL; CVP was 8 mm Hg; and PaO2 was 169 mm Hg on 30% FiO2. Because the patient was hypotensive, there was a decreased cerebral perfusion pressure and consequently a decreased O2 supply to the brain. The nurse increased the phenylephrine to increase CPP and maximize O2 delivery. Thoracic and lumbar spines were cleared and the nurse elevated the head of the bed to 30 to facilitate venous drainage and decrease the incidence of ventilator-associated pneumonia. Figure 3. Algorithm for brain tissue oxygen <20 mm Hg. Authorized by the Neurosurgery Faculty and the Neuroscience Nursing Committee at the Hospital of the University of Pennsylvania. (Used with permission.) Figure 4. Brain oxygen algorithm for high PbO2. Authorized by the Neurosurgery Faculty and the Neuroscience Nursing Committee at the Hospital of the University of Pennsylvania. (Used with permission.)

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TBI patients have an increased calorie and protein requirement. A nasoentric postpyloric feeding tube was placed during the patient's second day of hospital stay for initiation of total enteral

nutrition (TEN). However, because of the patient's need for a phenylephrine infusion, the neurosurgical team decided to hold enteral feedings because of the possibility of decreased gut perfusion. Days 3 4 Propofol infusion was stopped and the sublimaze infusion was decreased while keeping ICP <20 mm Hg. Eight hours later the patient began to localize with his right upper extremity and his GCS score was 7 (1 = eye opening, 1 = verbal, 5 = motor). His left side was markedly weaker and he could only flicker it in response to painful central stimuli. A head CT showed a small focal infarction of the left thalamus, with an evolving left posterior cerebral artery infarction. His ICP remained <20 mm Hg and the phenylephrine was decreased to maintain CPP >60 mm Hg. During this time his temperature became elevated to 102.1F. The nurse administered antipyretics and instituted cooling measures to decrease the brain tissue oxygen demand. Blood, urine, and sputum cultures were sent for laboratory testing and a chest X ray was performed to locate a source of infection. Nursing Considerations Fever increases the demand for oxygen the nurse administered acetominophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) and implemented ambient cooling Methods. The nurse readdressed the patient's nutritional status with the team and consulted the hospital's clinical nutrition service. HUP's policy is to identify one port on the central line solely for total parenteral nutrition (TPN) to decrease the risk for bloodstream infection; this caused a delay in TPN administration because the ports had been emergently used for propofol and phenylephrine. A new central line was placed and an infusion of sodium-free TPN was started. Days 5 8 During this time the patient began to stabilize. His laboratory values and hemodynamic status normalized, and he was weaned off phenylephrine on day 5. His PbO2 values were >32 mm Hg; his brain temperature was 37.6C 38.7C. His ICP and PbO2 remained stable and he was weaned off propofol infusion. During this time his GCS score was 9 (2 = eye opening, 1 = verbal, 6 = motor) and he began to intermittently follow commands with his right hand. After PbO2 and ICP were stable for 24 hours, the monitoring system was discontinued. During the following day the patient began to open his eyes, use his voice, and make eye contact with his family. Days 9 10

Stable pulmonary function and adequate peripheral oxygenation permitted successful extubation to 6L nasal cannula. The patient had minimal verbalization and confused conversation but no stridor was heard and, though weak, he did have a cough. The primary nurse arranged for speech and swallow consults to safely evaluate the patient's ability to take food and decrease his risk for aspiration. The speech pathologist detected mild dysphagia and cleared the patient for a mechanical soft diet. However, because the patient was consuming inadequate calories to support his nutritional needs, TPN was continued until a calorie count demonstrated sufficient calorie intake. Activity was increased so that the patient was out of bed twice daily and the nurse taught him and his family passive range-of-motion (ROM) exercises, which involved the family in his care. The patient's wife, a retired physical therapist, actively participated in the activities of daily living and ROM exercises for his limbs. Because of a short-term memory loss, the patient required frequent reorientation by the nurses and his family. A clock and an orientation board with day, date, place, and the name of the nurse caring for him was placed in his room. The staff also encouraged his wife to bring in pictures of his family and things he enjoyed to facilitate his memory. 3.7 CONCLUSION The patient was transferred out of the NTSICU to the surgical floor 10 days after his injury and underwent aggressive physical therapy. He had difficulty with gross motor function, particularly with controlling movements of his arms and legs; however, he could ambulate with moderate assistance. Short-term memory problems were apparent, but the patient was alert and oriented to person, place, and time. After a total hospital stay of just 3 weeks, the patient and his wife flew back home (Florida), where he attended an inpatient rehabilitation program. In April 2005, the patient underwent a cranioplasty, and according to his wife, he is slowly returning to the tasks he once loved. His wife noted that not only does he walk without assistance, but he also runs mile, shops for groceries, and one day plans to teach classes in a local dental school. She is amazed by his determination and progress to date, and most of all she reports that his kind smile and laugh have returned along with his sense of humor. TBI patients and their families experience physical and emotional devastation immediately following injury. TBI is life altering, and an MMM approach to patient care requires the participation of a vigilant bedside nurse to detect often subtle neurologic changes. Early detection and rapid intervention of these neurodynamic changes can make a difference in the development and progression of secondary injuries. This case study demonstrates how neurocritical care management with MMM can control ICP, maximize CPP, and prevent devastating secondary injury. The use of the HUP institutional TBI algorithm in concert with a multidisciplinary approach maximizes the capability of two of the instituion's most valuable resources the neuroscience nurse and technology increasing the potential for an excellent outcome in the management of severe TBI.

3.0 THEME 2 3.1 CASE STUDY 2 3.2 INTRODUCTION The purpose of this document is to provide recommendations based on current evidence that will help registered nurses, intensive care unit personnel, and institutions provide safe and effective care to severely injured patients with traumatic brain injury (TBI). For the purposes of this guideline, severe TBI is defined as a brain injury incurred by a traumatic mechanism of injury with a resultant level of consciousness categorized by a Glasgow Coma Scale (GCS) score of 8 or lower. The goal of these guidelines is to offer evidence-based recommendations on nursing activities that have the potential to maximize outcomes for severe TBI. These recommendations are not inclusive of all activities that might improve outcomes, but reflect interventions commonly found in the literature that have been scientifically examined within the last decade. Not all recommendations concern activities independently performed by nurses, but nurses are responsible for implementing and monitoring the outcomes of these activities. The evidence presented here may help neuroscience nurses make appropriate choices when caring for patients with severe TBI. 3.3 BACKGROUND Severe TBI kills more than 50,000 people yearly and can result in lifelong functional, behavioral, and cognitive disabilities (Novack, 2000). Falls (28%), motor vehicle crashes (20%), being struck by/against impact (19%), and assaults (11%) are the leading causes of TBI (Langlois, Rutland-Brown, & Thomas, 2006). TBI rates are highest among people age 15 24 years and those older than age 65 years (National Center for Injury Prevention and Control, 1999) and occurs 1.5 times more often in men than in women (Novack). The lifetime cost of caring for a person with a severe TBI is estimated at more than $3 million (Novack).

TBI has become the signature injury of military personnel involved in conflicts in the Middle East. In contrast to the civilian population, TBI in the military most often results from blast mechanism of injury. Of the 22,600 soldiers evacuated from Operation Enduring Freedom and Operation Iraqi Freedom to Walter Reed Army Medical Center, 28% were found to have at least a mild TBI (Warden, 2006). Among this group, 12% sustained penetrating injury of variable severity. Mild TBI affected fewer than 50% of patients in the sample. TBI severity generally is categorized with a GCS score. Data compiled by the Traumatic Coma Data Bank established that a GCS score of 3 8 identified a severe injury. Additional criteria for a severe injury include loss of consciousness for longer than 6 hours and posttraumatic amnesia lasting longer than one week (Greenwald, Burnett, & Miller, 2003). 3.4 CASE PRESENTATION

45 y/o with TBI from MVA 2005 Lives with mother Primary diagnosis Brain Injury Nec Secondary diagnoses Insomnia Nec, Seizure Disorder, Mental/behavior Problem NOS 3.5 EVALUATION AND DISCUSSION Risk: Factors Contributing to Premature NF Short Term Memory Deficits Poor Judgment Poor impulse control with socially inappropriate behavior. Agitated behavior Reduced attention span Needs assistance or dependent with most IADLs History of depression related to functional limitations

Medication non-compliance 3.6 Role of Nurses ADHC Interventions: RN and SW assess for anxiety and monitor medications and medication compliance with mother, MD, and MDT. RN, SW and MDT monitor for agitated and restlessness behavior. RN provides medication and team provides behavioral interventions. OT and ST provide functional cognitive-linguistic therapy to develop functional problem solving skills for IADLs. PT provides maintenance program to maintain mobility status at supervised level. SW, OT, ST and staff provide verbal cues, structure and redirection to reduce socially inappropriate behavior. SW and staff monitor for s/s of depressive feelings, provide emotional support and encouragement to increase self-esteem and reduce s/s of depression. 3.7 CONCLUSION Outcomes Past Six Months: Pt.s anxiety has decreased over last 6 months. SW and RN coordinated w/ c/g and PCP to address agitation and restlessness, resulting in changes in medication (addition of Valium). Pt. is responding well to medication change. Able to attend to 20 minutes semi-structured group activity on a regular basis, sometimes up to 40 minutes. Able to participate in a small group for focused cognitive therapies for 45 minutes. Improved ability to follow center and participant-specific rules with good understanding of consequences Able to determine appropriate solutions to problems with minimal to moderate verbal assist. Remains easily distracted and tangential. 3.8 DISCUSSION The rehabilitation physician plays a central role in leading, coordinating and providing a continuum of care and services over the course of the patients recovery. Therefore, early involvement of the rehabilitation physician as part of the acute managing team is imperative and this can be initiated either by a referral or during combined staff rounds. Some of the rehabilitation physicians specific roles include: 1) Identification of specific rehabilitation needs and physical impairments, which may be directly related to the brain injury or secondary to concomitant orthopaedic

or spinal cord injury. 2) Assessment of injury severity and initial functional prognostication based on acute injury variables. 3) Acute management of neuromedical complications and active prevention of immobility and other related complications, as well as multidisciplinary management of bladder, bowel and skin issues, including prolonged fevers, venous thromboembolism, anti-epileptic drug management, spasticity, heterotopic ossification, posttraumatic amnesia management and related agitated behaviour. 4) Coordination of early rehabilitation therapies, timing of transfer of patients to intensive brain injury rehabilitation units, as well as commencement of discharge planning processes. 5) Coordination of inpatient brain injury rehabilitation programmes and post-discharge rehabilitation therapies for social, educational and vocational reintegration, determining readiness for driving rehabilitation and prevention of second TBI. 6) Independent medical examinations for assessment of permanent disability, legal and workers compensation or litigation, end of life and legal-ethical issues for those in a permanent vegetative state. In summary, TBI rehabilitation is a recognized subspecialty of neurorehabilitation and there is increasing awareness of its important role in early management for all severities of injury. While evidence for its effectiveness and specific interventions is limited, emerging therapies, both at a cellular and therapeutic level, continue to be subjected to rigorous research. The families of TBI survivors, particularly the severely injured, young TBI and those in VS bear most of the social and societal burden of long-term care. It must be remembered that prevention of TBI is vital as there remains no cure for the sequelae of moderate-tosevere TBI. 4.0 CONCLUSIONS AND RECOMMENDATIONS 4.1 CONCLUSIONS Learning to effectively deal with potentially dangerous situations is a challenge unique to treating people with brain injuries. Patients can become extremely agitated and combative,

biting, yelling, shouting, hitting, and lashing out at those around them. Nurses must be familiar with different options available to help with these situations, such as special veil beds used to contain patients to bed with minimal restraint. Nurses must also learn to anticipate triggers that will set off a patient such as the need to use the bathroom, too much light or noise, pain, family issues or too many visitors at one time. When a person sustains a brain injury, the result is traumatic, not only for the patient but for his or her family as well. Families are often ill equipped to deal with the devastating changes brain injury can bring. It is hard for many families to accept these changes and to know what their responsibility is in the recovery process. It is the nurse's role to help family members through this difficult time. Families often find it hard to deal with the variety of complications that can result from brain injury, including loss of memory, poor judgement, loss of inhibitions and personality changes. In addition, long-standing family dynamics or feelings of guilt, anger or frustration may make the process more difficult. In treating brain injuries, nurses deal with the entire family, not just the patient. Nurses are also responsible to provide the education families need to be able to give ongoing support and care once the patient is released. Brain injury nursing can be challenging and requires a great deal of patience and skill, but it also offers many rewards including autonomy and flexibility. 4.2 RECOMMENDATIONS FOR PRACTICE uch information regarding TBI has come to light in recent years. However, there are countless individuals who sustained TBI years ago sequestered away in nursing homes and group homes. There are injured adult survivors living at home with their aging parents. Survivors and families that have given up hope or just choose to accept the limitations of years ago may not know of the inroads that are being made into the rehabilitation from TBI. Efforts should be made by survivor support groups and concerned professionals and other individuals to reach out to these forgotten survivors of TBI.

It is recommended that GPs, nurse practitioners, dentists and ambulance crews should receive training, as necessary, to ensure that they are capable of assessing the presence or absence of the risk factors There should be a protocol for all staff to introduce themselves to family members or carers and briefly explain what they are doing. In addition a photographic board with the names and titles of personnel in the hospital departments caring for patients with head injury can be helpful

Information sheets detailing the nature of head injury and any investigations likely to be used should be available in the emergency department. Staff should consider how best to share information with children and introduce them to the possibility of long-term complex changes in their parent or sibling. Literature produced by patient support groups may be helpful Healthcare professionals should encourage carers and relatives to talk and make physical contact (for example, holding hands) with the patient. However, it is important that relatives and friends do not feel obliged to spend long periods at the bedside. If they wish to stay with the patient, they should be encouraged to take regular breaks. There should be a board or area displaying leaflets or contact details for patient support organisations either locally or nationally to enable family members to gather further information 4.3 RECOMMENDATION FOR FURTHER RESEARCH

Transport to a specialist neuroscience unit compared with transport to the nearest district general hospital A study to determine whether the clinical outcome (mortality/morbidity) of patients with head injuries and reduced levels of consciousness is improved by direct transport from the scene of injury to a tertiary centre with neurosurgical facilities compared with the outcome of those transported initially to the nearest hospital without such facilities. Why this is important Limited evidence in this area has shown that patients do better in terms of outcome if they are transported directly to a neuroscience unit. Currently: patients are always transported to the nearest district general hospital, as is the case in most land vehicle deployment situations, or in some organisations, especially those involving helicopter emergency medical services, the decision is left to the judgement of the clinicians at the scene. Those transported to the nearest district general hospital may suffer a significant delay in receiving definitive treatment for their head injury. 4.2 Clinical decision rules on the selection of head-injured infants and children for CT imaging

Research to establish the validity of previously derived clinical decision rules on the selection of head-injured infants and children for CT imaging to exclude significant brain injury.

Why this is important The 2002 NICE guidelines recommended that children be selected for CT imaging on the basis of the Canadian Head CT rule, a clinical decision rule derived and validated in adults. There was an absence of such a rule derived in children. Since this date, the CHALICE rule has been published; this is a clinical decision rule derived in a large group of children and infants from the UK, and has good sensitivity and specificity. However, clinical decision rules often provide an overestimate of their performance when applied to new populations. We now recommend the use of the CHALICE rule for children suffering a head injury in the UK, with the caveat that a validation of the rule in a new population of head-injured UK patients be undertaken urgently to ensure its reliability and reproducibility. 4.3 Criteria for surgery for intracerebral lesions Research to develop consensus on criteria for lesions not currently considered surgically significant following imaging of a patient with a head injury. Why this is important One option in the management of traumatic intracerebral haemorrhage and cerebral contusions is to monitor the patient clinically or with intracranial pressure monitoring and other forms of brain tissue monitoring, such as brain tissue oxygen or microdialysis. When the patient deteriorates, he or she is rushed to the operating theatre. This approach has not been validated in a prospective randomised controlled trial. Waiting until the level of consciousness deteriorates or there is deterioration in the monitoring parameters builds delay into the management and results in secondary brain damage occurring and becoming established before surgery in all cases. There is no level 1 evidence about what to do with these patients and the need for research is urgent.

4.4 Outcomes of severely head injured adults who do not require operative neurosurgical intervention Research to determine which patients with significant traumatic brain injury who do not require operative neurosurgical intervention at presentation, but are still cared for in specialist neurosciences centres, have improved clinical outcomes when compared with similar patients treated in non-specialist centres. Why this is important Epidemiological evidence suggests that transfer of patients with GCS < 8 to neuroscience units results in improved outcomes, even if they do not require surgical intervention. However, this evidence does not dictate current practice in some regions, and there is a clear need for more information. In particular, we do not know whether specified subsets of patients in this category are more likely to benefit from transfer, and whether some of the factors that may improve outcome in neuroscience units can be translated to non-specialist centres, thus reducing the need for transfer. There are clear risks from transfer, and there could be clear harm, both in terms of clinical outcome and health economics, if the anticipated benefits were not realised. On the other hand, if the benefits from observational studies were confirmed by the trial, the resulting changes in management could potentially reduce case-mix-adjusted mortality by 26% and increase the incidence of favourable outcome in survivors by nearly 20%. 4.5 Long-term sequelae Research is needed to summarise and identify the optimal predictor variables for long-term sequelae following mild traumatic brain injury. Why this is important We performed a review of the literature in this area, repeated in this update process. While 394 studies were identified that attempted to use a wide range of variables and tests to predict a range of longer-term outcome measures, no robust clinical decision tools have successfully been derived and validated to identify patients at the time of injury who could be considered for follow-up

because of the higher risk of long-term sequelae. A systematic review of the literature would summarise and identify the optimal predictor variables for such a clinical decision rule and also identify the optimal outcome variables, thus laying the foundation for a derivation cohort study. 4.4 REFLECTION ON RESEARCHER An estimated 5.3 million Americans are living with disabilities from traumatic brain injuries. Traumatic brain injury (TBI) can cause a wide range of functional changes affecting thinking, emotions, and behaviors, or a combination of any of these. Reflecting on a self-care process for patients in TBI home rehabilitation programs becomes critical for nurses who desire to optimize patient functioning. As the young patients' brain plasticity impacts adjustments to deficits and injury, applying the self-care process in the home setting provides a natural healing environment. As TBI survivors recognize and regulate their own behaviors, application of nursing actions dynamically match this change. 5.0 REFERENCES 1. Bullock, R., Chestnut, R. M., Clifton, G., Ghajar, J., Marion, D. W., Narayan, R. K., et al. (2000). Guidelines for the management of severe head injury (2nd ed.). New York: Brain Trauma Foundation. 2. CDC report shows prevalence of brain injury. (1999). CNN Interactive. Retrieved July 13, 2000, from www.cnn.com/HEALTH/9904/14/ brain.injury 3. Centers for Disease Control and Prevention. (1996). Traumatic brain injury (TBI): Incidence and distribution. Retrieved September 2004, from www.cdc.gov 4. Guerrero, J. L., Thurman, D.J., & Sniezek, J. E. (2000). Emergency department visits associated with traumatic brain injury: United States, 1995 1996. Brain Injury, 14, 181 186. 5. Integra NeuroSciences/GMS. (2002). LICOX [product insert]. Plainsboro, NJ: Author. 6. Lexi-Comp Online. (n.d.). Retrieved from www.lexi.com/web/index.jsp 7. References: 8. 9. Adelson, P.D., Clyde, B., Kochanek, P.M.. Wisniewski, S.R., Marion, D.W. & Yonas, H. (1997). Cerebrovascular response in infants and young children following severe traumatic head injury: a preliminary report. Pediatric Neurosurgery, 26(4), 200-207. 10. 11. Albanese, J., Viviand, X., Potie, F., Rey, M., Alliez, B & Martin, C. (1999). Sufentanyl, fentanyl and alfentanyl in head trauma patients: a study on cerebral dynamics. Critical Care Medicine, 27(2), 262-263. 12. 13. Arbour, R. (1998). Aggressive management of intracranial dynamics. Critical Care Nurse, 18(3), 30-40. 14.

15. Chudley, S. (1994). The effect of nursing activities on intracranial pressure. British Journal of Nursing, 3(9), 454-459. 16. 17. Cruz, J. (1998). The first decade of continuous monitoring of jugular bulb oxyhemoglobin saturation: management and clinical outcome. Critical Care Medicine, 26(2), 344-351. 18. 19. Feldman, Z, Robertson, C.S, Contant, C.F., Gopinath, S.P. & Grossman, R.G. (1997). Positive end-expiratory pressure reduces intracranial compliance in the rabbit. Journal of Neurosurgical Anesthesiology, 9(2), 175-179. 20. 21. Forbes, M.L., Clark, R.S., Dixon, C.E., Graham, S.H., Marion, D.W., Dekowsky, S.T., Schiding, J.K. & Kochanek, P.M. (1998). Augmented neuronal death in CA3 hippocampus following hyperventilation early after controlled impact. Journal of Neurosurgery, 88(3), 549-556. 22. 23. Golding, E.M., Roberston, C.S. & Bryan, R.M. (1999). The consequences of traumatic brain injury on cerebral blood flow and autoregulation: a review. Clinical and Experimental Hypertension, 21(4), 299-332. 24. 25. Hall, C.A. (1999). Patient management in head injury care: a nursing perspective. Intensive and Critical Care Nursing, 13(6), 329-337. 26. 27. Kiening, K.L, Hartl, R., Unterberg, A.W., Schneider, G.H., Bardt, T. & Lanksch, W.R. (1997). Brain tissue pO2 monitoring in comatose patients: implications for therapy. Neurologic Research, 19(3), 233-240. 28. 29. Kokoska, E.R., Smith, G.S., Pittman, T. & Weber, T.R. (19998). Early hypotension worsens neurologic outcome in pediatric patients with moderately severe head trauma. Journal of Pediatric Neurosurgery, 33(2), 333-338. 30. 31. 32. Larson, G.Y. & Goldstein, B. (1999). Consultation with the specialist: increased intracranial pressure. Pediatrics in Review, 20(7), 234-239. 33. 34. Marik, P., Chen, K. Varon, J. Fromm, R. & Sternbach, G.L. (1999). Management of increased intracranial pressure: a review for clinicians. Journal of Emergency Medicine, 17(4), 711-719. 35.

36. Marion, D.W., Firlik, A. & Mclaughlin, M.R. (1995). Hyperventilation therapy for severe traumatic brain injury. New Horizons, 3(3), 439-447. 37. 38. Marion, D.W., Penrod, L.E., Kelsey, S.F., Obrist, W.D., Kochanek, P.M., Palmer, A.M., Wisniewski, S.R. & Dekosky, S.T. (1997). Treatment of traumatic brain injury with moderate hypothermia. New England Journal of Medicine, 336(8), 540-546. 39. 40. McLaughlin, M.R. & Marion, D.W. (1996). Cerebral blood flow and vasoresponsivity within and around cerebral contusions. Journal of Neurosurgery, 85(5), 871-876. 41. 42. McKinley, B.A., Parmley, C.L. & Tonneson, A.S. (1999). Standardized management of intracranial pressure: a preliminary clinical trial. Journal of Trauma-Injury, Infection and Critical Care, 46(2), 271-279. 43. 44. Metz, C., Holzschuh, M., Bein, T., Woertgen, C., Frey, A., Frey, I., Taeger, K. & Brawanski, A. Moderate hypothermia in patients with severe head injury: cerebral and extracerebral effects. Journal of Neurosurgery, 85(4), 533-541. 45. 46. Muizelaar, J.P., Marmarou, A., Ward, J.D., Kontos, H.A., Choi, S.C., Becker, D.P., Gruemer, H. & Young, H.F. (1991). Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. Journal of Neurosurgery, 75(5), 731-739. 47. 48. Naredi, S., Eden, E., Zall, S., Stephensen, H. & Rydenhag, B. (1999). A standardized neurosurgical neurointensive therapy directed toward vasogenic edema after severe traumatic brain injury: clinical results. Intensive Care Medicine, 24(5), 446-451. 49. 50. Newell, D.W., Weber, J.P., Watson, R., Aaslid, R. & Winn, H.R. (1996). Effect of transient moderate hyperventilation on dynamic cerebral autoregulation after severe head injury. Neurosurgery, 39(1), 35-43. 51. 52. Ong, L., Selladurai, B.M., Dhillon, M.K., Atan, M. & Lye, M.S. (1996). The prognostic value of the Glasgow Coma Scale, hypoxia and computerized tomography in outcome prediction of pediatric head injury. Pediatric Neurosurgery, 24(6), 285-291. 53. 54. Prabhu, V.C., Kaufman, H.H., Voelker, J.L., Aronoff, S.C., Niewiadomska-Bugaj, M., Mascaro, S & Hobbs, G.R. (1999). Prophylactic antibiotics with intracranial pressure monitors and external ventricular drains: a review of the evidence. Surgical Neurology, 52(3), 226-236. 55.

56. Qureshi, A.I., Suarez, J.L., Bardwaj, A., Mirski, M., Schnitzer, M.S., Hanley, D.F. & Ulatowski, J.A. (1998). Use of hypertonic saline/acetate infusion in the treatment of cerebral edema; effect on intracranial pressure and lateral displacement of the brain. Critical Care Medicine, 26(3), 440-446. 57. 58. Ratan, S.K., Kulshreshtha, R. & Pandey, R.M. (1999). Predictors of posttraumatic convulsions in head injured children. Pediatric Neurosurgery, 30(3), 127-131. 59. 60. Rising, C.J. (1993). The relationship of selected nursing activities to ICP. Journal of Neuroscience Nursing, 25(5), 302-308. 61. 62. Rosner, M.J., Rosner, S.D. & Johson, A.H. (1995). Cerebral perfusion pressure: management protocol and clinical results. Journal of Neurosurgery, 83(6), 949-962. 63. 64. Scherer, R.U. & Spangenberg, P. (1998). Procoagulant activity in patients with isolated severe head injury. Critical Care Medicine, 26(10), 149-156. 65. 66. Sharples, P.M., Stuart, A.G., Matthews, D.S., Aynsley-Green, A. & Eyre, J.A. (1995). Cerebral blood flow and metabolism in children with severe head injury. Part 1: relationship to age, Glascow Coma Score, outcome, intracranial pressure, and time after injury. Journal of Neurosurgical Psychiatry, 58(2), 145-152. 67. 68. Shiozaki, T., Sugimoto, H., Taneda, M., Oda, J., Tanaka, H., Hiraide, A. & Shimazu, T. (1998). Selection of severely head injured patients for mild hypothermia therapy. Journal of Neurosurgery, 89, 206-211. 69. 70. Scouts, P.J., Orozco, J.A., Carter, L.P., Weinand, M.E., Hamilton, A.J. & Williams, F.C. (1995). Continuous regional cerebral cortical blood flow monitoring in head injured patients. Neurosurgery, 36(5), 943-949. 71. 72. Skippen, P, Seear, M., Poskitt, K., Kestle, J., Cochrane, D. Annich, G. & Handel, J. (1997). Effect of hyperventilation on regional cerebral blood flow in head injured children. Critical Care Medicine, 25(8), 1402-1409. 73. 74. Stocchetti, N., Rossi, S., Buzzi, F., Mattioli, C., Paparella, A. & Colombo, A. (1999). Intracranial hypertension in head injury: management and results. Intensive Care Medicine, 25(4), 371-376. 75.

76. Stiver, J.F. & Stocker, R. (1998). Barbiturate coma may promote reversible bone marrow suppression in patients with severe isolated traumatic brain injury. European Journal of Clinical Pharmacology, 54(7), 529-534. 77. 78. Taylor, G., Heyers, S., Kurth, C.D., Duhaime, A.C., Yu, M., McKernan, M., Gallagher, P., ONeill, J. & Templeton, J. (1996). Hypertonic saline improves brain resuscitation in a pediatric model of head injury and hemorrhagic shock. Journal of Pediatric Surgery, 31(1), 65-70. 79. 80. Thiagarajan, A., Goverdhan, P.D., Chari, P. & Somasunderam, K. (1999). The effect of hyperventilation and hyperoxia on cerebral venous oxygen saturation in patients with traumatic brain injury. Anesthesia & Analgesia, 87(4), 850-853. 81. 82. Vigue, B., Ract, C., Benayed, M., Zlotine, N., Leblanc, P.E., Samii, K. & Bissonnette, B. (1999). Early SjvO2 monitoring inpatients with severe head injury. Intensive Care Medicne, 25(5), 445-451. 83. 84. Wainright, S.P. & Gould, D. (1996). Endotracheal suction in adults with severe head injury: literature review. Intensive and Critical Care Nursing, 12, 303-308. 85. 86. Yundt, K.D & Diringer, M.N. (1997). The use of hyperventilation and its impact on cerebral ischemia in the treatment of traumatic brain injury. Critical Care Clinics, 13(1), 163-184. 87. 88. Zauner, A., Doppenberg, E., Woodward, J.J., Allen, C., Jebraili, S., Young, H.F. & Bullock, R. (19997). Multiparametric continuous monitoring of brain metabolism and substrate delivery in neurosurgical patients. Neurologic Research, 19(3), 265-273. 89. 90. 91. 92. 93.