TRAUMATIC BRAIN INJURY Heather Hulien Ferris State University NURS 441

NURSING CARE PROBLEM Do characteristics of the ICU nurse influence judgments about: patient risk of secondary brain injury? determining if a situation is best managed solely with nursing interventions? determining if consultation with other members of the healthcare team is warranted?

NURSING THEORY Ida Jean Orlando’s Nursing Process Theory

STUDY METHODS AND RESULTS Study method: A factorial survey research design Results: The primary shift of the nurse and the experience level of the nurse were significant in predicting judgments and managing secondary brain injury

CRITIQUE OF THE RESEARCH STUDY Source Ethics Problem Literature review Design Sample Data collection Level of measurement Results

COLLABORATION Physician Respiratory therapist Pharmacist Nutritionist Physical therapist Occupational therapist Speech language pathologist Case manager Social worker Family

CASE STUDY Charles is a 44-year-old man who slipped on an ice-covered sidewalk and fell backwards, hitting his head on concrete. He lost consciousness for a few seconds. Within minutes he had a severe headache, started repeating himself, and became very forgetful. His wife drove him to the ED. After several hours of observation in the ED and a normal computed tomography (CT) scan, Charles was diagnosed with a concussion and released to go home. He and his wife were not given any instructions on what might be expected following a concussion, except that the physician thought he would be able to return to work 2 days later. Charles had a constant headache, nausea, dizziness, ringing in his ears and slept most of the day. He discomfort persisted for almost a week, so he was unable to return to work as expected. His wife noticed he wasn’t thinking clearly, so she took him to a larger hospital where a repeat CT was conducted. The repeat CT showed no abnormalities and no changes from the first CT. The physician diagnosed Charles with post-concussive syndrome and talked with him and his wife about the symptoms and what could be expected. He also referred Charles to a neuropsychologist for evaluation and testing. Testing showed deficits in his short-term memory and concentration. During the next several weeks, Charles realized he had a hard time being around groups of people and was more irritable. He also continued to have problems with dizziness, tiredness, balance, and memory. He wasn’t able to return to work for 6 weeks. For the next several months Charles had frequent headaches, noise bothered him, and he felt easily distracted and had a difficult time concentrating. A year later his wife noticed Charles had significant mood changes so he returned to the neuropsychologist who referred him to a psychologist. Charles was diagnosed with depression and was prescribed citalopram. Two and a half years after his fall, Charles says he feels he continues to have a lack of patience and intolerance of people. He feels he isn’t depressed but just doesn’t deal with stress well.

TRUEPIC 1. IDENTIFY… the variables in this situation 44 YO Male Mild traumatic brain injury Slipped on ice and diagnosed with concussion 7 days ago Experiencing headache, nausea, dizziness, and tinnitus Slept most of the day Deficits in short-term memory and concentration 2. RELATE…Or put the variables together to form propositions. Primary Proposition: “Patient is experiencing post-concussive syndrome (PCS).” Possible Assumptions: “Patient knows he is experiencing post-concussive syndrome because he was educated on symptoms of the condition before he was released from the ED.” Possible Confounding Variables: “Patient did not what to spend a lot of time in the hospital; eager to get back to work.” 3. UNDERSTAND…the importance of the propositions, assumptions, and confounding variables. Proposition: If the post-concussive syndrome is not treated, the condition can have a serious and long-term impact on the patient’s physical, cognitive, and psychological function. Significance of Assumptions: If the patient does not know the symptoms of PCS, he may not seek early treatment; therefore, he will not have the best possible recovery. Possible Confounding Variables: If the patient does not want to spend a lot of time in the hospital, he will be reluctant to receiving education about his condition. If the patient has a concussion, he will not learn about the symptoms of the possible complication of PCS; therefore, he will not receive early treatment for PCS.

TRUEPIC 4. EXPLAIN…the significance of the situation to those involved based on their individual KSVME Proposition: In a way that is understandable to the patient, explain what PCS is to the patient with consideration of the patient’s knowledge, skills, values, meanings, and experiences. Assumptions: Explain the symptoms of PCS and the benefits of receiving treatment immediately if symptoms occurs. Confounding Variables: Explain the role of education and knowledge in preventing further complications. 5. PREDICT…what will happen in this situation if one or more variables are not changed. Proposition: If the patient does not promptly receive treatment for PCS, his condition could result in impulsive behavior, easy frustration, impaired social judgment, and unpleasant personality changes. Assumptions: If the patient seeks treatment for PCS symptoms early, the risk of long-term negative effects will be lessened. Confounding Variables: If the patient agrees to learn what symptoms are expected in the days following his concussion, and what symptoms indicate a complication of his concussion, he will be more likely to receive effective treatment, and suffer from less long-term effects. 6. INFLUENCE…someone to change one or more variables in order to achieve a desired outcome or prevent an undesirable one. Proposition: Make sure the patient understands that the symptoms of PCS are not normal to experience after a concussion. Assumptions: Before discharging the patient from the ED, make sure the patient is knowledgeable of the cognitive, physical, and behavioral symptoms of PCS. Also make sure the patient knows what to do if he experiences those symptoms. Confounding Variables: Influence by explaining long-term effects and deficits that the patient may face if he does not receive immediate care for PCS. 7. CONTROL…one or more variables in order to achieve a desired outcome or prevent an undesirable one. To control isn’t an issue of wanting to dominate or do what is unreasonable or unwanted, but simply a matter of changing one or more variables in order to bring about a desired outcome when influence is not possible, realistic, or advisable. -The patient and his wife will review PCS educational material while in the hospital.

ADVOCATE ROLE

REFERENCES Brain Trauma Foundation. (n.d.). Tbi statistics. Retrieved from Colley, S. (2014). NURS 441 Nursing Theory 3 [Syllabus]. p. 6. Lavin, A. (2013, April). Post-concussive syndrome: What patients and providers need to know. Retrieved from McNett, M. (2009). Intensive care unit nurse characteristics impacting judgments about secondary brain injury. Dimension of Critical Care Nursing, 28(4), Retrieved from Orlando's nursing process theory. (2013, September 09). Retrieved from Singleterry, L. (2014). NURS 350 Research in Nursing [Syllabus]. P. 9.