الفهرس 
IntroductionOnly 14 pages are availabe for public view
 |  | from | 116 |  |  |
| | | from | 116 | | |
Abstract
Traumatic brain injury is an acute and sudden insult to the brain resulting in alteration and disruption in neural networks and accordingly in normal cognitive functions. Cognitive functions impairment after TBI are substantial sources of morbidity for TBI survivors, their family, and society. Recovery of cognitive functions is the one of the major obstacles facing the ICU team members particularly the CCNs.
Critical care nurses have a responsibility in mitigating severe TBI patients’ sufferings by enhancing cognitive recovery. Environmental enrichment through integrating of integrative nursing practices such as NMT, massage therapy and aromatherapy using lavender oil in the care provided to the severe TBI patients by the CCNs may potentially stimulate affected neural networks, accelerate brain plasticity, and avoid a sensory deprivation that could slow down the TBI patients’ cognitive recovery.
Aim of the study
The current study was conducted to determine the effect of implementing integrative nursing practices on cognitive recovery among severe TBI patients.
Materials & Method
A quasi experimental research design was utilized to accomplish this study. This study was conducted in four ICUs of AMUH namely Casualty ICU (unit I), General ICU (unit II), General ICU (unit III), and Triage ICU and general ICU of Smouha University Hospital.
A convenience sample of 60 adult patients suffering from severe TBI who admitted to the previously mentioned settings with the following inclusion criteria: patients who were in a state of a coma during the first three days post injury, had a GCS score of 3 - 8, stable hemodynamics, and aged from 21 years to 60 years of both sex. Patients who are receiving sensory suppression medications (sedatives, muscle relaxant) and those who had brain stem death, suffering from blindness, deafness, and seizures was excluded from the study.
To accomplish the aim of the current study; two tools were used for data collection. Tool one “Autonomic Responses Assessment Tool” It was developed by the researcher after reviewing the relevant literature (Arslan & Ozer, 2016; Chamine & Oken, 2016; Vahedian-Azimi et al., 2014) to monitor the TBI patients’s autonomic responses. Tool two: “Cognitive recovery assessment Tool”. It was adopted by the researcher after reviewing the relevant literature (Cusick et al., 2014; Jalali & Rezaei, 2014; Moattari et al., 2016) to assess the TBI patient’s cognitive recovery. It consists of three parts; part I: level of consciousness (LOC) assessment using FOUR score, part II: level of cognitive functioning (LCF) assessment using RLA scale, and part III: basic cognitive sensory recovery assessment using WNSSP scale.
The study design was accomplished as follow:
Approval of ethics committee of the faculty of nursing was obtained. Before data collection the researcher attended an extensive therapeutic massage training program. An official approval to conduct this study was obtained after providing explanation of the aim of the study. An informed consent was obtained from patients’ legal guardians. The study tools were tested for content validity by 7 experts in the field of the study. The necessary modifications were done accordingly. Reliability of tool one was tested using Cronbach’s Alpha test and result was 0.855 which is accepted. A pilot study was carried out on 10% of the study sample in order to test the clarity and applicability of the research tools.
Data were collected over a period of nine consecutive months (from July 2018 to March 2019). Patients who met the inclusion criteria were assigned into two equal groups, control and study, 30 patients in each. Data were collected from the control group first then from the study group.
For both groups: patients were approached in the fourth day post injury to ensure hemodynamic stability of them. The researcher selected 2 hours between 3 pm and 9 pm to avoid any conflict with medical rounds or nursing care provided to the patients(Moattari et al., 2016). The demographic and clinical data of the studied patients was collected from the patient’s chart or family and recorded. The baseline measurement of autonomic responses were obtained at the 1st day of the study using tool one. The baseline data of LOC, LCF, and basic cognitive sensory recovery were assessed at the 1st day of the study using tool two.
For the control group patients were subjected to the conventional care used in the study settings without the researcher interference. The researcher observed the conventional nursing care provided by the CCNs that may affect the patients’ cognitive recovery for 90 minutes per day for four consecutive days, from the fourth day to the seventh day post injury.
For the study group the integrative nursing practices; massage therapy, aromatherapy using lavender oil, and NMT were applied for 90 minutes per day for four consecutive days, from the fourth day to the seventh day post injury.
Integrative nursing practices were preceded by 10 minutes awakening period then each patient was massaged by the researcher during a 40 minute session. Back (10 minutes), feet and legs (10 minutes), abdomen (5 minutes), hands and arms (10 minutes), and chest (5minutes) were massaged during each session. Lavender oil was used for effleurage and massage facilitation and as a part of aromatherapy. Also, cotton gauze (2 × 2 cm) with 5 drops of lavender was attached to the front of the patient’s gown, approximately 12 inches below their nose for 10 minutes. Finally, patients were listened to 30 minutes of NMT after implementing of massage and aromatherapy.
For both groups after integrative nursing practices/ conventional nursing care. The autonomic responses were measured using tool one and LOC, LCF, and basic cognitive sensory recovery were assessed using tool two after each implementation of the integrative nursing practices for the study group and after 90 minutes of observation of conventional nursing care for the control group throughout the four days of the study period to be compared with the baseline data.
Results of the study
Most of studied patients in this study were males; middle aged less than thirty years old and MVA was the main mechanism of injury among them. Furthermore, there was no significant difference between the studied groups regarding demographic and clinical characteristics namely, sex, age, mechanism of injury, GCS, accompanying injuries, CT scan findings and the type of patient’s care management.
In relation to autonomic response the current study revealed that there was significant difference in the mean of pupils’ size, RR, HR, MAP, and SPO2 between patients in the study group compared to patients in the control group at the end of the study P= 0.045, P=0.011, P=<0.001, P=0.042, and P=<0.001respectively.
Regarding the LOC which was measured by the FOUR score, patients in the study group showed higher means of FOUR score all over the study period with implementation of integrative nursing practices compared with the means of FOUR score in control group. The mean FOUR score for the control group was 6.67 ± 2.28 compared to 7.20 ± 2.34 for the study group with no significant difference between the two groups at the start of the study (P=0.375). At the end of the study these means increased to 7.40±1.85 for the control group and to 9.67 ± 2.41 for the study group with a high significant difference between the two groups (P <0.001).
Also the current study showed that there as an increasing trend in the mean score of RLA scale ,which was used to assess the LCF, from the start to end of the study for patients in the study group which was higher than patients in the control group. For the study group the mean score of RLA scale was increased from 2.80 ± 1.24 at the start of the study to 5.13 ± 1.53 at the end of the study compared to 2.77 ± 1.19 to 2.80 ± 1.24 for the control group respectively. Also, it can be noted that there was no significant difference between the two groups in relation to the mean score of RLA scale at the start of the study (P=0.916), whereas there was a highly significant difference between them at the end of the study (P <0.001).
Concerning the basic cognitive sensory recovery which was measured by WNSSP scale, it can be noted that the mean score of WNSSP scale for the control group (19.90 ± 15.38) was higher than the study group (12.57 ± 14.53) at the start of the study. While, upon the completion of the study the mean score of WNSSP scale for the study group (62.30 ± 23.96) was higher than the control group (20.67 ± 19.12). Additionally, It can be observed that there was no significant difference between the two groups regarding to the mean score of WNSSP scale at the start of the study (P=0.063), whereas there was a highly significant difference between them at the end of the study (P <0.001).
Regarding clinical outcomes, despite weaning trials among the study group were more than the control group there was no significant difference between the two groups P=0.273. Also, it can be observed that 30% of patients in the study were weaned successfully compared to 10% of patients in the control group. The differences between the two groups were statistically significant (P=0.049). Concerning the mean duration of ICU stay, there was a significant statistical difference between the two groups P=0.015. Moreover, no significant difference between the two groups (P=0.184) regarding the long term mortality.
Conclusion
The current study aimed to determine the effect of integrative nursing practices on cognitive recovery among severe traumatic brain injury patients. Based on the current study findings, it can be concluded that:
• Implementation of integrative nursing practices (NMT, massage, and aromatherapy using lavender oil) has been shown to enhance cognitive recovery among severe TBI patients. It is associated with significant improvement of consciousness and arousal level, patients’ behaviors that are present in each level of cognitive functions recovery, and basic cognitive sensory recovery.
• Implementation of integrative nursing practices significantly improved the TBI patients’ autonomic responses.
• Implementation of integrative nursing practices is effective in decreasing ICU length of stay and promoting successful weaning from MV.
• The percent of adequacy of olfactory stimulation practices was the least among all other conventional nursing stimulation practices. While, the highest percent of adequacy was for tactile stimulation practices.
Recommendations
• Integrative nursing practices should be implemented by CCNs as a daily routine of care for severe TBI patients with cognitive impairment.
• Integrative nursing practices should not be started before 72 hours after TBI to ensure hemodynamic stability of severe TBI patients.
• In-service educational programs and workshops should be conducted to raise CCNs’ awareness regarding the safe use of different types of the integrative nursing practices for TBI patients with cognitive impairment.
• Hospital budget should be directed to provide the needed equipments and supplies for application of integrative nursing practices.
• Cognitive recovery assessments scales should be included in nursing flow-sheet.
• Replication of this study on large sample is needed for generalization of results.
• Consider further researches about identification of the potential use of virtual reality in promoting cognitive recovery among severe TBI patients
.