الفهرس 
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Abstract
Traumatic brain injury (TBI) is a major public health problem and a fundamental cause of morbidity and mortality worldwide. The burden of TBI disproportionately affects low- and middle-income countries. Intracranial hypertension is the most frequent cause of death and disability in brain injured people. Special interventions in the intensive care unit are required to minimize factors contributing to secondary brain injury after trauma. Therapeutic positioning of the head (different degrees of head of bed elevation (HBE)) has been proposed as a low cost and simple way of preventing secondary brain injury in these people (Alarcon et al., 2017).
Positioning is one of the most frequently performed nursing activities in the critical care, often providing a central pivotal focus for planning other nursing activities. Currently, the concept of therapeutic positioning is emerging in trauma and critical care with the adaptation of research-based positioning strategies designed to enhance or promote physiologic stability and tolerance of nursing and medical treatments. Therapeutic positioning is a core component of critical care nursing to optimize ventilation and perfusion and to promote effective pulmonary gas exchange (Anchala, 2016).
Hemodynamic instability is the main reason why critically ill patients stay in the supine position for extended periods. After a change in the body’s gravitational plane, the cardiovascular system tries to adjust in two ways: The shift in plasma volume may send messages to the autonomic nervous system telling it to change the vascular tone. An inner ear or vestibular response affects the cardiovascular system (Anchala, 2016).
Turning and positioning of critically ill patients in the intensive care unit (ICU) are well accepted activities, with the primary purpose being to relieve pressure, improve patients’ comfort, and aid pulmonary secretion. However, body positioning of critically ill patients may have a profound effect on arterial oxygenation, which is reflected by the oxygen saturation (SpO2) level in blood. The literature supports the benefits of frequent body positions changes particularly for a patient who is relatively immobile, unalert, severely debilitated, breathing at low lung volumes, obese, aged or very young, or has lost the sigh mechanism. The practice of routinely turning patients every 2hr continuously is an accepted standard of care (Frownfelter & Dean, 2013).
The present study aimed to determine the effect of body position on oxygenation and hemodynamic status among patients with traumatic brain injury this will be achieved through the following objectives:
Evaluate the effect of different body position on oxygenation status.
Determine the effect of changing body position on hemodynamic stability.
Determine the most effective position providing best oxygenation status and hemodynamic stability.
A quasi-experimental design (pretest / posttest) was applied to achieve the aim of the study on a purposive sample of (67) adult male and female patients with inclusion criteria (age from 19 to 65 years old) who were diagnosed as having traumatic brain injuries with GCS between (3 to14) and were admitted to general Critical Care Unit in El-Mansoura general hospital at El-Mansoura city. Data were collected over a period of six months from the beginning of (August 2019) to the end of (January 2020). Data were collected for three days a week from Wednesday to Friday at (morning shift from 8:00 am to 2:00 pm), (afternoon shifts from 2:00 pm to 8:00 pm) and (night shift from 8:00 pm to 8:00 am).
The following tools were utilized for data collection:
1- Structured interview questionnaire: This sheet contains items covers the socio-demographic data this part contain data related to (Age, Gender, Education, Occupation, Marital status).
2- Patients’ medical records: This sheet contains items covers two main parts:
- Part (1): covers clinical variables this part contain data related to (Duration of ICU Stay, Oxygen Devices, Body Mass Index (BMI), Current Diagnosis, general Medical History, general Surgical history and Medication).
- Part (2): covers cardiorespiratory assessment record: this part contain data related to assess physiological parameters in different four positions (left lateral position, supine position, right lateral position and semi fowlers position) such as; Hart Rate (HR), Respiratory Rate (RR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP), Central Venous Pressure (CVP) and Oxygen saturation (Sao2).
3- Glasgow Coma Scale (GCS): deals with assessment of conscious using Glasgow coma scale to evaluate eye opening, verbal and motor responses, and brainstem reflex function.
4- Richmond Agitation Sedation Scale (RASS): is the sedation scale that used to monitor serial changes in patient’s mental status.
The current study was carried out on two phases, designation and implementation phase. Designation phase was concerned with managerial arrangement to carry out the study in addition to construction and preparation of the data collection tools and granting the ethical committee approval. The implementation phase was concerned with the application of the designed tools.
Statistical analysis was done using SPSS program, relevant statistical analysis was used to test the obtained data. Descriptive statistical were applied (e.g., mean, standard deviation, frequency, percentage). Also, t-test was used to compare between premeasures and post measures in each four positions for all parameters. (ANOVA) test were applied using the significant level p 0.05.
The main findings of present study were as follows:
The current study shows that more than half of studied sample age was ranged from 19-30 years old, with mean age of (33.43 ±10.58), male subject represents the great majority. Also, two third of study sample had either secondary or university education in addition to more than half of the studied subjects were worker and around one third of the sample were employees. Besides, around three fourths were married.
Also regards to clinical variables, the current study shows that almost half of patients stayed in the intensive care unit for more than 6 days, with mean length of stay of (6.85 ± 3.69). More than half of the studied subjects were mechanically ventilated and more than two third their body mass index was ranged between 18.5–24.9 Kg/m2 (normal weight) with mean (23.48 ± 2.53).
Additionally, more than quarter of the studied subject were diagnosed as having skull fracture and brain contusion, followed by almost quarter of sample with (SDH) Subdural hemorrhage and (SAH) Subarachnoid hemorrhage. Also, all patients received antibiotics, antiepileptic and IV fluids with no surgical history. The current study shows that more than one third of sample was in sever coma Besides, more than one third was in mild coma. Regarding RASS almost half of sample were deeply sedated and unarousable.
In relation to oxygenation parameter the current study shows statistically significant decreased in the mean scores of oxygen saturation between pre-position and post-position in left lateral position (LLP) and supine position (SP). Also, there was significant increase between pre- and post-position in right lateral position (RLP). It also increased in semi fowler position (SFP) but it did not reach the significant level with (SFP). Based on the comparison of oxygen saturation in different body positions, the study revealed that, regarding the normal range, semi fowler position was the best in increasing the Oxygen saturation.
The current study shows that all hemodynamic parameters show highly statistically significant increase in the mean scores between pre-position and post-position in left lateral position (LLP) and supine position (SP). Also, the current study reveals that all hemodynamic parameters (heart rate (HR), respiratory rate (RR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) show statistically significantly decreasing in post position in right lateral (RLP) and semi fowler position (SFP). While a significant increase in Central Venous Pressure (CVP). But it didn’t reach significant level with Diastolic blood pressure (DBP) in right lateral position (RLP).
The current study reveals that best hemodynamic parameters and oxygen saturation as compared to normal range is in semi fowler position, as it improves significantly the SaO2, HR, RR, Systolic and diastolic blood pressure. Semi fowler position significantly decrease the heart rate, respiratory rate, systolic and diastolic BP, mean arterial BP. Also, it significantly increases the CVP and non-significantly increase the oxygenation.
Conclusion
The current study concluded that statistically significant increase in the mean scores of oxygen saturation between pre- and post-position in right lateral position (RLP) and semi fowler position (SFP) but it did not reach the significant level with (SFP). Also, the current study reveals that all hemodynamic parameters (HR, RR, SBP, DBP and MAP) show statistically significantly decreasing in post position in right lateral (RLP) and semi fowler position (SFP). While a significant increase in (CVP). But it didn’t reach significant level with (DBP) in right lateral position (RLP). Finally, the current study revealed that hemodynamic parameters and oxygen saturation significantly improved regarding normal range in semi fowler position
Recommendations
Based on the findings of this research, the following
recommendations suggested:
1. Develop nursing practice protocol for critical care nurses to position patients at semi fowler position (SFP) after traumatic brain injury to improve oxygenation and hemodynamic parameters.
2. Backrest elevation should be decided individually for each patient according to patient’s responses, including cardiovascular and hemodynamic parameters, and systemic oxygenation.
3. A study can be carried on the aspects of performance of critical care nurses towards therapeutic positions among patients with traumatic brain injury.
4. Further studies should be carried out in order to assess the effect of other body positions on the other medical conditions.