Thai trauma nurses' knowledge of neuroprotective nursing care of traumatic brain injury patients: A survey study.

Thai trauma nurses play a vital role in neuroprotective nursing care of patients with moderate or severe traumatic brain injury. Nurses' knowledge of the evidence underpinning initial neuroprotective nursing care vital to safe and high-quality patient care. However, the current state of knowledge of Thai trauma nurses is poorly understood. In this study, we investigated Thai nurses' knowledge of neuroprotective nursing care of patients with moderate or severe traumatic brain injury. Data were collected by a survey, comprising a section on participant characteristics and series of multiple-choice questions. All registered nurses (n = 22) and nursing assistants (n = 13) from the trauma ward of a regional Thai hospital were invited to participate: the response rate was 100%. Participants had limited knowledge of carbon dioxide monitoring; causes and implications of hypercapnia; mean arterial pressure and cerebral perfusion pressure targets; management of sedatives and analgesics; and management of hyperthermia. Improving their knowledge focusing on knowledge deficits through educational training and implementation of evidence-based practice is essential to improve the safety and quality of care for Thai patients with moderate or severe traumatic brain injury.

Procedural Pain in the Adult Neurological Intensive Care Unit: A Retrospective Study Examining Arterial Line Insertion.

BACKGROUND: This was a retrospective chart review of procedural pain assessments and interventions during arterial catheter insertion in an adult neurological intensive care unit where patients with impaired consciousness are common. Overall, pain assessment was well documented (100%) by Registered Nurses, but not specific to arterial line insertion. Nurse practitioners commonly placed arterial lines and used local analgesia in over 75% of the documented procedures. AIMS: The purpose of this study was to examine healthcare providers' pain-related practices documented during arterial catheter insertion, one of the most painful procedures in a neurological intensive care unit. Secondary purposes were determining whether patient characteristics, procedure-related factors, or provider licensure were associated with pain assessment or procedural pain interventions. DESIGN: A retrospective records review design was used. METHODS: 120 electronic patient medical records were reviewed during a one-year period. RESULTS: 100 charts met inclusion criteria. Nurses assessed all pain within 4 hours following the procedure in all charts but procedure-specific pain assessments were documented in 4% of charts. Pain-related interventions for arterial line insertion were local analgesic (76% of charts) and other procedure-specific interventions (10%). Significant associations occurred between procedure specific pain assessments and decreased number of insertion attempts (p = .006) and between pain interventions and number of insertion attempts (p = .003). No provider documented procedural pain assessment regarding arterial line insertion. Associations between patient characteristics and pain interventions were significant for patient ethnicity (F = 8.967, p = .007). CONCLUSIONS: Overall pain assessment was documented (100%) but not specific to arterial line insertion. Although arterial line insertion can be extremely painful, patients were rarely assessed for such pain by any clinician; 14% did not receive any preprocedural analgesia. CLINICAL IMPLICATIONS: The lack of procedural pain assessment in this vulnerable population indicates a need for increased pain management education for clinicians and further investigations to determine whether sufficient analgesia is provided to reduce procedural pain during arterial line insertion.

Nurses' understanding and experience of applying painful stimuli when assessing components of the Glasgow Coma Scale.

AIMS AND OBJECTIVES: To evaluate nurses' application, understanding and experience of applying painful stimuli when assessing components of the Glasgow Coma Scale. BACKGROUND: The Glasgow Coma Scale has been subjected to much scrutiny and debate since its publication in 1974. However, criticism, confusion and misunderstandings in relation to the use of painful stimuli and its application remain. An absence of evidence-informed guidance on the use and duration of application of painful stimuli remains, with the potential to negatively impact on decision-making, delay responsiveness to neurological deterioration and result in adverse incidents. DESIGN AND METHODS: This international study used an online self-reported survey design to ascertain neuroscience nurses' perceptions and experiences around the application of painful stimuli as part of a GCS assessment (n = 273). The STROBE checklist was used. RESULTS: Data revealed varied practices and a sense of confusion from participants. Anatomical sites for the assessment of pain varied, but most respondents identified the trapezius grip/pinch in assessing eye-opening and motor responses. Most respondents identified they assess eye-opening and motor responses together and apply pain for <6 s to elicit a response. Witnessed complications secondary to applying a painful stimulus were varied and of concern. CONCLUSION: Neuroscience nurses in this study clearly required evidence-informed guidelines to underpin practice both in applying painful stimuli and in managing the experience of the person in their care and the family response. A standardised approach to education is necessary to ensure greater interrater reliability of assessment not only within nursing but across professions. RELEVANCE TO PRACTICE: Results of this study illustrate inconsistency and confusion when using the Glasgow Coma Scale in practice; this has the potential to compromise care. Clarity around the issues highlighted is necessary. Moreover, these results can inform future guidelines and education required for supporting nurses in practice.

Empathy Huddles: Cultivating a Culture of Empathy.

Managing complex neurological patients challenges new nurses with minimal experience, which can interfere with their ability to relate empathetically to their patients. This article is the story of how 1 neuroscience unit's experience with Empathy Huddles improved the staff's ability to respond to their patients and families with empathy. The hospital collects quarterly patient satisfaction data using the Hospital Consumer Assessment of Healthcare Provider and Systems. In the third and fourth quarters of 2015, the unit's patient satisfaction scores had declined significantly and remained low, in particular, the score for "how often did nurses listen carefully to you." In February 2016, Empathy Huddles were implemented on the unit. Hospital Consumer Assessment of Healthcare Provider and Systems scores for this question were compared pre and post intervention. The top box response score was 46% preintervention (fourth quarter of 2015). After 2 quarters of Empathy Huddles, the top box score rose to 75% in the third quarter and 82% in the fourth quarter of 2016. The unit has maintained the top box score above 78%. In the fourth quarter of 2017, they achieved a top box score of 91%. Scores greater than 82% were sustained through the third quarter of 2018. Connecting was the overarching theme that emerged from interviews regarding Empathy Huddles. Interviewees described how Empathy Huddles helped them to connect empathetically with their patients, families, and each other. The huddles reminded staff to consider the day from the patients' point of view and be mindful of their experiences.

Electroencephalographic Patterns During Common Nursing Interventions in Neurointensive Care: A Descriptive Pilot Study.

BACKGROUND: Many patients with neurological insults requiring neurointensive care have an increased risk of acute symptomatic seizures. Various nursing interventions performed when caring for these patients may elicit pathological cerebral electrical activity including seizures and stimulus-induced rhythmic, periodic, or ictal discharges (SIRPIDs). The aim was to explore changes in electroencephalogram (EEG) due to neurointensive care nursing interventions. METHODS: A convenience sample was recruited between November 2015 and April 2016, consisting of 12 adult patients with impaired consciousness due to a neurosurgical condition. Continuous EEG and simultaneous video recordings of nursing interventions were collected 48 continuous hours for each patient. Two analysts categorized the video recordings for common nursing interventions, and a neurophysiologist analyzed the EEGs. RESULTS: In total, 976 nursing interventions were observed. Epileptiform activity was observed in 4 patients (33%), during 1 nursing intervention episode each (0.4%). The 4 observed episodes of epileptiform activity occurred during multiple simultaneous nursing interventions (n = 3) and hygienic interventions (n = 1). Stimulus-induced rhythmic, periodic, or ictal discharges were observed in 1 patient (8%), in 1 single nursing intervention (0.1%). The observed SIRPIDs occurred during repositioning of the patient. All patients had muscle artifacts, during 353 nursing interventions (36.3%). The duration of nursing interventions was longer for those with simultaneous muscle artifacts (median, 116 seconds) than those without muscle artifacts, epileptiform activity, or SIRPIDs (median, 89.0 seconds). With regard to epileptiform activity and SIRPIDs, the median durations of the nursing interventions were 1158 and 289 seconds, respectively. CONCLUSION: The results of this pilot study indicate that muscle artifacts seem prevalent during nursing interventions and may be a sign of stress. Nurses should be aware of the risk of inducing stress by performing regular nursing interventions in daily practice, consider shorter or fewer interventions at a time in sensitive patients, and administer sedation accordingly. Considering that this was a pilot study, more research that investigates correlations between EEG patterns and nursing interventions in larger samples is needed.

Clinical staff work sampling in a neurorehabilitation hospital and its relationship to severity of disease.

AIM: Study aimed to analyse how rehabilitation staff spends working time on specific activities in a neurorehabilitation hospital and to determine the number of direct activities received by patients with different levels of disease severity. BACKGROUND: Few studies have investigated how clinical staff spends their time on activities in rehabilitation hospitals without considering at the same time all working categories and without reporting the number of direct activities received by patients with respect to their disease severity. DESIGN: Self-reported observational study. METHOD: Work Sampling Technique was used to record direct, indirect, unit-related and personal activities every 5 min for 2 days. RESULTS: Total of 6,974 activities were recorded over 581 working hours. Physiotherapists and nurses spent 75.2% and 54.8% of their time in direct activities and medical doctors only 25.4%. Total time of direct activities was significantly different among worker categories (p = 0.001) and depended on patients' disease severity (p = 0.020) in a different manner among worker categories (interaction: p = 0.010). This time ranged from almost 4 hr up to 6½ hr for the most severely affected patients. CONCLUSION: Type of work differed among professionals. Workload greatly depended on degree of patients' disability. IMPLICATIONS FOR NURSING MANAGEMENT: Nurses and therapists spent most of their time in direct activities with patients. Economic burden of neurorehabilitation may vary greatly depending on disease severity.

The effect of Therapeutic Touch on Back Pain in Adults on a Neurological Unit: An Experimental Pilot Study.

BACKGROUND: Chronic back pain affects many aspects of everyday life and is a common reason for medical visits, leading to high direct and indirect health care costs. Innovative and cost-effective nonpharmacologic pain management methods should be promoted to ensure adequate treatment. AIMS: The aim of this pilot study was to investigate the pain-relieving effect of Therapeutic Touch in adult neurologic patients with back pain. DESIGN: A pretest-post-test randomized controlled trial. SETTINGS: A university hospital in Austria. PARTICIPANTS/SUBJECTS: Patients with back pain diagnosis (N = 29) on hospital admission. METHODS: A pilot study was conducted for 3 months. The control group (n = 14) received the pharmacologic pain management recommended by the World Health Organization; patients in the intervention group (n = 15) received additionally four Therapeutic Touch treatments on 4 consecutive days. The Quebec Back Pain Disability Scale and the Numeric Pain Rating Scale were used as outcome measures to evaluate activity domains affected by back pain and pain intensity. RESULTS: Pain improvement was found in the intervention group according to the mean score of the Quebec Back Pain Disability Scale (day 1: 72.53, standard deviation [SD] ± 14.10; day 4: 39.47, SD ± 8.77; p < .001). The Numerical Pain Rating Scale score averaged 4.33 points (SD ± 2.09) on the first day and 2.47 points (SD ± 1.12) on the fourth day. The long-term effect of Therapeutic Touch was significant and indicated a major effect (Pillai's trace = .641, F(3.12) = 7.1, p = .005, ηp2 = .641). CONCLUSIONS: Therapeutic Touch seems to be a noninvasive nursing intervention for back pain management to provide more professional patient care.

Consciousness assessment: A questionnaire of current neuroscience nursing practice in Europe.

AIMS AND OBJECTIVES: To study practice in consciousness assessment among neuroscience nurses in Europe. BACKGROUND: Over the years, several instruments have been developed to assess the level of consciousness for patients with brain injury. It is unclear which instrument is being used by nurses in Europe and how they are trained to use these tools adequately. DESIGN/METHODS: A cross-sectional questionnaire, created by the European Association of Neuroscience Nurses Research Committee, was sent to neuroscience nurses in 13 European countries. The countries participated in 2016 with a response period of 3 months for each country. RESULTS: A total of 331 questionnaires were completed by nurses in 11 different countries. Assessment of consciousness was part of the daily routine for a majority of bedside nurses (95%), with an estimated median frequency of six times per shift. The majority uses a standardised instrument, and the Glasgow Coma Scale is the most common. Most participants assess consciousness primarily for clinical decision-making and report both total scores and subscores. The majority was formally trained or educated in use of the instrument, but methods of training were divers. Besides the estimated frequency of assessments and training, no significant difference was found between bedside nurses and other nurse positions, educational level or kind of institution. CONCLUSION: Our study shows that consciousness assessment is part of the daily routine for most nurses working in neurology/neurosurgery/neurorehabilitation wards in Europe. The greatest variation existed in training methods for the use of the instruments, and we recommend standardised practice in the use of assessment scales. RELEVANCE TO CLINICAL PRACTICE: In clinical practice, both managers and staff nurses should focus on formalised training in the use of assessment tools, to ensure reliability and reproducibility. This may also increase the professionalism in the neuroscience nurses' role and performance.

Sustainability of a nurse-driven early progressive mobility protocol and patient clinical and psychological health outcomes in a neurological intensive care unit.

OBJECTIVES: To determine sustainable impact of an early progressive mobility protocol on mobility level and clinical outcomes. DESIGN/METHODS: Prospective, longitudinal, comparative study using three time points (pre-, immediate post-intervention and 12-month post-intervention sustainability). Analyses included comparative statistics and multivariable modelling. Data were collected by clinical nurses, from administrative databases. Psychological health data were collected using a valid, reliable tool. SETTING: Patients treated in a 22-bed Neurological Intensive Care Unit of a quaternary-care medical centre. OUTCOME MEASURES: Highest mobility level, length of stay, mortality, discharge disposition, quality metrics and psychological profile including depression, anxiety, and hostility. RESULTS: Amongst 260 pre-intervention, 377 post-implementation, and 480 twelve-month post-implementation patients (N = 1117) walking increased post-implementation and was sustained at the eight-month assessment, p < .001. After multivariable adjustment, unit and hospital length of stay and psychological distress were reduced compared to the pre-early mobility programmes (all p < .001). There were no differences in discharge disposition (i.e., home vs skilled nursing facility), mortality or quality metrics. CONCLUSION: Ongoing implementation of an early mobility programme in a neurological intensive care environment led to sustained improvement in patients' level of mobility, length of unit and hospital stay, depression, anxiety and hostility levels.

Tiered protocol implementation improves treatment of hypoglycaemia in a neurosciences critical care and surgical intensive care unit.

BACKGROUND: Although studies demonstrate techniques to limit hypoglycaemia in critically ill patients, there are limited data supporting methods to improve management of existing hypoglycaemia. OBJECTIVE: Assess the impact and sustainability of a computerised, three tiered, nurse driven protocol for hypoglycaemia treatment. DESIGN: Retrospective pre and post protocol study. SETTING: Neurosciences and surgical intensive care units at a tertiary academic medical centre. MEASUREMENTS: Patients with a hypoglycaemic episode were included during a pre-protocol or post-protocol implementation period. An additional six-month cohort was evaluated to assess sustainability. RESULTS: Fifty-four patients were included for evaluation (35 pre- and 19 post-protocol); 122 patients were included in the sustainability cohort. Hypoglycaemia treatment significantly improved in the post-protocol cohort (20% vs. 52.6%, p=0.014); with additional improvement to 79.5% in the sustainability cohort. Time to follow-up blood glucose was decreased after treatment from 122 [Q1-Q3: 46-242] minutes pre-protocol to 25 [Q1-Q3: 9-48] minutes post protocol (p<0.0001). This reduction was maintained in the sustainability cohort [median of 29min (Q1-Q3: 20-51)]. CONCLUSION: Implementation of a nurse-driven, three-tiered protocol for treatment of hypoglyacemia significantly improved treatment rates, as well as reduced time to recheck blood glucose measurement. These benefits were sustained during a six-month period after protocol implementation.

Developing a Mobile App for Neuroscience Nurses.

In this month's Magnet® Perspectives column, the recipient of the 2016 Magnet Nurse of the Year® Award for New Knowledge, Innovations, and Improvements shares her journey to develop and disseminate a mobile application for nurses who care for neurological patients. "Neuroscience nurse" puts the latest, evidence-based information at the fingertips of nurses at the bedside in an effort to increase confidence when caring for patients with stroke, traumatic brain injury, and other neurological impairments.Nurse practitioner Christi DeLemos explains where she got the idea and how she went about implementing it. She also discusses the ways in which the Magnet® environment at University of California (UC) Davis Medical Center encouraged and supported her. Since neurological nurse was released in 2015, more than 3000 users in 19 countries have downloaded it. The app's success led to the production of a teaching video to help nurses perform a neurological examination. In addition to her role at UC Davis Medical Center, DeLemos is president of the World Federation of Neuroscience Nurses.

Nursing Management of the Patient Undergoing Focused Ultrasound: A New Treatment Option for Essential Tremor.

Essential tremor (ET) is among the most common neurological movement disorders that causes postural or action tremors, with an estimated prevalence nationwide of less than 3% of the population. The incidence of ET increases with age but often affects younger adults and has a familial trait association. Depending on disease progression, ET can cause significant limitations for individuals, in many cases, significantly limiting their ability to perform activities of daily living and occupational responsibilities. Until recently, treatment of ET heavily relied on medication management and invasive surgery, such as deep brain stimulation. With advances in the use of focused ultrasound (FUS) for treatment of various medical conditions, recent clinical trials have revealed positive outcomes with the use of FUS as a less invasive approach to treat patients with medication-refractory ET. In a large academic medical center in the mid-Atlantic region, the Department of Neurosurgery conducted a continued access study, recently approved by the Food and Drug Administration, to evaluate the effectiveness of transcranial FUS thalamotomy for the treatment of medication-refractory ET. One patient's experience will be introduced, including discussion of evidence-based treatment options for ET and information on the nursing management of the patient undergoing FUS thalamotomy.

Nursing Management of Lumbar Drainage in Cryptococcal Meningitis: A Case Report.

Raised intracranial pressure is a hallmark of cryptococcal meningitis and is associated with increased mortality. Continuous drainage of lumbar cerebrospinal fluid is suggested to control intracranial pressure. The complications induced by this treatment have been described. However, nursing care associated with identification and management of complications is less well known. We encountered a patient with human immunodeficiency virus-negative cryptococcal meningitis who developed increasing cerebrospinal fluid pressure, hearing impairment, and limb weakness. The patient's symptoms improved significantly by antifungal therapy and continuous lumbar drainage. Nurses play a vital role in monitoring patients with lumbar drainage for complications and to maintain integrity of the system. The nursing role in this approach is discussed with particular emphasis on recognition of complications and responses toward immediate emergent intervention.

Agitation in Patients Recovering From Traumatic Brain Injury: Nursing Management.

This article reviews clinical and research literature regarding the nursing management of agitation after severe traumatic brain injury. Neuroscience nurses in acute rehabilitation settings use an evidence-based approach to perform multifaceted assessments and implement effective individualized plans of care. These essential efforts minimize the effects of agitation and help patients achieve optimal outcomes.

Promoting Bedside Nurse-Led Research Through a Dedicated Neuroscience Nursing Research Fellowship.

OBJECTIVE: We hypothesized that nurses would benefit from the fellowship model traditionally used to engage physicians in clinical research. The Neuroscience Nursing Research Center (NNRC) fellowship program was created as a model for engaging nurses at all levels of clinical practice to become active in clinical research. BACKGROUND: The NNRC was established in 2013 as a novel approach to promote bedside nurses as primary investigators in clinical research. METHODS: The NNRC developed 4 pathways to nursing research success: research fellowship, student-nurse internship, didactic training, and research consultation. RESULTS: Fellows have enrolled more than 900 participants in 14 studies. Nurses have presented more than 20 abstracts at 12 conferences and submitted 11 manuscripts for publication. The NNRC has provided research training to more than 150 nurses. CONCLUSIONS: The NNRC program is successful in engaging nurses in research. It shows promise to continue to develop nursing research that is applicable to clinicians and thus improve patient care.

Stroke and pregnancy: an integrative review with implications for neuroscience nurses.

Stroke in association with pregnancy is an infrequent occurrence, but there is evidence that the incidence is rising. The physiological changes of pregnancy are thought to increase stroke risk, and several conditions specific to pregnancy further increase risk. The provision of optimal care to pregnant and postpartum women who experience stroke requires awareness of how the physiological changes of pregnancy may affect the course of stroke and nursing actions. This article provides an overview of current knowledge about pregnancy-related stroke including underlying pathophysiology, risk factors unique to pregnancy, and treatment issues when stroke is a complication of pregnancy. Implications for the nursing care of women with pregnancy-related stroke and maternal child considerations are discussed.

Fever management practices of neuroscience nurses: what has changed?

Current evidence shows that fever and hyperthermia are especially detrimental to patients with neurologic injury, leading to higher rates of mortality, greater disability, and longer lengths of stay. Although clinical practice guidelines exist for ischemic stroke, subarachnoid hemorrhage, and traumatic brain injury, they lack specificity in their recommendations for fever management, making it difficult to formulate appropriate protocols for care. Using survey methods, the aims of this study were to (a) describe how nursing practices for fever management in this population have changed over the last several years, (b) assess if institutional protocols and nursing judgment follow published national guidelines for fever management in neuroscience patients, and (c) explore whether nurse or institutional characteristics influence decision making. Compared with the previous survey administered in 2007, there was a small increase (8%) in respondents reporting having an institutional fever protocol specific to neurologic patients. Temperatures to initiate treatment either based on protocols or nurse determination did not change from the previous survey. However, nurses with specialty certification and/or working in settings with institutional awards (e.g., Magnet status or Stroke Center Designation) initiated therapy at a lower temperature. Oral acetaminophen continues to be the primary choice for fever management, followed by ice packs and fans. This study encourages the development of a stepwise approach to neuro-specific protocols for fever management. Furthermore, it shows the continuing need to promote further education and specialty training among nurses and encourage collaboration with physicians to establish best practices.