Development Of A Protocol For Nursing Management Of Post –Operative Cerebral Aneurysm Patients .

https://doi.org/10.33698/NRF0241-Mahendra Kumar, Monaliza,Sukhpal Kaur, Pravin Salunka, Ashish Agarwal

Background: Post-operative cerebral aneurysm patients are at risk of developing hemodynamic instability and other neurological complications. Specic guidelines and protocol can guide nurses for early interventions and timely management to minimize complications and possibly improve outcome in these patients. Objective: To develop a protocol on nursing management of post-operative cerebral aneurysm patients. Methodology and results: Methodological study design was used to develop the protocol and checklist to implement protocol. The preliminary draft was prepared after reviewing relevant literature and assessment of current practices of the nurses regarding post-operative care of cerebral aneurysm patients. Focus group discussions were conducted with the nurses working in the neurosurgery units. Delphi rounds amongst the experts were carried out to validate the protocol. A try out was conducted to know feasibility of protocol. A checklist to be used for the evaluation of the protocol was also developed. Nurses were taught as per the developed protocol by holding one day workshop. Content Validity Index (CVI) of protocol and checklist was 100%. Overall Cronbach’s alpha value was 0.859. A pilot study was conducted and the protocol was found to be feasible in terms of understanding, clarity and easy implementation. Conclusion: The nal draft of the protocol included preparation of unit prior to admission; taking over from OT staff; neuro assessment of patients; vasospasm management etc. The present study has provided set of valid and reliable written guidelines for the nursing management of post-operative cerebral aneurysm patients by nurses.

Key words: Cerebral aneurysm; Nurses; Protocol

Corresponding author:

Dr Sukhpal Kaur Lecturer

National Institute of Nursing Education, PGIMER, Chandigarh

Introduction

A cerebral aneurysm is an abnormal focal dilation of an artery in the brain that results from weakening of the inner muscular layer of a blood vessel wall. This is a potentially life-threatening condition that can affect a person at any age and if rupture, it may result in brain damage, permanent neurological weakness and even death  if  not  treated  immediately.The annual rate of rupture is approximately 8-10 per  1,  00,000  people. and organising the care in highly  comple     environment.  Beyond  seeing  that  the e.2   A  number of       patient’s basic needs are met, the nursing complications may arise  after  cerebral a n e u r y s m s u r g e r y, l i k e s e i z u r e , hypertension, hypotension, vasospasm and neurological decits.3 Many studies reveal protocols must spell out how to handle the patients’ safety and provide comprehensive care.

Development of a protocol should be that complications in aneurysm are sudden and can cause permanent neurological decit or may prove to be life threatening.4 Cerebral aneurysm patients need special care after surgery in terms of observation, taking vital signs at specic intervals, periodically neurological assessment, assistance in early extubation, weaning planning to improve outcome and minimizing post-operative complications. Benets of clinical protocols, pathways and algorithms are clearly reported in literature and have been found useful for early assessment and to increase efciency of nurses. Studies have also shown that after protocol development, nursing care interventions can make a difference every day in the outcomes of patients.5,6 Protocols help newly qualied nurses integrate new knowledge into practice and promote effective decision- making. Certain protocols and guidelines are very important to support nurses to stay updated with new evidences. Nurses as the professional must reect the possibilities of quality care and identify alternatives to provide the best quality care aiming to improve the physical, mental, and psychological aspects of the patients. Implementation of evidence based guidelines or protocols for providing care based on clinical guidelines and need based assessment of patients and nurses. The protocol can assist nurses in making decisions about appropriate and effective care for the patients.

Objective of the study:

To develop a protocol for nursing management of post-operative cerebral aneurysm patients.

Methodology :

A methodological research approach was adopted to develop the protocol. The study was conducted in tertiary care center known for center of excellence in neuro surgery. Annually around 300-350 cerebral aneurysm surgeries are being conducted. Around 30-35 post-operative cerebral aneurysm patients are admitted at any given time. No structured protocol or guidelines were available for nursing care of these patients in this center. With the best available knowledge of authors, there is no as such protocol regarding care of post- operative cerebral aneurysm patient in northern region of India. Ethical permission was obtained from Institute Ethics Committee. The study was conducted during July to Sept. 2017.

The protocol development was carried out in four phases.

Phase-I: Preparation Phase:

The preparation phase included review of literature, assessment of current practices, and focus group discussion with nurses.

Step 1: Review of Literature: An extensive review of relevant literature was carried out on the recent evidences and latest practices regarding post-operative nursing care of cerebral aneurysm patient. Latest available literature was reviewed related to standard nursing practices, using neurosurgery books, national and international journals, manuals and web search of literature including both electronic data as well as printed material.

Step 2: Assessment of Current Practices: Assessment of current practices of nurses was done by using an observation checklist regarding care of post-operative cerebral aneurysm patients. Their practices were observed in all the duty shifts. Preparation of unit prior to receive the patients from OT were followed by less than 50% of nurses. Checking identication was observed by about 40% of nurses. Complete physical examination of patients was being done by less than 50% of nurses, neurological examination was performed by 25% of nurses, GUSS examination before starting oral feed was not carried out by any nurse and ICP prevention nursing interventions were followed by 60% of nurses.

Step 3: Focus Group Discussion (FGD): Three FGDs were organized among nurses working in neurosurgery units. The FGDs explored various issues pertaining to nursing care provision of operated cerebral aneurysm patients. Principle of redundancy was followed. Total thirty-seven nurses with10-12 in each group from respective neuro surgical units were involved to seek their suggestions and assess problems faced by them. Guided questions were used to conduct FGDs and each session took around 20-30 minutes. Nurses responded well and discussed their problems. Audio recording was done for each FGD. Important points were pendown.

Step 4: Preparation of preliminary draft of protocol: The preliminary draft of protocol and an observation checklist to assess the implementation of protocol were prepared using relevant literature search; incorporating the results of assessments of c u r r e n t s p r a c t i c e s ; a n d v a l u a b l e suggestions from nurses gathered in FGDs.

The protocol included different sequences of nursing interventions like preparation of units; receiving patients from OT; checking identication by Name and CR. No; shifting patients from trolley to bed safely; positioning of patients; hemodynamic monitoring; attaching ventilator to patients; checking vital signs; neurological assessment; history taking; assisting in investigations and ensuring reports; starting feeding after GUSS test; giving medication by following all 10 rights of drugs administration; prevention of increased intra-cranial pressure and monitoring of any symptoms of changes in neurological status like drowsiness; change in GCS; 30 minute frequency of GCS assessment and vital signs monitoring etc.

Phase II- Validation phase

The protocol was validated using Delphi technique. Selected Delphi experts were invited to participate in various rounds of Delphi. A Delphi panel of 13 members from eld of neurosurgery, nursing education and nursing practices was formulated. The rounds were repeated until the agreement amongst experts stabilized 100% consensus. They were requested to check each item by keeping in mind that the items listed in the protocol were relevant to subjects and were easily understandable and meaningful for the users.

Modifications made in preliminary draft in Delphi rounds

Delphi round I:

Majority of Delphi members gave suggestions to make protocol in the form of algorithm for post-operative nursing care of cerebral aneurysm patients

1. A) Items added: 1) Carbolized bed with clean bed sheet. 2) Debrillator should be charged

Delphi round II:

In the second Delphi round, it was suggested to club some nursing activities like skin care with positioning

1. Items added: 1) Check working

condition of monitors and ventilator 2) Monitor patient’s heart rate, respiratory rate and SpO2 just after suctioning.

The second draft had all steps of procedures under four main headings:

1. Preparation of unit
2. Physical examination and neurological assessment, physiotherapy and
3. Pressure sore and safety risk assessment.
4. Medications, IV Fluids, GUSS test before starting RT feed and allowing

Delphi round III:

Delphi members suggestions were discussed with the guide and the appropriate changes were incorporated in the protocol.

Phase III: Generation of final draft:

The modied draft was nalized and Content Validity Index of protocol was calculated for each item. After consultation with the guides prepared draft was re- circulated among all members of Delphi panel for third round.

1st tryout was performed in one of the selected neurosurgery unit. It was found that neuro examination of patients and assisting in investigations required more clarications. Neuro examination of patients by nurses was simplied and clear instruction regarding assisting in investigations were included in the protocol. No more corrections/suggestions were received from Delphi panelists and it was suggested to implement the protocol. The nal draft of protocol was converted in to an algorithm. Content Validity Index of each item of protocol was 1.

Phase IV: Testing feasibility of the protocol by pilot study:

First try out in the form of pilot studywas conducted on 30 nurses and 5 patients in month of July 2017 to check the feasibility of the developed protocol. Written permission and consent was taken for conducting the study. Purposive sampling technique was used. Data analysis and interpretation was done by descriptive and inferential statistics. The protocol was assessed for feasibility, language and completeness during pilot study. Nurses were trained according to the protocol by

Table 1a: Cronbach’s alpha of each item of checklist to implement protocol on care of cerebral aneurysm patients

 

S.No.	Nursing Actions	Scale Mean if Item Deleted	Corrected Item- Total Correlation	Cronbach’s Alpha if Item Deleted
	Preparing Unit For Receiving Patient From OT
1.	Ensures Carbolised bed with Airmattress	25.40	.660	.846
2.	Checks resuscitation trolley Ready	25.25	.294	.857
3.	Checks cardiac monitor working condition	25.21	.356	.856
4.	Checks ventilator with circuit ready to use	25.25	.361	.856
5.	Checks debrillator (charged)	25.25	.361	.856
	Receiving post-operative patients at unit from OT
6.	Checks Airway,Breathing, Circulation	25.21	.304	.857
7.	Checks Identication Data i.e. Name, CR No, age, gender	25.28	.220	.860
8.	Receives le and other documents from OT staff	25.25	.342	.856
9.	Safelyshift on bed from trolley and attach ventilator ( if patient is intubated )	25.25	.361	.856
10	Connects cardiac monitor and check vital signs	25.21	.304	.857
11	Position at 30-450 head end Elevation	25.21	.304	.857
12	Suctions stat and SOS	25.21	.304	.857
	Nursing assessment of patients
13	Assess level of Consciousness	25.21	.325	.857
14	Assess Glasgow Coma Scale	25.23	.253	.858
15	Assess PEARL(PupilsEqual and Reacting to light)	25.23	.253	.858
16	Assess muscle power strength	25.25	.352	.856
17	Checks for neurological decit	25.23	.253	.858

one day workshop. A total of 5 lectures with hands on training, group discussion and doubt clearance session on topics related to

care of post-operative cerebral aneurysm according to protocol were delivered by experts.

Table 1b: Cronbach’s alpha of each item of checklist to implement protocol on care of cerebral aneurysm patients

 

S.No.	Nursing Actions					Scale Mean if Item Deleted	Corrected Item-Total Correlation	Cronbach’s Alpha if Item Deleted
	Fluids and electrolytes
18	Ensures patent IV access					25.23	.253	.858
19	Starts IV uids and blood infusions as per prescription					25.26	.418	.854
20	Calculates total uid to be given and ow rate for 24Hours					25.26	.418	.854
21	Taken history of any sensitivity					25.18	.208	.859
22	Previous/Surgical & Medical History					25.18	.208	.859
23	Family H/O disease and co- Morbidity					25.18	.208	.859
24	Demographic details of patients					25.18	.208	.859
	Drugs administration
25	Checks sensitivity before giving antibiotics, and other  sensitivity prescribed drugs					25.20	.362	.856
26	Follows all 10 rights of drug Administration					25.21	.346	.856
27	Calculates drug dose					25.20	.362	.856
28	Ensures charting of medication in treatment chart					25.20	.362	.856
	Nutritional care
29	Performs GUSS test before starting R.T. feed					25.20	.362	.856
30	Ensures placement of Ryle’s tube 45o.before each feed	and	Propped	up	by30˚-	25.31	.482	.852
31	Starts orally allowed as per GUSS test ndings					25.31	.482	.852
32	RT feed amount anddaily calories requirement					25.31	.482	.852
	Elimination care
33	Auscultates bowel sounds before each feed					25.31	.482	.852
34	Provides stool softener if needed					25.31	.482	.852
35	Measures urine output one hourly for catheterized patients					25.31	.482	.852
	Investigations
36	Assists in sample taking					25.20	.429	.854
37	Assists patient for C.T. scan					25.31	.482	.852
38	Monitors lab reports results					25.20	.429	.854
39	CT scan SOS if patients neurological status changed					25.30	.375	.855

Nurses were given demonstrations of GUSS, GCS and Neuro examination in the workshop and in unit and return demonstrations were taken to  ensure that they were working as per the protocol. Nurses were observed while providing care

 

Table 4c: Cronbach’s alpha of each item of checklist to implement protocol on care of cerebral aneurysm patients

 

S.No.	Nursing Actions	Scale Mean if Item Deleted	Corrected Item-Total Correlation	Cronbach’s Alpha if Item Deleted
	Physiotherapy and mobilization
40	Performs limb and chest physiotherapy every 2 hourly	25.30	.375	.855
41	Mobilizes after 6 hours of surgery (conscious patients )	25.25	.218	.860
42	Continue with range of motion exercise (patients unconscious and on ventilator )	25.25	.218	.860
43	Provides pneumatic compressive Device	25.25	.218	.860
44	Initiates DVT pharmacological Prophylaxis	25.25	.218	.860
	Pressure sore Prevention interventions
45	Assesses skin for pressure sore every 3 hourly with Norton Scale	25.20	.520	.852
46	Provides back care every 3 Hourly	25.25	.218	.860
47	Changes Position every 2 Hourly	25.30	.348	.856
48	Checks skin integrity at time of back care	25.25	.218	.860
	Infection control measure
49	Performs hand hygiene as per CDC guidelines	25.54	.446	.854
50	Checks IV site and assesses for early signs of infection ( redness, discharge )	25.30	.468	.844
51	Checks Surgical site and all drain and indwelling catheter site for infection signs	25.25	.218	.860
52	Manages early fever (Cold sponging ,inj. PCM 1 gm. Stat 0 if Temp. rise more than 100.4 F)	25.23	.505	.852
	Comfort and safety
53	Provides comfortable Environment	25.25	.218	.860
54	Assesses risk of fall	25.16	.478	.854
55	Keeps side rails up	25.26	.390	.855
56	Assists in moving and lifting	25.25	.218	.860
57	Checks devices alarms each shift	25.21	.294	.857

 

to the patents using an observational checklist. Collected data was analyzed by using descriptive and inferential statistics with the help of SPSS(Version22.0).

Reliability of the checklist to implement protocol:

Cronbach’s alpha of each item on care of cerebral aneurysm patients is depicted in tables 1a to 1d. The total score coefcient alpha ranged from 0.80 to 0.87 which depicts Table 1a: Cronbach’s alpha of each item on protocol on care of cerebral aneurysm patients that the internal consistency reliability of each item of the checklist to implement developed protocol regarding care of post-operative cerebral aneurysm was good. If item no 41

Table 4d: Cronbach’s alpha of each item of checklist to implement protocol on care of cerebral aneurysm patients

 

S.No.	Nursing Actions	Scale Mean if Item Deleted	Corrected     Item- Total Correlation	Cronbach’s Alpha if Item Deleted
	Prevention of complications
58	Risk assessment for Increase Intra cranial pressure	25.25	.218	.860
59	Identies early symptoms of post-operative complications	25.25	.218	.860
60	Watched for electrolyte imbalance risk	25.25	.218	.860
	Monitoring intervals
61	Monitor Blood Pressure every 30 minute and SOS	25.30	.468	.844
62	Monitor Blood Pressure between 150/90 mmHg to 180/105 mmHg	25.30	.468	.844
63	Checks GCS every 30 minute and SOS	25.31	.468	.844
64	Checks blood glucose stat and every 4 hourly for rst 24 hours	25.25	.218	.860
65	Care of surgical drain in every Shift	25.30	.468	.844

 ‘mobilization after 6 hours of surgery and item no 42, continue with range of motion exercise deleted, then Cronbach’s alpha increased to 0.86 but as these are important steps to be monitored, so were not considered to be deleted. On the other Table 1b: Cronbach’s alpha of and item no 61 blood pressure monitoring every 30 minutes and SOS and item no 62, each item hand, if we delete item no 50 check IV access site and assess for early sign of infection. Blood pressure maintained between 150/90 mm/Hg the Cronbach’s alpha could be come down to 0.84. Once again suggestions of the Delphi panelists were asked for keeping or removing these items from the protocol. All Delphi panelists suggested to keep these items in

Table 2: Reliability statistics of the checklist to implement protocol on care of cerebral aneurysm patients

 

Reliability Statistics
Cronbach’s alpha	Cronbach’s alpha Based on Standardized Items	No. of Items
0.859	0.823	66

 the nal protocol. None of these items from checklist were dropped or deleted hence these items were retained in the nal protocol.

Overall Cronbach’s alpha coefcient was 0.85 which indicate the internal consistency and reliability of the checklist to implement developed protocol (Ideally Cronbach’s alpha coefcient should be equal or above 0.70) (Table 2).

After the implementation of the developed protocol feedback of nurses regarding the developed protocol was taken by conducting a series of FGD. Majority found the protocol easy to use. More than two third (76.6%) nurses believed that the protocol was extremely helped in ensuring that no step is missed while caring for post- operative cerebral aneurysm patients. Almost every one supported to implement of the protocol in their unit. (Table 3)

Table 3: Nurses’ response regarding evaluation of the acceptability of the developed protocol

 

S. No.	Items	Extremely (5)	Highly (4)	Moderately (3)	Slightly (2)	Rarely (1)
1	The protocol was benecial for providing care to cerebral aneurysm patients post operatively	20 ( 66.6)	08(26.66)	02 (6.66)	_	_
2	The protocol was easy to use	26 (86.66)	4(13.33)	02(6.66)	_	_
3	The protocol helped to provided autonomy to nurses while caring to cerebral aneurysm patients	18 (60)	10 (30)	02(10.0)	_	_
4	The protocol provided guidance for priority based interventions	24 (80)	6 (20)	_	_	_
5	The protocol saved time and energy	22(73.33)	5(16.66)	03(10.0)	_	_
6	The protocol improved skills of nurses	23(76.66)	5(16.66)	02(6.66)	_	_
7	The protocol language was understandable	25 (83.33)	5 (16.66)	_	_	_
8	The protocol helped not to miss any steps, while caring the post op. patients	23(76.66)	06(20)	01(3.33)	_	_
9	The protocol included most of steps required for effective nursing interventions required for post-operative cerebral aneurysm	22(73.33)	04(13.33)	04(13.33)	_	_
10	The support to implementation of the protocol in our unit	28(93.33)	02(6.66)	_	_	_

Results:

Protocol was found to be valid and feasible for care of post-operative cerebral aneurysm along with valid and reliable checklist. Ready to use algorithm technique was used to draw protocol and was made available in all units of neurosurgery.

Discussion:

The quality and consistency of clinical care can be improved by the readily availability of clear evidence-based guidelines. Clinical nursing protocols may enhance nursing efciency by working independently. Protocol contains a comprehensive, up-to-date review of the disease process and provides the rationale for each nursing action. The nursing protocols also represent an important educational resource for nurses. The aim of current study was to develop a protocol to help nurses to improve post-operative nursing care of cerebral aneurysm patients. These patients are at higher risk of developing complications like cerebral vasospasm, increased intra cranial pressure and sudden change in neurological status due to complex surgical interventions and disease condition7. So, it is important to have specic guidelines for such patients in order to reduce the complications. In the current study, whole process of protocol development was divided into four main phases. In phase one, review of literature was done to know standardized guidelines and related literature which was followed by assessment of current practices of nurses caring for the post-operative cerebral aneurysm patients.

It was seen that nurses were providing care to the post-operative cerebral aneurysm patients but few practices were either missing completely or needed to be rened. Nurse’s view about the laps and gap in practices was investigate by series of FGDs with nurses working in neurosurgery units. The number of FGDs to be conducted depends upon the purpose of development of protocol.8 In the present study all FGDs were conducted with small group of 9-12 members who had around 5-7 y e a r s o f w o r k i n g e x p e r i e n c e i n neurosurgery. FGDs were continued until saturation of information was achieved. Based on gathered information, nally a preliminary draft of protocol and checklists were prepared.

The Delphi technique has been employed in several studies especially in the development of slandered protocol and checklist9-11Delphi technique was used to establish the validity of the protocol. Total three Delphi rounds were conducted with experts from department of neurosurgery, nursing education and nursing services. As per another study conducted in Western Australia three Delphi rounds were good enough to established validity.8 Delphi rounds are to be conducted till the experts reached at the common consciences. Polit et al recommended that CVI is a plausible method of estimating the content validity of a new (or revised) scale.12 Cronbach’s alpha is used to assess internal consistency and reliability of the tool as reliability is best appreciated as a measure of the consistency of recorded observation. Cronbach’s alpha coefcient for the checklist was found to be 0.859. Ideally, Cronbach’s alpha coefcient value should be > 0. 70 or above.9

All items were internally consistent and contributing to the total reliability of the checklists. The results were discussed with Delphi panelists. All members were in the favor of keeping all the items because they were equally important in the protocol inspite of the low correlation indicated in the individual item score.

A Similar study by Bijarania et al on the development of a protocol for assessment of nurse’s practice while performing drugs administration, the Cronbach’s alpha has been shown to be 0.87 and 0.84.9 Devi et al on a study to develop a standard operational protocol for nurses on central line care in intensive care units has documented the checklist reliability established by Cronabch’s alpha as 0.75.10

The modied draft was nalized after consulting all stake holders to generate the nal draft of protocol including preparation of nursing units prior to admission to unit; neurological assessment of patients; bowel and urinary elimination care; increased intra cranial pressure care etc. Protocol was implemented in respective neurosurgery units.  Focus  group  discussion was conducted to assess acceptability of protocol by the nurses. 93% nurses found the protocol very useful. Kaur R et al in 2012 developed a nursing checklist for cardiac catheterization and evaluated its usability. The average agreement percentage for effectiveness of the tool was found to be 73%.11

The practice standards are not only desirable but are necessary for the healthy growth of nursing profession and for the professional dignity and identity. Cerebral aneurysm surgical outcome is limited due to complex surgical procedure and severity of rupture of aneurysm. The use of nursing protocols has been proven benecial for nurses and patients. Nurses are empowered to make decisions and initiate changes in patient care. It is recommended to use this protocol for care of post-operative cerebral aneurysm patients. The checklist can be used by nurse supervisors to assess the implementation of protocol.

Conclusion

The nursing care protocol for care of post-operative cerebral aneurysm patients hospitalized in neurosurgery units was found to be valid in its content with with potential applicability along with reliable checklist for its implementation. Nursing care during post-operative period is very important aspect of the outcome. A nursing protocol can improve nursing practices by applying evidence-based guidelines and can possibly minimize post-operative complications.

Reference

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