http://doi.org/10.33698/NRF0260 -Dimple Madaan, Satwant Baltej, S.K. Sharma, S.K. Gupta
Abstract : Neurosurgical patients are prone to develop the pulmonary complications because of neurological involvement and immobility. Brain is so sensitive towards the hypoxia. So it is prime responsibility of a Neurosurgical nurse to prevent these complications in neurosurgical patients. Thus, a quasi-experimental study was undertaken to evaluate the effectiveness of planned chest physiotherapy, endotracheal suctioning and every 2 hourly position change in prevention of pulmonary complications among neurosurgical unconscious patients. Total 60 purposively selected patients, 30 each in experimental and control group were studied during Jan-Feb 2003. Homogeneity among both the group was established in respect of age, diagnosis, type of management, mode of airway, GCS score, pre-intervention respiratory status, and other sociodemographic characteristics of the subjects. Findings of the study revealed that there was statistically significant difference in post intervention chest x-ray findings, ABG findings and other respiratory assessment findings (p < 0.01). This has indicated that planned regular chest physiotherapy, endotracheal suctioning and every 2 hourly position change was effective in prevention of pulmonary complications among neurosurgical unconscious patients.
Key Words :
Effectiveness, selected nursing interventions, prevention, pulmonary complications, neurosurgical unconscious patients
Correspondence at :
Dimple Madaan,
Shri Guru Ram Dass College of Nursing, Hoshiarpur, Punjab, India
Introduction
The brain is critically dependent on an adequate oxygen supply. Its oxygen consumption is approximately 3ml/100gm/ minute. The brain is so sensitive to oxygen depletion that electroencephalographic observation reveals the development of abnormal slow waves within seconds after deprivation occurs. With profound oxygen depletion abnormal cerebral function develop rapidly (less than 3 minutes) leading to central nervous system deprivation with coma and death. Irreversible parenchyma damage can occur very quickly. Hypoxia of even brief duration produces functional abnormalities of brain capillaries, these become more permeable to the passage of water resulting in the development of cerebral edema1
The injured brain may be more vulnerable to changes in the arterial blood because the normal lung protection provided by vascular reactivity and the blood brain barrier may be defective. The neurosurgical patient may suffer pulmonary complications or abnormal neural out put may indirectly derange gas exchanges in normal lungs. With such complexities of interacting factors, it is not surprising that the brain injury can be associated with an escalating problem of hypoxia and further brain damage2
Neurosurgical unconscious patients requires special airway and respiratory management. These patients have altered or depressed airway protective reflexes and are subjected to large airway obstruction decreased lung inflation, hypoxia and hypercarbia, atelectesis, apiration and pneumonia.2 Studies have suggested that 95 per cent of neurosurgical mortalities are primarily related to pulmonary complications as a specific contributing factor. Over t respiratory failure occur in 20 per cent of isolated head injury patients from pulmonary complications such as aspiration, pneumonia. Pulmonary abnormalities on postmortem examination were present in 85 per cent of isolated head injury in the Vietnamese’s study.10 In another study found that in elective brain surgery among elderly patients carries 17.5 per cent post operative pulmonary complications and 4 per cent mortality pulmonary complications. Atelectasis and pneumonia are the main complications among neurosurgical patients. Pulmonary complications contributes to the morbidity and mortality of a wide variety of neurological disorders. The morbidity and mortality of pulmonary complications can be reduced by early recognition and modification of management1.
To prevent all these pulmonary problems and there by morbidity and mortality among neurosurgical patients, these patients need to receive a special nursing management for respiratory system. Nursing action can influence the success or failure of neurosurgical interventions. Improved respiratory nursing care of unconscious neurosurgical patients make neurosurgery more effective.1 There are various nursing interventions e.g.,chest physiotherapy, endotracheal suctioning and every 2 hourly position change etc, which are believed to effective in prevention of pulmonary complications, but there has not been a single experimental or quasi-experimental study carried out in our scenario or in abroad. So this study is planned to see the effectiveness of these nursing interventions in prevention of pulmonary complications among neurosurgical patients.
Objective
To evaluate the effectiveness of selected nursing interventions in prevention of pulmonary complications among neurosurg- -ical unconscious patients.
Materials and Methods
This quasi-experimental study was conducted in neurosurgical units of the Nehru Hospital, PGIMER, Chandigarh during months of Jan-Feb 2003. It is tertiary care providing hospital which is well known for its neurosurgical facilities where annually about 1000 patients are treated with nerosurgeries. In months of Jan-Feb 2003, total 84 patients were treated with neurosurgeries. Out of them 60 purposively selected patients, 30 each in experimental and control group were studied. Both genders, who were unconscious patients and above the age of 12 years with endotracheal intubation/ tracheotomy were included in the study sample but patients with associated chest trauma or patients with less than 24 hours intubation were excluded from the study subjects. An identification data sheet, socio-demographic data sheet, observation check list were the tools of the study to collect the data, which were developed after thorough review on related literature. Validity was established by seeking the opinion of 5 experts who were from fields of research, nursing practice, neurosurgery and pulmonary medicine. A inter-rater reliability was also calculated and found to be significant for research tools. Data were collected though interview and participatory observation. Planned pulmonary assessment was carried out twice daily in morning (8.30 am) and in evening (4.30 pm) both control and experimental group for 5 consecutive days. Chest x-rays were interpreted by senior resident. As a par t of intervention experimental group received 4 times chest physiotherapy in a day and every two hourly suctioning and positioning without disturbing routine treatment.Collected data was analyzed by using both descriptive and inferential statistics. Ethical justification is provided by obtaining verbal consent from patient’ relatives and without disturbing routine.
Results
Findings of the study revealed that in both, experimental and control group more than 80% subjects were male and rest of them were female with mean age of 42.06±13.48 years and 46.1±16.79 years respectively. In both the groups 70% subjects were with medical diagnosis of head injury and rest of them were with brain tumor (10%) and intracranial hemorrhage (20%). In 28 (93.3%) subjects Glasgow Coma Scale (GCS) was < 8 and only 2 (6.7%) subjects had GCS > 8 in each group.
In control group 29 (96.7%) subjects had endotrachial intubation and rest one subject had tracheostomy, whereas in experimental group 23 (76.7%) subjects were having endotrachial intubation and rest 7 (23.3%) subject had tracheostomy mode of airway management. Pre-morbid 23.3% subjects were alcoholic in both groups, while smoking habit was found in 16.7% subjects of control and 10% of experimental group. Alcoholic and smoking both habits were found 10% subjects of control group and 16.7% ubjects experimental group. Tobacco chewing was reported in 3.3% subjects, whereas 46.7% subjects were free from any type of addiction in each group.
Table – 1 depicts that in control group, the difference in the initial (day 1) and final day (day 5) observation of respiratory rate, breath sounds, body temperature, amount of
Table – 1: Comparison of assessment findings of day 1 and day 5
|
Variables |
Control group Experimental group | |||||
| Day 1 (n=30) | Day 5 (n=30) | P value (n=30) | Day 1 (n=30) | Day 5 (n=30) | P value | |
| 1. Rate of resp./ min
– On IPPR – < 20 – 20-30 – > 30 2. Breath sounds – Normal – Diminished – Adventitious 3. Type of adventitious breath sounds – Crackles – Ronchi – Bronchial breathing 4.Tracheobronchial secretions (amount) – Nil – Scanty – Moderate – Copious 5. Tracheobronchial secretions (Type) – Mucoid – Purulent – Sarosanguinous 6. Body temp. – < 36.5 0C – 36.5 – 37.5 0C – 37.5 – 38.5 0C – > 38.5 0C |
07 |
12 |
09 |
07 |
p>.01 |
|
| 01 | 00 | p<.01 | 15 | 18 | (NS) | |
| 16 | 07 | (S) | 06 | 05 | ||
| 06 | 11 | 00 | 00 | |||
| 15 | 03 | 19 | 29 | |||
| 01 | 01 | p<.01 | 00 | 00 | p<.01 | |
| 14 | 26 | (S) | 11 | 01 | (S) | |
|
12 |
25 |
12 |
01 |
|||
| 15 | 27 | p>.01 | 08 | 00 | p>.01 | |
| 00 | 04 | (NS) | 01 | 01 | (NS) | |
|
02 |
00 |
p<.01 |
01 |
01 |
||
| 26 | 05 | (S) | 01 | 00 | p>.01 | |
| 02 | 17 | 21 | 20 | (NS) | ||
| 00 | 08 | 07 | 09 | |||
| 28 | 00 | p<.01 | 13 | 12 | p>.01 | |
| 02 | 28 | (S) | 17 | 18 | (NS) | |
| 00 | 08 | 00 | 00 | |||
| 01 | 03 | p<.01 | 01 | 01 | p>.01 | |
| 11 | 03 | (S) | 20 | 11 | (NS) | |
| 16 | 09 | 04 | 11 | |||
| 02 | 15 | 05 | 07 | |||
S- significant, NS- Not significant
tracheobronchial secretion, type of tracheobronchial secretion frequency was found to be statistically significant (p < 0.01). Whereas in type of adventitious breath sounds the frequency of adventitious sounds was found to be statistically insignificant (p > 0.01).
Table – 2 depicts that initially during pre intervention phase majority of the subjects i.e. 20 (66.7%) in control group and 16 (53.3%) in experimental group had normal chest x-ray findings whereas 10 (33.3%) subjects in control group and 14 (46.7%) subjects in experimental had infiltrates. Difference in pre intervention x-ray findings of control and experimental group was found statistically insignificant.
Post intervention on final observation, 15 (50%) Subjects in control and 16 (53.3%) in experimental group had normal chest x-ray findings. Deterioration was found in chest x- ray findings of 11 (36.7%) subjects in control group but not even a single subject in experimental group. Improvement was seenin chest x-ray of 6 (20%) subjects in the experimental group but not in any of the subjects of control group. Comparison of final chest x-ray findings of the control and experimental group showed highly staticallysignificant difference (p < 0.01)
Table – 3 shows that the post interven- -tion 5 (16.6%) subjects in both groups had PaO2 In control group 4 (13.3%) subject had PaCo2
Table – 2 : Comparison between pre & post intervention x-ray finding of the control & experimental groups
| Initial Chest x-ray findings Final Chest x-ray findings | ||||||||
| Normal | Infiltrates | P value | Normal | Improvement | No change | Deterioration | P value | |
| Control group | 66.7% | 33.3% |
P > .01 (NS) |
50% | 00% | 04% | 11% |
P < .01 (HS) |
| Experimental group | 53.3% | 46.7% | 16% | 06% | 08% | 00% | ||
S- significant, NS- Not significant
Table – 3 : Comparison between post intervention ABG finding of the control & experimental groups
| ABG Finding | Control group | Experimental group | x2 | d.f. | P value |
| PaO2< 80mmHg | 05 (16.7%) | 05 (16.7%) |
23.8 |
2 |
P < .01 (HS) |
| Pa Co2 > 45 mmHg | 04 (13.3%) | 01 (3.3%) | |||
| SaO2 < 95 mmHg | 07 (23.3%) | 02 (6.7%) |
> 45 mmHg but experimental group had only one (3.3%) such subjects. In control group 7 (23.3%) subjects had saturation < 95% whereas in experimental group only 2 (6.7%) subjects had saturation < 95%. The difference in the ABG findings between the control group and experimental group was found to be statistically significant (p <0.01).
Table – 4 depicts that less than 45 years age group 10 (33.3%) subjects in control and 5 (16.7%) subjects in experimental group did not had any pulmonary complications whereas 8 (26.7%) subjects in control group and 5 (16.7%) subjects in experimental group had some degree of pulmonary complications. Among 45 years or above age group patients 8 (26.7%) control group subjects and 9 (30%)
Table – 4 : Age of subjects and occurrence of pulmonary complications
| Age | Pulmonary complications | Control group | Experimental group | x2 | d.f. | P value |
| < 45 years | Absent | 10 (33.3%) | 05 (16.7%) |
5.67 |
3 |
P>.01 |
| Present | 08 (26.7%) | 05 (16.7%) | ||||
| ³ 45 years | Absent | 04 (13.3%) | 11 (36.7%) | |||
| Present | 08 (26.7%) | 09 (30%) |
experimental group subjects had developed pulmonary complications whereas 4 (13.3%) control group subjects and 11 (36.7%) experimental group subjects did not develop any pulmonary complications. The difference between less than 45 years age group subjects and more than 45 years age group subjects in occurrence of pulmonary complications did not reach to the level of significance (p > 0.01).
Discussion
Results of the study revealed that in control and experimental homogenous groups the difference in the initial (day 1) and final day (day 5) observation of respiratory rate, breath sounds, body temperature, amount of tracheobronchial secretion and type of tracheobronchial secretion frequency was found to be statistically significant (p < 0.01). Whereas in type of adventitous breath sounds the frequency of sounds was found to be statistically insignificant (p > 0.01).
In experimental group the difference in the initial (day 1) and final day (day 5) observation of respiratory rate, adventitious breath sounds, body temperature, amount of tracheobronchial secretion, type of tracheobronchial secretion frequency was found to be statically insignificant (p > 0.01). Whereas the difference between the initial and final day observation of breath sounds was found statistically significant (p< 0.01). The difference in the final chest x-ray findings between the experimental and control group was found statistically significant (p< 0.01). This statistically significant difference in the final chest x-ray finding between experimental and control group established the effectiveness of selected nursing interventions in prevention of pulmonary complications among neurosurgical unconscious patients. Similar findings has been reported by Mackenzine et al3, Joshi et al4, Fourrier et al5 in their studies.
Intergroup comparison of ABG findings between control and experimental group had shown statistically significant difference (p < 0.01). Thereby it established that planned chest physiotherapy, endotracheal suctioning and every 2 hourly position change are effective in prevention of pulmonary complications among neurosurgical unconscious patients. These findings of the study coincides with findings of the study conducted by Clesla Nancy6, Stiller7, Jones8, Chulay9.
The findings showed that the difference in development of pulmonary complication as per age of the control group and the experimental group subjects was not found statistically significant (p < 0,01). This had signified that age does not play a significant role in development of pulmonary complications among neurosurgical unconscious patients.
Conclusion
In both, experimental and control homogenous group, more than 80% subjects were male and rest of them were female with mean age of 42.06±13.48 years and 46.1±16.79 years respectively. It was revealed that there was statistically significant difference in post intervention chest x-ray findings, ABG findings and other respiratory assessment findings (p < 0.01). This has indicated that planned regular chest physiotherapy, endotracheal suctioning and every 2 hourly position change was effective in prevention of pulmonary complications among neurosurgical unconscious patients.
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