CNA535: Assessment 3 Online Discussion - Answer

Part A: Response to Four Discussion Posts

Post-traumatic amnesia is a state of confusion that is commonly seen in patients with TBI (Traumatic brain injury). It is a transient state of altered brain function following TBI. Having an understanding of the underlying pathophysiology behind post-traumatic amnesia is important to decrease the risk of secondary injuries. The condition implies generalized cerebral dysfunction. One main pathophysiological mechanism behind the condition is brain network dysfunction (Spiteri et al., 2022). A study revealed impaired functional connectivity between the parahippocampal gyrus and posterior cingulate cortex in affected individuals. Both these regions play a key role in encoding new memories. The extent of the dysfunction determines performance during neuropsychological testing. There is a chance of axonal dysfunction in the cingulum bundle, which connects the parahippocampus and posterior cingulate cortex (Parker et al., 2022). Hence, there are many pathophysiological mechanisms linked to the disease.

There are certain recommended guidelines for the management of patients. However, there is weak evidence for specific interventions. Some of the recommended interventions are keeping staff and physical surrounding as consistent as possible, providing orientation and familiarization information to patients, assessing cognitive functioning and monitoring post-traumatic amnesia using validated tools such as the Westmead PTA scale (Hart et al., 2020). These management techniques are relevant to prevent the deterioration of symptoms. Due to impaired functional connectivity at important regions involved in encoding memories, it is vital to provide a consistent surroundings. It can prevent behavioural disturbances such as feelings of agitation, impulsivity and restlessness due to the condition. Cognitive dysfunction affects the normal processing of stimuli and so providing a predictable environment is important (Block et al., 2021).

Some of the cornerstone management techniques for patients with TBI are paying extra attention to oxygenation, airway and hemodynamic support. These interventions are needed to prevent secondary injuries in patients such as hypoxia and hypertension. Such secondary injuries can aggravate a patient’s condition due to hypoxemia, hypertension or hypo or hyperglycemia (Crupi et al., 2022). Hence, the care of patients with TBI targets securing the patient’s airway and maintaining ventilation and circulation. The protocol for prehospital management involves the management of the airway or oxygenation by measuring oxygen saturation value and looking for signs of cyanosis. In case of an oxygen saturation value of less than 90%, airway repositioning maneuvers are conducted. Ventilation parameters are optimized with the use of mechanical ventilation. In case of signs of hypertension or hypotension, it is important to treat them with intravenous fluid resuscitation therapy (Dash & Chavali, 2018). However, it has been recommended to perform intubation by experienced providers as inexperienced staff may increase the risk of death four-fold. The main rationale for airway management is to prevent an increase in intracranial pressure and protect the brain from secondary brain damage such as hypoxemia (Abou El Fadl & O'Phelan, 2018).

Apart from airway management, anesthetic drugs are also used for rapid control of the airway and an increase in intracranial pressure. These interventions can provide hemodynamic stability to patients which is altered due to damage to the brain tissues in TBI patients. The pathophysiology of the disease shows that extracerebral organ dysfunction is triggered following TBI. It results in the upregulation of cytokine levels and systemic organ dysfunction. The development of neurogenic pulmonary edema is a possibility that contributes to an increase in hypoxia (Jung, 2015). Thus, the use of drugs like propofol is useful in providing hemodynamic stability to patients

Evidence-based management of TBI involves engaging in inter-collaborative practice to ensure that the patient gets support from a team of expert professionals. It involves teamwork, collaboration, communication and coordination to obtain optimal outcomes for the patient. Various healthcare settings around the world focus on the use of multi-disciplinary approaches to treat patients with TBI. As such patients develop various lesion sites, and they require a multi-professional team as different types of rehabilitative treatment are required (Rizzi & Tapia, 2016).

The common multi-professional teams involved in the care of patients with TBI are speech-language therapists, physicians, nurses, occupational therapists, social workers, physiotherapists, neuropsychologists and ophthalmologists. Each team members bring different expertise and manage the care of the patient. Multidisciplinary care is important as TBI patients experience various physical, cognitive and psychological symptoms (Li et al., 2022). The role of the occupational therapist is important in supporting patients in successful adaptation after TBI. Such patients are more likely to reduced capabilities in activities of daily living. Occupational therapists can assist with grooming, toileting, visual training, home management skills, fine motor skills, and the use of mobility equipment. They also support the patient to understand their capabilities and limitations (Klepo et al., 2022).

The neurologist plays a crucial role in conducting a thorough examination of the patient and prescribing medication. They also provide referrals to other specialists to promote the management of symptoms. The Speech-language therapist assists in managing swallowing difficulty and difficulty in speech after TBI. Nurses have the responsibility to assess the medical status of patients and coordinate with team members to evaluate nursing care and treatment. The physiotherapist plays a role in assisting them with movement and muscle strength (Bui, 2021)

Taking care of patients with severe TBI comes with many ethical and legal responsibilities. This is because there is a high risk of complications and healthcare professionals need to be vigilant about the care of patients. Still, during the point of care and while implementing treatment, several ethical challenges arise for clinicians as well as nurses. Firstly, telling the family members about the prognosis is difficult as one cannot predict the reaction of different individuals. Similarly, ethical challenges related to patient autonomy and beneficence arise while settings goals of care after TBI. This is because family members have different perspectives on good outcomes (Hawley et al., 2019). Thus, to avoid any ethical concepts or legal challenges due to violation of patient autonomy, the best option is to invite patient and family caregivers at all stages of care. Partnership with patients and family members is important to build a system of care and promote the inclusion of all rights (Kivunja, River & Gullick, 2018).

Another common ethical dilemma is faced when taking voluntary informed consent from vulnerable patients with TBI. For instance, patients may have mental impairments or they may be unconscious which may compromise their ability to take decisions. The ethical principle of autonomy dictates that informed consent should be taken for treatment. However, in such cases, there is a need for proxy decision-makers (Edlow & Fins, 2018). In addition, TBI is a condition where conditions may fluctuate abruptly. Nurses face challenges in modifying care during the chronic phase of TBI. Any mistake or negligence at this point could lead to negative ethical and legal implications. Skilled and experienced nurses are needed to manage multiple responsibilities such as patient assessment, care coordination and emotional support (Oyesanya et al., 2018).

Part B: Reflective paper on exploring the outcomes of the learning

In the discussion post completed previously, we explored different aspects related to the care of patients with TBI. The experience of completing the discussion post and research on the topic helped me in gaining knowledge about different aspects of TBI. The discussion post explored different aspects such as pathophysiology, management techniques to prevent secondary injuries, the role of a multi-professional team, ethical and legal challenges and management of patients experiencing critical issues such as decompressive craniotomies, sympathetic storming and increased intracranial pressure post-TBI (Kivunja, River & Gullick, 2018; Crupi et al., 2022). Each of these discussions has further increased my understanding of the disease and I will be better able to apply this learning to my practice. For instance, the pathophysiology of PTI can help to understand the rationale behind treatments like airway management and analgesics. As it affects different regions of the brain linked to memories, the process of orientation and familiarization is important. I will have better confidence in the management of patients with TBI while handling them in future practice.

The post-discussion increased my understanding of the pathophysiology of post-traumatic amnesia and what measures can aid recovery. The research revealed there is no strong evidence on interventions but guidelines exist on management and preventive steps. I plan to use this language and take further suggestions from my senior staff regarding hospital-based guidelines for managing post-traumatic amnesia. It can help to promote early recovery after a TBI (Segev et al., 2023). Initially, I had brief knowledge of the clinical condition and the core treatment method. But I lacked understanding regarding the special consideration while handling children with TBI. I learnt that children with TBI require different treatment approaches compared to adults. This is because there are age-related anatomical and physiological differences in patterns of injury because of the age of the child. I learnt about different management techniques for severe pediatric TBI such as intracranial pressure monitoring, the use of sedatives and analgesics, hyperosmolar therapy, hyperventilation and cerebrospinal fluid drainage (Araki, Yokota & Morita, 2017). However, I have just gained superficial knowledge. I aim to take part in additional training so that I can further gain more knowledge on intricacies related to each management step. 

The post-discussion increased my understanding of the nursing communication process and important ethical and legal considerations while handling patients. At all points of care, it is critical to preserve the ethical right to patient autonomy, beneficence, social justice and non-maleficence. This is required during treatment discussion, taking informed consent for treatment as well as modifying treatment in case of severity of the condition. In addition, I have gained competency in using communication techniques while disclosing the prognosis or while interacting with children with TBI. It involves changing the way the question is asked and use of different language while assisting patients (Oyesanya & Thomas, 2019). Informed by the above, I will be able to change my communication style and ensure that it is relevant to the age of the patient.

References

Abou El Fadl, M. H., & O'Phelan, K. H. (2018). Management of traumatic brain injury: an update. Neurosurgery Clinics, 29(2), 213-221.

Araki, T., Yokota, H., & Morita, A. (2017). Pediatric traumatic brain injury: characteristic features, diagnosis, and management. Neurologia medico-chirurgica, 57(2), 82-93.

Block, H., George, S., Milanese, S., Dizon, J., Bowen-Salter, H., & Jenkinson, F. (2021). Evidence for the management of challenging behaviours in patients with acute traumatic brain injury or post-traumatic amnesia: An Umbrella Review. Brain Impairment, 22(1), 1-19.

Bui, M. H. (2021). Physiotherapists’ role in increasing awareness and knowledge about traumatic brain injury in contact sports athletes: a qualitative research (Doctoral dissertation, foaf: name).

Crupi, R., Cordaro, M., Cuzzocrea, S., & Impellizzeri, D. (2020). Management of traumatic brain injury: from present to future. Antioxidants, 9(4), 297.

Dash, H. H., & Chavali, S. (2018). Management of traumatic brain injury patients. Korean journal of anesthesiology, 71(1), 12-21.

Edlow, B. L., & Fins, J. J. (2018). Assessment of covert consciousness in the intensive care unit: clinical and ethical considerations. The Journal of head trauma rehabilitation, 33(6), 424.

Hart, T., Ferraro, M., Rabinowitz, A., Fitzpatrick DeSalme, E., Nelson, L., Marcy, E., ... & Turkstra, L. (2020). Improving communication with patients in post-traumatic amnesia: development and impact of a clinical protocol. Brain Injury, 34(11), 1518-1524.

Hawley, L., Hammond, F. M., Cogan, A., Juengst, S., Mumbower, R., Pappadis, M. R., ... & Dams-O’Connor, K. (2019). Ethical considerations in chronic brain injury. The Journal of head trauma rehabilitation, 34(6), 433.

Jung, J. Y. (2015). Airway management of patients with traumatic brain injury/C-spine injury. Korean journal of anesthesiology, 68(3), 213-219.

Kivunja, S., River, J., & Gullick, J. (2018). Experiences of giving and receiving care in traumatic brain injury: An integrative review. Journal of clinical nursing, 27(7-8), 1304-1328.

Klepo, I., Sangster Jokić, C., & Tršinski, D. (2022). The role of occupational participation for people with traumatic brain injury: A systematic review of the literature. Disability and rehabilitation, 44(13), 2988-3001.

Li, L. M., Dilley, M. D., Carson, A., Twelftree, J., Hutchinson, P. J., Belli, A., ... & Greenwood, R. (2022). Response to: Management of traumatic brain injury: practical development of a recent proposal. Clinical Medicine, 22(4), 358.

Oyesanya, T. O., & Thomas, M. A. (2019). Strategies nurses use when caring for patients with moderate‐to‐severe traumatic brain injury who have cognitive impairments. Journal of clinical nursing, 28(21-22), 4098-4109.

Oyesanya, T. O., Bowers, B. J., Royer, H. R., & Turkstra, L. S. (2018). Nurses’ concerns about caring for patients with acute and chronic traumatic brain injury. Journal of Clinical Nursing, 27(7-8), 1408-1419.

Oyesanya, T. O., Bowers, B. J., Royer, H. R., & Turkstra, L. S. (2018). Nurses’ concerns about caring for patients with acute and chronic traumatic brain injury. Journal of Clinical Nursing, 27(7-8), 1408-1419.

Parker, T. D., Rees, R., Rajagopal, S., Griffin, C., Goodliffe, L., Dilley, M., & Jenkins, P. O. (2022). Post-traumatic amnesia. Practical Neurology, 22(2), 129-137.

Rizzi, E., & Tapia, M. (2016). Interprofessional Collaboration and Traumatic Brain Injury. https://ir.library.illinoisstate.edu/cgi/viewcontent.cgi?article=1000&context=giscsd

Segev, S., Silberg, T., Bar, O., Erez, N., Ahonniska-Assa, J., Brezner, A., & Landa, J. (2023). Prolonged duration of post-traumatic amnesia: A sensitive classification for predicting cognitive outcomes in children recovering from traumatic brain injury. Journal of the International Neuropsychological Society, 1-8.

Spiteri, C. J., Ponsford, J. L., Roberts, C. M., & McKay, A. (2022). Aspects of cognitive impairment associated with agitated behaviour during post-traumatic amnesia. Journal of the International Neuropsychological Society, 28(4), 382-390.

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