Introduction
Traumatic Brain Injury is one of the major causes of death in the world today. In areas where the prevalence of accidents is high, the associated brain injury is also significant. As such, effective techniques for the diagnosis, assessment and management of the injury and the resulting outcomes are necessary if successful treatment is to be achieved. Traumatic brain injury is characterized by a series of complex intra-cellular factors that may result in various outcomes including cell apoptosis. Traumatic Brain Injury has many potential negative outcomes besides the financial costs incurred in its management. For instance, patients who have undergone TBI can be faced with intellectual incapacitation and emotional distress among other factors. As such, effective management of TBI is an intensive process that requires a diverse range of resources. The following essay examines the phenomenon of traumatic brain injury with reference to its pathophysiology, diagnosis, assessment, management and resource requirements.
Pathophysiology of Traumatic Brain Injury
According to a report prepared by Werner and Engelhard (2007), traumatic brain injury originates from the direct damage of cranial tissue. This also comes with the impairment of cranial blood flow regulation and impairment of metabolism in the brain. TBI results from forceful impact on the cranium which frequently occurs during accidents in sports and on the road. This results in tissue injury, creation of damages such as lesions. Following the impairment of cranial blood flow, lactic acid is accumulated within the brain. This results in anaerobic glycolysis which causes increased permeability of brain cell membranes. In addition to this, oedema formation can also result from the accumulation of lactic acid in the brain. The entire process from tissue damage to oedema formation comprises the first phase of TBI.
During the second phase of progression, depolarization of terminal membranes can come about due to the presence of brain oedema. This depolarization results in increase in the rate of release of excitatory neurotransmitters such as glutamase. The effect of the neurotransmitters is to initiate rapid catabolic reactions in cells. Catabolic reactions are those during which cells are engaged in self digestion. In addition to this, depolarization also results in the activation of other enzymes like lipid peroxidase and proteases which enhance the concentration of free radicals as well as that of free fatty acids within cells. This is followed by a series of other intracellular reactions which initiate the production of several enzymes with destructive potential.
In the third phase of progression, endonucleases and translocases are activated through the continuing intracellular reactions (Werner & Engelhard, 2007). These enzymes initiate continuous changes in the structure of DNA strands. Some of the changes that may result include fragmentation of DNA strands and inhibition of repair in the DNA structures. The impacts of structural changes in DNA molecules include degradation of cellular and vascular structures in the cells. The inevitable end of this is through either cell apoptosis or necrotism. The progression of TBI results in physical outcomes such as seizures, headaches and dizziness as well as in other outcomes such as intellectual incapacitation and emotional distress which is portrayed through depression and/ or anxiety.
Standard of Practice for TBI
Pharmacological Treatments
Management of TBI comes with various challenges in the healthcare system. There are no specific pharmacological treatment procedures for TBI but patients are often treated for symptoms such as seizures, memory loss and therapy for other outcomes such as emotional distress. In particular, the most common treatments accorded to patients are distinguished according to the severity of damage caused by TBI. TBI is categorized as mild, intermediate or severe and the potential for resulting in long term seizures rises with increase in severity. For mild seizures, anticonvulsants are recommended for use (Algattas & Huang, 2014). In particular, the authors mention phenytoin as the most effective in the prevention of seizures during the early stages following TBI. However, the authors also report that phenytoin is not recommended for long term use due to its pharmacological effects.
Other anticonvulsants have been used previously for the treatment of seizures in TBI patients. However, some of them such as carbamazepine and Phenobarbital are not recommended for use in patients with mild conditions of TBI due to the potential for adverse effects. Additionally, these two drugs are also associated with strong pharmacological profiles which make them unsuitable for mild conditions and for the treatment of TBI among pediatrics. Another drug that has been found to be as effective as phenytoin is Levetiracitam (LEV). According to Algattas and Huang, LEV may also be used satisfactorily with an efficacy equal to that of phenytoin. However, the latter is more cost effective and hence most commonly used among all patients.
Apart from the anti-convulsants, psychostimulants like methylphenidate have been found effective in the acute phases of traumatic brain injury. The outcomes associated with the use of methylphenidate among patients with acute TBI include better motor skills, greater attention span and concentration for up to one month. This change is however not persistent past the third month hence it is reported that psychostimulants do not change the morbidity of TBI patients but only shorten recovery time. Other medications that have been used successfully with TBI patients include antidepressants such as sertraline and flouxetin which are administered for eight weeks and 3 months respectively. The two are effective for agitation and depressive moods while pathological crying is treated through administration of citalopram or paroxetine at a maximum of 40 mg. Anti-parkisonian drugs have also been confirmed effective for TBI treatment especially in circumstances involving right sided, frontal or diffuse brain injury. Such drugs include carbidopa and levodopa (Talsky et al., 2010).
In general, the treatment of TBI generally takes different courses for adults and children. Most of the medications used for adults are not appropriate for use with children hence is not recommended. Moreover, clinicians are tasked with the responsibility of making assessments on various factors influencing patient conditions prior to recommending any medications for them.
Guidelines for Assessment, Diagnosis and Patient Education
In the work of West et al (2011) the process of managing TBI comes with various requirements. This implies that practice has to entail exertion of expertise and experience. Prior to clinical testing and diagnosis, clinicians responsible for taking care of TBI patients have to be engaged in patient assessment. The assessment takes different perspectives. First, the nurse has to assess various aspects of communication, treatment plans and swallowing capabilities associated with the patient. This entails an assessment of factors such as cognition, language and speech production. Speech production is assessed through a physical therapy format. Each of these assessments is conducted to determine the risk factors associated with the patient in reference to severity of TBI. Following this, the nurse must also assess the past medical records of the patient.
Past medical records enable the clinicians to understand various risk factors for post TBI seizure. From this, the clinicians can then help the patients to understand their present conditions and to avert potential dangerous outcomes in futures. The assessment of past medical records comes with the evaluation of the patients’ renal functions. Renal function can affect post trauma recovery to a certain degree and also affects the type of diagnostic procedure to be used and the general management plans for the patient. Moreover, impaired renal functioning also increases the probability that the patient has catheter tubes, which comprise of ferromagnetic materials that are to be removed from the body before various modern imaging practices.
This brings about the need to assess patients on the presence of ferromagnetic materials in their bodies. Foreign bodies such as coils, implanted pumps, catheters and stimulators affect the results of imaging procedures hence have to be assessed prior to subjecting patients to processes such as CT Scans and MRI. The emotional condition of the patient must also be assessed prior to effective management. This involves determination of the level of anxiety in the patient and treatment of anxiety accordingly prior to treatment. Anxiety affects absorption capacities for various medications, especially neurotic conditions. The nurses have to take appropriate measures, therapy in this case to ensure that patients have overcome their anxiety before being subjected to testing for TBI (West et al., 2011).
The diagnostic procedures associated with TBI are of two major types. Following examination of symptoms, nursing practitioners can apply either CT scans or magnetic resonance imaging to determine exactly the extent of injury. In particular, non-contact CT scans are the most frequently used diagnostic tools for TBI patients who are in their conscious states. However, it is not recommended to be used for children and adults who are unconscious. As Ganti et al (2015) report, non- contact CT scan can result in the damage of pediatric brain cells by causing lesions on the brain. This is because the pediatric brain cells are weak and immature and are more vulnerable to damage. Similarly, the brain cells in a state of unconsciousness are also of similar characteristics and hence are easily destroyed. MRI is thus the most commonly used diagnostic tool for TBI as it is applicable for all cases of TBI and is appropriate for children as well as adults.
Following diagnosis and administration of effective treatment procedures, patients ought to be taught on how to continue managing the outcomes that come with TBI. Ganti et al (2015) categorizes the education practices for patients who have undergone TBI into different types. In all the education types, the first step is to communicate to the patient regarding the expectations that they can have following their experiences. The patients then have to be educated on managing the physical outcomes of their injury. Physical outcomes in this regard include dizziness, nauseas and headaches among others. To effectively manage these conditions, the patients must be educated on the need for resting and avoiding stimulators. Cognitively, patients may experience outcomes such as memory loss and amnesia. Such symptoms can be managed through assistive strategies. On the other hand, emotional symptoms such as irritability, depression and anxiety can only be managed by practices such as effective nutrition, exercise and stress management. This means that the nurse practitioners have to educate their patients on how to manage all these practices to prevent exacerbation of their conditions (Ganti et al., 2015).
Standards for Management
The management of TBI has no explicit standards across the international context. Algattas and Huang suggest that there are no first level recommendations for the management of TBI in the international healthcare context (2014). However, various level two recommendations are available for guiding nursing practitioners in managing TBI patients. Some of the most common recommendations across states include the management of individuals with seizures. The treatment of TBI can be considered to be multi-disciplinary as it involves the application of various procedures in the management of the condition holistically. Organizations such as the Brain Trauma Foundation continue to play a crucial role in providing support to the Virginia state healthcare systems for the management of TBI. In most cases across the world as in the county of Virginia, patients with TBI are placed under critical care until some of the symptoms such as unconsciousness wear off. This is followed with frequent check up, including repeat visits to the emergency departments following experiences of increased headache, dizziness and memory loss (West et al., 2011). In cases of TBI, patient centered treatment is recommended as it provides a more wholesome and satisfactory treatment for the conditions.
Resource Requirements for Management of TBI
Managing TBI is a resource intensive practice that can be hindered by the lack of some resources. As previously explained, TBI comes with multifaceted impacts and effective management requires holistic consideration of patient conditions. This implies that for patients to manage the condition effectively, considerable financial capacity has to be entailed. Costs of pharmacological treatment and therapy where necessary have to be incurred. Moreover, high levels of expertise are also a prerequisite in management, especially in cases of severe TBI. According to Arcinieges et al (2007), managing TBI requires intensive expertise which the patients cannot possess on their own. This needs medical practitioners to initiate and facilitate education of patients to enable them to handle their conditions effectively. Other resource requirements include emotional support in dealing with the outcomes of injury. As previously mentioned, patients of TBI may be vulnerable to seizures and depression among other outcomes. For them to be capable to adapt to lifestyle changes, it is imperative for them to have emotional support and / or physical support where this is needed.
In the present times, there is no equality in the provision of care across the world due to variances in resource distribution. Financial, natural and political resources vary in distribution between developing and developed countries hence resulting in better capacity to provide the level of patient centeredness that TBI requires. In some states, the level of healthcare is low in comparison to others. This thus means that provision of care for TBI patients may follow the same procedure yet be of dissimilar qualities depending on resource availability (Arcinieges et al., 2012).
Factors that contribute to effective disease management
The intensive resource requirements in TBI management imply that there are a variety of factors that increase potential for effective disease management in TBI. First, financial resources are the most essential determinant of effective management. This is because acquisition of medication, payment of care providers where necessary and transport are all dependent on the availability of finances. Without funds, a patient may receive prescriptions yet fail to acquire the corresponding medication. At the same time, patients with outcomes such as seizures and emotional disturbances may require therapy, which they have to pay for. Without finances, patient conditions deteriorate and may result in prolonged recurrence of seizures and depression among others. Apart from this, health insurance and Medicare can both influence management of TBI. This is because health support is provided through these services. While a patient may lack finances at hand, the availability of insurance and Medicare can help patients to cater for their treatment needs without any troubles. Lack of this only means more frustration in accessing healthcare and potentially aggravation of the injury outcomes.
Furthermore, access to healthcare also plays an essential role in management of TBI. As Arcinieges et al report, distribution of resources varies from country to country. As such, access to healthcare can be limited due to lack of facilities, technologies and expertise which all hamper effective diagnosis, assessment and care provision. This results to unmanaged conditions characterized by wrong diagnosis and at times failure to conduct timely diagnoses and treatment of conditions. Emotional support also influences effective management, especially with regards to cognitive and emotional problems such as depression and anxiety. Consequentially, patients who lack emotional support in TBI management are often characterized with higher levels of stress, which may result in the development of Post Traumatic Stress Disorders (Werner & Engelhard, 2007).
Effects of TBI : Disparities among patients, families and populations
According to Arcinieges et al (2012), TBI has several adverse effects on the victims, their families and the society at large. For the patients, the impacts of TBI include impaired intellectual capacity, physical effects such as seizures and emotional outcomes such as depression. Generally, the productivity of individuals with TBI is reduced greatly. This not only hampers their social capacities for interaction but also their financial capacity. For the families, the costs incurred are mainly social and financial. In particular, families taking care of TBI patients have to endure stigma following conditions such as seizures, which are prevalent among patients with TBI. Additionally, taking care of TBI patients requires large financial inputs which may not be affordable to families. Even in cases where families can afford to take care of their loved ones financially, the depression created by the condition is still large. As such, management of TBI in patients can only be described as a societal burden. Loss of productivity as a result of illness results in loss of national GDP hence impacting the national revenue negatively.
Costs of TBI management
In the US alone, the annual costs for treating TBI patients are approximately $48.3 billion. Of this, 10 to 30 billion dollars goes to the rehabilitation and management of acute TBI cases. The costs incurred include pharmacological treatment as well as wages and rehabilitation in cases where the injury is acute. These costs translate into a percentage of the national GDP which implies that TBI deducts part of the national revenue. From a study conducted by McGarry and others (2002), the costs of treating TBI vary significantly depending on the injury type and severity, with motor vehicle crashes incurring the highest costs in treatment. Similarly, hospitalization costs also vary depending on the nature of the injury. It can thus be concluded that TBI is indeed a huge burden to the society at large due to its potential impact on the economy.
Strategies for Best Practice Promotion
In order to ensure effectiveness in managing TBI, nursing practice should entail the application of various nursing theories. The most applicable and recommended practice in this regard is the use of patient centered care. This strategy would be effective since it involves focus on the patient and need for the patient’s greatest benefit. To evaluate the effectiveness of this strategy, it is recommended that patient progress in TBI related complications be charted in time series. Secondly, applying Orem’s self deficiency theory is also another strategy for effective TBI management in a healthcare organization. This theory enables the nursing practitioner to identify the different categories of limitations associated with the patients in order to determine the most appropriate intervention strategies for each of the deficiencies observed. In this way, progress can be measured by reduction in the level of deficiencies associated with the patient. In order to address TBI effectively, it would also be necessary to apply the social theory in the clinical context. When TBI patients experience outcomes such as depression, memory loss and anxiety, their close family members can be talked and educated into providing them with best chances for improving through association with others. Effectiveness in implementation can be evaluated through the use of social indicators such as reduced stress and anxiety levels. Each of these strategies is selected for their effectiveness in addressing specific patient problems without leaving out underlying causes and all the associated outcomes.
Conclusion
Traumatic Brain Injury is one of the major causes of death that results from accidents in the contemporary times. The management of TBI requires intensive input of resources such as finances as well as social resources. TBI is associated with complex intracellular reactions which result in various negative outcomes such as seizures. As such treatment focuses on the injury outcomes and differs across states. However, in order for effective management to be achieved, it is recommended that various strategies that rely on the application of nursing theories be applied and evaluated constantly.
References
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Algattas, H. and Huang, J. (2014). Traumatic Brain Injury Pathophysiology and Treatments: Early, Intermediate and Late Phases Post Injury. International Journal of Molecular Science, 15(1), 309-341.
Ganti, L., Daneshvar, Y., Bodhit, A., Ayala, S., Patel, P., Lottenberg, L., York, D., Counsell, C., and Peters, K. (2015). TBI Adapter: Traumatic Brain Injury Assessment Diagnosis Advocacy Prevention and Treatment from the Emergency Room – A Prospective Observational Study. Military Medicine, 180(4).
McGarry, L.J., Thompson, D., Millham, F.H., Cowell, L., Snyder, P.J., Lenderking, W.R., Weinstein, M.C. (2002). Outcomes and Costs of Acute Treatment of Traumatic Brain Injury. Journal of Trauma, 56(6), 1152- 1159.
Talsky, A., Pacione, L., Shaw, T., Wasserman, L., Lenny, A., Verma, A., Hurwitz, G., Waxman, R., Morgan, A., Bhalerao, S. (2010). Pharmacological Interventions for Traumatic Brain Injury. BMCJ, 53(1), 26-31.
Werner, C. and Engelhard, K. (2007). Pathophysiology of Traumatic Brain Injury. British Journal of Anesthesia, 99(1), 4-9.
West, T., Bergman, K., Biggins, M., French, B., Galletly, J., Hinkle, J. and Morris, J. (2011). Care of the Patient with Mild Traumatic Brain Injury: AANN and ARN Clinical Practice Guideline Series. American Association of Neuroscience Nurses and the Association of Rehabilitation Nurses.