INTRODUCTION:

Traumatic brain injury (TBI) is brains acquired injury due to an external power with a different intensity from mild to severe.[ Hoeman SP 2002].

The Center of Disease Control and Prevention is referred to TBI as the silent epidemic. High age is one of the risk factors, which is effective on the severity of disease after TBI.[ Thompson HJ 2006] According to the Statistical Center of Iran, in our country accidents are the most common cause of TBI.[ Iranian Journal of Nursing. 2010] Recent advances in medicine and expanding and improving health care services have been leaded to reduce mortality due to TBI. Although these advances can save lives, but there is no guarantee for these patients to back to prior health level. This has caused increasing the number of patients seeking disability after severe brain injury. [ Tarbiat Modares University; 1998]. In the United States spending an average of $1995 for inpatient, $105 823 for acute care and 58,415 dollars per patient cost for rehabilitation. The annual cost of caring from patients with brain injuries is about 15/6 billion dollars.[ Derstine BJ 2002]. Coma is one of the results of brain injuries.[ Davis AE 2003] On the other hand, sensory deprivation is one of the -complications, which have a high risk in intensive care unit (ICU) wards for these patients. Cause of nature of illness they are keeping in emphatic environments that it could lead to decreasing sensory inputs and in this condition brain does not have a normal level of brain activity and consequently would lead to sensory deprivation [ Taylor C 2005].

Being ensure that environmental stimuli are sufficiently significant and is the rational methods of nursing practice for patients who are at risk of sensory deprivation. To prevent sensory deprivation after brain injury in unconscious patients, a sensory stimulation program (SSP) beginning in the early stage of injury may be useful (Mitchell, Bradley, Welch, and Britton, 1990). Length of sessions referring to the allotment of time for stimulation will vary. In general, for more stable patients (other than ICU patients), the recommendations for length of sessions are 45 to 90 minutes per session. Sosnowski and Ustik (1994) believed that the patient was stable but too tired to successfully make it through 15 to 30 minutes; he or she might consider 10 to 15 minutes instead. Stimulation when administered should be meaningful, and repetition of stimuli for prolonged periods of time should be avoided. Sensory stimulation, as defined in this article, is a form of treatment that may increase the patient’s responsiveness; a healthcare professional or a family member systematically applies stimulation to the patient’s five sensory modalities. This SSP should be intensive enough to reach the heightened threshold of damaged reticular neurons and, as a result, to activate cortical activity. Similarly, Kater(1989) found that patients in the experimental group to whom sensory stimuli had been applied in a structured pattern had gained higher cognitive function scores than those of the control group. After applying the Coma Arousal Procedure in patients who were comatose from head injury, Mitchell et al. (1990) observed a faster rate of recovery and a shorter duration of coma. However, most of the earlier mentioned studies were retrospective or case reports. The studies differed widely in terms of study design and outcome measures. The purpose of this study was to prospectively examine the effects of an SSP on recovery in unconscious patients with traumatic brain injury.

NEED FOR THE STUDY:

An epidemiological study was conducted to determine epidemiological features of traumatic brain injury. In which records of 358 cases who were admitted at the department of neuro rehabilitation units. The result revealed that out of 358 cases 301 (84%) were male and 250 (70%) were in age between 18 to 45 years. Traumatic brain injury patients was seen mostly in industrial (31%) and motor vehicle accidents (24%) injuries. Traumatic brain injury was seen in 89.1% of cases are affecting the sense organs. The study concluded that traumatic brain injury was more prevalent in young male, industrial and motor vehicle accidents [Zeigler MD].

An epidemiological study was conducted to estimate the prevalence rate of Traumatic Brain Injury patients in US Army. A survey was done the duration of 3-4 months and 2525 were selected .The samples were used to validated clinical instruments to compare with soldiers reporting mild traumatic brain injury. The survey reported that 124 (4.9%) samples injuries had with loss of consciousness, 260 (10.3%) reported injuries with altered mental status, and 435 (17.2%) reported other injuries during deployment. Of those reporting loss of consciousness, 43.9% met criteria for post-traumatic stress disorder (PTSD), as compared with 27.3% of those reporting altered mental status, 16.2% with other injuries, and 9.1% with no injury. The study result showed that soldiers with mild traumatic brain injury, primarily those who had loss of consciousness, were significantly more likely to report poor general health, and a high number of somatic and post concussive symptoms than the soldiers with other injuries. The study concluded that Traumatic Brain Injury strongly associated with loss of consciousness and PTSD [Putukian, Margot MD 2001].

A critical part of recovering from traumatic brain injury (TBI) is ensuring that the brain continues to send signals through the appropriate neuropathways, even after damage has occurred. As a result, many treatment programs revolve around providing the patient with different types of stimulus which increases the neurological response on various levels. Sensory stimulation is used to help develop these pathways in infants and can be used as part of a treatment program for patients with traumatic brain injury. Sensory stimulation has the ability to affect rhythmic auditing which leads to an increase in mental arousal.

The brain is then made more aware of incoming stimuli which makes it easier to recognize and process. Continued sensory stimulation through environmental noises will help prevent deprivation. This treatment options allows for consistent patient monitoring to identify how responsive the patient is to the stimulation. A study was conducted on early and consistent administration of multimodal sensory stimulation therapy (MSST) to correct restoration and improvement of brain function, as well as social reintegration. Multimodal sensory stimulation therapy (MSST), was administered during an early phase of rehabilitation to patients who have been in a coma for more than 48 hours after trauma. This study, which was carried out over a period of 2 month, focuses on 89 patients aged 16-65 years suffering from severe brain injury. To identify the significant changes in two of the patients vegetative parameters (viz. heart and respiratory frequencies), even in cases of deep coma (GCS 3-4). The result shown that most significant changes were caused by auditory, tactile and acoustic stimulation (p<0.05). Standardized behavioural assessment turned out to be particularly advisable in cases of medium coma. Here, too, a stimulation of the auditory, tactile and acoustic senses resulted mainly in head and eye movements[Jellinger.K.A 2009] A study was conducted on sensory stimulation is efficacy in treating irritability in patients with Traumatic Brain Injury. In this study were volunteers were be asked to take either sensory stimulation twice a day for 60 days. At day 60, all the volunteers will begin taking sensory stimulation twice a day for one more month. The study considered volunteers includes people between the ages of 18-65 who have had a Traumatic Brain Injury (TBI) more than 6 months ago, and who experience at least moderately irritable(12.20 ± 0.92 vs. 3.9 ± 1.56, p<0.05).The study concluded that sensory stimulation may improve the level of consciousness[ Wedekind. C 2009].

STATEMENT OF THE PROBLEM:

“A study to evaluate the effectiveness of sensory stimulation to improve the level of consciousness among Traumatic Brain Injury patients with GCS 7 -10 at thanthai perriyar government head quarters hospital, erode”.

OBJECTIVES OF THE STUDY:

1. 1.To assess the level of consciousness before and after sensory stimulation among traumatic brain injury patients with GCS 7 – 10 in both experimental and control group.

2. 2.To implement and evaluate the effectiveness of sensory stimulation to improve the level of consciousness by comparing the pre and post test scores of experimental and control group.

3. 3.To find out the association between post test score of level of consciousness with selected demographic variables among experimental and control group.

HYPOTHESES:

H1: There will be a significant difference between the pre test and post test interventional scores of level of consciousness among traumatic brain injury patient with GCS 7 – 10 in the experimental group on after administering sensory stimulation.

H2: There will be a significant association between the level of consciousness among traumatic brain injury patients with selected demographic variables such as age, gender, marital status, type of family, religion, educational status, occupational status, area of admission, duration of hospital stay and cause of TBI.

DESCRIPTION OF THE INTERVENTION:

Sensory stimulation:

It is a reaction that promotes the physiological (or) nervous activity in the body; in this study sensory stimulation includes auditory-20mts, visual-15mts, and movements-10mts by using various A.V aids.

METHODOLOGY:

Research Approach:

The research Approach selected to accomplish the objective of the study was an evaluative approach

Research Design:

The Research design of this study was quasi experimental design with pre test –post test control group design. Quasi experimental design with pre test –post test control group design was used to select the sample.

Study setting:

The study was conducted at Thanthai Perriyar Government Head Quarters Hospital, Erode. .

Population:

The Target populations of this study were traumatic brain injury patients admitted in ICU with GCS 7 - 10.

Sample:

The samples of this study were traumatic brain injury patients with CGS 7-10 admitted in erode government hospital.

Sample size:

Sample consists of a sub set of a population selected to participate in a research study. In the present study the sample consisted of 40 traumatic brain injury patients. Samples include both male and female, 20 each in experimental and 20 in control group.

Sampling Technique:

The sample for the study was selected by using non randomized sampling technique of purposive sampling method.

Criteria for sample selection:

The sample for the study was selected based on the following criteria.

Inclusion criteria:

1. Traumatic Brain Injury of patients of both sexes.

2. The patient who are having GCS score 7-10.

3. The patient who are available during the period of study.

4. The patient who are able to understand Tamil and English language.

Exclusion criteria:

1. The patients who are admitted in emergency department.

2. The patients who are having tracheostomy tube and entotracheal tube.

DESCRIPTION OF THE TOOL:

The instruments comprised of two arts

Section A:

Selected demographic variable such as age, gender, religion, marital status, type of family, educational status, occupational status, family income, reason 40 for traumatic brain injury, areas of admission, patients Glasgow coma scale and duration of hospital stay.

Section B:

A standardized Glasgow coma scale to used assess level of consciousness which included aspects like:

ASPECTS	ITEMS
Eye opening response	4
Verbal response	5
Motor response	6

Scoring Procedure:

The assessment aspects placed on a rating scale. The scale consists of 3 aspects of 15 items.

Total score is divided as:

ASPECTS	SCORE	PERCENTAGE
Poor recovery	0-6	0-40%
Average recovery	7-12	46.6-80%
Good recovery	13-15	86.6-100%

PLAN FOR DATA ANALYSIS:

The data obtained would be analyzed by both descriptive and inferential statistics, on the basis of objectives and hypothesis of the study.

· Baseline proforma of the samples were described by frequency and percentage distribution

· Frequency and percentage was used to assess the level of Consciousness among traumatic brain injury patients in experimental and control group

· Paired ‘t’ test was used for Compare the effectiveness of sensory stimulation on level of consciousness among experimental and control group,

· Chi square test was used to find out the association between level of consciousness and selected variables of patients with traumatic brain injury in experimental and control group.

RESULTS:

Section-A Major findings of the study:

In the experimental group:

· Majority of the respondents 13 (65%) were between the group 31-40 years of age.

· Majority of the respondents 12 (60%) were male.

· Majority of the respondents 11 (55%) were married.

· Majority of respondents 12(60%) were belongs to nuclear family

· Majority of the respondents 9(45%) were from Hindu religion.

· Majority of the respondents 9(45.0%) were belongs to PUC.

· Majority of the respondents 8(40%), 8(40%) and8(40%) were belongs to government, private and unemployed.

· Majority of respondents 10(50%) were have family income of Rs.8000-10,000.

· Majority of respondents 9(45%) were not having driving experience.

· Majority of respondents 7(35%) were admitted in traumatic ICU.

· Majority of the respondents 17(85%) were stay in hospital duration is 1month.

· Majority of the respondents 14(70%) were between the GCS score\ of 8-9.

Section B Frequency and Percentage Distribution to assess the level of \consciousness:

Among the Traumatic Brain Injury Patients in Experimental and control Group:

In experimental group the pre test data showed majority of respondents were 15(75%) had average recovery and 5(25%) had good recovery. In control group the pre test majority of respondents were 16(80%) had average recovery and 4(20%) had good recovery. In experimental group the post test data showed majority of respondents were 3(15%) had average recovery and 17(85%) had good recovery. In control group the post test majority of respondents were 15(75%) had average recovery and 5(25%) had good recovery. In experimental group the pre test mean level of consciousness for eye opening response score is 3.20%, verbal response score is 3.50%, motor response score is 3.80%. The combine mean level of consciousness is 10.50%. In experimental group the post test mean level of consciousness for eye opening response score is 3.75%, verbal response score is 4.35%, motor response score is 4.90%. The combine mean level of consciousness is 13.0%. In control group the pre test mean level of consciousness for eye opening response score is 3.10%, verbal response was 2.90%, motor response is 2.95%. The combine mean level of consciousness is 8.95%. In control group the post test mean level of consciousness for eye opening is 3.15%, verbal response is 3.05%, motor response is 3.0%. The combine mean level of consciousness is 9.20%

Section-C Compare the effectiveness of sensory stimulation:

Among the Traumatic Brain Injury Patients in Experimental and control Group:

In experimental group mean post-test score of level of consciousness 13.0% is higher than the mean post-test score of level of consciousness of control group 9.20%. The combined pre-test post test mean consciousness score of experimental group is 10.50% and 13.0% with enhancement of 2.50% with paired ‘t’ value of 9.36 which is significant at 0.05 level. The combined pre-test post test mean consciousness score of control group is 8.95% and 9.20% with enhancement of 0.25% with paired ‘t’ value of 1.96 which is not significant at 0.05 level. The findings shows sensory stimulation has a significant effect in improving the level of consciousness of experimental group than control group. So the researcher concluded that sensory stimulation has played a significant role in improving the level of consciousness of traumatic brain injury patients with GCS 7 – 10.

Section-D Association between level of consciousness and selected variables of patients with traumatic brain injury in experimental and control group:

There was a significant association between the post-test level of consciousness scores of experimental group and variables like age (χ2 = 6.82, p < 0.05), gender (χ2 = 7.40, p < 0.05), type of family (χ2 = 7.58, p < 0.05), areas of admission (χ2 = 11.67, p < 0.05), duration of hospital stay (χ2 = 7.50, p < 0.05). But there was no significant association with other variables like marital status, religion, educational status, occupational status, family income, reason for traumatic brain injury, and patients Glasgow coma scale. There was a significant association between the post-test level of consciousness scores of control group and variables like age (χ2 = 13.70, p < 0.05), gender (χ2 = 7.35, p < 0.05), type of family (χ2 = 7.58, p < 0.05), patients Glasgow coma scale (χ2 = 11.39, p < 0.05), duration of hospital stay (χ2 = 8.45, p < 0.05). But there was no significant association with other variables like marital status, religion, educational status, occupational status, family income, reason for traumatic brain injury and area of admission.

CONCLUSION:

The findings imply the need for sensory stimulation on effective management of traumatic brain injury patients in improving the level of consciousness.

RECOMMENDATIONS:

Keeping in view the findings of the present study the following recommendations are made. Since this study was carried out on a small sample, the results can be used only as a guide for further studies.

1. A true experimental study can be conducted.

2. The study may be repeated by taking a larger sample.

3. A similar study can be conducted on chronic conditions like coma patients.

4. A similar study can be done with multiple time series design.

5. A similar study can be done with long-term intervention of Sensory Stimulation.

6. A comparative study can be done with other Intervention and Sensory Stimulation to know about the effectiveness of the therapy.

REFERENCE:

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2. Incidence report on traumatic brain injury , May-2010, Page No:8-9.

3. Clair Bryen , incidence rate of traumatic brain injury in Karnataka, Page no:33.

4. Gururaji.G ,problems and incidence of brain injury, Page no:28-30.

5. Wilson.S.L.et.al., Sensory stimulation in prolonged coma: four single case studies, Brain injury, Vol -5, No.4, 2009, Page no: 393-400

6. Ustik.L, Sensory stimulation in prolonged coma: Brain injury, Vol -3,No.4, 2006, Page no: 355-390.

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Received on 30.07.2014 Modified on 28.08.2014

Int. J. Adv. Nur. Management 2(4): Oct. - Dec., 2014; Page 216-220