A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME ON THE KNOWLEDGE OF NURSES

REGARDING CARE OF ACUTE HEAD INJURY PATIENTS IN
SELECTED HOSPITALS OF TUMKUR

By

Mrs. RENCY SAJI

Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

In partial fulfillment of the requirements for the degree of

MASTER OF SCIENCE
IN
MEDICAL SURGICAL NURSING

Under the Guidance of

Prof. Mrs MAGESWARI.K, M.Sc. (N)

HOD, Department of Medical Surgical Nursing

Akshaya College of Nursing, Tumkur

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 ACKNOWLEDGEMENT

With profound sentiments of gratitude I would like to acknowledge the encouragement

and help received from all those who have contributed to the successful completion of my work.

First of all I solemnly thank GOD ALMIGHTY whose grace and blessings led me
throughout the study.

I wish to express my sincere thanks to our Chairman Dr K.S. Shivakumar Akshaya

educational trust, Tumkur, Karnataka, for providing all the facilities to conduct the study.

It is my pleasure to express my deep sense of gratitude to Prof: Mrs. Mageswari K, Guide,

Head of the Dept. of Medical and Surgical Nursing, Akshaya college of Nursing, Tumkur for her
endless efforts & Valuable guidance & Encouragement.

I extend my sincere and affectionate regards to Mrs. Sinu Baby, Principal, Akshaya College
of Nursing, for her sincere guidance and support.

I extend my sincere and affectionate regards to Mrs. Suma V, Lecturer, Akshaya College
of Nursing, for her sincere guidance and support.
I extend my sincere and affectionate regards to my father Mr Sajikutty for his sincere
guidance and support.
I am extremely grateful to District surgeon of Tumkur for providing permission to conduct this
study for their timely support to carry out the project.

I express my heartful gratitude to the entire expert who spread their valuable time & effort for
content validity & refining the tool.
My sincere thanks to Lecturers of Akshaya College of nursing for their constant help.
 I Express my whole hearted thanks to all my classmate and other near and dear ones for their
moral support and encouragement during the entire period of my study.

I cannot express in words how much I owe to the Nurses of District Hospital, Tumkur as for
the understanding & full Co-Operation during my study period because with out them this study
cannot be completed.

Signature of the candidate

Ms Rency Saji
 LIST OF ABBREVIATIONS USED

(In alphabetical order)

A.N.M. = Auxillary nurse midwife

ABG = Arterial blood gas

B.Sc.N = Baccalaureate of science in Nursing

BI = Brain injury

BP = Blood pressure

CDC = Centre for Disease Control

CNS = Central nervous system

CSF = Cerebrospinal fluid

CT = Computed tomography

CVP = Central venous pressure

df = Degree of freedom

ED = Emergency Department

ET = Endotracheal tube

GCS = Glasgow coma scale

GNM = General nursing and midwifery

ICP = Intra cranial pressure

ICU = Intensive care unit

LOC = Level of consciousness

MRI = Magnetic resonance imaging

n = Total number of samples

 NS = Not Significant

OPD = Out Patient Department

OT = Operation Theatre

P = Probability

P.B.B.Sc. N = Post Basic Baccalaureate of science in Nursing

PET = Positron emission tomography

PTA = Post traumatic amnesia

PTP = Structured teaching programme

r = Karl Pearson’s Coefficient of Correlation

RTI = Road traffic injuries

S = Significant

S.D. = Standard Deviation

STP = Structured teaching programme

t = Student “t” test value

TBIs = Traumatic brain injuries

χ2 = Chi-square value
 LIST OF TABLES

S.N. Tables

1 Frequency and percentage distribution of subjects by Age.

2 Frequency and percentage distribution of subjects by Gender.

3 Frequency and percentage distribution of subjects by Religion

4 Frequency and percentage distribution of subjects by Professional qualification.

5 Frequency and percentage distribution of subjects by Total Clinical Experience.

6 Frequency and percentage distribution of subjects by Area of work.

Frequency and percentage distribution of subjects by In-service training

7
programme.

Mean and standard deviation for the knowledge of nurses regarding care of
8
acute head injury patients in the pre-test.

Level of knowledge of nurses regarding care of acute head injury patients in the
9
pre-test.
Mean and standard deviation for the knowledge of nurses regarding care of
10
acute head injury patients in the post-test.
Level of Knowledge of nurses regarding care of acute head injury patients in
11
the post-test.
Pre and post- test mean knowledge score of nurses regarding care of acute head
12
injury patients.

Association between the pre-test knowledge score with selected

13
sociodemographic variables of nurses.
 LIST OF FIGURES

Figure
Title
No.
1 Conceptual framework based on transactional model on general system theory (Ludwig

von Bertalanffy)

2 Schematic representation of the study design

3 Pie diagram showing distribution of subjects by Age

4 Pie diagram showing distribution of subjects by Gender

5 Doughnut diagram showing distribution of subjects by religion

6 Column diagram showing distribution of subjects by Professional qualification

7 Cylinder diagram showing distribution of subjects by total clinical experience

8 Column diagram showing distribution of subjects by area of work

9 Column diagram showing distribution of subjects by In-service training programme

10 Distribution of mean knowledge score of subjects in the pre test

11 Distribution of level of knowledge among subjects in the pre test

12 Distribution of mean knowledge score of subjects in the post-test

13 Distribution of level of knowledge among subjects in the post test

14 Comparison of Mean pre and post- test knowledge score among nurses
 ABSTRACT

BACKGROUND OF THE STUDY

This pity aphorism graphically tells us the sad state of affairs on the roads of India.

In India, head injury is the seventh-leading cause of mortality contributing to 11% of total

deaths; 78% of cases are due to road traffic injuries alone.

Learning to recognize a serious head injury, and implementing basic first aid, can

make the difference in saving someone’s life. Medical advances in detecting and treating these

injuries, have improved the outlook for meant of these patients.

Today nursing is considered as a discipline of higher technology coupled with a

wealth of complex information. As technology is advancing at a rapid speed, nurses involved in

patient care should up-to-date their knowledge. Having knowledge only is not adequate; they

should apply this knowledge while providing care to patients to improve the health of patients

and to prevent development of complications. This will lead to reduction in morbidity and

mortality rate of victims along with development of nursing profession.

OBJECTIVES OF THE STUDY

1. To assess the pre test knowledge score of nurses in providing care to patients with

acute head injury.

2. To assess the post test knowledge score of nurses in providing care to patients with

acute head injury after Structured teaching programme.

3. To determine the effectiveness of Structured teaching programme in providing care

to patients with acute head injury using pre and post test knowledge scores.
4. To find the association between pre test knowledge score of nurses with selected

sociodemographic variables of nurses.

METHOD

A pre-experimental one group pre-test and post-test research design was selected for

the study and non probability convenient sampling technique was used to select 60 nurses. Data

was collected by administering structured knowledge questionnaire on acute care of head injury

patients, prepared by the investigator. After collecting base line data, Structured teaching

programme was given to the subjects and on 7th day post test was conducted using the same

questionnaire used for collecting the baseline data. The collected data was analyzed by using

descriptive and inferential statistics.

RESULTS

The result showed the significant difference suggesting that the PTP was effective in

increasing the knowledge of the nurses (t = 20.94). The mean post-test knowledge (X2 = 20.20)

was higher than the mean pre-test knowledge (X1 =10.80). The improvement means score for

overall knowledge was 9.4 with the ‘t’ value of 20.954 and found to be significant at the level

of p<0.01. It evidenced that developed PTP was effective in improving the knowledge of nurses

regarding care of acute head injury patients.

There was significant association between the pre-test knowledge scores and the

selected sociodemographic variables like professional qualification (χ2 = 18.464), total clinical

experience (χ2 = 22.597), and area of work (χ2 = 48.590).

INTERPRETATION AND CONCLUSION

Findings of the study showed that the knowledge of the nurses was not satisfactory (X1

=10.80) before the introduction of the Structured teaching programme. The PTP helped them to

learn more about on acute care of head injury patients. The post-test knowledge score (X2 =

20.20) showed significant increase in knowledge of nurses. The improvement means score for

overall knowledge was 9.4 with the ‘t’ value of 20.954 and found to be significant at the level

of p<0.01. Hence Structured teaching programme is an effective strategy for providing

information and improving the knowledge of subjects.

KEY WORDS

Knowledge, Effectiveness, Acute care, Head injury, Structured Teaching Programme,

Nurses.
 1. INTRODUCTION

“A Sound mind and sound body contributes to the well being of an individual’”

-Plato

Every year, millions of people sustain a head injury. Most of these injuries are minor

because the skull provides the brain with considerable protection. The symptoms of minor head

injuries usually go away on their own. More than half a million head injuries a year, however,

are severe enough to require hospitalization. Learning to recognize a serious head injury, and

implementing basic first aid, can make the difference in saving someone’s life. Common causes

of head injury include traffic accidents, falls, physical assault, and accidents at home, work,

outdoors, or while playing sports1.

Of the 1.5 million people who sustain a TBI each year, 235,000 are hospitalized and

survive. Each year, 50,000 die of TBI. Each year, 80,000 to 90,000 people experience the onset

of long-term or lifelong disability associated with a TBI (CDC, 2006).2

Brain injury is a common cause of morbidity and mortality in all age groups and

represents a major public health problem with high annual cost. The mortality rate due to brain

injury at the global level is estimated to be 97/100,000 population per year. In India, it is the

seventh-leading cause of mortality contributing to 11% of total deaths; 78% of cases are due to

road traffic injuries alone3.

 In the state of Karnataka, there were over 6,500 deaths on the roads in 2006 and nearly

50,000 injuries. Because of high levels of under reporting the true figures are likely to be much

higher, particularly for the non-fatal crashes and less serious injuries4.

Population of Bangalore is 75 lakh, with 35.6 lakh vehicles (2008-09). In 75% of every

vehicle are two-wheelers, these two-wheelers are concerned in 37.96% of the totality accidents.

Of them, 39.46% are killed and 42.26% are injured. In 2008, 892 were killed in 7,772 accidents

in average of 27 road accidents every day5.

At the global level, it is estimated that the annual incidence and mortality from Acquired

Brain Injury (ABIs) or Traumatic Brain Injuries (TBIs) is 200 and 20 per 1,00,000 per year,

respectively. National level data in India is not available for traumatic brain injuries as in many

developed countries. The only epidemiological study undertaken in Bangalore by the authors has

revealed that the incidence, mortality and case fatality rates were 150/1, 00,000, 20/1, 00,000 and

10%, respectively. At the national level, nearly two million people sustain brain injuries, 0.2

million lose their lives and nearly a million need rehabilitation services every year. Nearly

10,000 people sustain brain injury every year in the city of Bangalore with more than 1,000

deaths. The data also showed that the majority of these individuals are males, in their early years

(5 - 44 years) and often involved in road traffic injuries. The survivors of injuries had various

problems in day-to-day life affecting almost every sphere of life.6

Studies conducted by Gururaj G revealed that Traumatic Brain Injuries (TBIs) constitute

nearly 40-50% of total injuries. Road Traffic Injuries (RTI) account for 60% of TBIs and nearly

half of these are among motorcycle (including scooters and mopeds) riders and pillions. Studies

of RTIs reveal that head is the most commonly injured organ of the body among two wheeler
occupants. These studies indicate that approximately 40-50% of injured motorcyclists and 1/3rd

of killed motorcyclists had sustained an injury to the brain. Analysis of both police and hospital

data indicate that nearly 1/3rd of injured motorcyclists have a brain injury. The various types of

brain injuries commonly seen among motorcyclists are concussion 60-70%, contusion 15-30%,

hemorrhage 10-15% and skull fracture 5-10%. 7

Half of all traumatic brain injuries (TBIs) are due to motor vehicle accidents. Military

personnel are also at risk. Symptoms of a TBI may not appear until days or weeks following the

injury. Serious traumatic brain injuries need emergency treatment8.

Type of craniocerebral trauma include injuries to the skull (including fractures), injuries to

the brain (including concussion and contusion), and intracranial hemorrhage (hematomas).Brain

injury can result either from the direct effects of the trauma on brain tissue or from secondary

responses to trauma, such as cerebral edema, hematoma swelling, or increased intracranial

pressure. These more serious head injuries cause various changes that vary with the degree of

trauma2.

Recent statistics from the National Centers for Injury Prevention and Control (NCIPC,

2006) indicate 1.4 million people sustain a TBI each year in the United States. The leading

causes of TBI are falls (28%), motor vehicle accidents (20%), being struck by or against an

object (19%), and assaults (11%). Diffuse axonal injury (DAI), one of the most important causes

of cognitive dysfunction after TBI, occurs in a more widespread pattern in certain regions of the

brain than the localized zone of focal injuries. It is one of the most devastating forms of TBI and

a common cause of vegetative state and severe disability. DAI occurs in 40%-50% of all patients

who are hospitalized from TBI. 9

 Treatment and outcome depend on the injury. TBI can cause a wide range of changes

affecting thinking, sensation, language, or emotions. TBI can be associated with post-traumatic

stress disorder. People with severe injuries usually need rehabilitation8.

The nurses’ role is extremely important because the expert nurse cognitively manipulates

many variables over a continuum of care and, if such tasks are skillfully and successfully

performed, the incidence of secondary brain injury is reduced.10

NEED FOR THE STUDY

Every day when we open newspaper, there are several news about accidents or mishap

and many people get disabled or succumb to death. Traumatic brain injury is the leading cause of

long term disability among children and young adults and the number of people surviving it with

impairment has increased significantly in recent years. This has led to a call for nurses’ skill in

trauma and rehabilitation, especially in acute phase.

India is facing the triple burden of communicable diseases, non-communicable diseases

and injuries. The number of deaths, hospitalization, disabilities due to injuries has been

increasing due to sociodemographic and epidemiological transition. The unprecedented

motorization, urbanization, rapid industrialization, increasing media penetration across society,

changing lifestyles and values of people along with absence of safety policies and programmes

has added further to this Scenario. As per a recent report entitled “First India Injury Report:

Problem – Solutions”, it is estimated that during 2004 nearly 8, 50,000 persons died and 16.5

million were hospitalized due to injuries in India. Among various injuries, TBIs are a leading

cause of morbidity, mortality, disability, socioeconomic losses and poor quality of life among

survivors. It is estimated that nearly 1 million persons are injured, 200,000 people die and nearly
1 million require rehabilitation services every year in India. In the city of Bangalore alone, nearly

10,000 individuals sustain brain injury and more than 1,000 die every year.6

A retrospective study was conducted in developing countries of the world. A total of

6709 patients with head and neck injuries were reported during the study period. Majority of the

victims were non-Qataris (68.7%), men (85.9%) and in the age group 20–44 years (68.5%).

There were statistical significant differences in relation to age, nationality, gender, and accident

during weekends for head and neck injuries (p<0.001). The male to female ratio for head and

neck injury was 6.1:1. There was a disproportionately higher incidence of accidents during

weekends (27.8%). Majority of the patients had mild injury (87.2%), followed by moderate

(7.3%) and severe (5.5%). The highest frequency of head injury was among the young adults 20–

44 years (68.5%). There was a remarkable increase in the incidence rate of head and neck

injuries per 10,000 population in the year 2005 (18.2) compared to previous years and declined

slightly in the year 2006 (17.1). Overall, the incidence of head and neck injuries from road traffic

crashes are increasing11.

In one of the recent studies in patients with brain injury in India, it was observed that

severe, moderate, and mild brain injuries constituted 16%, 14%, and 70% of cases, respectively.

It is surprising that only 24.3% patients with “mild” brain injury showed good recovery, 74.3%

showed moderate recovery, and 1.4% died. As many as 10% of the patients with mild brain

injuries needed continuous and long term supportive care. A disturbing fact is that the productive

20–29 year old age group is the most commonly affected3.

Road traffic deaths and injuries are continuously increasing in all states and union

territories of India. More than 100,000 persons are killed and around 500,000 are injured every
year in India. An estimated 7000 persons died and 51,000 persons sustained serious injuries

during 2004 in Karnataka. Bangalore city witnessed about 900 deaths and injuries among 10,000

persons during the year 2004. Among those killed and injured, nearly 40% occurred among

motorcycle riders and pillions, with more than a third due to traumatic brain injuries. For the

affected families, it is a time of intense agony and suffering along with huge socio-economic

burden. Human brain is the single most important organ in our body responsible for all our

activities. Injury to this part can lead to instantaneous death or various types of damage and

disabilities. The quality of life among injured is often poor and affects them for the rest of their

lives12.

A patient's recovery from a brain injury (BI) is unpredictable and requires flexible

nursing strategies for each stage of recovery. Empirical knowledge provides a framework for

delivering nursing care based on scientific principles. Aesthetic knowledge, including intuition,

provides a further opportunity to know and understand BI patients and their responses as they

progress along the trajectory of recovery. Incorporating both empirical and aesthetic knowledge

into the nursing plan of care for this population affords on opportunity for nurses to help patients

and their families negotiate the course of recovery with greater success13.

A study reported that qualified nurses are lacking in India, they have been replaced with

unqualified nurses in most of the clinical situations, and these unqualified nurses are being taught

by the Doctors who run the clinics14.

Nurses may lack knowledge, confidence and time in providing acute care to patients with

head injury. Nurses in ICU were extremely busy, and lack time for patient care, and for in-

service education. Also there is fast turnover of nurses due to global demand; therefore the
quality of nurses in ICU is poor. This could lead to poor quality of care to the patients. Therefore

assessment of the nurses’ knowledge, skill is essential before recruiting them to the ICU and

other clinical areas like OPD, Casualty, OT, General ward etc.

Very few studies were done on acute care of head Injury patients. A detailed review of

literature and the investigator’s clinical experience in intensive care unit, prompted her to

undertake a study of this nature.

 2. OBJECTIVES

This chapter deals with the statement of the problem, objectives, assumptions,

operational definitions, hypotheses and conceptual frame work. Reviews of literature,

discussion with experts and colleagues and the personal experience of the investigator

gave a foundation for selecting the problem statement.

STATEMENT OF THE PROBLEM:

“ A study to assess the effectiveness of structured teaching programme on the

knowledge of nurses regarding care of acute head injury patients in selected hospitals of

Tumkur.”

OBJECTIVES:

1. To assess the pre test knowledge score of nurses in providing care to patients with

acute head injury.

2. To assess the post test knowledge score of nurses in providing care to patients

with acute head injury after structured teaching programme.

3. To determine the effectiveness of structured teaching programme in providing

care to patients with acute head injury using pre and post test knowledge scores.

4. To find the association between pre test knowledge score of nurses with selected

sociodemographic variables of nurses.

ASSUMPTION:

The study assumes that:

1. The nurses will have some knowledge on care of acute head injury patients.

1
 2. Nurses can gain knowledge from structured teaching programme.

3. Education can bring positive changes in the health care practices of the nurses.

OPERATIONAL DEFINITIONS:

1. Acute Care: In this study, acute care means the care that is given immediately

after head injury within 48 to 72 hours thus prevent secondary complications.

2. Knowledge: In this study, knowledge refers to the right response given by nurses

to the questionnaire on acute care of head injury patients.

3. Effectiveness: In this study, effectiveness refers the extent to which the structured

teaching program has achieved the desired effect in terms of gain in knowledge

score.

4. Structured teaching programme: In this study, structured teaching programme

refers to systematically organized teaching strategy of 60 minutes duration on

care of acute head injury patients.

5. Head injury: Head injury means any traumatic damage to the head resulting from

blunt or penetrating trauma of the scalp, skull or brain. In this study the patient is

one who is diagnosed to have with acute head injury and is acutely ill.

6. Nurses: In this study, Nurses refers to individuals who are qualified as a

registered nurses working in selected hospitals of tumkur.

HYPOTHESES

H1: The mean post test knowledge scores of the nurses will be significantly higher than

the mean pre test knowledge scores.

2
H2: There will be a significant association between pre test knowledge score of nurses

with selected sociodemographic variables.

CONCEPTUAL FRAMEWORK

Concepts are building blocks of theory. Concepts are words or terms that

symbolize aspect of reality. The conceptual framework is related to objectives because

the problem leads directly to the objectives. Conceptual framework is a theoretical

approach to the study of problem that is scientifically based and emphasizes the selection,

arrangement and classification of its concepts. A conceptual framework helps to explain

the relationship between concepts, selected from several theories, from previous research

results or from the researchers own experience. 15

Conceptualization refers to the process of developing and refining abstract. A

conceptual model provides for logical thinking, for systematic observation and

interpreting the observed data. The model also gives direction for relevant questions on

phenomena and point out solution to practical problems. 15 To describe the relationship of

concepts in this, general theory by „Ludwig Von Bertalanffy‟ has been utilized.

General system theory serves as a model for viewing people as interacting with

the environment. A system consists of set of interacting components within a boundary

that filters the type and rate of exchange with the environment. A system consists of both

structural and functional components. A structure refers to the arrangement of the facts at

a given time. Function is the process of continuous change in the system as matter;

energy and information are exchanged with the environment.

3
 All living systems are open in that there is continual exchange of matter, energy

and information with the environment from which the system have varying degrees of

interaction with the system receive input and gives back output in the form of matter,

energy and information. The universe consists of hierarchy of systems (supra system,

system and subsystem), and each system may be viewed as having one or more

suprasystems and subsystem.16

The system uses the input, through self regulation to maintain the system‟s

equilibrium or homeostasis. Some types of input are used immediately in their original

state, where as others require complex transformation (process) for use. Matter, energy

and information are continuously processed through the system and released as output.

After processing input, the system returns output (matter, energy and information) to the

environment in an altered state, affecting the environment.

The feedback information of environment response to the system‟s output is used

by the system in adjustment, correction and accommodation to interaction with the

environment. Feedback may be positive negative or neutral.

Through dynamic interaction with the environment, the system exchanges

information in different forms such as verbal and nonverbal communication,

visualization, taste, smell and touch.

The present study aims at determining the effectiveness of structured teaching

programme of nurses regarding care of acute head patients. The frame of present study is

based on system model.

4
 This model consists of three phases: input, process and output.

1. Input: It refers to the learner or target group with their characteristics, level of

knowledge and competence, learning needs and interest.

In this study input includes, nurses and their variables like age in years, gender,

religion, education, experience, area of work and exposure to in-service education.

2. Process: It refers to the different operational procedures in the overall programme

implementation and includes the factors that facilitate or block the implementation of

various stages of programme development.

In the present study, process refers to the assessment of knowledge of nurses on

care of acute head injury patients by administering structured knowledge questionnaires,

development of structured teaching programme on care of acute head injury patients, its

administration and taking pre-test and post- test scores.

3. Output: It refers to the ultimate results that are expected following the programme

implementation. Change is a feature of the process that is observable and measurable as

output, which should be different from that which is entered into the system input.

In this study, the output measures the gain in knowledge by comparing the mean

post test scores with mean pretest scores.

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INPUT PROCESS OUTPUT

• Nurses: • Assessment of Gain in the

 Age in years knowledge on care of Knowledge
 Gender acute head injury
 Religion
patients by pre-test
 Education
 Experience • Development and
 Area of work validation of STP No gain in the
 Exposure to • Administration of STP Knowledge
inservice • Evaluation of STP by
education post-test

• Existing knowledge
of Nurses AREA NOT UNDER STUDY

FEEDBACK 6
 3. REVIEW OF LITERATURE

The review of literature is defined as a broad, comprehensive in-depth, systematic and

critical review of scholarly publications, unpublished scholarly print materials, audiovisual

materials and personal communications. It refers to an extensive, exhaustive and systematic

examination of publications relevant to the research project.17

Review of literature for the study has been organized under following heading.

Section I: Literature related to general information about head injury.

Section II: Literature related to studies on knowledge of nurses regarding care of acute head

injury patients.

Section III: Literature related to effect of planned teaching on the knowledge of nurses

regarding care of acute head injury patients.

Section I: Literature related to general information about head injury.

A study was conducted on Coup and contrecoup head injuries: Predictors of outcome at

NIMHANS. A retrospective study of 298 patients with head injuries who presented to

NIMHANS was carried out. There is evidence that Coup and contrecoup contusions comprise a

group of focal brain injuries. The pathogenesis of the two are different, the outcome in the two

would therefore be expected to be different. However there are no studies in literature comparing

outcome in coup-contrecoup injuries. At NIMHANS, Bangalore, two hundred and ninety eight

consecutive cases presenting with coup and contrecoup injuries over a 2-year period were

retrospectively analyzed. They were divided into three groups: Coup injuries with

intraparenchymal injury (n = 129), contrecoup injuries (n = 84) and coup-contrecoup injuries (n

= 85). The groups were comparable with respect to age and GCS. Site of primary impact was

determined by clinical and CT scans criteria. The mortality rates in each group were compared

with respect to age, GCS and CT pattern. Significance was calculated using the chi square test.

There was a statistically significant difference in mortality between patients with coup injuries

and patients with contrecoup (p< 0.005) and coup-contrecoup injuries (p<0.001). There was no

significant difference in mortality between contrecoup and coup-contrecoup injuries (p = 0.1).

Mortality in patients aged less that 60 years and patients with GCS > 8 was significantly higher

in patients with contrecoup and coup-contrecoup injuries. Presence of a contrecoup component

on CT scan may portend a worse outcome in head injuries and may warrant closer monitoring

and more aggressive management of these patients.18

A study conducted on Epidemiology of Traumatic Brain Injuries: Indian Scenario, in

2002 revealed that among those injured, 59% of TBIs were due to road traffic injury, followed

by falls (25.0%) and assaults (10.3%). Hit by or fall off an external object, work-related injuries

and sports injuries accounted for 2.5%, 0.1%, and 0.2%, respectively. This observation indicates

that road traffic injuries are the leading cause of TBIs in Bangalore. Some of the earlier Indian

studies have shown similar distribution in various parts of the country. Analysis of information

on place of injury occurrence revealed that 72% of TBIs had occurred on roads, 20% at homes,

3% in agricultural lands, 2% in construction places (due to fall or fall off objects), 1% in play

areas and 0.6% in industrial work places.19

The Centers for Disease Control and Prevention (CDC) and the National Center for Injury

Prevention and Control (NCIPC) conducted a separate study considered the immediate medical

effects of TBI‟s caused by a sudden jolt to the head or a penetrating head injury. The agencies

concluded that: 1.4 million Americans experienced a traumatic brain injury. Out of those: 1.1
million were treated and released from in local emergency rooms, 235,000 were hospitalized,

and 50,000 died from their injuries. A TBI can result in lifelong physical, cognitive, emotional

and behavior problems. Other symptoms can include fatigue, confusion, headaches, sleep

disorder, memory problems, nausea, and/or mood swings. Typically, victims notice symptoms of

TBI very soon after the accident or injury, but some symptoms can take up to a few weeks after

the event to appear.20

An article on Traumatic brain injury and increased intracranial pressure, in the year 2010

cited that Traumatic brain injury (TBI) affects approximately 1.4 million individuals and has a

mortality rate greater than 30% in the first 72 hours after injury. The patient with TBI can present

a significant challenge for the perianesthesia nurse in the acute care setting. Increased

intracranial pressure is a common consequence of TBI and the rapid assessment and

management can affect the long term outcome of the patient with TBI. New monitoring

modalities have been developed to monitor cerebral blood flow and nutritional supply to

neurologic tissues. A case scenario will be used to identify priorities for the perianesthesia nurse

caring for this challenging patient.21

In an article, „Traumatic brain injury outcome: concepts for emergency care stated that

injury to the brain is the leading factor in mortality and morbidity from traumatic injury. The

devastating personal, social, and financial consequences of traumatic brain injury (TBI) are

compounded by the fact that most people with TBI are young and previously healthy. From the

emergency physician's standpoint, patients with severe TBI are those with a presenting Glasgow

Coma Scale score of less than 9. Over the past 30 years, mortality from severe traumatic brain

injury for those patients who survive to the hospital has been reduced by half from nearly 50% to

approximately 25%. Because most of the pathologic processes that determine outcome are fully
active during the first hours after TBI, the decisions of emergency care providers may be crucial.

This review addresses new concepts and information in the pathophysiology of TBI and

secondary brain injury and demonstrates how emergency management may be linked to

neurologic outcome.22

Section II: Literature related to studies on the knowledge of nurses regarding care of acute

head injury patients.

A contemporary nursing literature emphasizes the desirability of clinical nurses being

“knowledgeable”. However, the need for nurses constantly to acquire more knowledge is

reiterated. Lack of knowledge is seen to underlie an array of professional problems. Little is

known of how nurses themselves understand what it means to practice knowledgeably. The

findings contest the notion, espoused in nursing literature, that acquisition of knowledge can

“empower” nurses, thus providing the solution to problems they may experience. Rather,

strategies are required that challenge and disrupt relations of power that construct nurses as

“ignorant”23.

A study quoted that, staff members who care for the polytrauma population needs diverse

educational programs even if they have many years of experience working in the brain-injury

rehabilitation field24.

A study was conducted to assess and evaluate registered nurses‟ baseline knowledge of

the three behavioral responses that make up the assessment tool; to review the recording of

Glasgow Coma Scale in neuroscience areas compared with non-specialist units; and to ascertain

when the Glasgow Coma Scale is taught during nurse training and the background experience of

the lecturers who teach it. In this study, several areas for improvement were identified; including
the use and application of painful stimulus. The use of sternal rubbing and nail bed compression

continues to be common practice. Data collected also suggested a lack of knowledge of the path

physiology underpinning the three components that make up the scale. Problems were evident in

the record keeping, with very few examples of documentation within nursing records of the

separate components of the Glasgow Coma Scale. Finally, the questionnaires returned from the

universities revealed that students were introduced to the assessment tool during the first year of

training, normally by lecturers with a critical care or accident and emergency clinical

background25.

A study was conducted on effect of planned teaching on the knowledge of nurses

regarding care of head injury patients, and found that, 71% of the staff nurses had knowledge

score in the range of 10-23, and 18% in the range of 24-30, (overall knowledge score range of

30), which indicates that nurses had less knowledge in providing nursing care to patient with

head injury26.

A study on Nursing Interventions for Critically Ill Traumatic Brain Injury Patients‟ in the

year 2010, quoted that Neuroscience intensive care unit (ICU) nurses deliver a number of

interventions when caring for critically ill traumatic brain injury (TBI) patients. Yet, there is little

research evidence documenting specific nursing interventions performed. As part of a larger

study investigating ICU nurse judgments about secondary brain injury, ICU nurses were asked to

identify interventions routinely performed when caring for TBI patients. Quantitative and

qualitative analyses indicate that all nurses routinely monitored hemodynamic parameters such

as oxygen saturation, blood pressure, and temperature. Nurses were responsible for monitoring

intracranial pressure and cerebral perfusion pressure approximately 50% of the time. Qualitative

analyses revealed that additional nursing interventions could be categorized as

neurophysiological interventions, psychosocial interventions, injury prevention interventions,

and interventions to maintain a therapeutic milieu. Findings from this study provide evidence of

the multifaceted role of the neuroscience ICU nurse caring for TBI patients and can be used in

future research investigating the impact of nursing interventions on patient outcomes.27

In an article, „The pupillary response in traumatic brain injury quoted that traumatic brain

injuries (TBIs) affect more than 1.4 million Americans annually. Trauma nurses caring for these

patients routinely perform serial neurologic assessments, including pupillary examinations.

While trauma nurses are likely familiar with basic components of the pupillary examination,

some confusion about more specific aspects of the examination and the physiologic basis of the

pupillary response may still remain, particularly as it pertains to patients with TBI. The purpose

of this article was to identify the key components of a pupillary examination and its associated

physiologic response. A case study is provided to illustrate the application of this information

among patients with TBI.28

In an article, Care of the critically ill patient with penetrating head injury stated that

patients who have penetrating head injury all too often present with some of the most devastating

and challenging intracranial injuries. The mechanisms of injury and associated neuropathology

affect every body system and require a multidisciplinary approach. Evidence-based guidelines

have been developed to offer some direction to clinicians involved in their care. Much remains

scientifically unsubstantiated, however. Optimal management of critically ill patients who have

penetrating head injury requires clinical expertise and care of the highest quality.29

Section III: Literature related to effect of planned teaching on the knowledge of nurses

regarding care of acute head injury patients.

 In a study conducted on effect of planned teaching on the knowledge of nurses regarding

care of head injury patients, it was found that in the pre - teaching phase 71 % of the sample had

knowledge score in the range of 10 - 23 and 18% in the range of 24 - 30.The knowledge score of

the sample showed marked improvement in the post teaching phase. The score of 98.3 % ranges

between 24 - 30. This indicates that planned teaching is effective in improving the knowledge of

the nurses26.

A study on effect of planned teaching on the knowledge and practices of nurses in

providing oral care to patients on mechanical ventilators found that planned teaching was

effective in improving the knowledge of the nurses. The study showed that the knowledge of

nurses from different hospitals may differ but planned teaching can have a positive effect on the

knowledge of nurses from all hospitals30.

A study was conducted on effect of planned teaching programme on knowledge, attitude

and knowledge on practice of acute respiratory infections among mothers revealed that, there

was a gross inadequacy (100%) of knowledge regarding acute respiratory infection among

mothers. The pre test mean in experimental group was 18.2 and post test mean was 65.56 in

experimental group. Planned teaching programme was found to be effective in improving the

knowledge, attitude and knowledge on practice of mothers regarding acute respiratory infection

as shown by post-test scores of experimental group31.

A study was conducted with the aim to evaluate effectiveness of structured teaching

programme on knowledge and practice regarding management of thrombolytic therapy among

staff nurses working in selected hospital Bangalore among 40 samples selected by purposive

sampling technique. The findings suggested that mean post test knowledge score 69.19 was
higher than mean pre test knowledge score 34.05 with the„t‟ value of 26.05 and found to be

significant at the level of p<0.001. The author concluded that structured teaching programme

was effective method of providing information on knowledge and practice regarding

management of thrombolytic therapy.32

A study was conducted to assess intensive care nurses' knowledge of pressure ulcers and

the impact of an educational program on knowledge levels. A knowledge assessment test was

developed. A cohort of registered nurses in a tertiary referral hospital in New Zealand had

knowledge assessed 3 times: before an educational program, within 2 weeks after the program,

and 20 weeks later. Multivariate analysis was performed to determine if attributes such as length

of time since qualifying or level of intensive care unit experience were associated with test

scores. The content and results of the assessment test were evaluated. Completion of the

educational program resulted in improved levels of knowledge. Mean scores on the assessment

test were 84% at baseline and 89% following the educational program. The mean baseline score

did not differ significantly from the mean 20-week follow-up score of 85%. No association was

detected between demographic data and test scores. Content validity and standard setting were

verified by using a variety of methods. The author concluded that levels of knowledge to prevent

and manage pressure ulcers were good initially and improved with an educational program.33

A study was conducted to investigate effectiveness of a training program for emergency

department nurses in managing violent situations in 2004. In particular, their knowledge, skills

and attitudes relating to management of workplace violence were examined. Results show that a

training program has many positive outcomes which enhance nurses' ability to manage

aggressive behaviours. With some basic training, ED nurses can be more prepared to manage

violent and potentially violent situations, and by doing so may in fact reduce the incidence of
aggression in their workplace by 50%. This has largely been achieved by raising the awareness

of ED nurses to the nature of the problem, developing their knowledge and skills in managing

aggressive behaviour, and improving their attitudes toward potentially violent patients.34

A descriptive evaluatory study to assess the effectiveness of planned teaching programme

on alcoholism for students of selected degree colleges in Mangalore. By sing multipurpose

stratified random technique 102 college students were selected as samples and their knowledge

was tested by structured knowledge questionnaire. Results showed that the difference in

knowledge score was statistically significant at 0.001 level (t (101) = 41.12, p≤ 0.001). 35

A study was conducted to evaluate the effectiveness of a PTP on knowledge and practices

of breast self examination among school teachers. The study was conducted in selected schools

of Kerala. A convenience sample of 50 school teachers was selected for the study. A Structured

knowledge questionnaire was used to elicit the knowledge and practice regarding breast self

examination. A quasi experimental approach was used with one group pretest post test design.

The result showed that the mean post test score significantly higher than the mean pretest score (t

(49) =28.3; p<0.05). This shows their effectiveness of STP in increasing the knowledge of school

teachers regarding breast self examination. 36

A study was conducted to assess the effectiveness of structured teaching programme on

knowledge of adolescent adjustment problems among school teachers at selected schools at

Mangalore consisted of 30 school teachers selected by convenient sampling method. An

evaluatory approach with one group pretest post test design was used in this study. The result

showed that the significant gain in knowledge scores (t (29) = 18.70). The mean posttest

knowledge score(X2 = 23. 6) was higher than the mean pretest knowledge scores (X1 = 13.2).
This study concluded that the planned teaching programme was an effective teaching strategy in

improving the knowledge of the subjects. 37

This chapter dealt with the review of research and non-research literature related to the

present study. The review has enables the researcher to establish the need for the study, develop

conceptual work, adopt the research design, develop the tool and teaching programme, select a

data collecting technique and to decide upon plan of statistical analysis.

 4. RESEARCH METHODOLOGY

Research methodology refers to investigations of the ways of obtaining,

organizing and analyzing data, methodologic studies address the development, validation

and evaluation of research tools or methods. 38

This chapter deals with the methodology adopted for the present study such as

research approach, research design, variables, setting, population, and sample, sampling

technique, sampling criteria, development of tool, content validity, reliability, pilot study,

and method of data collection, and plan for data analysis. The present study is aimed to

assess the effectiveness of Structured Teaching Programme on the knowledge of nurses

regarding care of acute head injury patients in selected hospitals, Tumkur.

RESEARCH APPROACH

Research approach is an umbrella that covers the basic procedure for conducting

research.39 An evaluative research approach was considered to be the most appropriate

and adopted to assess the effectiveness of structured Teaching Programme on the

knowledge of nurses regarding care of acute head injury patients.

RESEARCH DESIGN

The research design is a blue print for conducting the study that maximizes

control over factor that could interfere with the validity of findings.40 The research design

selected for this study was pre-experimental, i.e. one group pre-test post-test design

because this study was intended to ascertain the gain in knowledge by the nurses who

were subjected to structured teaching program. Thus only one group is observed twice,
i.e., before and after introducing the independent variable. The effect of the treatment

would be equal to the level of the phenomenon after the treatment minus the level of the

phenomenon before treatment. This can be represented as:

Pre – experimental one group pre-test – post-test design

GROUP PRE TEST INTERVENTION POST TEST

I O1 X O2

The study design selected was pre-experimental one group pretest post test design

(O1 X O2). Here the investigator introduced a base measure before and after a structured

exposure, which is depicted as O1 and O2 respectively. In the present study the

knowledge is measured by structured knowledge questionnaire on care of acute head

injury patients. The intervention given in the study was structured teaching programme,

which is depicted as X. The schematic representation of the study was given in figure 2.
 Figure 2: SCHEMATIC RESEARCH DESIGN

Target population
60Nurses

Accessible population
Nurses working in district hospital tumkur
Convenient
Sampling

Demographic
Variables Pretest
1. Age
2. Gender
Structured
3. Religion Structured Teaching Programme Knowledge
4. Education Questionnaire
5. Clinical experience
6. Area of work
7. Exposure to Posttest
in-service education

Data Analysis and Interpretation

Descriptive and Inferential Statistics

Criterion Measure
Findings
Knowledge Scores

Dissertation Report
VARIABLES UNDER STUDY

A variable is any quality of a person, group, or situation that varies or takes on different

values.41

Dependent variable

It is the outcome variable of interest; the variable that is hypothesized to depend on or be

caused by the independent variable.41 It is also called the effect, the response, the criterion

measure; behavior or outcome that is researcher wishes to predict, study, explain.

In the present study, it refers to the knowledge of nurses on care of acute head injury

patients.

Independent variable

It is the variable that is believed to cause or influence the dependent variable; in

experimental research, the manipulated (treatment) variable.41

In this study it refers to the structured teaching programme which has brought about

change in the knowledge of nurses.

Extraneous variable

It is a variable that may influence the results of a study as it intervenes the operations of

the phenomenon being studied.42

In this study, it refers to the selected variables such as age, gender, religion, qualification,

years of experience, area of work, exposure to in-service education etc.

SETTING OF THE STUDY

 The setting is the physical location and condition in which data collection take place in a

study.41 Based on the geographical proximity, feasibility and familiarity with the setting, the

investigator selected District hospital, Tumkur to carry out the present study.

POPULATION

The term population refers to the group of individuals or objects that meet the common

criteria of research’s interest.42

In the present study, the population is nurses working in selected hospitals of Tumkur.

SAMPLE

A sample is a subset of a population selected to participate in a research study.41 Here the

study sample comprised of 60 nurses working at District Hospital, Tumkur.

SAMPLING TECHNIQUE

Sampling technique is a process of selecting a portion of the population to represent the

entire population.38

In this study non probability convenient sampling technique was used for selecting the

samples.

SAMPLING CRITERIA

Inclusion criteria

The inclusion criteria for sampling were

1. Nurses who are G. N. M. or B. Sc. Nursing.

2. Nurses who are willing to participate in the study.

3. Nurses who are available during data collection.

Exclusion criteria

1. Nurses who are only A. N. M.

2. Nurses who had already undergone in-service education on care of acute head

injury patients.

DEVELOPMENT OF THE INSTRUMENT

After an extensive review of literature, discussion with the guide and the various experts

in the field of nursing and based on the investigator’s personal experience the self administered

Structured Knowledge Questionnaire on care of acute head injury patients is developed. The first

draft of the tool consisted of 40 items, based on pre-test, i.e. item analysis (Discriminative index

0.3% and Difficulty index 75%) some of the items are modified (3,4,12,21,26,33,38,39) in a

simplified way and ten items are removed (2,5,6.10,11,13,15,19,23,24) thus the second draft of

the tool of 30 items are prepared.

Description of the tool

Structured knowledge questionnaire consists of 2 parts i.e. Part I and part II

Part I: Consists of items on demographic variables like, age, gender, religion, professional

qualification, total clinical experience, area of work and exposure to in-service education.

Part II: Consists of 30 knowledge items related to care of acute head injury patients, which

include Anatomy and physiology of brain (4) items, general information about head injury (6)

items, and Nursing management (acute care) (20) items.

SCORING KEY

Scoring key is prepared for Part-I by coding the demographic variables. For Part-II score ‘1’ and

‘0’ are awarded to correct and wrong response respectively. Thus the maximum score is 30.
To interpret the level of knowledge, the scores subjected as follows:

Inadequate <50%, Moderate 50- 75%, Adequate > 75%

DEVELOPMENT OF STRUCTURED TEACHING PROGRAMME (STP)

The structured teaching programme was developed for nurses working at selected

hospitals at Tumkur . It was prepared based on review of literature, non-research literature,

discussion with experts and personal experience of the investigator. The steps involved in the

development of STP were:

• Assessing learning needs from study population for which the investigator collected relevant

information on the knowledge level of nurses regarding care of acute head injury patients.

• Review of literature on the topic.

• Preparation of the blue print.

• Consultation with experts in the field.

• A set of related teaching aids.

• Development of criteria checklist and content validity.

• Preparation of final draft of STP.

Preparation of the first draft of STP

The STP was developed according to the objectives prepared. The investigator prepared

the overall of STP and LCD as AV aids. The developed STP was given to the experts to establish

content validity. Experts were asked to give their opinion and suggestions about the content of

STP. They were given the criteria checklist and asked to place a tick mark against very relevant,

relevant, needs modification, not relevant and remarks if any. There was 100% agreement of the

content of STP. The final draft was prepared.

Description of STP

The content area of the structured teaching programme was divided into Anatomy and

physiology, Definition, Classification, Etiology and risk factors, Mechanism and

pathophysiology, Clinical manifestations, and Nursing management (Acute care). Based on the

suggestions of the experts, after validity of the findings and pretest the final draft was prepared.

CONTENT VALIDITY

Validity refers to whether a measurement instrument accurately measures what it is

supposed to measure. When an instrument is valid, it truly reflects the concept, it is supposed to

measure. Content validity refers to the adequacy of the sampling of the domain being studied.17

The developed structured knowledge questionnaire and STP on care of acute head injury

patients were given to 11 experts from the field of nursing along with criteria rating scale for

establishing the validity. Based on their suggestions and recommendations the structured

knowledge questionnaire and structured teaching Programme were modified (such as

simplification of some of the items). Thus final draft of the tool consisted 30 knowledge items.

RELIABILITY

Reliability of research instrument is defined as the extent to which the instrument yields

the results on repeated measures. It is concerned with consistency, accuracy, precision, stability,

equivalence, and homogeneity.17

In order to establish reliability of the tool, the technique called Split Half method was

used and reliability co-efficient was calculated by using raw score formula. The calculated ‘r’

value is 0.83 and the developed tool was found to be highly reliable.
PILOT STUDY

Pilot study is the smaller version of a proposed study conducted to develop and refine the

methodology, such as the treatment, instruments, or data collection process to be used in the

larger study.43

After obtaining formal permission from the Hospital authority, Tumkur, pilot study was

conducted among 10 subjects selected by non probability convenient sampling technique. The

investigator given self introduction explained the purpose of the study, subject’s willingness to

participate in the study was ascertained. The subjects are assured anonymity and confidentiality

of the information provided by them and written informed consent was obtained. The pre-test

was conducted by administering the Structured Knowledge Questionnaire followed by Structured

Teaching Programme on care of acute head injury patients. On the 7th day post-test was

conducted by using the same tool.

METHOD OF DATA COLLECTION

After obtaining the formal permission from the district surgeon of district hospital Tumkur,

main study was conducted for a period of 4weeks, among 60 subjects; the subjects are selected by

non probability convenient sampling technique. The investigator given self introduction explained

the purpose of the study, subjects’ willingness to participate in the study was ascertained. The

subjects are assured anonymity and confidentiality of the information provided by them and

written informed consent was obtained. The pre-test was conducted by administering the

Structured Knowledge Questionnaire followed by STP on care of acute head injury patients. On

the 7th day post-test was conducted by using the same tool. Each subject took 45 minutes to

complete the knowledge questionnaire.

PLAN FOR DATA ANALYSIS

Descriptive and Inferential statistics will be used to find out the for analysis of data and the

significant of difference between the pre and post test knowledge scores, chi-square test to

determine the association between the pre-test knowledge score with selected variables of nurses.

SUMMARY

This chapter dealt with the description of research approach, research design, variables,

setting, population, sample and sampling technique, development and description of the tool,

validity and reliability of tool, pilot study, procedure for data collection and the plan for data

analysis.
 5. RESULTS

This chapter deals with analysis and interpretation of data collected to determine the

effects of structured teaching programme about knowledge of nurses regarding care of acute

head injury patients.

Analysis is a process of organizing and synthesizing data in such a way that research

questions can be answered and hypotheses can be tested.41

Interpretation is the process of making sense of the results and examining the
41
implications of the within a broader context. Interpreting the research findings require the

investigator to be creative.

The data was collected from 60 nurses before and after the administration of STP. The

collected information was organized, tabulated analyzed and interpreted by using descriptive and

inferential statistics.

The data has been analyzed and interpreted in the light of the objectives and hypotheses of

the study.

OBJECTIVES OF THE STUDY

1. To assess the pre test knowledge score of nurses in providing care to patients with acute

head injury.

2. To assess the post test knowledge score of nurses in providing care to patients with acute

head injury after structured teaching programme.

 3. To determine the effectiveness of structured teaching programme in providing care to

patients with acute head injury using pre and post test knowledge scores.

4. To find the association between pre test knowledge score of nurses with selected

sociodemographic variables of nurses.

The collected data were analyzed, organized and presented under the following sections:

Section I: Sociodemographic profile of nurses.

Section II: Knowledge of nurses regarding care of head injury patients in the pre and post-test.

Section III: Comparison of pre and post test knowledge of nurses regarding care of head injury

patients.

Section IV: Association between the pre test knowledge score with selected demographic

variables of nurses.
SECTION I: SOCIODEMOGRAPHIC PROFILE OF NURSES

Table - 1: Frequency and percentage distribution of subjects by Age

n=60

Age Frequency Percentage

a)21-30 yrs
43 71.67%
b)31-40 yrs
15 25%
c) 41-5o yrs.

2 3.33%

The above table depicts that majority of the subjects 43(71.67%) were between age group

of 21-30 years and only 2(3.33%) were belong to age group of 41-50 years.

Fig. 3: Pie diagram showing distribution of subjects by Age

Table- 2: Frequency and percentage distribution of subjects by Gender

n=60

Gender Frequency Percentage

a) Male 20 33.33%

b) Female
40 66.67%

The above table depicts that majority of the subjects 40(66.67%) were females and only

20(33.33%) subjects were male.

Fig. 4: Pie diagram showing distribution of subjects by Gender

Table- 3: Frequency and percentage distribution of subjects by Religion

n=60

Religion Frequency Percentage

46 76.67%
a) Hindu

b) Christian 14 23.33%

The above table depicts that majority of the subjects 46(76.67%) were Hindus and only

14(23.33%) subjects were Christians.

Figure 5: Doughnut diagram showing distribution of subjects by religion

Table- 4: Frequency and percentage distribution of subjects by Professional

qualification.

n=60

Professional Qualification Frequency Percentage

a) GNM 49 81.67%

b) B.Sc.Nursing
11 18.33%

From the above table it is evident that majority of the subjects undergone GNM

49(81.67%) and only 11(18.33%) subjects were graduated in B.Sc. nursing.

Figure 6: Column diagram showing distribution of subjects by Professional qualification

Table-5: Frequency and percentage distribution of subjects by Total Clinical Experience

n=60

Total Clinical
Frequency Percentage
Experience

a) Less than 1 yr 24 40%

b) 1-2yrs
11 18%
c) 2-3yrs
6 10%
d) 3-4yrs

e) 4-5yrs 3 5%

f) More than 5 yrs

6 10%

10 17%

The above table depicts that majority of the subjects 24(40%) had overall experience

below 1year, 10(17%) had more than 5 years experience and only 3(5%) subjects had 3-4 years

of experience.
 Figure 7: Cylinder diagram showing distribution of subjects by total clinical experience

Table- 6: Frequency and percentage distribution of subjects by Area of work.

n=60
 Area of work Frequency Percentage

a) ICU 6 10%

b) General ward 21 35%

c) OPD 13 21.67%

d) Casualty 8 13.33%

5 8.33%
e) Neuro ICU
7 11.67%
f) OT

The above table depicts that majority of the subjects 21(35%), working in general ward

and only 5(8.33%) subjects working in Neuro ICU.

Fig. 8: Column diagram showing distribution of subjects by area of work
Table- 7: Frequency and percentage distribution of subjects by In-service training

programme

n=60

In-service training Frequency Percentage

programme

a) Yes 0 _

b) No
60 100

The above table depicts none of the subjects 60(100%) were undergone any training

programme regarding care of acute head injury patients.

Fig. 9: Column diagram showing distribution of subjects by In-service training programme

SECTION II: KNOWLEDGE OF NURSES REGARDING CARE OF ACUTE HEAD

INJURY PATIENTS IN THE PRE AND POST- TEST.

Table-8: Mean, Standard Deviation and Standard Error Mean for the knowledge of nurses

regarding care of acute head injury patients in the pre-test.

n=60

S.N. Knowledge Maximum Mean S.D. Std.

variables Error
score
Mean

1 Anatomy
and
physiology 4 1.883 0.825 0.106
of Brain

2 General
information
6 2.350 0.988 0.127
about Head
injury

3 Acute care
of Head
injury 20 6.566 3.131 0.4 04
patients

4
Overall
30 10.800 3.785 0.488
Knowledge

The above table shows that the maximum mean knowledge score obtained by the subjects

was 6.566 with standard deviation of 3.131 in the aspect of acute care of head injury patients

where as minimum mean knowledge score obtained by the subjects was 1.883 with standard

deviation of 0.825 in the area of anatomy and physiology of brain. The overall knowledge score

obtained by subjects was 10.800 with standard deviation 3.785. (Fig-10)

Fig. 10: Distribution of mean knowledge score of subjects in the pre test
Table-9: Level of knowledge of nurses regarding care of acute head injury patients in the

Pre-test

n=60

S. Knowledge variables < 50% 50-75% >75%

N.
F % F % F %

1. Anatomy and
20 33.4 38 63.3 2 3.3
physiology of Brain

2. General information
37 61.7 23 38.3 _ _
about Head injury

3. Acute care of Head

47 78.4 13 21.6 _ _
injury patients

Overall Knowledge 47 78.4 13 21.6 _ _

The above table depicts that majority of the subjects 47(78.4%) had inadequate

knowledge regarding Acute care of head injury patients, 38(63.3%) subjects were having

moderate knowledge in concept of Anatomy and physiology of Brain and none of them had

adequate knowledge about General information regarding Head injury and Acute care of Head

injury patients. The overall knowledge level shows that majority of subjects 47(78.4%) had

inadequate knowledge and only 13(21.6%) subjects had moderate knowledge regarding Acute

care of Head injury patients. (Fig11)

Fig.11: Distribution of level of knowledge among subjects in the pre test
Table -10: Mean, Standard Deviation and Standard Error Mean for the knowledge of

nurses regarding care of acute head injury patients in the post-test.

n=60

Maximum Std. Error

S.
Knowledge variables Mean S.D.
N. score Mean

1 Anatomy and physiology of Brain 4 3.383 0.584 0.075

General information about Head

2 6 5.183 0.676 0.087
injury

Acute care of Head injury

3 20 11.633 3.030 0.391
patients

Overall Knowledge 30 20.200 3.090 0.399

The above table shows that maximum mean knowledge score obtained by the subjects

was 11.63 with the standard deviation of 3.03 in the aspect of acute care of head injury patients

where as minimum mean knowledge score obtained by the subjects was 3.38 with standard

deviation of 0.58 in the area of anatomy and physiology of brain. The overall mean knowledge

score obtained by subjects was 20.20 with standard deviation 3.09. (Fig-12)
Fig.12: Distribution of mean knowledge score of subjects in the post-test
Table-11: Level of Knowledge of nurses regarding care of acute head injury patients in the

Post test.

n=60

S.N. <50% 50-75% >75%

Knowledge Variables
F % F % F %

Anatomy and physiology of

_ _ 34 56.67 26 43.33
1. Brain

General information about

_ _ 9 15 51 85
2. Head injury

Acute care of Head injury

17 28.33 31 51.67 12 20
3. patients

Overall Knowledge _ _ 45 75 15 25

The above table depicts that the maximum number of subjects 34(56.67%) had moderate

knowledge regarding Anatomy and physiology of Brain where as 12(20%) subjects had adequate

knowledge in the concept of Acute care of Head injury patients.

Fig13: Distribution of level of knowledge among subjects in the post test
SECTION III: COMPARISON OF PRE AND POST TEST KNOWLEDGE OF NURSES

REGARDING CARE OF ACUTE HEAD INJURY PATIENTS.

Table-12: Pre and post- test mean knowledge score of nurses regarding care of acute head

injury patients.

n=60

S. Knowledge variable Post Test Pre Test Paired ‘t’ Inference

N.
Mean Mean Value

1. Anatomy and physiology of

3.383 1.883 11.821 S*
Brain

2. General information about

5.183 2.350 18.143 S*
Head injury

3. Acute care of Head injury

11.633 6.566 12.477 S*
patients

Overall Knowledge 20.200 10.800 20.954 S*

S*=Significant, df= 59, P<0.01 at level of significance.

From the above table it is evident that there was a significant improvement in all aspects

of knowledge of the subjects. The comparison of overall mean knowledge score (9.4) revealed

that there was a significant improvement in the post test knowledge. It is evidenced that

developed STP was effective in improving the knowledge of subjects regarding care of acute

head injury patients.

Fig14: Comparison of Mean pre and post- test knowledge score of subjects
SECTION IV: ASSOCIATION BETWEEN KNOWLEDGE SCORE WITH SELECTED

SOCIODEMOGRAPHIC VARIABLES OF NURSES.

Table-13: Association between the pretest knowledge score with selected socio-

demographic variables of nurses.

Median Value = 15 n=60

S. N. Demographic Total Score

df χ2 value
Variables <Median >Median

1 Age

a) 21 – 30 38 5
2 6.443
b) 31 – 40 9 6

c) 41 – 50 2 0

2 Gender

a. Male 17 3 1 0.223

b. Female 32 8

3 Religion

a) Hindu 44 2 1 27.754**

b) Christian 5 9

4 Professional Qualification

c) GNM 45 4
1 18.464**
d) B.B.Sc.Nursing 4 7
 5 Total clinical experience

g) Less than 1 yr 24 0

h) 1-2yrs 11 0

i) 2-3yrs 3 3 5 22.597**

j) 3-4yrs 2 1

k) 4-5yrs 2 4

l) More than 5 yrs 7 3

6. Area of work

a) ICU 1 5

b) General ward 21 0

c) OPD 13 0 5 48.590**

d) Casualty 7 1

e) Neuro ICU 0 5

f) OT 7 0

7 In-service training

programme
_ _
c) Yes _ _

d) No 49 11

** P<0.01

The above table shows that, there is a highly significant (P<0.01) association between the

knowledge of the nurses regarding care of acute head injury patients and selected

sociodemographic variables like religion, professional qualification, total clinical experience and

area of work.
 6. DISCUSSION

This chapter discusses the major findings of the study and reviews them in relation to

findings from the results of other studies.

The aim of this study was to develop and implement a structured structured teaching

programme to improve the knowledge of nurses on care of acute head injury patients. The

effectiveness of the structured teaching programme was evaluated by assessing the knowledge of

nurses before and after the structured teaching programme.

The findings of the study are discussed under following headings.

Section I: Sociodemographic variable of the nurses.

Section II: Knowledge level of nurses regarding care of acute head injury patients in the pre and

post test.

Section III: Effectiveness of structured teaching programme regarding knowledge on care of

acute head injury patients.

Section IV: Association between the pre-test knowledge score with selected sociodemographic

variables of nurses.

SECTION I: SOCIODEMOGRAPHIC VARIABLE OF NURSES

Age in years

The distribution of the subjects by age revealed that majority of the subjects 43(71.67%)

was between age group of 21-30 years. This was evident from similar findings of Ahamed
Kabeer Thayyil (2010) who reports that the majority of subjects 30(50%) belongs to the age

group of 21-25 years. 44

Gender

As per the findings of the study, majority of the subjects 40(66.67%) were females and

only 20(33.33%) of the samples were male, it might be due to the nature of the profession where

more females selecting nursing as their carrier. The above findings are consistent with the study

findings of Ahamed Kabeer Thayyil (2010) in which most of the subjects 44(73.3%) were

female and 16(26.7%) were male. A study was conducted to find out the “effectiveness of

structured teaching programme on knowledge on safe methods of administration of oral

medication in children below three year among staff nurses in selected hospitals at Bangaluru.44

Religion

The distributions of the subjects by religion revealed that majority of the subjects

46(76.67%) were Hindus and only 14(23.33%) were Christians. The above findings are

consistent with the study findings of Mamatha G.C (2010) in which most of the subjects

35(70%) were Hindus and only 15(30%) were male. A study was conducted to find out the

effectiveness of structured teaching programme on knowledge and attitude of nurses regarding

ethical issues in patient care at selected hospitals in Bangalore. 45

Professional Qualification

In relation to professional qualification most of the subjects were GNM. The findings of

the present study were consistent with the study findings of Sandhya (2004) who found that

majority of subjects (78%) were qualified in GNM .46

Total clinical experience

Pertaining to distribution of total clinical experience most of the subjects 24(40%) had

overall experience below 1year. These findings are consistent with the study findings of Sniley

Varghese (2009) in which the majority of the subjects 14 (34%) had 1-3yrs experience. The

study was conducted to evaluate the effectiveness of structured teaching programme on

knowledge and practice of staff nurses regarding IV cannulation at selected hospitals.47

Area of work

In relation to area of experience majority of the subject’s 21(35%), area of work is

general ward which is consistent with the findings of Meena chacko (2008) who had 48% of the

subjects experienced in general ward. 32

SECTION II: KNOWLEDGE LEVEL OF NURSES REGARDING CARE OF ACUTE

HEAD INJURY PATIENTS IN THE PRE AND POST TEST

The present study reveals that overall mean knowledge score obtained by the subjects

was 10.80 with standard deviation 3.78 in the pre-test and the overall knowledge score obtained

was 20.20 with standard deviation 3.08 in the post-test.

The findings of the present study were consistent with the study of Mrs. Shameer

Selvaraj (2005) who assessed effectiveness of structured teaching on the knowledge of nurses

regarding care of acute head injury patients and found that the pre-test mean knowledge score

was 16.10 and post test mean knowledge score 27.65.26

The findings of the present study were consistent with the study findings of Ndosi,

Mwidimi E (2009) who assessed effectiveness structured teaching program on Nurses'

knowledge of pharmacology behind drugs they commonly administer and found that the pre-test

mean knowledge score was 42 % and post test mean knowledge score 78%.48

The study findings of Jaslin (2005) was similar to the present study findings who

assessed effectiveness of self instructional module on selected drugs used in critical care units

and found that the mean knowledge score was 33 % in the pretest and mean knowledge score

was 73% in the post test49.

SECTION III: EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME

REGARDING KNOWLEDGE ON CARE OF ACUTE HEAD INJURY PATIENTS.

The present study reveals that overall mean knowledge score obtained by the subjects

was 10.80 with standard deviation 3.78 in the pre-test and the overall knowledge score obtained

was 20.20 with standard deviation 3.08 in the post-test. The improvement means score for

overall knowledge was 9.4 with the ‘t’ value of 20.954 and found to be significant at the level of

p<0.01. It evidenced that developed STP was effective in improving the knowledge of nurses

regarding care of acute head injury patients.

These findings were consistent with the study findings of Dane FC (2000) who found that

ACLS-trained nurse were four times more likely to survive the patients with higher discharge

rates than discovered by a nurse without ACLS training.50

These findings were consistent with the study findings of Meena chacko (2007) which

revealed that the teaching programme was effective in increasing the knowledge of nurses on

thrombolytic therapy as the computed‘t’ value was significant at 0.05 level.32

The findings were consistent with the study findings of Mrs. Shameer Selvaraj (2005)

who assessed effectiveness of structured teaching on the knowledge of nurses regarding care of
acute head injury patients and found that the knowledge score of the sample shows marked

improvement in the post- teaching phase. The score of 98.3% ranges between 24 -30 (maximum

score 30). This indicates that structured teaching is effective in improving the knowledge of the

nurses. The study also showed that the knowledge of nurses from different hospitals may differ

but structured teaching can have a positive effect on the knowledge of nurses from all hospitals.26

The above findings indicate that structured teaching programme was effective in

increasing the knowledge of the subject. Hence the research hypotheses stated that there will be

significant difference between the pre test and post test knowledge score was accepted.

SECTION IV: ASSOCIATION BETWEEN PRE-TEST KNOWLEDGE SCORE WITH

SELECTED SOCIODEMOGRAPHIC VARIABLES OF NURSES

It was evident that there was no statistically significant association between the

knowledge score with sociodemographic variables like age and gender but there is statistically

significant association between the knowledge score with sociodemographic variables like

religion, professional qualification, clinical experience and area of work, at the level of p<0.01.

Hence the research hypotheses stated that there will be significant association between the

knowledge score with selected sociodemographic variable of nurses was accepted.

The above findings were consistent with the study findings of Manisha Kadam (2005)

who conducted a study to assess the knowledge and effectiveness of structured teaching program

on breast cancer and breast self examination among working women.

The findings on relationship between knowledge regarding Breast cancer and Breast self-

examination and selected variables of the working women shows that there is no association

between age, marital status, occupation and income but there is a significant association between
knowledge and education. It is interpreted that there is a significant association between

knowledge and certain selected variables.

SUMMARY

This chapter dealt with the findings of the present study in accordance with the objectives

and with appropriate supportive findings.

 7. CONCLUSION

This chapter deals with the conclusions drawn based on the findings of the study. The

conclusions drawn were:

1. The present study revealed that majority of subjects 47(78.4%) had inadequate knowledge

and only 13(21.6%) subjects had moderate knowledge regarding Acute care of Head injury

patients. The overall mean knowledge score obtained by subjects was 10.800 with standard

deviation 3.785.

2. Post-test findings showed that, maximum mean knowledge score obtained by the subjects

was 11.63 with the standard deviation of 3.03 in the aspect of acute care of head injury

patients. The overall mean knowledge score obtained by subjects was 20.20 with standard

deviation 3.09.

3. Hence the above findings indicated that Planned Teaching Programme was effective in

increasing the knowledge of the subjects regarding Acute care of Head injury patients, and it

was found to be appropriate, effective and can motivate the nurses to enhance their

knowledge.

4. The findings were influenced by selected sociodemographic variables.

NURSING IMPLICATIONS

The study has implication in the area of nursing practice, nursing education, nursing

administration and nursing research.

Nursing Practice

Nurses should have knowledge and skill in care of acute head injury patients as it is

important in saving the life of the patients. Making this aspect of care more efficient, thorough
knowledge regarding prompt and continuous neurological assessment, maintaining airway and

breathing pattern, ensuring proper oxygen supply, maintaining adequate cerebral blood flow,

controlling raised ICP, managing other injuries and prevention of seizures is necessary. The

findings of the study evident that nurses should periodically update their knowledge. Teaching

programme can be conducted for nursing students, and nursing professionals, as it would allow

both experienced and inexperienced nurses to enhance their knowledge.

There is a need for efforts by all nurses to increase the knowledge and awareness

regarding acute care of head injury patients, and to disseminate information through planned and

incidental teaching. Findings of the study can be used to prepare standardized protocol on care of

acute head injury patients to improve the cognitive affective and psychomotor domains of all

nurses working in hospital to impart the comprehensive nursing care. This can be done in

collaboration with the nurse administrators by planning and conducting in-service education

periodically in priority areas.

Nursing Education

Education is the base for knowledge. The present health care delivery system is emphasis

more on preventive rather than the curative aspect. The study also implies that health personnel

have to be properly trained on how to improve their education in healthcare. Nursing curriculum

should be such that it prepares the prospective nursing students to assist the client and

community in aspects of health care. The nursing personnel should be given in-service education

to upgrade their knowledge and should also be trained to prepare and conduct PTP regarding this

topic by using various methods of educational technology.

The curriculum may be responsible for imparting knowledge among nurses in acute care

but nurse educators have the additional responsibility to update their knowledge. The existing
nursing curriculum on care of acute head injury patients should be strengthened where as the

students will be enhanced with the knowledge on care of acute head injury patients. PTP can be

used in education programme where classroom attendance is minimal i.e. distance education

programmes.

Nursing Administration

Staff development programme in any organization is the prime responsibility of the nurse

administrator. The availability of such staff development programme in nursing profession is

inadequate at present. Administration plays a major role in regulating and coordinating the laws.

Institutions rendering services to the clients should review their policies and practices. Nursing

administrator should co-ordinate and conduct various educational programme in order to

improve and update nurses’ knowledge on care of acute head injury patients.

In collaboration with education department, there should be necessary health education

materials and administrative support provided to conduct health programmes. Cost effective

production of health education should be provided to develop health teaching materials and make

them accessible to all staff in the hospital as well as community.

Nursing administration must awaken to the fact that the public education is a necessity

and should provide resources in terms o manpower, money and materials.

Nursing Research

Nurses need to be vigilant when giving care to the patient. The scope of interventions for

a wide variety of disease conditions and the research basis for practices are continuing to expand

in a phenomenal rate. Nurses need to be actively engaged in all phases of the research process, to

address ongoing questions of interest to continually improve client care. There is a need for
extensive and intensive research in this area so that strategies for educating nurses on the

continuous neurological assessment, maintaining airway and breathing pattern, ensuring proper

oxygen supply, maintaining adequate cerebral blood flow, controlling raised ICP, managing

other injuries and prevention of seizures and other secondary complications. The nurse

researcher should conduct the research on care of acute head injury patients which provides more

scientific data and adds more scientific body of information and nursing care.

LIMITATIONS

The present study has the following limitations:

1. The study is limited to nurses working in the selected hospitals.

2. Getting adequate sample takes time because of work schedule.

RECOMMENDATIONS

1. Similar study can be replicated on a large sample to generalize the findings.

2. An experimental study can be done with a control group.

3. A comparative study can be conducted between the government and private hospital

nurses.

4. A similar study can be done by assessing attitude and practice.

SUMMARY

The chapter dealt with implications for nursing practice, nursing education, nursing

administration and nursing research based on the study, it clarifies the limitations of the study

and recommendations for future research.

 8. SUMMARY

The present study is undertaken to evaluate the effectiveness of Structured Teaching

Programme on the knowledge of Nurses regarding care of Acute Head injury patients, in selected

hospitals of Bangalore.

The study aimed at accomplishing the following objectives.

OBJECTIVES OF THE STUDY

1. To assess the pre test knowledge score of nurses in providing care to patients with acute

head injury.

2. To assess the post test knowledge score of nurses in providing care to patients with acute

head injury after structured teaching programme.

3. To determine the effectiveness of structured teaching programme in providing care to

patients with acute head injury using pre and post test knowledge scores.

4. To find the association between pre test knowledge score of nurses with selected

sociodemographic variables of nurses.

RESEARCH HYPOTHESES

The study attempted to examine the following hypotheses.

H1: The mean post test knowledge scores of the nurses will be significantly higher than the

mean pre-test knowledge scores.

H2: There will be a significant association between pretest knowledge score of nurses with

selected sociodemographic variables.

METHODOLOGY

The conceptual framework was based on general system theory (Ludwig von

Bertalanffy).The study is based on evaluative approach; one group pre-test post-test design was

used for the collection of the data. The independent variable refers to Structured Teaching

Programme on Care of acute head injury patients and the dependent variable refers to knowledge

of nurses regarding Care of acute head injury patients.

Structured Knowledge Questionnaire on Care of acute head injury patients was

developed to collect data. The tool consisted two parts: Part I and part II.

Part I: Consisted items on demographic variables like, age, gender, religion, professional

qualification, clinical experience, area of work and exposure to in service education on care of

acute head injury patients.

Part II: Consisted 30 knowledge items related to Care of acute head injury patients.

After obtaining formal permission from the Managing Director of Kavitha Hospital,

Bangalore, pilot study was conducted from 15-9-2010 to 22-09-2010 among 10 subjects selected

by non probability convenient sampling technique to find out feasibility of study. The main study

was conducted at Sree Venkateshwara Hospital, Jnanajyothinagar, Bangalore and Unity Lifeline

Hospital, Nagarabhavi 2nd Stage, Bangalore, from 1-10-2010 to 31-10-2010 among 60 subjects.

The subjects were selected by non probability convenient sampling technique and the collected

data was analyzed and interpreted using descriptive and inferential statistics.
FINDINGS OF THE STUDY

Findings related to sociodemographic variables

Majority of the subjects 43(71.67%) were between age group of 21-30 years and majority

of the subjects 40(66.67%) were females. In relation to religion majority of the subjects were

46(76.67%) were Hindus. In relation to professional qualification majority of the subjects were

GNM 49 (81.67%). Pertaining to total clinical experience majority of the subjects 24(40%) had

experience below 1 year. In relation to area of work majority of the subjects 21(35%) were

working in general ward. In relation to exposure to in service training education all of the

subjects 60(100%) were not undergone any training programme.

Findings related to pre and post test Knowledge regarding Care of acute head injury

patients.

The overall mean knowledge score obtained by the subjects was 10.800 with standard

deviation 3.785 in the pre-test and the overall mean knowledge score obtained was 20.20 with

standard deviation 3.09 in the post-test.

Findings related to effectiveness of Structured Teaching Programme

The mean pre test knowledge score of 10.800 was increased to 20.20 after STP. The

obtained ‘t’ value 18.143 for knowledge is greater than table value and found to be significant at

the level of p<0.01. Hence research hypotheses stated that the mean post test knowledge scores

of the nurses will be significantly higher than the mean pre-test knowledge scores was accepted.

Findings related to association between pretest knowledge score with selected demographic

variables
 Findings revealed that there was statistically no significant association between the

knowledge score with demographic variables like age and gender but there was statistically

significant association between the knowledge score with socio- demographic variables like

religion, professional qualification, clinical experience and area of work at the level of p<0.01.

Hence the research hypotheses stated that there will be significant association between the

pretest knowledge score with selected demographic variables was accepted.

SUMMARY

This chapter briefs the objectives of the study, research hypotheses, methodology and

major findings.
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 LETTER SEEKING CONSENT OF THE SUBJECTS TO PARTICIPATE

IN RESEARCH STUDY

Dear participant,

I am a post graduate nursing student at Akshaya College of Nursing, Tumkur. As

a partial fulfillment of my M.Sc. Nursing course, I am interested in conducting a study to
“ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON
THE KNOWLEDGE OF NURSES REGARDING CARE OF ACUTE HEAD INJURY
PATIENTS IN SELECTED HOSPITALS OF TUMKUR,” which helps in providing
comprehensive care to the patients and thereby improving the standard of our nursing profession.
Your kind cooperation will always be appreciated with deep gratitude.

I request you to answer the given questionnaire with the most appropriate
responses. Kindly do not leave any question unattended. The information given by you will be
kept confidential and used only for the study purpose. Kindly sign the consent form given
below.

Thanking you,

Yours faithfully

Ms Rency Saji

CONSENT FORM

I------------------------------------------------------------ hereby give my consent for participation in

above mentioned study.

Place: Signature of the participant

Date:
 ANNEXURE 6a

STRUCTURED KNOWLEDGE QUESTIONNAIRE

PART I: DEMOGRAPHIC DATA

Instructions to Participants: I request you to go through each item carefully and give your

response by making a right [√] against the correct response.

DETAILS OF THE PARTICIPANT:

Participant No:

1) Age in years:
a) 21 – 30 [ ]
b) 31 – 40 [ ]
c) 41 – 50 [ ]
d) 51 and above [ ]
2) Gender:
a) Male [ ]
b) Female [ ]
3) Religion:
a) Hindu [ ]
b) Muslim [ ]
c) Christian [ ]
d) Other [ ]
4) Professional qualification:
a) GNM [ ]
b) B.B.Sc.Nursing [ ]
c) P.B.B.Sc. Nursing [ ]
d) Any other (Specify) _______________________ [ ]
 5) Total clinical experience :
a) Less than 1 year [ ]
b) 1 – 2 years [ ]
c) 2 – 3 years [ ]
d) 3 – 4 years [ ]
e) 4 – 5 years [ ]
f) More than 5 years [ ]
6) Area of work
a) ICU [ ]
b) General ward [ ]
c) OPD [ ]
d) Casualty [ ]
e) Neuro ICU [ ]
f) Any other Specify______________ [ ]
7) Exposure to in service education:
a) Yes [ ]
b) No [ ]
 ANNEXURE 6b

PART II: STRUCTURED KNOWLEDGE QUESTIONNAIRE ON ACUTE

CARE OF HEAD INJURY PATIENTS

A) ANATOMY AND PHYSIOLOGY OF THE BRAIN:

1) The largest part of the brain is;

a) Diencephalons [ ]
b) Brainstem [ ]
c) cerebrum [ ]
d) cerebellum [ ]
2) The outermost layer covers the brain is;
a) pia mater [ ]
b) arachnoid mater [ ]
c) dura mater [ ]
d) gray mater [ ]
3) The amount of blood receives by the brain per minute is about;
a) 250ml [ ]
b) 500ml [ ]
c) 750ml [ ]
d) 1000ml [ ]
4) The lobe, devoted to all aspects of visual perception is;
a) frontal lobe [ ]
b) parietal lobe [ ]
c) temporal lobe [ ]
d) occipital lobe [ ]

B) GENERAL INFORMATION ABOUT HEAD INJURY

5) The leading cause of head injury in young people is;

a) Fall [ ]
b) motor vehicle accident [ ]
 c) assault [ ]
d) sport injury [ ]
6) Group at the highest risk for Traumatic Brain Injury (TBI) is the male person
between the age group of;
a) 10 to 14 [ ]
b) 15 to 24 [ ]
c) 25 to 34 [ ]
d) 35 to 44 [ ]
7) The peak occurrence of head injury is during;
a) morning and afternoon [ ]
b) afternoon and evening [ ]
c) evening and night [ ]
d) night and morning [ ]
8) The normal ICP is;
a) 0 to 10 mmHg [ ]
b) 5 to 15 mmHg [ ]
c) 0 to 20 mmHg [ ]
d) 15 to 20 mmHg [ ]
9) The most common, accounting for 80% of all skull fractures are;
a) linear fractures [ ]
b) comminuted fractures [ ]
c) depressed fractures [ ]
d) basilar fractures [ ]
10) CSF escapes from the ears (CSF Otorrhea) and the nose (CSF Rhinorrhea) is
indicative of;
a) basilar skull fractures [ ]
b) linear skull fractures [ ]
c) depressed skull fractures [ ]
d) comminuted fractures [ ]
B) NURSING MANAGEMENT (ACUTE CARE) OF HEAD INJURY PATIENTS:

11) Physician documented a presence of Battle’s sign in a client with basilar skull
fracture. Which of the following would the nurse expect to note in the client;
a) ecchymosis (bruising) behind the ear [ ]
b) edematous periorbital area [ ]
c) bruised periorbital area [ ]
d) presence of epistaxis [ ]
12) The common complication of contusions of the brain, leading to increased ICP,
hypoxia and further brain damage is;
a) hydrocephalus [ ]
b) cerebral edema [ ]
c) meningitis [ ]
d) post traumatic epilepsy [ ]
13) The Glasgow coma scale score ranges between;
a) 0-13 [ ]
a) 3-15 [ ]
b) 5-16 [ ]
c) 7-18 [ ]
14) A Glasgow Coma Scale (GCS) score of 8 or less is the indication of;
a) mild head injury [ ]
b) moderate head injury [ ]
c) severe head injury [ ]
d) coma [ ]
15) A nurse is assessing a client with a brain stem injury. In addition to performing the
Glasgow Coma Scale, the nurse plans to;
a) check cranial nerve functioning and respiratory rate and rhythm [ ]
b) perform arterial blood gases [ ]
c) assist with a lumber puncture [ ]
d) perform a pulmonary wedge pressure [ ]
16) A client is being brought into the emergency department after suffering a head
injury. The first action by the nurse is to determine the client’s;
a) respiratory rate and depth [ ]
b) pulse and blood pressure [ ]
c) level of consciousness [ ]
d) ability to move extremities [ ]
17) Patency of air way is indicated by;
a) equal bilateral chest movement [ ]
b) normal air entry on auscultation [ ]
c) oxygen saturation above 95 % [ ]
d) all the above [ ]
18) The head injury patient with airway obstruction requires;
a) turning of head on one side [ ]
b) oxygen inhalation [ ]
c) deep breathing [ ]
d) immediate endotracheal intubation [ ]
19) A nurse evaluates the arterial blood gas (ABG) results of a head injury patient who
is receiving supplemental oxygen. Which finding would indicate that the oxygen level
was adequate;
a) PaO2 of 80 mmHg [ ]
b) PaO2 of 60 mmHg [ ]
c) PaO2 of 50 mmHg [ ]
d) PaO2 of 45 mmHg [ ]
20) A nurse is determining the need for suctioning in a head injury client with an
endotracheal tube attached to a mechanical ventilator. Which observation by
the nurse indicates this need?
a) low peak inspiratory pressure on the ventilator [ ]
b) visible mucus bubbling in the ET tube [ ]
c) apical pulse rate of 72 beats/min [ ]
d) clear breath sounds [ ]
21) Head injury patients are usually kept sedated and relaxed to allow;
a) decrease in intra cranial pressure quickly [ ]
b) effective mechanical ventilation [ ]
c) to provide intensive nursing care [ ]
d) to monitor patient promptly [ ]
22) Head injury patient have leaking from the ear. Immediately the nurse should
plan to;
a) irrigate the ear canal gently [ ]
b) test the drainage for glucose [ ]
c) test the drainage for pH [ ]
d) notify the physician [ ]
23) The first thing to do when a head injury patient develop generalized
convulsion;
a) monitor vital signs [ ]
b) administer oxygen [ ]
c) protect the client from harm [ ]
d) administer parenteral diazepam [ ]
24) A newly admitted head injury patient has difficulty in breathing and at the
same time he is bleeding profusely from the scalp, the first action should be;
a) administer oxygen [ ]
b) propped up position [ ]
c) arrest the bleeding [ ]
d) check the vital signs [ ]
25) The major post-operative complication to be monitored by the nurse following
craniotomy is;
a) increased ICP [ ]
b) motor weakness [ ]
c) visual changes [ ]
d) wound infection [ ]
26) A nurse is caring for a client admitted to the hospital after sustaining head
injury. To prevent increased ICP the nurse appropriately positions the client;
a) with the head elevated on a pillow [ ]
b) in left Sims’ position [ ]
c) in reverse Trendelenburg [ ]
d) with the head of the bed elevated 30 to 45 degrees [ ]
27) While performing endotracheal suction in a head injury patient, the nurse
should observe for the following complication;
a) hypertension [ ]
b) cardiac irregularities [ ]
c) a reddish colouration of face [ ]
d) a pulse oxymetry level of 95% [ ]
28) The nurse performs following activities to prevent convulsion;
a) administer anticonvulsant drugs round a clock [ ]
b) maintain environmental control [ ]
c) provide safe environment and thus prevent injury [ ]
d) all of above [ ]
29) To prevent complications of prolonged bed rest, position of head injury
patient should be changed every;
a) 2 hourly [ ]
b) 4 hourly [ ]
c) 8 hourly [ ]
d) Hourly [ ]
30) A nurse is caring for a client who sustained a head injury from a fall. The
nurse avoids which of the following in the care of this client?
a) keeping the client in a sitting up position [ ]
b) forcing fluids [ ]
c) keeping the client awake as much as possible [ ]
d) performing neurological assessment [ ]
 ANNEXURE 8

BLUE PRINT OF STRUCTURED KNOWLEDGE QUESTIONNAIRE ON

CARE OF ACUTE HEAD INJURY PATIENTS

DOMAINS OF OBJECTIVES
S.N. CONTENT TOTAL
Knowledge Comprehension Application Analysis %

1 Anatomy & 1,2,3,4

physiology 13.33%
of Brain
2 General 5,6,7,8,9 10
information
about head 20%
injury

3 Acute care of 12,13 14,17,19, 20 15,16,18,21,22, 11,25,27

head injury 23,24,26,28,29,
66.67%
patients 30

4 TOTAL 11 5 11 3 100%
(36.67%) (16.66%) (36.67%) (10%)
 ANNEXURE 10

ANSWER KEY OF STRUCTURED KNOWLEDGE QUESTIONNAIRE ON

CARE OF ACUTE HEAD INJURY PATIENTS

Question No. Correct Answer Question No. Correct Answer

1. c 16. a

2. c 17. d

3. c 18. d

4. d 19. a

5. b 20. b

6. b 21. a

7. c 22. b

8. b 23. d

9. a 24. c

10. a 25. a

11. a 26. d

12. b 27. b

13. b 28. d

14. c 29. a

15. a 30. b
Scanned by CamScanner
Scanned by CamScanner
 ANNEXURE -I

LETTER SEEKING PERMISSION TO CONDUCT RESEARCH STUDY

107
 Annexure-II

LETTER REQUESTING OPINION AND SUGGESTIONS OF

EXPERTS FOR ESTABLISHING CONTENT VALIDITY OF
RESEARCH TOOL

From,
Ms Rency Saji
2nd year M.Sc.Nursing
Akshaya College of Nursing
Tumkur.

To,

Respected Sir/Madam,

Subject: - Request for opinion and suggestions of experts for establishing content
validity of the research tool.

I am a post graduate student of Medical Surgical Nursing of the Akshaya

College of Nursing, Tumkur. I have selected the below mentioned topic for research
project to be submitted to Rajiv Gandhi University of Health Sciences as a partial
fulfillment of Master of Science in Nursing (Medical-Surgical Nursing).

Topic: “A study to assess the effectiveness of Structured teaching programme on the

knowledge of nurses regarding care of acute head injury patients in selected
hospitals of Tumkur.”
Herewith I have enclosed,
1. Objectives of the study
2. Structured questionnaire
3. Criteria checklist
4. Blue print
5. Lesson plan

108
 With regard to this, I kindly request you to validate my tool for its
appropriateness and relevancy. I would be highly obliged for your kindness in
validating my tool.

Thanking You,

Yours Faithfully

Ms Rency Saji

Date:

Place: Tumkur

109
 ANNEXURE III

CRITERIA RATING SCALE FOR VALIDATING THE TOOL

Instruction: Please review the items in the tool and give your valuable suggestions

regarding accuracy, relevance and appropriateness of the content. Kindly place a tick

mark () in the appropriate column. If there are any suggestions or comments please

mention in the remarks column.

PART- I: DEMOGRAPHIC DATA

ITEM VERY RELEVANT NEEDS NOT REMARKS

NO RELEVANT MODIFICATION RELEVANT

1
2
3
4
5
6
7

PART-II STRUCTURED KNOWLEDGE QUESTIONNAIRE

ITEM VERY RELEVANT NEEDS NOT REMARKS

NO RELEVANT MODIFICATION RELEVANT

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
110
 16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

SIGNATURE OF VALIDATOR

SUGGESTIONS____________________________ NAME:

__________________________________________ DESIGNATION:

111
 ANNEXURE IV

EVALUATION CRITERIA CHECKLIST FOR VALIDATING THE

STP ON CARE OF ACUTE HEAD INJURY

Instruction: Please review the items in the tool and give your valuable suggestions

regarding accuracy, relevance and appropriateness of the content. Kindly place a tick

mark () in the appropriate column. If there are any suggestions or comments please

mention in the remarks column.

S. N. Content Very relevant Needs Not remarks

relevant modification relevant

1 Objectives:
1. General objectives.
2. Specific objectives.
3. Nurses oriented.
4. Realistic to achieve the
outcome.
5. Specific measures of the
outcome.
2 Selection of content:
1. Adequate to achieve
the objectives.
2. According to the
nurses’ cognitive level.
3. Aims to improve the
knowledge of the nurses.
4. Continuity of the content.
3 Organization of content:
1. Arranged in logical
sequence
2. Integration of the content

112
4 Language
1. Simple to comprehend.
2. Clear to perceive the
meaning of the content.
5 Practicability and feasibility
1. Content motivates the
participants.
2. Content improves the
knowledge of staff nurses.
3. Content presented in
interesting manner.
4. Content is structured and
adheres to provide
adequate information.

SIGNATURE OF VALIDATOR

SUGGESTIONS____________________________ NAME:

113
 ANNEXURE V

CONTENT VALIDATION CERTIFICATE

I hereby certify that I have validated the tool of Ms Rency Saji, IInd year M. Sc.

Nursing student of Akshaya College of Nursing, Tumkur; who is undertaking the

following study:

TOPIC: “A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME ON THE KNOWLEDGE OF NURSES

REGARDING CARE OF ACUTE HEAD INJURY PATIENTS IN SELECTED

HOSPITALS OF TUMKUR.”

Signature of the Expert

Designation and address

Place:

Date:

114
 ANNEXURE VI

LETTER SEEKING CONSENT OF THE SUBJECTS TO

PARTICIPATE IN RESEARCH STUDY

Dear participant,

I am a post graduate nursing student at Akshaya College of Nursing,

Tumkur. As a partial fulfillment of my M.Sc. Nursing course, I am interested in
conducting a study to “ASSESS THE EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME ON THE KNOWLEDGE OF NURSES
REGARDING CARE OF ACUTE HEAD INJURY PATIENTS IN SELECTED
HOSPITALS OF TUMKUR,” which helps in providing comprehensive care to the
patients and thereby improving the standard of our nursing profession. Your kind
cooperation will always be appreciated with deep gratitude.

I request you to answer the given questionnaire with the most

appropriate responses. Kindly do not leave any question unattended. The information
given by you will be kept confidential and used only for the study purpose. Kindly sign
the consent form given below.

Thanking you,

Yours faithfully

Ms Rency Saji

CONSENT FORM

I------------------------------------------------------------ hereby give my consent for

participation in above mentioned study.

Place: Signature of the participant

Date: Name and

115
 ANNEXURE VII

List Of Experts

1. Mrs MAGESWARI.K 6 Mr. EDWIN SAM .M.Sc. N

HOD, Department of Medical and Assistant professor
Sri Ramana Maharshi college of Nursing,
Surgical Nursing, Akshaya College of
Tumkur
Nursing, Tumkur
7. Dr.Naveen MBBS, MD,
Consultant cardiologist.
ShriDevi medical college
Mr.ESWARAPPA. M.Sc (N)
2. Tumkur
H.O.D.
Dept of Medical-Surgical Nursing
Mr. RIYAZ KALBURGI .
Shridevi College of Nursing,
8. Bio-Statistician.
Tumkur.
Shri devi College and Hospital.
Tumkur.
Mrs. Savitha M.Sc (N),
H.O.D,
3.
Dept of Medical-Surgical Nursing,
9. Mr.RAMANJANYA
KNN College OF Nursing,
Medical sociology
Bangalore
Sridevi college of nursing
Tumkur
Mr. Rajashekar
4.
Vice principal
Tulaza Bavani College Of Nursing
BIJAPURA.

BALACHANDRA P.G
5
Lecturer,
Sri Ramana Maharshi college of
Nursing,
Tumkur..

116
 ANNEXURE VIII

STRUCTURED KNOWLEDGE QUESTIONNAIRE

PART I: DEMOGRAPHIC DATA

Instructions to Participants: I request you to go through each item carefully and give

your response by making a right [√] against the correct response.

DETAILS OF THE PARTICIPANT:

Participant No:

1) Age in years:
a) 21 – 30 [ ]
b) 31 – 40 [ ]
c) 41 – 50 [ ]
d) 51 and above [ ]
2) Gender:
a) Male [ ]
b) Female [ ]
3) Religion:
a) Hindu [ ]
b) Muslim [ ]
c) Christian [ ]
d) Other [ ]
4) Professional qualification:
a) GNM [ ]
b) B.B.Sc.Nursing [ ]
c) P.B.B.Sc. Nursing [ ]
d) Any other (Specify) _______________________ [ ]
5) Total clinical experience :
a) Less than 1 year [ ]
b) 1 – 2 years [ ]
c) 2 – 3 years [ ]
d) 3 – 4 years [ ]
e) 4 – 5 years [ ]
f) More than 5 years [ ]

117
 6) Area of work
a) ICU [ ]
b) General ward [ ]
c) OPD [ ]
d) Casualty [ ]
e) Neuro ICU [ ]
f) Any other Specify______________ [ ]
7) Exposure to in service education:
a) Yes [ ]
b) No [ ]

118
 PART II: STRUCTURED KNOWLEDGE QUESTIONNAIRE ON
ACUTE CARE OF HEAD INJURY PATIENTS

A) ANATOMY AND PHYSIOLOGY OF THE BRAIN:

1) The largest part of the brain is;

a) Diencephalons [ ]
b) Brainstem [ ]
c) cerebrum [ ]
d) cerebellum [ ]
2) The outermost layer covers the brain is;
a) pia mater [ ]
b) arachnoid mater [ ]
c) dura mater [ ]
d) gray mater [ ]
3) The amount of blood receives by the brain per minute is about;
a) 250ml [ ]
b) 500ml [ ]
c) 750ml [ ]
d) 1000ml [ ]
4) The lobe, devoted to all aspects of visual perception is;
a) frontal lobe [ ]
b) parietal lobe [ ]
c) temporal lobe [ ]
d) occipital lobe [ ]

B) GENERAL INFORMATION ABOUT HEAD INJURY

5) The leading cause of head injury in young people is;

a) Fall [ ]
b) motor vehicle accident [ ]
c) assault [ ]
d) sport injury [ ]

119
6) Group at the highest risk for Traumatic Brain Injury (TBI) is the male
person
between the age group of;
a) 10 to 14 [ ]
b) 15 to 24 [ ]
c) 25 to 34 [ ]
d) 35 to 44 [ ]
7) The peak occurrence of head injury is during;
a) morning and afternoon [ ]
b) afternoon and evening [ ]
c) evening and night [ ]
d) night and morning [ ]
8) The normal ICP is;
a) 0 to 10 mmHg [ ]
b) 5 to 15 mmHg [ ]
c) 0 to 20 mmHg [ ]
d) 15 to 20 mmHg [ ]
9) The most common, accounting for 80% of all skull fractures are;
a) linear fractures [ ]
b) comminuted fractures [ ]
c) depressed fractures [ ]
d) basilar fractures [ ]
10) CSF escapes from the ears (CSF Otorrhea) and the nose (CSF Rhinorrhea)
is
indicative of;
a) basilar skull fractures [ ]
b) linear skull fractures [ ]
c) depressed skull fractures [ ]
d) comminuted fractures [ ]

120
B) NURSING MANAGEMENT (ACUTE CARE) OF HEAD INJURY
PATIENTS:

11) Physician documented a presence of Battle‟s sign in a client with basilar

skull
fracture. Which of the following would the nurse expect to note in the
client;
a) ecchymosis (bruising) behind the ear [ ]
b) edematous periorbital area [ ]
c) bruised periorbital area [ ]
d) presence of epistaxis [ ]
12) The common complication of contusions of the brain, leading to increased
ICP, hypoxia and further brain damage is;
a) hydrocephalus [ ]
b) cerebral edema [ ]
c) meningitis [ ]
d) post traumatic epilepsy [ ]
13) The Glasgow coma scale score ranges between;
a) 0-13 [ ]
a) 3-15 [ ]
b) 5-16 [ ]
c) 7-18 [ ]
14) A Glasgow Coma Scale (GCS) score of 8 or less is the indication of;
a) mild head injury [ ]
b) moderate head injury [ ]
c) severe head injury [ ]
d) coma [ ]
15) A nurse is assessing a client with a brain stem injury. In addition to
performing the Glasgow Coma Scale, the nurse plans to;
a) check cranial nerve functioning and respiratory rate and rhythm [ ]
b) perform arterial blood gases [ ]
c) assist with a lumber puncture [ ]
d) perform a pulmonary wedge pressure [ ]
e)

121
16) A client is being brought into the emergency department after suffering a
head injury. The first action by the nurse is to determine the client‟s;
a) respiratory rate and depth [ ]
b) pulse and blood pressure [ ]
c) level of consciousness [ ]
d) ability to move extremities [ ]
17) Patency of air way is indicated by;
a) equal bilateral chest movement [ ]
b) normal air entry on auscultation [ ]
c) oxygen saturation above 95 % [ ]
d) all the above [ ]
18) The head injury patient with airway obstruction requires;
a) turning of head on one side [ ]
b) oxygen inhalation [ ]
c) deep breathing [ ]
d) immediate endotracheal intubation [ ]
19) A nurse evaluates the arterial blood gas (ABG) results of a head injury
patient who is receiving supplemental oxygen. Which finding would indicate
that the oxygen level was adequate;
a) PaO2 of 80 mmHg [ ]
b) PaO2 of 60 mmHg [ ]
c) PaO2 of 50 mmHg [ ]
d) PaO2 of 45 mmHg [ ]
20) A nurse is determining the need for suctioning in a head injury client with
an endotracheal tube attached to a mechanical ventilator. Which
observation by the nurse indicates this need?
a) low peak inspiratory pressure on the ventilator [ ]
b) visible mucus bubbling in the ET tube [ ]
c) apical pulse rate of 72 beats/min [ ]
d) clear breath sounds [ ]

21) Head injury patients are usually kept sedated and relaxed to allow;
a) decrease in intra cranial pressure quickly [ ]
b) effective mechanical ventilation [ ]
c) to provide intensive nursing care [ ]
d) to monitor patient promptly [ ]
122
 22) Head injury patient have leaking from the ear. Immediately the nurse
should
plan to;
a) irrigate the ear canal gently [ ]
b) test the drainage for glucose [ ]
c) test the drainage for pH [ ]
d) notify the physician [ ]
23) The first thing to do when a head injury patient develop generalized
convulsion;
a) monitor vital signs [ ]
b) administer oxygen [ ]
c) protect the client from harm [ ]
d) administer parenteral diazepam [ ]
24) A newly admitted head injury patient has difficulty in breathing and at the
same time he is bleeding profusely from the scalp, the first action should be;
a) administer oxygen [ ]
b) propped up position [ ]
c) arrest the bleeding [ ]
d) check the vital signs [ ]
25) The major post-operative complication to be monitored by the nurse
following craniotomy is;
a) increased ICP [ ]
b) motor weakness [ ]
c) visual changes [ ]
d) wound infection [ ]

26) A nurse is caring for a client admitted to the hospital after sustaining head
injury. To prevent increased ICP the nurse appropriately positions the
client;
a) with the head elevated on a pillow [ ]
b) in left Sims’ position [ ]
c) in reverse Trendelenburg [ ]
d) with the head of the bed elevated 30 to 45 degrees [ ]

123
27) While performing endotracheal suction in a head injury patient, the nurse
should observe for the following complication;
a) hypertension [ ]
b) cardiac irregularities [ ]
c) a reddish colouration of face [ ]
d) a pulse oxymetry level of 95% [ ]
28) The nurse performs following activities to prevent convulsion;
a) administer anticonvulsant drugs round a clock [ ]
b) maintain environmental control [ ]
c) provide safe environment and thus prevent injury [ ]
d) all of above [ ]
29) To prevent complications of prolonged bed rest, position of head injury
patient should be changed every;
a) 2 hourly [ ]
b) 4 hourly [ ]
c) 8 hourly [ ]
d) Hourly [ ]
30) A nurse is caring for a client who sustained a head injury from a fall. The
nurse avoids which of the following in the care of this client?
a) keeping the client in a sitting up position [ ]
b) forcing fluids [ ]
c) keeping the client awake as much as possible [ ]
d) performing neurological assessment [ ]

124
 ANNEXURE IX

BLUE PRINT OF STRUCTURED KNOWLEDGE QUESTIONNAIRE

ON CARE OF ACUTE HEAD INJURY PATIENTS

DOMAINS OF OBJECTIVES
S.N. CONTENT TOTAL
Knowledge Comprehension Application Analysis %

1 Anatomy & 1,2,3,4

physiology 13.33%
of Brain
2 General 5,6,7,8,9 10
information
about head 20%
injury

3 Acute care of 12,13 14,17,19, 20 15,16,18,21,22, 11,25,27

head injury 23,24,26,28,29,
66.67%
patients 30

4 TOTAL 11 5 11 3 100%
(36.67%) (16.66%) (36.67%) (10%)

125
 ANNEXURE X

ANSWER KEY OF STRUCTURED KNOWLEDGE QUESTIONNAIRE

ON CARE OF ACUTE HEAD INJURY PATIENTS

Question No. Correct Answer Question No. Correct Answer

1. c 16. a

2. c 17. d

3. c 18. d

4. d 19. a

5. b 20. b

6. b 21. a

7. c 22. b

8. b 23. d

9. a 24. c

10. a 25. a

11. a 26. d

12. b 27. b

13. b 28. d

14. c 29. a

15. a 30. b

126
 ANNEXURE XI

STRUCTURED TEACHING PROGRAMME ON ACUTE CARE OF HEAD INJURY PATIENTS

STUDENT TEACHER : Ms Rency Saji

SUBJECT : MEDICAL SURGICAL NURSING

TOPIC : CARE OF ACUTE HEAD INJURY PATIENTS

GROUP : 60 NURSES

PLACE : CONFERENCE HALL OF THE SELECTED HOSPITALS

DURATION : 60 MINUTES

MEDIUM OF INSTRUCTION : ENGLISH

METHOD OF TEACHING : LECTURE CUM DISCUSSION

AUDIO VISUAL AIDS : LCD PROJECTOR (POWER POINT PRESENTATION USING LCD)

GENERAL OBJECTIVE: at the end of the Structured teaching session, the group will be able to provide efficient nursing care to

patients with acute head injury.

107
SPECIFIC OBJECTIVES: The Group will be able to;

1) Review the Anatomy and Physiology of the brain or structures within the cranium.

2) Defines the term „Head Injury‟.

3) Classify the head injury.

4) Enlist the causes (etiology) and risk factors.

5) Explain the mechanism and pathophysiology of patient with head injury.

6) Recognize the signs and symptoms of different type of head injury.

7) Enlist the diagnostic test which is carried out in patients with head injury.

8) Enumerate the complications of head injury.

9) Describe the medical and surgical management of patients with head injury.

10) Describe the Nursing management of patients with head injury.

a) Make general, neurological assessment of patients with head injury.

b) Assess the G C S and interpret it.

c) Applies acute nursing care in managing the patients with head injury.

108
Time Specific Content Teacher‟s Participant‟s A.V. Aids Evaluation
Objectives Activity Activity
2min INTRODUCTION
Every year, millions of people sustain a head injury. Explanation Listening
Most of these injuries are minor because the skull provides
the brain with considerable protection. More than half a
million head injuries a year, however, are severe enough to
require hospitalization. Brain injury is a common cause of
morbidity and mortality in all age groups and represents a
major public health problem with high annual cost.

5min Review ANATOMY AND PHYSIOLOGY Explanation Listening What is the

anatomy  The brain is part of the CNS, housed within the and and anatomy
and cranial vault. discussion observing and
physiology  The major parts of the brain are: cerebrum, physiology
of brain diencephalons, brainstem and the cerebellum. of brain?
 Cerebrum: This is the largest part of the brain and it
occupies the anterior and middle cranial fossae. It is
divided into right and left cerebral hemispheres;
each containing one of the lateral ventricles.
Transverse fissure separates the cerebrum from the
cerebellum. Each hemisphere receives sensory and
motor impulses from the opposite side of the body.
Left hemisphere is responsible for the control of
language while right for the nonverbal perceptual
functions. Each cerebral hemisphere is divided into
frontal, parietal, temporal and occipital lobes.
Frontal lobe is the largest lobe which is responsible
for concentration, abstract thought, information
storage or memory and motor function.

109
Time Specific Content Teacher‟s Participant‟s A.V. Aids Evaluation
Objectives Activity Activity
Parietal lobe is concerned with sensation.
Temporal lobe incorporates the auditory centre.
Occipital lobe is devoted to all aspects of visual
perception.
Basal ganglia: These are areas of gray matter, lying
deep within the cerebral hemispheres, with
connections to the cerebral cortex and thalamus. It
involved in initiating muscle tone in slow and
coordinated activities.
 Diencephalon: It is embedded in the cerebrum
superior to the brainstem. It consists of the thalamus,
hypothalamus and epithalamus. Diencephalon
conducts sensory and motor impulses, regulates
autonomic nervous system, regulates and produces
hormones and mediates emotional responses.
 Brainstem: The brainstem consists of the midbrain,
pons, and medulla oblongata. The midbrain is a
center for auditory and visual reflexes. In addition, it
functions as a nerve pathway between the cerebral
hemispheres and lower brain. The pons is located just
below the midbrain. It consists mostly of tracts, but it
also contains nuclei that control respiration.
The medulla oblongata, located at the base of the
brainstem, is continuous with the superior portion of
the spinal cord. Medulla oblongata contains motor
fibers from the brain to the spinal cord and sensory

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 fibers from the spinal cord to brain. Nuclei of the
Medulla oblongata play an important role in
controlling cardiac rate, blood pressure, respiration
and swallowing.
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 Cerebellum: The cerebellum is connected to the

midbrain, pons and medulla. Its function includes co-
coordinating skeletal muscle activity, maintaining
balance, and controlling fine movements.
 Ventricles: The brain contains four Ventricles (right
and left lateral ventricles, third and fourth ventricles),
which are chambers filled with CSF.
 CSF forms a cushion for the brain tissue, protects the
brain and spinal cord from trauma, helps provide
nourishment for the brain, and removes waste
product of cerebrospinal cellular metabolism.
 Meninges: The brain and spinal cord are covered and
protected by three connective tissue membranes
called meninges.
The meninges have three layers. The
outermost layer covers the brain and the spinal cord
is dura mater. The middle layer is the arachnoid
mater, which encloses the entire CNS. It forms the
subarachnoid space that contains CSF. The innermost
layer, the pia mater, clings to the brain, spinal cord
and segmental nerves and is filled with small blood
vessles.
 Cerebral circulation: The brain receives about

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 750ml of blood per minute, approximately 15% of
the cardiac output. The anterior part of the brain is
supplied with blood by the two internal carotid
arteries and the posterior part of the brain is supplied
with blood by the vertebral arteries.
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1min Define DEFINITION Defining Listening What do
head injury Head injury is a broad term that includes injury to you mean
the scalp, skull, or brain. by head
The National Head Injury Foundation defines injury?
Traumatic Brain Injury (TBI) as a traumatic insult to the
brain capable of causing physical, intellectual, emotional,
social and vocational changes.

1min INCIDENCE Explanation Listening

The incidence of TBI varies by age, gender, region
and other factors. Approximately 1 million people receive
treatment for head injuries every year. Of these, 230,000are
hospitalized, 80,000 have permanent disabilities, and 50,000
people die. The annual incidence of mild TBI is difficult to
determine but may be100-600 people per 100,000.
In India, it is the seventh-leading cause of mortality
contributing to 11% of total deaths; 78% of cases are due to
road traffic injuries alone.

5min Classify CLASSIFICATION Explanation Listening and LCD What is the

TBI TBI is usually classified based on mechanism (the and discussing classifica-
causative forces), severity and pathological features of the discussion tion of TBI
injury. on the basis

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 of
Classification based on Mechanism (causative forces): mechanism?
1. Closed or nonpenetrating (blunt) injury occurs
when the brain is not exposed.
2. Open or penetrating injury occurs when an object
pierces the skull and breaches the dura mater.

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Classification based on severity:
severity GCS PTA LOC
Mild 13-15 <1 day 0 – 30
minutes
Moderate 9-12 >1 to <7 >30 min to
days <24 hours
Severe 3-8 >7 days >24 hours
N.B. GCS- Glasgow coma scale
PTA- Post traumatic amnesia
LOC- Loss of consciousness

Classification based on pathological features of the

injury:
1. Extra-axial – Lesions can be extra-axial i.e.
occurring within the skull but outside of the brain.
2. Intra-axial – Lesion occurring within the brain
tissue.
OR
1. Concussions: A concussion is head trauma that may
result in loss of consciousness for 5 minutes or less
and retrograde amnesia. There is no break in the skull

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 or dura, and no visible damage on a CT or MRI scan.
2. Contusions: Contusions damage the brain itself,
causing multiple areas of petechial and punctate
hemorrhage and bruised areas.
3. Diffuse Axonal Injury: This is the most severe form
of head injury. It begins with immediate loss of
consciousness, prolonged coma, abnormal flexion or
extension posturing, increased ICP, hypertension and
fever.
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2min Enlist the ETIOLOGY AND RISK FACTORS Explanation Listening and What are
causes and Males aged 15 to 24 years are three times more likely and discussing the causes
risk factors to succumb to a Traumatic head injury than are females. discussion and risk
Peak occurrence is during evenings, nights, and weekends. factors of
Motor vehicle accidents are the foremost cause of head head injury?
injuries. Other causes are assaults, falls, sport injury,
domestic violence, abuse, industrial accidents, firearms and
blast injuries from explosions.
Risk factors: Alcohol abuse, drug abuse, careless
driving, using cell phones while driving, not wearing
helmets, failure to wear seat belt and protective gear, and
improper use of weapons.

6min Explain the MECHANISM AND PATHOPHYSIOLOGY Explanation Listening and LCD
mechanism Head injuries are caused by a sudden force to the head. The and observing
and patho- results are complex. Three mechanisms contribute to head discussion
physiology trauma:
What do
1. Acceleration: An acceleration injury occurs when you mean

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 the immobile head is struck by a moving object. by
2. Deceleration: If the head is moving and hits an acceleration
immobile object, a deceleration injury occurs. injury?
3. Deformation: It refers to injuries in which the force
results in deformation and disruption of the integrity
of the impacted body part (e.g. skull fracture).
In an acceleration-deceleration injury, a moving
object hits the immobile head, and then the head hits
an immobile object. These injuries are also associated
with rotation injury, where the brain is twisted within
the skull.
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PATHOPHYSIOLOGY: What are
the causes
Research suggests that not all brain damage occurs at of increased
the moment of impact. Damage to the brain from traumatic ICP?
injury takes two forms: Primary injury and secondary
injury.
Primary injury is the initial damage to the brain that
results from the traumatic event. Secondary injury evolves
over the ensuing hours and days after the initial injury and is
due primarily to brain swelling or ongoing bleeding. Thus,
any bleeding or swelling within the skull increases the
volume of contents with in a container of fixed size and so
can cause increased ICP. The normal ICP is 5 to 15 mmHg.
If the increased pressure is high enough, it can cause a
downward or lateral displacement of the brain through or
against the rigid structures of the skull. Herniation occurs as
brain tissue forced out from higher pressure to lower

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 pressure compartment. This causes restriction of blood flow
to the brain, decreasing oxygen delivery and waste removal.
Thus cerebral hypoxia and ischemia occurs due to
brain swelling or bleeding, raised ICP and reduced perfusion
pressure. Cells within the brain become anoxic and cannot
metabolize properly, producing ischemia, infarction,
irreversible brain damage, and eventually brain death.

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CLINICAL MANIFESTATIONS
7min Able to Explanation Listening LCD What is
recognize The symptoms, apart from those of the local injury, depend concu-
the signs on the severity and the distribution of brain injury. ssion?
and 1. Following concussion, observers report a loss of
symptoms consciousness for 5 minutes or less and retrograde
of head amnesia, PTA or both.
injury 2. Signs of post concussion syndrome may include
headache, dizziness, anxiety, irritability, and lethargy.
3. Contusions are often associated with other serious
injuries, including cervical fractures. The common
complication of contusions of the brain, leading to
increased ICP, hypoxia and further brain damage is
cerebral edema.
4. Persistent localized pain usually suggests that a

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 fracture is present. The most common, accounting
for 80% of all skull fractures are linear fractures.
5. Fractures of the Base of the skull frequently
produce hemorrhage from the nose, pharynx or ears
and blood may appear under the conjunctiva.
6. An area of ecchymosis (bruising) may be seen over answering What is
the mastoid (Battle‟s sign). Battle’s
7. Basilar skull fractures are suspected when CSF sign?
escapes from the ears (CSF Otorrhea) and the nose
(CSF Rhinorrhea).
8. A halo sign (a blood stain surrounded by a yellowish
stain) may be seen on bed linens or the head dressing and
is highly suggestive of a CSF leak. Bloody CSF suggests
a brain laceration or contusion.

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9. Brain injury may have various signs including
altered LOC, confusion, Pupillary abnormalities,
altered or absent gag reflex, absent corneal reflex,
sudden onset of neurologic deficits, Changes in vital
signs (altered respiratory pattern, hypertension,
bradycardia), hypothermia or hyperthermia, vision
and hearing impairment and sensory dysfunction
10. In acute or subacute subdural hematoma, changes
in level of consciousness, papillary signs,
hemiparesis, coma, hypertension, bradycardia, and
slowing respiratory rate are signs of expanding mass.
11. Chronic subdural hematoma may result in severe
headache, alternating focal neurologic signs,

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 personality changes, mental deterioration, and focal
seizures.
DIAGNOSTIC ASSESSMENTS
2min Enlist the  Diagnostic assessments, such as x-rays, CT or MRI Explanation Listening What are
diagnostic scan, may reveal fractures and areas of bleeding or and and the common
tests brain shift. discussion answering diagnostic
 Functional imaging (PET scan) can measure cerebral tests used to
blood flow or metabolism, inferring neuronal activity assess head
in specific regions and potentially helping to predict injury?
outcome.
 Electroencephalography and transcranial Doppler
may also be used.
 Lumber puncture can also be used to assess for
bleeding within the subarachnoid space.
 Cerebral angiography may also be used to identify
and intracerebral hematomas and cerebral contusions.
Content
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2min Enumerate COMPLICATIONS Explanation Listening What are
the 1. Cerebral edema the common
complica- 2. Infection (e.g. meningitis, brain abscess) complica-
tions of 3. Acute hydrocephalus tions of
head injury 4. Diabetes insipidus head injury?
5. Syndrome of inappropriate secretion of antidiuretic
hormone (SIADH)
6. Dysrhythmias
7. Neurogenic pulmonary edema
8. Arteriovenous aneurysms
9. Altered behavior

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 10. Post trauma response What is the
Medical
5min Describe MEDICAL AND SURGICAL MANAGEMENT Explanation Listening LCD manage-
the All therapy is directed toward preserving brain homeostasis and and ment of
Medical and preventing secondary brain injury. discussion answering head injury?
and  Management involves supportive care, control of
Surgical ICP, maintenance of fluid and electrolyte balance,
manage- administration of antihypertensive, antipyretic,
ment analgesics, diuretics, anticonvulsants, sedatives,
paralytic agents, muscle relaxants, antacids, stool
softeners, antibiotics etc.
 Increased ICP is managed by adequate oxygenation,
mannitol administration, ventilator support,
hyperventilation, elevation of the head of the bed,
maintenance of fluid and electrolyte balance,
nutritional support, pain and anxiety management, or
neurosurgery.

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SURGERY: The treatment of choice for epidural What are
hematomas and large acute subdural hematomas is surgical the common
evacuation of the clot. This can often be performed through complica-
burr holes made into the skull. Surgical procedure that tions of
involves an incision through the cranium to remove craniotomy?
accumulated blood or tumor is craniotomy. Complications
of this procedure include increased ICP from cerebral edema,
hemorrhage, or obstruction of the normal flow of CSF.
How will
NURSING MANAGEMENT you make

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10 Make Assessment: Explanation Listening LCD neurolo-
min general,  Obtain health history, including time of injury, cause of and and gical
neurologic injury, direction and force of the blow, loss of discussion answering assessment
and GCS consciousness, and condition following injury. Detailed of a head
assessment neurologic information (level of consciousness, ability injury
to respond to verbal commands if patient is conscious), patient?
response to tactile stimuli (if patient is unconscious),
pupillary response to light, corneal and gag reflexes,
motor function, and system assessments provide baseline
data.
 Glasgow Coma Scale (GCS) serves as a guide for
assessing level of consciousness (LOC) based on three
criteria:
1. Eye opening,
2. Verbal responses, and
3. Motor responses to a verbal command or
painful stimulus.

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Glasgow Coma Scale Explanation Listening LCD How will

and and you assess
The Glasgow Coma Scale is a tool for assessing a discussion observing LOC by
patient’s response to stimuli. Score ranges from 3 (deep and using GCS?
coma) to 15(normal). discussing

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 EYE OPENING Spontaneous 4
RESPONSE To voice 3
(Record “C” if eyes To pain 2
closed by swelling)
None 1

BEST VERBAL Oriented 5

RESPONSE Confused 4
(Record “E” if Inappropriate words 3
endotracheal tube in
Incomprehensible sounds 2
place,
Record “T” if None 1
tracheostomy tube in
place)
BEST MOTOR Obeys command 6
RESPONSE Localizes pain 5
to painful stimuli Withdraws 4
Flexion 3
(Record best upper
limb response) Extension 2
None 1
Total 3 to
15

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 A GCS score 8 or less is generally accepted as
indicating a severe head injury.
 Inspects the patient‟s scalp for any laceration,
hemorrhage, contusion, abrasion, concussion,
compression. Palpate the patient’s head to detect or

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 assess fractures, hematomas and ecchymosis.
 Inspects ears, nose for CSF leak, hemorrhage. Inspects
other body parts for bone fracture, laceration, dislocation,
hemorrhage, abrasion.
 Avoid flexion, hyper extension, rotation of the neck.
Application of cervical collar, placing sand bag on either
side of the head, use of spine board till cervical injury if
ruled out.
 Monitoring vital signs: Monitor patient at frequent
intervals to assess intracranial status. Assess for
increasing ICP, including slowing of pulse, increasing
systolic pressure and widening pulse pressure. Monitor
for rapid rise in body temperature; keep temperature
below 38oC (100.4oF) to avoid increased metabolic
demands on brain. Keep in mind that tachycardia and
hypotension may indicate bleeding elsewhere in the
body.
 Assessing motor function: Observe spontaneous
movements; ask patients to raise and lower extremities; How will
compare strength of hand grasp at periodic intervals. you assess
Note presence or absence of spontaneous movement of motor
each extremity. Assess responses to painful stimuli in function?
absence of spontaneous movement. Determine patient’s
ability to speak; note quality of speech.
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 Evaluating eye signs: Evaluate spontaneous eye
opening. Evaluate size of pupils and reaction to light
(unilaterally dilated and poorly responding pupils may
indicate developing hematoma). If both pupils are fixed

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 and dilated, it usually indicates overwhelming injury and
poor prognosis.
 Assess cranial nerve functioning and respiratory rate
and rhythm of a client with a brain stem injury along
with GCS.
 Oxygen needs are also monitored by assessing tissue
perfusion, oximetry readings, and ABG analysis results.
 Assess fluid status with the help of B.P; CVP; fluid How will
balance and hourly output. you assess
 Monitoring for complications (cerebral edema and fluid status?
herniation): Deterioration in condition may be due to
expanding intracranial hematoma, progressive brain
edema, and herniation of the brain. Peak swelling occurs
about 72 hours after injury, with resulting elevation of
ICP.
 Monitoring for other complications: Assess for
complications, including systemic infections or
neurosurgical infections, wound infection, osteomyelitis,
or meningitis. After injury, some patients develop focal
nerve palsies, such as anosmia (lack of sense of smell) or
eye movement abnormalities and focal neurologic defects
such as aphasia, memory defects, and post traumatic
seizures or epilepsy. Patients may be left with organic
psychosocial deficits and may lack insight into their
emotional responses.
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10 Apply Acute Nursing Care: Explanation Listening and LCD Discuss
min acute and discussing acute care
nursing Maintaining the airway and breathing pattern: discussion of head

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 care  First determine patient’s respiratory rate, rhythm and injury
depth. patient
 Guard against aspiration and respiratory
insufficiency. The head injury patient with airway
obstruction requires immediate endotracheal
intubation.
 Patency of airway is indicated by equal bilateral chest
movement, normal air entry on auscultation and
oxygen saturation above 95 %.
 Position the unconscious client to facilitate drainage
of secretions, elevate head of bed 30 to 45 degrees to
decrease intracranial venous pressure.
 Establish effective suctioning procedures. Visible
mucus bubbling in the ET tube indicates the need for
suctioning.
 Monitor ABGs to assess adequacy of ventilation.
 Monitor patient on mechanical ventilation.
 Humidified oxygen, endotracheal intubation, a
tracheostomy, or a mechanical ventilator may be
required to maintain Pao2 at 80 mmHg or above.
 Monitor for pulmonary complications (ARDS and
pneumonia).
Maintaining adequate cerebral tissue perfusion:
 Administer the medications that are ordered to reduce
cerebral edema (e.g. osmotic diuretics,
corticosteroids).
 Maintain normothermia.
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 Elevating the head of the bed to at least 30degrees,

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 keeping the head in neutral position, and avoiding
extreme hip flexion can facilitate venous jugular
drainage and decrease cerebral edema.
 Early treatment of dysrhythmias and blood
replacement as indicated may be necessary for
maintenance of an adequate cardiac output.
 Control active bleeding by compression when
possible, unless a skull fracture is present.
Control of increased ICP:
 Elevate the head of the bed to 300.
 Hyperventilate the patient.
 Prevent the Valsalva maneuver.
 Maintain the patient’s head and neck in a neutral
position.
 Maintain normothermia.
 Maintain fluid restriction.
Maintaining fluid and electrolyte balance:
 Fluid and electrolyte balance is particularly important
in patients receiving osmotic diuretics, those with
inappropriate antidiuretic hormone secretion, and
those with posttraumatic diabetes insipidus.
 Monitor serum and urine electrolyte levels (including
blood glucose and urine acetone), osmolality, and
intake and output to evaluate disorders of sodium
regulation and endocrine function.
 Record daily weights if possible (which may indicate
fluid loss from diabetes insipidus).

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objectives Activity Activity
Providing adequate nutrition:
 Parenteral nutrition via a central line or enteral
feedings administered via a nasogastric tube.
 Start nasogastric feedings as soon as condition
stabilizes unless there is discharge of CSF from the
nose; oral feeding tubes may be used. Food intake
may resume when swallowing reflex returns and
patient can meet caloric requirements orally.
 Give small, frequent feedings to lessen the possibility
of vomiting and diarrhea; elevate head of bed, and
check residual feeding before feedings.
Monitoring for seizure development and preventing Explanation Listening and How will
injury: and discussing you protect
 Protect the client at risk, prophylactically, by placing discussion the client
padding on side rails, keeping the bed in a low from injury
position, giving the anticonvulsant medication (e.g. who is at
diazepam) on time. risk for head
 If a seizure does occur, call for help as you are injury?
protecting the client’s head and turning the client to a
lateral position to displace the tongue and to promote
an open airway.
 Stay with the client; protect the client from harm; and
observe the onset, progression, and duration of the
seizure.
 Suction as necessary and monitor vital signs.
 Notify the physician, give oxygen and prepare for
administration of an IV anticonvulsant.
 Observe for restlessness, which may be due to
hypoxia, fever, pain, or a full bladder.

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 Avoid bladder distention.
 Avoid restraints when possible because straining can
increase ICP.
 Avoid using narcotics for restlessness because they
depress respiration, constrict pupils, and alter LOC.
 Keep environmental stimuli to a minimum.
 Provide adequate lighting to prevent visual
hallucinations.
 Do not disrupt sleep/wake cycles.

Preventing infection:
 Prevent risk for infection by not suctioning a client
nasally if an anterior fossa or basilar fracture or CSF
leakage from the ears (Otorrhea) or nose
(Rhinorrhea) is present.
 If drainage is present test it for the presence of
glucose. Use sterile dressings to absorb the fluid.
Change them whenever they become wet to decrease
the entry of microorganisms.
 If the client is conscious, discourage nose blowing,
coughing, and inhibition of sneezing. Instruct the
client to sneeze through an open mouth; suppressing
a sneeze forces the bacteria backward.
 Administer prescribed antibiotics on time.
 Report any signs of meningitis.
 Use an external sheath catheter for incontinence
because an indwelling catheter may produce

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 infection.
 Use strict aseptic technique.

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Maintaining body temperature:
 Monitor temperature every 2 to 4 hours.
 If temperature rises, administer acetaminophen and
cooling blankets as prescribed to achieve
normothermia.
 Monitor for infection related to fever.
Maintaining skin integrity:
 Assess all body surfaces, and document skin integrity What is
every 8 hours. your role to
 Head injury patient’s position is changed every 2 maintain
hourly to prevent complications of prolonged bed skin
rest. integrity of
 Provide skin care every 4 hours; Use skin lubricant to a patient
prevent irritation due to rubbing against the sheet. with head
 Assist patient to get out of bed three times a day injury?
(when appropriate).
Maintaining cognitive functioning:
 Develop patient’s ability to devise problem-solving
strategies through cognitive rehabilitation overtime;
use a multidisciplinary approach.
 Be aware that there are fluctuations in orientation and
memory and that these patients are easily distracted.
 Do not push to a level greater than patient’s impaired
cortical functioning allows because fatigue,
headache, and stress (headache, dizziness) may

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 occur.
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Preventing sleep patterns disturbance:
 Group nursing activities so that patient is disturbed
less frequently.
 Decrease environmental noise, and dim room lights.
 Provide strategies (e.g. back rubs) to increase
comfort.
Monitoring and managing potential complications:
 Monitor for a patent airway, altered breathing pattern,
and hypoxemia and pneumonia. Assist with
intubation and mechanical ventilation.
 Provide enteral feedings, IV fluids and electrolytes,
or insulin as prescribed.
 Initiate PN as ordered if patient is unable to eat.
 Monitor for systemic or neurosurgical infection.
 Take measures to control cerebral perfusion pressure:
elevate head of bed 30 degrees, maintain head and
neck in alignment (no twisting), prevent Vulsalva
maneuver, use medications to decrease ICP, Maintain
normal body temperature, hyperventilate on
mechanical ventilation, maintain fluid restriction,
avoid noxious stimuli (suctioning), administer
sedation to reduce metabolic demands.
 Monitor for major post operative complications like
increased ICP, Hemorrhage, and obstruction of the
normal flow of CSF after craniotomy.
 Assess carefully for development of posttraumatic
seizures.

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 Providing psychological support to patient and family.

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1min SUMMARY
We have seen the review of anatomy and physiology of
brain, definition, incidence, the etiology and risk factors,
pathophysiology, the signs and symptoms, general
neurological assessment, GCS assessment and interpretation,
the nursing management such as maintaining airway,
breathing, adequate tissue perfusion, fluid and electrolytes
maintenance, providing nutrition, monitoring seizures,
preventing infection and injury, maintaining body
temperature and skin integrity, assessing for complications
and providing psychological support.

1min CONCLUSION
As nurses, we can do lots in this area through our health
educational skills emphasizing the dangers associated with
head injury and its detrimental effects to those patients and
their families who have suffered minor head injuries and
made a good recovery. We can stress upon the driver
behavior and safe work practices, the use of seat belt, use of
protective head gear for motor-cyclists and horse-riders.
Encouraging people to consider healthy lifestyle and prevent
over indulgement in alcohol, and prevent consumption of
alcohol while driving.

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 BIBLIOGRAPHY

1. Anne Waugh, Allison Grant. Ross and Wilson Anatomy and Physiology in health and illness. Ninth Edition; 2001; Hartcourt Publishers
Limited, London. P. 146-157.
2. Brenda Bare, Suzanne Smeltzer. Brunner and Suddarth’s Text book of medical surgical nursing. Eleventh edition; 2004; Wolters Kluwer
publication, New Delhi. P. 1911-1917.
3. http://en.wikipedia.org/wiki/Traumatic_brain_injury.
4. Joanne v. Hickey. The clinical practice of Neurological and Neurosurgical Nursing. Third Edition; 1992; J. B. Lippincott Company,
Philadelphia. P. 113- 143,352- 393.
5. Joycee M. Black, Jacobs. Medical-Surgical Nursing. Fifth edition; 1980; Published by Hartcourt Brace & Company Asia Pvt.Ltd; New
Delhi. P.820-831.
6. K. Reddemma. A Text book of Neuro Science Nursing. First Edition; 2004; Department of Nursing, NIMHANS, (Deemed University)
Tumkur-29. P. 137- 146.
7. Linda Anne Silvestri. Saunders Comprehensive Review for the NCLEX-RN Examination. Fourth Edition, 2008; Published by Elsevier
India Pvt. Ltd; New Delhi. P. 1030-1032.
8. Priscilla Lemone, Karen Burke. Medical Surgical Nursing. Fourth edition; 2008; Published by Dorling Kindersley (India) Pvt.Ltd; New
Delhi. P.1554-1568.

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