Developing A Clinical Pathway Map for Patients with Traumatic Spinal Cord Injury Based on Needs Assessment

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1 Developing A Clinical Pathway Map for Patients with Traumatic Spinal Cord Injury Based on Needs Assessment Thesis Submitted for Partial Fulfillment of The Requirements of the Master Degree In Nursing Sciences (Medical Surgical Nursing) By Amira Hedaia Morad Demonstrator in Medical Surgical Nursing Department Faculty of Nursing Ain Shams University Ain Shams University Faculty of Nursing 2010

2 Developing A Clinical Pathway Map for Patients with Traumatic Spinal Cord Injury Based on Needs Assessment Thesis Submitted for Partial Fulfillment of The Requirements of the Master Degree In Nursing Sciences (Medical Surgical Nursing) Under supervision of Prof.Dr.Tahany Elsenosy Prof.of Medical Surgical Nursing Department Faculty of Nursing Ain Shams University Dr.Neamat Allah Gomaa Lecture of Medical Surgical Nursing Department Faculty of Nursing Ain Shams University Ain Shams University Faculty of Nursing 2010

3 خريطة تطويرالمسار الا كلينيكى للمرضى ذوىالا صابات الا رتطاميه للنخاعالشوكى قاي مه على تقييم الا حتياجات لديهم رساله مقدمه للحصول على درجة الماجستير فى علوم التمريض (تمريض جراحى باطنى) مقدمه من أميره ھدايه مراد إبراھيم معيده بقسم جراحى باطنى كلية التمريض جامعة عين شمس كلية التمريض جامعة عين شمس ٢٠١٠

4 خريطة تطويرالمسار الا كلينيكى للمرضى ذوىالا صابات الا رتطاميه للنخاعالشوكى قاي مه على تقييم الا حتياجات لديهم رساله مقدمه للحصول على درجة الماجستير فى علوم التمريض (تمريض جراحى باطنى) تحت إشراف أ.د/ تھانى السنوسى أستاذ بقسم تمريض جراحى باطنى كلية التمريض جامعة عين شمس د/ نعمت الله جمعه مدرس بقسم تمريض جراحى باطنى كلية التمريض جامعة عين شمس كلية التمريض جامعة عين شمس ٢٠١٠

5 Abstract Abstract Spinal cord injury (SCI) is one of the most divesting calamities in human life. An injury to spinal cord can potentially affect every system of the body. It can be a catastrophic injury that changes patients' life completely.this injury affects that total physiologic, economic and social well being of the individual which might be disastrous. Aim of the study Assess the needs of patients with traumatic spinal cord injury, develop clinical pathway map for patients with traumatic spinal Cord injury based on their need assessment. Priorities of care may change depending on the client and setting, care focuses on maximizing functional health status to preserve quality of life. To conduct this study a purposive sample of multidisciplinary team which consisted of (12physician, 15nurses, 1pharmacist, and 2technician) within 3 months duration was selected from the Emergency Unite at Eldemrdash hospital. Tools of data collection were done using questionnaire sheet and observational check list. The results of the study showed More than two (66.3%)third of health team agree that clinical pathway give vision about expected prognosis and almost all of the team (93.3%) never assesses respiratory system as regard to percussion, palpitation, auscultation, and inspection. The study concluded that almost all (83.4%) of medical health team never does intervention as regard to pulse oximitar, attached to halo vest and tissue repair. This study recommended that Nurses should educate patients and their families about the clinical pathway map including medications, diet, exercise, activity, self care and its impact in patients prognosis and outcome.

6 Abstract

7 Developing A Clinical Pathway Map for Patients with Traumatic Spinal Cord Injury Based on Needs Assessment Protocol Submitted in partial Fulfillment of Requirement of Master Degree in Nursing Science (Medical Surgical Nursing) By Amira Hedaia Morad Demonstrator in Medical Surgical Nursing Faculty of Nursing Ain Shams University Under Supervision of Prof. Dr. Tahany El-senosy Prof. of Medical Surgical Nursing Chairman of Medical Surgical Nursing Department Faculty of Nursing Ain Shams University Dr. Neamat Allah Gomaa Lecturer of Medical Surgical Nursing Faculty of Nursing Ain Shams University. Ain Shams University Faculty of Nursing 2008

8 Introduction Spinal cord injury (SCI) occurs when a traumatic event results in damage to cells within the spinal cord or severs the nerve tracts that relay signals up and down the spinal cord. The most common types of spinal cord injury include contusion (bruising of the spinal cord) and compression (caused by pressure on the spinal cord). Other types of injuries include lacerations (severing or tearing of some nerve fibers, such as damage caused by a gun shot wound), and central cord syndrome (specific damage to the corticospinal tracts of the cervical region of the spinal cord (Smeltzer, 2000 & Lemone and Burke, 2008). Patient with spinal cord injury involuntarily places a heavy burden on health care system, not only in the phase of acute care, but also in the first years following injury.the median survival time of patients sustaining an spinal cord injury between the age of 25 and 34 years has been pradicted to be 38 years postinjury, with 43% surviving for at least 40 years.thay estimated spinal cord injury incidence to be between 13 and 33 cases per million per year(national Center for injury Prevention and control,2005). As regard incidence in Egypt; reported El-demrdash hospital that 300 new cases admitted with spinal cord injury through year 2007 /2008 Spinal injuries result from motor vehicle accidents, falls, diving into shallow water and gunshot wounds. Less serious injuries result from heavy object lifting and minor falls. Spinal dysfunction may also result from hyperparathyroidism and neoplastic lesions.( British Journal of Nursing,2005) 1 -

9 The effects of spinal cord injury depend on the type of injury and the level of the injury. Spinal cord injury can be divided into two types of injury - complete and incomplete. A complete injury means that there is no function below the level of the injury; no sensation and no voluntary movement. Both sides of the body are equally affected. An incomplete injury means that there is some functioning below the primary level of the injury. A person with an incomplete injury may be able to move one limb more than another, may be able to feel parts of the body that cannot be moved, or may have more functioning on one side of the body than the other. With the advances in acute treatment of spinal cotd injury, incomplete injuries are becoming more common. (Lemone and Burke, 2008). Management of spinal cord injury include; surgery, Stabilization, and immobilization. Early surgical treatment may be necessary if there is evidence of compression of the spinal cord by bone fragments or a hematoma. Stabilization and immobilization, as a results of one or more dislocations or fracture of cervical vertebrae (Timby and Smith, 2007). Patient with a spinal cord injury has complex needs that involve all members of the health care team.because these injuries are more common in younger patients. Consideration of lifelong effects on both patient and family is essential. The nurse coordinates patient care and develops and implements a care plan that is individualizes to each patient and family. The focus of the care plan is to prevent secondary complications of immobility and altered body functions, to promote selfcare, and to educate the patient and his family (Blank, Hawks and Keene, 2001 ; Lemone and Burke, 2008). A Clinical pathway is a standardized multidisciplinary care plan that projects the expected course of the patient's treatment and progress over the hospital stay. It is a method for describing the plan of care by predicting the course of patient's hospital stay and prescribing the care and out comes on a day by day basis. It provides clinical practice guidelines for health care professionals in hospitals, home health care, and long term care. (Blancett, 2007). 2 -

10 Patient is an immense challenge for the acute care multidisciplinary team; clinical pathway needs to maintain a comprehensive knowledge base to provide the care management that is essential to the care of patient with traumatic spinal cord injury. With the active participation of the patient and family in care delivery decisions, the health care professional can help to assess the psychosocial and physical needs of the patient and family (Journal of Advanced Nursing. 2005). Aim of the Study: This study aims to:- 1-Assess the needs of patients with traumatic spinal cord injury. 2-Develop clinical pathway map for patients with traumatic spinal cord injury based on their need assesment Research questions -Is the current management of patient with traumatic spinal cord injury at the research site apply clinical pathway? - Is the Develop clinical pathway map valid and reliable to be applied in the future for such group of patients? Subject and Methods: -Technical design: Research design: It is Descriptive study Setting: The study will be conducted in The Emergency Unit, in Eldmrdash hospital Subjects: 1- The patients - Based on 2008 year statistics 300 patients were admitted to Eldmerdash hospital with traumatic spinal cord injury so 10% of this number will be select as research subject for this study. 3 -

11 2- The staff a-the multidisciplinary team physician, nurses, physical therapists, technicians, pharmacists, speech therapists, case manegers whom will be responsible about applying the clinical path way map b- All the available nurses working in the emergency and caring the With traumatic spinal cord injury Selection criteria: All adult patients with traumatic spinal cord injury for both sex Tools of data collection: -Questionnaire sheet and check list to assess emergency staff performance while management patients with traumatic Spinal cord injury -Opinionnaire sheet to the multidisciplinary team whom will be responsible about applying the clinical pathway -The Develop clinical pathway map for patients with traumatic spinal cord injury based on available literature review Ethical considerations: Prior to the pilot study, ethical approval will be obtained from the Scientific Research Ethical Committee of Ain Shams University. In addition written informed consent will be obtained from each participant.they will be assured that anonymity and confidetiality would be guaranteed and the right to withdraw from the study at any time. Administrative design: Approval to carryout this study will be obtained from directors of Ain shams university hospitals. ٤ -

12 Statistical design: The data obtained will be synthesized, analyzed, and presented in numbers, percentages, in tables, figures and diagrams as required and suitable statistical tests will be used to test the significant of results obtained Discussion: Discussion of obtained results will be done in the light of review of international and local literature relevant to the study. Conclusion and Recommendation: Summary: It will be derived from the results of the study. It will present in brief various aspects of the study ٥ -

13 Reference Black,J.M., and Hawks.J.H.,(2005): Medical Surgical Nursing,7 th ed,elservier saunders, USA,PP Blancett,G.,(2007);The Implementation of clinical pathway, Carondelet Health Network, A workplace Excellence Award Winner.2(1) Blank, J.M.; Hawks.J.H.and Keene.A.M, (2001): Medical Surgical Nursing,6 th ed, Saunders company, USA,PP Vol. 14, Iss. 3British Journal of Nursing, 10 Feb 2005, pp Danials,R.;Nasek.L,and Nicoll,L.,(2007):Contemporary Medical Surgical Nursing,1 st ed Thomson,USA,p Mahon, Pamela Young MA, RN, CNAA Journal of Advanced Nursing. 24(6): , December National Center for Injury Prevention and Control.Injury Fact Book (2005) Lemone,P.,Burke,K.,(2008):Medical Surgical Nursing 4 th ed,person Prentice hall,usa,p813 Phipps,W.J.;Marck,J.F;Monahan,F.D;Nighbors,M.;Sands,J. and Green,C.J.(2003): Medical Surgical Nursing Health and Illnes Perspective,7 th ed., Mosby,Toronto,USA,P614 Pryzby, B. (2005). Effects of nurse caring behaviours on family stress responses in critical care. Intensive and Critical Care Nursing, 21(1), Smeltzer.S.,and Bore.B.G,(2000): Medical Surgical Nursing, 9 th ed,lippincott,london,p 985. Timby.K.B.,and Smith.E.N.,(2007):Introductory Medical Surgical Nursing, 9 th ed. Lippincott Williams Wilkins,London,P2217,2220 ٦ -

14 Content Content Title Page List of tables Abstract... Introduction and aim of the study 8 Review of literature... - Anatomy and physiology of nervous system 9 - Anatomy and physiology of spinal cord.9 - Definition of spinal cord injury 14 - Incidence &prevalence of spinal cord injury 16 - Pathophysiology of spinal cord injury 18 - Etiology and risk factors of spinal cord injury 20 - Classifications of spinal cord injury 23 - Clinical manifestation of spinal cord injury 26 - Diagnostic studies and procedures 28 - Complications of spinal cord injury 32 - Medical management of spinal cord injury 36 - Surgical management of spinal cord injury 38 - Nursing management of spinal cord injury 43 - Over view of clinical pathway 73 Subjects and methods 83 Results 97 Discussion 128 Conclusion and recommendations 129 Summary 130 References 133 Appendices 146 Arabic summary

15 Acknowledgement First and foremost, I feel always indebted to Allah, the most kind and most the merciful for all his blessing and for given me the will and strength for completion of this work. I wish to express my deep appreciation and gratitude to Professor Dr. Tahany El-Senosy; professor of Medical surgical Nursing, faculty of Nursing, Ain Shams University, words cannot describe how grateful I am for her guidance, valuable support, constructive criticism, and continuous, unlimited help. I would not have been able to start and reach perfection of this work without her. I am deeply grateful to Dr. Neamatalla Gomaa, Lecturer of Medical surgical Nursing, faculty of Nursing, Ain Shams University, for her supervision, help and valuable support and guidance, I am deeply affected by her noble character, perfection, care and consideration. Last but not least, I am grateful to my family and to all those who sincerely helped me to fulfill this work.