NCP of Head Injury

By Dr. Ravindra Patil

NCP means nursing care plan.

Any severe blow to the brain, skull or the scalp is considered a head injury. It ranges from a minor bump to a fractured skull.Along with the neurosurgeons and critical care specialists, nurses have a major role in managing head injury and traumatic brain injury. Nurses have a nursing care plan for managing every type of patients, and similarly they have a nursing care plan or NCP for managing head injury patients.

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Primary Goal

• The primary goal of nursing care plan head injury is to maintain adequate blood supply and improve cerebral blood flow in order to prevent cerebral ischaemia and secondary injury to the brain.
• The intracranial pressure of CSF must also be under control.
• Blood oxygen and CO₂ saturation must be maintained in every nursing care plan of head injury.
• Nursing care plan on head injury must ensure that the patient has no seizures.
• If the patient is unconscious, the NCP for unconscious patient will come into play.

Nursing Diagnosis

Nurses have their own head injury nursing diagnosis. While surgeons operate and physicians decide the medicines, a proper nursing care plan of head injury helps administer medicines and take due patient care. Remember, a critically ill head injury patient needs constant care from his or her head to his or her toes. For a nurse, the head injury is a just one part.

In head injury nursing management, most important is general nursing care which includes eye care, hair care, nail care, intubation and ventilator care, urinary catheter care, intravenous lines care, central line care, feeding and feeding tube care and so on. Over and above all this the nurse will care for the head injury with her nursing care plan for head injury.

If a patient is unable to move or is unconscious, he/she has to be turned over every two hours to prevent pressure sores. Such patients are on diapers and the diapers need to be changed and the area sponged and cleaned. The patient’s body must be sponged at least once or twice a day. Head injury nursing management also includes urinary catheter care.o.

Raised Intracranial pressure [ICP]

Because of various reasons, the pressure of the cerebrospinal fluid [CSF] may increase in head injury patients. The patient will have an optimal cerebral tissue perfusion only with a normal ICP. To maintain normal ICP, in every nursing care plan for head injury, the nurse will monitor the patient’s neurological status by checking the pupils, Level of Consciousness [LOC] and Glasgow Coma Scale [GCS] scores continuously.

Remember, it is the nursing staff who is with the patient 24×7. Only the nurses can observe such changes and report them to the physician, who in turn can take appropriate action.

Any changes in vital signs may be a sign of increased pressure in the brain. An increased ICP causes slowing heart rate, a widening pulse pressure, and irregular respiration.

Every nursing care plan on head injury will check for fluid leakage from the ears and nose. Leakage of a clear liquid from the nose (rhinorrhoea) and ears (otorrhea) might be the cerebrospinal fluid leaking after head injury caused by fractures. Because there is no accumulation of fluid in the brain, there might be no signs of raised ICP.

O2 and CO2 Levels

In a typical ICU patient’s file will be written:

“Keep PO2 between 80 and 100 mmHg and PCO2 between 35 and 38 mmHg.”

These are levels of blood oxygen and carbon-dioxide which are to be maintained by the oxygen administered through nasal prongs, mask, or a tube inside the trachea, a process called “Intubation”. When a patient is intubated, a machine called the “ventilator” controls the patient’s breathing.

In every NCP of head injury, the goal is to prevent prolonged states of hypoxemia (decreased blood level of oxygen) and hypercarbia (increased amount of carbon dioxide). 

Besides all that, look after…

A competent ICU nurse’s nursing management of head injury will avoid any activities and symptoms that increase ICP. They are:

• Keep patient’s head straight
• Do endotracheal suctioning
• Prevent patient’s coughing, vomiting
• Head injury nursing management must prevent bending at the waist
• Reduce Pain
• Prevent Fever
• Don’t allow shivering in the patient

In a good nursing care plan of head injury, although it is essential, it is good to limit suctioning and do hyperoxygenation before suctioning to help keep ICP at bay.

Intracranial monitoring system

Head injury nursing management may have equipment to measure ICP continuously. An ICP that is greater than 15 mmHg should be reported right away.

A nurse must administer medication as ordered to decrease ICP. Medicines used to reduce ICP are:

• Hyperosmotic agents (Mannitol)
• Steroids
• Barbiturates
• Antipyretics
• Muscle relaxants
• Anticonvulsants

Thus, all the above types of medicines are a vital necessity in a nursing care plan for head injury.

Control Seizures

Seizures are caused by many reasons, some of which are:

• Intracranial Bleeding
• Contusion
• Hyponatremia
• Open and closed brain injuries
• Hypoxia
• Protect the patient’s airway during seizure activity.

Every nurse trained in a nursing care plan on head injury must know how to look the above. A good nurse must have her own head injury nursing diagnosis. The above characteristics of seizures must be noted by nurses and recorded:

The worst that can happen during head injury nursing management is patient’s self-injury. To prevent injuries, do this:

• Reduce disturbance
• Pad side rails of the patient’s bed
• Place the bed in the lowest position
• Provide head protection by extra pillows

Every nursing care plan of head injury must assist the patient during the seizure by:

• Turning the patient’s head to the side
• Suctioning if necessary

These measures protect the patient’s airway during and after the seizure.

Anticonvulsants medicines must be given as ordered. Phenytoin is given as an anti-seizure medicine. But it requires close monitoring or toxicity may occur.

Acute Confusion due to increased ICP

ICU nursing care plan for head injury includes very close constant monitoring of the patient’s consciousness. The nurse must check for:

• Assess the patient’s level of consciousness frequently as ordered.
• A change in mental status might indicate an increase in ICP.
• Reorient the patient to person, time, place, and situation frequently.

Memory might be affected. Hence requires frequent repetition of the same information. Informing the patient about their situation might reduce anxiety levels and bring their cognitive status back to baseline.

Talk to the patient

Only in the NCP for unconscious patient will communication with the patient be not be possible. Otherwise in every nursing care plan for head injury, the nurse must talk to the patient often and explain things in short and simple sentences before and throughout the process. Also;

• Promote continuity of care.
• A good nursing care plan of head injury will prevent frequent changes in staff
• Don’t change environment as it might further worsen the patient’s confused state.
• If possible, have the family communicate with the patient via a smartphone.
• Seeing familiar faces and recognizing familiar voices might stimulate memory and help with reorientation.

Deficient Knowledge, Difficult Healing

No patient knows about his head injury. Hence head injury patients are very, very confused. It is a sudden event. Hence the nursing care plan on head injury must factor this in.

Brain injury might affect short-term memory and cause behaviour and mood changes.  Ability to focus and learn new information might be difficult and take more time. Most patients and families have no prior experience with head trauma injuries. In most cases, head injuries arise from very sudden and unexpected events.

Managing the relatives

Whatever good care is taken, it must be communicated to the patients and family members daily. Family members and caregivers are a vital part of the healthcare team.

Head injury nursing management will prepare the patient and family for the need for physical therapy, occupational therapy, speech therapy and home nursing care. This does not raise expectations greatly and helps the family adjust themselves to the new situation.

All in all, along with the surgeon, only a good head injury nursing care plan implemented by committed nurses will make the head injury patient better.

And at Samarth Neuro and Superspeciality Hospital, run by neurosurgeon Dr. Ravindra Patil, this combination of a competent neurosurgeon and the best nursing care is accessible around-the-clock.

Special Note

In the above essay, nurses are mentioned as women only for the sake of convenience. Male nurses are also equally dedicated and capable.

Brain Tumour Surgery Cost in India

By Dr. Ravindra Patil

When the diagnosis is of a brain tumour, the first fear is of death and the second fear is the cost of treatment.

Treatments of tumours is usually of three types, with medicines [called chemotherapy], brain tumour surgery and radiation therapy.

Everyperson will try to seek brain tumour treatment without surgery first because everyone is afraid of surgery. Yes, brain tumour treatment without surgery is possible, but a benign tumour [non-cancerous tumour] is best treated by surgery as it can be removed totally.

Brain tumour treatment without surgery would seem to be so ideal. No need to cut open the skull with the possibility of damaging the brain. What are the types of brain tumour treatment without surgery?

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Chemotherapy

Medical treatment for brain tumour treatment without surgery is called chemotherapy. it uses anti-cancer (cytotoxic) drugs to destroy brain tumour cells. But remember, medicines whether injected or taken orally circulate throughout your body in the bloodstream. Thus the cytotoxic drugs may damage other parts of the body. Besides, it can be difficult to treat brain tumours with some chemotherapy drugs because the drugs cannot cross what is know as the “blood brain barrier”.

A typical a course of chemotherapy treatment may last 6-12 months, consisting of 6-12 cycles. Patients are given chemotherapy for a few days, every few weeks.

Radiation Therapy

There are three main types of treatments. You may need more than one type of treatment.

• First is the External Beam Radiation Therapy (EBRT). For this type, a machine sends the rays of energy to the tumour. This treatment is usually done every weekday over several weeks.
• Internal radiation (brachytherapy). This is also called interstitial therapy. Small seeds of radiation are put inside or near the tumour for a short while. The seeds have to removed in some types of treatments.
• Gamma Knife radiation. This uses radiation beams called gamma rays. The rays are sent from a machine and focused at the tumour from hundreds of angles at the same time. Treatment is usually done in 1 session.However there is no real knife, the precise hammering of the gamma rays has probably given the name: Gamma Knife.

Brain Tumour Operation

This is of course the mainstay of treatment in benign [non-cancerous] brain tumours. Remove it and forget it.

But in many cases all three types of treatments are used in treating brain tumours. The surgeon removes the tumour, the radiation oncologist gives radiation to treat any residual tumour cells and the medical oncologist gives anti-cancer cytotoxic medicines to completely eradicate any cancer cells.

Where?

It seems obvious that brain tumour surgeries can be done only in major cities and in large corporate hospitals. Such hospitals have the best equipment and the best doctors under one roof. But they also charge a lot of money. Brain surgery cost in India or anywhere is always high. But there are reasons for that.

Brain tumours treatments needs a lot of diagnostic workup. Imaging like CT scan, MRI scan and PET scan are required. Then brain tumour operations require a lot of very expensive equipment. The operation theatre itself must be made specially with HEPA filters and laminar airflow.

The equipment inside a brain surgery operation theatre must ideally have a stereotactic frame, surgical navigation andimaging screens apart from the operation theatre lights, operation theatre table, anaesthesia trolley and so on. Special equipment like CUSA [Cavitronic Ultrasonic Surgical Aspirator] may be required, which again adds to the cost.

For recovery after a brain tumour operation requires an intensive care unit [ICU] for a few days. Later on the patient can be shifted to a special room. He/she cannot be put in a general ward as brain tumour patients need special care.

Physiotherapy is necessary after the brain tumour operation. Functional recovery must be slowly gained by appropriate gentle exercise under the supervision of a trained physiotherapist.

Sometimes speech therapy may be required. Other therapies like occupational therapies may be needed.

Sometimes implants or devices are put into the skull or brain and these stay inside the brain forever. Such devices are extremely expensive. They add to brain surgery cost in India.

Lastly but also very importantly, hospitals in metropolitan or cosmopolitan cities occupy land that is very, veryhigh-priced. That also coverts to higher costs of every brain tumour treatment patient. Building a new hospital in a city like Mumbai is unthinkable even for large corporates because of the high cost of land.

A good hospital in a small town

Not surprisingly, lot of overhead costs are reduced when there is a good hospital with a good team of medical and paramedical professionals in a small town.

Samarth Neuro and Superspeciality Hospital is a good example of a Corporate Hospital in smaller twin towns of Miraj and Sangli in the south of the state of Maharashtra in India.

Dr Ravindra Patil, a gold medallist neurosurgeon heads Samarth Neuro and Superspeciality Hospital. They do lots of brain tumour surgeries there. Their outcomes are comparable to brain tumour operations done anywhere in India.

And Samarth Neuro and Superspeciality Hospital charges much less as compared to the cost of brain tumour operations in cosmopolitan or metropolitan cities.

There are many reasons that the cost of brain tumour surgery in India is lesser in smaller cities and towns. It starts from lower cost of land, less land revenue, smaller distances https://marry.ua/ to the city centre and relatively easier approachability.

Dr Ravindra Patil trained in large cities and did thousands of surgeries  before he decided to settle in his home-town smaller cities of Miraj and Sangli. His aim was to to serve his fellow citizens and also to get away from the crowds. But the biggest reason was that he could build a sustainable hospital in these smaller tier two cities. Thus began the journey of Samarth Neuro and Superspeciality Hospital alongwith Dr Ravindra’s surgical skills.

He began with small brain tumour operations and soon increased his services to head injuries and road traffic accidents and surgeries for many other brain disorders. Today Dr Ravindra is one of the foremost neurosurgeons in south Maharashtra and Samarth Neuro and Superspeciality Hospital has top end equipment for nearly every brain tumour operation. Apart from CT Scanner and well-equipped operation theatres with laminar air flow and HEPA filters, his hospital has Surgical Navigation systems for ultra-precision brain tumour operations of different types.

But what is the cost?

One website promotes medical tourism in India has shown the following rates of brain tumour operation or surgeries in India in different cities. Again, the figures are only general and for advertisement. The cost for brain tumour surgery in India or anywhere will depend on the type of the brain tumour operation.

• Bengaluru INR 1,25,000 – INR 3,60,000
• New Delhi INR 1,20,000 – INR 3,95,000
• Mumbai INR 1,30,000 – INR 4,90,000
• Gurgaon INR 1,25,000 – INR 3,60,000
• Chennai INR 1,35,000 – INR 3,10,000
• Hyderabad INR 1,15,000 – INR 3,80,000
• Add to the above the cost of travelling plus cost of food and stay of the accompanying person/s in the above cities

It can be seen that the brain tumour surgery cost in Indiain most cities is somewhat same except in Mumbai, where the brain tumour surgery cost is the highest. But that is because Mumbai is one of the costliest cities to live in.

As has been mentioned, the brain tumour surgery cost increases in major cities because of the infrastructure, the land cost, the staff salary cost, the local taxes, cost of electricity, cost of CNG, cost of medicines, medical gases and consumables,  all of which attract additional surcharges.

And not surprisingly, each and every thing of the above comes at a much lower cost in tier two or tier three cities.

However, if the skill of the leaders of the surgical team is the same, automatically the brain tumour surgery cost is reduced!

And that is why Samarth Neuro and Superspeciality Hospital headed by neurosurgeon Dr Ravindra Patil offers treatments like complex brain surgeries at a much reasonable cost in the towns of Miraj and Sangli in India. The bill for a complex surgery on a baby was only Rs 200,000 [rupees two lakhs].

AND REMEMBER, THE BABY’S FAMILY DID NOT HAVE TO INCUR ADDITIONAL COSTS IN TRAVELLING TO AND STAYING IN THE LARGER CITIES, WHICH SOMETIMES DOUBLES THE COST!

We discussed Parkinson’s disease, which is is a progressive nervous system disease that affects movement, expression, speed and so on. 

In the second part, we discuss surgical treatment and living with Parkinson’s disease. 

Table of Contents

Surgical procedures

Surgery for Parkinson’s disease is ‘Deep Brain Stimulation’ [DBS]. Surgeons implant electrodes in the brain. The other ends of the electrodes are connected to a generator implanted in the patient’s chest near the collarbone. It may reduce symptoms of Parkinson’s disease.

DBS is effective in controlling erratic and fluctuating responses to levodopa or for controlling dyskinesia that doesn’t improve with medication adjustments.

DBS is offered to patients with advanced Parkinson’s disease, who have unstable Levodopa responses. It can stabilize medication fluctuations, reduce dyskinesia, tremor, rigidity and slowing of movements. Risks of DBS are infection, Cerebrovascular Stroke or brain haemorrhage. 

Lifestyle Changes & Home Remedies

While no food or combination of foods has been proved to help in Parkinson’s disease, some foods may help ease symptoms. Eating foods high in fiber and drinking an adequate amount of fluids can help prevent constipation which is common in Parkinson’s disease. A balanced diet also provides omega-3 fatty acids, which are beneficial for Parkinson’s disease patients.

Exercise

Exercise may increase patient’s muscle strength, flexibility and balance. It also helps improve the sense of well-being and reduces depression. Best exercises are walking, swimming, gardening, dancing, water aerobics, or stretching.

Parkinson’s disease can disturb the sense of balance, making a normal gait difficult. Exercise may improve gait. These are special suggestions for patients:

Try not to move too quickly

Aim for your heel to strike the floor first when you’re walking. Avoid shuffling, walk erect, and look in front, not at the ground, while walking.

Avoid falling down

Patients in the later stages of Parkinson’s fall more easily. To prevent falls, do this:

• While walking, take a U-turn instead of pivoting your body over your feet.
• Distribute your weight evenly between both feet, and don’t lean or stoop.
• Avoid carrying things while you walk.
• Avoid walking backward.

Daily living activities

Daily living activities — such as dressing, eating, bathing, and writing — can be difficult for people with Parkinson’s disease. An occupational therapist can help.

Alternative medicine

Supportive therapies can help ease some of the symptoms and complications of Parkinson’s disease, such as pain, fatigue and depression when performed in combination with medical treatment.

• Massage can reduce muscle tension and promote relaxation. 
• Tai chi is an ancient form of Chinese exercise. It employs slow, flowing motions that may improve flexibility, balance, and muscle strength and may help prevent falls. 
• Yoga through gentle stretching movements and poses may increase flexibility and balance. 
• Meditation, in which the patient quietly reflects and focuses his/her mind on an idea or image. Meditation may reduce stress and pain and improve your sense of well-being. 
• Having a pet dog or a pet cat may increase your flexibility and movement and improve your emotional health.

Coping with Parkinson’s disease Problems

It’s normal for patients to feel angry, depressed or discouraged at times, as walking, talking and even eating become more difficult and time-consuming.

Depression is common but antidepressant medications help ease the symptoms of depression.

Family and friends are the best support group for patients. Support groups offer a place for patients and their families to find people who are going through similar situations and that helps greatly. Psychologists or social workers trained in working with people who have chronic conditions are also helpful, if available.

Preparing for the specialist’s appointment

Because there’s often a lot to discuss, it’s a good idea to prepare for your appointment. 

1. Write down any symptoms you’re experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment. 
2. Write down key personal information, including any major stresses or recent life changes.
3. Make a list of all medications, vitamins and supplements that you’re taking. 
4. A family member or friend should accompany the patient, if possible. https://kmcentr.com.ua Sometimes it can be difficult for the patient to remember all the information provided by the doctor during the consultation. If someone accompanies you, he/she may remember the advice. 
5. Write down questions to ask your doctor, because your time with your doctor is limited. 
6. Some important questions for Parkinson’s disease patients are: 
   • What’s the most likely cause of my symptoms? 
   • Are there other possible causes? 
   • What kinds of tests do I need? Do these tests require any special preparation? 
   • How does Parkinson’s disease usually progress? 
   • Will I eventually need long-term care? 
   • What treatments are available, and which do you recommend for me? 
   • What types of side effects can I expect from treatment? 
   • If the treatment doesn’t work or stops working, do I have additional options? 
   • I have other health conditions. How can I best manage these conditions together? 
   • Are there any brochures or other printed material that I can take home with me? 
   • What websites do you recommend?

In addition to the questions that you’ve prepared to ask your doctor, don’t hesitate to ask questions that occur to you during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Be ready to answer them. Your doctor may ask:

1. When did you first begin experiencing symptoms?
2. Do you have symptoms all the time or do they come and go?
3. Does anything seem to improve your symptoms?
4. Does anything seem to make your symptoms worse?

To Summarise…

Parkinson’s disease has no perfectly known causes and no cure at present. New research will surely bring some help to patients. 

But everything is not gloomy with Parkinson’s disease. Medicines, exercise, and occupational therapy ease symptoms hugely, improve quality of life, and increase the life span. And most importantly, people learn to live with Parkinson’s disease.