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Copyright @ 2010 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

Nursing Interventions for Critically IllTraumatic Brain Injury Patients

Molly M. McNett, Anastasia Gianakis

ABSTRACTNeuroscience intensive care unit (ICU) nurses deliver a number of interventions when caring for criticallyill traumatic brain injury (TBI) patients. Yet, there is little research evidence documenting specificnursing interventions performed. As part of a larger study investigating ICU nurse judgments aboutsecondary brain injury, ICU nurses were asked to identify interventions routinely performed whencaring for TBI patients. Quantitative and qualitative analyses indicate that all nurses routinely monitoredhemodynamic parameters such as oxygen saturation, blood pressure, and temperature. Nurses wereresponsible for monitoring intracranial pressure and cerebral perfusion pressure approximately 50% ofthe time. Qualitative analyses revealed that additional nursing interventions could be categorized asneurophysiological interventions, psychosocial interventions, injury prevention interventions, andinterventions to maintain a therapeutic milieu. Findings from this study provide evidence of themultifaceted role of the neuroscience ICU nurse caring for TBI patients and can be used in future researchinvestigating the impact of nursing interventions on patient outcomes.

Traumatic brain injuries (TBIs) account for over200,000 hospital admissions every year in theUnited States, costing over 3.2 billion health-

care dollars annually (Langlois, Rutland-Brown, &Thomas, 2006; Russo & Steiner, 2007). It is es-timated that 71% of TBI hospitalizations are for pa-tients with severe injuries necessitating critical caremonitoring (Russo & Steiner, 2007). Neuroscienceintensive care unit (ICU) nurses deliver a myriad ofinterventions when caring for these critically ill TBIpatients. Yet, there is little research evidence docu-menting specific interventions performed. This in-formation is needed to highlight the autonomy androle of the neuroscience ICU nurse when caring forcritically ill TBI patients and as a basis for future re-search investigating how nursing interventions im-pact patient outcomes. Therefore, the purpose of thisarticle was to present findings from a research studyin which neuroscience ICU nurses described inter-ventions routinely performed when caring for TBIpatients.

BackgroundDescriptions of Nursing InterventionsSeveral reports identify nursing interventions forcritically ill TBI patients. Although these reports are

not based on research evidence, they do provide gen-eral descriptions of ICU nurse responsibilities whencaring for TBI and other neurologically impaired pa-tients (Ladanyi & Elliot, 2008; Littlejohns & Bader,2009; Olson & Graffagnino, 2005; Presciutti, 2006;Wong, 2000). Responsibilities include monitoring pa-tient physiological parameters and ensuring hemo-dynamic stability, performing serial neurologicalexaminations, preventing secondary injury, and pro-viding emotional support for patients and families(Chamberlain, 1998; Olson & Graffagnino, 2005;Presciutti, 2006). More recently, ICU nurses are in-volved with advanced technologies, such as moni-toring and maintenance of brain tissue oxygenationand monitoring electroencephalograph and bispec-tral index readings (Albano, Comandante & Nolan,2005; Bader, Littlejohns, & March, 2003; Littlejohns& Bader, 2009). Collectively, these described inter-ventions comprise the multifaceted role of nurses car-ing for TBI patients in the ICU, where technical andinterpersonal competencies are crucial.

Nursing Priorities of CareThe interventions described earlier are often guidedby nursing priorities that have been identified inthe research literature (Fonteyn & Fisher, 1994;Villanueva, 1999). Two qualitative studies specifi-cally describe nursing priorities and associated inter-ventions when caring for critically ill neurologicallyimpaired patients. A key priority when caring for un-conscious patients is ‘‘giving the patient a chance,’’ inwhich interventions center on learning about thepatient, maintaining and monitoring patient status,talking to the patient, and working with the family(Villanueva, 1999).

Volume 42 & Number 2 & April 2010 71

Question or comments about this article may be directed toMolly M. McNett, PhD RN, at [email protected]. Sheis a senior nurse researcher at MetroHealth Medical Center,Cleveland, OH.

Anastasia Gianakis, BSN RN CCRN, is a nurse manager atNeurosurgical, Spine, and Surgical Intensive Care Unit,MetroHealth Medical Center, Cleveland, OH.

Copyright B 2010AmericanAssociation ofNeuroscienceNurses


In a separate study, nurse priorities when caringfor postoperative craniotomy patients are the fol-lowing: (a) The patient will become responsive and(b) the patient will remain hemodynamically stable(Fonteyn & Fisher, 1994). Nursing interventionsrelated to these priorities include assessments of pa-tients’ level of consciousness or neurological status,blood pressure (BP), breath sounds, temperature,amount of respiratory secretions, central venous pres-sure, heart rate and rhythm, pulse pressure, andarterial blood gases. These studies contribute in-formation about nursing priorities guiding interven-tions for neurologically impaired patients in theICU. However, findings from these studies are limitedby small sample sizes (n = 16 and n = 3, respec-tively), and interventions described are not specificto the complex care often required for critically illTBI patients.

Factors Influencing Nurse InterventionsThe presence of external factors can influence nurs-ing interventions performed with neurologically im-paired patients (Cook, Deeny, & Thompson, 2004;McNett, 2009; McNett, Doheny, Sedlak & Ludwick,2009). Nursing judgments about appropriate inter-ventions when managing secondary brain injury incritically ill TBI patients are influenced by worsen-ing values for oxygen saturation, intracranial pres-sure (ICP), cerebral perfusion pressure (CPP), andnursing shift. Nurses are less likely to rely solely onnursing interventions and more likely to consult an-other member of the healthcare team as values foroxygen saturation, ICP, and CPP fall farther from rec-ommended parameters. In addition, nurses workingday shift are more likely to rely solely on nursing in-terventions and less likely to consult other healthcareteam members than are their night shift colleagues(McNett, 2009).

When managing subarachnoid hemorrhage, neu-roscience ICU nurses are influenced by knowledgeof current standards and therapies for fluid and hy-dration management. Judgments about interventionscenter on the nursing process of assessment, plan-ning, implementation, and evaluation. Using this pro-cess, nurses rely on patient cues, such as physicalappearance, recorded intakeYoutput, and neurologicalstatus when determining need for interventions (Neal& Deeny, 2004). When managing fever in neurolog-ically impaired patients, nurses describe decisionsabout interventions being influenced by the individualnurse, the patient, and the barriers present within theorganization or nursing unit (Thompson, Kirkness &Mitchell, 2007).

The studies mentioned contribute informationabout nursing priorities and factors influencing

nurse interventions for neurologically impaired pa-tients. However, there is no research evidence docu-menting specific interventions performed by ICUnurses when caring for critically ill TBI patients.The purpose of this article therefore was to presentfindings from a research study in which neurosci-ence ICU nurses reported routine interventions ad-ministered when caring for TBI patients.

MethodsProceduresThe findings presented here are part of a largerstudy investigating ICU nurse judgments about sec-ondary brain injury using a prospective factorial sur-vey research design (McNett, 2009; McNett et al.,2009). Approval for the study was obtained from theinstitutional review boards and nursing administra-tion at both study sites. An anonymous survey wasadministered to 67 nurses working in three ICUsfrom two level I trauma centers who routinely carefor critically ill TBI patients. Both study sites weredesignated as level I trauma centers by the AmericanCollege of Surgeons and were classified as largeteaching hospitals. Both were similar in terms ofdelivery and structure of nursing care, staffing ratios,and nurse characteristics. Study site A had a largertrauma volume, admitting approximately 3,000 traumapatients per year, whereas study site B averaged1,000 trauma admissions annually. Study site A hadrecently identified the Guidelines for the Manage-ment of Severe Traumatic Brain Injury (Brain TraumaFoundation, American Association of NeurologicalSurgeons, The Joint Section on Neurotrauma of Crit-ical Care, 2007) as a reference to guide care of thecritically ill TBI patient in their ICUs. However,there were no standing order sets or standardizedcare plans in place for critically ill TBI patients ateither study site.

Nurses from both sites were invited to participatein the study if they held an active state license as aregistered nurse; were employed full-time, part-time,

Extrinsic factors as disparate

as worsening oxygen saturation

and shift worked can influence

the interventions nurses

employ with neurologically

impaired patients.

Journal of Neuroscience Nursing72


or per diem as a clinical bedside nurse in an ICU thatadmits critically ill TBI patients; and were employedin the current ICU for a minimum of 3months. Nurseswere excluded if they did not have experience caringfor critically ill TBI patients, were currently in nursingorientation, or were not directly responsible for thecontinuous bedside monitoring and delivery of careto critically ill TBI patients in that ICU. A poweranalysis indicated that a sample size of 60 would besufficient to detect a medium small effect size of .20with a power of .80.

Nurses in the ICU were approached during unitstaff meetings and change-of-shift report times andinvited to participate in the study. The study surveyhad three parts: Part A contained a series of ques-tions about the last TBI patient nurses cared for intheir unit and interventions typically performed whencaring for these patients, part B contained case sce-narios in which nurses were asked to indicate judg-ments they were most likely to make, and part Cgathered demographic information about nurse re-spondents. Findings from the latter two survey sec-tions have been previously reported (McNett, 2009). Inthis article, findings from survey part A (nurse inter-ventions) are presented.

Part A of the study survey contained six fixed-response questions about the last TBI patient nursescared for in their ICU. Nurses were asked how longago they took care of a TBI patient, which physio-logical parameters they were responsible for man-aging, and the patient’s mechanism of injury, age,gender, and comorbidities. Content for these ques-tions was derived from an extensive review of theliterature describing various nursing interventionsand was validated by a team of clinical nurses andtwo clinical nurse specialists who routinely care forcritically ill TBI patients. A final open-ended ques-tion on the study survey asked nurses to identifyusing free-text responses what interventions theyperformed when caring for this patient.

Data AnalysisDescriptive analyses, including means, standard de-viations, and frequencies, were performed, with thequantitative data gathered from the fixed-responsequestions on the study survey. Methods for quali-tative data analyses outlined by Pope and Mays(1999) were then performed with the free-text re-sponses nurses provided. All free-text responses wererecorded and systematically reviewed using first-levelcoding to identify recurring phrases and common-alities among responses. The constant comparisonmethod was used to ensure that the identified codeswere inclusive of all data. These first-level codes werethen reviewed and grouped into larger categories

using second-level coding, which described the typesof interventions performed by nurses. The recordeddata, initial codes, and overall themes were reviewedby a second investigator with extensive neurocriticalcare experience to validate the findings.

ResultsStudy SampleTable 1 presents a summary of the characteristics ofnurse respondents. A total of 67 nurses returned com-pleted surveys, yielding a 44% response rate. Mostnurses in the study were between the ages of 26 and40 years (64%), Caucasian (92.4%), and women(76.1%). Many nurses had less than 10 years of ex-perience working in the ICU (70.1%) and caring

TABLE 1. Summary of NurseCharacteristics

Demographic Characteristics % n

Age (years)

25 or younger 9 6

26Y40 64 43

41Y50 18 12

51 or older 9 6

Gender

Male 23.9 16

Female 76.1 51

Ethnicity

Caucasian 92.4 61

Other 7.5 5

Years in intensive care unit

0Y10 70.1 47

11Y20 19.4 13

21 or more 10.4 7

Years with traumatic brain injury

0Y10 74.6 50

11Y20 16.5 11

21 or more 9.0 6

Highest nursing degree

Associate degree 22.4 15

Nursing diploma 19.4 13

Bachelor of science in nursing 58.2 39

Primary shift

Days 25.4 17

DayYNight 29.9 20

DayYEvening 10.4 7

Evening 1.5 1

Nights 32.8 22



for TBI patients (74.6%). Over half of the nurses(58%) held bachelor degrees, and primary shiftsincluded days (25.4%), dayYnight rotating (29.9%),dayYevening rotating (10.4%), evenings (1.5%), andnights (32.8%).

Quantitative DataDescriptive analyses were used to analyze the firstsix questions on the study survey. ICU nurses wereasked to indicate how long ago they last cared for aTBI patient in their unit and which physiologicalparameters they were responsible for managing andto identify the patient’s mechanism of injury, gen-der, age, and comorbidities. Table 2 provides a sum-mary of ICU nurse responses.

All ICU nurses had cared for a critically ill TBIpatient either within the last week (65.7%) or month(34.3%). ICU nurses indicated that they were re-sponsible for monitoring BP, oxygen saturation, andtemperature among all of these recent patients. Ap-proximately 50% of nurses indicated that they werealso responsible for monitoring ICP and CPP. Mostnurses described their most recent TBI patients asmale patients (85%), between the ages of 36 and 65years (55.2%), and being injured from amotor vehiclecrash (46.3%). Over 60% of patients recently caredfor by nurses had also experienced extracranial in-juries requiring additional nursing care, and smallerpercentages of patients had other comorbidities, suchas hypertension (34.3%) or diabetes (14.9%).

Qualitative DataNurses in the ICU were then asked to identify ad-ditional nursing interventions performed when car-ing for their most recent TBI patient. Qualitativeanalyses of these responses indicated that inter-ventions could be grouped into four categories:neurophysiological interventions, psychosocial inter-ventions, injury prevention interventions, and inter-ventions to maintain therapeutic milieu. Figure 1displays each category and the corresponding inter-ventions reported by nurses.

Neurophysiological InterventionsNurses in the ICU reported being responsible formonitoring and maintaining various physiologicalparameters to ensure neurological stability in patients.Consistent with their responses to the quantitativequestions, nurses described monitoring patient oxy-gen saturation, BP, ICP, CPP, and temperature. Inaddition to these parameters, nurses also monitoredpulmonary artery and central venous pressure read-ings, cerebral spinal fluid drainage, serial laboratoryvalues, and carbon dioxide parameters. By keeping

these values within acceptable limits, nurses were pre-venting secondary brain injury and promoting neuro-logical stability. Additional interventions to monitorneurological stability included performing neurolog-ical assessments at a minimum of every hour andtransporting and monitoring patients for computedaxial tomography scan and magnetic resonance im-aging testing. Several nurses also cited assisting withbrain death examinations and preparing patients fororgan donation as other interventions.

Within this category of neurophysiological inter-ventions, nurses provided evidence of specific in-terventions performed to ensure that the mentionedphysiological parameters remained within normal

TABLE 2. Characteristics of MostRecent TBI Patient

Last Case Information % n

Last time cared for TBI patient

Within last week 65.7 44

Within last month 34.3 23

Parameters responsible for managing

BP 100 67

O2Sat 100 67

Temperature 100 67

ICP 52.2 35

CPP 50.7 34

Other 16.4 11

Patient mechanism of injury

Motor vehicle accident 46.3 31

Fall 34.3 23

Assault 10.4 7

Other 9.0 6

Patient gender

Male 85.1 57

Female 14.9 10

Patient age (years)

18Y35 29.9 20

36Y65 55.2 37

66Y85 10.4 7

Over 85 4.5 3

Patient comorbidities

Extracranial injuries 61.2 41

Hypertension 34.3 23

Diabetes mellitus 14.9 10

Other 10.4 7

Note. TBI = traumatic brain injury; BP = blood pressure;O2Sat = oxygen saturation; ICP = intracranial pressure;CPP = cerebral perfusion pressure.



limits. To obtain acceptable values for oxygen satu-ration, nurses cited being responsible for ventilatormanagement and suctioning. To keep BP, ICP, andCPP within normal limits, nurses administered medi-cations such as mannitol, propofol, and narcotics andkept the patient’s head of bed elevated and neck ina midline position. Nurses also administered bloodproducts and closely monitored intakeYoutput to en-sure adequate circulating blood volume, thus promot-ing cerebral perfusion.

Psychosocial InterventionsNurses in the ICU described delivering a variety ofinterventions that were psychosocial in nature. In-terventions in this category involved coordinatingmeetings and communication between family mem-bers and various members of the healthcare team,both in the acute (i.e., coordinating with physiciansor organ donation teams) and long-term plans ofcare (i.e., coordinating with case management, so-cial work). ICU nurses also provided education tofamily members about the plan of care, possible pa-tient outcomes, and rationale for current therapies.Finally, nurses described simply serving as a sourceof support for family members by listening and pro-viding necessary reassurance.

Injury Prevention InterventionsThe third type of interventions reported by nurses in-cluded those aimed at preventing additional patientcomplications and ensuring patient safety. Within thiscategory, some interventions were specific to TBI pa-tients, such as maintaining spine precautions and fre-quently reorienting patients. Other interventions wereconsidered routine care for any critically ill patient.These included frequent turning and repositioning ofpatients to prevent complications of immobility, suchas skin breakdown and ventilator-associated pneumo-nia. ICU nurses also reported ensuring patient safetyby preventing falls and determining the need for andmonitoring restraint use to prevent disruption of medi-cal devices. All interventions in this category were de-livered to ensure a safe environment for patients andto prevent further injury.

Maintaining Therapeutic MilieuThe final category of interventions reported by nursesincluded those performed to maintain a therapeuticenvironment for the critically ill TBI patient. Theseinterventions included intangible care given by nursesconsidering the special needs of TBI patients. Spe-cifically, nurses reported working to limit environ-mental stimuli for patients. Interventions included

FIGURE 1 Nurse Interventions for Critically Ill Traumatic Brain Injury PatientFIGURE 1



regulating visitors, decreasing lighting, and mini-mizing noise. Many nurses also cited spacing nurs-ing activities to allow for adequate rest periods andto limit increases in ICP.

DiscussionNeuroscience ICU nurses have an integral role inthe care of the critically ill TBI patient. Interven-tions routinely performed prevent secondary braininjury and patient complications and provide thenecessary support and guidance for family mem-bers. Yet, there is no research documenting specificinterventions associated with this multifaceted role,neither is there data indicating positive outcomesassociated with these nursing interventions. Thesedata are needed to acknowledge the unique contri-bution of ICU nurses as part of the interdisciplinaryteam caring for TBI patients and as a basis for fu-ture research investigating how ICU nurses impactpatient and family recovery from TBI during theacute stage of injury.

Findings from this study support the anecdotal de-scriptions of ICU nurse responsibilities when caringfor neurologically impaired patients (Chamberlain,1998; Ladanyi & Elliot, 2008; Littlejohns & Bader,2009; Presciutti, 2006). The four categories of in-terventions described indicate that neuroscience ICUnurses must possess extensive knowledge of the path-ophysiological processes associated with primary andsecondary brain injury. Nurses must also have thetechnical skills to effectively manage these processesand ensure neurological stability. Finally, excellentinterpersonal skills are crucial to communicate withfamilies and other members of the healthcare team.

When examining the interventions reported bynurses, it is interesting to note that most interven-tions were classified as neurophysiological, whichcentered on ensuring the neurological and physio-logical stability of the patient. This finding is sup-ported by findings from the larger study in whichthe physiological parameters, specifically a patient’soxygen saturation, ICP, and CPP, were the most sig-nificant variables influencing ICU nurse judgmentswhen caring for TBI patients (McNett et al., 2009).This is consistent with smaller qualitative studiesconcluding that maintenance of physiological andneurological parameters is a priority when caring forneurologically impaired patients (Fonteyn & Fisher,2004; Villanueva, 1999). Thus, although the ICUnurse caring for critically ill TBI patients is re-sponsible for a number of interventions, it doesappear that stabilizing the patient’s physiologicalparameters and neurological status is the key pri-ority. This certainly is of utmost importance because

these factors ultimately are what influence patientmortality and outcome.

The study is limited by the fact that data were onlygathered from two study sites in one geographicallocation. As a result, findings may not be general-izable to all neuroscience ICU nurses. In addition,nurses in this study were asked to recall interventionsthey performed with previous TBI patients and there-fore may not remember all interventions deliveredwhen caring for that patient. It is likely that additionalinterventions were done but not necessarily reportedby the nurses in the study. Despite these limitations,findings do provide baseline evidence of specific in-terventions of ICU nurses. This information is neces-sary for future research investigating the impact ofthese interventions on outcomes.

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For more than 33 additional continuing education articles related to Neurological topics, go towww.NursingCenter.com/CE.


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