Pielęgniarstwo Neurologiczne i Neurochirurgiczne

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1 Pielęgniarstwo Neurologiczne i Neurochirurgiczne THE JOURNAL OF NEUROLOGICAL AND NEUROSURGICAL NURSING eissn: ISSN: March 2016 Volume 5 Issue 1 Pages 1 36 Contents/Spis treści Editorial/Od Redakcji 3 Original/Artykuły oryginalne The Symptoms of Depression and the Sociodemographic Factors in Patients with Multiple Sclerosis Symptomy występowania depresji a czynniki socjodemograficzne chorych ze stwardnieniem rozsianym Dorota Winiecka, Joanna Olkiewicz, Robert Ślusarz 4 Strategies for Coping with Neuropathic Pain and Impact of Pain on the Functional Condition of Patients Strategie radzenia sobie z bólem neuropatycznym oraz wpływ dolegliwości bólowych na stan funkcjonalny chorych Małgorzata Kołpa, Beata Jurkiewicz, Ewa Mężyk 10 Knowledge of Medical Staff on Medical Segregation of Patients Having Suffered in Mass Accidents and Disasters Wiedza pracowników personelu medycznego na temat segregacji medycznej poszkodowanych w wypadkach masowych i katastrofach Katarzyna Sienkiewicz, Dorota Kulina, Katarzyna Przylepa, Irena Wrońska 16 Evaluation of Pain and Fear Associated with Putting on the Stereotactic Frame in Patients Planned for the Biopsy of a Brain Tumour with the Possibility of the Pharmacological Alteration Ocena bólu i lęku związanego z założeniem ramy stereotaktycznej u pacjentów planowanych do biopsji guza mózgu z możliwością modyfikacji farmakologicznej Anna Raszka, Ewa Kociniewska, Aleksander Goch 21 Review/Artykuły poglądowe Rapid Sequence Intubation for Head Injury Patients. A Practice Sekwencja Szybkiej Intubacji u pacjentów z urazami głowy. Praktyka Paweł Witt, Wojciech Leśniak 28 Clinical, Therapeutic and Caring Aspects of Epilepsy at the Developmental Age Kliniczne, terapeutyczne i opiekuńcze aspekty padaczki w wieku rozwojowym Ewa Kontna, Marta Lewicka, Bogumiła Małecka, Ewa Barczykowska 31

2 PIELĘGNIARSTWO NEUROLOGICZNE I NEUROCHIRURGICZNE THE JOURNAL OF NEUROLOGICAL AND NEUROSURGICAL NURSING International Scientific Board/ Editorial Board/Rada Redakcyjna Editor-in-Chief/Redaktor naczelny Robert Ślusarz (UMK, CM, Bydgoszcz, Polska) Deputy Editors/Zastępcy redaktora naczelnego Beata Haor (PWSZ, Włocławek, Polska) Monika Biercewicz (UMK, CM, Bydgoszcz, Polska) International Editors/Redaktorzy międzynarodowi Janice L. Hinkle (The Catholic University of America, USA) Catheryne Waterhouse (Royal Hallamshire Hospital, Sheffield, UK) Managing Editor/Sekretarz redakcji Anna Antczak (UMK, CM, Bydgoszcz, Polska) Language Editors/Redaktorzy językowi Mary E. Braine (University of Salford, England) Roksana Rybicka (UMK, CM, Bydgoszcz, Polska) Statistical Editor/Redaktor statystyczny Magdalena Zając (UKW, Bydgoszcz, Polska) Section Editors/Redaktorzy tematyczni Krystyna Jaracz (UM, Poznań, Polska) Pielęgniarstwo neurologiczne Regina Lorencowicz (UM, Lublin, Polska) Pielęgniarstwo neurochirurgiczne Międzynarodowa Rada Naukowa Ewa Barczykowska (UMK, CM, Bydgoszcz, Polska) Monika Biercewicz (UMK, CM, Bydgoszcz, Polska) Mary E. Braine (University of Salford, England) Sharryn Byers (Nepean Hospital Sydney, Australia) Vicki Evans (Royal North Shore Hospital, Sydney, Australia) Theresa Green (University of Calgary, Calgary, Canada) Beata Haor (PWSZ, Włocławek, Polska) Janice L. Hinkle (The Catholic University of America, USA) Krystyna Jaracz (UM, Poznań, Polska) Hatice Kaya (Istanbul University, Istanbul, Turkey) Lenka Kopacevic (Sestre Milosrdnice, University Hospital Center, Zagreb, Croatia) Regina Lorencowicz (UM, Lublin, Polska) Jasna Nikolcic (Special Hospital for Cerebrovascular Disease, Belgrade, Serbia) Alvisa Palese (Udine University, Italy) Virginia Prendergast (Barrow Neurological Institute, Phoenix, Arizona, USA) Joanna Rosińczuk (UM, Wrocław, Polska) Marcelina Skrzypek-Czerko (GUM, Gdańsk, Polska) Robert Ślusarz (UMK, CM, Bydgoszcz, Polska) Catheryne Waterhouse (Royal Hallamshire Hospital, Sheffield, UK) Paul Van Keeken (Radboud University Nijmegen MC, HAN University of Applied Sciences, Netherlands) Editorial Office/Redakcja: Polskie Towarzystwo Pielęgniarek Neurologicznych, ul. Dębinki 7, Gdańsk, Polska Poland tel , redakcjajnnn@gmail.com Published by/wydawca: Polskie Towarzystwo Pielęgniarek Neurologicznych, ul. Dębinki 7, Gdańsk, Polska Poland tel , redakcjajnnn@gmail.com Graphics and Cover/Grafika i okładka: Karolina Janik Polskie Towarzystwo Pielęgniarek Neurologicznych and Editorial Board, Wszelkie prawa zastrzeżone/all rights reserved. Wydawca/Redakcja nie ponosi odpowiedzialności za treść reklam oraz artykuły sponsorowane. The Publisher/Editors accept no responsibility for the advertisement contents and sponsored articles.

3 Editorial/Od Redakcji Dear Readers, It is my great pleasure to introduce the current issue of our quarterly Neurological and Neurosurgical Nursing. The journal is a specialized quarterly and international platform for the exchange of practical experience between experts in the field of neuroscience nursing. The Editorial Staff is proud to announce that starting from 2016 the journal has a new patron. It is Polskie Towarzystwo Pielęgniarek Neurologicznych (PTPN). Last year 24 articles were published including 14 original works, 4 review articles and 6 case studies. The journal was first introduced four years ago and since then the interest in its content has been steadily growing, and now we can observe the journal climbing on the ranking of journals within the field of nursing. Currently the journal is indexed in part B of the journals recognized by the Polish Ministry of Science and Higher Education with 6 points for each published article. I would like to encourage you to further cooperation between you, the readers and authors, and the journal in the creation of Neurological and Neurosurgical Nursing. Articles from Polish and international researchers are very welcome. On behalf of the Editorial Staff and myself I wish to thank you for your commitment, support and valuable contribution to our journal. Editor-in-Chief Robert ŚLUSARZ Szanowni Państwo, Z ogromną przyjemnością przekazuję Państwu do rąk już siedemnasty numer naszego kwartalnika Pielęgniarstwo Neurologiczne i Neurochirurgiczne. Czasopismo jest międzynarodowym specjalistycznym kwartalnikiem i platformą wymiany doświadczeń praktycznych pomiędzy ekspertami w dziedzinie neurosciences nursing. W wyniku wielu starań i mając na uwadze Państwa oczekiwania mam przyjemność poinformować, że od roku 2016 patronat nad czasopismem sprawuje Polskie Towarzystwo Pielęgniarek Neurologicznych (PTPN). W minionym roku wydawniczym, opublikowaliśmy łącznie 24 artykuły, w tym 14 prac oryginalnych, 4 prace poglądowe oraz 6 prac kazuistycznych (opis przypadku). W okresie czteroletniego funkcjonowania kwartalnika zaobserwowaliśmy istotny wzrost zainteresowania artykułami w nim publikowanymi oraz wzrost pozycji w rankingu czasopism z obszaru pielęgniarstwa. Aktualnie czasopismo sklasyfikowane jest w części B wykazu listy czasopism punktowanych Ministerstwa Nauki i Szkolnictwa Wyższego z przyznaną 6 punktową wartością za opublikowanie w nim artykułu. Zapraszamy do wyboru naszego kwartalnika Koleżanki i Kolegów z ośrodków naukowych zarówno z Polski jak i z zagranicy. Zachęcam Państwa do dalszej współpracy i zaangażowania we współtworzenie czasopisma Pielęgniarstwo Neurologiczne i Neurochirurgiczne, jednocześnie przypominając, że to Państwo, jako czytelnicy i autorzy publikowanych prac, współtworzycie czasopismo, do czego w imieniu własnym i Redakcji bardzo Państwa zachęcam i bardzo dziękuję. Redaktor naczelny Robert ŚLUSARZ 3

4 Pielęgniarstwo Neurologiczne i Neurochirurgiczne The Journal of Neurological and Neurosurgical Nursing 2016;5(1):4 9 THE JOURNAL OF NEUROLOGICAL AND NEUROSURGICAL NURSING eissn ISSN Original DOI: /PNN The Symptoms of Depression and the Sociodemographic Factors in Patients with Multiple Sclerosis Symptomy występowania depresji a czynniki socjodemograficzne chorych ze stwardnieniem rozsianym Dorota Winiecka 1, Joanna Olkiewicz 2, Robert Ślusarz 3 1 The Neurology Ward and Rehabilitation Studio at Ludwik Błażek Multispeciality Hospital in Inowroclaw, Poland 2 Neurology Ward and Stroke Unit at W. Biegański Regional Hospital in Grudziądz, Poland 3 Department of Neurological and Neurosurgical Nursing, Faculty of Health Sciences, Nicolaus Copernicus University, Bydgoszcz, Poland 4 Abstract Introduction. Multiple sclerosis is a common, chronic disease of the central nervous system. It is a disorder that causes major changes in an organism and disorganizes to a large extent both patient s and his family s life. Mainly, it can worsen the functional ability of a patient in all aspects of daily life. One of the symptoms that occur in the course of the illness is depression (with a broad spectrum of its severity). Aim. The aim of this work is to analyze the occurrence of depression symptoms in correlation with sociodemographic factors in patients suffering from multiple sclerosis. Material and Methods. The research was carried out in the neurology ward and rehabilitation studio at Ludwik Błażek Multispeciality Hospital in Inowroclaw. The participants were 91 patients with multiple sclerosis. The research was done with the use of diagnostic survey method (a survey technique based on a questionnaire prepared by the researchers) and Beck s Depression Inventory. Results. The sociodemographic factors that affect the occurrence of depression symptoms in patients with multiple sclerosis are: their age (p=0.000), level of education (p=0.009) and professional activity (p=0.001). Conclusions. The research showed that more than half of participants have depression symptoms with a broad spectrum of its severity. (JNNN 2016;5(1):4 9) Key Words: multiple sclerosis, depression, sociodemographic factors Streszczenie Wstęp. Stwardnienie rozsiane jest przewlekłą i bardzo często występującą chorobą ośrodkowego układu nerwowego. To schorzenie, które wprowadza istotne zmiany i w dużym stopniu zaburza życie chorego i jego rodziny. Przede wszystkim pogarsza sprawność funkcjonalną chorego we wszystkich aspektach życia codziennego. W przebiegu stwardnienia rozsianego bardzo często spotykane jest zjawisko depresji, z różnym stopniem jej nasilenia. Cel. Celem pracy była analiza występowania symptomów depresji w korelacji z czynnikami socjodemograficznymi u osób ze stwardnieniem rozsianym. Materiał i metody. Badania przeprowadzono w Szpitalu Wielospecjalistyczny im. Ludwika Błażka w Inowrocławiu na Oddziale Neurologii i Pracowni Rehabilitacyjnej na grupie 91 pacjentów ze zdiagnozowanym stwardnieniem rozsianym. Badania wykonano metodą sondażu diagnostycznego, techniką ankietową z wykorzystaniem autorskiego kwestionariusza ankiety oraz skali depresji Becka. Wyniki. Do czynników socjodemograficznych różnicujących występowanie symptomów depresji należą wiek (p=0,000), wykształcenie (p=0,009) i aktywność zawodowa (p=0,001) chorych na stwardnienie rozsiane. Wnioski. Przeprowadzone badania wskazały, że u ponad połowy badanych występują symptomy depresji o różnym stopniu nasilenia. (PNN 2016;5(1):4 9) Słowa kluczowe: stwardnienie rozsiane, depresja, czynniki socjodemograficzne

5 Winiecka et al./jnnn 2016;5(1):4 9 Introduction Multiple Sclerosis SM (Latin sclerosis multiplex) is a common chronic disease of the central nervous system. It is a disorder that causes major changes in an organism and disorganizes to a large extend both patient s and his family s life. Mainly, it can worsen the functional ability of a patient in all aspects of daily life. The symptoms that occur in the course of multiple sclerosis result from the damage of different parts of nervous system. The characteristic feature of this illness is that the changes advance in time and location. The most common symptoms are changes in sensation, upper motor neuron lesion, cerebellar syndrome, nystagmus, urological diseases, tiredness or vision disorder. The other possible symptoms that may occur are: various emotional states (depression, euphoria), the impairment of cognitive and sexual functions and the occurrence of pain [1 3]. It has been noticed that patients with multiple sclerosis tend to quit job earlier, they suffer from depression and have low self-assessment, social support and lower level of marital satisfaction [4]. The analysis of the course of the illness shows that 50% of the patients reach successive stages of disability [5]. It negatively influences the general well-being of an individual (the quality of life). The results of the research show that the assessment of the quality of life in patients suffering from multiple sclerosis is often influenced by the occurrence of depression symptoms [6]. Depression may affect the natural course of the illness, its treatment and rehabilitation and at the same time it can lower the quality of patient s life. It has been shown that patients without depression have significantly higher quality of life when compared with those who suffer from mild and particularly moderate or severe depression. It has been estimated that about 50% of patients with Multiple Sclerosis suffer from depression [7]. Many research papers confirm that disturbances of mood, mostly depression, are one of the factors that lower the quality of patient s life [7,8]. The aim of this study was to analyze the occurrence of depression symptoms in correlation with sociodemographic factors in patients suffering from multiple sclerosis. Material and Methods The research was carried out in the neurology ward and rehabilitation studio at Ludwik Błażek Multispeciality Hospital in Inowroclaw. The participants were 91 patients with multiple sclerosis at the age of (Table 1). Table 1. The characteristic of the researched group Gender Variable N (%) Female 68 (74.73) Male 22 (25.27) Age (23.08) (45.05) (31.87) Marital status Single 27 (29.67) Married 64 (70.33) Place of residence City 59 (64.84) Village 32 (35.16) Education Basic 15 (16.48) Professional 39 (42.86) Medium 29 (31.87) Higher 8 (8.79) Professional activity Employed 13 (14.28) Unemployed 78 (85.71) The research was done with the use of diagnostic survey method (a survey technique based on a questionnaire prepared by the researchers) and Beck Depression Inventory. The questionnaire allowed for verifying the sociodemographic background of the examined group. Beck Depression Inventory [9,10], was used for the self-assessment of the occurrence of depression symptoms. Giving the answer to 21 questions, the participants could score 63 points. The following criteria were applied; 0 11 points lack of depression, points mild depression, points moderate or severe depression, points very severe depression. This study has been approved by the Bioethics Committee of Nicolaus Copernicus University Collegium Medicum in Bydgoszcz, Poland and the hospital authorities. The statistical analysis was done with the use of the program IBM SPSS Kołmogorowa-Smirnow and Shapiro Wilk s tests allowed us to compare the distribution of quantitive variables with a standard normal distribution. The results of the normality tests were the basis for the choice of nonparametric methods. The significance of the difference between two groups in the range of quantity variables was checked with the use of Manna-Whitney s test. The difference between three or more groups was measured with the use of Kruskal-Wal- 5

6 Winiecka et al./jnnn 2016;5(1):4 9 lis test. The accepted significance level applied for the tests was p<0.05. Results The research showed that more than half of the participants (47 52%) showed the symptoms of depression with different spectrum of its severity (Table 2): 32 participants had mild depression, 14 participants showed the symptoms of moderate depression and only one person suffered from severe depression. Table 2. The results obtained in Beck s Depression Inventory Beck s Depression Inventory N (%) No depression 44 (48) Depression symptoms* 47 (52) Mild depression (12 26 points) 32 (68) Moderate severe depression (27 49 points) 14 (29) Very severe depression (50 63 points) 1 (3) *N=47 (100%) There were no statistically significant differences in the range of the variables between males and females (Table 3). Males and females scored similar results in Beck s Depression Inventory. The scores of the test (the symptoms of moderate and severe depression) increased with age (p=0.000) which means that the scores of all participants differ with reference to the age group they belong to with the upward trend in particular ranges (Figure 1). There was no statistically significant difference observed between married and single patients. The variables were not affected by the place of residence. Participants who live in the country and in the city obtained similar results in Beck s Depression Inventory. The comparison of participants with different levels of education showed statistically significant differences in the range of Beck s Depression Inventory (p=0.009). It means that the highest scores were obtained by people with vocational qualifications (the symptoms of moderate or severe depression), the lower scores were obtained by participants with higher education level (Figure 2). The variable of Beck s Depression Inventory was statistically higher among the unemployed (p=0.000), Table 3. The variables and statistical values of Beck s Depression Inventory 6 Variable x SD Me Value test p Gender Female Male Age Marital status Single Married Place of residence City Village Education Basic Professional Medium Higher Professional activity Employed Unemployed Note: x average; SD standard deviation; Me median U Manna-Whitneya; Kruskala-Wallisa

7 Winiecka et al./jnnn 2016;5(1):4 9 which means that unemployed people obtained higher scores (moderate or severe depression symptoms) than those unemployed (Figure 3). Discussion Figure 1. The age and the results of Beck s Depression Inventory Figure 2. The education level and the results of Beck s Depression Inventory Figure 3. The professional activity and the results of Beck s Depression Inventory Depression is one of the symptoms that frequently occur in the course of Multiple Sclerosis. It may occur with a broad spectrum of its severity [11 15]. While studying the occurrence and severity of depression in patients with multiple sclerosis Skorupska-Król et all [16] concluded that it concerns almost half of the number of participants (40 50% of patients). Its occurrence may be the result of motional consequences of multiple sclerosis, side effects of pharmacological or immunomodulatory treatment, the course of the illness or the location of inflammatory conditions. The authors assume that co-occurrence of depression and multiple sclerosis in consequence leads to some difficulties in the context of patient s cooperation in the process of rehabilitation. At the same time it lowers their general physical ability and subjective quality of life. The results of our own research proved that most of the participants (52%) have depression symptoms (assessed with the use of Beck s Depression Inventory). The severity of symptoms was various. The results showed that 68% of participants had mild depression, the emotional state of 29% participants was classified as moderate depression, whereas 3% of participants suffer from severe depression. The detailed analysis of the results received after the use of Beck s Depression Inventory showed that bad psychic condition leads to lowered confidence. It also entails sleeping problems and lack of interest in sex. After the analysis of our own research it turned out that the problem of lowered confidence concerned more than one quarter of participants (26%). Most of participants complain about sleeping problems (86%). As regards sex, in the opinion of more than 1/3 participants their interest in sex has changed they are not so interested in it as before and almost 1/5 of patients with multiple sclerosis have lost all their interest in sex. 7

8 Winiecka et al./jnnn 2016;5(1):4 9 The research carried out by Karakiewicz et all [3] on a group of 64 patients with multiple sclerosis show that the assessment of patient s quality of life is not affected by gender and their place of residence. However, it was shown that the advanced age of a patient is the significant factor that lowers most of the assessed categories of life quality. Some authors claim that the quality of patient s life is mostly influenced by the length (duration) of the illness, motional disability and emotional states (depression, fear) [17]. The research carried out by Stachowska et all [6] on the group of 75 patients suffering from multiple sclerosis showed that most of the participants examined with the use of Beck s Depression Inventory did not show any depression symptoms (52%) or showed mild depression symptoms (40%). There were no participants with severe depression. It was also concluded that the unemployed had higher scores in the range of Beck s Depression Inventory. The authors also claim that the assessment of patient s quality of life is affected by such factors as: age, gender, professional activity, the stage of the disease, depressive and sexual disorders. The research on the level of illness acceptance and the occurrence of depression was carried out by Skorupska-Król et al. [16,18]. The group of participants 2consisted of 38 patients of the Clinic of Neurology in Cracow. The research showed that the severity of depression in the surveyed group varied. The results of the Beck s Depression Inventory showed that 23.7% of patients suffered from mild depression. The emotional state of another 23.7% patients was classified as moderate depression. The self-assessment of two numerically identical groups (7.9%) suggests the severe and very severe depression. The age and the gender of the participants were not closely related with the emotional state presented. However, the detailed analysis of depression occurrence in particular age groups shows that young people (aged 20 29) do not feel its symptoms. The authors also showed that among participants there is no statistically significant correlation between the acceptance of the illness and its severity. Conclusions The research showed that more than half of participants have depression symptoms with a broad spectrum of its severity. The sociodemographic factors that affect the occurrence of depression symptoms in patients with multiple sclerosis are: the age, education and professional activity. Implications for Nursing Practice Due to the mood disturbances that occur in clinical picture of multiple sclerosis, a nurse should use different diagnostic methods (observation, interview, tests and scales) to identify patient s emotional problems and give the patient professional help to eliminate them. References [1] Fryze W. Zespoły bólowe występujące u chorych ze stwardnieniem rozsianym. Farmakoter Psychiat Neurol. 2005;3: [2] Jamroz-Wiśniewska A., Papuć E., Bartosi-Psujek H., Belniak E., Mitosek-Szewczyk K., Stelmasiak Z. Analiza walidacyjna wybranych aspektów psychomotorycznych polskiej wersji Skali Wpływu Stwardnienia Rozsianego na Jakość Życia Chorych (MSIS 29). Neurol Neuroch Pol. 2007;41(3): [3] Karakiewicz B., Stala C., Grochans E. i wsp. Ocena wpływu wybranych czynników socjodemograficznych na jakość życia osób chorujących na stwardnienie rozsiane. Annals Academiae Medicae Stetinensis. 2010;56(3): [4] Kerns R. Ból w stwardnieniu rozsianym spojrzenie z perspektywy biopsychospołecznej. Rehabil Med. 2003;7: [5] Skalska-Izdebska R., Bojczuk T., Hołys E. Jakość życia u osób chorych na stwardnienie rozsiane. Young Sport Science of Ukraine. 2011;3: [6] Stachowska M., Grabowska M., Szewczyczak M., Talarska D. Ocena jakości życia chorych ze stwardnieniem rozsianym. Pielęgniarstwo Polskie. 2013;50(4): [7] Brola W., Fudala M., Czernicki J. Effect of depression on quality of life of patients with multiple sclerosis. Med Rehabil. 2007;11:1 5. [8] Fruehwald S., Loeffler-Stastka H., Eher R. et al. Depression and quality of life In multiple sclerosis. Acta Neurol Scand. 2001;104: [9] Beck A.T., Ward C.H., Mendelson M., Mock J., Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4: [10] Paradowski T., Jernajczyk W. Inwentarz depresji Beck a w ocenie nastroju osób zdrowych i chorych na choroby afektywne (ocena pilotażowa). Psychiatr Pol. 1977;11 (4): [11] Jaracz J. Zaburzenia psychiczne spowodowane uszkodzeniem lub dysfunkcją mózgu. W: Bilikiewicz A., Pużyński S., Rybakowski J., Wciórka J. (Red.), Psychiatria. Urban & Partner, Wrocław 2002; [12] Dudek D., Siwek M., Grabski B. Zaburzenia psychiczne w neurologii. Termedia, Poznań [13] Wrzesińska M., Opuchlik K., Kocur J. Ocena umiejscowienia kontroli zdrowia oraz poczucia własnej skuteczności i optymizmu u chorych na stwardnienie rozsiane. Postępy Psychiatrii i Neurologii. 2008;17(4): [14] Schumann R., Adamaszek M., Sommer N., Kirkby K.C. Stress, depression and antidepressant treatment options 8

9 Winiecka et al./jnnn 2016;5(1):4 9 in patients suffering from multiple sclerosis. Curr Pharm Des. 2012;18(36): [15] Feinstein A., Magalhaes S., Richard J.F., Audet B., Moore C. The link between multiple sclerosis and depression. Nat Rev Neurol. 2014;10(9): [16] Skorupska-Król A., Pejas-Grzybek L., Oskędra I. Obecność oraz nasilenie depresji wśród chorych ze stwardnieniem rozsianym. Journal of Neurological and Neurosurgical Nursing. 2014;3(4): [17] Fruehwald S., Loeffler-Stastka H., Eher R., Saletu B., Baumhackl U. Depression and quality of life in multiple sclerosis. Acta Neurol Scand. 2001;104(5): [18] Pejas-Grzybek L., Skorupska-Król A. The Degree of Illness Acceptance among Patients with Multiple Sclerosis. Journal of Neurological and Neurosurgical Nursing. 2015;4(1): Corresponding Author: Dorota Winiecka Rojewo 137, Rojewo, Poland dorotawiniecka1@wp.pl Conflict of Interest: None Funding: None Author Contributions: Dorota Winiecka B, C, E, F, H, Joanna Olkiewicz C, E, F, H A, C, D, E, F, G, H, Robert Ślusarz (A Concept and design of research, B Collection and/or compilation of data, C Analysis and interpretation of data, D Statistical analysis, E Writing an article, F Search of the literature, G Critical article analysis, H Approval of the final version of the article) Received: Accepted:

10 Pielęgniarstwo Neurologiczne i Neurochirurgiczne The Journal of Neurological and Neurosurgical Nursing 2016;5(1):10 15 THE JOURNAL OF NEUROLOGICAL AND NEUROSURGICAL NURSING eissn ISSN Original DOI: /PNN Strategies for Coping with Neuropathic Pain and Impact of Pain on the Functional Condition of Patients Strategie radzenia sobie z bólem neuropatycznym oraz wpływ dolegliwości bólowych na stan funkcjonalny chorych Małgorzata Kołpa 1, Beata Jurkiewicz 1, Ewa Mężyk 2 1 Institute of Health Sciences, State Higher Vocational School in Tarnów, Poland 2 Graduate student of Institute of Health Science, State Higher Vocational School in Tarnów, Poland Abstract Introduction. Determining the strategies, which patients implement in order to fight the pain and the extent, to which they are able to control symptoms can greatly facilitate the selection of appropriate treatment. Aim. The study aimed at assessing strategies to cope with pain by patients suffering from neuropathic pain. Material and Methods. The study group consisted of 60 patients of the Pain Management Unit aged of years suffering from neuropathic pain. The study was performed with the use of Coping Strategies Questionnaire (CSQ), Visual Analogue Scale (VAS) as well as a survey of own design. Results. The average intensity of pain in the study group was 7.88 in VAS (±1.64). The most widely used strategy for dealing with pain in the study group was Praying (av. 3.3±1.1), whereas on the second place was Catastrophizing (av. 3.1±1.6). The patients over the age of 60 are significantly more likely to apply those strategies than younger patients. The other strategies were applied above all by the patients below 60. Conclusions. The most often applied strategies in the study group was Praying and Catastrophizing. The choice of strategies for coping with pain varied depending on age, to lesser extend it was conditioned the gender. (JNNN 2016;5(1):10 15) Key Words: neuropathic pain, coping with pain, CSQ, VASh Streszczenie Wstęp. Poznanie strategii, jakie podejmuje pacjent w walce z bólem oraz stopnia, w jakim jest w stanie opanować dolegliwości może znacznie ułatwić dobór odpowiedniego leczenia. Cel. Celem pracy była ocena strategii radzenia sobie z bólem przez pacjentów cierpiących z powodu bólu neuropatycznego. Materiał i metody. Badaniem objęto 60 pacjentów Poradni Leczenia Bólu w przedziale wiekowym lat, cierpiących z powodu bólu neuropatycznego. Posłużono się kwestionariuszem Strategii radzenia sobie z bólem (ang. Coping Strategies Questionnaire, CSQ), wzrokowo-analogową skalą oceny bólu (ang. Visual Analogue Scale, VAS) oraz kwestionariuszem ankiety własnej konstrukcji. Wyniki. Średnie natężenie dolegliwości bólowych w badanej grupie wynosiło 7,88 pkt w skali VAS (±1,64 pkt). Najpowszechniej stosowaną strategią radzenia sobie z bólem w badanej grupie była modlitwa (śr. 3,3±1,1), a na drugim miejscu katastrofizowanie (śr. 3,1±1,6). Pacjenci powyżej 60 roku życia istotnie częściej niż młodsi chorzy wybierali powyższe strategie. Wybór pozostałych strategii był domeną chorych poniżej 60 roku życia. Wnioski. Najczęściej stosowanymi strategiami w badanej grupie były modlitwa i katastrofizowanie. Dobór strategii radzenia sobie z bólem był zróżnicowany w zależności od wieku, w mniejszym stopniu zależał od płci badanych. (PNN 2016;5(1):10 15) Słowa kluczowe: ból neuropatyczny, radzenie sobie z bólem, kwestionariusz CSQ, skala VAS 10

11 Kołpa et al./jnnn 2016;5(1):10 15 Introduction The pain is understood as an unpleasant sensory and emotional experience associated with real or possible tissue damage or described in terms of such damage (definition according to International Association for the Study of Pain, IASP) [1]. Chronic pain is continuous or recurrent pain that persists for more than 3 6 months, which itself is a disease and therefore requires regular analgesic therapy [2,3]. This kind of pain is responsible for a number of physical and physiological changes such as: limitation of physical activity, addiction to drugs or the medicines applied, isolation from the environment as well as apathy, anxiety and depression [4]. According to IASP definition, the neuropathic pain is caused by structural damage and nerve cell dysfunction in the peripheral or central nervous system [1]. Neuropathic pain is unique of its kind, given the characteristic clinical picture and it responds differently to drug therapy, namely the medicines reveal low efficiency [5]. According to Torrance et al. approximately 8% of population suffer from neuropathic pain, which corresponds to 17% of patients with chronic pain of varying aetiology [6]. The most common neuropathic pain syndromes are post-herpetic neuralgia and painful diabetic neuropathy [7]. Much less frequent are traumatic peripheral neuropathy, mainly prolonged post-operative pain, multi- -symptomatic local pain syndromes, phantom pain, or central pain after stroke [8,9]. Despite advances in medicine, research in many centres around the world and the systematic introduction of new drugs for treatment, the efficacy of treatment of neuropathic pain is still not satisfactory, which in turn translates into the day-to-day functioning of patients [10]. The aim of this study was to find out the strategies for coping with pain by patients suffering from neuropathic pain. Material and Methods The study included 60 patients of Pain Management Unit of Health Centre in Tuchów (including 65.0% of women) aged years, suffering from neuropathic pain. The patients were classified into two groups: group I (n=30; 50.0%) consisted of patients diagnosed with post-herpetic neuropathy, diabetic neuropathy, peripheral neuropathy and patients with phantom pain after amputation. Group II (n=30; 50.0%) included patients with chronic back pain caused by pressure on the nerve roots. Patients were informed about the aim of the study, its voluntary and anonymous character as well as they were instructed on the method of filling in the questionnaire. The research was carried out by means of diagnostic survey, using a questionnaire. In order to examine ways of coping with neuropathic pain, there was applied a questionnaire Strategies of dealing with pain by A.K. Rosenstiel and F.J. Keefe in the Polish language adaptation developed by Zygfryd Juczyński. The questionnaire contains 42 statements for assessing strategies to cope with pain and their effectiveness in controlling and reducing pain. Ways of dealing with pain correspond to 7 strategies (6 cognitive and 1 behavioural), which in turn are part of the 3 factors: active coping (Reinterpreting Pain Sensations, Ignoring Pain Sensations, Coping Self-statements); distraction and taking alternative actions (Diverting Attention and Increasing Activity Level), catastrophic thinking and the search for hope. The composition of each of the 7 strategies includes 6 statements (with points from 0 to 6). The task of respondents is to assess the frequency of acting in a certain manner in the event of pain (from 0 never to 6 I always do it ). A higher score means assigning greater importance to a given way of combating pain. The last two categories concern the ability to manage and opportunities to reduce pain. The range of results is from 0 to 6 [11]. The study also involved The own questionnaire containing socio-demographic data and information about pain (duration, nature, severity of pain), day-to-day functioning and emotional sphere of the participants. The respondents used a 5-level Likert scale in order to answer the question about satisfaction with their health and with themselves and the impact of pain on contact with family and friends. To assess the severity of pain Visual Analogue Scale has been applied. It is a universal tool, used for subjective assessment of the degree of pain experienced by patients. The patient assesses pain intensity, indicating a specific number on a simple scale from 0 to 10, where 0 means no pain and 10 the greatest imaginable pain [12]. Statistical analysis were performed using STATIS- TICA for Windows 9.0. Mann-Whitney U test, Chi² test and phi Yul test as well as V Kramer coefficient were used. Statistically significant were the results for which the significance level was lower than or equal to Results The largest number of respondents, defined the duration of pain as lasting from 1 to 1.5 years (28.3%, n=17), slightly fewer patients reported that they suffer from neuropathic pain lasting from 3 to 12 months (26.7%; n=16), and further from 1.5 to 2 years (20.0%, 11

12 Kołpa et al./jnnn 2016;5(1):10 15 n=12), from 2 to 3 years (11.7%, n=7), from 3 to 4 years and >4 years (each group 6.7%, n=4). Data concerning pain The largest number of the surveyed specified the duration of pain as lasting from 1 to 1.5 years (28.3%, n=17), slightly fewer reported that they suffer from neuropathic pain from 3 to 12 months (26.7%; n=16), and further from 1.5 to 2 years (20.0%, n=12) from 2 to 3 years (11.7%, n=7), from 3 to 4 years and >4 years (by 6.7%, n=4). The vast majority of respondents identified the nature of pain as stinging (68.3%; n=41), slightly fewer as sharp (66.7%; n=40), tingling (65.0%; n=39), the patients rarely used such expressions as rapid (58.3%, n=35), numbing (41.7%, n=25), stinging (38.3%, n=23), electrifying (25.0%, n=15 ) or dull (3.3%; n=3). The average intensity of pain in the study group was 7.88 on VAS (±1.64). Slightly greater degree of pain was perceptible in the case of the patients suffering from diabetic neuropathy, post-herpetic neuropathy as well as in the case of the patients after amputation (av ±1.65) than it was by the patients with pain due to nerve root oppression (av. 7.50±1.57), however this result was not statistically significant (p>0.05). The applied forms of pain therapy The majority of respondents (58.6%; n=34) previously benefited from physiotherapy treatments to reduce pain. The therapies most often mentioned included: laser therapy (51.7%), magnet therapy and electrotherapy (each 33.3%; n=20), whereas the least popular was hydrotherapy (3.3%; n=2). The percentage values do not add up to 100% because it was a multiple-choice question. Acupuncture was used only by 15.0% of respondents (n=9), therapeutic massage was slightly more popular 48.3% (n=29). Improving exercises were used by 45.0% of patients (n=27). The impact of pain on daily functioning Sleep disorders resulting from the pain experienced were stated by 68.3% of respondents (n=41), fewer respondents complained about dizziness 32.8% (n=19). These symptoms were significantly more frequent in the case of those with post-herpetic as well as diabetic neuropathy and patients after amputation than in the case of patients with nerve root opression (p=0.01). The vast majority of patients (81.4%; n=48) said that the pain hindered their daily functioning and 66.7% (n=38) reported that these problems affected their physical activity. The most common forms of physical activity undertaken in the study group were the following: work in the garden (48.3, n=29), walk (43.3%; n=26), cycling (36.7%; n=22) Nordic Walking (13.3%, n=8), swimming (11.7%, n=7) and aerobics (6.7%; n=4). The percentage values do not add up to 100% because it was a multiple-choice question. According to the majority i.e. 44.8% of respondents (n=26) the pain moderately hindered contacts with family and friends. In the case of 22.4% of patients (n=13) the pain did not influence the relations with people, according to 19.0% (n=11) it had a slight impact, in the case of 10.3% (n=6) of respondents the pain had a significant effect on the relations, whereas 3.4% (n=2) indicated a significant impact. Influence of pain on the emotional status of the respondents The majority of respondents, 52.6% (n=30), were quite satisfied with their health, 29.8% (n=17) of respondents were dissatisfied, 10.5% (n=6) very dissatisfied and 7.0 % were satisfied (n=4). None of the respondents was very satisfied with their health. Most respondents, 43.1%, were not satisfied with themselves (n=25), 41.4% (n=24) were quite satisfied, 10.3% (n=6) were satisfied, 3.4% (n=2) were very unhappy, and the remaining 1.7% (n=58) very satisfied. It is worth noting that both less satisfied with themselves (p=0.02) as well as with their health (p=0.001) were the respondents suffering from diabetic and post-herpetic neuropathy and those after amputation than patients with root syndrome. As many as 60.3% (n=35) of respondents reported that they often felt depressed or resigned. Slightly fewer 32.8% (n=19) stated that such emotions affected them rarely, and 6.9% (n=4) answered that they never had such a feeling. Significantly fewer patients, who felt affliction, were those with neuropathies resulting the oppression of the nerve roots (p=0.005). Strategies for coping with pain The most widely used strategy for dealing with pain in the study group was Praying (av. 3.3±1.1), whereas Catastrophizing were the second (av. 3.1±1.6) (Figure). The respondents in their conviction slightly better coped with pain (av. 2.9±1.3) than were able to reduce it (av. 2.8±1.1). The study revealed that the patients aged over 60 were significantly more likely than younger patients to cope with pain choosing such strategies as Catastrophizing 12

13 and Praying. Selection of other strategies was the domain of patients younger than 60. It was also found that women more often cope with pain through praying than men (Table). Discussion The nature of strategies for coping with pain depends on individual predisposition of a given person that strengthens or weakens the experience of pain [13]. The studies carried out by Rosenstiel and Keefe dealing with chronic pain, most frequently used the following strategies: Praying and Coping Self-statements and the patients were least likely to apply Reinterpreting Pain Sensations [14]. In our study, the most commonly used strategies for coping with pain were Praying and Catastrophizing, whereas Reinterpreting Pain Sensations Kołpa et al./jnnn 2016;5(1):10 15 Table. Strategies for coping with pain depending on age and gender of the respondents Strategy Average [points] Up to 60 years of age Age Average [points] >60 years of age p U Mann Whitney Average [points] Women Gender Average [points] Men p U Mann Whitney Ability to Control Pain <0.0001* Ability to Decrease Pain <0.0001* Diverting Attention * Reinterpreting Pain Sensations * Catastrophizing <0.0001* Ignoring Pain Sensations <0.0001* Praying or Hoping * <0.0001* Coping Self-statements * Increasing Activity Level * * statistically significant differences Figure. Frequency of application of given strategies for coping with pain by the respondents (averaged values) was the method applied most rarely. The results obtained by the authors to some extent differ from the results of studies achieved by other authors. Both Kadłubowska et al. [15] conducting an analysis of patients with rheumatoid arthritis and Andruszkiewicz et al. [16] studying the cases of patients with degeneration of a hip showed that patients most often have used such strategies as: Praying and Coping Self-statements, whereas Reinterpreting Pain Sensations was the method applied least frequently. The studies of Juczyński that were conducted among respondents suffering from degenerative changes of the spine revealed that the patients often chose to cope by Ignoring Pain Sensations [17]. The turn towards religion is a distinctive strategy in the case of conditions where pain is one of the dominant elements. This is confirmed by, among others, a study conducted among Americans by Quiuling et al. [18] on the basis of which it was reported that more than half of the respondents coped with the pain through prayer. Also Cigrang et al. [19] observed that patients suffering from chronic pain coped with it due to religious practices and found the strength to cope with the limitations. In addition, some studies indicate that the increase in religiosity causes a decrease in the level of depression and anxiety as well as increase in adaptation to the disease progress [20]. The second way of coping with pain most frequently reported by patients was Catastrophizing, which is classified as non-adaptive strategy. Research conducted by Toth et al has shown that this type of strategy is associated with less effective treatment, more likely discontinuation concerning the application of medicines, 13

14 Kołpa et al./jnnn 2016;5(1):10 15 deepening disability and thus a significant decrease in quality of life [21]. Our results are consistent with the foreign data, which show a strong connection between catastrophic thinking and neuropathic pain [22 24]. Conclusions 1. The most commonly used strategies in the study group were prayer and catastrophic thinking, whereas re-evaluation of pain sensation was the least frequently used. 2. Selection of strategies to cope with the pain varied, depending on the age and to a lesser extent, depending on the gender of the respondents. 3. The intensity of pain in the study group was at a high level. Implications for Nursing Practice Understanding the strategies which let the patient control the pain and the extent to which they are able to control symptoms may facilitate the selection of appropriate treatment so that the patient will have a better chance of recovery. Multidimensionality of pain requires an interdisciplinary program of care and treatment, including wide- -ranging co-operation of nurses, doctors, physiotherapists and psychologists in order to be appropriate and effective [25]. References [1] Merskey H., Lindblom U., Mumford J.M. et al. Part III: Pain Terms, A Current List with Definitions and Notes on Usage. In: Merskey H., Bogduk N. (Ed.). Classification of Chronic Pain, Second Edition. IASP Press, Seattle 1994; [2] Turk D.C., Okifuji A. Pain Terms and Taxonomies of Pain. In: Loeser J.D. (Ed.). Bonica s Management of Pain. 3rd ed. Lippincott Williams & Wilkins, Philadelphia 2001; [3] Kumar N. WHO normative guidelines on pain management. Report of a Delphi Study to determine the need for guidelines and to identify the number and topics of guidelines that should be developed by WHO, Geneva [4] Harvard Mental Health Letter Depression and Pain. Retrieved July 02, 2015, from harvard.edu/mind-and-mood/depression_and_pain/ article/. [5] Butera J.A. Miniperspectives: recent approaches in the treatment of neuropathic pain. J Med Chem. 2007;11: [6] Torrance N., Smith B.H., Bennett M. et al. The epidemiology of chronic pain of predominantly neuropathic origin. Results from a general population survey. Journal of Pain. 2006;7: [7] Wordliczek J., Dobrogowski J. Leczenie bólu. PZWL, Warszawa [8] Stannard C., Kalso E., Ballantyne J. (Red.), Evidence-based chronic pain management. Blackwell Publishing, Chichester [9] McMahon S., Koltzenburg M. Wall and Melzack s Textbook of Pain. Churchill Livingstone, Edinburgh [10] Szczudlik A., Dobrogowski J., Wordliczek J. et al. Diagnosis and management of neuropathic pain: review of literature and recommendations of the Polish Association for the study of pain and the Polish Neurological Society part one. Neurol Neurochir Pol. 2014;48: [11] Juczyński Z. Narzędzia pomiaru w promocji i psychoonkologii zdrowia. Pracownia Testów Psychologicznych, Warszawa 2009; [12] Domżał T.M. Ból przewlekły problemy kliniczne i terapeutyczne. Pol Prz Neurol. 2008;4:1 8. [13] de Walden-Gałuszko K., Majkowicz M. Psychologiczno- -kliniczna ocena bólu przewlekłego. Wskazania dla lekarzy pierwszego kontaktu oraz poradni przeciwbólowych i paliatywnych. Akademia Medyczna, Gdańsk [14] Rosenstiel A., Keefe F. The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment. Pain. 1983;17: [15] Kadłubowska M., Kózka M., Bąk E. i wsp. Zachowania zdrowotne jako determinanta strategii radzenia sobie z bólem chorych z reumatoidalnym zapaleniem stawów. Probl Hig Epidemiol. 2015;96: [16] Andruszkiewicz A., Wróbel B., Marzec A. i wsp. Strategie radzenia sobie z bólem u pacjentów ze zmianami zwyrodnieniowymi stawu biodrowego. Probl Piel. 2008;16: [17] Juczyński Z. Spostrzegana kontrola a strategie radzenia sobie z przewlekłym bólem. Sztuka leczenia. 2001;2:9 16. [18] Qiuling S., Langer G., Cohen J. et al. People in pain: How do they seek relief? J Pain. 2007;8: [19] Cigrang J., Hryshko-Mullen A., Peterson A. Spontaneous reports of religious coping by patients with chronic illness. J Clin Psychol Clin Settings. 2003;10: [20] Bovero A., Leombruni P., Miniotti M. et al. Religiosity, pain and depression in advanced cancer patients. World Cultural Psychiatry Research Review. 2012;8: [21] Toth C., Brady S., Hatfield M. The importance of catastrophizing for successful pharmacological treatment of peripheral neuropathic pain. J Pain Res. 2014;7: [22] Haythornthwaite J.A., Clark M.R., Pappagallo M. et al. Pain coping strategies play a role in the persistence of pain in post-herpetic neuralgia. Pain. 2003;106: [23] Jensen M.P., Ehde D.M., Hoffman A.J. et al. Cognitions, coping and social environment predict adjustment to phantom limb pain. Pain. 2002;95: [24] Sullivana M.J.L., Lynchb M.E., Clark A.J. Dimensions of catastrophic thinking associated with pain experience and disability in patients with neuropathic pain conditions. Pain. 2005;113:

15 Kołpa et al./jnnn 2016;5(1):10 15 [25] Wössmer B., Loosli P., Hochstrasser J. Multidisciplinary treatment of chronic pain opportunities and challenges for collaboration between psychosomatic medicine and physiotherapy. Ther Umsch. 2007;64: Corresponding Author: Beata Jurkiewicz Institute of Health Sciences, State Higher Vocational School in Tarnów ul. Mickiewicza 8, Tarnów, Poland Conflict of Interest: None Funding: None Author Contributions: Małgorzata Kołpa A, C, D G, H, Beata Jurkiewicz B, C, E, F B, C, F, Ewa Mężyk (A Concept and design of research, B Collection and/or compilation of data, C Analysis and interpretation of data, D Statistical analysis, E Writing an article, F Search of the literature, G Critical article analysis, H Approval of the final version of the article) Received: Accepted:

16 Pielęgniarstwo Neurologiczne i Neurochirurgiczne The Journal of Neurological and Neurosurgical Nursing 2016;5(1):16 20 THE JOURNAL OF NEUROLOGICAL AND NEUROSURGICAL NURSING eissn ISSN Original DOI: /PNN Knowledge of Medical Staff on Medical Segregation of Patients Having Suffered in Mass Accidents and Disasters Wiedza pracowników personelu medycznego na temat segregacji medycznej poszkodowanych w wypadkach masowych i katastrofach Katarzyna Sienkiewicz 1, Dorota Kulina 2, Katarzyna Przylepa 3, Irena Wrońska 2 1 University Children s Hospital in Lublin, Poland 2 Department of Development in Nursing at Medical University in Lublin, Poland 3 Department of Foreign Languages at Medical University in Lublin, Poland Abstract Introduction. Ever growing pace of life in developing societies results in a considerable increase in abrupt threats to life and health. Both Accidents and Emergency Unit workers to whom a patient is referred having been ascribed a provisional category as well as members of Medical Rescue Teams who are the first medical staff to have contact with a patient ought to apply a correct procedural variant in their interactions with patients. Aim. The aim of the research was an attempt to evaluate medical personnel s knowledge levels within the scope of segregating patients having suffered in mass accidents and disasters. Material and Methods. The diagnostic poll method was used in this work and a survey form was the research tool. The research involved 50 persons employed in Accident and Emergency Units and Medical Rescue Teams. Results. A general proportion of correct responses averaged out at 63% for both groups. No statistic correlation was found between the two groups. Conclusions. Knowledge level referring to medical segregation that medical staff presented proved unsatisfactory. The study shows there is a need for training within the scope of medical segregation in mass accidents and disasters. (JNNN 2016;5(1):16 20) Key Words: medical segregation Streszczenie Wstęp. Wzrastające tempo życia rozwijających się społeczeństw niesie ze sobą olbrzymi wzrost gwałtownych zagrożeń zdrowia i życia ludzi. Prawidłowym wariantem postępowaniem z poszkodowanymi powinni posługiwać się zarówno pracownicy Szpitalnych Oddziałów Ratunkowych, do których poszkodowany trafia poniekąd już z pierwotną kategorią, jak również osoby mające pierwszy kontakt medyczny jakim są Zespoły Ratownictwa Medycznego. Cel. Celem przeprowadzonych badań było próba oceny poziomu wiedzy pracowników personelu medycznego na temat segregowania poszkodowanych w wypadkach masowych i katastrofach. Materiał i metody. W pracy wykorzystano metodę sondażu diagnostycznego. Narzędziem badawczym była autorski kwestionariusz ankiety. Badaniami objęto 50 osób zatrudnionych w Szpitalnych Oddziałach Ratunkowych i Zespołach Ratownictwa Medycznego. Wyniki. Ogólny odsetek wskazań wspólny dla obu grup w przypadku prawidłowych odpowiedzi wynosi 63%. Nie stwierdzono istnienia zależności statystycznej pomiędzy dwoma grupami badanych. Wnioski. Poziom wiedzy pracowników ochrony zdrowia w zakresie segregacji medycznej jest niezadowalający. Badania dowodzą konieczności prowadzenia szkoleń w zakresie segregacji medycznej w trakcie wypadków masowych i katastrof. (PNN 2016;5(1):16 20) Słowa kluczowe: segregacja medyczna 16

17 Sienkiewicz et al./jnnn 2016;5(1):16 20 Introduction The term triage was introduced by a surgeon Larey a, the marshal of Napoleon. Napoleon s surgeons were the first to segregate the wounded on the battlefield, introducing three categories of aid [1]. Triage is a system of segregation of victims, used to assess the condition of the victim and his prognosis for survival the next day. Today there are many systems of segregation of the injured in mass incidents that use the assessment of vital functions and the extent of injuries of patients to determine the order of therapeutic procedures. They are based on anatomical assessment of injuries or identification of injury mechanism in emergency mass situations [2]. According to M. Skalski in Poland, principles of medical segregation result from the war surgery which distinguishes diagnostic segregation, transport evacuation segregation, inside scoring and predictive segregation. As a part of medical segregation there are two groups among the wounded of an intern and surgical profile: seriously injured, who need to get help as soon as possible and slightly injured, who can postpone the time of the aid [3]. The purposes of medical segregation, with the rational use of the means and health protection measures include: separation of the injured dangerous for the environment, ie. radioactively contaminated and contaminated with persistent toxic agents, preventing their contact with other victims, determining the nature, scope and sequence of medical assistance, including the expected prognosis and timing of treatment: determining the stage of medical evacuation, to which the injured should be directed, determining the sequence, means and method of evacuation, determining the functional division of the medical evacuation stage, to which the victim should be directed [3 5]. The START System The START System (Simple Triage And Rapid Treatment) is to enable a simple segregation and fast treatment. It is a system whose criterion consists in simple parameters of vital signs. The assessment base of segregation in the system is made according to the following criteria: the ability to walk independently, airway, breathing rate, the rate of capillary recurrence, and in severe weather conditions or poor lighting the peripheral pulse and appearance of the skin, the ability to perform simple commands [6]. In order to improve the implementation process of segregation at different stages, contractual logos were specified [7]. The system START (Eng. Simple Triage And Rapid Treatment) distinguishes four categories of victims, which correspond to four band colors or badges given at the scene, depending on their health and suffered injuries [8]. Red the person needing immediate stabilization of vital signs and includes persons: in the state of shock for any reason, with difficulties in breathing, with head injuries, accompanied by asymmetry of pupils, with large internal hemorrhage. Yellow a person requiring constant monitoring, medical care can be somewhat delayed. This category includes victims with abdominal injuries, open fractures, fracture of the thigh/pelvis, extensive burns, unconscious patients with head injuries, the victim in the unstable general state. Green deferred treatment, wounded patients: small fractures, small wounds and burns. Black dead and agonizing patients [6,7,9]. Segregation of children should be conducted separately. The Jump Start or Pediatric Triage Tape for example, should be used for that purpose [4,10 12]. The aim of the study was an attempt to assess the level of knowledge of medical personnel members about sorting the victims of mass accidents and disasters. Material and Methods In the work, the method of diagnostic survey was applied. The research material was collected using a proprietary questionnaire. It consisted of 24 questions. The questions in the survey were divided into two parts. The first part was designed to examine the knowledge of the respondents regarding accidents and mass disasters. The second part was designed to determine knowledge about the correctness of allocated codes on the basis of the colors used in the START system. The research work was carried out in November 2013, two substations of ER and two emergency departments in Lublin. Patients were informed of the anonymous nature of the study and each of the respondents agreed to complete the questionnaire. The study was conducted in accordance with the Helsinki Declaration. The specific time limit was not provided. The study used descriptive statistics and Chi² test. The level of significance at p<0.05 was adopted. The study involved 75 people who worked in the aforementioned medical facilities. 25 questionnaires were rejected because the answers to the questions were 17

18 Sienkiewicz et al./jnnn 2016;5(1):16 20 checked selectively. To analyze the remaining 50 surveys. In this group of 24 people were working in the Hospital Emergency Department (ED), and 26 in the Medical Rescue Teams (ZRM). The majority of respondents obtained their degree in post-secondary school/vocational studies (68%), university graduates 32% of respondents. Results Among the respondents, 76% (38 people) can correctly define the START system. Using it in practice was declared by 62% of respondents (31 people). Mass accident was correctly defined by only 50% of the respondents (25 people). Only 34% (n=17) of respondents declared using the segregation sets. The most common set was Box Med set, however in this group, only 6% were able to identify the correct part of this set. 70% (n=35) employees of SOR and ZRM properly defined the scope of the vital parameters used to assess the condition of the patient in the START system. Rules of proper designation of zones in the place of disaster were known to 96% (n=48) of patients. The problem appeared in an answer to he question relating to the responsibility for the life and health of victims in the danger zone, because in this case only 44% (n=23) of respondents gave the correct answer. Among the respondents, only 34% (n=17) declared knowledge of the plans developed by the organizational units for the purposes of the proceedings during the mass accident or disasters. At the same time 80% (n=40) stated that such plans are needed. Among the respondents, only 54% (n=27) participated in exercises, simulations or courses concerning behaviour during mass accidents or disasters. At the same time, up to 94% (n=56) of respondents thought that these forms of professional qualifications were unnecessary. In the second part of the questionnaire, the questions referred to the issue of assignment of specific codes of segregation conducts to individuals or groups of people located in specific situations. When analyzing the situation, several passengers were standing about 50 meters away from the accident with visible superficial injuries, arguing, shouting, looking for the guilty participants of the event. 98% (n=49) of respondents identified the correct segregation code (green). A high percentage of correct answers was also obtained in the case of a man aged 35, sitting on the side with a visible open fracture of the right lower limb and non-physiological arrangement of the upper left limb, complaining of shortness of breath, numbness of the left limb and radiating pain to the left shoulder and severe pain of the abdominal area. In this case, 86% (n=43) of the survey participants marked the correct segregation code (red). In the case of a man aged 50, unconscious, lying on the ground, breathing heavily and gasping the air, in whom respiratory rate is 8/min, heart rate 148/min, groaning from time to time the correct segregation code (red) was indicated by 82% of participants (n=41). While assessing the patient s condition of the bus driver with legs crashed by the dashboard, with the respiratory rate of 25/min, capillary relapse 4 sec., muttering in response to the voice 80% (n=40) of respondents correctly assigned the red code to him. The situation was an adult male lying in the wreckage of the bus, not breathing, lack of pulse, the body burns 20% III of the degree properly evaluated by 70% (n=35) of the respondents (code: black). A similar result was obtained by respondents when it comes to assessing the situation of a young woman walking around the scene of the accident with visible light abrasion of the temple and right cheek, heavily pregnant, looking for her husband, being in a daze, giving her the correct code: red. Optimally the condition of, a man aged 27, strolling around the scene of the accident, crying and asking for help, there are visible burn wounds, with respiratory rate of 25/min., capillary relapse 1 sec. was evaluated by 68% (n=34) of the respondents (green code). The lower result was obtained in the case of a woman about 35 years of age with craniofacial trauma and acute respiratory failure, capillary relapse above 2 sec., where the correct segregation code was indicated by 64% (n=32) of the respondents (green code). In the case of a mature man, dazed and confused, complaining about a sore right shoulder, with a visible large wound without damaging the skull cap on the left side of the head, when asked cannot go to a specific place, with the respiratory rate of 22/min., heart rate of 90/min. and the capillary return of less than 2 sec., fulfilling simple commands proper segregation was made by 56% (n=28) of respondents. Whereas the woman of about 20, lying on the ground, with the soot visible on her face, asking for help with a little screeching voice, of the respiratory rate of 22/min, capillary return of 1 sec. was marked with the correct code yellow by 52% (n=26). In the case of a woman of about 30, lying on the ground with visible abrasions of the skin on the forehead, respiratory rate of 28/min, heart rate of 92/min, capillary return of 2 sec., performing simple commands, the correct segregation code (yellow) was indicated by 50% (n=25) of respondents. However, in the case of conscious man, breathing with difficulties, whose breathing is 28/min., and the garment has visible spots of blood in the place where the piece of metal pierced the chest, of a capillary return of about 3 sec., having more and more trouble breathing only 34% (n=17) of respondents made the correct segregation assigning him the red code. Even 18

19 Sienkiewicz et al./jnnn 2016;5(1):16 20 lower result was obtained in the case of the victim of a man lying on the roadside, of the respiratory rate of 20/min, who has a strong pulse on the perimeter, fulfilling commands, informing that he cannot move his legs. In this situation, the correct separation code (yellow) was indicated by only 28% (n=14) of respondents. Analysing the answers according to granting the correct code of segregation depending on the workplace of respondents, it was stated that the participants employed in the Hospital Emergency Department gave a total of 65% of correct indications, and the Medical Rescue Teams 61%. The overall percentage of indications common to both groups in the case of correct answer is 63%. There was no statistical relationship between the existence of two groups of patients (Chi²=1.061, p=0.303). Discussion The development of communication technologies and the threats of the modern world make the ability to act correctly on the site of mass accidents or disasters extremely significant. Unfortunately, the authors analyzing the available databases, did not find scientific reports on the evaluation of the level of health care staff s knowledge in this field. It is therefore not possible to carry out discussion on the results of other authors. At the same time they are aware of the limitations of the studies, in particular the size of the examined group and its territorial coverage. Authors deliberately chose the employees of Hospital Emergency Departments Medical Rescue Teams since as a rule they will usually be the first who will make a segregation of victims in these types of events. Overall assessment of correct answers in both groups was only at 63% of the total responses. So every other employee could perform the correct segregation of victims in the event of an accident or a mass disaster. A higher percentage of correct answers by 4% was obtained by ER employees, but the difference was not statistically significant. However, on the other hand, respondents also in 96% declare that they do not need any form of additional training in this area. This may result from having superficial knowledge, inability of its application in practice, or performing medical segregation in a mechanical, routine manner, without thinking about the improvement of ongoing procedures. Responses on the knowledge of segregation sets the use of which was declared only by 34% of respondents, and in this group, only 6% were able to specify correctly the composition of a given set. They assess the knowledge of assigning the appropriate codes of segregation, in certain cases a large spread of results was also obtained. In some situations, the correct code of segregation could be chosen by nearly 100% of the respondents, or more than 80%. But also the results at 34% and 28% of correct answers were obtained. In most cases, the correct codes of segregation were assigned by about 50% of the respondents. It should be remembered that the assumptions of the Triage claim that it is a continuous function and every step should be conducted at one hundred percent capacity according to the knowledge, applicable standards, and above all, the health of the victim. Categorizing the most common mistakes committed by the survey participants is the overtriage depending mostly on qualification to higher segregation group. Conclusions 1. The level of knowledge of health care staff in the field of medical segregation is unsatisfactory. 2. Research shows the need for training in medical segregation during mass accidents and disasters. Implications for Nursing Practice Introduction of regular staff training of health care employees in the field of medical segregation during mass accidents and disasters. References [1] Sacco W.J., Navin D.M., Fiedler K.E., Waddell R.K., Long W.B., Buckman R.F. Jr. Precise formulation and evidence based application of re source-constrained triage. Acad Emerg Med. 2005;12: [2] Rasmus A., Gaszyński W. Medycyna ratunkowa i medycyna katastrof. Uniwersytet Medyczny w Łodzi, Łódź [3] Skalski M., Dójczyński M., Nowakowski R., Przybycień A. Segregacja medyczna poszkodowanych w ognisku strat masowych spowodowanych katastrofami. Acta Clinica et Morphologica. 2001;4(3): [4] Trzos A. Triage segregacja medyczna. Na Ratunek. 2007;3: [5] Trzos A. e-triage. Retrieved March 3, 2014, from ratownictwo.wasko.pl/artykuly/item/43-etriage. [6] Ciećkiewicz J. Ratownictwo medyczne w wypadkach masowych. Wydawnictwo Medyczne Górnicki, Wrocław [7] Goniewicz M., Goniewicz K., Balcerzyk-Barzdo E., Burska K. Systemy i zestawy segregacyjne stosowane w zdarzeniach masowych. W: Goniewicz M. (Red.), Medycyna katastrof. Problemy organizacyjno-diagnostyczne. Kielce 2012; [8] Ciećkiewicz J. Zasady postępowania przedszpitalnego w wypadkach masowych i katastrofach. Polski Przegląd Chirurgiczny. 1999;71(5):

20 Sienkiewicz et al./jnnn 2016;5(1):16 20 [9] Trzos A. Wypadki masowe, a koncepcja współpracy wielu podmiotów ratowniczych. Retrieved March 7, 2014, from Arkadiusz%20TrzosWypadki%masowe%20%C3%A2% C2%80%C2%93%20KONCEPCJA%20wsp%C3% B3%C5%82pracy%20wielu%20podmiot%C3%B3 w%20ratowniczych.pdf [10] Aoki B.Y., McCloskey K. Dziecko w stanie zagrożenia życia. Ocena, postępowanie, transport. Medycyna Praktyczna, Kraków [11] Strange G., Arens W., Schafermeyer R., Toepper W. Medycyna ratunkowa wieku dziecięcego. Urban & Partner, Wrocław [12] Trzos A. Dziecko w zdarzeniu masowym. Ogólnopolski Przegląd Medyczny. 2004;8: Corresponding Author: Dorota Kulina Katedra Rozwoju Pielęgniarstwa ul. Staszica 4-6, Lublin, Poland dorota.kulina@umlub.pl Conflict of Interest: None Funding: None Author Contributions: Katarzyna Sienkiewicz A, B, C, Dorota Kulina A, C, D, E, Katarzyna Przylepa C, D, E F, G, H, Irena Wrońska (A Concept and design of research, B Collection and/or compilation of data, C Analysis and interpretation of data, D Statistical analysis, E Writing an article, F Search of the literature, G Critical article analysis, H Approval of the final version of the article) Received: Accepted:

21 Pielęgniarstwo Neurologiczne i Neurochirurgiczne The Journal of Neurological and Neurosurgical Nursing 2016;5(1):21 27 THE JOURNAL OF NEUROLOGICAL AND NEUROSURGICAL NURSING eissn ISSN Original DOI: /PNN Evaluation of Pain and Fear Associated with Putting on the Stereotactic Frame in Patients Planned for the Biopsy of a Brain Tumour with the Possibility of the Pharmacological Alteration Ocena bólu i lęku związanego z założeniem ramy stereotaktycznej u pacjentów planowanych do biopsji guza mózgu z możliwością modyfikacji farmakologicznej Anna Raszka 1, Ewa Kociniewska 1, Aleksander Goch 2 1 Clinic of Neurosurgery 10th Military Clinic Hospital with the Polyclinic, Bydgoszcz, Poland 2 Clinic of Cardiology and Cardiac Surgery 10th Military Clinic Hospital with the Polyclinic, Bydgoszcz, Poland Abstract Introduction. Results of the intensive development of the research on the pathogenesis of tumours of the nervous system allow increasingly to understand the nature of illnesses, contributing to the development of effective methods of their treatment. Taking sample material for the pathomorphology examination by means of the stereotactic biopsy is a method widely applied in the diagnostics of brain tumours. The diagnostic methods carried out are associated with the pain and fear felt by the patient during the operation. The pharmacological alteration will allow to minimize pain and fear while putting on the stereotactic frame. Aim. The aim of the study was the comparative evaluation of level of pain and fear perceived by patients while having the stereotactic frame put on for the biopsy of a brain tumour as well as the assessment of the effectiveness of pharmacological measures applied before performing the stereotactic biopsy. Material and Methods. Research was carried out at the Clinic of Neurosurgery in the 10th Military Clinic Hospital with the Polyclinic. The research included a group of 60 patients, who were subject to stereotactic biopsy of brain tumour. Our own questionnaire of surveys, evaluation of pain on the VAS scale and the standardized questionnaire form of self-assessment STAI X-1 and STAI X-2 were the research tools. Results. Having examined the research group of 60 patients a dependence on the applied premedication, gender and individual age groups was observed. No relation between feeling pain as well as fear were observed regarding the domicile and the level of education. Conclusions. On the basis of an analysis conducted in age groups towards examined factors it is possible to notice positive effects of Dormicum application compared to the group patients without the premedication. In the case of patients, in whom giving medicines was not applied it is possible to notice an increase in the parameter of fear along with age, contrary to the situation in the group examined where Dormicum was being applied. Ketonal had no effect on changes in the parameters examined. In none of examined groups a relation between the age and the level of pain feeling measured on the VAS scale was indicated. (JNNN 2016;5(1):21 27) Key Words: pain, fear, biopsy, stereotaxis, stereotactic frame Streszczenie Wstęp. Wyniki intensywnego rozwoju badań nad patogenezą guzów układu nerwowego pozwalają w coraz pełniejszym stopniu zrozumieć istotę choroby, przyczyniając się do opracowania skutecznych metod leczenia. Pobieranie materiału do badania patomorfologicznego za pomocą biopsji stereotaktycznej jest metodą szeroko stosowaną w diagnostyce guzów mózgu. Przeprowadzane metody diagnostyczne łączą się z odczuwaniem przez pacjenta bólu oraz lęku podczas zabiegu. Modyfikacja farmakologiczna pozwoli zminimalizować ból oraz lęk podczas zakładania ramy stereotaktycznej. 21

22 Raszka et al./jnnn 2016;5(1):21 27 Cel. Celem pracy była ocena porównawcza poziomu odczuwanego bólu oraz lęku u pacjentów podczas założenia ramy stereotaktycznej do biopsji guza mózgu oraz dokonanie oceny skuteczności podawanych środków farmakologicznych przed wykonaniem biopsji stereotaktycznej. Materiał i metody. Badania zostały przeprowadzona w Klinice Neurochirurgii w 10 Wojskowym Szpitalu Klinicznym z Polikliniką. W przeprowadzonych badaniach uczestniczyła 60-osobowa grupa pacjentów poddanych zabiegom biopsji stereotaktycznej guza mózgu. Narzędziem badawczym był autorski kwestionariusz ankiet, ocena bólu za pomocą skali VAS oraz ankieta standaryzowana samooceny STAI X-1 oraz STAI X-2. Wyniki. Po zbadaniu 60-osobowej grupy badawczej zaobserwowano zależność od stosowanej premedykacji, płci oraz poszczególnych grup wiekowych. Nie zaobserwowano zależności odczuwania bólu oraz lęku w stosunku do miejsca zamieszkania oraz wykształcenia. Wnioski. Na podstawie analizy w przeprowadzonych grupach wiekowych w stosunku do badanych czynników można zauważyć pozytywne efekty stosowania Dormicum w porównaniu do grupy pacjentów bez premedykacji. U osób, u których nie podjęto podawania leków można zauważyć wzrost parametru lęku wraz z wiekiem, a odwrotną sytuację odnotowuje się w grupie badanej z podawanym lekiem Dormicum. Na zmiany w badanych parametrach nie miał wpływu Ketonal. W żadnej z badanych grup nie wykazano zależności między wiekiem a poziomem odczuwania bólu mierzonego w skali VAS. (PNN 2016;5(1):21 27) Słowa kluczowe: ból, lęk, biopsja, stereotaksja, rama stereotaktyczna Introduction In recent years an intense development of the research on the nosogenesis of tubers of the nervous system has been observed. Its results increasingly allow to understand the nature of illness, significantly contributing to the development of effective methods of treatment. The great majority of cancers of the nervous system are located intracranialy i.e %. According to cancer wards given to the Centre in Warsaw the incidences of primaeval brain tumours with reference to the Polish population amount to rates respectively 6.6 women, 7.9 men/100 thousand/year. This rate is rising along with age. Among small children under the age of 5 it is approximately 2.5/100 thousand/year, whereas in the group aged over 55 it is about 20/100 thousand/year [1,2]. A brain tumour is a very wrong tissue developing in the skull which normally is filled up entirely by the brain. These changes can be of gentle or malicious character, both kinds being life-threatening. Malignant tumours of the brain can give distant transport, some changes can develop without symptoms, others are leading quickly to the end of their life. The presence of wrong mass within the skull is a condition of the appearance of general clinical symptoms which reflect increased intracranial pressure, as well as manifestations of focal lengths, resulting directly from damaging the defined structures in the brain. In the case of brain tumours it is necessary to take into account histologic type, degree of the malice as well as the nature of the tumour growth. Clinical symptoms are usually not very specific. In some cases even a little bump often triggers heavy neurological disorders. However, manifestations more often appear when the pathological change is already really significant. One of methods of taking the sample material for the purpose of pathomorphology examination, successfully applied in the diagnostics of brain tumours is stereotactic biopsy which involves taking the fragment of the changed tissue from the determined location of the brain [3 6]. The stereotactic method enables a very precise and accurate access with surgical instrument to the pathological changes located deep inside of solid tissue with the minimal damage of the surrounding healthy tissues. It enables to carry out a sequence of diagnostic and healing treatments which include: taking tissue samples for the purpose of histological examination. The development of neuroendoscopy and neuronavigation makes it possible to operate accurately within intracranial spaces under control of eyesight and enables precise placement of the surgical instrument towards the image of the computed axial tomography or the magnetic resonance in the real time. The basis of stereotaxy is a statement of Descartes according to which in the space it is possible to determine putting every point with the arrangement of three mutually perpendicular axes of coordinates of purpose. For the needs of the stereotactic biopsy an outside frame of reference is used and the stereotactic frame is attached to the head of the patient [7 9]. The computed axial tomography is performed to a patient. In a CT picture there is a visible cut in two heads and four groups for three points, from the centre of which there are outlining the X axes (horizontal) and Y (vertical), and extreme distance from the plain of the frame (coordinate from). Modern stereotactic systems are conjugated with a CAT scanner and coordinates of the purpose are determined directly from the CT image. The patient during the treatment lies on the moving operating table, on which the stereotactic frame is being put on, locating CT examination is performed and the treatment itself is conducted [10,11]. 22

23 Raszka et al./jnnn 2016;5(1):21 27 The diagnostic methods conducted are associated with the pain and fear felt by the patient during the implemented treatment. International Association of Studying Pain (IASP) defines unpleasant, sensory and emotional experience accompanying the existing or threatening tissue damage or referring to such damage. Pain is a subjective feeling, which means that it contains everything that the sick person associates with the term pain irrespective of objective manifestations associated with it [12]. Pain is a sensory experience, associated with the effect of the damaging stimulus as well as coming into existence based on psychological interpretation of the occurrences taking place, modified by previous experiences and psychosomatic conditioning [13]. Fear is defined as a group of emotional reactions freed by incentives themselves both from the inside and outside of the organism. These reactions are characterized by the fact that they have a negative colouring, are perceived by the individual as something unpleasant and severe which is not possible to be got rid of as well as connected with physiological reactions such as the accelerated heartbeat, increased blood pressure, muscle tension [14,15]. Analysing concepts it is possible to state that fear is an unpleasant emotional state being characterized by persistent feeling of peculiar distress which is accompanied by irrationality and helplessness [16,17]. The purpose of this work was to make a comparative evaluation of the level of pain and fear experienced by patients while the stereotactic frame was being put on for the biopsy of a brain tumour as well as to assess the effectiveness of certain pharmacological centres before performing the syereotactic biopsy. Material and Methods In the examination a group of 60 patients of the 10th Military Clinic Hospital with the Polyclinic were categorised to stereotactic biopsy of a brain tumour. The patients were divided into three groups. The first group consisted of those to whom pharmacological means were not applied. The second group contained the patients to whom Dormicum was given orrally up to 7.5 mg before the treatment. In the third group there were patients to whom Ketonal of 100 mg was given intravenously before the treatment. All groups consisted of an equal number of patients. For the purpose of conducting research the questionnaire form was used: evaluation of pain with the VAS scale and the standardized questionnaire form of the STAI X-1 self-assessment and STAI X-2 (Table). Table. Group of examined patients The group without premedication applied Patients The group with Dormicum applied Assessed The group with Ketonal applied STAI X-1 STAI X-2 VAS Statistical analysis with the use of Statistica 10.0 The data analysis was conducted based on the Statistica 10.0 software package, from the own questionnaire towards the results gained from the sheet of the STAI self-assessment and the VAS scale of feeling pain. Results For the purpose of conducting the comparison the ANOVA Kruskal-Wallis test was applied for details on the non-parametric disintegration, independent of itself, carried out for comparing more than two examined groups. Conducting a test allowed to answer whether the type of the applied treatment has a statistically significant impact on the number of points scored in the STAI X-1 questionnaire, STAI X-2 and on the VAS scale of pain. The first comparison which was carried out for determining differences in the number of points scored on the STAI X-1 scale, STAI X-2 and the VAS scale conducted among the three examined groups from which the first control group, was the groupwhere no medicine was applied, and in the case of two remaining Dormicum and Ketonal treatment were applied. In the conducted comparison statistically significant results were received only in the case of the evaluation of the parameter among the examined groups on the VAS scale (Figure 3). The most interesting fact is that in the case of Dormicum taking patients the received results were the lowest. For the scores achieved for the STAI X-1 parameter (Figure 1) STAI X-2 (Figure 2). there are no noticable differences among the examined groups of patients. In the case of a change of the STAI X-1 for parameter of patients who did not receive premedication it is possible to notice the increase of this variable along with the age of patients. The youngest patients felt the lowest fear whereas the oldest patients felt the highest fear (Figure 1). In case of the patients who received the Dormicum premedication a fall in the examined STAI X-2 factor is observed according to age (Figure 2). 23

24 Raszka et al./jnnn 2016;5(1):21 27 Figure 1. Changes of the STAI X-1 parameter depending on the age group and the applied premedication Figure 2. Changes of the STAI X-2 parameter depending on the age group and the applied premedication Figure 3. Changes of the VAS parameter depending on the age group and the applied premedication The conducted ANOVA Kruskal-Wallis test of significance shows that the differences appear to be statistically significant in the case of those patients who did not receive premedication. In the analysis carried out with the division according tothe gender the results received were below the assumed threshold of the statistical significance for parameters STAI X-1 and STAI X-2 (Figure 4 and 5). In the case of the evaluation of pain, there appears on the VAS scale a correlation between the parameter tested and the gender (Figure 6). It is possible to notice that there appears to be no difference regarding fear between most women and men not-accepting medicines whereas such a difference is noticeable in the case of subjective feeling of pain. Apparent relations between the number of points scored in the STAI questionnaire and the evaluation of VAS pain according to the gender of those examined were shown in the conducted comparison of patients who had been subject to the Dormicum treatment. In the analysis carried out, the received results were above the assumed threshold of the statistical significance for all three parameters. However, it is possible to notice the apparent statistical tendency regarding the points for the evaluation of fear in the case of the scores gained in the STAI X-2 sheet with the division into groups. Even though in the case of the two remaining parameters (STAI X-1 and VAS) no important differences were identified, it is possible to notice that the results obtained by women are higher. That can suggest that men react better to Dormicum than women do (Figure 5). In the performed analysis, where Ketonal was being given to patients we obtained results above the assumed threshold of the statistical significance in the case of the evaluation of pain whereas for STAI X-1 and STAI X-2 parameters differences between women and men differ in the statistically significant way. For the conducted analysis it is possible to observe that men better react to Ketonal and results for all three analysed parameters are lower than for the group of women accepting Ketonal (Figure 6). 24

25 Raszka et al./jnnn 2016;5(1):21 27 When analysing patients in terms of their gender it turns out that in the case of women and men statistically significant changes appear in the STAI X-1 questionnaire form only when Ketonal was applied, for the remaining cases generally no change has been observed. In the STAI X-2 questionnaire form men to whom Ketonal was applied scored fewer points and there is a significant difference (Figure 5). Considering all remaining cases, the differences have not been statistically significant. It is possible to notice that in the case of the division made according to the gender criterion, men had lower results than women for the examined factors, and those differences have often been statistically significant. They appeared in the situation when medicines were given to both groups. As regards the analysis where the premedication was not applied, women achieved better results than men and it is them who had lower results, a statistically significant difference appeared in analysis of pain feeling on the VAS scale. The largest differences observed, appeared between women and men accepting Ketonal (Figure 6). In the case of a change of the STAI X-1 parameter of patients who did not receive the premedication it is possible to notice an increase of this variable along with the age of patients. The youngest patients felt the lowest fear whereas in the case of the oldest its level was the highest (Figure 1). Conducted Kruskal-Wallis ANOVA test of significance shows that statistically significant differences appear in patients who did not receive the premedication. In the case of those who received the Dormicum premedication a decrease of the examined STAI X-1 factor is observed along with age (Figure 1). Considering the VAS scale, in the examined groups there was no relation indicated between the age and the level of feeling pain and no statistical relations have appeared (Figure 3). Figure 4. Change of the STAI X-1 parameter depending on the applied premedication and the sex Figure 5. Change of the STAI X-2 parameter depending on the applied premedication and the sex Figure 6. Change of the VAS parameter depending on the applied premedication and the gender 25

26 Raszka et al./jnnn 2016;5(1):21 27 Discussion Stereotactic method permits the biopsy its precise execution, an access to the pathological changes done to brain tissues located deep inside with the minimal damage to correct surrounding tissues as well as enables to conduct a sequence of diagnostic and healing treatments. Treatment taken is connected with pain felt and fear experienced by the patient during its performance. Many researchers refer to the fact that the predisposition to reacting with fear is an inborn property, and learning of fear when appropriate incentives freeing the first stronger reactions of fear will work. From the research conducted by Pawlak [18] it is possible to conclude that the parameter of fear in the perioperative period is correlating with age, therefore deliberate perception of the feeling of anxiety and fear is conditioned on the age of the patient and is sustained at a high level. Therefore, proceedings of painkilling and reducing the feeling of fear during the process of executing medical procedures, not only are really important and justified for humanitarian reasons but also because of stopping the development of the entire series of pathophisiological processes. They concluded that particular attention should paid to patients with higher feeling of fear and one should take due actions in order to minimize this factor for the purpose of the possible improvement in the perioperative care. Perski [19] describes increased appearance of perioperative complications in combination with the continually increased factor of fear and depression. On the basis of studies of patients carried out on the group, where the relation of the appearance of fear and the age was being examined, they concluded that the observed parameter had kept at a high level and its experiencing increased along with the age of patients. Fear is a developing factor in the awareness of patients indicating high increase of this parameter in the perioperative period. Based on the research conducted by Alexander [20] it is possible to come to the conclusion, that the level of fear in the examined patients remained at a high level. In the examinations carried out in groups of patients an effect of the age on the level of fear was being taken into consideration, and the highest level was also stated among two parameters examined. Therefore, the proceedings aimed at the reduction of feeling fear while executing medical procedures, are really important and justified not only for humanitarian reasons but also because of their contribution to the entire process of patophisiological changes [21 24]. Based on our own research it can be stated that among patients who did not get medicines it was possible to notice the growth of feeling fear along with age, and the opposite situation is being observed in the group surveyed where Dormicum medicine had been applied. The Dormicum application has no effect on the level of feeling pain with the division made according to the gender criterion. Statistically significant differences appear when there are analysed patients without the premedication as well as those to whom before putting the frame on Ketonal was given. In the first case of patients without the premedication it is noticable that male patients feel the stronger pain in a statistically significant degree. However, the situation is quite the opposite in the case of Ketonal application, where women experience pain stronger than men do. The results of the analysis of studying pain experienced while fixing the sterereotactical frame has his confirmation in research which was carried out in 2010 at the same clinic [25]. After examining the group of 60 patients a dependence on the applied premedication, the gender and individual age groups was observed. A relation of feeling pain as well as a medicine were not observed in reference to the place of residence and education. They confirm the obtained results, that applying exclusively a local anesthesia before putting the stereotactical frame on does not eliminate feeling of pain by the patient. Only giving premedication or Ketonal depending to the gender and age can reduce this unpleasant emotion. Conclusions In the research group where before putting the stereotactical frame on, the patients had received Ketonal statistically significant changes were not observed in the case of patients in all sorts of age groups. It is possible to notice that the examined STAI X-1 factor is of similar value in all groups. The patients who received Ketonal scored the similar number of points in every age group. The largest differences noted appeared between women and men receiving Ketonal. In case of the STAI X-2 sheet in the group of the patients to whom the premedication had not been applied it is possible to observe the growth of the number of obtained points along with the increase of the age. These changes are at a statistically significant level. Among people who did not receive medicine it is possible to notice the increase in the parameter of fear along with age, whereas the opposite situation is being recorded in the group examined with the Dormicum medicine applied. In the three conducted correlation analyses of the age towards the factors studied it is possible to notice positive effects in the case of Dormicum in comparison 26

27 Raszka et al./jnnn 2016;5(1):21 27 to the control group (patients without the premedication). A relation of the baulk was shown in none of examined groups with the age but the level of felt pain measured on the VAS scale. Implications for Nursing Practice Widely applied diagnostic methods conducted with the stereotactical biopsy for the purpose of taking samplematerial for the patomorphological examination are connected with pain and fear being experienced by the patient during the performed treatment. Monitoring the complaint by the nursing staff applying a therpy individually adapted to every patient feeling pain and feeling fear will let effectively minimize it and affect the frame of mind during the treatment. The participation in the pharmacological alteration will permit to minimize both pain and fear while putting the stereotactic frame on. References [1] Nowicki A. Pielęgniarstwo onkologiczne. Termedia, Poznań [2] Walsh K. Neuropsychologia kliniczna. PWN, Warszawa [3] Ząbek M. Zarys neurochirurgii. PZWL, Warszawa [4] Rowland L.P., Pedley T.A. Neurologia. Urban & Partner, Wrocław [5] Szylberg T., Harat M., Furtak J. Badanie patomorfologiczne w biopsji stereotaktycznej guzów mózgu. Neurol. Neurochir. Pol. 2001;35(5): [6] Nowacki P., Tabaka J., Jeżewski D. Diagnostyka glejaków mózgu pobranych drogą biopsji stereotaktycznej wspomaganej optycznym systemem neuronawigacji. Neurol. Neurochir. Pol. 2004;(38)1:3 8. [7] Moskała M., Adamek D., Gościński I., Kałuża J., Polak J., Krupa M. Techniczne i diagnostyczne problemy występujące podczas biopsji i operacji stereotaktycznych guzów mózgu. Biuletyn Wojsk. Szp. Klin. 1997;3 20. [8] Lech A., Stępień T., Bierzyńska-Macyszyn G. Biopsja stereotaktyczna bezpieczeństwo metody na podstawie doświadczeń własnych. Neurol. Neurochir. Pol. 2001;(35)5: [9] Moskała M., Adamek D., Gościński I., Kałuża J., Polak J., Krupa M. Operacje stereotaktyczne guzów mózgu w materiale Kliniki Neurotraumatologii CM UJ w Krakowie. Neurol. Neurochir. Pol. 2001;35(5): [10] Harat M., Sokal P. Wykorzystanie metody stereotaktycznej w praktyce neurochirurgicznej. Neurol. i Neurochir. Pol. 2001;34(5): [11] Moskała M. Współczesne znaczenie biopsji i operacji stereotaktycznych mózgu w neuroonkologii i neurotraumatologii na podstawie badań własnych: rozprawa habilitacyjna. Wyd. Uniwersytetu Jagiellońskiego, Kraków [12] Dobrogowski J., Wordliczek J. (Red.), Medycyna bólu. Wyd. Lek. PZWL, Warszawa [13] Dobrogowski J., Wordliczek J. (Red.), Ból przewlekły. MCKP UJ, Kraków [14] Bętkowska-Korpała B., Gierowski J.K. (Red.), Psychologia lekarska w leczeniu chorych somatycznie. Wyd. Uniwersytetu Jagiellońskiego, Kraków 2007; [15] Kozielecki J. Koncepcje psychologiczne człowieka. Wyd. Akademickie Żak, Warszawa 2000;131. [16] Juczyński Z. Radzenie sobie ze stresem spowodowanym chorobą nowotworową. Biblioteka Psychiatrii Polskiej. 2000; [17] Salmon P. Psychologia w medycynie. GWP, Gdańsk [18] Pawlak A., Krejca M., Janas-Kozik M., Krupka-Matuszczyk I., Rajewska J., Bochenek A. Ocena lęku i depresji w okresie okołooperacyjnym u pacjentów poddawanych rewaskularyzacji mięśnia sercowego. Psychiatria Polska. 2012;(46)1: [19] Perski A., Feleke E., Anderson G. et al. Emotional distress before coronary bypass grafting limits the benefits of surgery. Am Heart J. 1998;136(3): [20] Alexander D.A., Naji A.A., Pinion S.B. et al. Randomised trial comparing hysterectomy with endometrial ablation for dysfunctional uterine bleeding: psychiatric and psychosocial aspects. BMJ. 1996;312(7026): [21] Książek J., Piotrkowska R., Gaworska-Krzemińska A. Ocena jakości życia pacjentów w teorii i praktyce pielęgniarskiej. Pielęg. Położ. 2005;4: [22] Wrześniewski K., Sosnowski T., Jaworowska A., Fecenec D. Inwentarz stanu i cechy lęku STAI: polska adaptacja STAI. Pracownia Testów Psychologicznych Polskiego Towarzystwa Psychologicznego, Warszawa [23] Meder J. (Red.), Aktualne zasady postępowania diagnostyczno-terapeutycznego w onkologii. Centrum Medyczne Kształcenia Podyplomowego, Warszawa [24] Chmura K., Harat M., Litwinowicz A., Podsiadły J., Dobrowolski M., Grabowski P. Techniki znieczulenia stosowane u pacjentów poddanych zabiegom stereotaktycznym, Valetudinaria. 2000; [25] Wójcik A. Ocena bólu u pacjentów neurochirurgicznych w dobie zabiegu neurochirurgicznego, praca magisterska pod kierunkiem prof. M. Harata, Toruń Corresponding Author: Anna Raszka Klinika Neurochirurgii 10 Wojskowy Szpital Kliniczny z Polikliniką w Bydgoszczy ul. Powstańców Warszawy 5, Bydgoszcz, Poland anarasz-21@wp.pl Conflict of Interest: None Funding: None Author Contributions: Anna Raszka A, B, C, E, F, Ewa Kociniewska A, B, C, F A, C, D, G, H, Aleksander Goch (A Concept and design of research, B Collection and/or compilation of data, C Analysis and interpretation of data, D Statistical analysis, E Writing an article, F Search of the literature, G Critical article analysis, H Approval of the final version of the article) Received: Accepted:

28 Pielęgniarstwo Neurologiczne i Neurochirurgiczne The Journal of Neurological and Neurosurgical Nursing 2016;5(1):28 30 THE JOURNAL OF NEUROLOGICAL AND NEUROSURGICAL NURSING eissn ISSN Review DOI: /PNN Rapid Sequence Intubation for Head Injury Patients. A Practice Sekwencja Szybkiej Intubacji u pacjentów z urazami głowy. Praktyka Paweł Witt 1, Wojciech Leśniak 2 1 Department of Anesthesiology, Intensive and Postoperative Care, Independent Public Children s Hospital, Warsaw, Poland 2 Clinical Department of Cranio-Dental-Facial Surgery, Military Medical Institute, Warsaw, Poland Abstract Rapid Sequence Intubation is one of most commonly applied procedures for trauma patient in emergency practice such as Medical Rescue Service as Emergency Hospital Ward, but in the case of patients with maxillofacial trauma it is usually complicated. Firstly the trauma directly involves the airway, but also the commonly associated injuries and conditions, such as craniocelebrar injuries often limit the options in management. The aim of this article is to describe rapid sequence intubation protocol for this group of critical injured patients. (JNNN 2016;5(1):28 30) Key Words: rapid sequence intubation, emergency airway puncture, maxillofacial trauma, head injury, Medical Rescue Service Streszczenie Sekwencja Szybkiej Intubacji jest jedną z najczęściej stosowanych procedur u pacjentów urazowych w ratownictwie medycznym jak również w Szpitalnym Oddziale Ratunkowym. Procedura ta ulega skomplikowaniu u pacjentów z urazami twarzowoczaszkowymi oraz współistniejącymi urazami czaszkowomózgowymi. Celem artykułu jest opisanie protokołu szybkiej intubacji dla tej grupy pacjentów. (PNN 2016;5(1):28 30) Słowa kluczowe: Sekwencja Szybkiej Intubacji, konikopunkcja, uraz szczękowo-twarzowy, uraz głowy, Zespół Ratownictwa Medycznego Introduction The Rapid Sequence Intubation (RSI) is a commonly used method of respiratory protection against gasping, especially in trauma patients. In Poland, RSI protocol has been modified due to the need to adapt to the conditions of the emergency medical team. Head injuries, including craniocelebrar injuries with accompanying injuries within the facial skeleton are an essential issue which must teams must face. The aim of the work is to discuss the problem of modification of the RSI Protocol in this group of patients. Rapid Sequence Intubation Rapid Sequence Intubation (RSI) is the recommended method for respiratory protection against gasping, particularly in trauma patients. RSI stands for quick induction to the anesthesia, however, in literature it occurs in both the determination of induction and endotracheal intubation [1,2] This widely used technique is based on the patient s oxygenation (preoxygenation), induction of anesthesia, muscle relaxant drugs and performance of endotracheal intubation. The main purpose of the RSI is a quick protection of the patient against aspiration of food content, which is a common cause of serious complications and deaths. The RSI Protocol is implemented by the rescue team leader or a person who has the best experience in endotracheal intubation: 1) preparation of necessary equipment for 28

29 Witt and Leśniak/JNNN 2016;5(1):28 30 endotracheal intubation, medication and equipment to carry out alternative methods, 2) start monitoring the patient: hemoglobin saturation with oxygen (SpO2), heart rate (HR), non-invasive blood pressure measurement (NIBP) of the heart electrical function (ECG) [2,3]. In the literature, classic RSI is based on anaesthetic using etomidate (0.3 mg/kg iv) and suxamethonium (1.5 mg/kg iv) [1 3]. For patients with cardiovascular disease it is recommended to reduce by half the dose of etomidate. Etomidate is the drug of choice because it works most reliably on the circulatory system, compared with propofol or tiopental [4], but it does not apply to emergency medical teams in Poland. Propofol is applied 2 3 mg/kg, Thiopental 5 mg/kg or Ketamina 2 mg/kg iv. Currently, in Poland rocuronium is commonly applied as the alternative for suxamethonium (0.6 1 mg/kg iv) [2] Head Injuries. The road traffic accidents and beatings are the major cause of head injuries in the population. It regards mainly men aged between Intubation is more difficult and complex in the case of face skeleton fractures. There are fractures of the upper, middle and lower parts of the face. Among the fractures of the upper part of face, depending on the clearance plane, the direction and strength of the trauma there are breaking the cranio-orbital fracture, frontal-orbito-nasal fracture and the upper face massive displacement. In the case of these fractures associated with bruise and swelling of the brain, the occurrence of intracranial hematoma, fractures in the anteriol and the middle cranial fossa, the patient s condition requires rapid airway protection and multidisciplinary treatment of: the neurosurgeon, neurotraumatologist, maxillofacial surgeon and the intensive care team. Among the fractures of the middle part of the face there are isolated fractures of the orbital fracture, zygomatic-orbital fracture, zygomatic-maxillo-orbital fracture and orbitonasal displacement [5 7] Unless it is accompanied by multiorgan injury, they are generally not life-threatening. Fractures of the lower part of the face in the form of mandibular fractures on both may lead to coverage for the front of the tongue and its maturity by closing the airway. However, it should be noted that all of the aforementioned injuries, broken teeth or prosthetic restorations, bleeding in the mouth and swelling in this area always carry a possible risk of airway obstruction and require bservation and often also the airway intubation [7]. Modification of the RSI in a patient with maxillofacial trauma. Trauma within the facial skeleton is difficult and often prevents the use of classical RSI protocol. Treatment of injuries within the facial skeleton requires free access to the oral cavity and most cases applyin intermaxillar fixation, which is not possible in the case of tracheal intubation through the mouth. It is worth noting, however, that the aforementioned injuries are often accompanied by breaking in the front and the middle cranial fossa, which is contraindication to intubate through the nose. Therefore, in the situations of emergency there should be applied intubation through the mouth and the way of intubation should be changed before the operation or performing tracheostomy or submental intubation [7] However, there are cases in which damage to the faces is so severe, that it is not possible to execute intubatation through the mouth. In that case the RSI protocol should be modified. The first modification in the case of bleeding, movable sections of the bone of the mandible, tongue collapsing, leaving foreign bodies (food scraps, fragments of teeth, prosthetic restorations), first having drained off the liquid content, they should be gently removed them with the use of Mogilla forceps. In order to make the intubation easier. use the bougie [2]. The second modification, in the case of major damage to the covering the bottom of the mouth, strong bleeding from and ineffective removing of foreign bodies and the blood from the airway, or when the direct laryngoscopy increased the damage and not giving certainty for the possibility of intubation, or the mandibular fractures prevent opening the mouth, it is necessary to execute puncture of cricothyroid ligament-shield (emergency airway puncture) or carry out submental intubation (in the case when there are connection between Modification of drugs. In Poland the drugs of first choice for induction of anesthesia in medical rescue teams are propofol or tiopental. Tiopental is not recommended in the case of patients with milutiorgan trauma and hypovolemic shock, because this type of drugs by the greatest cardiodepressy results in lowering blood pressure. Its advantage is that this drug is neuroprotective in brain tissue, which can be useful in the case of cranio-cerebral trauma, often co-existing in this group of patients. Propofol is a drug becoming more accessible, and easier to apply compared to tiopental because it does not require dissolution, which in the case of rapid inductions is of great importance. Propofol is not approved for induction in patients with epilepsy, since according to a number of authors it is pronvulsive. Based on the longstanding experience of the authors, it appears that the pre-hospital aid in the case of RSI very rarely used muscle relaxants. Contrary to the terms of Emergency Department of the Hospital. In patients with the socalled difficult air passages trying to execute the intubation, the patient in the anesthesia, but on their own breath. Muscle relaxant drugs should be applied to stop the patient s breath of residual injury, although it does not give the certainty for the possibility of intubating the patient. Rescue teams in Poland do not have drugs for reversal of neuromuscular blockade such as Sugammatex, Neostygmina. Besides, specialized rescue team are equipped with muscle relaxants. Most teams are basic rescue medical teams. In summary, it seems that the RSI is better in a combination of intravenous an- 29

30 Witt and Leśniak/JNNN 2016;5(1):28 30 aesthetics with opioids such as Fentanyl than in the combination of anaesthetics with muscle relaxant drugs. Summary Intubation of patients with craniofacial trauma (Figure), especially with a particular craniobrain trauma is always a quick and dramatic procedure. In addition, some physiological and anatomical conditions such as: large tongue. a short neck swelling of tissues in the course of pregnancy, generate problems with the epiglottis showing and complicate tracheal intubation. In a situation where anatomical, physiological conditions overlap the difficulties arising from the nature of the injuries, a modification of the RSI protocol ought to be considered. Patients with head injuries need multidisciplinary treatment from the early moments while they are being taken to hospital. The team of Emergency Unit should be supported by other specialists, particularly by the Otolaryngologist, Neurotraumatologist, Neurosurgeon and Maxillofacial Surgeon, in order to perform tracheal intubation with fiberoscopy, percutaneous or submental tracheostomy. References [1] Ballow S.L., Kaups K.L., Anderson S., Chang M. A standardized rapid sequence intubation protocol facilitates airway management in critically injured patients. J Trauma Acute Care Surg. 2012;73(6): [2] Lyon R.M., Perkins Z.B., Chatterjee D., Lockey D.J., Russell M.Q. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care. 2015; 19(1):134. [3] Frerk C., Mitchell V.S., McNarry A.F. et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6): [4] Forman S.A. Clinical and Molecular Pharmacology of Etomidate. Anesthesiology. 2011;114(3): [5] Mroczyk B., Philavong P., Leszczyńska M., Wierzbicka M. Mnogie złamania w obrębie twarzoczaszki spowodowane wypadkiem komunikacyjnym. Postępy w Chirurgii Głowy i Szyi. 2014;2: [6] Choonthar M.M., Raghothaman A., Prasad R., Pradeep S., Pandya K. Head Injury A Maxillofacial Surgeon s Perspective. J Clin Diagn Res. 2016;10(1):ZE01 6. [7] Gupta B., Prasad A., Ramchandani S., Singhal M., Mathur P. Facing the airway challenges in maxillofacial trauma: A retrospective review of 288 cases at a level i trauma center. Anesth Essays Res. 2015;9(1): Corresponding Author: Paweł Witt ul. Liwiecka 17/34, Warszawa, Poland pawwitt@gmail.com Figure. An example of the patient with craniofacial trauma Conflict of Interest: None Funding: None Author Contributions: Paweł Witt A, E, F A, E, F, Wojciech Leśniak (A Concept and design of research, E Writing an article, F Search of the literature) Received: Accepted:

31 Pielęgniarstwo Neurologiczne i Neurochirurgiczne The Journal of Neurological and Neurosurgical Nursing 2016;5(1):31 35 THE JOURNAL OF NEUROLOGICAL AND NEUROSURGICAL NURSING eissn ISSN Review DOI: /PNN Clinical, Therapeutic and Caring Aspects of Epilepsy at the Developmental Age Kliniczne, terapeutyczne i opiekuńcze aspekty padaczki w wieku rozwojowym Ewa Kontna 1, Marta Lewicka 1, Bogumiła Małecka 2, Ewa Barczykowska 3 1 Department of Anaesthesiology and Intensive Children s Therapy, The Josef Brudziński Provincial Children s Hospital in Bydgoszcz, Poland 2 Paediatry, Haematology, Oncology and Rheumatology Ward, the Regional Children s Hospital in Bydgoszcz, Poland 3 Division of Pediatric Nursing, Department of Preventive Nursing, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland Abstract Epilepsy is a neurological disorder characterized by the occurrence of seizures of distinct nature. At the developmental age it occurs in 0.5% of people. Diagnostic and therapeutic process is complex. In the treatment, pharmacological, surgical, and dietetic methods are used. In the handling of a child affected by epilepsy, we should take into account the impact of the disease on the quality of patient s life and on that of their families. The aim of the work is to present the current clinical knowledge on the subject of epilepsy at the age of development and the problems, which the children and their parents must face. (JNNN 2016;5(1):31 35) Key Words: epilepsy, children, diagnostic, treatment Streszczenie Padaczka jest schorzeniem neurologicznym charakteryzującym się występowaniem napadów padaczkowych o różnym charakterze. W wieku rozwojowym występuje u 0,5% osób. Proces diagnostyczny i terapeutyczny jest złożony. W leczeniu wykorzystuje się metody farmakologiczne, chirurgiczne, dietetyczne. W postępowaniu z dzieckiem chorym na padaczkę należy uwzględnić wpływ choroby na jakość życia pacjenta i jego rodziny. Celem pracy jest przedstawienie aktualnej klinicznej wiedzy na temat padaczki w wieku rozwojowym oraz problemów z jakim muszą zmierzyć się dzieci oraz ich rodzice. (PNN 2016;5(1):31 35) Słowa kluczowe: padaczka, dzieci, diagnostyka, leczenie Introduction Epilepsy is a disease which has accompanied the human for centuries. The perception of the disease has changed over the years. The introduction of the new definition of epilepsy and its classification allows for the appropriate implementation of treatment. New diagnostic and therapeutic methods which were adopted in the past decade will affect the perception of the disease both by society and by the patient. A major problem is the drug-resistance phenomenon and side effects of anti-epileptic drugs. In the care of the sick child with epilepsy, we should take into account the problems of everyday life, such as schoolwork, society education, patient s society stigma. The aim of the work is to present the current clinical knowledge on the subject of epilepsy at the age of development and the problems, which the children and their parents must face. Overview Epilepsy is a disease known for centuries. The disease is first mentioned in Persian documents and Egyptian 31

32 Kontna et al./jnnn 2016;5(1):31 35 Papyrus. Code of Hammurabi is dated to the early 18th century B.C and contains the record of a patient suffering from epilepsy. In ancient Mesopotamia, a document from the year 1050 B.C was found, which described convulsions. It mentioned the person in whom there had been tension in the hands and feet, wrest neck, wide open eyes and sialorrhea, and then loss of consciousness. Events about Jesus Christ healing of the affected for epilepsy can be read in the New Testament. This disease is described in the Jewish Talmud and in the works of the Roman thinkers [1]. For many centuries seizures were treated as a manifestation of demon possession. In dealing with the affected, spells and witchcrafts were applied. Only the Greek physician Hippocrates in 400 B.C in his work On the Sacred Disease described epilepsy as a brain affliction requiring treatment and diet. He mentioned, also a craniotomy as an alternative form of treatment [2]. During the Middle Ages people came back to the theory of declaring that the reason for the emergence of seizures was the Satan s action. It was only in the 19th century that research of neurophysiology allowed in 1850 for the recognition of epilepsy as a neurological disease. The introduction of electroencephalogram test (EEG) by Berger in 1928 became a breakthrough in the diagnosis of the disease [3]. Epilepsy is one of the most common chronic diseases of the nervous system. Among children and the young the prevalence of the disease is similar to that in adult population and it amounts to 0.5%. In the countries of Latin America and Africa from 1 to 1.5 % of children suffer from it. Parasitic infections prevalent in these areas may be a cause of epilepsy. In about 3% of children suffering from epilepsy, epilepsy seizures (SE) appear. The incidence rate of epilepsy depends on age. The highest, is during the neonatal period. A typical symptom for the infantile period is also the presence of the most severe epileptic syndromes. The reason is the imposition of various etiological factors. This includes adolescence and maturity of CNS (central nervous system also known as OUN) dysfunctions, intrauterine and perinatal CNS damage, genetic disorders [4,5]. The International League Against Epilepsy (ILAE) introduced the new definition of epilepsy in The disease can be divided into the following cases [6]: 1. At least two unprovoked (or reflex) seizures occurring more than 24 hours apart; 2. One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years; 3. Diagnosis of an epilepsy syndrome. Epileptic seizure is caused by the unloading of groups of neurons of the cerebral cortex. It is an unpredictable and uncontrolled phenomenon. Transitional brain dysfunction is caused by excessive and sudden bioelectric unloading in nerve cells [1]. The clinical picture of epileptic seizure can be different, depending on the location and the size of the irregular uploading. Spasticity, sensory, vegetative, mental disorders might appear, sometimes the disorder of consciousness may accompany. When uploading spreads to adjacent areas of the cortex, we are dealing with secondary generalized seizure. According to the classification, epilepsy seizures are divided into focal and generalized. In the diagnosis, an accurate description of the seizure is of significant importance [6,7]. In the classification of the concept of epilepsy syndromes one can identify the type of epilepsy seizures based on age, the prevalence of the first symptoms, diversity of generalized and partial epilepsy, and the distinction between the genetically epilepsy or different reasons. An example of epilepsy of infancy are Dravet s and West s syndrome (severe myoclonic epilepsy of infancy SMEI). During the infantile period epilepsy may be characterized by Lennox-Gastatut Syndrome (LGS), epilepsy in children with the seizures of unconsciousness [4]. Taking into account the cause, there are genetic origin of epilepsy, based on the knowledge or on suspected genetic defect. The second group of epilepsy is conditioned structurally or metabolically. Structural damage can be the result of trauma, stroke or infection. The reason may be also the disease with damage of the cerebral cortex such as tuberous sclerosis. The third group of epilepsy are diseases of unknown etiology [6,8]. In the diagnostic process, epilepsy requires to be differentiated from other epileptic events occurring in children s age. Fainting, involuntary movements, apnea, onanism, psychogenic dysfunction, Sandifer s Syndrome, sleep disorder belonged to the non-epileptic seizures (NES) symptoms [9,10]. Electroencephalogram test (EEG) has an indispensable role in the diagnosis of epilepsy and other epileptic seizures. This test shall be performed on each child of anamnesis indicating the presence of seizures. EEG is used to specify the type of seizures and indicate the factors provoking reasons for seizures. The test is useful in children with febrile seizures, in differential diagnosis of consciousness disorders in children. The appropriate factors of the EEG is the preparation of the child and its parents. The test must be carried out in physiological conditions, during the peaceful watch and sleep. Before the EEG is accomplished, it is good to alleviate fear and anxiety of the child through a short conversation or game. After the electrodes are put on, infants should be fed and put to sleep, so as to limit touching during the test. EEG lab should be child-friendly, located away from sources of noise. The behavior of the test taker has a significant impact. In the diagnosis of 32

33 Kontna et al./jnnn 2016;5(1):31 35 epilepsy, brain bioelectrical activity is performed using modern techniques, such as Holter EEG monitoring and videometry [11]. In the diagnostic imaging, magnetic resonance imaging (MRI) and computed tomography (CT) are applied. The results allow to immortalize the structural change of the damaged encephalon showing the location, nature, and the extent of the pathological changes. In determining the epileptic focal radioisotope methods are also helpful. Single photon emission computed tomography (SPECT) allows to indicate the part of the brain responsible for uploading, specifying the increased cerebral flow during the seizure, however after seizure this location indicates the reduced flow. In distinguishing epileptic seizures positron emission tomography (PET) is also used. It specifies the place of increased metabolism of epileptic focal [12,13]. Epilepsy treatment in large part has a pharmacological character. It should be noted that anti-epileptic drugs have anticonvulsant activity, which do not show anti-epileptogenic activity. The Polish Society of Child Neurologists indicates in its recommendations the principle of treatment depending on the type of epilepsy, using split of medication for first, second and third type. When choosing a drug, it should be directed to the effectiveness of the relevant types of epilepsy, as well as safety, good tolerance, and speed of the therapeutic dose. The form of the medication must be adopted to the age and condition of the patient. When choosing the anti-epileptic drugs, other medications must be considered to be taken by a child, in order to avoid unfavourable interactions. It should be noted that children have faster metabolism than adults. Therefore, larger and more frequent doses of drugs are required [4,6]. The use of the monotherapy is effective in 70% of children in the treatment of epilepsy. In other cases, it is necessary to use two or more drugs at the same time. In case of polytherapy failure, epilepsy is described as drug-resistant [14 16]. Pharmacological treatment is associated with the possibility of side effects occurrence. The reason for their occurrence may be the mechanism of medications action, excessive immune reaction, or cytotoxic response of a sensitive person. Adverse reactions may result from the accumulation of drugs in the case of long-term therapy. Some of the anti-epileptic drugs may have teratogenic and carcinogenic impact. The side effects include: dizziness, headaches, drowsiness, ataxia, reduced concentration, difficulty with memory, hyperactivity, decrease or increase in weight, symptoms of liver damage or pancreas, mineralization of bones dysfunction, dermal changes. In order to minimize the occurrence of side effects of taking anti-epileptic drugs in children, periodical checkups must be fulfilled (complete blood count, liver function tests, visual field testing, calcium-phosphate metabolism), also monitoring the level of drugs in the blood serum must be carried out [6,17]. High hopes of the treatment of drug-resistant epilepsy involves the search for alternative routes of administration of anti-epileptic drugs, gene therapy, and cells implementation. In the treatment, the substances interacting with anti-epileptic drugs also are applied, potentiating their reaction. Research on the effectiveness of application of preparations, containing cannabis has not been proved [18,19]. Single cases of patients with drug-resistant epilepsy, in which the use of medical cannabis had therapeutic importance has been published in the scientific literature. Cannabis is a psychoactive compound with a long history of recreational and therapeutic use. Current considerations regarding cannabis use for medical purposes in children have been stimulated by recent case reports describing its beneficial effect with refractory epilepsy. Overall, there are insufficient data to support either the efficacy or safety of cannabis use for any indications in children, and an increasing amount of data suggests possible harm, most importantly in specific conditions. The potential for cannabis as a therapeutic agent must be evaluated carefully for both efficacy and safety in treating specific pediatric health conditions. Recommendations for therapeutic use in exceptional pediatric cases are offered, always providing that this treatment course is carefully evaluated in individuals and in ongoing, well-designed research studies to determine safety and efficacy [20,21]. Non-pharmacological treatment of epilepsy is the ketogenic diet. Implementing of a ketogenic diet precedes 1 2 days of starvation diet. Then the children are given 1g of protein per kg and from 2 to 4g of fat per of kg body weight. The amount of consumed carbohydrates is small. Diet causes acidosis and the emergence of the ketonemia. This affects the reduction of bioelectrical of the brain [4,19]. Failure in the pharmacological treatment of epilepsy can be caused by both the drug-resistance phenomenon as well as by other reasons. It might happen that epilepsy was not properly classified, the drugs were not selected, too small or too big doses of medication were applied. The lack of treatment effects may be caused by the presence of factors that trigger seizures, failure to comply with the recommendations of the pharmacological treatment or skipping doses of drugs. In the case of drug-resistance confirmation, a child may be qualified for neurosurgical treatment [22]. Surgical methods of treatment of epilepsy are divided into resection methods, involving the removal of part of the brain with focal point and palliative methods. The resection methods of surgical treatment of epilepsy include: lobectomy (mostly temporal lobe or its part, rarely occipital lobe, parietal lobe and frontal lobe), hemispherectomy (removes all cerebral hemisphere) and 33

34 Kontna et al./jnnn 2016;5(1):31 35 lesionectomy (removal of epileptic focal emerging in structural changes). Among palliative methods of surgical treatment of epilepsy callosotomy is applied. Callosotomy is the intersection of the long fiber bundle passing through the corpus callosum. The effect of the treatment is to interrupt the spread of neurons uploading from one hemisphere to the other. Stimulation of the vagus nerve and deep stimulation of the brain belong to the palliative methods [2,23,24]. In the care of a child with epilepsy, the process of education should be taken into account. There is no contraindications to attending classes to pre-school or school. In exceptional cases, a child may benefit from individual learning in school or at home. With good control of seizures, it is necessary to ensure the right activity for the child s age. There should be no extreme sports, however, the child can ride a bike, swim, take part in activities with their peers. However, the child should always be secured with the presence of a caregiver. Planning the professional career for child, you need to pay attention to the types of work which is prohibited for patients with epilepsy (work at height, uniformed services, work on mechanical devices, professional driver) [6]. Epilepsy is a disease that has an impact both on the child s life and its family. Epilepsy seizures as well as adverse reactions of drugs taken often confine daily functioning. Children and youth suffer from a lack of acceptance on the part of their peers, from the stigma, often requiring psychological and psychiatric support, due to depression [25 27]. Chronic disease of the child causes disturbance of the psycho-social functioning of the whole family. From the moment of the diagnosis, parents go through a period of adaptation to the new situation. An important aspect is to provide comprehensive information for caregivers relevant essence of disease, the need for treatment, behavior during the attack, and the consequences of the disease. It becomes necessary to draw attention to the situation of the patient s siblings, as it often happens that the parents are focus all their attention mainly on the sick child. Caregivers of sick children suffering from epilepsy often struggle with low esteem and emotional exhaustion [28]. Conclusions 1. Epilepsy is a chronic disease of the nervous system in children, it mainly begins during the neonatal period. 2. Any attacks which may suggest epilepsy require full diagnostics in order to make correct identification and implementation of appropriate treatment. 3. In the treatment, the pharmacological, surgical, and dietetic methods are used. When implementing anti-epileptic drugs, the possibility of adverse reactions must be taken into consideration. 4. Taking care of the sick child suffering from epilepsy should be perceived as his/hers problems in a holistic way. Good cooperation with parents and teaching environment will include proper care of the child, considering its development, the need of education and psycho-social needs. 5. A child suffering from epilepsy is not an inconsiderable challenge for nursing staff. Knowledge of the current guidelines of the diagnostic process and therapeutic possibilities will allow a nurse to provide the child and the child s family with professional care. References [1] Jędrzejczak J. Wprowadzenie. W: Szczudlik A., Jędrzejczak J., Mazurkiewicz-Bełdzińska M. (Red.), Padaczka. Termedia Wydawnictwa Medyczne, Poznań 2012; [2] Kaczorowska B., Pawełczyk M., Przybyła M. Chirurgiczne metody leczenia padaczki. Aktualności Neurologiczne. 2012;12(3): [3] Motta E., Kazibutowska Z. Padaczka rys historyczny. W: Szczudlik A., Jędrzejczak J., Mazurkiewicz-Bełdzińska M. (Red.), Padaczka. Termedia Wydawnictwa Medyczne, Poznań 2012; [4] Kaciński M. Choroby układu nerwowego. W: Kawalec W., Grenda R., Ziółkowska H. (Red.), Pediatria. Wydawnictwo Lekarskie PZWL, Warszawa 2013; [5] Służewski W., Służewska-Niedźwiedź M. Uwarunkowania diagnostyczno-terapeutyczne w padaczce wieku rozwojowego. Polski Przegląd Neurologiczny. 2010;6(3): [6] Domańska-Pakieła D. Padaczka aktualne możliwości terapii i zalecenia. Standardy Medyczne. Pediatria. 2014; 11(6): [7] Szarpak Ł., Madziała M. Występowanie epizodów padaczki u dzieci. Nowa Pediatria. 2012;16(1):3 7. [8] Szczepanik E. Urazy czaszkowo-mózgowe u dzieci a padaczka. Neurologia Dziecięca. 2011;20(39): [9] Masztalerz A., Müller L., Wesołowska M., Sergot-Martynowska G. Trudności diagnostyczne w padaczkach wieku niemowlęcego ze szczególnym uwzględnieniem zespołu Sandifera. Neurologia Dziecięca. 2010;19(37): [10] Borkowska J., Kotulska-Jóźwiak K. Napady afektywnego bezdechu. Pediatria po Dyplomie. 2012;16(2): [11] Artemowicz B., Sobaniec P. Badania EEG w neuropediatrii. Neurologia Dziecięca. 2011;20(41): [12] Michalska J., Kociemba W., Steinborn B., Stajgis M., Paprzycki W. Rola spektroskopii rezonansu magnetycznego w padaczce. Neurologia Dziecięca. 2008;17(34): [13] Nagańska E. Znaczenie badania pozytonowej tomografii emisyjnej w diagnostyce padaczki. Postępy Nauk Medycznych. 2013;26(10):

35 Kontna et al./jnnn 2016;5(1):31 35 [14] Bogucki P. Politerapia padaczki. Neurologia po Dyplomie. 2013;8(5): [15] Fröscher W. Padaczka oporna na leki. Epidemiologia. 2012;20(1): [16] Mazurkiewicz-Bełdzińska M. Nowe leki przeciwpadaczkowe u dzieci czy spełniły pokładane w nich oczekiwania? Neurologia Dziecięca. 2014;23(46):9 17. [17] Steinborn B. Objawy niepożądane leków przeciwpadaczkowych. W: Szczudlik A., Jędrzejczak J., Mazurkiewicz- -Bełdzińska M. (Red.), Padaczka. Termedia Wydawnictwa Medyczne, Poznań 2012; [18] Kazula A., Kazula E. Terapia genowa padaczki. Farmacja Polska. 2014;70(10): [19] Klimek A. Alternatywne sposoby leczenia padaczki. Aktualności Neurologiczne. 2012;12(1): [20] Rieder M.J. Is the medical use of cannabis a therapeutic option for children? Paediatr Child Health. 2016;21(1): [21] Maa E. Paige F. The case for medical marijuana in epilepsy. Epilepsia. 2014;55(6): [22] Rysz A. Kwalifikacja do leczenia neurochirurgicznego padaczki. Neurologia po Dyplomie. 2012;7(3): [23] Rola R. Zastosowanie głębokiej stymulacji mózgu jako alternatywa w leczeniu padaczki lekoopornej. Neurologia Praktyczna. 2012;12(2):7 12. [24] Waliszewska R., Królikowska A., Banaś N., Rudaś M., Harat M. Pacjent po wszczepieniu stymulatora struktur nerwowych. Magazyn Pielęgniarki i Położnej. 2011;(3): [25] Talarska D., Steinborn B. Wpływ wybranych leków przeciwpadaczkowych na jakość życia dzieci i młodzieży z padaczką. Neurologia Dziecięca. 2009;18(36): [26] Bosak M., Dudek D., Siwek M. Leczenie depresji u chorych z padaczką. Przegląd Lekarski. 2013;70(7): [27] Zachwieja J. Stygmatyzm padaczki a praca zawodowa opis przypadku. Journal of Neurological and Neurosurgical Nursing. 2013;2(1): [28] Rozenek H., Owczarek K. Padaczka u dziecka i jej wpływ na wybrane aspekty funkcjonowania rodziny. Neurologia Dziecięca. 2008;17(34): Corresponding Author: Ewa Kontna Oddział Anestezjologii i Intensywnej Terapii Dziecięcej, Wojewódzki Szpital Dziecięcy im. J. Brudzińskiego w Bydgoszczy ul. Jana Karola Chodkiewicza 44, Bydgoszcz, Poland ewakontna@o2.pl Conflict of Interest: None Funding: None Author Contributions: Ewa Kontna A, C, E, F, H, Marta Lewicka A, F, G, H, Bogumiła Małecka F, G, H A, F, G, H, Ewa Barczykowska (A Concept and design of research, C Analysis and interpretation of data, E Writing an article, F Search of the literature, G Critical article analysis, H Approval of the final version of the article) Received: Accepted:

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