Stimulasi Sensori (Audio, Visual, dan Afektif) untuk Meningkatkan

Level Kesadaran pada Pasien Cedera Kepala

Sensory Stimulation (Audio,Visual, and Affective) to Enhance The Level of
Consciousness Among Brain Injury Patients

Carina Rega Utomo 1, Adelia Rochma2, Sanda Prima Dewi3, and Edy Purwanto4
1Department of Nursing, Universitas Airlangga, Surabaya, Indonesia
2Department of Nursing, Universitas Airlangga, Surabaya, Indonesia
3Department of Nursing, Universitas Airlangga, Surabaya, Indonesia
4
Department of Nursing, Universitas Airlangga, Surabaya, Indonesia
Carina.rega.utomo-2017@fkp.unair.ac.id, Adelia.rochma-2017@fkp.unair.ac.id, Sanda.prima.dewi-2017@fkp.unair.ac.id,
Edy.purwanto-2017@fkp.unair.ac.id.

Keywords: brain injury, sensory stimulation, and ICU.

Abstract: Background: Sensory stimulation (Auditory, visual and affective) is one of nursing intervention to enhance
the level of consciousness among comatose patient caused by brain injury in Intensive Care Unit (ICU).
However, little is known about the effect of sensory stimulation on brain injury patients. This study aims to
examine the effectiveness of sensory stimulation in level of consciousness among brain injury patients in ICU.
Method: source of the articles used are obtained from Scopus, Sage, PubMed, and Google scholar databases
from year 2007 up to 2017. Fifteen articles was measured by using PICOT and SORT methods. Results:
Sensory stimulation can be applied twice a day among brain injury patients to enhance the level of
consciousness. Given sensory stimulation, the consciousness level of all patients was increase by measuring
the Glasgow Coma Scale (GCS). Conclusion: Sensory stimulation (Auditory, visual and affective) is known
to be more effective on enhancing level of consciousness when combined.

.
1 INTRODUCTION
Head trauma is the most common cause of disability,
death and hospitalization in intensive care units (ICU)
throughout the world (Aghakhani et al., 2013).
Patients with head trauma usually have different types
levels of consciousness and cognitive function
(Borlongan et al., 2015). In addition, patients with
head injury usually takes a long time for the recovery
process. If the patient does not get up from the coma
will be complications like cognitive impairment,
contractures, speech disorders, and brain death
(Moattari, Shirazi, Sharifi, and Zareh, 2016).
In the United States, about 1.5 million people had
head trauma, and 52,000 died from head trauma.
From 1.5 million people who suffered head trauma,
90,000 people suffered severe head injuries that cause
disability in a long time (Ferdon, Dahlberg, and
Kegler, 2013). Although the incidence of mild and
moderate head injuries decreased, the incidence of
severe head injuries does not decrease. Patients with
head trauma have neurological problems such as
coma so that one of the main rehabilitation objectives
is to awaken from the coma (Park, 2016).
A wide variety of rehabilitation techniques can be
used for clients on head trauma (Abbate, Trimarchi,
Basile, Mazzucchi, and Devalle, 2014). Sensory
stimulation technique is non-invasive, low risk,
inexpensive, and easy to apply for comatose patients
after head trauma. The more sensors stimulation, the
patient may show changes in the level of
consciousness and awareness faster recovery (Kalani,
Pourkermanian, & Alimohammadi, nd; Park, 2016).
Sensory stimulation techniques included in
rehabilitation techniques (Abbate et al., 2014).
Several studies have described that this technique
effectively used for head trauma patients in intensive
care units (Moattari et al., 2016). Research related to
sensory stimulation in patients with head trauma
known to have a good relationship between the
stimulation of the healing process of patients with
head injury (Johnstone, Yoon, Rupright, & Reid-
Arndt, 2009).
Interventions using this sensory stimulation
provide stimulus to the body. This intervention is
usually divided into Kinestethic,
Auditory,Tactile,and Visual,thus providing multiple
functions simultaneously. Auditory and visual
stimulation is known to activate the limbic system
which will be interpreted in the cerebral cortex to
increase awareness. So, hopefully with lots of
stimulus will be more efforts to activate the limbic
system (Salmani, Mohammadi, Rezvani, &
Kazemnezhad, 2017).
The explanation above describes the importance
of stimulation to increase client awareness with head
trauma in ICU. Thus, it is important to know the
effects of sensory stimulation on head trauma.
2 MATERIALS AND METHODS
The methods used in the preparation of systematic
review begins with the selection of the topic,
keywords to search articles using the database
Scopus, sage, pumbed, and googlescholar which was
published in 2007 to 2017 with a combination of
keywords brain injury, injury, sensory, ICU, and
stimulation. All articles identified selected in
according with research questions. Question of
research on systematic review this is how evidence
based (study of facts) about the effectiveness of
sensory stimulation in patients with head injury
consciousness in the ICU? How much time is needed
to raise awareness of the patient? Inclusion criteria for
this study is the use of the English language and the
sample population was patients with head injury with
loss of consciousness. From all articles that match the
theme and the inclusion criteria then analyse again
with Picot and methods scoring with SORT article.
3 RESULTS /REVIEW
The initial search found 32 articles. Read the article
back if in accordance with the inclusion criteria.
Found 17 articles that match and 25 articles into the
exclusion criteria. 17 articles then go back and do a
review in accordance criteria inclusion. So
determined appropriate article 15 (Figure 1).
15 study that aims to explain the effectiveness of
sensory stimulation to the head trauma was found
(Johnstone et al., 2009; Kalani et al., Nd; Moattari et
al., 2016; Park, 2016; Salmani et al., 2017). 5 The
study focuses on the sensory stimulus auditory parts,
one focusing on visual studies, and 9 other research is
a combination of multimodal sensory stimulus that is
affective. All articles are at level 1, 2, and 3
(Appendix 1).
3.1 Auditory Sensory stimulation
The auditory sensory stimulation can increase the
awareness of patients with head injury (Kalani et al.,
Nd; Moattari et al., 2016; Park, 2016; Salmani et al.,
2017).

Figure 1: Flow diagram systematic review articles
Patients were more significantly enhanced awareness
when listening to recordings of voice or family or
people they care compared to listening to the voice of
a nurse or a stranger. Sensory stimulation to the
auditory part also increased more significantly when
in stimulus directly, rather than indirectly. Examples
stimulus Direct is a sound family visit and examples
of indirect stimulus is sound TV.
3.2 Visual Sensory Stimulation
The visual sensory stimulation can also increase
awareness. Visual sensory stimulation can be done
using a virtual reality (VR). Virtual reality will show
both 2-dimensional images and three-dimensional.
Patients can be given a stimulus with photos or video
without the sound of people loved. In addition, also
using natural pictures such as forest or mountain can
be given. However, the visual sensory stimulation is
more effective when combined with auditory
stimulation.
3.3 Affective Sensory stimulation of
Affective stimulation means the sensory stimulus is
given by people known to the patient. This
stimulation include multimodal stimulation on the
auditory, visual, and kinesthetik conducted by
relatives of known patients. Stimulus is known to
raise awareness of head trauma patients in ICU.
Increased awareness of unknown began to occur on
the seventh day.
3.4 Total Time Giving Stimulus
Stimulus length of time given by the researchers to
raise awareness of head trauma patients have a
different number of days, starting from 5 days, 7 days,
14 days, 4 weeks, and 6 weeks. The number of days
that is commonly used is 14 days. Despite all the
number of days to raise awareness of head trauma
patients, the number of days which is effective for
patients experienced a significant increase in
awareness is not yet known. Providing a stimulus to
do almost all researchers 2 times a day at the same
hour. Unknown stimulus effectively done for 15-30
minutes each meeting. Increased awareness of head
trauma patients who do sensory stimulus in the ICU
with measurement GlaslowComa Scale (GCS) on
average increased after day 7 to 14 days the amount
of stimulation (Moattari et al., 2016).
4 DISCUSSION
Providing stimulation is a challenge to nurses who
provide care in the intensive care unit with a brain
injury patients. One of the serious problems in
patients with head injury is a comma on sensory
deprivation (Moattari et al., 2016). This can cause an
impact on the mental and perceptual problems and
life-threatening conditions. Provide necessary
stimulation given to the client even though the
conditions of loss of consciousness or coma
(Johnstone et al., 2009).
The first objective of this study was to compare
the effectiveness of sensory stimulation auditory,
visual and affective. Auditory sensory stimulation
may alter cognitive function by increasing ventricular
fluid drainage without negative impact to the physical
such as increased ICP or cerebral perfusion pressure
(Pape et al., 2015; Park, 2016). The other explanation
may be the stimulus auditory provided directly have
a level high interpersonal and content of the voice has
an important meaning for the patient so as to activate
the central motoric system with this stimulation (Ali
& Gorji, 2014; Sullivan et al., 2017; Tavangar,
Kalantary, Salimi, & Jarahzadeh, 2015).
Visual sensory stimulation increased awareness
by providing stimulating effects that facilitate the
dendrites to grow and connect with synaps. Another
possible explanation is the incorporation of auditory
and visual stimuli provide a soothing effect for
patients. So the recovery process can be maximum
(Gerber et al., 2017). It is also said that the possibility
of combining some of the stimulus is more effective
than a single stimulus. This is supported by studies on
affective sensory stimulus.
Affective sensory stimuli that are provided by the
family or nurse may be activate the limbic system.
After that, it will increase sympathetic activity and
increase norepinephrine at the nerve terminal. It is
then interpreted by the cerebral cortex and ultimately
raise awareness and spirit. Additionally, when
families communicate, in which there is an element
of visual stimulation, auditory and kinetic. In terms of
auditory family may give positive expectations, or
create positive memories. This is consistent with the
model psiconeuroimunological that positive thinking
would be associated with better health status.
Moreover, it may also be due to each person will lean
on spiritual beliefs to help them reduce stress. So the
patient remain optimistic and reduced stress
(Johnstone et al., 2009; Salmani et al., 2017; Schmidt-
Wilcke et al., 2017).
Three explanations above show that more
stimulus is given to patients with head injury who
experienced loss of consciousness, will give a lot of
response from the body. However, when compared
one by one between the effects of audio, visual, and
tactile, as well as affective until today still can not
explain exactly which one is more effective when
using only one stimulus compared to using a lot of
stimulus. Thus, the need for further research related
to the effects of stimulus audio, visual, and tactile
carried out by the use of the proper protocol by
nurses.
The second research objective was to answer the
time required for the stimulation of consciousness.
Recovery in patients ranging from days 7 to 14 at the
client with the most common used GCS is 8. To date,
there is no clarity researchers examined the number
of days studied and how many days are most effective
used. Stimulus performed usually twice by
investigators. Stimulus is done in a short time and
repeats more effective than done in the long term.
This is supported by research that the stimulus
Meghan five times within 15 minutes is more
effective than 1 time in 1 hour (Megha, Harpreet, and
Nayeem, 2013). So, there is still need for further
research how many days are effective to provide a
stimulus to an increase in awareness significantly.
4 IMPLICATIONS FOR NURSING
PRACTICE
Providing caring is the main task of a nurse
(Abdullah, Idris, and Saparon, 2017). This role must
be adhered to by nurses, including nurse in the ICU
who have the challenge to stimulate the client's level
of consciousness as in the case of head trauma. Until
more research is growing about the effectiveness of
each of these stimuli, clinicians should use clinical
recommendation today that have been proven, such
as providing stimulus sensory in patients using
stimulus auditory in directly that have been proven to
raise awareness, or using a combination of auditory
and visual, as well as involve the family as affective
stimuli. Nurses and family can provide this stimulus
of about 15 minutes at a stimulus and performed
several times in one day. Given stimulus can improve
patient recovery phase. Although, research related to
the effectiveness of each stimulus is limited.
5 CONCLUSION
Sensory stimulation to the auditory, visual, and
affective known to be effective is used in patients
with head injury with GCS at least 5 in the ICU. The
combination of multiple sensory stimuli such as
auditory and visual known to be effective to increase
awareness. However, there is a shortage of evidence
based research on the effectiveness of each stimulus
on head trauma in ICU. Clients are given a head
trauma stimulation will begin to make a change after
day 7. Intervention given a short time but often more
effective than one but in a long time. However, up to
now unknown number of days it takes to make it work
significantly stimulation. Thus, it is advisable to more
researchers studied the effects of long-term and short-
sensory stimulation and to compare each stimulus. So
that stimulation can know the effectiveness of sensory
stimulus auditory, visual and kinetic.
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