Evaluation and Feasibility of a Head Positioning Intervention in Patients with Intraparenchymal Hemorrhage
Authors:   ,   University of Tennessee Health Science Center, Dusenbury Wendy 
Published: November 2021

Stroke caused by intraparenchymal hemorrhage (IPH) is most commonly the result of hypertension-induced blood vessel rupture in the brain and is associated with devastating disability and high rates of death. To date, no intervention has improved outcomes in IPH stroke patients; however, head elevation may be one of the most important first steps to promote clinical stability in the hyperacute stage of IPH stroke because of the risk of increased intracranial pressure (ICP) in these patients. Nursing research completed in the late 1970s and early 1980s in patients with increased ICP due to traumatic brain injury showed that elevating the head of bed (HOB) increased gravity drainage of venous blood and cerebrospinal fluid, lowering ICP, However, no study has yet been completed in a generalizable sample of hyperacute IPH stroke patients to examine serial changes in clinical stability in relation to HOB positioning. Recently, the Head Position in Stroke Trial (HeadPoST), which enrolled a highly heterogeneous sample of subacute stroke patients, found that head position does not affect 3-month outcome; however, the study was heavily criticized by international stroke experts due to significant internal validity concerns. HeadPoST findings have created significant confusion within the acute stroke practice community about whether there is a role for head positioning in hyperacute IPH stroke management. The focus of our research was to build knowledge of key clinical methods that will support future definitive HOB research in hyperacute IPH stroke patients. We established 1) the clinical knowledge and skill set supporting nurses’ ability to localize stroke disability within vascular territories in the brain and 2) use of the National Institutes of Health Stroke Scale as a valid assessment tool for serial monitoring of clinical change in hyperacute IPH patients. We also 3) examined the degree of acceptance of HeadPoST findings internationally among nurse and physician clinicians caring for IPH stroke patients and 4) evaluated elements tied to the feasibility of conducting hyperacute IPH HOB research at a large, comprehensive stroke center in the Midsouth. Collectively, the chapters in this dissertation create a foundation for future IPH head-positioning research, providing direction for our next steps in understanding the contribution of HOB positioning to hyperacute IPH patient management. Patients with hypertensive IPH stroke suffer significantly higher rates of disability and death compared to other forms of stroke, yet despite a great deal of inquiry into interventions to improve outcomes, none have been successful. Positioning the patient’s HOB at 30-degrees may be one of the most important early interventions that nurses can employ to impart stability in hypertensive IPH patients. Our research and conclusions position nurse scientists to further their examination of the effect of this simple HOB-positioning intervention in this highly vulnerable patient population.