Thesis--Wisconsin. / Includes bibliographical references (leaves 43-49).

Bakgrund: Patienter som ventilatorvårdas på intensivvårdsavdelning behöver ofta någon form av lätt sömn (sedering) för att tolerera endotrachealtuben och ventilatorbehandling. De traditionella intravenösa läkemedel som ges har lång halveringstid och det är stor risk för kvardröjande effekter. Syfte: Denna pilotstudie syftar till att studera sederingsdjupet enligt MAAS hos de patienter som blivit sederade med inhalationsgas, kontrollera vakenhetsgraden enligt GCS hos dessa patienter efter avslutad sedering, samt beskriva vilka patientgrupperna är som fått inhalationssedering. Metod: Journalgranskning där resultatet har analyserats och kategoriserats, därefter har en sambandsanalys gjorts. Resultat: I resultatet identifierades 3 patientkategorier som fått isofluransedering: patienter med hotad luftväg som förväntats behöva kort sederingstid och snabb väckning, patienter som var svåra att sedera optimalt med intravenös metod samt patienter med organsvikt där risk för ackumulation och/ eller förlängd elimination av läkemedel förelåg. Något samband mellan MAAS 12 timmar före extubation och GCS- värde efter väckning hos de 14 patienter som ingick i studien har inte kunna styrkas. Konklusion: Inhalationssedering med isofluran förefaller vara en effektiv sederingsmetod när en lättstyrd sederingssituation med möjlighet till snabb väckning prioriteras, samt när man strävar efter att patienten ska uppnå 14-15 i GCS- värde så snart som möjligt efter väckning och extubation. / Background: Patients which are nursed by ventilator at the intensive care unit often need some form of sedative in order to tolerate an endotracheal tube and the ventilator treatment. The traditional intravenous drugs have a long half- life and potential risk for lingering effects. Aim: This pilot study aim to study the depth of sedation according to MAAS with the patients having been sedated with inhalation gas, check alertness according to GCS with these patients after completion of sedation, and describe which group of patients that have received inhalation treatment. Method: Journal Review where the result have been analysed and categorized then a link analysis has been made. Result: In the result three patient categories were identified which had received isoflurane sedation: patients with threatened airway and expected short time of sedation and fast wake- up, patients which were difficult to sedate optimally with intravenous method, and patients with organ failure where risk for accumulation and/ or  extended elimination of drugs were expected. Any relationship between MAAS 12 hour prior to extubation and GCS- score after awakening with the 14 patients included in the study have not been established. Conclusion: Sedation by isoflurane inhalation seems to be an effective sedation method when an easily controlled sedation situation with the possibility of a fast awakening are prioritized as well as when the strive is to achieve a GCS- score of 14-15 as soon as possible after awakening and extubation.

Background Stroke is a major cause of disability worldwide. After treatment in a specialized stroke unit, early supported discharge (ESD) followed by home rehabilitation has shown to be an effective way to improve patient outcome and quality of care for persons with mild to moderate stroke. ESD service is recommended in the national and international guidelines for stroke care, but has only partially been implemented in Sweden. Following stroke, fatigue is a common consequence that often becomes more evident when the patient comes home. Currently, there is insufficient evidence about how to measure, treat and handle post-stroke fatigue. The overall aim of this thesis was to evaluate and implement early supported discharge (ESD) based on stroke patients experience after discharge from the stroke unit and local conditions. The aim was also to evaluate post-stroke fatigue with a potentially valid and reliable scale and finally to prepare for a study to evaluate cardiorespiratory training as a part of ESD service for patients with post-stroke fatigue. Methods In paper I, nine strategically chosen patients were interviewed of their experience of falling ill, the hospital stay, discharge, contact with health care after discharge and their request of support. Papers II-III describe and evaluate the development, content, implementation and effects of a locally adopted method for early supported discharge (Umeå Stroke Center ESD) in modern stroke care. Paper II included 153 consecutive patients and paper III, 30 232 patients with first-ever stroke registered in the Riksstroke registry in Sweden. Paper II evaluated number of patients/year, clinical and functional health status, satisfaction in relation to needs, accidental falls/other injuries and resources with the result summarized in a value compass. The implementation process was evaluated retrospectively by means of Consolidated Framework for Implementation (CFIR). Paper III evaluated patient reported outcome measurements (PROMs) at 3 months. The primary outcome in paper III was satisfaction with the rehabilitation after discharge. Secondary outcomes were information about stroke provided, tiredness/fatigue, pain, dysthymia/depression, general health status and dependence in activities of daily living (mobility, toilet hygiene and dressing). Multivariable logistic regression models for each PROM was used to analyze associations between PROMs and ESD/no ESD. In Paper IV, the Fatigue Assessment scale (FAS) was translated into Swedish and evaluated regarding psychometric properties when self-administered by persons with mild to moderate stroke. 72 consecutively patients selected from the stroke unit admission register received a letter including three questionnaires: the FAS, the Short Form Health Survey (SF-36) subscale for vitality and the Geriatric Depression Scale GDS-15. A second letter with FAS was sent within 2 weeks, for re-test evaluation. Paper V is a study protocol for a planned randomized controlled trial (RCT) of 50 consecutive stroke patients will who receive stroke unit care followed by ESD-service at Umeå Stroke Center, University Hospital, Umeå, Sweden. Paper V will investigate if a structured cardiorespiratory interval training program (CITP) added to the ESD-service may result in relieved post-stroke fatigue and increased oxygen uptake. Results The interviews in Paper I revealed three main categories with subcategories: “Responsible and implicated”, “Depersonalized object for caring measures” and “The striving for repersonalization and autonomy”. The findings indicate that coming home gave the informants’ important insights and understanding of the stroke, its consequences and was also an important factor for the recovery. Paper II-III showed that it is possible to develop and implement an adapted ESD service for stroke patients based on the patients’ experiences and requests, evidence-based recommendations and local conditions. The ESD service reduced dependence of activity, increased mobility with seemingly no increased risk of accidental falls or other injuries. The patient satisfaction in relation to needs regarding the ESD was high. Paper III showed that patients that received ESD were more satisfied with rehabilitation after discharge, had less need for assistance with ADL and less dysthymia/depression compared to patients that did not receive ESD. Study IV showed that the Swedish FAS used at home as a selfadministered questionnaire is a reliable and valid questionnaire for measuring fatigue in persons with mild to moderate stroke. The internal consistency was good, the agreement between the test and retest reliability for individual items (weighted kappa) was for the majority of items good or moderate. The relative reliability for total scores was good and the absolute reliability was 9 points. The Swedish FAS had no floor nor ceiling effects and correlated both with the SF-36, subscale for vitality and the GDS-15 indicating convergent construct validity, but not divergent construct validity. Conclusion It is possible to develop and implement ESD care for stroke patients based on patients’ experience and needs, evidence-based principles and local conditions. Early supported discharge (ESD) in the setting of modern stroke unit care appears to have positive effects on rehabilitation in the subacute phase. The Swedish FAS used at home as a self-administered questionnaire is reliable and valid for measuring fatigue in persons with mild to moderate stroke.

Research regarding the potential value of using a personal construct psychology (PCP) framework to explore recovery in psychosis has been minimal. Mental health policy guidelines (Shepherd et al., 2008) recommend that recovery in mental health is an important area that needs further research. This study aims to further understanding of recovery in service users with psychosis, by examining personal constructs elicited from participants, in contrast to the researcher supplying constructs (Bell and McGorry, 1992). Further, it attempts to define the degree of recovery using the Recovery Assessment Scale (RAS, Corrigan et al., 1999). Thirty two adults from the NHS and voluntary sector participated in the study; each completed a repertory grid (Kelly, 1955). The RAS enabled recovery to be defined by splitting the sample, and comparisons made between low to moderate and high recovery groups. The main findings of the study show that participants in the high recovery group showed less differentiation between their different selves; greater self-esteem; an experienced sense of control over their environment; a higher degree of quality and quantity of support; and a higher degree of hope and goal setting than participants in the low to moderate recovery group. In addition, content analysis (Landfield, 1971) of current self constructs showed that participants in high recovery construed themselves as being more self-sufficient, more active socially, and displayed higher tenderness compared to those in low to moderate recovery. Findings show how repertory grid methods can be applied clinically in order to help with case assessment and formulation, and help facilitate individually tailored therapeutic interventions to enhance recovery. For example, self differentiation findings suggest that to help an individual move towards a higher degree of recovery involves firstly loosening, and then tightening up their construing system. Secondly, self-esteem measures enabled identification of personal goals to strive towards in terms of an individual’s conception of their current and ideal self, and thus steps to take to progress toward recovery. Thirdly, the Pawn and Origin Scale (Westbrook and Viney, 1980) highlighted the degree of control over one’s external and internal world, thus highlighting areas that could be worked on to progress toward higher recovery. Clinical interventions addressing implicative dilemmas were also identified as enabling a change in behaviour, and therefore movement toward recovery. Limitations of the study are discussed, including using HICLAS (De Boeck, 1992) to measure self elaboration in recovery; and future research outlined, including exploring recovery in psychosis through a longitudinal study, and sampling across different mental health populations.

Alzheimer’s disease (AD) progressively impairs cognitive and functional abilities. Research on pharmacological treatment of AD is shifting to earlier forms of the disease, including preclinical stages. However, assessment methods traditionally used in clinical research may be inappropriate for these populations. The Alzheimer Disease Assessment Scale-cognitive (ADAS-cog), a commonly used cognitive battery in AD research, is most sensitive in the moderate range of cognitive impairment. It focuses on immediate recall and recognition aspects of memory rather than retention and delayed recall. As clinical trials for dementia continue to focus on prodromal stages of AD, instruments need to be retooled to focus on cognitive abilities more prone to change in the earliest stages of the disease. One such domain is delayed recall, which is differentially sensitive to decline in the earliest stages of AD. A supplemental delayed recall subtest for the ADAS-cog is commonly implemented, but we do not know precisely where along the spectrum of cognitive dysfunction this subtest yields incremental information beyond what is gained from the standard ADAS-cog. An item response theory (IRT) approach can analyze this in a psychometrically rigorous way. This study’s aims are twofold: (1) to examine where along the AD spectrum the delayed recall subtest yields optimal information about cognitive dysfunction, and (2) to determine if adding delayed recall to the ADAS-cog can improve prediction of functional outcomes, specifically patients’ ability to complete basic and instrumental activities of daily living. Results revealed differential functioning of ADAS-cog subtests across the dimension of cognitive impairment. The delayed recall subtest provided optimal information and increased the ADAS-cog’s measurement precision in the relatively mild range of cognitive dysfunction. Moreover, the addition of delayed recall to the ADAS- cog, consistent with my hypothesis, increased covariation with instrumental but not basic activities of daily living. These findings provide evidence that the delayed recall subtest slightly improves the ADAS-cog’s ability to capture information about cognitive impairment in the mild range of severity and thereby improves prediction of instrumental functional deficits.

Bakgrund: Undernäring är ett vanligt förekommande problem bland den äldre befolkningen. Att kunna identifiera de människor som lider av undernäring ligger inom sjuksköterskans omvårdnadsansvar. Mini Nutritional Assessment (MNA) skalan är ett av de olika mätinstrument som används för att i tidigt skede upptäcka undernärda äldre eller de som riskerar att bli undernärda. Syfte: Att beskriva sjuksköterskans erfarenheter av användning av MNA-skalan hos äldre patienter. Metod: Semistrukturerade intervjuer med hjälp av en intervjuguide genomfördes med tio yrkesverksamma sjuksköterskor på två geriatriska avdelningar. Data bearbetades med en kvalitativ innehållsanalys. Resultat: Studien resulterade i tre huvudkategorier; osäker bedömning, del av rutin och bra redskap. Slutsats: MNA-skalan upplevdes som ett bedömningsverktyg som ger bra vägledning. Dock bör sjuksköterskor komplettera bedömningen med andra faktorer bland annat den kliniska blicken som innefattar sjuksköterskans teoretisk grund, praktisk erfarenhet samt sunt förnuft för att resultatet ska vara säkert och tillförlitlig. Kliniska betydelsen: Genom att sjuksköterskan använder MNA-skalan tillsammans med sin kliniska blick och kompetens, kan undernärda patienter identifieras tidigt. På så sätt kan detta leda till betydande potential för att skydda mot mänskligt lidande och spara på samhällsekonomiska resurser. / Background: Malnutrition is a commonly recurring problem among the elderly population. To be able to identify patients who suffer from malnutrition is an important care responsibility of the nurse. The Mini Nutrition Assessment (MNA) scale is one of many different screening tools which are used for identifying malnutrition or risk for malnutrition among elderly, at an early stage. Aim: To describe nurses`- experiences of using the MNA-scale among the elderly patients. Method: Semi-structured interviews based on questionnaires were conducted with ten professional nurses in two geriatric wards. The data was processed with a qualitative manifest content analysis. Results: Three main categories of results emerged. These were unsure assessment, part of the routine and useful tool. Conclusion: The MNA-scale is an assessment tool that provides good guidance. However, it is necessary to complement the MNA-scale with other factors, for example, with clinical competence that includes the nurse's theoretical foundation, practical experience and common sense to get a safer and more reliable nutrition status. Clinical implication: By using MNA-scale with clinical impressions and competence, nurses can identify malnutrition early stage. This can lead to significant potential for savings in both human suffering and economic resources.

Hospice services are utilized by more than 1.6 million people yearly, and there are a great number of caregivers who are tasked with caring for these individuals at home. Caregivers are at risk for fatigue, burnout, and decline in their own physical and mental health. While the Centers for Medicare and Medicaid Services (CMS) cover costs of temporary respite care for hospice patients, the caregivers' needs for respite care are often unrecognized and unaddressed. The purpose of this project was to plan a respite program within the hospice agency consisting of revised respite policy and procedures, the Caregiver Reaction Assessment (CRA) tool to routinely assess the caregiver for burnout and/or fatigue, and a detailed outline for the implementation of respite care. Anderson's behavioral model of service was used to guide the project's understanding of the underutilization of respite services. This project was guided by the practice-focused question examining the development of an evidence based caregiver respite program within the hospice agency. The program was developed based on a review of peer reviewed research studies and the input of a project team of local experts. The project team participated in the project that created a respite policy which includes a biweekly caregiver assessment and step-by-step directions on how to implement respite care. A final report was developed and submitted to the Hospice agency. This revised policy and procedure includes a blueprint for implementation and a full set of recommendations on the process, use of the CRA, educational in-services, and evaluative methods. These recommendations have the potential for positive social change by increasing patient and caregiver outcomes, serving as an example for other hospice agencies to follow, and improving care at the end of life.

No description available.

The present study was conducted with the aim of constructing and validating a short form of the Profile of Mood States (POMS). The POMS is a widely-applied measure for the assessment of an individual’s mood. Thus, it is of great relevance for many research questions in clinical and social psychology. To develop the short scale, we first examined psychometric properties and found the optimal 16-itemsolution among all valid combinations of the full POMS in an exploratory subsample (n = 1,029) of our complete representative sample of the German general population. We then validated this model in a confirmatory subsample (n = 977). Additionally, we examined its invariance across age groups and sex, as well as its reliability. Our results indicate that the POMS-16 is a valid and reliable measure of mood states with minimal losses compared to the 35-item version. Particularly where brevity and an economical assessment is desired, the POMS-16 should be considered.

Smärta är den vanligaste sökorsaken för patienter på akutmottagningar, trots detta visar forskning att underbehandling av akut smärta förekommer över hela världen På grund av att smärta är subjektiv kan det vara mycket svårt att mäta patienternas smärta. Bedömningen av smärta bygger på patienternas självskattning. Adekvat bedömning av smärta är avgörande för att effektiv smärtlindring ska kunna ges. Syftet med kvalitetförbättringsstudien var att införa ett nytt smärtskattningsverktyg samt att utvärdera om en utbildningsintervention i form av korta utbildningstillfällen kan öka antalet smärtskattningar på en akutmottagning. Studien hade en kvasi-experimentell design. Avbruten tidsserie användes för utfallsmätning före och efter utbildningsinterventionen. Utbildningsinterventionen bestod av korta utbildningstillfällen under en veckas tid där information gavs om smärtskattning med hjälp av smärtskattningsskalan Verbal Rating Scale och hur smärtskattningen skulle dokumenteras. Studien utfördes simultant på två akutmottagningar i södra Sverige under en period av totalt 13 veckor under våren 2022. Resultatet av studien visar att före interventionen genomfördes i medel 5,6% smärtskattningar och efter interventionen ökade antalet smärtskattningar per vecka i till 9,3%. Kvalitetsförbättringsstudien har varit till fördel på respektive akutmottagning då dokumentation av smärtskattning har ökat. För att bibehålla och vidareutveckla denna kunskap krävs det fortlöpande utbildningstillfällen och påminnelser kring smärtskattning samt regelbunden utvärdering av mängden dokumenterad smärtskattning. / Pain is the most presenting complaint to emergency departments. Despite this, research shows that undertreatment of acute pain occurs worldwide Because pain is subjective, it can be very difficult to measure patients pain. The valuation of pain is based on patients self-assessment. Adequate assessment of pain is crucial for effective pain relief to be provided. The purpose of this study was to introduce a new pain assessment tool and to evaluate whether an educational intervention in the form of short training sessions can increase the number of pain estimates in an emergency department. The study had a quasi-experimental design. Interrupted timeseries was used for outcome measurement before and after the training intervention. The training intervention consisted of short micro sessions over a period of one week where information was given about pain assessment using the Verbal Rating Scale and how the pain assessment was to be documented. The study was performed simultaneously in two emergency departments in southern Sweden for a period of a total of 13 weeks in the spring of 2022. The results of the study show that before the intervention, 5.6% pain estimates were performed and after the intervention the number of pain estimates per week increased to 9.3%. The quality improvement study has been to the advantage of the respective emergency department as documentation of pain assessment has increased. In order to maintain and further develop this knowledge, continuous training opportunities and reminders about pain assessment are required, as well as regular evaluation of the amount of documented pain assessment.