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Mobiliseringsmetoder vid en intensivvårdsavdelning- En litteraturstudieKarlsson, Sofia, Lindberg, Annelie January 2016 (has links)
No description available.
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Omvårdnadsåtgärder som underlättar vid urträning ur respirator inom intensivvården : En kvalitativ intervjustudie med utgångpunkt i Fundamentals of Care.Edmark, Hillevi, Kjellberg, Linnéa January 2024 (has links)
Bakgrund: Att arbeta som specialistsjuksköterska inom intensivvård innebär att du kommer möta patienter som vårdas i respirator. En respiratorbehandling är många gånger livräddande, men lång respiratorbehandling associeras även med flera komplikationer och ett stort lidande för den enskilde patienten. Fundamentals of Care (FoC) kan användas som ett stöd för att tillhandahålla en personcentrerad grundläggande omvårdnad. På grund av de komplexa kraven på urträning är det särskilt viktigt att identifiera och tillgodose patienters grundläggande vårdbehov under urträningsprocessen. Syfte: Syftet är att beskriva intensivvårdssjuksköterskors erfarenheter av omvårdnadsåtgärder som underlättar patientens urträning ur respirator utifrån FoC. Metod: En kvalitativ intervjustudie med deduktiv ansats. Totalt rekryterades åtta informanter från två intensivvårdsavdelningar på ett universitetssjukhus i Mellansverige. Insamlad data analyserades med en kvalitativ innehållsanalys enligt Graneheim och Lundman (2004). Resultat: Tre kategorier presenteras i resultatet med utgångspunkt i FoC: etablerad vårdrelation, grundläggande vårdbehov och vårdkontext. Resultatet visade att intensivvårdssjuksköterskorna upplevde att närvaro bidrog till trygghet för patienten, och att kontinuitet i vårdandet kunde underlätta urträningsprocessen. Intensivvårdssjuksköterskorna belyste även vikten av en personcentrerad vård och individanpassad information som viktiga omvårdnadsåtgärder i urträningsprocessen. Slutsats: Genom att tillämpa delarna i FoC kan ramverket fungera som en vägledning för att tillhandahålla en personcentrerad omvårdnad i takt med urträningsprocessen. Att beskriva omvårdnadsåtgärder som kan underlätta urträning ur respirator kan bidra till att göra urträningsprocessen skonsammare för den enskilde patienten. / Background: Working as a critical care nurse means encountering patients undergoing mechanical ventilation. Mechanical ventilation is often life-saving, however prolonged mechanical ventilation is also associated with several complications and patient suffering. Fundamentals of Care (FoC) can be used as a guidance to provide person-centered care. Given the complex demands of weaning, it is important to identify and address patients' basic care needs during the weaning process. Aim: The aim is to describe critical care nurses’ experiences of nursing interventions facilitating the patient's weaning from mechanical ventilation based on FoC. Method: A qualitative interview study with a deductive approach. A total of eight informants were recruited from two critical care units at a university hospital in central Sweden. Collected data were analyzed using qualitative content analysis following Graneheim and Lundman (2004). Result: Three categories are presented in the results based on FoC: relationship, integration of care and context of care. The results showed that critical care nurses experienced that presence contributed to providing a sense of security for the patient, and that continuity in care could facilitate the weaning process. Critical care nurses also highlighted the importance of person-centered care and information as important nursing interventions in the weaning process. Conclusion: By applying the components of FoC, the framework can serve as guidance for providing person-centered care during the weaning process. Describing nursing interventions that can facilitate weaning can contribute to making the weaning process gentler for the patient.
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Critical care nurses' perception towards family witnessed resucitationDe Beer, Jennifer 30 November 2005 (has links)
The aim of the study was to describe the perceptions of critical care nurses concerning family witnessed resuscitation, presenting arguments for or against the practice thereof.
A quantitative, descriptive and exploratory approach was used. For the study, a non- probability convenience sample of 100 critical care nurses from five critical care units were used. A combined open-ended and closed-ended questionnaire was used.
The majority of critical care nurses in the study disapproved of the idea of family witnessed resuscitation. They believed it to be traumatic for relatives, threatening to the resuscitation process and increasing litigation. Although the dominant feeling was one of disapproval, some critical care nurses felt that family witnessed resuscitation was beneficial to relatives. Recommendations for future practice included incorporation of educational programmes for critical care nurses concerning family witnessed resuscitation and providing training to deal with the stresses of family witnessed resuscitation. / Health Studies / M.A (Health Studies)
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Critical care nurses' perception towards family witnessed resucitationDe Beer, Jennifer 30 November 2005 (has links)
The aim of the study was to describe the perceptions of critical care nurses concerning family witnessed resuscitation, presenting arguments for or against the practice thereof.
A quantitative, descriptive and exploratory approach was used. For the study, a non- probability convenience sample of 100 critical care nurses from five critical care units were used. A combined open-ended and closed-ended questionnaire was used.
The majority of critical care nurses in the study disapproved of the idea of family witnessed resuscitation. They believed it to be traumatic for relatives, threatening to the resuscitation process and increasing litigation. Although the dominant feeling was one of disapproval, some critical care nurses felt that family witnessed resuscitation was beneficial to relatives. Recommendations for future practice included incorporation of educational programmes for critical care nurses concerning family witnessed resuscitation and providing training to deal with the stresses of family witnessed resuscitation. / Health Studies / M.A (Health Studies)
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Intensive Care in Oncology: Admission and Outcomes in Adult Patients with CancerJohn, Surya 01 January 2016 (has links)
Background: Historically, patients with cancer have been perceived as poor candidates for ICU admission. General ICU admission criteria lists cancer patients as low priority in ICU admission depriving them of the care they rightfully deserve. The purpose of this literary synthesis was to examine ICU admission criteria, risk factors, and outcomes of ICU admission in relation to hematological and solid tumor cancers and discuss ways that practitioners and nurses can educate patients with cancer and their families on appropriateness of ICU care.
Methods: A total of 768 articles were found in a literature search including all literature from 2005 to 2016 from all countries using the databases CINAHL Plus, MEDLINE, PsycINFO, and Academic Search Premier. These were further narrowed down based on relevancy by topic or reading abstracts. A total of 13 articles utilizing the inclusion and exclusion criteria of the literature search were included in the final literature synthesis.
Results: In addition to general ICU admission criteria several other criteria and scores can be helpful in admitting patients with cancer to the ICU including cancer specific criteria, mortality predictor tools, performance status, and ICU trials. Mortality predictors, in combination with other patient characteristics, demonstrated effectiveness to predict outcomes in patients with cancer. Survival rates in hematological and solid tumor cancers have improved from the past, and lower prognostic scores can predict who will have better outcomes.
Conclusion: Cancer specific criteria, mortality predictor tools, performance status, and ICU trials in addition to general ICU criteria should be used for admission of cancer patients into ICU. Practitioners and nurses should become familiar with the newest outcomes in patients with cancer to make collaborative informed decisions about ICU admission.
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A comparison of the potentiation by desflurane of the effects of rocoronium and cisatracuriumScheepers, Pamela Anne 12 1900 (has links)
Thesis (MMed)-- Stellenbosch University, 2013. / ENGLISH ABSTRACT: Introduction:
Of the volatile anaesthetic agents, desflurane causes the greatest degree of potentiation of the
neuromuscular blocking drugs (NMB). The purpose of this study was to determine whether
desflurane prolongs the effects of 3xED95 doses of rocuronium and cisatracurium to the same
degree. The two NMB represent potent and less potent classes respectively.
Methods:
Informed, written consent was obtained from 63 adult patients scheduled for routine surgery.
They were randomly allocated to one of four groups to receive either desflurane-sufentanil
(end-tidal partial pressure 4.0 kPa) or propofol-sufentanil anaesthesia and either rocuronium
(0.9mg/kg) or cisatracurium (0.15mg/kg). All patients received a target-controlled sufentanil
infusion (0.5 ng/ml). Neuromuscular blockade was recorded using accelerometry (TOFGUARD
®, Organon) while patients recovered spontaneously to a Train-of-Four ratio of 0.9
(TOFR0.9). Data were analysed using one- and two-way analysis of variance. The main
effects were the types of anaesthetic and NMB on indices of recovery.
Results:
Compared with propofol-sufentanil anaesthesia, mean times to recovery to T125% and
TOFR0.9, were prolonged by desflurane-sufentanil (p<0.01). There were no interactions. Mean prolongation of time to TOFR0.9 was 41 min (SD 36) for cisatracurium and 26.6 min
(SD 39) for rocuronium.
Discussion:
Whereas previous studies did not reveal prolongation of the duration of action of rocuronium
by desflurane, we demonstrated a statistically significant prolongation of the spontaneous
recovery times of both rocuronium and cisatracurium by desflurane. From the data we could
not conclude that there was a difference between the two NMB. A power study revealed that
in order to detect a difference between times to recovery to TOF0.9, a sample size of 101
subjects per group would be required.
Conclusion:
Desflurane prolongs the mean time to spontaneous recovery from neuromuscular blockade
after 3xED95 doses of both cisatracurium (a potent NMB) and rocuronium (a less potent
NMB). There was wide inter-individual variation in times to spontaneous recovery. Any
difference in the mean prolongations between the different types of NMB is unlikely to be of
clinical importance. / AFRIKAANSE OPSOMMING: Inleiding
Van al die vlugtige narkosemiddels veroorsaak desfluraan die grootste mate van potensiasie
van die neuromuskulêre blokkeermiddels. Die doel van hierdie studie was om vas te stel of
desfluraan wel die effek van driedubbel die ED95 dosis van rokuronium en cisatrakurium tot
dieselfde mate sal verleng.
Metodiek
Geskrewe ingeligte toestemming is verkry van 63 pasiënte wat voorgedoen het vir roetiene
chirurgiese prosedures. Pasiënte is lukraak in een van vier groepe ingedeel om of desfluraansufentaniel
(eind-gety parsieële druk 4.0 kPa) of propofol-sufentaniel narkose en of
rokuronium (0.9 mg/kg) of cisatrakurium (0.15 mg/kg) te ontvang. Alle pasiënte het 'n
teiken-beheerde sufentaniel infusie (0.5 ng/ml). Neuromuskulêre blokkade is waargeneem
met behulp van aksellerometrie (TOF-GUARD, Organon) terwyl pasiënte spontaan herstel
het tot “reeks-van-vier” verhouding (Engels “Train-of-four” ratio) 0.9 (TOFR0.9). Data
analise is gedoen met behulp van een- en tweerigting analise van variansie.
Resultate
Desfluraan-sufentaniel het die gemiddelde hersteltyd tot T125% en TOFR0.9 verleng in
vergelyking met propofol-sufentaniel. Geen interaksies is waargeneem nie. Gemiddelde verlenging van TOFR0.9 vir cisatrakurium was 41 minute (standaardafwyking 36) en vir
rokuronium 26.6 minute (standaardafwyking 39).
Bespreking
Vorige studies kon nie vasstel of desfluraan die werkingsduur van rokuronium verleng nie.
Ons het in hierdie studie vasgestel dat desfluraan wel 'n statisties beduidende verlenging in
die hersteltyd van beide rokuronium en cisatrakurium veroorsaak. Ons kon egter nie 'n
verskil tussen die twee neuromuskulêre agente aandui nie. 'n onderskeidingsvermoëstudie
het getoon dat ten minste 101 pasiënte per groep benodig sou word om 'n beduidende verskil
tussen die hersteltye tot TOFR0.9 te verkry.
Gevolgtrekking
Desfluraan verleng die gemiddelde hersteltyd tot spontane herstel van neuromuskulêre
blokkade na driedubbele ED95 dosisse van beide cisatrakurium en rokuronium. Daar was
egter groot interindividuele variasie ten opsigte van spontane hersteltyd. Enige verskille in
die gemiddelde verlenging is onwaarskynlik van kliniese belang.
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Renal dysfunction associated with infrarenal cross clamping of the aorta during major vascular surgeryVan der Merwe, Wynand Louw 03 1900 (has links)
Dissertation (MD)--Stellenbosch University, 2000. / ENGLISH ABSTRACT: Acute renal failure still is, with the exception of cardiac deaths, the most important
pathological process associated with perioperative mortality in patients operated for
abdominal aortic aneurysms. The intraoperative change in renal blood flow (RBF) and
glomerular function have been investigated in human and animal models, particularly
over the past 15 years. Despite large variation in study populations, measurement
techniques and study designs in general, a significant body of evidence has developed
which suggests infrarenal aortic clamp-induced renal ischemia to be the cause of
postoperative acute renal failure when this complication does occur.
It is rather surprizing then that, despite some recent studies which have reported on
various pharmacological interventions to prevent intraoperative renal ischemia (with
variable success), very little has apparently been done to unravel the pathogenesis
and exact pathophysiology of this potentially lethal complication. Although a number of
investigators suggest the possibility of hormonal involvement (particularly reninangiotensin,
antidiuretic hormone (ADH) and catecholamines) in the process, the exact
role of these mediators have not been explored (or reported) in a structured fashion.
In an initial human study, renal hemodynamics and function were measured from the
preoperative period, during the intraoperative phase and at least until 4 hours after
aortic unclamping. To investigate the possibility of a temporal relationship between
renal changes and fluctuations in hormonal concentrations, plasma concentrations of
relevant hormones were determined at every sampling period where renal parameters
were measured.
The decrease in RBF and glomerular filtration rate (GFR) which we demonstrated to
coincide with infrarenal aortic cross clamping, is consistent with results previously
published. We demonstrated persistence of the impairment of these parameters as
long as 4 hours into the postoperative phase; which has previously only been reported
for the period until immediately after aortic unclamping with the abdomen still open.
The persistence of a depressed GFR until the time of discharge of patients is cause for
concern, particularly in patients with compromised renal function prior to surgery. Of the measured hormones with a potential influence on RBF and nephron function,
renin was the only mediator where changes in plasma concentrations coincided with
the depression of RBF and GFR after aortic cross clamping. The design of our study
did not allow us to conclude whether the concomitant increase in angiotensin II was
primarily responsible for the change in renal hemodynamics, or whether the raised
renin (and angiotensin) levels were stimulated by the decrease in RBF induced by
another mechanism.
In another patient group, we demonstrated that the combination of mannitol and
dopamine provided no protection against the deleterious effects of aortic cross
clamping. In fact, the high urine volumes produced under the influence of these
agents (which did not correlate with RBF at the corresponding periods), is likely to
prompt a false sense of security. Given the lack of any objective benefit afforded by
these agents, their use in these clinical circumstances should be discouraged.
The animal studies were aimed at elucidation of the exact role of angiotensin in the
pathogenesis and pathophysiology of the renal changes associated with infrarenal
aortic clamping, as well as the interaction of angiotensin with other modulators for
which an interactive relationship had been described previously under other
experimental and/or clinical circumstances.
The first study showed that, although renin (and thus angiotensin) concentrations were
high after aortic unclamping, the hormone had no pathogenic or pathophysiological
role of significance in the observed renal changes during this period (since blocking
angiotensin II activation by the prevention of renin release, or by inhibiting the
conversion enzyme, did not prevent a substantial decrease in RBF or GFR during that
period). Preventing angiotensin II activation did, however, prevent renal changes
during aortic clamping. This beneficial effect did not establish a primary role for
angiotensin during that period, since the favourable influence could also (at least
partially) be explained by prevention of the permissive influence of angiotensin on
other vasoconstrictors and/or other vasodilatory influences of ACE inhibition and [1-
blockade which are unrelated to angiotensin. This study did indicate that (at least
partially) different mechanisms are responsible for the renal changes seen during
aortic clamping, and after aortic unclamping. The second study explored the role of calcium in the renal pathophysiological changes
during aortic clamping and after unclamping. The protective influence effected by
the administration of a Ca2
+ -blocker suggest the dependence of the renal
vasoconstrictive and glomerular pathophysiological process( es) on the cellular influx of
Ca2
+ through voltage-gated channels. It unfortunately provides no definitive insight
into the primary instigators of these processes. However, it does offer a clinically
useful method of preventing these changes and protecting the kidney against ischemic
injury during abdominal aortic surgery.
The third component of the animal studies demonstrates the importance of the
protective effect of renal prostaglandins during the specific experimental (and probably
also the clinical) circumstances. Again, it does not provide definitive information on the
mediators responsible for the renal changes, since the deleterious effects of numerous
endogenous substances have previously been shown to be counterbalanced by
intrarenal synthesis of prostaglandins under various experimental and clinical
circumstances. The extent of the pathophysiological and ultrastructural changes which
occurred under the influence of a NSAID does, however, suggest that these drugs
should not be used under these clinical circumstances.
The last component of the study provides evidence that angiotensin only plays a
secondary/supplementary role in the renal pathophysiological process even during
aortic clamping. This may explain the contradictory evidence regarding the potential
beneficial effect of ACE inhibition (on renal hemodynamics and glomerular function)
during abdominal aortic surgery (Licker et al. 1996, Colson et al. 1992a). Based on
our studies, ACE inhibition can not be supported for this purpose. / AFRIKAANSE OPSOMMING: Akute nierversaking is met die uitsondering van kardiale sterftes, steeds die
belangrikste patologiese proses wat geassosieer is met perioperatiewe mortaliteit in
pasiënte wat opereer word vir abdominale aorta aneurismes. Die intraoperatiewe
veranderinge in renale bloedvloei (NBV) en glomerulêre funksie is die afgelope 15 jaar
ondersoek en gerapporteer in pasiënte- sowel as diere-modelle. Ten spyte van groot
variasies in studie-populasies, meettegnieke en ontwerp van studies in die algemeen,
dui 'n wesenlike hoeveelheid getuienis daarop dat infrarenale klemming van die aorta
renale isgemie induseer, wat die oorsaak is van postoperatiewe akute nierversaking
wanneer hierdie komplikasie voorkom.
Dit is verbasend dat, ten spyte van sommige onlangse studies wat rapporteer oor 'n
verskeidenheid farmakologiese ingrepe om intraoperatiewe renale isgemie te voorkom
(met wisselende sukses), baie min oënskynlik gedoen is om die patogenese en die
presiese patofisiologie van hierdie potensieel dodelike komplikasie te ontrafel. Hoewel
verskeie outeurs die moontlikheid van hormonale betrokkenheid (veral renienangiotensien,
antidiuretiese hormoon en katekolamiene) in hierdie proses suggereer, is
die presiese rol van hierdie mediators nog nie op 'n gestruktureerde wyse ondersoek
(of rapporteer) nie.
In ons aanvanklike pasiënte-studie is renale hemodinamika en -funksie gemeet vanaf
die preoperatiewe periode, gedurende die intra-operatiewe fase en tot minstens vier
uur na ontklemming van die aorta. Serumkonsentrasies van relevante hormone is
bepaal tydens elke metingsperiode waar renale parameters gemeet is, ten einde die
moontlikheid van 'n temporale verwantskap tussen renale veranderinge en variasies in
hormoonkonsentrasies te ondersoek.
Die vermindering in NBV en glomerulêre filtrasiespoed (GFS) wat ons aangetoon het
om saam te val met infrarenale aortaklemming, stem ooreen met resultate wat tevore
deur ander navorsers publiseer is. Ons het aangetoon dat die inkorting van hierdie
parameters voortduur tot minstens vier uur na aorta-ontklemming. Hierdie
veranderinge is tevore slegs rapporteer vir periodes tot kort na aorta-ontklemming voor
sluiting van die buikwond. Die feit dat die GFS steeds verlaag is met ontslag van hierdie pasiënte, skep rede tot kommer, veral in pasiënte wat alreeds ingekorte
nierfunksie het voor die chirurgiese prosedure.
Van die gemete hormone wat moontlik 'n invloed sou kon uitoefen op NBV eh
nefronfunksie, was renien die enigste waarvan verandering in plasmakonsentrasies
saamgeval het met die onderdrukking van NBV en GFS na aortaklemming. Die
ontwerp van ons studie het ons nie toegelaat om 'n besliste uitspraak te maak of die
geassosieerde verhoging in angiotensien II primêr verantwoordelik was vir die
verandering in renale hemodinamika, of dat die verhoogde renien (en angiotensien)
bloedvlakke moontlik sekondêr stimuleer is deur die verandering in NBV wat deur 'n
ander meganisme induseer is.
In 'n ander pasiëntegroep het ons aangetoon dat die kombinasie van mannitol en
dopamien geen beskerming verleen het teen die nadelige effekte van aorta-klemming
nie. Die groot volumes uriene wat uitgeskei is onder die invloed van hierdie middels
(wat nie korreleer het met NBV tydens ooreenstemmende periodes nie), het
inderwaarheid 'n ontoepaslike gerustheid uitgelok. Weens die ooglopende gebrek aan
objektiewe voordeel wat verleen word deur hierdie middels, behoort hulle gebruik
tydens hierdie kliniese omstandighede ontmoedig te word.
Die doel van die diere studies was die identifisering van die presiese rol van
angiotensien in die patogenese en patofisiologie van die renale veranderinge
geassosieer met infrarenale aortaklemming, sowel as die interaksie van angiotensien
met ander modulators waarvoor 'n interaktiewe verwantskap voorheen beskryf is onder
eksperimentele en/of kliniese omstandighede.
Die eerste studie het getoon dat alhoewel renien (en dus angiotensien) konsentrasies
hoog was na aorta-ontklemming, die hormone geen betekenisvolle patogenetiese of
patofisiologiese rol in die waargenome renale veranderinge gedurende hierdie
periode het nie (aangesien blokkade van angiotensien aktivering deur voorkoming van
renien vrystelling, of deur inhibisie van angiotensien omsettingsensiem (AOE), nie 'n
daling in NBV of GFS kon voorkom nie). Voorkoming van angiotensien II aktivering het
egter wel renale verandering voorkom gedurende aortaklemming. Dié voordelige
effek het nie 'n primêre rol vir angiotensien gedurende die periode bevestig nie,
aangesien die gunstige invloed ook (ten minste gedeeltelik) verduidelik kon word deur
die voorkoming van die fassiliterende invloed van angiotensien op ander vasokonstriktore en/of ander vasodilator-invloede van die onderdrukking van AOE en
ïs-blokkers (wat geen verband het met angiotensien of die blokkade daarvan nie). Die
studie het aangetoon dat (ten minste gedeeltelik) verskillende meganismes
verantwoordelik is vir renale veranderinge wat gesien is gedurende aortaklemming
en na -ontklemming.
Die tweede studie het die rol van kalsium in die renale patofisiologiese veranderinge
gedurende aortaklemming en na ontklemming ondersoek. Die beskermende
invloed wat deur die toediening van Ca2
+ -blokkers bewerkstellig is, het bevestig dat die
renale vasokonstriktoriese en glomerulêre patofisiologiese prosesse afhanklik is van
sellulêre influks van kalsium deur spannings-afhanklike kannale. Dit het ongelukkig
geen definitiewe insig verleen ten opsigte van die primêre inisieerders van die proses
nie. Dit verskaf nogtans 'n bruikbare kliniese metode om daardie veranderinge te
voorkom en die niere teen isgemiese besering gedurende abdominale aorta-chirurgie
te beskerm.
Die derde komponent van die diere-studies demonstreer die belangrikheid van die
beskermende effek van renale prostaglandiene tydens die spesifieke eksperimentele
(en waarskynlik ook die kliniese) omstandighede. Weereens gee dit nie definitiewe
inligting oor die bemiddelaars wat verantwoordelik is vir die renale veranderinge nie,
aangesien die skadelike effekte van verskeie endogene stowwe voorheen aangetoon
is om beperk of voorkom te word deur die intrarenale vrystelling van prostaglandiene.
Die omvang van die patofisiologiese en ultrastrukturele veranderinge wat ontstaan het
onder die invloed van nie-steroïed anti-inflammatoriese middels (wat gebruik is om
prostaglandien sintese te inhibeer), dui aan dat hierdie middels vermy moet word
onder soortelyke kliniese omstandighede.
Die laaste komponent van die studie verskaf 'n sterk aanduiding dat angiotensien slegs
'n sekondêre/aanvullende rol speel in die renale patofisiologiese proses, selfs
gedurende aortaklemming. Dit mag die weersprekende getuienis oor die potensiële
voordeel van AOE onderdrukking (op renale hemodinamika en glomerulêre funksie)
gedurende abdominale aortachirurgie (Licker et al. 1996, Colson et al. 1992a) verklaar.
Gebaseer op ons studies, kan AOE onderdrukking nie ondersteun word vir hierdie doel
nie.
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Mortality prediction and acuity assessment in critical careJohnson, Alistair E. W. January 2014 (has links)
Accurate mortality prediction in intensive care units (ICUs) allows for the risk adjustment of study populations, aids in patient care and provides a method for benchmarking overall hospital and ICU performance. ICU risk-adjustment models are primarily comprised of an integer severity of illness score which increases with increasing patient risk of mortality. First published in the 1980s, the improvements to these scores primarily consisted of increasing the dimensionality of the model, and hence also increasing their complexity. This thesis aims to improve upon these models. First, the field is surveyed and the major models for risk-adjusting critically ill patient cohorts are identified including the acute physiology score (APS) and the simplified acute physiology score (SAPS). A key component of model performance is data preprocessing. The effect of preprocessing ICU data is quantified on a dataset of 8,000 ICU patients, and it is shown that after preprocessing to remove extreme values a logistic regression (LR) model performed competitively (AUROC of 0.8633) with the more complex machine learning model; a support vector machine (SVM) which had an AUROC of 0.8653. For validation, model development was repeated in a larger database containing over 80,000 patients admitted to 89 ICUs in the United States. Results were similar (AUROC of 0.8895 for the LR vs 0.8917 for the SVM) but showed the performance gain when using automated outlier rejection is less pronounced in well quality controlled datasets (0.8883 for LR without rejection). It is hypothesised from this that simpler models can perform competitively with more complicated models, while having a greatly reduced burden of data collection. A severity score is developed on the large multi-center database using a Genetic Algorithm and Particle Swarm Optimisation. The severity score, named the Oxford Acute Severity of Illness Score (OASIS), is shown to outperform the APS III (AUROC 0.837 vs 0.822) and perform competitively with APACHE IV when used as a covariate in a regression model (AUROC 0.868 vs 0.881). The severity score requires only 10 variables (58% as many as APS III), reducing the burden of quality control and data collection. These variables are routinely collected in critical care by continuous monitors and do not include comorbidities, diagnosis or laboratory measurements. The severity score is then externally evaluated in an American hospital and shown to discriminate well (AUROC 0.790 vs. 0.782 for the APS III) with excellent calibration. Finally, the severity score was evaluated in an English hospital and compared to other severity scores. OASIS again had excellent calibration and discrimination (AUROC 0.776 vs 0.750 for APS III) whilst requiring a much smaller number of variables. OASIS has many applications, including both simplifying data collection for studies and improving the risk assessment therein.
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Creating a community of practice to prevent readmissions : An improvement work on shared learning between an intensive care unit and a surgical wardLupaszkoi Hizden, Thomas January 2016 (has links)
Background ICU readmissions within 72 hours after discharge from the intensive care unit (ICU) is a problem because this leads to higher mortality and longer hospital stays. This is a particular problem for the hospital studied for this thesis because there are only three fully equipped ICU beds available. Aim To prevent readmissions by introducing nursing rounds as a concept of “communities of practice” (CoP) and to identify supportive and prohibitive mechanisms in the improvement work and knowledge needed for further improvement work in similar settings. Methods Questionnaires, focus groups, Nelson’s improvement ramp, and qualitative content analysis. Results There were no readmissions from the participating ward after the nursing rounds started, but the reason for this is not clear. The staff experienced the nursing rounds as valuable and they reported greater feelings of confidence, increased exchange, and use of their own knowledge. Discussion The findings presented here support that hypothesis that CoP builds knowledge that can improve patient care. The information provided to the participants during the improvement project was identified as the most supportive mechanism for improvement work, and a lack of resources was seen as the most prohibitive mechanism.
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Intensivvårdssjuksköterskors upplevelser av att vårda patienter som i självdestruktivt syfte överdoserat läkemedel / Critical nurses’ experiences of caring for patients who self-harmed with intentional drug overdoseLindell, Gabrielle January 2017 (has links)
Självdestruktiva handlingar innebär att medvetet tillfoga sig skada. Hos personer som avsiktligt självskadar sig är suicidtankar vanligt förekommande men syftet kan vara ångestlindring och uttryck för psykiskt illabefinnande. Mellan 2005-2014 vårdades 77371 personer inom slutenvård på grund av avsiktlig självdestruktiv handling och risken för suicid är höjd efter en självdestruktiv handling. Syftet med denna studie var att undersöka intensivvårdssjuksköterskans upplevelse av att vårda patienter som avsiktligt överdoserat läkemedel i självdestruktivt syfte. Fem kvalitativa intervjuer med semistrukturerad intervjuguide analyserades med innehållsanalys och materialet utmynnade i fem kategorier samlade under ett tema: Att vilja men inte alltid kunna. Kategorierna var: Att känna hjälplöshet i den psykiatriska omvårdnaden, Att ha kännedom om patientens sammanhang, Att prioritera bort samtal, Att attityder påverkar samarbetet med kollegor, Att ha behov av samverkan och stöd från psykiatrin. Studien visade att upplevelsen av att vårda patienter som överdoserat läkemedel i självdestruktivt syfte påverkades av patientens bakgrund, social kontext och livssituation. Bakgrund i missbruk, låg ålder och kvinnligt kön medförde att handlingen upplevdes mer impulsartad. Upplevelsen av att vårda var komplex och intensivvårdssjuksköterskan kände sympati, frustration och otillräcklighet i omvårdnaden av patienten. Samarbetet på intensivvårdsavdelningen påverkades av attityder inom personalgruppen där intensivvårdssjuksköterskan kände sig ensam ansvarig för samtal kring självdestruktivitet och mående. Det förelåg svårigheter i det multiprofessionella teamarbetet samt i förmågan att uppnå holistisk och personcentrad vård. Intensivvårdssjuksköterskorna upplevde att samarbetet med psykiatrin var bristfälligt och hade negativ påverkan på upplevelsen. Intensivvårdssjuksköterskans upplevelse var att slitas mellan sympati och frustration. Den moraliska stressen kan leda till att patienten får bristfällig omvårdnad och risken för framtida suicid kan öka.
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