Over 13 million adolescents sustain traumatic injuries yearly, resulting in functional disability, disfigurement, psychosocial problems and fractures. These fractures are increasingly being treated with orthopedic external fixation devices (EFDs). The purpose of this study was to describe the experience of traumatically injured adolescents treated with EFDs. The 4 aims of the study focused on the circumstances leading to the traumatic event, experiences following the traumatic event, the impact of EFD treatment, and adolescents’ role in pin-care self-management, which is crucial to preventing infection. This longitudinal, qualitative descriptive study used purposive sampling to recruit 5 male and 4 female adolescents, 13-20 years old, from a New England level-1 trauma center. Participants were injured in motor vehicle crashes (including an all-terrain vehicle), falls, by gunshot, trampoline and football trauma. Interview questions were framed by two themes from a study of adult recovery from physical injury, i.e., the event and fallout. Participants were interviewed within days of the injury, 2 weeks after returning home, and within one month of EFD removal. Data were coded from verbatim transcripts using NVIVO and organized into themes guided by the principles of qualitative analysis. An overarching theme of “old self no more; forever changed” emerged from 26 interviews. The participants’ experience affected all tasks of adolescence: independence from parents, accepting body image, peer relations, and forming an identity. Major themes included “what risk?”, regarding circumstances leading to the traumatic event, mastering the environment, was 2 part first, processing the event, where determining fault and realizing everything has changed, they were ambivalently lucky, and not invincible. Secondly “suck it up and deal with it”, where strategies to deal with traumatic injury emerged (i.e. medication, channeling outlets, and slow caution). EFD experience revealed “Space age robot” and “they’ll do it themselves” as emergent themes. EFDs were described as painless, robotic, no big deal and necessary. One draining pin-site was noted. Findings related to use of self-administered analgesics, information technology, recall of detail, and gender differences in coping may lead to future interventions. These findings lay the groundwork for future studies that may improve care of adolescents during acute recovery from traumatic injury.

The senior care means nowadays mostly the family care. This diploma thesis deals with the experience of family members with the care of a non-self-sufficient senior. The main aim is to take a look at this issue from the point of view of the caregivers and to examine how family caregivers perceive their situation. With the aging of the population, the question arises: how to properly set up a care system for the needs of an aging population members. For the right setting of intervention strategies, it is necessary to listen to those on whom lies the responsibility for the caretakers. The first part of the thesis consists of a theoretical establishment of family care and support, which is provided to the caregivers. Then, it covers various topics related to the changed role of the caregiver (eg. motivation for care, needs and difficulties of caregivers). The theoretical part of the diploma thesis concludes the chapter dealing with gender issues of caregivers. A qualitative research strategy was selected for the research and data collection was conducted through semi-structured interviews with 20 caregivers - 10 males and 10 females. The empirical part maps the care of a non-self-sufficient family member from the point of view both women and men. Afterwards, it describes the circumstances in which a...

Bakgrund: Intrahospitala transporter är transporter inom ett sjukhus och sker dagligen i intensivvården. Forskning visar att intrahospitala transporter är förenade med negativa händelser och påverkar patientsäkerheten. De negativa händelser som kan uppstå under den intrahospitala transporten kan leda till onödigt lidande. Syfte: Att identifiera och sammanställa vilka risk- och framgångsfaktorer som finns vid intrahospitala transporter av patienter med intensivvårdsbehov. Metod: En litteraturstudie med systematisk ansats baserad på 17 kvantitativa artiklar. Resultatet sammanställdes genom narrativ syntes. Resultat: Flera riskfaktorer identifierades, exempelvis inotropa läkemedel, akuta transporter och medicinsk teknik. Identifierade framgångsfaktorer innefattade bland annat interventionsprogram och säkerhetsarbete. Slutsats: Kunskap om vilka riskfaktorer och framgångsfaktorer som finns kan leda till en mer patientsäker omvårdnad och ett minskat lidande för patienten. För att skapa evidensbaserade rutiner kring intrahospitala transporter behövs ytterligare forskning.

Background. Specialist nurses in intensive care may feel insecure when caring for obstetric patients, partly because they lack experience for the patient group, and partly because they lack knowledge about physiological changes during pregnancy. To achieve a holistic view of nursing, the aim of this study was to examine obstetric patients' experiences of being cared for in ICU. The method applied was a literature study and was conducted by analyzing the results of seven scientific articles with a qualitative and quantitative approach. The results of this study can be divided into two main categories. The first category was about feelings and experiences of obstetric patients at the ICU, including for example worries, anxiety, disappointment, stress, shame, and confusion. The second category deals with nursing interventions that obstetric patients consider benefiting their well-being during the ICU period. These include transparent information, person-centered encounters, presence of next-of-kin, contact with the newborn, breastfeeding-support, spiritual/existential support, and a calm environment. Based on these results, the conclusion is that obstetric patients in ICU are particularly exposed to negative experiences and have an increased risk of depression. A holistic nursing approach aimed at this patient group can increase the patient's well-being and lead to better mother-child-attachment. / Bakgrund. Specialistsjuksköterskor inom intensivvård kan känna sig osäkra när de vårdar obstetriska patienter på en intensivvårdsavdelning, dels för att de saknar erfarenhet för denna patientgrupp, dels för att de saknar kunskap om fysiologiska förändringar under graviditet. För att kunna uppnå en holistisk syn på omvårdnad var syftet med denna litteraturstudie att beskriva obstetriska patienters upplevelser av att vårdas inom intensivvården. Som metod för att svara på detta syfte genomfördes en litteraturöversikt som inkluderar sju vetenskapliga artiklar med kvalitativ och kvantitativ ansats. Studiens resultat delas upp i två huvudkategorier. Den första huvudkategorin handlar om känslor och upplevelser som obstetriska patienter som vårdas på IVA erfar. Dessa är exempelvis oro, ångest, besvikelse, stress, skam och förvirring. Den andra huvudkategorin handlar om omvårdnadsåtgärder som patienterna anser gynna deras välbefinnande på IVA. Dessa inkluderar tydlig information, personcentrerat bemötande, närståendes närvaro, kontakt med barnet, amningsstöd, spirituellt/religiöst stöd samt en lugn vårdmiljö. Utifrån resultatet dras slutsatsen att obstetriska patienter inom intensivvården är särskilt utsatta för negativa erfarenheter samt har en ökad risk för depression. Ett holistiskt synsätt och specifika omvårdnadsåtgärder riktade till denna patientgrupp kan öka patientens välbefinnande och leda till en bättre anknytning mellan mor och barn.

When patients develop new-onset infections after hospital admission, the origin of the infection is typically assumed to be nosocomial; however, ambulances are potentially unexplored reservoirs for emerging pathogens. This study seeks to identify the scope of bacterial contamination in rural East Tennessee ambulances. Though universal precautions and cleaning procedures aim to reduce the spread of infectious diseases to provider and patient, little is known about the bacterial microbiome of ambulances. To the best of our knowledge, this is the first study of its kind to be performed in the state of Tennessee and the first since the introduction of UVGI units as an ambulance-based COVID-19 infection control measure. Our dissemination of post-pandemic findings may impact ambulance sanitation measures and will add to the national and global knowledge pertaining to the microbiome of emergency medical patient transport systems. Ambulances in East Tennessee were sampled using environmental sampling contact plates. At least one active ambulance unit for each EMS service underwent sampling. Three samples were obtained from each of three areas: the floor of the ambulance transport area, the rear door panel inside the transport area and stretcher. The plates were then incubated at 30-35C for 48 hours. Colony counts were manually performed before the plates were shipped for species identification via MALDI-TOF DNA analysis by MIDI laboratories (Newark, DE). One plate from each ambulance door and stretcher was sent for bacterial identification. Only one sample returned free of growth. All floor samples, several stretcher samples, and three door samples presented vast growth with colonies too numerous to count. The results from bacterial identification showed all flora were human commensal flora or environmental flora. The flora found on ambulance doors with opportunistic capabilities are as follows: Staphylococcus hominis, Staphylococcus epidermidis, Enterobacter cloacae, Enterobacter xinagfangensis, Bacillus cereus, Klebsiella oxytoca, and Bacillus subtilis; and the flora found on the stretchers with opportunistic capabilities are as follows: Staphylococcus haemolyticus, Staphylococcus epidermidis, Staphylococcus cohnii ssp urealyticus, Bacillus cereus, Corynebaccterium mucifaciens, Staphylococcus pettenkoferi, Klebsiella oxytoca, Staphylococcus capitis, Bacillus subtillis, and Staphylococcus caprae. In this era of increasing antibiotic resistance, it is concerning that several microbes with pathogenicity were found, including species that often confer the spread of resistance such as Klebsiella oxytoca and Enterobacter cloacae. Overall, the finding of numerous diverse colonies does not support adequate sanitation of the ambulances. Further study is required to identify the most effective sanitation methods, and further metagenomic study is needed to explore the presence of genes that facilitate the spread of microbial resistance.

Background: Sepsis, a leading cause of US deaths, is associated with high mortality, although advances in early recognition and treatment have increased survivorship. Many aspects of sepsis pathophysiology and epidemiology have not been fully elucidated; the heterogeneous nature of infections that lead to sepsis has made fully characterizing the underlying epidemiology challenging. Methods: The University HealthSystem Consortium (UHC) from 2011-2014 and the Cerner HealthFacts® database from 2008-2014 were used. We examined associations between infection source and in-hospital mortality in the UHC dataset, stratified by age and presenting sepsis stage. We examined recent temporal trends in present-on-admission (POA) sepsis diagnoses and mortality and predictors of 30-day sepsis readmissions following sepsis hospitalizations using the HealthFacts® dataset. Results: Patients with sepsis due to genitourinary or skin, soft tissue, or bone sources had lower mortality than patients with sepsis due to respiratory sources regardless of age or presenting sepsis stage. Overall diagnoses of sepsis increased from 2008-2014; however, POA diagnoses and case fatality rates decreased. Factors that predicted re-hospitalization for sepsis included discharge to hospice, admission from or discharge to a skilled nursing facility, and abdominal infection. Conclusion: Further investigation will reveal more detail to explain the impact of infection source on in-hospital sepsis mortality for all age groups and sepsis stages. Decreasing mortality rates for all POA sepsis stages and all age groups suggest current approaches to sepsis management are having broad impact. Sepsis survivors are at significant risk for re-hospitalization; further studies are needed to understand the post discharge risks and needs of survivors.

Bakgrund: Professionell identitet tolkas utifrån tidigare studier som ett relativt inkonsekvent begrepp, vilket leder till att begreppet är svårt att konkret använda och tillämpa inom sjuksköterskeprofessionen. Det förefaller även finnas en kunskapslucka vad gäller professionell identitet i relation till specialistsjuksköterskor inom intensivvård samt hur professionell identitet kan ses ur ett livsvärldsperspektiv. Syfte: Belysa professionell identitet som begrepp för specialistsjuksköterskor inom intensivvård i kontext till deras livsvärld. Metod: En begreppsanalys enligt Walker och Avant med avsikt att finna betydelsen av professionell identitet som begrepp. Resultat: Utifrån ett livsvärldsperspektiv består professionell identitet av specialistsjuksköterskans upplevelse av sig själv, i en omgivning eller situation, via mötet med andra livsvärldar. Professionell identitet formas utifrån specialistsjuksköterskans egna levda erfarenheter och har starkt samband till den personliga livsvärlden. Professionell identitet karaktäriseras utifrån fyra attribut. Dessa innebär att (1) specialistsjuksköterskan inom intensivvård har den kunskap som krävs för att vårda kritiskt sjuka, samt värnar om professionens kärnvärderingar i sitt arbete. Att (2) specialistsjuksköterskan identifierar sig personligen med rollen som specialistsjuksköterska och utifrån en god självbild agerar med självförtroende. Vidare innebär det att (3) specialistsjuksköterskan agerar autonomt och utför sina arbetsuppgifter på ett yrkesskickligt vis som inger förtroende i arbetsgruppen. Detta för att (4) till sist urskilja sig från andra professioner dock med intentionen att vara en god samarbetspartner i teamet kring patienten. Positiva konsekvenser efterföljer in i verkligheten om förutsättningarna för professionell identitet som begrepp existerar. Slutsats: Fördjupad insikt i vad professionell identitet innebär som begrepp kan bidra positivt till att specialistsjuksköterskan inom intensivvård upplever starkare känsla av professionell identitet.

Malgré les récents progrès dans la prise en charge des patients en réanimation, la mortalité en réanimation reste élevée: environ 30%. L’atteinte cérébrale en est un déterminant majeur. Le concept de l'implication d'un dysfonctionnement du tronc cérébral dans la survenue de la mort en réanimation est bien établi. Cependant, les signatures neurophysiologiques de cette atteinte du tronc cérébral ne sont pas encore bien caractérisées. Certains paramètres de l'électroencéphalogramme (EEG) et des potentiels évoqués (PE) pourraient permettre l'évaluation de l'état fonctionnel du tronc cérébral en réanimation. La réactivité de l'EEG aux stimulations nociceptives permet de tester le fonctionnement du tronc cérébral par la voie extra-lemniscale (spino-thalamique). Les potentiels somesthésiques (PES) et auditifs précoces (PEAP) explorent respectivement les voies lemniscale médiane et lemniscale latérale dans le tronc cérébral.Dans les travaux présentés ici, nous avons évalué les anomalies de réponses neurophysiologiques du tronc cérébral et leur impact sur le pronostic dans différentes cohortes de patients en soins intensifs. En effet, le manque de réactivité de l'EEG à la stimulation douloureuse, ainsi que l'allongement du temps de conduction subcortico-corticale (PES P14-N20_ IPL) ont été chacun indépendamment corrélé à la mort en réanimation. L'allongement du temps de conduction ponto-mésencéphalique (PEAP III-V _ IPL) a tendance à être associé à l'apparition du délire ou du réveil retardé. Nos travaux fournissent des substrats neurophysiologiques des dysfonctionnements du tronc cérébral observés chez les patients gravement malades et leur relation avec le pronostic. Des études avec d'autres marqueurs neurophysiologiques ciblant le tronc cérébral comme les enregistrements du réflexe de clignement, des PE laser et des PE respiratoires, sont nécessaires. / Despite recent progress in the management of critically ill patients, mortality in the ICU remains high (around 30%). Neurological impairment is a major determinant of mortality in ICU. It has been hypothesithed that brainstem dysfunction might play a role in mortality in the ICU. However, neurophysiological signatures of brainstem failure in ICU patients have not yet been characterized. Electroencephalogram (EEG) and sensorial evoked potentials (EP) parameters could enable the assessment of the functional status of the brainstem at the bedside in the ICU. EEG reativity to intense painful stimuli allows testing the proper functioning of the brainstem via the extra-lemniscal pathway (spino-thalamic). Somatosensory (SSEP) and brainstem auditory (BAEP) evoked potentials respectively explore the median lemniscal and the lateral lemniscal pathways within the brainstem.In the works presented here, we assessed brainstem neurophysiological responses' and their impact on prognosis in various cohorts of critically ill patients. A lack of EEG reactivity to painful stimulation as well as the lengthening of subcortico-cortical conduction time (SSEP P14-N20_ IPL) was each independantly correlated with death in the ICU. The lengthening of ponto-mesencephalic conduction time (BAEP III-V _ IPL) tended to be associated with the onset of delirium or delayed awakening. Our work provides neurophysiological substratum for the concept of the brainstem dysfunctions in critically ill patients and their relationship with prognosis. Supplemental studies with other neurophysiological markers involving the brainstem such as recordings of blink reflexes, laser EP and respiratory EP, are needed to confirm these results.

Bakgrund: Mekanisk respiratorbehandling är en den mest använda kortsiktiga livsuppehållande interventionen och den vanligaste behandlingsformen inom intensivvården och syftar till att understödja och stötta andningssvikt. Smärta är en vanlig upplevelse hos patienter som vårdas inom intensivvårdsavdelen och som behandlas med mekanisk ventilation, inte bara för själva respiratorbehandlingen utan även för de undersökningar och behandlingar som pågår samtidigt.  Motiv: Smärta är vanligt förekommande hos patienter som vårdas inom intensivvården relaterat till sjukdom, skada, behandling, procedurer och omvårdnad. När patienter vårdas i respirator försvinner förmågan att kunna uttrycka sig verbalt, det gör att de inte med ord kan förmedla sin smärta.   Metod: Kvalitativ innehållsanalys med individuella semistrukturerade intervjuer med induktiv ansats.   Syfte: Syftet var att belysa intensivvårdssjuksköterskors erfarenheter av att tolka smärta hos sederade patienter i respirator.   Resultat: Analysen av studien resulterade i två huvudkategorier med vardera tre subkategorier. Personliga aspekter med följande subkategorier; Individuella bedömningar, tolkning av patientens uttryck och komplexitet i bedömningar. Nästa huvudkategori var; Organisatoriska aspekter med följande subkategorier; sjuksköterskans framträdande roll i teamet, strukturerad informationsöverföring samt professionellt engagemang med kompetens  Konklusion: Resultatet visade att det finns hinder som påverkar bedömning av smärta hos respiratorvårdade patienter. Intensivvårdssjuksköterskan använder erfarenheter och tidigare kunskap istället för formella smärtskattningsinstrument. De uttryckte svårigheter i att bedöma skillnad på oro och smärta. Intensivvårdssjuksköterskorna upplever att det är deras ansvar att patienten får rätt smärtlindring och lyfta diskussionen kring smärta. De belyser även vikten av tydlig dokumentation och rapportering. / Background: Mechanical ventilator treatment is one of the most widely used short-term-life-sustaining interventions and the most common form of treatment in intensive care and aims to support respiratory failure. Pain is a common experience in patients who are cared for in the intensive care unit and who are treated with mechanical ventilation, not only for the respiratory treatment itself but also for the examinations and treatment that take place at the same time.   Motive: Pain is common symptom for intensive care patients, related to illness, injury, treatment, procedures and nursing. When patients are cared for in a ventilator, the ability to express themselves verbally disappears, which means that they cannot convey their pain with words.    Method: Qualitative content analysis with individual semi-structured interviews with an inductive approach.   Aim: The aim was to examine intensive care nurses' experience of interpreting pain in sedated patients on a ventilator.  Results: The analysis of the study resulted in two main categories with three subcategories each. The first main category was Personal aspects with the following subcategories; Individual assessments, interpretation of the patient's expression and complexity in assessments. The next main category was; Organizational aspects with the following subcategories; the nurse's prominent role in the team, structured information transfer and professional commitment with competence.  Conclusion: The results showed that there are obstacles that affect the assessment of pain in respiratory patients. The intensive care nurse uses experience and previous knowledge instead of formal pain assessment instruments. They expressed difficulty in distinguishing between anxiety and pain. The intensive care nurses feel that it’s their responsibility to get the patient the right pain relief and raise the discussion about pain. They also highlight the importance of clear documentation and reporting.

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