Bakgrund: I en rapport från socialstyrelsen framgår det att akutmottagningarna runt omi landet har ca 2,5 miljoner patientfall, därtill kommer ännu fler anhöriga ochnärstående. Patientnämnden, som är det organ som hanterar klagomål från patienter ochanhöriga, uppger att det varje år kommer ungefär 4000 anmälningar där patienter ochanhöriga har känt sig kränkta och dåligt bemötta i sjukvården. Syfte: Syftet var attbeskriva hur vuxna anhöriga upplever bemötandet av sjuksköterskan vid akutasjukdomstillstånd inom somatisk vård. Metod: Arbetet skrevs som en allmänlitteraturstudie, enligt metod för kvalitativ manifestinnehållsanalys. Resultat:Anhörigas upplevelser i bemötandet från sjuksköterskorna kunde delas in i tre olikakategorier: trygghet-otrygghet, att bli sedd och bekräftad och sjuksköterskansmaktutövande. I det trygga och bekräftande bemötandet upplevde anhöriga känslor avtrygghet och betydelsefullhet, detta gav dem förutsättningar att skapa en handlingsplanför framtiden. När sjuksköterskan istället utövade sin maktställning upplevde anhörigakänslor av maktlöshet och att befinna sig i en beroendeställning. Detta gjorde attanhöriga fastnade i känslor av skuld och kunde inte ta sig vidare. / Background: A report from the National Board shows that emergency departmentsaround the country has about 2.5 million patient cases, which must be added even morefamily and friends. Patients Board, which is the body that handles complaints frompatients and relatives, said that each year, approximately 4000 notifications in whichpatients and families have felt insulted or badly treated in health care. Objective: Theaim was to describe how adult relatives are experiencing the hospitality of the nurse inacute illness in somatic care. Methods: This work was written as a general literaturestudy, by method of qualitative manifest content analysis. Results: Relatives'experiences of nurses' attitudes could be divided into three different categories:security-insecurity, to be seen and confirmed and nurses exercise of power. In the safeand confirmatory hospitality experienced relatives feelings of security and greatness,this gave them the ability to create an action plan for the future. When the nurse insteadexercised their position of power experienced relatives feelings of powerlessness andbeing in a position of dependence. This meant that families got stuck in feelings of guiltand could not get on.

Background: Our innate immunesystem protects us from infections but, since its methods is not all specific for microorganisms, may also induce collateral damage. Severe physical injury often proved deadly throughout evolution. Such injuries may induce massive collateral damage. Nowadays we can initiate advanced critical care for affected patients and save them from imminent trauma-related death. We are therefore faced with the fact that the collateral damage from the immune system may pose a major threat to the patient, the pathophysiology of which is not amenable to direct medical treatment and which leaves us with only passive supportive measures. In this thesis we investigated the role of leucocytes under such circumstances. Our main aim was to understand better the role of leucocytes in the development of increased vascular permeability after burns and trauma. More specifically we investigated the impact of an injury on the function of leucocytes such as the dynamic change of certain cell-surface receptors on the leucocytes and in their numbers and immature forms. We wanted to find out if the increased pulmonary vascular permeability after a burn could be mediated through heparin binding protein (HBP) released from granuloctes, and whether HBP could be used as a biomarker for respiratory failure after trauma. We also wanted to confirm the possible role of histamine as a mediator of the systemic increase in vascular permeability after burns. Methods: The dynamic change of cell-surface receptors was measured by flow-acquired cytometer scanning (FACS) on blood samples taken after burns. The concentrations of HBP after a burn and mechanical trauma were analysed in plasma. Pulmonary vascular permeability after a burn was assessed using transpulmonary thermodilution. The histamine turnover after a burn was assessed with high performance liquid chromatography (HPLC) for concentrations of histamine and methylhistamine in urine. Results: We confirmed earlier investigations showing altered expression of receptors on leucocytes after a burn, receptors intimately associated with leucocyte functions (study I). In a pilot study of 10 patients we measured plasma concentrations of HBP and found them to be increased soon after a burn (study II). This finding was not confirmed in a larger, more extensive and specific study of 20 patients. We did, however, find an association between alterations in the number of leucocytes soon after a burn and pulmonary vascular permeability, indicating that they had a role in this process (study III). In another study of trauma (non burn) we found an association between the concentration of HBP in early plasma-samples after injury and the development of ARDS, indicating that granulocytes and HBP have a role in its aetiology (study IV). We found a small increase in urinary histamine and normal urinary methylhistamine concentrations but had anticipated a distinct increase followed by a decrease after reading the current papers on the subject. This indicates that the role of histamine as a mediator of increased vascular permeability after burns may have been exaggerated (study V). Conclusions: We conclude that leucocytes are affected by burns and trauma, and it is likely that they contribute to the development of respiratory failure and acute respiratory distress syndrome (ARDS). HBP is a candidate biomarker for the early detection of ARDS after trauma, and the white blood count (WBC) is a useful biomarker for the detection of decreased oxygenation soon after a burn.

Résumé : Cette thèse s’intéresse au temps d’émergence et aux asynchronies patient-ventilateur à l’origine de lésions pulmonaires chez des patients en soins critiques sous algosédation durant la phase aiguë de la ventilation mécanique. L’originalité de cette recherche consiste à comparer un protocole d’algosédation guidé par l’échelle de Ramsay (le standard) à celui guidé par la technologie BIS. Méthodologie. Suivant un devis mixte inter groupe et intrasujets, cette recherche comporte deux groupes de patients adultes et se déroule sur une période de quatre ans. Le premier groupe comprend 23 patients dont le protocole d’algosédation est guidé par l’échelle de Ramsay. Le second groupe compte 18 patients soumis à la même stratégie de ventilation et au même protocole d’algosédation mais guidé cette fois-ci par la technologie BIS. Mesures. Le temps d ’émergence pour un retour à la ventilation spontanée soutenue (TEVSS) suivant l’arrêt de la perfusion de l’algosédation et les interactions patient-ventilateur (synchronies et asynchronies) durant la phase aiguë de ventilation constituent les variables dépendantes. Résultats. Le groupe bénéficiant de la technologie BIS présente un TEVSS médian de 3,1 heures comparé à 22,5 heures pour le groupe guidé par l’échelle de Ramsay (valeur p=0,001). De plus, le groupe bénéficiant de la technologie BIS présente 11% de moins d’asynchronies patient-ventilateur que celui guidé par l’échelle de Ramsay (valeur p<0,001). En outre, parmi les paramètres de la technologie BIS, l’électromyogramme (EMG) s’avère l’élément le plus robuste à prédire l’asynchronie patient-ventilateur. Conclusion. La réduction du TEVSS ainsi que la diminution des asynchronies patient-ventilateur démontrent un avantage considérable à utiliser la technologie BIS en soins critiques chez les patients adultes non communicatifs durant la phase aiguë de ventilation mécanique. De plus, l’EMG de la technologie BIS permettrait vraisemblablement de déceler de façon précoce l’expression préclinique de la douleur. Enfin, cette thèse propose un algorithme de contrôle de l’algosédation en soins critiques en référence à la technologie BIS. // Abstract : This thesis focuses on emergence time from algosédation (for which a prolongation increases complex investigations and costs) and on patient-ventilator interaction (related to lung injuries) in critical care patients undergoing mechanical ventilation with algosedation perfusion during the acute phase of ventilator support. More specifically, the originality of this research stems from the simultaneous comparison of the emergence time for a retum of sustained spontaneous breathing and the presence of asynchronies, by eomparing algosedation guided by the Ramsay scale (gold standard) in a first group and by the BIS technology in a second group. Methodology. Following a mixed design of an inter group, intra subject, this research is performed in two groups of adults over a period of four years. The first group consists of 23 patients where algosedation is guided with the Ramsay scale whereas the second group consists of 18 patients with the same ventilation strategy and same algosédation protocol but guided using the BIS technology. This research evaluates the effectiveness of both instruments to guide algosedation during the acute phase of ventilation. Measures. Dependent variables consist of the emergence time for a sustained spontaneous breathing following cessation o f algosedation and patient-ventilator interaction (asynchronies) during the acute phase of ventilatory support. Results. The group guided with BIS technology has a median emergence time for a sustained spontaneous breathing of 3.1 hours compared to 22.5 hours for the Ramsay scale guided group (p value=0.001). Furthermore, patients benefiting from the BIS technology presented 11% less asynchrony than those with the Ramsay scale (p value <0.001). More specifically, among BIS technology parameters, electromyography (EMG) appeared the best indicator to predict patient-ventilator asynchrony in both groups. Conclusion. In the second group, the reduction in the emergence time for a sustained spontaneous breathing and the decrease of patient-ventilator asynchronies mandates the use o f BIS technology in critical care to guidee algosedation among non-communicative adults during the acute phase of ventilatory support. EMG from the BIS technology might be able to detect pre-clinical pain expression. This thesis also favors the implementation of a décision algorithm in the control of algosedation in critical care.

Inadequate delivery of nutrition to the critically ill is common, and may adversely affect clinical outcomes, including survival. This thesis reports studies designed to characterise the gastrointestinal dysfunction underlying feed intolerance in the critically ill, as well as the pathophysiology of these dysfunctions, and investigate potential therapeutic measures. While it has been established that enteral nutrition is frequently unsuccessful in the critically ill, assessment of the success of feeding in an Australian intensive care unit (ICU) had not been performed previously. A prospective survey examined the incidence of, and risk factors for, feed intolerance in the ICU at the Royal Adelaide Hospital and demonstrated that, in 40 patients receiving enteral feeding, only about 60% of their nutritional requirements were met at the end of the first week. The main cause for this lack of success was large gastric residual volumes, indicative of delayed gastric emptying (GE). This study, accordingly, quantified the limitations of nutritional delivery in contemporary practice in a local ICU. The results suggest that a better understanding of the pathogenesis underlying this problem is warranted in order to direct research into improved therapies. Scintigraphy is the most accurate technique to measure GE, but is difficult to perform in the ICU. A simpler, more convenient, test would increase the accessibility of GE measurement for both research and clinical purposes. A study comparing a breath test technique and gastric residual volume measurement to the scintigraphic measurement of GE in 25 mechanically ventilated patients demonstrated that GE measured by a breath test technique closely correlated with that measured by scintigraphy. While the breath test had a specificity of 100% it only had a sensitivity of about 60% in the prediction of delayed GE. Similarly, gastric residual volume measurement correlated with scintigraphic measurement of GE but also lacked sensitivity. The breath test has previously been demonstrated to be highly reproducible and it represents a useful option for repeated measurement of GE in the same patient. It is therefore likely to be useful to determine changes in GE over time or in response to a therapeutic intervention. There is a lack of information about the prevalence and determinants of delayed GE in the critically ill. Previous studies have substantial limitations and scintigraphic measurement of GE has only rarely been used. A study comparing GE measured by scintigraphy in 25 patients to 14 healthy subjects demonstrated that GE was delayed in approximately 50% of the ICU patients (>10% retention at 4h) and markedly delayed in about 20% (>50% retention at 4h). Patients with trauma and sepsis appeared to have a relatively higher prevalence of delayed GE (80% and 75% respectively). In addition, the longer the patient had been in ICU the more normal the rate of GE. Quantification of delayed GE may prove useful by defining patients who may benefit from preventative or therapeutic options. The abnormalities in gastrointestinal motility underlying delayed GE in the critically ill are poorly characterised. Simultaneous manometric and gastric emptying measurements were performed in 15 mechanically ventilated patients and 10 healthy subjects. These studies demonstrated that delayed GE was associated with reduced antral activity, increased pyloric activity and increased retrograde duodenal activity in the patients. Persistent fasting motility during feeding was also frequently observed. Furthermore, the feedback response to small intestinal nutrients was enhanced. This latter observation may provide an explanation for the delayed GE and warrants further investigation. Recent studies suggest that the hormone cholecystokinin may be a mediator of increased small intestinal feedback and, if confirmed, this has clear therapeutic implications. Nutrient absorption has rarely been measured in the critically ill. GE and glucose absorption (using 3-O-methyl glucose) were measured simultaneously in 19 ICU patients and compared to 19 healthy subjects. Glucose absorption was shown to be markedly reduced in the patients. Slow GE was associated with delayed, and reduced, absorption. However, glucose absorption was also reduced in patients with normal GE suggesting that reduced glucose absorption in critical illness is only partly due to delayed GE. Accordingly, measures to improve the effectiveness of GE and thereby improve overall nutritional status may be compromised by abnormal small intestinal absorption. The mechanisms underlying this warrant further investigation. A number of therapeutic options directed at improving the delivery of nutrition were examined. In a study involving 20 mechanically ventilated patients, administration of 200mg erythromycin intravenously was shown to be superior to placebo for treating feed intolerance. The optimal dose of erythromycin, however, was unclear. In a subsequent study involving 35 ICU patients, GE was measured using a breath test technique, before and after 2 different doses of erythromycin or placebo and a ‘low’ intravenous dose (70mg) of erythromycin appeared to be as effective as a ‘moderate’ dose (200mg). Both doses were only effective in subjects who had delayed GE at baseline. Based on the outcome of these studies, low doses of erythromycin have subsequently been routinely used to treat feed intolerance in the critically ill patients at the Royal Adelaide Hospital. Animal and human studies suggested that the antibiotic, cefazolin, may have a prokinetic effect. Cefazolin, however, did not demonstrate similar prokinetic activity at a ‘low’ dose (50mg) in a critically ill cohort. The results of this study do not support the use of this agent, at this dose, as a prokinetic, in this population. If nasogastric administration of nutrition proves unsuccessful an alternative is to infuse nutrient directly into the small intestine. However, the placement of feeding tubes distal to the pylorus is technically difficult. A novel technique for postpyloric tube insertion was examined with promising results. In summary, the studies described in this thesis have provided a number of insights relevant to the management of the critically ill by quantifying the prevalence of feed intolerance and delayed GE, characterising some of the disturbances in gastrointestinal motility underlying this problem, and evaluating a number of therapeutic interventions. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1345143 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2008

Inadequate delivery of nutrition to the critically ill is common, and may adversely affect clinical outcomes, including survival. This thesis reports studies designed to characterise the gastrointestinal dysfunction underlying feed intolerance in the critically ill, as well as the pathophysiology of these dysfunctions, and investigate potential therapeutic measures. While it has been established that enteral nutrition is frequently unsuccessful in the critically ill, assessment of the success of feeding in an Australian intensive care unit (ICU) had not been performed previously. A prospective survey examined the incidence of, and risk factors for, feed intolerance in the ICU at the Royal Adelaide Hospital and demonstrated that, in 40 patients receiving enteral feeding, only about 60% of their nutritional requirements were met at the end of the first week. The main cause for this lack of success was large gastric residual volumes, indicative of delayed gastric emptying (GE). This study, accordingly, quantified the limitations of nutritional delivery in contemporary practice in a local ICU. The results suggest that a better understanding of the pathogenesis underlying this problem is warranted in order to direct research into improved therapies. Scintigraphy is the most accurate technique to measure GE, but is difficult to perform in the ICU. A simpler, more convenient, test would increase the accessibility of GE measurement for both research and clinical purposes. A study comparing a breath test technique and gastric residual volume measurement to the scintigraphic measurement of GE in 25 mechanically ventilated patients demonstrated that GE measured by a breath test technique closely correlated with that measured by scintigraphy. While the breath test had a specificity of 100% it only had a sensitivity of about 60% in the prediction of delayed GE. Similarly, gastric residual volume measurement correlated with scintigraphic measurement of GE but also lacked sensitivity. The breath test has previously been demonstrated to be highly reproducible and it represents a useful option for repeated measurement of GE in the same patient. It is therefore likely to be useful to determine changes in GE over time or in response to a therapeutic intervention. There is a lack of information about the prevalence and determinants of delayed GE in the critically ill. Previous studies have substantial limitations and scintigraphic measurement of GE has only rarely been used. A study comparing GE measured by scintigraphy in 25 patients to 14 healthy subjects demonstrated that GE was delayed in approximately 50% of the ICU patients (>10% retention at 4h) and markedly delayed in about 20% (>50% retention at 4h). Patients with trauma and sepsis appeared to have a relatively higher prevalence of delayed GE (80% and 75% respectively). In addition, the longer the patient had been in ICU the more normal the rate of GE. Quantification of delayed GE may prove useful by defining patients who may benefit from preventative or therapeutic options. The abnormalities in gastrointestinal motility underlying delayed GE in the critically ill are poorly characterised. Simultaneous manometric and gastric emptying measurements were performed in 15 mechanically ventilated patients and 10 healthy subjects. These studies demonstrated that delayed GE was associated with reduced antral activity, increased pyloric activity and increased retrograde duodenal activity in the patients. Persistent fasting motility during feeding was also frequently observed. Furthermore, the feedback response to small intestinal nutrients was enhanced. This latter observation may provide an explanation for the delayed GE and warrants further investigation. Recent studies suggest that the hormone cholecystokinin may be a mediator of increased small intestinal feedback and, if confirmed, this has clear therapeutic implications. Nutrient absorption has rarely been measured in the critically ill. GE and glucose absorption (using 3-O-methyl glucose) were measured simultaneously in 19 ICU patients and compared to 19 healthy subjects. Glucose absorption was shown to be markedly reduced in the patients. Slow GE was associated with delayed, and reduced, absorption. However, glucose absorption was also reduced in patients with normal GE suggesting that reduced glucose absorption in critical illness is only partly due to delayed GE. Accordingly, measures to improve the effectiveness of GE and thereby improve overall nutritional status may be compromised by abnormal small intestinal absorption. The mechanisms underlying this warrant further investigation. A number of therapeutic options directed at improving the delivery of nutrition were examined. In a study involving 20 mechanically ventilated patients, administration of 200mg erythromycin intravenously was shown to be superior to placebo for treating feed intolerance. The optimal dose of erythromycin, however, was unclear. In a subsequent study involving 35 ICU patients, GE was measured using a breath test technique, before and after 2 different doses of erythromycin or placebo and a ‘low’ intravenous dose (70mg) of erythromycin appeared to be as effective as a ‘moderate’ dose (200mg). Both doses were only effective in subjects who had delayed GE at baseline. Based on the outcome of these studies, low doses of erythromycin have subsequently been routinely used to treat feed intolerance in the critically ill patients at the Royal Adelaide Hospital. Animal and human studies suggested that the antibiotic, cefazolin, may have a prokinetic effect. Cefazolin, however, did not demonstrate similar prokinetic activity at a ‘low’ dose (50mg) in a critically ill cohort. The results of this study do not support the use of this agent, at this dose, as a prokinetic, in this population. If nasogastric administration of nutrition proves unsuccessful an alternative is to infuse nutrient directly into the small intestine. However, the placement of feeding tubes distal to the pylorus is technically difficult. A novel technique for postpyloric tube insertion was examined with promising results. In summary, the studies described in this thesis have provided a number of insights relevant to the management of the critically ill by quantifying the prevalence of feed intolerance and delayed GE, characterising some of the disturbances in gastrointestinal motility underlying this problem, and evaluating a number of therapeutic interventions. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1345143 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2008

Thesis (MNutr)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Objectives: The objectives of this study were to determine the nutritional content/ contribution of intravenous (IV) fluid and electrolyte administration on the total feeding prescription of intensive care unit (ICU) patients. Methods: Retrospective review of ICU charts of consecutive patients (>18 years) with APACHE II scores ≥10 and on ≥72 hours nutrition therapy (NT) admitted to a medical/surgical ICU. Total fluid, electrolyte, energy and macronutrient intake from nutritional and non-nutritional sources were reviewed from ICU admission until discharge, discontinuation of NT or death for ≤7 days. Energy and protein delivery were compared to calculated targets of 25.4 – 28.6kCal/kg and 1.3 – 1.5g/kg respectively. Summary statistics, correlation coefficients and appropriate analysis of variance were used to describe and analyse the data. Results: A total of 71 patients (49% male), average age 49.2 ± 17.1, average APACHE II score 21.0 ± 6.1, 68% medical and 32% surgical, were included. Fluid and nutrient intake were reviewed over a mean of 5.7 ± 1.1 days. Mean daily fluid delivery was 3.2 ± 0.6L. IV fluid therapy (IVFT) contributed 32.0 ± 12.0% to total fluid delivery (TFD), whereas IV drug administration, including fluids used for reconstitution and dilution purposes, contributed 20.7 ± 8.1% to TFD. Balanced electrolyte solutions (BES) were the crystalloid of choice, prescribed in 91.5% of patients with a mean daily volume (MDV) of 0.5 ± 0.4L. Hypertonic low molecular weight (LMW) 130/0.4kD hydroxyethyl starch (HES) was the colloid of choice, prescribed in 78.9% of patients with a MDV of 0.2 ± 0.1L. Potassium salts were the most frequently prescribed IV electrolyte supplement (IVES), prescribed in 91% of patients (±20 – 60mmol per administration). NT was initiated within 14.5 ± 14.1 hours. The majority (80%) received enteral nutrition (EN). The mean daily energy delivered was 1613 ± 380kCal (25.1kCal/kg), meeting 93.6 ± 17.7% of mean target range (MTR). Mean daily protein delivery (PD) was 72 ± 22g (1.1g/kg), meeting 82.8 ± 19.9% of MTR. Non-nutritional energy sources (NNES), mostly derived from carbohydrate-containing IV fluids, contributed 10.1 ± 7.5% to total energy delivered (156kCal/d). Mean cumulative energy and protein balance was -674.0 ± 1866.1kCal and -86.0 ± 106.9g respectively. The majority (73%) received >90% of the minimum energy target but only 49% >90% of minimum protein target; 59% of those with energy intake 90-110% of target had adequate protein intake. A significant negative correlation was found between cumulative energy/protein balance and the time to initiation of NT (energy: r=-0.28, p=0.02; protein: r=-0.32, p=0.01). Conclusion: In this ICU BES are the crystalloid of choice and hypertonic LMW 130/0.4kD HES the colloid of choice for IVFT. Potassium salts are the most frequently prescribed IVES. NNES added significantly to energy delivery and should be included in the calculation of feeding prescriptions to avoid the harmful effects of overfeeding. Early initiation of EN with conventional products which are energy rich is insufficient to achieve adequate PD. EN formulae with a more favorable nitrogen to non-protein energy ratio could help to optimise PD during the first week of ICU care. / AFRIKAANSE OPSOMMING: Doelwitte: Die doelwit van hierdie studie was om die voedingswaarde/ bydrae van intraveneuse (IV) vog en elektroliet toediening tot die totale voedings voorskrif van pasiënte in ‘n intensiewe sorg eenheid (ISE) te bepaal. Metodes: Retrospektiewe bestudering van die ISE kaarte van agtereenvolgende pasiënte (>18 jaar) opgeneem in ‘n mediese/chirurgie ISE en met APACHE II tellings ≥10 en ≥72 ure voedingsterapie (VT). Totale vog, elektroliet, energie en makronutriënt inname vanaf voedingsverwante en nie-voedingsverwante bronne is vanaf ISE opname tot en met ontslag, staking van VT of sterfte, vir ≤7 dae hersien. Energie en proteiën inname is vergelyk met berekende doelwitte van 25.4 – 28.6kKal/kg en 1.3 – 1.5g/kg onderskeidelik. Beskrywende statisitiek, korrelasie koeffisiënte en toepaslike analises van variansie is gebruik vir data analise. Resultate: 71 pasiënte (49% mans), gemiddelde ouderdom 49.2 ± 17.1, gemiddelde APACHE II telling 21.0 ± 6.1, 68% medies en 32% chirurgie, is ingesluit. Vog en voedingstof inname is hersien oor ‘n gemiddelde tydperk van 5.7 ± 1.1 dae. Gemiddelde vog inname was 3.2 ± 0.6L/dag. IV vog terapie (IVVT) het 32.0 ± 12.0% bygedra tot totale vog inname (TVI). IV medikasie toediening, insluitende die herkonstruksie en verwatering van medikasie, het 20.7 ± 8.1% bygedra tot TVI. Die mees voorgeskrewe kristalloiëd en kolloiëd vir IVVT was gebalanseerde elektroliet oplossings (GEO), voorgeskryf in 91.5% van pasiënte (gemiddeld 0.5 ± 0.4L/dag), en hipertoniese lae molekulêre gewig (LMG) 130/0.4kD hidroksie-etiel stysel (HES), voorgeskryf in 78.9% van pasiënte (gemiddeld 0.2 ± 0.1L/dag), onderskeidelik. Die mees voorgeskrewe IV elektroliet supplement was kalium soute, voorgeskryf in 91% van pasiënte (±20 – 60 mmol per toediening). VT is binne 14.5 ± 14.1 ure geinisieër. Die meerderheid (80%) het enterale voeding (EV) ontvang. Die gemiddelde daaglikse energie inname van 1613 ± 380kCal (25.1kKal/kg) het 93.6 ± 17.7% van die gemiddelde doelwit rykwydte (GDR) bereik. Die gemiddelde daaglikse proteiën inname van 72 ± 22g (1.1g/kg) het 82.8 ± 19.9% van die GDR bereik. Nie voedings-verwante energie bronne (NVEB), meestal vanaf koolhidraat-bevattende IV vloeistowwe, het 10.1 ± 7.5% tot totale energie inname (TEI) bygedra (156kKal/d). Die gemiddelde kumulatiewe energie en proteiën balans was -674.0 ± 1866.1kKal en -86.0 ± 106.9g onderskeidelik. Die meerderheid (73%) het >90% van die minimum energie doelwit (ED) bereik. Slegs 49% het >90% van die minimum proteiën doelwit (PD) bereik. Opsomming: Die kristalloiëd en kolloiëd van keuse vir IVT is GEO en hipertoniese LMG 130/0.4kD HES onderskeidelik. Kalium soute word mees algemeen voorgeskryf. NVEB dra beduidend by tot TEI en moet inaggeneem word tydens die berekening van voedingsvoorskrifte ten einde oorvoeding te voorkom. Vroeë inisiëring van EV met konvensionele energie-ryke EV produkte is onvoldoende om genoegsame proteiën inname te verseker. EV produkte met ‘n gunstiger stikstof tot nie-proteiën energie verhouding sal help om proteiën inname gedurende die eerste week van intensiewe sorg te optimaliseer.Slegs 59% van pasiënte met genoegsame energie inname (90-110% van ED) het hul minimum PD bereik. Daar was ‘n beduidende negatiewe korrelasie tussen kumulatiewe energie/proteiën balans en die tyd tot inisiëring van VT (energie: r=-0.28, p=0.02; proteiën: r=-0.32, p= 0.01).

Bakgrund: Runt om i världen och på svenska sjukhus och , överrapporteras dagligen flertaletpostoperativa patienter mellan anestesi-och intensivvårdssjuksköterskor. Vad somkommunicerats har stor betydelse för patienternas fortsatta vård och sjuksköterskornasupplevelse av överrapportering. Bristande överrapportering kan få konsekvenser som sämrevårdkvalité och ökad risk för komplikationer för patienterna. Syfte: Att beskriva anestesi-ochintensivvårdssjuksköterskors upplevelser av överrapportering av postoperativa patienter. Metod:Intervjuer genomfördes i form av fokusgrupper, en med anestesisjuksköterskor och en medintensivvårdssjuksköterskor. Materialet analyserades enligt kvalitativ innehållsanalys. Resultat:Fem huvudkategorier: Behov av att dubbelkolla och dubbeldokumentera, att inte veta vilkeninformation som är relevant och sakna förståelse för varandra, att den postoperativaavdelningen är rörig och orsakar störningar i överrapportering, attoperationssjuksköterskornas överrapportering är viktig och behov av att överrapportera vidpatienterna och upprätthålla fullständig sekretess. Slutsats: Tydliga rutiner behövs gällande vadpostoperativ överrapportering ska innehålla, samt utveckling av samarbete mellan de som deltar iöverrapportering. Behov av att kunna genomföra överrapportering vid patienterna men ändåupprätthålla sekretess var ett komplext område. Operationssjuksköterskans deltagande iöverrapportering var ett av de största förbättringsområden som framkom denna studie.

Estudo transversal realizado em um hospital universitário de grande porte do sul do Brasil com o objetivo geral de analisar associações entre os discriminadores dos fluxogramas do Sistema de Triagem de Manchester (STM) e os Diagnósticos de Enfermagem (DE) segundo a taxonomia da NANDA-I em pacientes adultos de uma emergência clínica com prioridade clínica I (emergência) e II (muito urgente). Os objetivos específicos foram identificar as principais queixas, fluxogramas e discriminadores do STM e os DE mais frequentes. A amostra foi constituída de 219 pacientes, sendo 66 com prioridade clínica I e 153 com prioridade clínica II. A coleta de dados foi realizada no prontuário online dos pacientes. A análise estatística foi realizada pelo Statistical Package for Social Sciences (SPSS), versão 21.0, com uso do teste exato de Fisher ou qui-quadrado e o modelo de regressão de Poisson para estimar a razão de prevalência (RP). O estudo foi aprovado pelo Comitê de Ética e Pesquisa sob o n° 140145. Os resultados demonstraram como principais queixas dos pacientes a dispneia e a dor. Foi identificado o uso de 14 diferentes fluxogramas do STM, sendo os mais frequentes Dispneia em adulto, Mal estar em adulto e Dor torácica, seguidos de 16 diferentes discriminadores, sendo os mais prevalentes Dor precordial ou cardíaca, Saturação de oxigênio (Sat O2) muito baixa, Respiração inadequada, Pulso anormal e Déficit neurológico agudo. Entre os 14 diferentes DEs reais identificados, os mais prevalentes foram Padrão respiratório ineficaz e Dor aguda. Entre os nove diferentes DEs de risco identificados, os mais prevalentes foram Risco de perfusão tissular cerebral ineficaz, Risco de quedas e Risco de Glicemia instável. Houve associação estatisticamente significativa entre os discriminadores Dor precordial ou cardíaca e Dor intensa com o DE Dor Aguda (p < 0,001). O discriminador Dor precordial ou cardíaca também apresentou associação significativa com o DE Conforto Prejudicado (p = 0,008). Os discriminadores Sat O2 muito baixa e Respiração inadequada associaram-se significativamente ao DE Padrão respiratório ineficaz (p < 0,001). Pulso anormal apresentou associação significativa com o DE Débito cardíaco diminuído (p = 0,030), assim como Déficit neurológico agudo (p < 0,001) e Alteração súbita da consciência (p = 0,024) com o DE Negligência unilateral. Entre os diagnósticos de risco, os discriminadores Déficit neurológico agudo (p < 0,001) e Convulsionando (p = 0,009) associaram-se significativamente ao DE Risco de perfusão tissular cerebral ineficaz, assim como Hipoglicemia associou-se significativamente ao DE Risco de glicemia instável (p < 0,001). O discriminador Convulsionando ainda associou-se ao DE Risco de quedas (p = 0,037). Conclui-se que as associações estatisticamente significativas encontradas entre os discriminadores do STM e os DE estabelecidos estão baseadas em uma adequada coleta de dados do paciente, embora estas sejam etapas executadas em momentos e com objetivos diferentes na emergência. Isso permite um julgamento clínico acurado, que subsidia os enfermeiros para a seleção rápida do cuidado a ser prestado na busca de melhores resultados, além de otimizar o tempo e organizar o trabalho na unidade, favorecendo a segurança do paciente. / Cross-sectional study conducted in a large teaching hospital in the South of Brazil with the overall objective of analyze associations between the discriminators of the Manchester Triage System flowcharts (MTS) and the Nursing Diagnoses (ND) according to the taxonomy of NANDA-I in adult patients of an emergency room with clinical priority I (immediate) and II (very urgent). The specific objectives were to identify the main complaints, flowcharts and discriminators of the MTS and the most frequent ND. The sample was composed of 219 patients, being 66 with clinical priority I and 153 with clinical priority II. Data were collected in online patients’ records. A statistical analysis was performed by the Statistical Package for Social Sciences (SPSS), version 21.0, with the use of chi-square or Fisher’s exact test and Poisson regression model to estimate the prevalence ratio (PR). The study was approved by the Ethics and Research Committee under the number 140145. The results showed that the main complaints reported by the patients were dyspnea and chest pain. It was identified the use of 14 different flowcharts of the MTS, being the most frequent Dyspnea in adults, Illness in adults and Chest pain, followed by 16 different discriminators, being the most prevalent Precordial chest pain, very low Oxygen saturation (O2 Sat), Inadequate breathing, Abnormal pulse and Acute neurological deficit. Among the 14 different ND which were identified, the most prevalent ones were Ineffective breathing pattern and Acute pain. Among the nine different ND of risk which were identified, the most prevalent were Risk for ineffective cerebral tissue perfusion, Risk for falls and Risk for unstable glycemia. There was statistically significant association between Precordial chest pain and Intense pain with ND of Acute Pain (p < 0,001). The discriminator Precordial chest pain has also showed significant association with Impaired comfort (p = 0,008). The discriminator very low O2 Sat and Inadequate breathing associated significantly with Ineffective breathing pattern (p < 0,001). Abnormal pulse showed significant association with Decreased cardiac deficit (p = 0,030) as well as Acute neurological deficit (p < 0,001) and Sudden change of consciousness (p = 0,024) with Unilateral neglect. Among risk diagnoses, the discriminator Acute neurological deficit (p < 0,001) and Seizuring (p = 0,009) were significantly associated with Risk for ineffective cerebral tissue perfusion as well as Hypoglycemia was significantly associated with Risk for unstable glycemia (p < 0,001). The discriminator Seizuring was also associated with Risk for falls (p = 0,037). It is concluded that statistically significant associations between the discriminators of the MTS and the established ND are based on an appropriate patient data collection even though they are steps performed in different moments and with different goals in emergency rooms. This allows an accurate clinical evaluation and that subsidizes the nurses for quick selection of care to be provided in the search for better results, besides optimizing time and organizing the work in the unit, promoting patients’ safety. / Estudio transversal realizado en un hospital universitario de gran porte del sur de Brasil con el objetivo general de analizar asociaciones entre los discernidores de los diagramas de flujo del Sistema Triaje de Manchester (STM) y los Diagnósticos de Enfermería (DE) según la taxonomía de NANDA-I en pacientes adultos de una emergencia clínica con prioridad clínica I (emergencia) y II (muy urgente). Los objetivos específicos fueron identificar las principales quejas, diagramas de flujo y discernidores del STM y los DE más frecuentes. La muestra fue constituída por 219 pacientes, siendo 66 con prioridad clínica I y 153 con prioridad clínica II. La colecta de datos fue realizada en el prontuario online de los pacientes. El análisis estadístico fue realizado por el Statistical Package for Social Sciences (SPSS), versión 21.0, con el uso del Test Exacto de Fisher o chi-cuadrado y el modelo de regresión de Poisson para estimar la razón de la prevalencia (RP). El estudio fue aprobado por el Comité de Ética y Pesquisa con el número 140145. Los resultados demostraron como principales quejas de los pacientes, la disnea y el dolor. Fue identificado el uso de 14 diagramas de flujo diferentes del STM, siendo los más frecuente Disnea en adultos, Malestar en adultos y Dolor toráxica, seguidos por 16 diferentes discernidores, siendo los más prevalentes el Dolor precordial o cardíaco, la Saturación de oxígeno (SAT O2) muy baja, la Respiración inadecuada, el Pulso anormal y el Déficit neurológico agudo. Entre los 14 diferentes DEs reales identificados, los más prevalentes fueron el Patrón respiratorio ineficaz y el Dolor agudo. Entre los nueve diferentes DEs de riesgo identificados, los más prevalentes fueron el Riesgo de perfusión tisular cerebral ineficaz, el Riesgo de caídas y el de Glicemia inestable. Hubo una asociación estadísticamente significativa entre los discernidores Dolor precordial o cardíaca y Dolor intenso, con DE Dolor agudo (p < 0,001). El discernidor Dolor precordial o cardíaco también presentó asociación significativa con DE Confort perjudicado (p = 0,008). Los discernidores SAT O2 muy baja y Respiración inadecuada se asociaron significativamente con el DE Patrón respiratorio ineficaz (p < 0,001). El Pulso anormal presentó asociación significativa con el DE Débito cardíaco disminuído (p = 0,030), así como el Déficit neurológico agudo (p < 0,001) y la Alteración súbita de conciencia (p = 0,024) con el DE Negligencia unilateral. Entre los diagnósticos de riesgo, los discernidores Déficit neurológico agudo (p <0,001) y Convulsionando (p = 0,009), se asociaron significativamente al DE Riesgo de perfusión tisular cerebral ineficaz, así como Hipoglicemia se asoció significativamente al DE Riesgo de glicemia inestable (p < 0,001). El discernidor Convulsionando aún se asoció al DE Riesgo de caídas (p = 0,037). Se concluye que las asociaciones estadísticamente significativas encontradas entre los discernidores del STM y los DE establecidos están basadas en una adecuada colecta de datos del paciente a pesar de ser etapas ejecutadas en momentos y con objetivos diferentes en la emergencia. Esto es lo que permite un juicio crítico acurado y que subsidia a los enfermeros para la selección rápida del cuidado que será proporcionado en la búsqueda de mejores resultados, además de optimizar el tiempo y organizar el trabajo en la unidad, favoreciendo la seguridad del paciente.

In-patient deterioration is a global phenomena and timely recognition and action improves outcome. Intensive care facilities are scarce and expensive and therefore patient care must be optimal. A retrospective health record analysis was used for this study. The findings indicated that nursing personnel do not recognize patient deterioration timeuously. However, the implementation of an outreach team and clinical markers training program improved the recognition of patient deterioration in general wards with three hours and 40 minutes. It is recommended to implement a comprehensive hospital program that addresses the basic knowledge and skills of general ward personnel to observe, recognize, assess and intervene to patients with clinical deterioration. Together with an extensive training program, a basic physiological parameters guideline to activate a team of experts to the bedside, such as an Outreach team, assist nursing personnel to recognize and manage those patients timeuously and ensure treatment in an appropriate level of care. / Health Studies / M. A. (Health studies)

Made available in DSpace on 2015-05-08T14:47:53Z (GMT). No. of bitstreams: 1 arquivototal.pdf: 2491613 bytes, checksum: 35174a214f0ba089cebe18cb7b0d87fe (MD5) Previous issue date: 2010-12-13 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Introduction: The intensive nursing care constitutes a continuous improvement process taking into account the magnitude and the complexity of clinical decisions that the nurses are led to take, in regard to the daily practice of taking care of ill people, in a highly unstable clinical course, with a high life risk and in health conditions subject to frequent variations. Nevertheless, the nurses involved in the specialized assistance do need to have in mind that, in the caring process, the high level of technological incorporation existent in the ICU can never overshadow the real focus of their actions and attention: the client in a critical state, to whom care should be provided. Objectives: To construct an instrument of nursing data collection for adult clients hospitalized in the General ICU of the HULW/UFPB, based on Horta´s Theory of Basic Human Needs; and to validate the instrument content with assistant nurses and professors who act in the area. Methodology: It is a methodological research developed in the General ICU of the Intensive Therapy Center of the University Hospital Lauro Wanderley (HULW), placed at Campus I of the Federal University of Paraíba, in the town of João Pessoa - PB, having as population and sample the assistant nurses and the professors of the Nursing in Emergency and ICU subject, of the Federal University of Paraíba (UFPB). Such research was developed in three phases: identification of the empirical indicators by means of a large bibliographical survey about the basic human needs in hospitalized adults in units for critical care; validation of the empirical indicators and the preliminary version arrangement of the data collection instrument; apparent and content validation with a posterior arrangement of the instrument final version of nursing data collection. Results: A number of 545 empirical indicators were identified, being 451 of them related to the psychobiological needs, 88 indicators pertaining to psychosocial needs and 06 of them refer to psychospiritual needs. From this total of indicators identified in literature and analyzed by the nurses, 179 remained with IC ≥ 0.80, being 164 related to the psychobiological needs and 15 referring to the psychosocial needs. After the construction and arrangement of the preliminary version of the data collection instrument with a posterior validation of appearance and content, the final version of data collection instrument was made up in four large domains, such as: Identification; Interview; Physical Test; and Nurses´ Impressions and Intercurrences. Final comments: It is believed that this Nursing History will allow a closer contact and a better interpersonal relationship among nurses, clients and families; it will reveal the systematization imperativeness of the nursing assistance as concerns care quality; it will prompt new researches which focus on Nursing tools as well as it will incite their agents to adopt more and more suitable practices for specific clients, and to accomplish the Nursing Process in all its essence and conjuncture. / Introdução: O cuidado de enfermagem intensivo se constitui em um contínuo processo de aperfeiçoamento, tendo em vista a magnitude e a complexidade das decisões clínicas que os enfermeiros são levados a tomar, diante da prática cotidiana de cuidar de pessoas doentes, em curso clínico altamente instável, com elevado risco de vida e em condições de saúde sujeitas às frequentes variações. Entretanto, os enfermeiros envolvidos na prestação de assistência especializada precisam ter em mente que, no processo do cuidar, o alto grau de incorporação tecnológica existente no ambiente da UTI jamais pode obscurecer o real foco das suas ações e atenções: o cliente em estado crítico, para quem se devem voltar os cuidados prestados. Objetivos: Construir um instrumento de coleta de dados de enfermagem para clientes adultos hospitalizados na UTI Geral do HULW/UFPB, fundamentado na Teoria das Necessidades Humanas Básicas de Horta; e validar o conteúdo do instrumento com enfermeiros assistenciais e docentes que atuam na área. Metodologia: Trata-se de uma pesquisa metodológica desenvolvida na UTI Geral do Centro de Terapia Intensiva do Hospital Universitário Lauro Wanderley (HULW), localizado no Campus I da Universidade Federal da Paraíba, no município de João Pessoa - PB, tendo como população e amostra os enfermeiros assistenciais e as docentes da disciplina Enfermagem em Emergência e UTI da Universidade Federal da Paraíba (UFPB). Foi desenvolvida em três fases: identificação dos indicadores empíricos por meio de um amplo levantamento bibliográfico sobre as necessidades humanas básicas em adultos hospitalizados em unidades de cuidados críticos; validação dos indicadores empíricos e formatação da versão preliminar do instrumento de coleta de dados; validação aparente e de conteúdo com posterior formatação da versão final do instrumento de coleta de dados de enfermagem. Resultados: Foram identificados 545 indicadores empíricos, sendo que 451 são indicadores das necessidades psicobiológicas, 88 pertencentes às necessidades psicossociais e 06 indicadores à necessidade psicoespiritual. Desse total de indicadores identificados na literatura e analisados pelos enfermeiros, 179 permaneceram com IC ≥ 0.80, estando 164 nas necessidades psicobiológicas e 15 nas necessidades psicossociais. Após a construção e formatação da versão preliminar do instrumento de coleta de dados com posterior validação de aparência e conteúdo, a versão final do instrumento de coleta de dados elaborada ficou estruturada em quatro grandes domínios, assim distribuído: Identificação; Entrevista; Exame Físico; e Impressões do Enfermeiro e Intercorrências. Considerações finais: Acredita-se que este Histórico de Enfermagem permitirá maior aproximação e melhor relacionamento interpessoal entre enfermeiros, clientes e familiares; divulgará a imperatividade da sistematização da assistência de enfermagem na qualidade do cuidado; suscitará novas pesquisas que trabalhem com ferramentas próprias da Enfermagem; bem como instigará seus agentes a adotar práticas cada vez mais adequadas para clientes específicos, e a realizar o Processo de Enfermagem em toda a sua essência e conjuntura.