ABSTRACT  Background: ICU diaries are initiated by critical care nurses to document events that take place during patients’ ICU stays with the aim to help patients recall memories of what happened. The relationship dimension in the Fundamentals of Care (FoC) framework begins with the ability of nurses to connect with patients, and through this connection, nurses try to meet and help the patient to meet his/her fundamental needs. The role of ICU diaries in establishing a nurse-patient relationship is unknown. Aim: The aim of the study was to examine the use of the ICU diary as a tool to strengthen nurse-patient relationships.  Method: A literature review with inductive content analysis of 20 primary articles. The results were interpreted and discussed using the establishing relationship dimension of the FoC framework. Findings: The statements of patients and nurses about the use of diaries reflect a strong nurse-patient relationship dimension. When combined with ICU follow-up sessions, the relationship is further strengthened, as there is more understanding and knowledge of the bond retrospectively. Conclusion: All elements of the FoC establishing relationship dimension, namely focus, knowing, trusting, anticipating and evaluating are visible in the diaries, and several statements by nurses suggest that using the diaries may have a positive effect on the nurse-patient relationship. However, to what extent the nurse-patient relationship is strengthened by the use of the diaries is less clear and remains an open question. To answer this question, controlled comparative studies would be required. / SAMMANFATTNING Bakgrund: IVA-dagböcker initieras av intensivvårdssjuksköterskor för att dokumentera vad som händer under en patients IVA-vistelse, med syftet att hjälpa patienter att senare komma ihåg vad de varit med om. Dimensionen etablera vårdrelation i ramverket Fundamentals of Care (FoC) börjar med sjuksköterskors förmåga att anknyta till patienter, och genom denna anknytning försöker sjuksköterskorna att möta och hjälpa patienten för att tillfredsställa dennes fundamentala behov. Det är inte känt vilken roll IVA-dagbok spelar i att etablera en vårdrelation mellan sjuksköterska och patient. Syfte: Studiens syfte var att undersöka användning av IVA-dagbok som ett verktyg för att stärka vårdrelation mellan sjuksköterska och patient. Metod: Litteraturöversikt med induktiv innehållsanalys av 20 originalartiklar. Resultaten tolkades och diskuterades inom ramen för FoC-dimensionen etablera vårdrelation. Resultat: Det patienter och sjuksköterskor säger om användning av IVA-dagbok ger uttryck för en stark vårdrelation. När dagboken efter att patienten skrivits ut används vid uppföljning på IVA stärks denna relation ytterligare, eftersom uppföljningen leder till att patienten får en fördjupad förståelse och kunskap om den vårdrelation som etablerats under vistelsen på IVA. Slutsats: Alla element i FoC-dimensionen etablera vårdrelation (vara närvarande, vara påläst, skapa förtroende, förutse behov, reflektera och utvärdera) är synliga i det patienter och sjuksköterskor säger om dagbok. Utsagor från flera sjuksköterskor tyder på att användning av IVA-dagbok kan ha en positiv effekt på vårdrelationen, men i vilken utsträckning dagboken stärker relationen är mindre klart och fortsätter att vara en öppen fråga. För att besvara denna fråga skulle kontrollerade jämförande studier behövas.

Trycksår är en vårdskada och uppkommer av långvarigt tryck utav utrustning eller benutskott. På barnintensivvårdsavdelning vårdas barn med observerbar svikt i minst ett organ, dessa barn har stor risk att utveckla trycksår. Patricia Benners omvårdnadsteori är teoretisk referensram för studien. Syftet med studien var att beskriva sjuksköterskans trycksårsförebyggande åtgärder för barn som vårdas på barnintensivvårdsavdelning. En systematisk litteratursökning genomfördes i tre databaser. Sökningen genererade elva resultatartiklar. Resultatet presenteras i tre kategorier: följa rutiner och riktlinjer, identifierade trycksårsrisker för patienter på avdelningar som bedriver barnintensivvård samt omvårdnadshandlingar och hjälpmedel. Resultatet påvisade att många trycksårs fall går att förebygga med rutiner, utbildning samt hjälpmedel. Barn med massiv svikt kunde vara så ostabila att trycksårsförebyggande åtgärder var omöjliga. Personal samt verksamhet kan med fördel implementera de evidensbaserade trycksårsförebyggande åtgärderna men fortsatt forskning utav utbredningen av trycksår på barnintensivvårdsavdelning i Sverige kan behöva genomföras. / Pressure ulcer is an injury caused by hospitalizations when sustained pressure over bony prominence or devices for a prolonged period of time pressure ulcer may appear. Critically ill infants and children admitted to the pediatric intensive care unit (PICU) are at risk of developing pressure ulcer. Patricia Benner’s nursing theory is used as theoretical guideline for this study. The aim of this study was to describe preventing measures against pressure ulcers performed by nurses for infants and children admitted at PICU.  A systematic literature review was conducted and three databases resulting in eleven articles. The result was presented in three categories: follow routines and guidelines, identify associated risk factors for pressure ulcer on patients in the PICU and also practical nursing and tools. The result of this study showed that pressure ulcer can be prevented with guidelines, education and tools. For some patients in the PICU pressure ulcer could not be prevented due to their clinical instability. Hospital staff and board should implement evidence basted pressure ulcer prevention measures. Further research concerning Swedish practice could be needed.

SAMMANFATTNING   Bakgrund: Tidigare studier visar att patienter påverkas både fysiskt och psykiskt vid överflyttning från en miljö till en annan. Att överflyttas från den specialiserade, högteknologiska intensivvårdsavdelningen till en vårdavdelning kan skapa upplevelser och känslor av stress, oro, ångest, osäkerhet, depression, sömnstörningar, minnesbortfall, mardrömmar med mera. Syfte: Att utforska hur miljöns utformning för vårdandet påverkar patientens välbefinnande efter överflyttning från intensivvårdsavdelning till kirurgisk vårdavdelning. Metod: Syftet besvarades med hjälp av upprepade observationer med informella intervjuer av tre patienter som hade vårdats på en intensivvårdsavdelning och hade överflyttats till en kirurgisk vårdavdelning. Deduktiv innehållsanalys användes och utgick från en tidigare skapad modell av begreppet miljö. Resultat: Patienternas välbefinnande påverkades av miljön efter överflytten till den kirurgiska vårdavdelningen. Resultatet presenteras efter modellens kategorier atmosfär, omvärld, omgivning, medelpunkt och förhållande. Slutsats: Att överflyttas till en lägre vårdnivå som en vårdavdelning är en stor omställning för patienterna både fysiskt och psykiskt. Resultatet stödjer att det finns en kunskapslucka som består av skillnader i miljön, skillnader i sjuksköterskors kompetens och skillnader i kommunikationen mellan intensivvårdsavdelningar och vårdavdelningar. Det är viktigt att tydliga rutiner finns kring hur en intensivvårdspatient ska tas emot och vårdas vid överflyttningen till en vårdavdelning. För att miljöombytet inte ska bli för omfattande för patienten kan överflyttning först ske till en intermediärvårdsavdelning innan vidare överflyttning till en vårdavdelning sker. / ABSTRACT Background: Previous studies showed that patients are affected both physically and mentally when they transferring from one environment to another. To be transferred from the specialized, high-tech intensive care to a ward can create experiences and feelings of stress, worry, anxiety, insecurity, depression, sleep disorders, memory loss, and nightmares with more. Aim: The aim of this study was to explore how environmental design for care affects the patient's well-being after transfer from intensive care to the surgical ward. Method: The aim was answered with help from repeated observations with informal interviews with three patients who had been treated in an intensive care unit and had been transferred to a surgical ward. Deductive content analysis was used and was based on a previously created model. Result: The patients' well-being was affected by the environment after transfer to the surgical ward. The results are presented according to the categories atmosphere, entourage, surroundings, midpoint and relationship. Conclusion: Be transferred to a lower level of care as a ward is a big change for the patients both physically and psychologically. The result supports that there is a knowledge gap which consist of differences in the environment, differences in nurses' skills and differences in communication between intensive care units and wards. It is important that there are clear procedures on how an intensive care patient to be received and cared for at the transfer to a ward. To move from one environment to another should not be too extensive for the patient can first be transfer place to an Intermediate Care Facility before further transfer to a ward occurs.

Bakgrund: År 2012 skapades Sveriges första nationella program och kunskapsstöd för palliativ vård. Den palliativa vården finns beskriven av Socialstyrelsen utifrån fyra hörnstenar, symtomlindring, multiprofessionellt samarbete, stöd till anhöriga samt kommunikation och relation. Det är oftast sjuksköterskan som identifierar behovet av palliation, men läkaren är den som fattar beslutet om palliation ska påbörjas. Detta kan vara en lång process och orsaka barnet onödigt lidande. Syfte: Att beskriva sjuksköterskans erfarenheter av att avsluta livsuppehållande behandling för att övergå till palliativ vård på barnintensiven. Metod: Studien genomfördes som en kvalitativ intervjustudie. Sex individuella semistrukturerade intervjuer med utbildade intensivvårdssjuksköterskor på en barnintensivvårdsavdelning i Sverige genomfördes. Dessa analyserades med utgångspunkt från Elo och Kygnäs metod för kvalitativ innehållsanalys och utmynnade i tre huvudkategorier. Resultat: Sjuksköterskornas erfarenheter av att avbryta livsuppehållande vård för att övergå till palliativ vård presenterades i resultatet utifrån tre huvudkategorier, Det oåterkalleliga livet, Sista tiden av livet samt Vad kan sjuksköterskan göra för anhöriga?. Slutsats: Att avbryta livsuppehållande vård för att övergå till palliativ vård är ett komplext och etiskt svårt beslut. / Background: In 2012 Sweden created its first natinal program and knowledge base for palliative care. Palliative care is described by the Swedish National Board through four bases, symptom relifes, multi-professional cooperation, support to relatives, and communication and relationship. It is usually the nurse that identifies the need for palliation, but the doctor is the one that makes the decision to begin palliative care. This can be a long process and cause the child unnecessary suffering. Aim: To describe the intensive care nurses experiences in ending life support and the transition to palliative care of children intensive care. Method: The study was conducted as a qualitative interview study. Six individual semi-structured interviews with intensive care nurses at a childrens intensive care unit in Sweden was carried out . These interviews were analyzed on the basis of Elo and Kygnäs method of qualitative content analysis and resulted in three main categories. Result: The nurses' experiences of withdrawing lifesustaining treatment and the transition to palliative care was presented in the result within three main categories, ”The irrevocable life”, ”The end of life” and ”What can the nurse do for the family?”. Conclusion: To discontinue life-sustaining care and transition to palliative care is a complex and difficult ethical decision.

Critically ill patients admitted to the intensive care unit (ICU) commonly develop severe muscle wasting and weakness and consequently impaired muscle function. This not only delays respirator weaning and ICU discharge, but has deleterious effects on morbidity, mortality, financial costs, and quality of life of survivors. Acute Quadriplegic Myopathy (AQM) is one of the most common neuromuscular disorders underlying ICU muscle wasting and paralysis, and is a consequence of modern intensive care interventions, although the exact causes remain unclear. Muscle gene/protein expression, intracellular signalling, post-translational modifications, muscle membrane excitability, and contractile properties at the single muscle fibre level were explored in order to unravel the mechanisms underlying the muscle wasting and weakness associated with AQM and how this can be counteracted by specific intervention strategies. A unique experimental rat ICU model was used to address the mechanistic and therapeutic aspects of this condition, allowing time-resolved studies for a period of two weeks. Subsequently, the findings obtained from this model were translated into a clinical study. The obtained results showed that the mechanical silencing of skeletal muscle, i.e., absence of external strain (weight bearing) and internal strain (myosin-actin activation) due to the pharmacological paralysis or sedation associated with the ICU intervention, is likely to be the primary mechanism triggering the preferential myosin loss and muscle wasting, features specifically characteristic of AQM. Moreover, mechanical silencing induces a specific gene expression pattern as well as post-translational modifications in the motor domain of myosin that may be critical for both function and for triggering proteolysis. The higher nNOS expression found in the ICU patients and its cytoplasmic dislocation are indicated as a probable mechanism underlying these highly specific modifications. This work also demonstrated that passive mechanical loading is able to attenuate the oxidative stress associated with the mechanical silencing and induces positive effects on muscle function, i.e., alleviates the loss of force-generating capacity that underlie the ICU intervention, supporting the importance of early physical therapy in immobilized, sedated, and mechanically ventilated ICU patients.

Cardiovascular disease is a large problem in the intensive care unit (ICU) due to its high prevalence in modern society. In the ICU, intensive monitoring is required to help diagnose cardiac and circulatory dysfunction. However, complex interactions between the patient, disease, and treatment can hide the underlying disorder. As a result, clinical staff must often rely on their skill, intuition, and experience to choose therapy, increasing variability in care and patient outcome. To simplify this clinical scenario, model-based methods have been created to track subject-specific disease and treatment dependent changes in patient condition, using only clinically available measurements. The approach has been tested in two pig studies on acute pulmonary embolism and septic shock and in a human study on surgical recovery from mitral valve replacement. The model-based method was able to track known pathophysiological changes in the subjects and identified key determinants of cardiovascular health such as cardiac preload, afterload, and contractility. These metrics, which can be otherwise difficult to determine clinically, can be used to help provide targets for goal-directed therapies to help provide deliver the optimal level of therapy to the patient. Hence, this model-based approach provides a feasible and potentially practical means of improving patient care in the ICU.

Critically ill patients often exhibit abnormal glycaemia that can lead to severe complications and potentially death. In critically ill adults, hyperglycaemia is a common problem that has been associated with increased morbidity and mortality. In contrast, critically ill infants often suffer from hypoglycaemia, which may cause seizures and permanent brain injury. Further complicating the matter, both of these conditions are diagnosed by blood glucose (BG) measurements, often taken several hours apart, and, as a result, these conditions can remain poorly managed or go completely undetected. Emerging ‘continuous’ glucose monitoring (CGM) devices with 1-5 minute measurement intervals have the potential to resolve many issues associated with conventional intermittent BG monitoring. The objective of this research was to investigate and develop methods and models to optimise the clinical use of CGM devices in critically ill patients. For critically ill adults, an in-silico study was conducted to quantify the potential benefits of introducing CGM devices into the intensive care unit (ICU). Mathematical models of CGM error characteristics were implemented with existing, clinically validated, models of the insulin-glucose regulatory system, to simulate the behaviour of CGM devices in critically ill patients. An alarm algorithm was also incorporated to provide a warning at the onset of predicted hypoglycaemia, allowing a virtual dextrose intervention to be administered as a preventative measure. The results of the in-silico study showed a potential reduction in nurse workload of approximately 75% and a significant reduction in hypoglycaemia, while also providing insight into the optimal rescue dose size and resulting dynamics of glucose recovery. During 2012, ten patients were recruited into a pilot clinical trial of CGM devices in critical care with a primary goal of assessing the reliability of CGM devices in this environment, with a specific interest in the effects of CGM device type and sensor site on sensor glucose (SG) data. Results showed the mean absolute relative difference of SG data across the cohort was between 12-24% and CGM devices were capable of monitoring some patients with a high degree of accuracy. However, certain illnesses, drugs and therapies can potentially affect sensor performance, and one particular set of results suggested severe oedema may have affected sensor performance. A novel and first of its kind metric, the Trend Compass was developed and used to assesses trend accuracy of SG in a mathematically precise fashion without approximation, and, importantly, does so independent of glucose level or sensor bias, unlike any other such metrics. In this analysis, the trend accuracy between CGM devices was typically good. A recent hypothesis suggesting that glucose complexity is associated with mortality was also investigated using the clinical CGM data. The results showed that complexity results from detrended fluctuation analysis (DFA) were influenced far more by CGM device type than patient outcome. In addition, the location of CGM sensors had no significant effect on complexity results in this data set. Thus, while this emerging analytical method has shown positive results in the literature, this analysis indicates that those results may be misleading given the impact of technology outweighing that of physiology. This particular result helps to further delineate the range of potential applications and insight that CGM devices might offer in this clinical scenario. In critically ill infants, CGM devices were used to investigate hypoglycaemia during the first 48 hours after birth. More than 50 CGM data sets were obtained from several studies of CGM in infants at risk of hypoglycaemia at the Waikato hospital neonatal ICU (NICU). In light of concerns regarding CGM accuracy, particularly during the first few hours of monitoring and/or at low BG levels, an alternative, novel calibration scheme was developed to increase the reliability of SG data. The recalibration algorithm maximised the value of very accurate calibration BG measurements from a blood gas analyser (BGA), by forcing SG data to pass through these calibration BG measurements. Recalibration increased all metrics of hypoglycaemia (number, duration, severity and hypoglycaemic index) as the factory CGM calibration was found to be reporting higher values at low BG levels due to its least squares calibration approach based on the assumption of a less accurate calibration glucose meter. Thus, this research defined new calibration methods to directly optimise the use of CGM devices in this clinical environment, where accurate reference BG measurements are available. Furthermore, this work showed that metrics such as duration or area under curve were far more robust to error than the typically used counted-incidence metrics, indicating how clinical assessment may have to change when using these devices. The impact of errors in calibration measurements on metrics used to classify hypoglycaemia was also assessed. Across the cohort, measurement error, particularly measurement bias, had a larger effect on hypoglycaemia metrics than delays in entering calibration measurements. However, for patients with highly variable glycaemia, timing error can have a significantly larger impact on output SG data than measurement error. Unusual episodes of hypoglycaemia could be successfully identified using a stochastic model, based on kernel density estimation, providing another level of information to aid decision making when assessing hypoglycaemia. Using the developed algorithms/tools, with CGM data from 161 infants, the incidence of hypoglycaemia was assessed and compared to results determined using BG measurements alone. Results from BG measurements showed that ~17% of BG measurements identified hypoglycaemia and over 80% of episodes occurred in the first day after birth. However, with concurrent BG and SG data available, the SG data consistently identified hypoglycaemia at a higher rate suggesting the BG measurements were not capturing some episodes. Duration of hypoglycaemia in SG data varied from 0-10+%, but was typically in the range 4-6%. Hypoglycaemia occurred most frequently on the first day after birth and an optimal measurement protocol for at risk infants would likely involve CGM for the first week after birth with frequent intermittent BG measurements for the first day. Overall, CGM devices have the potential to increase the understanding of certain glycaemic abnormalities and aid in the diagnosis/treatment of other conditions in critically ill patients. This research has used a range of prospective and retrospective clinical studies to develop methods to further optimise the use of CGM devices within the critically ill clinical environment, as well as delineating where they are less useful or less robust. These latter results clearly define areas where clinical practice needs to adapt when using these devices, as well as areas where device makers could target technological improvements for best effect. Although further investigations are required before these devices are regularly implemented in day-to-day clinical practice, as an observational tool they are capable of providing useful information that is not currently available with conventional intermittent BG monitoring.

Uppmärksamhet och stöd till intensivvårdspatienters anhöriga kan ibland bli begränsad då sjuksköterskan ofta fokuserar på patientens behov och glömmer bort de anhöriga. Eftersom möten med anhöriga sker frekvent inom sjuksköterskeyrket är det därför viktigt att sjuksköterskan har insikt och förståelse för vad anhöriga upplever som stödjande. På en intensivvårdsavdelning är tillståndet hos patienten ofta kritiskt och de anhöriga behöver stöd för att hantera, förstå och anpassa sig till situationen. Syftet med den strukturerade litteraturstudien är att belysa anhörigas upplevelser av sjuksköterskans stöd inom intensivvård. Sammanlagt har 10 vetenskapliga artiklar såväl med kvalitativ och kvantitativ ansats analyserats tematiskt och analysen gav fyra kategorier, Tillit och förtroende, Närvaro och delaktighet, Tröst och empati samt Tillgänglighet och kontinuitet. Sammanfattningsvis finns det ett stort behov av att få stöd som anhörig. De anhöriga är i allmänhet nöjda med stödet de får av sjuksköterskan inom intensivvården men det behövs ytterligare forskning om vad för stöd som behövs samt hur stödet upplevs av de anhöriga. / The attention and support given to family members at the Intensive Care Unit can sometimes be limited due to that the nurses often focus on the patient's needs and forget about family members needs. Since nurses meet family members on a daily basis it is important for them to know what family members find supportive. The condition of patients at the intensive care unit is often critical and family members need support to cope, understand and adapt to the situation. The aim of the study was to highlight family members´ experiences of support from nurses at the intensive care unit. A structured literature review was conducted in which 10 articles with both qualitative and quantitative design underwent thematic analysis. The analysis gave four categories: Trust and reliance, Presence and participation, Comfort and empathy and Availability and continuity. To sum up; family members at the Intensive Care Unit have a great need of support. Family members are in general satisfied with the support, but there is need for more research in what kind of support they require and how family members experience the support.

Bakgrund:Att vara anhöriga till en person med psykisk sjukdom medför ofta en egen försämrad psykisk hälsa samt kan vara både tidskrävande och kostsamt. Känslor av skuld och skam samt stigmatisering från omvärlden är vanligt förekommande. Anhöriga önskar delaktighet i vården men exkluderas ofta. Det finns nationella riktlinjer och lagar som betonar vikten av anhörigas delaktighet, trots detta upplevs anhöriga ofta påträngande. De finns lite kunskap om anhörigas kontakt med psykiatriska intensivvårdsavdelningar. Syfte:Syftet med denna studie var att beskriva sjuksköterskors erfarenheter av möten med anhöriga på psykiatriska intensivvårdsavdelningar Metod:Studien har en kvalitativ design med induktiv ansats. Sju sjuksköterskor på psykiatriska intensivvårdsavdelningar i Sverige intervjuades enligt semistrukturerade metod. Materialet analyserades med kvalitativ innehållsanalys. Resultat:Resultatet från intervjuerna utmynnade i fyra kategorier: Organisatoriska förutsättningar för att möta anhöriga, Olika syn på anhöriga, Utmaningar i mötet med anhöriga samt Att möta och kommunicera med anhöriga. Diskussion:Resultatet i studien diskuteras i relation till tidigare forskning och Andersheds teori om Delaktighet i Ljuset – Delaktighet i mörkret. I resultatet framkom aspekter som kan tänkas leda till både delaktighet i ljuset och i mörkret. / Background: Being a relative to someone with mental disorder often causes a decreased mental health and can be both time-consuming and costly. Feelings of guilt and shame and stigmatization from the surroundings are common. Relatives’ wishes to participate in care but often get excluded. National guidelines and laws emphasize the importance of relatives’ participation; despite this relatives' often get perceived as intrusive. Little is known about relatives contact with psychiatric intensive care units. Aim: The aim of this study was to describe nurses’ experiences from meeting relatives at psychiatric intensive care units. Method: This study has a qualitative design with an inductive approach. Seven nurses at psychiatric intensive care units in Sweden were interviewed with semistructured method. The material was analyzed using a qualitative content analysis. Results: The result from the interviews developed into four categories: Organizational requirements to meet relatives, Different views on relatives, Challenges in the meeting with relatives, and To meet and communicate with relatives. Discussions: The result is being discussed in relation to previous research and Andershed's theory of Involvement in the light – Involvement in the dark. In the result aspects emerged that can lead to both participation in the light and in the darkness.

Class of 2012 Abstract / Specific Aims: The purpose of this study is to evaluate and compare clinical outcomes and cost involved with use of poractant versus beractant for the treatment of respiratory distress syndrome (RDS) in a level III, neonatal intensive care unit (NICU) within an academic medical center. Methods: This retrospective cohort study included patients if they were admitted to the NICU for RDS between April 1, 2010 to November 30, 2010 and December 1, 2010 to June 30, 2011 treated with beractant and poractant respectively. Patients were excluded from the study if they were greater than 35 weeks gestational age and survived less than 48 hours. This is a review and the information needed from the patients was submitted in a data extraction form. Data collected included demographic variables (age, birthweight, birth length, gender, and race/ ethnicity), FiO2 measurement, mechanical ventilation time, length of hospitalization in the NICU, the incidence complications in the first 28 days, number of doses given, use of the nasal CPAP, concurrent complications or comorbidites such as pulmonary hemorrhage, bronchopulmonary dysplasia, patent ductus arteriosis, intraventricular hemorrhage, and retinopathy of maturity. Main Results: Data from 27 neonates in beractant and 13 in poractant groups were collected. The FiO2 measurements in both groups were generally similar. However, FiO2 was consistently lower in the poractant group. (p = 0.044 from a runs statistical test) Conclusions: The FiO2 measurement is poractant group was lower compared with beractant group, however the difference was noted to be not statistically significant.