Ischemic stroke is the leading cause of disability world-wide and affects over 800,000 people per year in the United States. The majority of these strokes are ischemic due to a blockage of blood flow to the brain. Damage to the brain occurs at the onset of stroke, neuronal cell death is irreversible and therefore, quick treatment to remove blockage is critical factor in the recovery from stroke. Mechanical thrombectomy as a treatment for ischemic stroke provides an ideal opportunity to collect blood distal and proximal to the cerebral thrombus to examine neurochemical changes occurring during stroke. The purpose of this dissertation was to explore the trajectory of neurochemical changes that occur in response to ischemic stroke during the first 72 hours and the physiological response from stroke patients to improve stroke outcomes. The specific aims were to: 1) to determine whether venous blood gases predict infarct volume and/or mortality in acute ischemic stroke in young male rats; 2) determine whether venous blood gases predict infarct and edema volume, and/or mortality in acute ischemic stroke in aged male and female rats; 3) compare the presence and relative concentrations of acid/base and electrolytes in static blood distal to thrombus and in peripheral blood drawn from adults who received thrombectomy for ischemic stroke and identify associations to postreperfusion functional outcomes. Specific Aim One was addressed by evaluation of young (three-month old) Sprague-Dawley rats that underwent permanent or transient middle cerebral artery occlusion (MCAO). Pre- and post-MCAO venous samples from permanent and transient models provided pH, carbon dioxide, oxygen, bicarbonate, glucose, hematocrit, hematocrit, and electrolyte values of ionized calcium, potassium and sodium. The analyses indicated that mean differences in the blood gas and electrolytes between pre- to post-MCAO and pH and iCa2+ were predictors of infarct volume in the permanent MCAO model. The second aim was addressed by evaluation of aged (18 month old) male and female rats pre-MCAO, post-MCAO, and at 72 hours of permanent MCAO venous blood gas samples (pH, carbon dioxide, oxygen, bicarbonate, glucose, hematocrit, hematocrit, and electrolyte concentrations of ionized calcium, potassium and sodium). Changes in pH (from pre-MCAO to post-MACO and post-MCAO to 72 hours) and changes in Na+ and iCa2+ (from post-MCAO to 72 hours) were predictors of infarct volume and edema volume, respectively in both sexes. Cox regression revealed there was a 3.25 times increased risk for mortality based on changes (cut-off range within -2.00 to - 7.00) in bicarbonate levels (pre- to post-MCAO). The third aim was addressed by evaluation of acid/base balance (pH, carbon dioxide, oxygen, bicarbonate, ionized calcium, potassium and sodium) of ischemic stroke patients who underwent mechanical thrombectomy. Our results suggests sex differences matter in ischemic stroke populations. Significant differences occur within proximal blood between the sexes. Additionally, females had approximately 2.5 hour increased time between stroke symptom onset to thrombectomy completion time (described as infarct time). Changes in bicarbonate and base deficit were predictors of infarct time, but only in our female population.

Moral distress is a complex and challenging problem that may cause negative biopsycohosical and professional outcomes for critical care nurses. The purpose of this work was to explore the relationship between the ethical climate of the work environment and moral distress as experienced by critical care nurses; and to explore relationships among mediators of stress (nurse characteristics e.g. education (BSN, nonBSN), years certified as a critical care nurse, and tolerance of ambiguity) and their relationship with perceived stress, moral distress, health status and salivary alpha amylase. A descriptive correlational cross-sectional design was used for this pilot study of 100 critical care nurses working in adult intensive care units in one large academic medical center. Data were analyzed using descriptive statistics to characterize the sample and the model variables. Regression analysis using a stepwise regression model building technique was used to determine predictors of the study outcomes (moral distress, health status, and salivary alpha amylase). The findings demonstrate that the ethical characteristics of the work environment and perceived stress were predictive of moral distress, psychological/emotional outcomes and stress symptoms. Other variables thought to mediate these relationships were not significant. Future research is needed to find ways to prevent moral distress from occurring and to support nurses dealing with moral distress.

The purpose of the study was to identify NANDA - I diagnoses, NOC outcomes, and NIC interventions used in nursing care plans for ICU patient care and determine the factors which influenced the change of the NOC outcome scores. This study was a retrospective and descriptive study using clinical data extracted from the electronic patient records of a large acute care hospital in the Midwest. Frequency analysis, one-way ANOVA analysis, and multinomial logistic regression analysis were used to analyze the data. A total of 578 ICU patient records between March 25, 2010 and May 31, 2010 were used for the analysis. Eighty - one NANDA - I diagnoses, 79 NOC outcomes, and 90 NIC interventions were identified in the nursing care plans. Acute Pain - Pain Level - Pain Management was the most frequently used NNN linkage. The examined differences in each ICU provide knowledge about care plan sets that may be useful. When the NIC interventions and NOC outcomes used in the actual ICU nursing care plans were compared with core interventions and outcomes for critical care nursing suggested by experts, the core lists could be expanded. Several factors contributing to the change in the five common NOC outcome scores were identified: the number of NANDA - I diagnoses, ICU length of stay, gender, and ICU type. The results of this study provided valuable information for the knowledge development in ICU patient care. This study also demonstrated the usefulness of NANDA - I, NOC, and NIC used in nursing care plans of the EHR. The study shows that the use of these three terminologies encourages interoperability, and reuse of the data for quality improvement or effectiveness studies.

Bakgrund: Arbetet på en intensivvårdsavdelning ställer stora krav på de nyutbildade intensivvårdssjuksköterskornas kompetens. Den första tiden i yrket innebär att i socialiseringsprocessen förvärva de kunskaper och färdigheter som krävs i yrket. Nyutbildade intensivvårdssjuksköterskors kompetens anses inte motsvara vårdens kompetenskrav. Syfte: Syftet med studien var att beskriva nyutbildade intensivvårdsjuksköterskors uppfattningar om sin yrkeskompetens. Metod: Studien genomfördes med kvalitativ metod och intervjuer valdes som datainsamlingsmetod. Tio deltagare medverkade i studien. Intervjuerna analyserades efter en modifierad variant av Graneheim och Lundmans kvalitativa innehållsanalys. Resultat: I resultatet framkom två huvudkategorier. I den första huvudkategorin framkom att de nyutbildade intensivvårdsjuksköterskorna kontinuerligt utvecklade sin yrkeskompetens. Utvecklingen främjades av positiva attityder till yrket, användning av tidigare erfarenheter och kollegialt stöd. I den andra huvudkategorin framkom att de nyutbildade intensivvårdssjuksköterskorna uppfattade att de hade bristande kliniska erfarenheter, det var svårt att införliva sig med den nya yrkesrollen och det var svårt att prioritera. Slutsats: Nyutbildade intensivvårdssjuksköterskor är inte helt förberedda för det kommande yrket. De har goda teoretiska kunskaper men saknar färdigheter i de praktiska momenten. Resultatet bekräftas av tidigare studier och Benners beskrivning av vad som karakteriserar sjuksköterskan som novis. / Background: The work in a critical care unit is posing great demands on the newly graduated critical care nurses competence. During the first episode in the profession a process of socialization occurs, where the newly graduated acquire the knowledge and skills needed in the profession. The newly graduated critical care nurses competence is not considered to meet the caregiver’s demands. Purpose: The purpose of this study was to describe the newly graduated critical care nurses perceptions of their competence. Method: The study was conducted with a qualitative approach. Interviews were used as datacollection method. Ten participants were included in the study. Interviews were analyzed after a modified variant of Graneheim and Lundman’s qualitative content analysis. Results: The results revealed two main categories. The first major category revealed that the newly graduated critical care nurses continuously developed their skills. The development was promoted by positive attitudes to the work, use of past experiences and collaboration. The major second category revealed that the newly graduated critical care nurses perceived a lack of clinical experiences, difficulties to incorporate themselves with the new professional role and difficulties with priority. Conclusion: The newly graduated critical care nurses are not entirely prepared for the future profession. They have good theoretical knowledge but lack in practical skills. The result is confirmed by previous studies and Benner’s description of what characterizes the nurse as a novice.

The purpose of this dissertation was to evaluate outcomes associated with blood component (BC) transfusion in adult trauma patients. Specific aims were to: 1) explore the relationship between traumatic injury, hemorrhage, and BC transfusion, focusing on consequences of the component storage lesion through presentation of a conceptual model; 2) systematically review research literature comparing outcomes of massively transfused major trauma patients based on ratios of BCs received; 3) evaluating the relationship between type of blood transfusion trauma patients received (whole blood versus BCs) and mortality likelihood after controlling for demographic and clinical variables; 4) evaluating the relationship between volume and ratio of BCs transfused to trauma patients and development of inflammatory complications (ICs) after controlling for demographic and clinical variables. Specific aim one was addressed through the development of a conceptual model, depicting the current state of knowledge regarding the storage lesion, and short-/long-term outcomes of traumatic injury, hemorrhage, and blood transfusion. The second specific aim was addressed through a systematic review of studies that grouped critically injured, massively transfused patients based on ratios of BCs they received, and compared clinical outcomes among groups. Findings from this analysis revealed increased survival likelihood with massive transfusion of BCs in a 1:1:1 (packed red blood cells [PRBCs], fresh frozen plasma [FFP], platelets [PLTs]) fashion. The third specific aim involved a secondary analysis of the National Trauma Data Bank to evaluate the relationship between type of transfusion trauma patients received (whole blood versus BCs) and mortality. Patients who received BCs experienced a higher mortality likelihood compared with those who received whole blood. The fourth specific aim was addressed through a secondary analysis of the Inflammation and Host Response to Injury Trauma-Related Data Base, to evaluate the relationship between volume and ratio of BCs transfused and development of ICs in patients with major trauma. Findings revealed that total transfused volume of PRBCs, injury severity, and comorbidities were associated with development of ICs. There were no differences in time to complication between PRBCs:FFP or PRBCs:PLTs ratio groups.

The purpose of this research was to seek a deep understanding of the lived experience of intensive care nurses caring for patients with delirium. Delirium affects a large proportion of adult patients in the intensive care unit (ICU). Delirium has been linked to increased morbidity and mortality, longer intensive care and hospital length of stay, long-term cognitive impairments, short-term and long-term psychological distress, and increased hospital and health system costs. Critical care nurses play central roles in preventing, identifying, and treating ICU patients with delirium. Semi-structured interviews were conducted with eight intensive care nurses working in an ICU in a tertiary level, university-affiliated hospital in Ontario, Canada. The researcher analyzed the interviews using an interpretive phenomenological approach as described by van Manen (1990). The essence of the experience of critical care nurses caring for ICU patients with delirium was revealed to be finding a way to help them come through it. Six main themes emerged: It's Exhausting; Making a Picture of the Patient's Mental Status; Keeping Patients Safe: It's a Really Big Job; Everyone Is Unique; Riding It Out With Families; and Taking Every Experience With You. The findings describe how intensive care nurses find a way to help patients and their families through this complex and often distressing experience. This study has contributed to the understanding of the lived experience of ICU nurses caring for patients with delirium.

The purpose of this study was to describe critical care nurses' perceptions of their experiences with nursing quality assurance activities. Using an exploratory, descriptive design, data were collected in a survey, utilizing a self-administered questionnaire. A convenience sample of critical care nurses, who are members of the Canadian Association of Critical Care Nurses, was used. The results showed that these particular nurses knew what comprised the components of a nursing quality assurance program, however, their participation in these activities was low. In addition, the majority identified that the primary purpose of nursing quality assurance activities was to meet the accreditation requirements of the hospital. Finally, the results also identified that all of this particular group of nurses felt that nursing quality assurance activities involved them, and the majority felt that these activities were part of their professional responsibilities. / Applied Science, Faculty of / Nursing, School of / Graduate

Bakgrund: Barn behöver få information anpassad för sin ålder. Enligt barnkonventionen har barn rätt att säga sin åsikt och att bli hörda. Om barn får besöka en svårt sjuk familjemedlem kan det påverka den sjuke positivt genom att hen känner mer hopp. Även barn kan påverkas genom att de känner mindre hopplöshet och skuldkänslor. Syfte: Att undersöka hur intensivvårdssjuksköterskan bemöter barn som är anhörig på en intensivvårdsavdelning. Metod: En integrativ litteraturstudie, sökningar gjorda i PubMed och CINAHL. Resultat: Utifrån syftet identifierades tre huvudteman: stöd till barn som besöker, anpassa mötet efter barns behov och intensivvårdssjuksköterskans attityder till barn som anhörig. Sex studier ingår i resultatet, studierna är av kvantitativ, kvalitativ och mixad metod. Konklusion: Intensivvårdssjuksköterskan behöver i bemötandet av barn engagera och bekräfta barnet genom att se till barnets individuella behov. Det kan göras genom att i mötet med barn informera, visa och engagera. Intensivvårdssjuksköterskans attityd till att bemöta barn kan påverka barns möjligheter att få komma på besök. Det finns attityder som underlättar för barn att få komma på besök medan andra attityder kan hindra barn som besökare.

This is a quality improvement project that focuses on implementing screening for acute stress disorder using the Acute Stress Disorder Structured Interview–DSM-IV tool in a Trauma Intensive Care Unit (ICU) at a Level 2 Trauma Center in Nashville, TN. Currently, at this hospital there is not a screening process implemented for these patients. Every trauma patient meets the criteria for acute stress disorder. Starting the process early aims for patients to be properly educated about their trauma and gets them the resources they need to heal mentally from the trauma. During the 6-week implementation period of this project, the trauma performance investigator (TPI) team screens patients for acute stress disorder. The team records how many patients screened, how many patients were available to screen, if they screened positive with a 9 or greater score, if they received a “telepysch” visit, and if a referral card for mental health visit after discharge was given. From this information, it will be determined how to continue to improve the implementation process. Information gathered data by the TPI will be recorded in Excel spreadsheets. The ASD screening tool scores will be used to compare the mechanism of injury to the score to determine if a correlation exists. Some patients that do not screen positive still want a referral card due to the education provided during the screening process. This shows the continued need for patient screening and education about acute stress disorder for this patient population.

Acute and critical care patients experience significantly more pain than those patients on a general nursing unit. Due to the severity of their condition, acute care patients may be nonverbal and unable to self-report their pain. Behavioral pain assessment tools are a method of objectively measuring pain in patients who are unable to communicate. While the use of these tools has been shown to improve short- and long-term outcome for patients, there is a paucity of evidence as to nurses' perceptions related to their use. The purpose of this study is to investigate acute care nurses' perceptions of the relationship between the use of behavioral pain assessment tools and pain outcomes in nonverbal patients. A survey was developed to determine the perception of this relationship. A total of 23 acute and critical care nurses participated. The survey asked multiple perception-based questions related to pain assessment and management in nonverbal patients including but not limited to, the importance of pain assessment, the frequency of use of behavioral pain assessment tools, the use of pain scores in patient hand-off, and education related to behavioral pain assessment tools. Open ended questions were also posed inquiring as to participants perceptions of the effect of using behavioral pain assessment tools on pain assessment and pain outcomes. Survey results showed a majority (82.6%, n=19) of participants think the use of behavioral pain assessment tools improves pain assessment and outcomes. Participants reported they perceive the use of these tools allows for a thorough standardized assessment which allows for the objective evaluation of pain outcomes, and ultimately, effective pain relief.