Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2018-10-10T10:11:41Z No. of bitstreams: 1 Bruno Benndorf Mangolini.pdf: 694533 bytes, checksum: a5bb7db9ef942ef5e9d99efc7b5a1f57 (MD5) / Made available in DSpace on 2018-10-10T10:11:41Z (GMT). No. of bitstreams: 1 Bruno Benndorf Mangolini.pdf: 694533 bytes, checksum: a5bb7db9ef942ef5e9d99efc7b5a1f57 (MD5) Previous issue date: 2018-09-05 / Conselho Nacional de Pesquisa e Desenvolvimento Científico e Tecnológico - CNPq / This paper presents a case that was treated at a Psychosocial Care Center in the city of São Paulo. The study raises pertinent questions to the clinical point of view, considering the challenge of acting in cases of delusional patients. The case is presented since his arrival at the institution, when referral information was initially discussed in psychiatric terms, which addresses the history and evolution of nomenclature. The research reveals the difficulties of adherence to the treatment, as well as the strategies for the binding process. Then, the first consultations and the impressions of the researcher are presented, which starts to seek references for clinical care. The psychoanalytic conceptions of psychosis and delirium and how they could contribute to the care in question are discussed. Finally, we use the schizoanalytic reference, through concepts such as machine, agency and body without organs, to point out another way of thinking and acting in the case / Este trabalho apresenta um caso que foi atendido em um Centro de Atenção Psicossocial (CAPS) na cidade de São Paulo. O estudo suscita questões pertinentes ao ponto de vista clínico, considerando o desafio de se atuar em casos de pacientes delirantes. O caso é apresentado desde sua chegada à instituição, quando as informações de encaminhamento foram inicialmente discutidas em termos psiquiátricos, em que se aborda a história e evolução da nomenclatura. A pesquisa revela as dificuldades de aderência ao tratamento, bem como as estratégias para o processo de vinculação. Em seguida, apresenta-se os primeiros atendimentos e as impressões do pesquisador, que passa a buscar referências para os atendimentos clínicos. Discute-se as concepções psicanalíticas de psicose e delírio e de que maneira elas poderiam contribuir para os atendimentos em questão. Por fim, utilizase do referencial esquizoanalítico, através de conceitos como o de máquina, agenciamento e corpo sem órgãos, para apontar um outro modo de se pensar e atuar no caso

Delirium är ett akut insättande förvirringstillstånd och vanligt förekommande på intensivvårdsavdelningar. Delirium är allvarligt och livshotande med fluktuerande förlopp. Att drabbas av delirium innebär ett ökat lidande för patienten och dess anhöriga. Det medför ökade vårdtider och en stor kostnad för samhället. Det finns flera olika instrument för att identifiera delirium, CAM-ICU är det enda skattningsinstrumentet som är översatt och validerat till svenska. Kunskap saknas om bakomliggande orsaker till det bristande användandet av skattningsinstrument och om hur intensivvårdssjuksköterskan upplever det att ta hjälp av ett skattningsinstrument för att uppmärksamma delirium. Syfte med studien var att undersöka intensivvårds-sjuksköterskors upplevelse av att arbeta kliniskt med skattningsinstrumentet CAM-ICU. Den vetenskapliga ansatsen var kvalitativ, då datainsamlingen utfördes genom semistrukturerade intervjuer. Kvalitativ innehållsanalys har används för att analysera resultatet. Resultatet redovisas i form av två huvudkategorier samt fem underkategorier. I resultatet framkommer att implementering av skattningsinstrumentet CAM-ICU bidrar till en ökad medvetenhet om delirium som leder till ett förändrat vårdande av intensivvårdspatienten. Informanterna upplevde CAM-ICU som ett användbart skattningsinstrument för delirium, men för att kunna utnyttja instrumentet fullt ut, krävdes tid och erfarenhet. Ett evidensbaserat skattningsinstrument som CAM-ICU bidrar till en ökad patientsäkerhet, förbättrad vårdkvalitet och är en ekonomisk vinst för samhället. Implementering av evidensbaserat arbetssätt är tidskrävande men ger långsiktigt en bättre prognos för patienten, sjukvården och samhället. / Program: Specialistsjuksköterskeutbildning med inriktning mot intensivvård

Konfusion kan drabba vem som helst, men risken ökar med stigande ålder. Det är en störning av medvetande och kognitiva funktioner. Utlösande faktorer kan vara medicinska tillstånd som allvarlig sjukdom, infektioner, metabola rubbningar, dehydrering eller läkemedel. Konfusion ökar risken för skador och komplikationer, försvårar vårdandet, förlänger vårdtiden samt innebär ett lidande för patienter och anhöriga. Syftet är att identifiera omvårdnadsaktiviteter som kan förebygga och lindra konfusion hos patienter som vårdas på sjukhus. Metoden är en litteraturstudie. Sökning har skett i Cinahl och Medline. Sökord har varit ”acute confusion”, delirium, nursing och ”confusion nursing”. 15 artiklar har analyserats. Nio har en kvantitativ ansats och sex har en kvalitativ ansats. Resultatet sammanfattas i tre teman och nio subteman. Ett tema är vikten av beredskap. Denna består i att identifiera riskfaktorer, eliminera riskfaktorer samt identifiera tidiga tecken på konfusion. Det andra temat är anpassning av miljön. En säker miljö för patienterna bör eftersträvas eftersom de ofta utsätter sig själva för fara. Både en stimulerande miljö och en begriplig miljö lindrar konfusion. Det tredje temat handlar om att patienten med konfusion är i behov av ett äkta möte med vårdaren. Patienten känner sig ofta ensam med sina märkliga upplevelser och vårdaren bör ta sig tid att försöka förstå. Vidare kan patienten behöva känna bekräftelse. Slutligen bör patienten få stöd i att bearbeta sina upplevelser. I diskussionen framkommer vikten av att sjuksköterskan tillägnar sig kunskap för att förebygga och lindra konfusion. God omvårdnad är konfusionsförebyggande och kan förhindra onödigt lidande, komplikationer och därmed ökade kostnader.

Patienter som vårdas på en intensivvårdsavdelning (IVA) är där på grund av allvarlig sjukdom eller skada. Många av dessa patienter drabbas av intensivvårdsrelaterat delirium som räknas som en vanlig komplikation av att vårdas på IVA. Varför patienterna i så hög grad utvecklar delirium är inte tillräckligt kartlagt men de patienter som drabbas riskerar att få ett ökat lidande, förlängd vårdtid och ökad mortalitet. Syftet med denna studie var att beskriva sjuksköterskors erfarenheter av att förebygga och vårda patienter med intensivvårdsrelaterat delirium. En kvalitativ design med forskningsintervjuer som datainsamlingsmetod användes för att besvara syftet. I resultatet presenteras sjuksköterskornas förebyggande arbete och deras erfarenheter av att vårda patienter med delirium med hjälp av tre kategorier och tillhörande underkategorier. Sjuksköterskorna betonar vikten av att förmedla trygghet till patienten och genom att främja delaktighet och ge patienten kontroll över situationen försöker de bland annat förebygga delirium. Sjuksköterskornas erfarenhet är att behovet att information och sömn är stort hos patienter som vårdas på IVA och viktigt för att förhindra utveckling av delirium samt för att vårda och behandla en patient som har utvecklat ett delirium. Sjuksköterskorna uppger att det kan vara svårt att veta om en patient har utvecklat ett delirium trots att studier visar att 11-87% av patienterna som vårdas på IVA blir deliriska. En tredje del av dessa fall förblir oupptäckta. Fler patienter hade fått en mer anpassad vård om sjuksköterskorna kunnat identifiera delirium och därför är det av största vikt att intensivvårdssjuksköterskor utbildas inom området och att avdelningarna inför skattningsinstrument för att minska utbredningen av delirium. / Program: Specialistsjuksköterskeutbildning med inriktning mot intensivvård

The purpose of this thesis has been to explore the discursive production of delirium in people over the age of 65 years. The philosophical approaches underpinning the study were derived from the field of critical gerontology, postmodernism and the utilisation of a Foucauldian understanding of discourse and power/knowledge. Data sources included published documents on delirium, interviews with people over the age of 65 years who had been delirious (as well as their clinical notes), family members, registered nurses and a doctor.Textual analysis revealed the presence of two contesting and contradictory discourses that impacted on being an older person who had delirium. These were identified as the discourse of delirium as a syndrome and a personal discourse of delirium. The discourse of delirium as a syndrome is underpinned by the biomedicalisation of the ageing process. This process utilises scientific methods as the foundation from which to understand, research and provide a health service to older people with delirium. Any personal perspectives on delirium are rendered unimportant and relegated to marginalised positions. Nursing through its vicarious relationship to medicine is interpellated into deploying the discourse of delirium as a syndrome and has largely ignored the personal dimensions associated with this phenomenon. Consequently, the older delirious 'body' is known and inscribed as unruly, problematic, physically unwell, cognitively impaired and at risk.Conversely, a personal discourse of delirium privileges the individual narratives of people who have been delirious and provides a different perspective of delirium. The deployment of a personal discourse of delirium offers another position that views this group of older people as bringing to the health care setting a rich tapestry of life experiences that are more than a cluster of signs and symptoms. It is these varied life experiences that need to be included as a legitimate source of knowledge about delirium. This thesis demonstrates how nursing needs to espouse a critical gerontological position when working with older people who have delirium. Critical gerontology provides nurses with the theoretical tools to challenge the status quo and uncover the multiple, varied, contradictory and complex representations of delirium in older people.

Increasing numbers of older patients with cognitive impairment and disturbed behaviour are likely to present to acute care hospitals in the future. Nurses are not well disposed towards care due to safety and morale issues caused by knowledge deficits, job stress, oppressed group behaviours and ageist attitudes. Patient outcomes are often poor with multiple adverse events, long lengths of stay and levels of mortality. Disturbed behaviour may be caused by delirium, depression or other mental disorders and dementia or all. The research question addressed was “Can the instigation of a person-centred approach to care of patients with cognitive impairment and disturbed behaviour result in decreased nursing stress, improved patient care practices, outcomes and relatives’ satisfaction?” A conceptual framework incorporating the constructs of Person-Centred Care, the Integrated Structural Model of Human Behaviour and Practice Development informed the action research methods utilised. The processes of facilitation were used to undertake four action research cycles incorporating plans, actions, observations and reflections in one 25-bed acute aged care ward in a large tertiary referral hospital The first cycle involved setting up the study, recruitment of nurses and patients, gathering of baseline data and application of nonparticipant observational studies of the quality of nurse-patient interactions which served to inform the plan for interventions. The following three cycles demonstrated efforts to undertake those interventions through strategies to increase nursing empowerment and knowledge in the context of constant staff turnover and diversions that compromised support and participation. During the study there were few apparent adverse patient outcomes with significant improvements in patient analgesic administration, relatives’ satisfaction with care, nursing care practices involving the completion of a Communication and Care Cues form and nurses’ interactions with the patients. New care planning tools were developed that will enable ongoing activities for practice improvement. Conversely, there was a significant increase in the nurses’ stress levels when caring for hypoactive delirious patients, a trend towards more emotional exhaustion, high nursing turnover and increased sick leave rates. Nursing care practices were unchanged and the new care planning tools were not well utilised. Reflection on the implications and limitations of action research methods supported by practice development strategies in the dynamic, often chaotic environment experienced during the study, suggested that if there is an absence of hierarchical managerial sponsorship for such activities, then sustainable change is difficult. Therefore, it was shown that a person-centred approach to care of patients with cognitive impairment and disturbed behaviour using action research methods in this environment, can result in some enhanced nurse-patient interactions, patient care practices, outcomes and relatives’ satisfaction. However, progress is likely to be slow and time consuming. Further improvements require attention to the well-being status of the nurses through actions that generate feelings of empowerment through individual recognition, knowledge enhancement, adequate access to patient information and sufficient time to undertake their duties as equal members of the multidisciplinary team.

Delirium is a disturbance of consciousness and cognition that affects many terminally ill patients before death. It can manifest as confusion, hallucinations, and restlessness, all of which are known to be distressing to patients, families, and professional caregivers. Underlying the contemporary palliative care movement is a belief in the idea that a good death is possible; that dying can be made better for patients and families through the proper palliation of distressing symptoms and through proper attention to psychological, social, and spiritual issues that affect wellbeing at the end of life. Given that delirium is potentially disruptive to all that the good death assumes, i.e., mental awareness, patient-family communication, peace and comfort, the question was asked: What is the relationship between end-of-life delirium and the good death in hospice care? Ethnographic fieldwork was conducted at a freestanding residential hospice over a period of 15 months in a suburban community in eastern Canada. The research methods included participant observation (320 hours over 80 field visits), interviews with 28 hospice caregivers, and document analysis. The findings of this study provide an in-depth examination of the nature of caregiving relationships with patients and with families in end-of-life care. They illustrate how a commitment toward providing for the good death prevails within the cultural community of hospice, and how the conceptualization, assessment, and management of end-of-life delirium are organized within such a commitment. In this setting, experiences of conscious and cognitive change in dying are woven by hospice caregivers into a coherent system of meaning that is accommodated into prevailing scripts of what it means to die well. At the same time, delirium itself provides a facilitative context whereby processes of supporting families through the patient’s death are enabled. This study highlights the relevance of considering the contextual and cultural features of individual end-of-life care settings that wish to examine, and perhaps improve, the ways in which care of delirious patients and their families is provided.

Intensive care delirium prevention is currently a practice improvement goal of the Society of Critical Care Medicine. Delirium increases morbidity, mortality, time mechanically ventilated, length of stay, and health care spending. The Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit (PAD guidelines) were revised and published in 2013. The ICU Delirium and Cognitive Impairment Study Group at Vanderbilt University have developed the ABCDEF Bundle protocol as a way of operationalizing the 2013 PAD guidelines. Implementation of the ABCDEF Bundle protocol has been shown to decrease occurrence and duration of delirium while improving morbidity and mortality therefore decreasing length of stay. The purpose of this project is to develop an implementation and evaluation plan of the ABCDEF Bundle for a community hospital's TSICU in Arizona. The Squire guidelines for quality improvement reporting are followed for this project. Implementation and evaluation of the ABCDEF bundle are explained in detail.

Acute confusional state (ACS) or delirium according to DSM-III-R holds a central position in the medicine of old age. ACS is a common and sometimes the only symptom of diseases and medical complications in the elderly patient. The aim of this study was to elucidate ACS in patients with femoral neck fractures and patients with acute stroke with regard to frequency, predictors, possible pathogenetic mechanisms, associated complications, assessment and documentary routines and the clinical outcome for the patients. An intervention program to prevent postoperative ACS based on our results was developed and evaluated. The main findings of the study were high frequencies of ACS in elderly patients with femoral neck fractures (61 %) and in patients with acute stroke (48 %). The main risk factors for ACS in patients with femoral neck fractures were old age, diseases and drug treatment interfering with cerebral cholinergic metabolism. There was no link between anaesthetic technique and ACS but the connection between peroperative hypotension, early postoperative hypoxia and ACS was close. In stroke patients the degree of extremity paresis and old age were independent ACS risk factors. ACS was commonly associated with post stroke complications such as myocardial infarction, pneumonia, urinary infection and urinary retention. In stroke patients there was a close connection between high hypothalamic-pituitary-adrenal axis (HPA-axis) activity and ACS. High HPA-axis activity and disturbances in the cerebral cholinergic system may be two important ACS mechanisms. A correct diagnosis is a prerequisite for proper treatment of ACS and its underlying causes. In the orthopaedic wards both physicians and nurses diagnosed and documented ACS poorly and therefore associated complications were insufficiently treated. The intervention program for postoperative ACS, aimed mainly at protecting the cerebral oxidative metabolism and thereby the cerebral cholinergic metabolism which is especially sensitive to hypoxia. Postoperative complications associated with ACS were also treated. The intervention resulted in reduced frequency, duration and severity of postoperative ACS and in shorter orthopedic ward stay for patients with femoral neck fractures.Key words: Acute confusional state, delirium, elderly / <p>S. 1-76: sammanfattning, s. 77-175: 6 uppsatser</p> / digitalisering@umu

Urinary tract infection (UTI) is a common bacterial infection in women of all ages but the incidence and prevalence increase with age. Despite the high incidence of UTI, little is known about its impact on morale or subjective wellbeing and daily life in old women. UTI in older people can be a complex problem in terms of approach to diagnosis, treatment and prevention because in these patients it frequently presents with a range of atypical symptoms such as delirium, gastrointestinal signs and falls. Even if UTI has been shown to be associated with delirium it has frequently been questioned whether UTI can cause delirium or if it is only accidentally detected when people with delirium are assessed. The main purpose of this thesis was to describe the prevalence of UTI, to identify factors associated with UTI among very old women and to illuminate the impact of a UTI on old women’s health and wellbeing.  This thesis is based on two main studies, the GErontological Regional DAtabase (GERDA) a cross-sectional, population-based study carried out in the northern parts of Sweden and Finland during 2005-2007 and a qualitative interview study in western Sweden 2008-2009. Data were collected from structured interviews and assessments made during home visits, from medical records, care givers and relatives. UTI was diagnosed if the person had a documented symptomatic UTI, with either short- or long-term ongoing treatment with antibiotics, or symptoms and laboratory tests judged to indicate the presence of UTI by the responsible physician or the assessor. One hundred and seventeen out of 395 women (29.6%) were diagnosed as having suffered from at least one UTI during the preceding year and 233 of these 395 (60%) had had at least one diagnosed UTI during the preceding 5 years. These old women with UTI were more dependent in their activities of daily living, and had poorer cognition and nutrition. In these women, UTI during the preceding year was associated with vertebral fractures, urinary incontinence, inflammatory rheumatic disease and multi-infarct dementia. Eighty-seven of 504 women (17.3%), were diagnosed as having a UTI with or without ongoing treatment when they were assessed, and almost half (44.8%) were diagnosed as delirious or having had episodes of delirium during the past month. In all, 137 of the 504 women (27.2%) were delirious or had had episodes of delirium during the past month and 39 (28.5%) of them were diagnosed as having a UTI. Delirium was associated with Alzheimer’s disease, multi-infarct dementia, depression, heart failure and UTI. Forty-six out of 319 women (14.4%) were diagnosed as having had a UTI with or without ongoing treatment and these had a significantly lower score on the Philadelphia Geriatric Center Morale Scale (PGCMS), (10.4 vs 11.9, p=0.003) than those without UTI, indicating a significant impact on morale or subjective wellbeing among very old women. The medical diagnoses significantly and independently associated with low morale were depression, UTI and constipation. The experience of suffering from repeated UTI was described in interviews conducted with 20 old women. The interviews were analysed using qualitative content analysis. The participants described living with repeated UTI as being in a state of manageable suffering and being dependent on alleviation. Being in a state of manageable suffering was described in terms of experiencing physical and psychological inconveniences, struggling to deal with the illness and being restricted regarding daily life. Being dependent on alleviation was illustrated in terms of having access to relief but also experiencing receiving inadequate care. In conclusion, UTI is very common among old and very old women and is a serious health problem. UTI seems to be associated with delirium and to have a significant impact on the morale or subjective wellbeing of old women and those affected suffer both physically and psychologically and their social life is limited. UTI was also associated with vertebral fractures, urinary incontinence, inflammatory rheumatic disease and multi-infarct dementia which might raise the suspicion that UTI can have serious medical effects on health in old women. / Embargo t o m 2011-11-11