Thesis (M.S.)--University of Michigan, 1987.

Thesis (M.S.)--University of Michigan, 1975.

Thesis (M.S.)--University of Michigan, 1979.

Thesis (M.S.)--University of Michigan, 1979.

Thesis (M.S.)--University of Michigan, 1978.

Thesis (Ph. D.)--University of Texas at Austin, 2004. / Supervisor: Angela P. Clark. Vita. Includes bibliographical references.

Thesis (Ph.D.)--Duquesne University, 2006. / Title from document title page. Abstract included in electronic submission form. Includes bibliographical references (p.117-123) and index.

Patients who are critically ill get often admitted to intensive care units (ICUs). The majority of these patients require support with their breathing and are thus connected to a mechanical ventilator. One aspect to consider in the mechanically ventilated patient is endotracheal tube cuff pressure (ETT) management. The management of ETT cuff pressure entails that nurses working in ICUs have the responsibility of ensuring that ETT cuff pressure is kept within normal range of 20-30 cmH20 for the safety of the patients in order to avoid complication of over and under inflation. Poor management of ETT cuff pressure places the mechanically ventilated patients under risk of tracheal injury. Tracheal injury may also be caused by over or under inflation of the ETT cuff. Over inflation of the ETT cuff can lead to the occlusion of capillaries lining the trachea at the cuff site, tracheal stenosis, and can also lead to the death of mucus membranes around the area, just to mention a few. On the other hand, under inflation of the ETT cuff, can lead to air leaks as well as aspiration of gastric contents into the tracheal tree. Therefore, in order to maintain ETT cuff pressure within normal ranges, evidence-based guidelines related to the management of ETT cuff pressure should be used. However, in Malawi the management of endotracheal tube cuff pressure in mechanically ventilated adult patients by nurses in ICUs is not well explored and it is not clear whether this practice is based on evidence-based guidelines. Furthermore, strategies on how to implement evidence-based guidelines in the ICU might not be known and poorly defined because of the complexity of the context. The study is therefore aimed at implementing and evaluating the effect of an evidence-based guideline on the management of ETT cuff pressure in mechanically ventilated adult patients by nurses in ICUs in Malawi using active (printed educational materials and monitoring visits) and passive (printed educational materials only) implementation strategies. The research study used a quantitative approach with multi-designs. Four phases were used in order to achieve the four objectives that were set. Phase one was the pre-test and used a survey design, two was the expert panel review of the evidence-based guideline, three was the implementation of the reviewed evidence-based guideline using a randomised controlled trial design and phase four was the post-test which used a survey design. The RCT included 25 participants from the control and 27 from the intervention group. Each group had three ICUs of which one in each group was from a private hospital and the other were government. Data collection in phases one and four was by a hand delivered pre-and post-questionnaire. In phase two the expert panel members with experience in critical care used the AGREE II Instrument to review the evidence-based guideline that was implemented. In order to gather data during the monitoring visits, the researcher recorded field notes. The applications that were developed by the University statistician consultant using visual basic applications in excel were used to analyse data. Two different implementation strategies were used to implement the evidence-based guideline. The control group used passive implementation strategy which was printed educational materials thus the evidence-based guideline and algorithm. The intervention group used both active and passive implementation strategies which was the printed educational materials thus the evidence-based guideline and algorithm plus monitoring visits by the researcher. In order to establish the effect of the implemented evidence-based guideline on the nursing care practice for the management of endotracheal tube cuff pressure an evaluative posttest survey was conducted in phase four of the research study. The results revealed that the majority of participants had gaps in both groups regarding nursing care practice for the management of endotracheal tube cuff pressure for the mechanically ventilated adult patients in the pretest but improved in the posttest. In the control group 52% had very low knowledge score, 16% had low score, 28% average, and 4% high score while in the category of very high score there was nobody. However, in the posttest those in the very low score were only 44% while the percentage in the low score remained 16%. There was an improvement in the average scores in the posttest such that only 44% were in this category. There was no one in the high and very high score in the pretest. On the other hand, in the intervention group, 78% had a very low score, 9% low score, and 13% were in the category of average score, while in the high and very high score category there was zero percent in the pretest. However, there was also an improvement in the posttest such that only 44% a very low knowledge score. But 19% had a low score, there were 37% in the average category and no one was in the high and very high score. Statistical analysis revealed that the results were not significantly different between and within groups. Improvements were observed in the two groups regarding the scientific knowledge scores for the nursing care practices in the posttest. Upon qualitative analysis of the data from the open-ended question, two main themes emerged thus the need for documentation of endotracheal tube cuff and the process of implementation the evidence-based guidelines. Sub themes such as lack of documentation; no part of routine care and monitoring not done at all were identified under the main theme of the need for documentation of ETT cuff pressure. The Guideline itself need to be clear; implementation strategies; follow up; incentives; supervision; incentives; time factor; resources or equipment required for successful implementation; nurses buy-in critical for the implementation; training detrimental to EBP implementation; nurses attitude crucial to implementation of EBGs and knowledge of nurses for guideline essential for the implementation were the sub themes identified under the main theme of the process of implementing the evidence-based guideline. All appropriate ethical considerations such as principles of autonomy and self-determination, confidentiality and anonymity, voluntary participation, right to receive treatment, informed consent, were adhered to throughout the research study. The research study was unique in nature because it was the first of its kind in Malawi and it contributed to the awareness of the recommended practice for management of endotracheal tube cuff pressure in the ICUs in the country by implementing an evidence-based guideline. The unique contribution of the study is that it is a challenge to implement evidence-based guideline in poor and resource constraint countries like Malawi.

nÃo hà / MudanÃas que aconteceram no sÃculo XX, permitiram que avanÃos tecnolÃgicos aumentassem a sobrevida diante de doenÃas anteriormente incurÃveis e processos patolÃgicos irreversÃveis. No entanto, a busca incessante pela cura, alÃm de levar ao aumento da sobrevida, tambÃm gerou a obstinaÃÃo terapÃutica, ou seja, medidas terapÃuticas fÃteis diante de evoluÃÃo inexorÃvel para a morte, impactando em indicadores como Ãndice de satisfaÃÃo do cliente e cuidadores, tempo mÃdio de permanÃncia, elevaÃÃo de custos, bem como em prejuÃzo na distribuiÃÃo equitativa de recursos. No inÃcio dos anos 90, a limitaÃÃo do suporte de vida (LSV) comeÃou a ser estudada e considerada, em paÃses da Europa, Estados Unidos, Canadà e Austrlia, como forma de assistir os pacientes nesses casos, uma vez que as medidas terapÃuticas nÃo mais trariam benefÃcios, mas gerariam prolongamento do sofrimento e do processo de morrer. No Brasil, contudo, os estudos sÃo limitados e os dados referentes ao Nordeste do paÃs sÃo ainda muito escassos. O objetivo do estudo foi caracterizar as condutas mÃdicas que antecederam o Ãbito de pacientes em UTI pediÃtrica e neonatal em um hospital de referÃncia do Nordeste Brasileiro. Foram estudados 86 prontuÃrios de pacientes que morreram nas referidas UTIs no perÃodo de dezembro/09 a novembro/10. Apenas 3,5% dos Ãbitos ocorreram apÃs LSV registrada em prontuÃrio, destes 33,7% tinham doenÃa crÃnica associada, sendo as neoplasias as mais comuns. As causas de Ãbito mais comuns foram sepse (23,5%), falÃncia de mÃltiplos ÃrgÃos (18,8%), insuficiÃncia respiratÃria (12,9%), cardiopatias congÃnitas (8,2%) e as outras causas somaram 36,6%. A maior parte dos pacientes morreu apÃs aumento das medidas de suporte avanÃado de vida, considerando as ultimas 24h antes do Ãbito: drogas vasoativas (59,3% 24h antes e 70,9% no momento do Ãbito); VentilaÃÃo mecÃnica (89,5% 24h antes e 95,2% no momento do Ãbito). Enquanto as medidas de cuidados e conforto nÃo tiveram a mesma expressÃo, tendo um aumento irrelevante: sedaÃÃo (39,5% 24h antes e 43% no momento do Ãbito); analgesia (60% 24h antes e 60,5% no momento do Ãbito). As manobras de ressuscitaÃÃo cardiopulmonar foram registradas em 4,7% 48h antes do Ãbito, 29,1% 24h antes e 69,4% no momento do Ãbito. O uso de adrenalina foi registrado em 55,4% antes do Ãbito. Conclui-se que a LSV ainda nÃo à frequentemente considerada como uma alternativa de assistÃncia de final de vida a pacientes pediÃtricos e neonatais no Estado do CearÃ, onde as condutas mais prevalentes incluem o incremento do suporte avanÃado de vida em detrimento das medidas de conforto e cuidados paliativos. Comparando-se com estudos do Sul e Sudeste do paÃs, evidencia-se uma grande diferenÃa, onde se observam uma maior prevalÃncia de LSV e cuidados paliativos para pacientes em fase terminal, o que denota prÃticas mais humanas e de maior qualidade na assistÃncia. / Changes around the world at the XX century allowed new technologies to improve the possibilities of surviving in so many cases of sickness that were incurable before. Besides the benefits it brought, other consequences have come together specially futility, in other words futile therapeutic measures when the cure is impossible and the death is inevitable. These facts have influence in client satisfaction, lengh of stay and costs elevation. Since 1990 life support limitation (LSL) started to be considered in Europe, United States, Canada and Austrlia to assist patients in terminal conditions to whom curative practices wouldnât bring any benefit. In Brazil there is a limited number of studies and the data from the Northeastern are even less. The aim of this study was to describe the medical practices before death in patients in PICU and NICU at a reference pediatric hospital in Brazilian Northeastern. Data were collected from 86 medical charts. Only 3.5% of LSL was registered. 33.7% of patients had some chronic disease and neoplasic ones were more comons. The main causes of death were: sepsis (23.5%), MDOS (18.8%), respiratory failure (12.9%), congenital heart disease (8.2%) and the other causes 36.6% together. Most of patients died after increment in vasoatives administration, considering the final 24 hours before death (59.3% 24h before, 70.9% at the momento of death). Mechanical ventilation (89.5% 24h before, 95.2% at the moment). In the other hand palliative care and pain control were not so frequent as could be expected: sedative (39.5 24h before, 43% at the moment) analgesic (60% 24h before, 60.5% at the moment). CPR was offered in 4.7% of patients 48h before death, 29.1% 24h before and 69.4% at the moment of death. Adrenaline was used in 55.4% at the moment of death. These data show that LSL is not a frequente alternative to assist terminal patients at PICU and NICU in Brazilian Northeastern, where more prevalent practices are to maintain life support instead of offer palliative care and pain control. At Southern and Southeastern practice include LSL and palliative care more frequently, what suggests better practices of the end-of-life care.

M.Cur. / It is a well known fact that the environment plays an important rol in the development of the individual. In an intensive care unit, a child is exposed to an enormous amount of stimuli that is confusing and frightening and also has no meaning for the child. The experience of a child in an intensive care unit, upon whom major procedures are performed, is observed. The purpose of this study is to examine and describe the intensive care experience of children between the ages of 3 and 12 so that guidelines for the nursing of these children can be provided. This is a qualitative study and the phenomenological method of research was used. Interviews were conducted with the help of three photographs. These were shown to the respondents and they were asked to tell a story about the child in the photo. Fieldnotes were taken immediately after each interview to describe the situation and the researchers impressions. A taperecording was made of each interview and was transcribed verbatim. The transcriptions were analised and conclusions were reached. Guidelines can thus be drawn up for the nursing of a child in an intensive care unit.