Background Nutritional treatment in the intensive care unit (ICU) has evolved from meeting nutritional requirements to manipulating patient outcome. Pharmaconutrition, referring to nutrients that are applied for their pharmacological properties, forms part of the standard nutritional care plan. The most abundant amino acid in the body, glutamine, is also the most-researched pharmaconutrient. It is an independent predictor of mortality in ICU patients, at both deficient and very high levels. Glutamine supplementation is recommended in the ICU setting for its proven outcome benefits. However, recent data showed that glutamine supplementation increases mortality risk in certain patient groups. Moreover, it suggested that not all ICU patients are glutamine deficient. Therefore, the main aim of this study was to investigate the plasma glutamine levels of adult ICU patients, on admission to the ICU. In addition, to elucidate the profile of ICU patients that can be expected to present with a glutamine deficiency or excess, with regards to gender, diagnosis and inflammatory markers. Methods In this observational, cross-sectional study, 60 mixed ICU adult patients admitted to two hospitals in the North West province were included in the study group. Blood sampling was conducted within 24 hours following ICU admission, to determine plasma glutamine, interleukin (IL)-6 and C-reactive protein (CRP) levels. Plasma glutamine levels were compared with those of a control group of healthy individuals, matched by age, race, and gender. Gender-related differences in plasma glutamine levels were investigated, as well as differences between patients with various medical conditions. The relationship between plasma glutamine levels and IL-6 or CRP was examined. Additionally, a CRP concentration cut-off point at which glutamine becomes deficient was determined by means of a receiver operating characteristic (ROC) curve. Results and discussion Intensive care unit patients had significantly lower plasma glutamine levels than healthy individuals on day one of ICU admission (p < 0.0001). However, only 38.3% (n = 23) had deficient plasma glutamine levels (< 420 μmol/L), while 6.7% (n = 4) presented with supra-normal levels (> 930 μmol/L). No significant difference could be detected between the plasma glutamine levels of male and female ICU patients (p = 0.116). Likewise, levels between diagnosis categories were also not significantly different (p = 0.325). There was a significant inverse association between plasma glutamine levels and CRP concentrations (r = -0.44, p < 0.05), and a trend towards an inverse association with IL-6 (r = - 0.23, p = 0.08). A CRP cut-off value of 95.5 mg/L was determined, above which plasma glutamine values became deficient; however, more research is needed to confirm this result. Conclusion and recommendations This research therefore showed that ICU patients, when compared with healthy individuals, had lower plasma glutamine levels on day one of admission to the ICU. However, not all were glutamine deficient, as the majority had normal and some presented with supra-normal plasma glutamine levels. An individualised approach should therefore be followed in identifying candidates for glutamine supplementation. The patients‟ condition alone may not be sufficient to predict glutamine status, but an association between plasma glutamine levels and CRP was firmly established, as well as a cut- off CRP-value above which glutamine can be expected to become deficient, which could be of use in this regard. / MSc (Dietetics), North-West University, Potchefstroom Campus, 2015

Text in Afrikaans / In hierdie beskrywende, verkennende en kontekstuele studie is ondersoek gedoen na redes waarom opgeleide intensiewesorgverpleegkundiges uit die intensiewesorgomgewing bedank en buite die intensiewesorgomgewing werk in die noordelike gedeelte van Gauteng. Doelwitte vir die studie was om die faktore te bepaal wat bydra tot die bedanking uit die intensiewesorgeenheid, die identifisering van die nie-verpleegkundige beroepe wat tans beoefen word en die bepaling van die faktore wat bydra tot die beoefening van 'n nie-verpleegkundige beroep. Die data is ingesamel deur middel van 'n vraelys wat voltooi is deur opgeleide intensiewesorgverpleegkundiges wat bedank het uit die intensiewesorgomgewing. Die sneeubalsteekproeftegniek is gebruik. Die data-analise het getoon dat redes vir bedanking uit die intensiewesorgomgewing die volgende insluit: onvoldoende salarisse, te veel stres en emosionele uitputting, ongerieflike werkure, personeeltekort en onbevredigende werkomstandighede. Daar is bevind dat verpleeg-sessiewerk steeds deur die respondente gedoen word, al werk hulle huidig voltyds buite die intensiewesorgomgewing. / In this exploratory, descriptive and contextual study research has been done to establish the reasons why intensive care nursing personnel resign from the intensive care environment in the northern Gauteng region. The researcher aimed to establish the factors that contributed to the resignations from the intensive care environment, to identify the non-nursing careers currently being practised by former intensive care nursing staff and to establish the factors that influenced them to practice non-nursing careers. The data was collected through questionnaires completed by former intensive care nursing personnel. The snowball test sampling method has been used. Data analysis has shown the following to be inter alia the reasons for the resignations from the intensive care environment: insufficient income, exhaustion and emotional stress, inconvenient working hours, staff shortages and unsatisfactory working conditions. One finding is that respondents are still doing nursing session work although they are working full-time in nonnursing capacities. / Health Studies / M.A. (Verpleegkunde)

The overall aim of the present thesis was to study aspects of patient safety in critically ill patients with special focus on airway management, respiratory complications and nursing procedures. Study I describes a method called pharyngeal oxygen administration during intubation in an experimental acute lung injury model. The study showed that pharyngeal oxygenation prevented or considerably increased the time to life-threatening hypoxemia at shunt fractions by at least up to 25% and that this technique could be implemented in airway algorithms for the intubation of hypoxemic patients. In study II, we investigated short-term disconnection of the expiratory circuit from the ventilator during filter exchange in critically ill patients. We demonstrated that when using pressure modes in the ventilator, there was no indication of any significant deterioration in the patient's lung function. A bench test suggests that this result is explained by auto-triggering with high inspiratory flows during the filter exchange, maintaining the airway pressure. Study III was a clinical observational study of critically ill patients in which adverse events were studied in connection with routine nursing procedures. We found that adverse events were common, not well documented, and potentially harmful, indicating that it is important to weigh the risks and benefits of routine nursing when caring for unstable, critically ill patients. In study IV, we conducted a retrospective database study in patients with pelvis fractures treated in the intensive care unit. We found that the incidence of respiratory failure was high, that the procedure involved in surgical stabilization affected the respiratory status in patients with lung contusion, and that the mortality was low and probably not influenced by the respiratory condition. In conclusion, the results obtained in the present thesis have increase our knowledge in important areas in the most severely ill patients and have underlined the need for improvements in the field of patient safety.

Cette étude examine la qualité et fidélité d'implantation du programme d'intervention comportementale intensive (ICI) destiné aux enfants ayant un trouble envahissant du développement (TED) âgés de moins de six ans, suivis dans des centres de réadaptation en déficience intellectuelle et trouble envahissant du développement (CRDITED). À cette fin, un questionnaire maison adapté au contexte spécifique du programme a été jumelé au questionnaire sur la fidélité d'implantation de Joly (2006). L'échantillon comporte 74 intervenants, 14 superviseurs et 8 coordonnateurs rattachés au programme ICI et provenant de 6 CRDITED. Les intervenants ont complété les questionnaires tandis qu'une entrevue semi-structurée auprès des coordonateurs [i.e. coordonnateurs] et des superviseurs permettaient de compléter les données. Les résultats indiquent un niveau de fidélité élevé selon les intervenants et une bonne qualité d'implantation malgré une grande variabilité dans les pratiques. En effet, des différences significatives sont observées entre les centres en ce qui concerne l'adhésion au manuel d'instruction, la participation de la clientèle et la fidélité d'implantation. En ce qui concerne les facteurs associés à la fidélité d'implantation, des lacunes au niveau de la documentation spécifique au programme ICI et au sujet de la formation offerte aux intervenants sont rapportées. Enfin, les trois facteurs qui favorisent le plus l'implantation du programme sont la formation TED, la supervision et la collaboration des partenaires alors que ceux qui nuisent le plus sont l'instabilité de l'équipe, le manque de formation et l'absence de locaux adaptés. La discussion fait état des aspects positifs de l'implantation de ce programme mais aussi d'améliorations nécessaires au programme ICI dans le souci que les enfants ayant un TED et leur famille puissent bénéficier d'une plus grande qualité de service.

Intra-aortic balloonpump (IABP) counterpulsation therapy is a volume displacement device designed to provide partial assistance to the left ventricle of the heart. Critical care nurses are expected to manage IABP therapy. It is therefore important that the critical care nurse has the knowledge to manage IABP therapy in a safe and therapeutic manner. The question arises: does the critical care nurse have the knowledge to manage IABP therapy? The purpose of this research study is to explore and describe the knowledge of the critical care nurse regarding the management of IABP therapy. The design of this research study is a quantitative, descriptive and contextual study, in which a sample survey was performed, using a questionnaire (based on a literature study) under controlled conditions. The knowledge of the majority of critical care nurses tested was found to be insufficient. Safe management guidelines and in-service training have been proposed to improve the situation. / lntra-aortiese ballonpomp (IABP) teenpulsasie terapie is 'n volume verplasings apparaat, antwerp om gedeeltelike ondersteuning aan die linker ventrikel van die hart te bied. Kritiekesorgverpleegkundiges is verantwoordelik vir die hantering van rASP terapie. Die vraag ontstaan: beskik die kritiekesorgverpleegkundige oor voldoende kennis rakende die hantering van IABP terapie? Die doel van hierdie studie is om die kennis van kritiekesorgverpleegkundiges te ondersoek en te beskryf rakende die hantering van IABP terapie. Die resultate van hierdie navorsingstudie dui daarop dat die meerderheid kritiekesorgverpleegkundiges wat getoets was oor onvoldoende kennis beskik ten opsigte van IABP terapie. Formulering van riglyne en indiensopleiding is aanbeveel om hierdie situasie te verbeter. Die navorsingsontwerp is kwantitatief, beskrywend en kontekstueel van aard, waartydens 'n gerieflikheidsteekproeftrekking gedoen is, met gebruik van 'n vraelys (gebasseer op 'n literatuurstudie) onder gekontrolleerde toestande. / Health Studies / M.A. (Nursing Science)

The tenn Acute Coronary Syndrome (ACS) encompasses a spectrum of patients who present with chest discomfort or other symptoms caused by myocardial ischemia or infarction. Since critical or acute care nurses care for such patients, they should have a thorough knowledge of ACS pathophysiology and current treatments for ACS The purpose of this research study is to explore and describe the knowledge level that the critical care nurses in a state hospital in East Texas feel they have regarding ACS. This study was quantitative, descriptive and contextual in design, in which a sample survey was performed, using a questionnaire based on a literature study. The response of most ofthe critical care nurses tested was that they felt they had insufficient knowledge. An in-service training session has been proposed to help improve the nurses' knowledge and expertise on ACS. / Health Studies / M.A. (Nursing Science)

The research objective was: to determine (a) the extent of the present involvement of neonatal intensive care nurses in technology assessment, (b) their perceptions of the technologies with which they worked, and (c) their perceptions of requirements for improvements in the technology assessment process. Nurses and senior staff (nursing s.u perv.i sors, NICU consultants and training officers) ln the neonatal intensive care units (NICUs) of five hospitals in London were included in the study sample. They completed questions regarding new medical technologies in general and NICU technologies in particular. Nurses and senior does not prepare Further, in some training regarding staff believed that nurses' training them adequately for new technologies. instances, nurses had not received a new technology prior to using it. Neither nurses nor senior staff were fully aware of formal processes for technology assessment in their hospitals, but did identify informal processes. While a small minority of the nurses had been directly involved in decisions regarding the new technologies, more than half had made recommendations. The nurses considered their level of involvement unsatisfactory, and believed (as did the senior staff) that their hospital could improve its procedures for purchasing, introducing and using new technologies. Most of the nurses who were planning to remain in neonatal intensive care were dissatisfied with their involvement and with their hospital's methods for adopting new technologies. One-third of the nurses and most of the senior staff identified examples of nurses' having contributed to the development and adaptation of new equipment and procedures, either formally or informally. The impacts considered most significant by nurse participants were: job stress, increased ethical, legal or social concerns, and decreased reliance on clinical judgment or skills of nurses.

Bakgrund: När sjukvården till stor del förlitar sig på medicinsk teknik och läkemedelsbehandling är det lätt att omvårdnadsåtgärder som syftar till att förebygga och lindra lidande inte ges tillräckligt utrymme. Intensivvårdsdelirium är ett förhållandevis outforskat område inom barnintensivvården. Idag finns inga riskskattningsinstrument översatta till svenska.   Syfte: Syftet var att studera barns beteenden när de vårdades på en barnintensivvårdsavdelning. Dessutom undersöktes om dessa beteenden kunde användas för att besvara frågor från ett engelskspråkigt riskskattningsinstrument för delirium.   Metod: Studien utfördes som en fokuserad etnografisk observationsstudie där sju patienter på en barnintensivvårdsavdelning observerades under tre timmar vardera. Utifrån observationernas fältanteckningar gjordes en innehållsanalys med fokus på manifest innehåll. I ett andra steg utfördes en deduktiv analys där kategorierna från fältanteckningarna jämfördes mot frågor från riskskattningsinstrumentet för delirium.   Resultat: Innehållsanalysen av fältanteckningarna resulterade i åtta kategorier som representerade barnens beteende under observationerna: reagerar på vårdhandling, förmedlar fysiska behov, förmedlar smärta, svarar på fråga, sysselsätter sig själv, stimuleras av underhållning, uppmärksammar omgivningen och väcks av stimuli. Den deduktiva innehållsanalysen visade att fyra av de åtta frågorna från riskskattningsinstrumentet kunde besvaras med hjälp av kategorierna.   Slutsats: Urvalet bestod av en homogen subgrupp där inga beteenden med tydlig koppling till risk för delirium kunde observeras. Miljörelaterade riskfaktorer för delirium i form av frekventa vårdhandlingar, höga ljud och störd sömn förekom. Trots att denna grupp patienter inte visade tecken på delirium kan förebyggande av dessa störningar leda till minskat vårdlidande. Barnintensivvården kan ytterligare minska vårdlidande genom att öka föräldrarnas möjligheter att vara hos sitt sjuka barn dygnet runt. / Background: Nursing and preventive measures may be overlooked when health care in large relies on medical technology and medical treatment. Intensive care delirium is a relatively unexplored area in pediatric intensive care. There are currently no risk assessment tools translated to Swedish.   Aim: The objective was to study children's behaviour when they were cared for in a pediatric intensive care unit. In addition, it was questioned whether these behaviours where able to answer questions originating from an English language risk assessment tool for delirium.   Method: Using focused ethnographic observation seven patients were observed during three hours each. Content analysis was performed on the field notes from the observations with focus on manifest content. As a second step, a deductive analysis compared the categories with questions from the risk assessment tool for delirium.   Findings: The content analysis of field notes resulted in eight categories which represented the children’s behavior during the observations: reacting to care, expressing physical needs, expressing pain, answering question, occupying oneself, stimulated by entertainment, observing the surroundings and awakened by stimulus. The deductive analysis showed that four of the eight questions from the risk assessment tool could be answered with the categories.   Conclusion: The selection consisted of a homogenous subgroup where no obvious behaviors related to risk of delirium was observed. Environmental risk factors for delirium such as frequent care related interventions, loud noise and disturbed sleep where observed. Despite that, prevention of these disturbances could reduce health care related suffering even though this group of patients did not show signs of delirium. Pediatric intensive care units can further reduce healthcare related suffering by enabling families to be present with their sick child during all hours of the day and night.

Thesis (MCurr)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: The increasingly complex role of the critical care nurse in an intensive care environment demands a much higher level of critical thinking and clinical judgment skill than ever before. Critical thinking in nursing practice may be defined as the cognitive ability to analyse, predict and transform knowledge, ensuring quality nursing care. To reason from a nurse’s perspective requires that we learn the content of nursing; this includes the concepts, ideas and theories of nursing. The aim and objectives of the study were to explore critical care nurses’ perspectives and experiences with regards to the concept of critical thinking, facets influencing the application of critical thinking skills in clinical practice and how these impact on the delivery of quality nursing care. A qualitative approach, using a case study design was utilised. A sample of six participants, who met the study inclusion criteria and consented to participate, were interviewed individually. Subsequently, five of these six participants took part in a focus group discussion to capture additional data to clarify and enrich the individual interview data. A field worker was present during the interviewing processes to note non-verbal data and later verify transcribed data. Feasibility of the proposed study was established by conducting a pretest which elicited relevant information. Ethical approval for the study was obtained from the Health Research Ethics Committee at the Faculty of Medicine and Health Sciences, Stellenbosch University. Permission and consent was obtained from the relevant hospital group to interview nurses working in the intensive care units. Qualitative content analysis, which focuses on the content or contextual meaning, was used to analyse interview data. Coding of the data through emergent themes and sub-themes was done by the researcher and supported through independent coding to verify and strengthen the analysis and interpretation of the researcher. . The results depicted how the participants personally understood the concept of critical thinking and the components influencing the application of critical thinking skill in clinical practice. The study of the participants’ perspective of the concept of critical thinking and portrayed how they experience analytical and independent thinking, competence and confidence, as well as knowledge, skill and expertise, to influence the quality of patient care. The data revealed several themes that facilitated critical thinking in critical care nurses. These themes were ‘team support’, ‘experience and exposure’ and ‘empowering the mind’. Emergent themes elaborating the limitations of critical thinking included ‘being stressed’, ‘professional boundaries’ and ‘being busy’. Several recommendations and suggestions for future research were offered. / AFRIKAANSE OPSOMMING: Die toenemende komplekse rol van die kritieke-sorgverpleegster in ’n intensiewe-sorg omgewing verg ’n veel hoër vlak van kritiese denke en ’n kliniese oordeelvaardigheid as ooit tevore. Kritiese denke in ’n verplegingspraktyk kan gedefinieer word as die kognitiewe vermoë om te kan analiseer, om vooruit situasies te kan bepaal en die vermoë om kennis te omskep sodat kwaliteit verpleegsorg verseker kan word. Om soos ’n verpleegster te kan dink, stipuleer dat die inhoud van verpleging geleer moet word wat konsepte, idees en teorieë daarvan insluit. Die doel en oogmerke van die studie is om die ervarings en perspektiewe van kritieke-sorgverpleegsters te ondersoek, met betrekking tot die konsep van kritiese denke, fasette wat die toepassing van kritiese denkvaardighede in ’n kliniese praktyk beïnvloed en die impak daarvan op die lewering van kwaliteit verpleegsorg. Die metodologie wat toegepas is, is ’n kwalitatiewe benadering deur middel van ’n gevalle-studie ontwerp. ’n Steekproefgrootte van ses deelnemers wat aan die inklusiewe kriteria voldoen het, is mee onderhoude individueel gevoer en daarna is met vyf van hierdie ses deelnemers in ’n fokusgroep onderhoude gevoer ten einde data op te neem wat andersins verlore kon geraak het. ’n Veldwerker was teenwoordig gedurende die proses van onderhoudvoering om die opgeneemde en getranskribeerde data te verifieer. Die data-insamelingsinstrument is in die vorm van ’n onderhoudsgids ontwikkel om die navorser gedurende die onderhoudvoering te help. ’n Loodsondersoek is uitgevoer om die haalbaarheid van die voorgestelde studie te ondersoek en is sodoende geskep om relevante inligting te onthul. Etiese goedkeuring vir die studie is verkry van die Gesondheidsnavorsing Etiese Komitee aan die Fakulteit van Geneeskunde en Gesondheidswetenskappe, Universiteit Stellenbosch. Goedkeuring en toestemming is van die hospitaalgroep aan wie die hospitaal behoort verkry, waar die studie onderneem is om sodoende onderhoude te kan voer met verpleegsters wat in die intensiewe-sorgeenhede werk. ’n Primêre, kwalitatiewe inhouds analise is gebruik om omderhoud data te analiseer wat fokus op die inhoud of kontekstuele betekenis daarvan. Kodering van die data deur die toepassing van die temas en sub-temas wat voorgekom het, is deur die navorser gedoen. Die data is onafhanklik gekodeer om die analise en interpretasie van die navorser te verifieer en te bekragtig ten einde die akkuraatheid en getrouheid in die formulering van die betekenis en interpretasie van gebeure met juiste weergawe daarvan, te verseker. Die resultate wat as hooftemas vanuit die individuele onderhoude voortgespruit het, asook die van die fokusgroep het die deelnemers se eie begrip van die konsep van kritiese denke en komponente wat die toepassing van kritiese denkvaardigheid in ’n kliniese praktyk beïnvloed, getoon. Die konsep van kritiese denke het die wyse waarop analitiese en onafhankilke denke, bevoegdheid en selfvertroue, asook kennis, vaardigheid en kundigheid die kwaliteit van pasiëntsorg beïnvloed, uitgebeeld. Die voortkomende data het daartoe aanleiding gegee dat die faktore wat die fasilitering en beperking van kritiese denke beïnvloed, bespreek kon word. Data rakende fasilitering het getoon hoedat die ondersteuning van die span, ervaring, blootstelling en die verruiming van die gees, kritieke-sorgverpleegsters positief kan beïnvloed om kritiese denke in hulle daaglikse verplegingsaktiwiteite effektief te kan toepas. Data wat verband hou met beperkings het getoon hoedat stres, professionele kwessies en besigwees kritieke-sorgverpleegsters negatief kan beïnvloed in die toepassing van kritiese denke gedurende daaglikse verplegingsaktiwiteite. Verskeie aanbevelings vir toekomstige navorsing is voorgestel.

published_or_final_version / Community Medicine / Master / Master of Public Health