Children heart diseases can be divided into congenital and acquired heart defects. The acquired heart defects can be further divided into acquired heart defects, heart rhythm disorders, including hypertension, inflammatory heart diseases and heart failure. Children heart diseases can occur at any age, even if it is a congenital heart defect that is less severe. The goal of this thesis was to find out the specifics of nursing care of children with heart diseases who are hospitalized at ICU and to find out the most common nursing diagnoses according to NANDA II taxonomy, and their treatment in case of children with heart diseases who are hospitalized at ICU. During the realization of the research part, a qualitative research survey was conducted using semi-structured interviews with the nurses, participant observation and the method of content analysis, which provide a more complex view of the composition of the children with heart disease hospitalized at ICU. The interviews were conducted with the nurses at the children's ICU, where the participant observation and the method of content analysis took place as well. The results of the research show that nursing care differs in the case of cardiologic disordered children and otherwise disordered children in some areas, as well as the needs. In the research part it was found out what the most frequent nursing interventions in case of these children are and how much they differ from the interventions of children with other diseases, who are also hospitalized at ICU. Furthermore, the research shows that nurses have a negative opinion on nursing diagnoses, although they are used in the documentation. This was found not only in the semi-structured interviews with the nurses, but also during the participated observation and the content analysis of the documentation. The research also revealed that some nursing diagnoses are specific to cardiologic disordered children, but, for example, the nursing diagnosis of the risk of infection associated with invasive entry is used in case of all children hospitalized at ICU. The diploma thesis should inform nurses about nursing care in case of children with heart disease hospitalized at ICU.

O ritmo intenso do envelhecimento populacional no Brasil tem levado a questionamentos sobre o impacto das mudanças demográficas em diferentes âmbitos da Seguridade Social, dentre os quais destacamos a área da saúde e, mais especificamente, as Unidades de Terapia Intensiva. Os avanços representados pelos princípios do Sistema Único de Saúde, a criação do Estatuto do Idoso e a preocupação com os direitos humanos tornam urgentes reflexões sobre o que se coloca como desafio no atendimento médico à população idosa em UTI. Médicos intensivistas têm sua atuação marcada, dentre outros fatores, pelos sentidos que atribuem à fase da vida e a visão que têm de seus pacientes idosos. Esta pesquisa teve por objetivo compreender quais os sentidos que médicos que atuam em UTI atribuem a velho/velhice/envelhecimento e suas relações com as práticas de assistência prestada aos pacientes idosos. Trata-se de pesquisa qualitativa, realizada por meio de observação participante de reuniões de equipes que atuam em UTI de um hospital escola na cidade de São Paulo, e de entrevistas com médicos que compõem estas equipes. Os dados foram analisados sob a ótica Construcionista. Os resultados apontam para a existência de uma polissemia relacionada à velhice, incluindo sentidos que podem produzir práticas idadistas quando não há uma postura reflexiva dos profissionais a respeito do tema, ou quando conflitos decorrentes da complexidade que envolve o atendimento hospitalar em diferentes contextos econômicos se impõem aos profissionais, dificultando o diálogo entre os envolvidos mais diretamente na situação de internação (profissionais da saúde, pacientes, familiares, cuidadores, gestores). Essa nova realidade demográfica deve ser discutida na formação profissional, envolvendo as novas e diferentes demandas da população idosa. Relacioná-las ao respeito ao direito humano à vida e à dignidade, e aos sentidos atribuídos aos profissionais à essa fase da vida, aos velhos e ao processo de envelhecimento, bem como à forma como esses sentidos são produzidos e os seus contextos de produção, pode contribuir para que práticas de exclusão não se (re)produzam. / The intense pace of population aging in Brazil has led to questions about the impact of demographic changes on different aspects of Social Security, among which we highlight the area of health and, more specifically, the Intensive Care Units (ICU). The advances represented by the principles of the Unified Health System (SUS), the creation of the Elderly Statute and the concerns for Human Rights, have sped up reflections on what it is a challenge in the medical care to old people population in the ICU. Intensive care physicians have marked their performance, among other factors, by the meanings they attribute to this stage of life and by the vision they have of their elderly patients. This research aimed to explain which are the meanings attributed by that physicians working in ICUs to old/old people/aging, and their relationship to practical assistance provided to elderly patients. This is a qualitative research, resulting from the participatory observations of teams working at ICU in a university hospital in São Paulo, and from interviews with the physicians who take part in these teams. Data have been analyzed from the constructionist perspective. The results signalize to the existence of an age-related polysemy, including meanings that may produce ageist practices when there is a lack of reflexive posture of professionals about the subject, or when conflicts arising from the complexity that involves inpatient care in different economic contexts are imposed to professionals, impeding the dialogue among those involved more directly in the hospitalization (healthcare professionals, patients, family members, caregivers, managers). This new demographic reality should be discussed during professional training, involving new and different demands of the elderly population. Relate those demands to the respect to the human rights, to life and dignity, and to the meanings attributed by the professionals to this stage of life, to the old people and to the aging process, as well as to the way these meanings are produced and their contexts of production, can contribute to impede the re(production) of exclusionary practices.

A segurança do paciente grave é uma meta da qualidade do atendimento em Unidade de Terapia Intensiva (UTI), daí a necessidade de se investigar os fatores relacionados à ocorrência de eventos adversos nesse contexto. Trata-se este estudo de uma pesquisa quantitativa, retrospectiva, analítico-transversal que teve como objetivo analisar os fatores associados aos incidentes e/ou eventos adversos (INC/EA) no preparo e administração de medicamentos, nos cuidados com tubo endotraqueal/traqueostomia, sondas, drenos, cateteres e queda em UTI segundo as características demográficas e clínicas do paciente e recursos estruturais da Unidade. Os dados foram coletados por meio dos registros de INC/EA dos prontuários dos pacientes que tiveram notificado algum tipo de INC/EA no período de 2003 e 2006, inclusive, em cinco UTI de cinco hospitais do Município de São Paulo. No tratamento estatístico, foi utilizada a análise de regressão logística multivariada para a identificação dos fatores independentes de INC/EA e condições de saída da Unidade. Para a identificação dos fatores independentes do tempo de permanência nas UTI, utilizou-se a análise de regressão linear múltipla. As variáveis que entraram nos modelos foram aquelas que apresentaram na regressão logística univariada um valor de teste Wald<0,20; em todas as análises realizadas foi utilizado o nível de significância de 5%. Do total de 21.230 admissões nas UTI, 377 (1,78%) pacientes sofreram algum tipo de INC/EA. Foram notificadas 461 ocorrências, a maioria relacionada ao preparo e administração de medicamentos (196-42,51%), seguidas aos cateteres periféricos e arteriais (105-22,77%) e às sondas nasogástricas (73-15,83%). Quanto aos fatores associados aos INC/EA e recursos materiais/equipamentos e ambiente físico das unidades, o baixo número de ocorrências (16-2,82%) inviabilizou a análise dessas variáveis. Da mesma forma, nenhum hospital dispunha das escalas diárias de enfermagem com dados retrospectivos sobre os recursos humanos existentes no período do estudo. Verificou-se que o número de dias de permanência dos artefatos terapêuticos foi um dos principais fatores independentes associados aos INC/EA quer no preparo e administração de medicamentos (número de dias de TE/Traq.), quer nos cuidados com cateter periférico, sonda nasogástrica e cateter central (número de dias de artefatos terapêuticos), seguidos da gravidade e da não sobrevivência dos pacientes. Referente ao tempo de permanência na UTI, os fatores associados foram número de dias de sondas, drenos e cateteres, número de itens da prescrição medicamentosa, não sobrevivência e INC/EA com cateteres periféricos e medicamentos. Finalizando, constatou-se que pacientes não sobreviventes tiveram maior número de dias com TE/Traq., eram mais graves e apresentaram, aproximadamente, cinco vezes mais chance de sofrer um INC/EA com TE/Traq.. Considerando que o enfoque da segurança do paciente é de responsabilidade compartilhada de todos os profissionais, da área de saúde ou não, julga-se que os resultados dessa investigação contribuam para a melhoria da assistência ao paciente crítico, por abrir perspectivas para o estabelecimento de protocolos de prevenção dessas ocorrências / The safety of serious patients is a goal of the quality of service in Intensive Care Units (ICUs), therefore, the need to investigate the factors related to the occurrence of adverse events in this context. This study reports a quantitative, retrospective, analytic-transversal research that aimed to analyze the factors associated with the incidents and/or adverse events (INC/AE) in the preparation and administration of medication, in the care of endotracheal/tracheostomy tubes, probes, drains, catheters and fall in ICUs according to the demographic and clinical characteristics of patients and structural resources of the Units. Data was collected from the registry of INC/AE made in the charts of patients that were notified with some type of INC/AE in five ICUs of five hospitals of the City of Sao Paulo from 2003 to 2006. The statistical treatment consisted of an analysis of multivariate logistic regression to identify the independent factors of INC/AE and exit conditions of the Units. The author also ran the multiple linear regression analysis to identify the independent factors of the length of stay in the ICUs. Variables that presented a Wald test rate <0,20 in the univariate logistic regression entered in the models. All analysis adopted a 5% significance level. From 21.230 total admissions in the ICUs, 377 (1,78%) patients suffered some type of INC/AE. A total of 461 occurrences were notified. Most of these occurrences were related to the preparation and administration of medication (196-42,51%), followed by the peripheral catheters and A- lines (105-22,77%), and the nasograstic tubes (73-15,83%). The low number of occurrences (16-2,82%) of factors associated with INC/AE, material/equipment resources and physical settings of the units made the analysis of these variables unfeasible. The same way, no hospital made available daily nursing schedules that contained retrospective data about the existing human resources at the time of the study. The author verified that the number of days of use of therapeutic artifacts was one of the main independent factors associated with INC/AE. These related to the preparation and administration of medication (number of days of TE/Traq.), as well as to the care of peripheral catheters, nasograstic tubes and central catheters (number of days of therapeutic artifacts), followed by seriousness and non-survival of the patients. The factors associated with the length of stay in the ICU were number of days with probes, drains and catheters, number of items of the prescribed medication, non-survival and INC/AE with peripheral catheters and medication. At last, the author established that non-survival patients spent a greater number of days with TE/Traq. They were also more serious and were about five times more likely to suffer INC/AE with TE/Traq. Considering that the focus of a patient safety is shared responsibility of all professionals, from the health field or not, the author considers that the results of this investigation contribute to the improvement of the assistance to critical patients, as it opens perspectives for the establishment of protocols for the prevention of such occurrences

O ritmo intenso do envelhecimento populacional no Brasil tem levado a questionamentos sobre o impacto das mudanças demográficas em diferentes âmbitos da Seguridade Social, dentre os quais destacamos a área da saúde e, mais especificamente, as Unidades de Terapia Intensiva. Os avanços representados pelos princípios do Sistema Único de Saúde, a criação do Estatuto do Idoso e a preocupação com os direitos humanos tornam urgentes reflexões sobre o que se coloca como desafio no atendimento médico à população idosa em UTI. Médicos intensivistas têm sua atuação marcada, dentre outros fatores, pelos sentidos que atribuem à fase da vida e a visão que têm de seus pacientes idosos. Esta pesquisa teve por objetivo compreender quais os sentidos que médicos que atuam em UTI atribuem a velho/velhice/envelhecimento e suas relações com as práticas de assistência prestada aos pacientes idosos. Trata-se de pesquisa qualitativa, realizada por meio de observação participante de reuniões de equipes que atuam em UTI de um hospital escola na cidade de São Paulo, e de entrevistas com médicos que compõem estas equipes. Os dados foram analisados sob a ótica Construcionista. Os resultados apontam para a existência de uma polissemia relacionada à velhice, incluindo sentidos que podem produzir práticas idadistas quando não há uma postura reflexiva dos profissionais a respeito do tema, ou quando conflitos decorrentes da complexidade que envolve o atendimento hospitalar em diferentes contextos econômicos se impõem aos profissionais, dificultando o diálogo entre os envolvidos mais diretamente na situação de internação (profissionais da saúde, pacientes, familiares, cuidadores, gestores). Essa nova realidade demográfica deve ser discutida na formação profissional, envolvendo as novas e diferentes demandas da população idosa. Relacioná-las ao respeito ao direito humano à vida e à dignidade, e aos sentidos atribuídos aos profissionais à essa fase da vida, aos velhos e ao processo de envelhecimento, bem como à forma como esses sentidos são produzidos e os seus contextos de produção, pode contribuir para que práticas de exclusão não se (re)produzam. / The intense pace of population aging in Brazil has led to questions about the impact of demographic changes on different aspects of Social Security, among which we highlight the area of health and, more specifically, the Intensive Care Units (ICU). The advances represented by the principles of the Unified Health System (SUS), the creation of the Elderly Statute and the concerns for Human Rights, have sped up reflections on what it is a challenge in the medical care to old people population in the ICU. Intensive care physicians have marked their performance, among other factors, by the meanings they attribute to this stage of life and by the vision they have of their elderly patients. This research aimed to explain which are the meanings attributed by that physicians working in ICUs to old/old people/aging, and their relationship to practical assistance provided to elderly patients. This is a qualitative research, resulting from the participatory observations of teams working at ICU in a university hospital in São Paulo, and from interviews with the physicians who take part in these teams. Data have been analyzed from the constructionist perspective. The results signalize to the existence of an age-related polysemy, including meanings that may produce ageist practices when there is a lack of reflexive posture of professionals about the subject, or when conflicts arising from the complexity that involves inpatient care in different economic contexts are imposed to professionals, impeding the dialogue among those involved more directly in the hospitalization (healthcare professionals, patients, family members, caregivers, managers). This new demographic reality should be discussed during professional training, involving new and different demands of the elderly population. Relate those demands to the respect to the human rights, to life and dignity, and to the meanings attributed by the professionals to this stage of life, to the old people and to the aging process, as well as to the way these meanings are produced and their contexts of production, can contribute to impede the re(production) of exclusionary practices.

Royal Perth Hospital is the largest hospital in Western Australia and also has the largest intensive care unit (ICU) in the State. It was the first public hospital to provide intensive care services in Western Australia. This thesis examines the intermediateand long-term outcomes of patients admitted to the Royal Perth Hospital ICU between 1987 and 2002. Intermediate-term survival, defined as survival after discharge from hospital to one year and long-term survival, that exceeding one year after discharge, are important outcomes. Information on outcomes can be used by ICU staff in discussions with patients and their families and to inform policy decision-making and future research. The aim of this research was to examine one-year and long-term outcomes of patients admitted to the ICU between 1987 and 2002 and explore the factors that might be associated with the outcomes for 22,298 patients admitted to the ICU. A clinical ICU database was linked to morbidity and mortality databases by Data Linkage WA. A wide range of demographic and clinical factors were examined for their effect on outcome. These included age, sex, comorbidity, severity of illness, organ failure, ICU diagnostic groups, type of admission (medical, elective surgical and non-elective surgical), length of stay in ICU and era of admission (1987-1990, 1991-1994, 1995-1998, 1999-2002). Patients were followed-up to study end, 31st December 2003 or death if it occurred before study end, that is, up to 17 years after the index ICU admission. Kaplan Meier survival curves and Cox regression models were used to examine intermediate and long-term survival for patients who survived to hospital discharge. A comparison of admissions to hospital before and after the index ICU admission was made using descriptive statistics and logistic regression. Throughout the study period survival for the ICU cohort was shorter when compared to the Australian population. This was consistent throughout the follow-up period. The most important determinants of long-term survival were age, comorbidity, severity of illness and diagnostic group but the strength of association varied with the duration of follow-up. Although age, comorbidity and severity of illness increased among the critically ill survival improved over time. Hospital admissions were more frequent after a discharge from hospital that required an admission to ICU than before the index admission, even after adjusting for the ageing of the cohort. This study provides unique information about the survival and other outcomes of patients discharged from a hospital admission that included an ICU stay. The strength of this study lies in the follow-up to 17 years and the more comprehensive range of explanatory factors than in previous studies. This thesis demonstrates that follow-up studies after intensive care should be of sufficient duration to account for the changes that occur in survival over time and indicates the range of factors that should be taken into account when making comparisons of long-term survival.

<p><strong>Bakgrund:</strong> Människan tillbringar en tredjedel av sitt liv i sömn det är ett behov vilket hon inte kan vara utan. Patienter som vårdas på IVA drabbas frekvent av sömnstörningar och därmed sömnbrist. Tidigare gjorda studier tyder på att IVA patienter upplever sömnstörningar som ett stort problem.<strong> Syfte:</strong> Att beskriva sömnförändringar, sömnpåverkande faktorer och sömnförbättrande omvårdnadsåtgärder för IVA-patienter.<strong> Metod:</strong> Databassökning gjordes och nyckelord har identifierats. Studier som inkluderar vuxna patienter som vårdats på en IVA har valts för denna beskrivande litteraturstudie.<strong> Resultat:</strong> IVA-patienter drabbas av fragmenterad sömn uppdelad i korta abnorma perioder. Sömnen påverkas av mänsklig intervention, diagnostiska tester samt miljöbetingad ljus och ljud. Minskning av ljud- och ljusnivån samt sammanhängande vilotid utan intervention var de främst undersökta sömnfrämjande omvårdnadsåtgärder i de granskande artiklarna.<strong> Slutsats: </strong>Alla IVA-patienter upplevde störd sömnrytm. I vilken utsträckning sömnrytm stördes berodde på ålder, sjukdom, erfarenhet av IVA-vård och respiratorvård. Omvårdnadsåtgärder som planerad vilotid, sänkningar av ljud och ljus förbättrade sömnmönstret och skapade möjlighet till förbättrad sömn.</p>

<p>Transesophageal echocardiography (TEE) has become a useful tool in monitoring the heart in patients during open-heart surgery. This study was undertaken to evaluate whether it is feasible to use TEE to assess left ventricular myocardial viability in anesthetized patients scheduled for coronary artery bypass grafting (CABG).</p><p>A total of 84 patients were studied. To test myocardial viability, TEE and a low-dose dobutamine stress regimen were used. Echocardiographic data were analyzed off-line using a visual or semiautomatic analysis of segmental left ventricular wall motion (LVWM). Visual assessment was performed by readers blinded to the sequence of events. The agreement between readers in visual analysis of segmental LVWM in the transgastric short-axis view was 73% or higher. Segmental LVWM assessed by TEE was compared to hemodynamic data obtained by thermodilution pulmonary artery catheter (PAC) and coronary angiographic data. Also, using the same low-dose dobutamine stress regimen, TEE findings in the anesthetized patient perioperatively were compared with preoperative transthoracic echocardiography (TTE) findings in the awake patient.</p><p>TEE was found to be feasible and adequate for testing left segmental ventricular viability. A concomitant increase in stroke volume assessed by PAC and decrease in LVWM-score assessed by TEE was found with dobutamine stimulation. Abnormal segmental LVWM corresponded to angiographically stenosed supplying coronary artery vessels. During dobutamine stimulation, 69% of the corresponding segments responded which is a sign of viability. The LVWM response to preoperative TTE and perioperative TEE dobutamine stress was comparable except for a significant difference in the apical segments.</p><p>This study showed that perioperative TEE dobutamine stress could be used to test left ventricular viability and was also a valuable supplement to PAC, angiography and TTE. The acquired knowledge is important and suggest that further development of transesophageal ultrasound technology is warranted.</p>

Transesophageal echocardiography (TEE) has become a useful tool in monitoring the heart in patients during open-heart surgery. This study was undertaken to evaluate whether it is feasible to use TEE to assess left ventricular myocardial viability in anesthetized patients scheduled for coronary artery bypass grafting (CABG). A total of 84 patients were studied. To test myocardial viability, TEE and a low-dose dobutamine stress regimen were used. Echocardiographic data were analyzed off-line using a visual or semiautomatic analysis of segmental left ventricular wall motion (LVWM). Visual assessment was performed by readers blinded to the sequence of events. The agreement between readers in visual analysis of segmental LVWM in the transgastric short-axis view was 73% or higher. Segmental LVWM assessed by TEE was compared to hemodynamic data obtained by thermodilution pulmonary artery catheter (PAC) and coronary angiographic data. Also, using the same low-dose dobutamine stress regimen, TEE findings in the anesthetized patient perioperatively were compared with preoperative transthoracic echocardiography (TTE) findings in the awake patient. TEE was found to be feasible and adequate for testing left segmental ventricular viability. A concomitant increase in stroke volume assessed by PAC and decrease in LVWM-score assessed by TEE was found with dobutamine stimulation. Abnormal segmental LVWM corresponded to angiographically stenosed supplying coronary artery vessels. During dobutamine stimulation, 69% of the corresponding segments responded which is a sign of viability. The LVWM response to preoperative TTE and perioperative TEE dobutamine stress was comparable except for a significant difference in the apical segments. This study showed that perioperative TEE dobutamine stress could be used to test left ventricular viability and was also a valuable supplement to PAC, angiography and TTE. The acquired knowledge is important and suggest that further development of transesophageal ultrasound technology is warranted.

Introduction. Multiple clinical methods for detecting myocardial ischemia are utilised in the hospital setting each day, but there is uncertainty about their diagnostic accuracy. In the operating room, multiple methods may be employed, while in the CCU advanced electrophysiological (ECG) techniques for myocardial ischemia detection, and in particular, ST segment analysis, are common. Vectorcardiography (VCG) is one form of ECG. Several conditions other than ischemia may cause marked ST changes, which can impair the process of diagnosis of clinical ischemia. Elevated HR is one of these factors, which is studied here. The hypotheses were about concordance of different methods to detect ischemia, and relation of ECG ST levels to HR with and without myocardial ischemia. Methods. Study I. Anesthetised vascular surgical patients with coronary artery disease were studied during the start of anesthesia and surgery: ECG, hemodynamic, mechanical, and metabolic parameters were measured and categorised as positive or negative with reference to a specific definition of myocardial ischemia. Study II. Awake patients with no ischemic heart disease were paced in graded steps, and VCG ST analyses were performed. Study III. Anesthetised pigs were studied for local metabolic and VCG ST changes related to controlled HR levels and transient coronary occlusion. Study IV. Thirty five anesthetised coronary artery disease (CAD) patients and ten non-CAD patients were paced at controlled levels, and great coronary artery vein (GCV) lactate measurement was used to determine presence or absence of myocardial ischemia. The CAD patients were paced up to HR levels where myocardial ischemia could be confirmed. The relation of HR-related VCG ST levels to presence or absence of ischemia was analysed. In Studies II,, III, and IV the ST vector magnitude (ST-VM), the change from baseline in ST-VM (STC-VM), and the vector angle change from baseline (STC-VA) were analysed for each step. Results. Study I. Poor concordance was demonstrated for positive events (presumed myocardial ischemia) between the hemodynamic, ECG, mechanical, and metabolic detection methods. Study II. STC-VM but not ST-VM levels demonstrated HR-related increases in the presumed absence of myocardial ischemia in 18 awake subjects. J point time to ST measurement did not affect the response of VCG ST to HR. Study III. STC-VM levels showed HR-related increases in the absence of ischemia (tested by local metabolic observations). VCG ST parameters responded positively to transient regional ischemia. Study IV. CAD patients, which demonstrated a clear pattern of onset and progress of ischemia during pacing, were further analysed for the relation of VCG ST level to ischemia. Sensitivity and specificity of STC-VM levels were described by ROC analysis for a range of STC-VM levels. Conclusions. Concordance of different measures for detection of onset of myocardial ischemia is difficult to assess in the absence of a very reliable reference method. The contribution of HR and ischemia to VCG ST levels were estimated in study subjects. HR-related increases in STC-VM occur in the absence of ischemia. HR levels need to be considered when interpreting STC-VM as a diagnostic test for ischemia. Further study is needed to establish criteria that take into account multiple clinical factors in order to improve the predictive value of our tests for myocardial ischemia.

Det övergripande syftet med avhandlingsarbetet är att illustrera och belysa upplevelsen av att vara patient med behov av ledprotes, avseende aspekterna kommunikation, smärtupplevelse, lidande och tillfredsställelse med vård och behandling. Under väntetiden för ledprotesoperation upplever deltagarna i studierna lidande i olika former, tillika att vården är otillgänglig och onåbar i ett ansiktslöst system (I). Att få information om sin sjukdom vad man kan/får/ska göra är nästan omöjligt. Kontakten med sjukvården är svår att upprätta och det är mestadels patientens ansvar att söka information om vad som händer (II). Den bristfälliga kommunikationen som deltagarna i delstudie I upplever, leder till att de känner sig missförstådda och nedvärderade av sjukvårdssystemet, och därmed befinner sig i en ständig kamp för att få sitt vårdbehov bekräftat. Under deltagarnas vandring i sjukvårdssystemet förändras deras negativa uppfattning om vården till att bli mer positiv när en reell kommunikation och personlig kontakt etablerats (IIV). Fynden i arbetena (I-IV) tolkas inom ramen för Katie Erikssons och Lennart Fredrikssons beskrivningar av lidande och det vårdande samtalet. En del deltagare i studierna har av egen kraft, eller till följd av personliga egenskaper uppnått insikter om sig själva och försonats med sitt lidande, på så sätt har de kunnat bibehålla eller uppnå mening i sin tillvaro. Av egen kraft, eller med hjälp av anhöriga kan individerna få sitt lidande bekräftat och därmed möjligheten att kunna lida ut och försonas med sig själv och den förändrade tillvaron. Så länge som sjukvården upplevs som ett ansiktslöst system finns det deltagare i avhandlingen som inte klarar av att ta itu med sitt lidande. Under patientens vandring i sjukvårdssystemet blir det uppenbart att systemet får ett ansikte först när deltagarna kan relatera till vården i form av en reell person. Vården får inte ett ansikte så länge som patienten upplever sig dåligt bemött utan detta sker när det med Fredrikssons termer uppstår ett vårdande samtal. Under väntetiden för operation finns det relativt få tillfällen där ett vårdande samtal har möjlighet att uppstå. Möjligheten för detta är dock större när patienten väl är inlagd på sjukhuset för att bli opererad, vilket återspeglas i den höga grad av tillfredsställelse med vården som uttrycks i delstudie II-IV. Patienterna är tillfredsställda med vård och behandling, trots att de har upplevt postoperativ smärta i en hög grad. I delstudie III var det 68% (n=40) och i delstudie IV 83.5% (n=50) som hade upplevt smärtor motsvarande ≥ 4 på Visuell Analog Skala (VAS). Under sjukhusvistelsen upplever sig patienten bekräftad och synlig i systemet. Synligheten är ömsesidig då även vården (systemet) får ett ansikte på patienten. I ett vårdande samtal uppstår en känsla av tillit och när detta sker vågar patienten och vårdaren kommunicera på ett öppet sätt där de båda är närvarande i situationen / The overall objective of the thesis is to describe and illustrate the experience of being an arthroplastic surgery patient during the perioperative period with regard to the issues of communication, pain,suffering and satisfaction with care. While waiting for surgery, the participants in this thesis experience suffering in different ways and mainly experience health care as being unavailable and negative in a faceless system (I). Obtaining information related to their illness is difficult, as it is hard to establish contact with health care providers. The responsibility for establishing contact and obtaining information rests solely with the patients (II). In Paper I, due to poor communication, the respondents express feelings of abandonment, anonymity and being disparaged by the health care system. During the participants' journey through the health care system, the negative experience acquires a more positive nature, as personal contacts are established with health care representatives (I-IV). The findings in the different papers (I-IV) are interpreted in the light of Katie Eriksson and Lennart Fredriksson’s descriptions of suffering and the caring conversation. There are participants in this thesis who have been able to reach a personal understanding of themselves and have found reconciliation in suffering. In this way, they have been able to maintain or obtain meaning in their lifeworld. Through their own power, or with the help of family and friends, individuals may be able to attain confirmation of their suffering, have the time and space to suffer and find reconciliation. However, as long as health care is experienced as a faceless system, there are individuals in this study who are unable to face their suffering. During the patients’ journey through the system, it becomes obvious that the system obtains a face when the individuals are able to establish trustful contact with an actual person within the system. The system does not obtain a face as long as the individuals perceive themselves as being poorly treated by health care representatives. In these cases, the system is actually the cause of additional suffering. In the terms defined by Fredriksson, the system obtains a face when a turning point occurs in the form of a caring conversation. During the waiting time, there are few opportunities for a caring conversation. An opportunity is more likely to occur when the individual is admitted to hospital. This is reflected in the extensive degree of satisfaction with care as expressed in Papers II-IV. High levels of satisfaction are reported, although the participants report having experienced high levels of postoperative pain. In Paper III, 68% (n=40) and, in Paper IV, 83.5% (n=50) of the patients experienced pain of ≥ 4 on the Visual Analogue Scale (VAS). When they have been admitted to hospital, the individuals sense that they are confirmed by and visible in the system. This visibility is mutual, as the individual becomes an actual person to health care representatives. In a caring conversation, a sense of trust is established and, as this occurs, the individual and the care provider dare to communicate in an open way, where both are present in the situation.