Vårdas på en intensivvårdsavdelning och vara allvarligt sjuk är för många en obehaglig upplevelse. Övervakning och behandling av vitala funktioner sker dygnet runt i en miljö som är främmande för patienten. Många patienter har på grund av läkemedel och behandling svårt att kommunicera, vilket kan leda till minnesförlust och hallucinationer. Sjuksköterskan kan som en del i omvårdnaden skriva en dagbok över vårdtiden. Syftet med litteraturstudien var att belysa patientens upplevelser av att läsa sin dagbok över vårdtiden på intensivvårdavdelningen och hur det kan påverka patientens återhämtning. Tolv artiklar analyserades och sammanställdes i fem kategorier: Upplevelse av att få och läsa sin dagbok, Betydelsen av att känna sig omhändertagen, Att få insikt i sin egen sårbarhet, Att tolka minnen och fylla minnesluckor och Dagbokens betydelse för återhämtningen. Många patienter mår psykiskt dåligt efter intensivvårdstiden. Resultat visar att dagboken hjälpte dem att hantera tiden efteråt med att fylla minnesluckor och snabbare återhämta sig. Patienterna upplevde sig mer omhändertagna och såg dagboken som en gåva. För att hjälpa patienten på bästa sätt skulle vidare forskning om vad dagboken bör innehålla vara av intresse. / To become seriously ill and cared for in an intensive care unit is for many an unpleasant experience. Monitoring and treatment of vital functions takes place around the clock in an environment that is foreign to the patient. Many patients, due to drug treatment and difficulties in communication, can suffer from memory loss and hallucinations. As an act of caring, the nurse can write a diary throughout the hospital stay. The aim of this study was to focus on the patient's experience of reading a personal diary of their time in the intensive care unit and assess how it can affect the patient's recovery. Twelve articles were analyzed and summarized in five categories: Experience of receiving and reading the diary, The importance of feeling cared for, To gain insight into their own vulnerability, To interpret memories and fill memory gaps and The diary's importance for recovery. Many patients feel unpleasant after a period of intensive care. Results have shown that the diary helped them cope with time afterwards as it filled memory gaps which supported a faster recovery. Patients felt a greater level of care and received the diary as a gift. To optimize this support for the patient, further research on what the diary should contain would be of interest.

SAMMANFATTNING Syftet med studien var att studera hur sjuksköterskan inom intensivvård använder NuDesc(The Nursing Delirium Screening Scale) och om de anser sig ha tillräcklig kunskap för attbedöma delirium med hjälp av NuDesc. Studien är en kvantitativ tvärsnittsstudie med datainsamling via en enkät som konstrueratsspeciellt för denna studie. Enkäten besvarades av 15 intensivvårdssjuksköterskor på ettuniversitetssjukhus i Mellansverige. Resultatet visade att bedöma delirium på en intensivvårdsavdelning uppfattas avrespondenterna som ganska svårt även om de tycker sig ha tillräckligt med kompetens attanvända bedömningsinstrument NuDesc. Den psykomotoriska förlångsamningen tillsammansmed hallucinationer/ illusioner uppfattas av sjuksköterskorna som svårast att bedöma. / ABSTRACT The aim of the study was to examine how the nurse in intensive care use NuDesc (TheNursing Delirium Screening Scale) and if they feel they have sufficient knowledge to assessdelirium using NuDesc. The study is a quantitative cross-sectional study with data collection through a questionnairedesigned specifically for this study. The survey was answered by 15 ICU nurses at auniversity hospital in central Sweden. The results showed that to assess delirium in intensive care was perceived by respondents tobe quite difficult even if they think they have enough skills to use the assessment instrumentNuDesc. Psychomotor retardation with illusions/ hallucinations are perceived by nurses as themost difficult to assess.

published_or_final_version / Nursing Studies / Master / Master of Nursing

Bakgrund: Organdonation från avlidna är idag vanligt förekommande för att ge liv och hälsa åt svårt sjuka patienter. Operations- och intensivvårdssjuksköterskor är två av de yrkeskategorier som arbetar mest intimt med donatorvård, ett arbete som befunnits kunna ge såväl etiska som psykologiska efterverkningar. Syfte: Att sammanställa kunskap kring hur dessa yrkesgrupper upplever och hanterar arbetet med att vårda avlidna donatorer, med fokus på de strategier som används för att patienten ska behandlas med respekt och värdighet. Metod: Litteraturstudie med kvalitativ ansats. En litteratursökning i databaserna PubMed och CINAHL resulterande i 15 artiklar som inkluderades i resultatet. Resultat: Analysen genererade tre teman; ”Att vårda de döda” samlar utsagor och företeelser förknippade med denna vård. Här framkom synen på arbetet som stressigt och mentalt mycket tungt. Bristande förmåga att ta till sig hjärndödhetsbegreppet var vanligt och gjorde arbetet än svårare och mer etiskt utmanande. ”Att möjliggöra ett värdigt slut” beskriver en värdig behandling och strävan mot ett värdigt slut för donatorerna som de mest centrala förhållningssätten i vården av avlidna donatorer. I ”Att själv finna mening” beskrivs hur respondenterna, framför allt, genom att stötta varandra och genom vetskapen om det goda som kom ut av organdonation, både för de anhöriga och för organmottagarna. Ändå fann arbetet meningsfullt och givande. Slutsats: Denna studies resultat visar upp en bred problematik på en rad områden gällande vård av avlidna donatorer. Samtidigt som värdighet och respekt för de avlidna ansågs både viktigt och tillfredsställande. Att se sig själv och det goda som uppnåddes med arbetet, i ett större perspektiv gjorde arbetet positivt och tillfredsställande, trots de negativa aspekterna. / Background: Organ donation from deceased donors has become a common procedure that enables health and prolonged life for critically ill patients. Two of the professions most intimately involved with the care of the donors are operating room and intensive care nurses. This care has been found to cause adverse effects, ethical and psychological. Aim: To gather knowledge regarding how these two professions perceive, and cope with, the care of deceased donors. Focusing on strategies used to preserve and maintain respect and dignity for the donors. Method: Literature review with a qualitative approach. Results: Three themes emerged; ”Caring for the dead” collects statements and phenomena associated with the care. This was perceived as mentally exhausting and very stressful. Lack of understanding for the concept of brain death was common, which made the work harder and more ethically challenging. ”Facilitating a dignified end” established that very concept as the main purpose of the actions during donor care. ”To find a purpose” describes how the respondents, mainly, through support for each other and through the knowledge of the positive outcomes of organ donation, both for the donors’ families and for the organ recipients, still found meaningfulness and satisfaction in their work. Conclusion: This study displays a broad spectrum of adversities associated with donor care, in several areas. Dignity and respect for the deceased was deemed both highly important and personally satisfying. To see oneself and the good things achieved through ones labor, in a larger perspective, made donor care both positive and satisfying.

Tidigare forskning inom intensivvårdsområdet har visat att ej adekvat utförd munvård kan leda till allvarliga livshotande sjukdomar. Det är av därför av vikt att munvård utförs enligt gällande rekommendationer och följer evidensbaserad forskning. Syftet var att identifiera intensivvårdssjuksköterskans beskrivning av tillvägagångssätt, delaktighet och dokumentation vid utförande av munvård hos patienter inneliggande på IVA. En kvantitativ ansats valdes med målsättning att göra en undersökning med hjälp av enkätfrågor. Inklusionskriterier var specialistutbildade sjuksköterskor inom intensivvård som tjänstgjorde på tre intensivvårdsavdelningar i västra Sverige under aktuell studieperiod. Sammanlagt distribuerades 182 enkäter och 103 svar erhölls vilket gav en svarsfrekvens på 60 %. Resultatet visade att munvård var en prioriterad omvårdnadsåtgärd på avdelningarna och tillvägagångssättet följde till stor del fastställda riktlinjer. Det framkom att i begreppet munvård ingick huvudsakligen inspektion av munhålan, mekanisk rengöring, fuktning av slemhinna och läppar, inspektion av tänder och tandkött samt sugning av munhåla och svalg. De verktyg som huvudsakligen användes var tandborste, muntork eller liknande samt antibakteriellt medel. Ett signifikant samband förekom vad gäller sjuksköterskans delaktighet vid utförande av munvård hos intuberade patienter jämfört med övriga patienter (p=0,02). Detta ansågs vara en mer komplex omvårdnadsåtgärd vilken krävde samarbete med övriga medarbetare. Munvård delegerades ofta till undersköterskor men det är dock sjuksköterskans uppgift att leda och ansvara för omvårdnaden.  Dokumentation vad gäller munvård utfördes i de flesta fall på en observationskurva. Ett mindre antal sjuksköterskor angav att dokumentation även utfördes i datajournal. Ett flertal sjuksköterskor angav att dokumentation dessutom utfördes på interna checklistor. Det framkom att flera sjuksköterskor dokumenterade i datajournal enbart vid avvikelser eller om komplikationer tillstött. / Previous studies in the intensive care areas have shown that inadequate oral care may predispose patients to life-threatening diseases and conditions. The role of oral hygiene in maintaining the health of patients in the ICU is indisputable and therefore the importance of oral care evidence-based clinical recommendations. The purpose of this study was to identify the intensive care nurses description of the conducting, participation and documentation of oral care performed by nurses on patients in ICUs. A quantitative study with a describing design has been used which is based on the statistical analysis of data collected by structured questionnaires. The inclusion criteria were nurses working in three ICUs located in West Sweden during the study period. One hundred eighty-two questionnaires were distributed and replies were received from 103 nurses which gave a response rate of 60%. The result showed that the oral care conducted followed the evidence-based clinical recommendations and was given a high priority. The majority of the nurses performed an oral assessment before beginning oral care which included inspection of the oral cavity and inspection of teeth and gum. Oropharyngeal suction and moisturizing of lips and the mucosal membrane was also included. The most common used equipment was toothbrushes and foam swabs. Chlorhexidine was the most common solution used. A significant correlation was observed regarding nurse participation when conducting oral care for an intubated patient compared to other patients (p=0,02). Intubated patients were considered having more complex oral care needs which were associated with the demand of more than one person providing oral care. In practice, nurses frequently delegate the conducting of oral hygiene to nursing assistants, but the law clearly describes the role of the nurse as responsible and the leader of care practices. Oral care was in most cases documented on the unit’s flow sheet. A fewer number of nurses commented on that oral care was documented in the electronical clinical journal. A considerable   number of nurses also indicated that oral care in addition was documented on the unit’s internal checklists. It appeared that several nurses used the electronical clinical journal in cases only when abnormalities or complications had occurred.

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Η Μονάδα Εντατικής Θεραπείας – Μ.Ε.Θ. (Intensive Care Unit – ICU) προϋποθέτει ευρύ φάσμα γνώσεων από έναν επαγγελματία υγείας (νοσηλευτή ή ιατρό), που εργάζεται στον χώρο. Σε καθημερινή βάση έρχεται αντιμέτωπος µε απειλητικές καταστάσεις για τη ζωή του ασθενούς και η αντιμετώπιση των διαταραχών της οξεοβασικής ισορροπίας είναι το στοίχημα, που πρέπει να κερδηθεί. Η ορθή ερμηνεία της ανάλυσης των αερίων του αρτηριακού αίματος από έναν επαγγελματία υγείας αποτελεί το βασικό συστατικό για την προαγωγή της υγείας ενός ασθενή στη Μ.Ε.Θ. Όμως παρά την αλματώδη τεχνολογική εξέλιξη του εργαστηριακού τομέα διαπιστώνουμε μια πολύχρονη στασιμότητα στον διαγνωστικό τομέα. Αυτό έχει ως αποτέλεσμα την επιπλέον επιβάρυνση της υγείας του ασθενή, αλλά και επιπρόσθετο φορτίο στο οικονομικό σκέλος. Στη παρούσα διπλωματική εργασία περιγράφεται η δημιουργία ενός ευφυούς συστήματος υποστήριξης αποφάσεων, με σκοπό να αποτελέσει σύμβουλο λήψης αποφάσεων από μη εξειδικευμένους επαγγελματίες υγείας, όταν αυτοί αντιμετωπίζουν προβλήματα οξεοβασικών διαταραχών στις ΜΕΘ, αλλά και να συμβάλλει στην αποτελεσματικότερη και ταχύτερη υποστήριξη του νοσηλευτικού και ιατρικού προσωπικού γενικά. Επίσης στόχος της διπλωματικής αυτής εργασίας είναι να αξιολογηθούν και να συγκριθούν οι μέθοδοι, διά των οποίων δημιουργήθηκε το ευφυές σύστημα. Για να γίνει αυτό δημιουργήσαμε 4 διαφορετικά συστήματα. Στη δημιουργία του πρώτου συστήματος χρησιμοποιήθηκαν κανόνες ασαφούς λογικής(FuzzyClips) και στα επόμενα τρία, μέθοδοι εξόρυξης γνώσης με μηχανική μάθηση. Στο τέλος έγινε η σύγκριση αποτελεσματικότητάς τους, με βάση διεθνώς χρησιμοποιούμενες μετρικές.Τα συστήματα με τη βοήθεια μεθόδων εξόρυξης γνώσης του WEKA παρουσίασαν και τη μεγαλύτερη αποτελεσματικότητα. Τα συστήματα αυτά δεν έχουν σκοπό την αντικατάσταση ενός επαγγελματία υγείας. Έχουν ως κύριο στόχο να λειτουργήσουν επικουρικά, στην καλύτερη, ταχύτερη και πιο αξιόπιστη διάγνωση οξεοβασικών διαταραχών των ασθενών, που νοσηλεύονται σε Μονάδα Εντατικής Θεραπείας ενός νοσοκομείου, αλλά και να χρησιμοποιηθεί ως εργαλείο με εκπαιδευτικό χαρακτήρα σε αρχάριους επαγγελματίες υγείας . / -

Septic shock is frequently seen in intensive care units and is associated with significant mortality. Endotoxin – a major mediator of the pathophysiologic responses – is released during lysis of Gram-negative bacteria. These responses can be mimicked in the endotoxaemic pig. This thesis focuses on the following topics: the inflammatory and pathophysiological responses to various endotoxin doses and infusion patterns; covariations between endotoxin induced inflammatory and pathophysiological responses; whether the biological effects of endotoxin can be modulated by clopidogrel and whether tobramycin or ceftazidime reduce plasma cytokine levels. Endotoxin induced linear log-log cytokine and F2-isoprostane responses. Leukocyte and platelet responses, pulmonary compliance, circulatory variables as well as indicators of plasma leakage and hypoperfusion exhibited log-linear responses to the endotoxin dose. Biological responses to endotoxaemia such as inflammation, hypotension, hypoperfusion and organ dysfunction were more expressed when the organism was exposed to endotoxin at a higher rate. These results may facilitate the possibility to choose relevant endotoxin administration, when experiments are set up in order to evaluate certain responses to endotoxaemia. Correlation studies between cytokines, leukocytes, platelets and the endotoxin dose were in agreement with the well-known ability of endotoxin to induce cytokine expression and to activate both primary haemostasis and leukocytes. Free radical mediated lipid peroxidation and COX-mediated inflammation correlated to cytokine expression and organ dysfunction in endotoxaemic shock. Endotoxaemic pigs pretreated with clopidogrel, exhibited a trend towards less expressed deterioration of renal function, although blocking of ADP-induced primary haemostasis is not a key mediator of endotoxin induced deterioration of renal function. Tobramycin did not neutralise the biological effects of endotoxin or the plasma levels of endotoxin, suggesting that these antibiotics do not bind to endotoxin. Reduction in IL-6 was greater in pigs treated with ceftazidime and tobramycin as compared with those given saline, indicating a possible anti-inflammatory effect of both antibiotics.

A substantial number of patients undergoing cardiac surgery are on dual anti-platelet treatment with clopidogrel and aspirin. A disadvantage with this treatment is increased risk of bleeding. Bleeding is a complication of major concern associated with adverse outcome for the patient and increased hospital resource utilization. Great variability in individual response to clopidogrel has been reported. If in vitro measurements of platelet reactivity would correlate with clinical bleeding parameters, potential bleeders could be identified preoperatively. The aims of this thesis were: (1) to describe the degree of pre-operative platelet inhibition in patients scheduled for primary isolated coronary artery bypass graft surgery; (2) to prospectively investigate whether the pre-operative platelet inhibition correlated with intra- and postoperative bleeding and transfusion requirements; and (3) to test the ability of clinically relevant risk factors to predict re-exploration for bleeding. (4) In addition, a cost analysis was performed on patients re-explored for bleeding, to analyse the magnitude of added resource utilization and costs. Based on this, a cost model of prophylactic treatment with haemostatic drugs was calculated. Platelet function tests investigated were: (1) flow cytometry, (2) VASP, (3) VerifyNowSystem, (4) PlateletMapping (a modified TEG), and (5) PFA-100. Clinical risk factors for re-exploration and the influence of antiplatelet and antifibrinolytic therapy were evaluated in a retrospective analysis. Cost analysis at three cardiothoracic centres was performed in a case-control study. In conclusion, there was no clinically useful correlation between preoperative assessment of platelet inhibition and blood loss or transfusion requirements during coronary artery bypass surgery. Furthermore, there was only modest agreement between the methods evaluating ADP-receptor blockade. Pre-operative treatment with the P2Y12-receptor inhibitor clopidogrel was an essential risk factor for re-exploration due to bleeding. Except for clopidogrel, no strong clinical factor to predict the risk of re-exploration was identified. The resource utilisation costs were 47% higher in patients requiring re-exploration due to bleeding than in those not requiring re-exploration. Prolonged stay in the ICU and recovery ward accounted for half of the added cost, a third was due to the costs of surgery, one fifth due to increased cost of transfusions, and <2% was due to haemostatic drug treatment.