Sammanfattning Syftet med studien var att belysa vilka faktorer expertsjuksköterskor vid intensivvårdsavdelningar ansåg vara viktiga att ta hänsyn till vid lyckad urträning av patienter vid ventilatorvård. En beskrivande kvalitativ ansats valdes för denna studie. Datainsamlingen genomfördes med semistrukturerade intervjuer och analyserades med kvalitativ innehållsanalys. Tolv expertsjuksköterskor inom intensivvård valdes ut av sina avdelningschefer på tre intensivvårdavdelningar i Mellansverige under hösten 2008. I resultatet från intervjuerna framkom åtta kategorier som bildade två teman. Första temat var, sjuksköterskan driver processen framåt genom erfarenhet och beslutsamhet. Det bildades ur kategorierna, helhetsbild av urträningsprocessen, patientens förutsättningar, beslutsprocessen, tvärprofessionellt samarbete och sjuksköterskornas egna upplevelser. Det beskrev hur urträningsprocessen drevs framåt av intensivvårdssjuksköterskornas beslutsamhet och erfarenhet, men visade också hur viktigt teamarbetet var. Det andra temat var, sjuksköterskan använder sig själv som verktyg. Det framkom ur kategorierna, en trygg patient, samarbete med patienten och anhörigas roll. Temat visade att sjuksköterskornas intuition och fingertoppskänsla var viktig och att sjuksköterskrna hade ett stort personligt engagemang i patientens med- och motgångar. Studien visade att det inte finns någon enhetlig metod eller "guidelines" för att träna ur patienterna vid ventilator behandling. Mycket av framgången berodde på teamets förmåga till samarbete. Intensivvårdssjuksköterskor verkade ha en central roll i hela urträningsprocessen och använde sig själv som redskap. Nyckelord: urträning, omvårdnad, intensivvård, teamarbete / Abstract The aim of the study was to elucidate which factors expert nurses at intensive care units considered to be important with regard to successful weaning patients from ventilator treatment. A descriptive qualitative approach was chosen for this study. The data collection was conducted with semi-structured interviews. Twelve expert nurses in intensive care were chosen by their head nurses at three intensive care units in mid Sweden in autumn 2008. In the results based on interviews eight categories emerged that formed two themes. The first theme was, the nurse drives the process forward by experience and determination. It was formed from the categories: the overall picture of the weaning process, the patient’s condition, the decision process, interdisciplinary cooperation and the nurses own experiences. It described how the weaning process was driven forward by the intensive care nurses determination and experience, but also showed how important the teamwork was. The second theme was, the nurse uses herself as a tool. It was formed from the categories: a confident patient, cooperation with the patient and the role of the relatives. The theme showed that the nurses’ intuition and instinctive feeling were important and that the nurses really were engaged in the patients’ successes and setbacks. The study demonstrated there is no homogeneous method or guidelines how to perform weaning from the ventilator. The success was depending on the teamwork. Intensive care nurses seemed to have a central roll thru the entire weaning process and used them self as tools in the process. Keywords: weaning, care, intensive care, teamwork

Thermoregulation is considered a top priority in neonatology due to the fact that relative to adults, neonates have a morphological susceptibility to excessive heat exchange with the environment, and exhibit limited physiological/behavioural responses to thermal strain. Consequently, the environmental conditions in which they are nursed must be tightly regulated to maintain body temperature stable. Neonatal intensive care units (NICU) use radiant warmers (RW) to thermally manage many newborns. However, recent evidence suggests that RW induce intermittent bouts of thermal strain that could adversely affect patients. This warrants further investigation of neonatal heat balance and the pertinent factors affecting it. Conducting an exhaustive audit of heat exchanges affecting the body during standard care under a RW could yield important information that would lead to the improvement of clinical practice in NICUs. The present thesis focuses on neonatal thermoregulatory responses, various body heat exchange mechanisms and processes during standard care under RW.

The pediatric intensive care unit (PICU) has been described as a stressful place for parents of critically ill children. Research to date has examined parents’ needs and stressors with a child in PICU. There is a paucity of research examining the experience for parents of a child who is transferred from the PICU to the hospital ward. Open-ended interviews were conducted with 10 parents within 24-48 hours after transfer from a PICU to a hospital ward at a children’s hospital in Canada to understand this experience. Parents revealed that the experience involved a search for comfort through transitions as expressed through the themes of: ‘being a parent with a critically ill child is exhausting’, ‘being kept in the know’, ‘feeling supported by others’, and ‘being transferred’. The findings from this study can help nurses and other health professionals working with parents to support them through the transition from PICU. Recommendations are made for the inclusion of family-centered care practices to assist parents through transitions.

Some aspects of the stress response during acute intensive care for severe burns are described and quantified by measuring hormonal and neuroendocrine patterns and relating these to organ function in the short term. This includes an assessment of whether there are markers for the severity of stress that are better than conventional descriptors of the severity of a burn in predicting failing organ function. P-CgA after a major burn injury is an independent and better predictor of organ dysfunction assessed as SOFA score than the traditionally used TBSA% burned. The results also suggest that the extent of neuroendocrine activation is related to organ dysfunction, and this motivates a more extensive effort to evaluate P-CgA as a prognostic marker with respect to mortality and long-term outcome. P-NT-proBNP exhibited a complex pattern with considerable inter-individual and day-to-day variations. Values of P-NT-proBNP were related to size of burn, water accumulation and systemic inflammatory response. A considerable covariation with trauma response and SOFA scores was observed in day by day analyses, but with weight change only on day 2. Maximum P-NT-proBNP showed a stronger correlation with SOFA score on day 14, with mortality, and with LOS, than did age and TBSA% burned. High values were also independent predictors of all subsequent SOFA scores up to two weeks after injury. P-NT-proBNP and NT-proANP reflect and predict organ function after burn injury similarly, notwithstanding a significantly larger intra-individual variability for P-NT-proBNP. P-NT-proBNP, but not NT-proANP, reflects the systemic inflammatory trauma response. Free cortisol concentration was related to the size of burns, as was the circadian cortisol rhythm. This effect of burn size was, at least in part, related to its effect on organ function. This thesis points to the fact that the stress response is richly interwoven, and cannot be adequately assessed by one biomarker only. All biomarkers studied here can be viewed as representing efferent limbs of the stress reaction, and they would need to be supplemented by biomarkers representing individual physiologic responses that follow the stress signaling.

This study examines the impact of the physical setting in the care and healing process of hospitalized children, their families, and the caregivers in two selected pediatric intensive care units (PICUs) in the U.S. and Turkey. A holistic, cross-cultural, comparative, and naturalistic approach emphasized the importance of the total (i.e., physical, social, cultural, spiritual, organizational, political) environment and quality of life to health and healing. Information was gathered through qualitative methods such as participant observations, behavioral maps, in-depth interviews, and floor plan analysis. Despite some universal features of the PICU atmosphere, the value and place ascribed to pediatric critical care in Turkey and the U.S. present different worldviews. Field studies revealed social interaction as a universal healing function despite its cultural specificity stemming from socio-cultural, ethnic, economic, and religious differences between different groups. Crowding, parental absence, and over-stimulation, which stem from the lack of individual patient rooms, and organizational problems related with human resources and staffing shortage play against the critically ill child’s deep need to heal in the Turkish PICU. Despite spatial limitations, informal social interactions and cooperative relationships among caregivers, their devotion, and their ability to adapt to the existing physical and social environment enable care delivery. While staffing shortage continues to be a crucial problem in the U.S. model, specialization of labor and the systemic organization in general support care delivery, reducing the importance of informal social interactions and cooperation among caregivers. However, emphasizing the role of the family in the child’s care, social interaction is also identified as a healing function in this setting. Therefore, despite the significant role the physical setting may play in healing, social interaction is found to be more important for improving patient outcomes and the well-being of families and caregivers. The study focuses on six healing design interventions to increase the chances for positive social interaction and collaboration. These are programmatic (provisional, scale, locational), functional, ambient, symbolic, social and psychological interventions.

The prevalence of psychiatric symptoms in next-of-kin (NOK) of intensive care unit (ICU) patients has been reported at higher than 70% when screening is performed using the Hospital Anxiety and Depression Scale (HADS). The primary purpose of this study was to assess the ability of the HADS to predict psychiatric illness, diagnosed with the aide of a validated tool, the Structured Clinical Interview for DSM-IV (SCID). In addition, we asked NOK to rate aspects of the ICU experience to determine possible associations with psychiatric diagnosis. Thirty-four NOK were enrolled in this study from July 2006 to November 2006. Subjects were interviewed to gather demographic information, their perception of the ICU experience, and to administer the SCID and the HADS. At least 6 months later, subjects were contacted by telephone to determine presence of psychiatric morbidity after the ICU experience. Fifty-six percent of all NOK experienced symptoms of either anxiety or depression during the ICU admission and 24% had psychiatric illness. The HADS had 100% sensitivity and 58% specificity when used as a screening tool for psychiatric diagnosis. Those with any SCID diagnosis were more likely to be a spouse (50% vs. 9%, p = 0.013) or a primary caregiver (60% vs. 8%, p = 0.003). Most NOK identified the healthcare team as supportive, though a subgroup of NOK who slept in the ICU reported that they found the healthcare team less supportive. This small study suggests the HADS is able to predict psychiatric illness in NOK of ICU patients. The ability to implement this tool as part of clinical practice to better meet the needs of families in the ICU warrants further investigation.

Thesis (Ph. D.)--University of Texas at Austin, 1999. / Vita. Includes bibliographical references (leaves 131-169). Available also in a digital version from Dissertation Abstracts.

Thesis (MCur (Nursing Science))--University of Pretoria, 2009. / Summary in English. Includes bibliographical references.

Thesis (MCur (Nursing Science))--University of Pretoria, 2009. / Summary in English. Includes bibliographical references.

Thesis (Ph.D.) -- Simmons College, 2009. / Includes bibliographical references (l. 238-247)