Studier visar att ungefär var tionde patient upplever stickrädsla, en rädsla för nålstick som gör att de undviker att söka vård vilket i sin tur kan leda till hälsoproblem på lång sikt. Att utföra venpunktion är en vanlig arbetsuppgift för anestesisjuksköterskan och hur hon hanterar patientens stickrädsla är av stor betydelse för hur patienten upplever vården som helhet. Anestesisjuksköterskan ska genom dialog med patienten bekräfta patientens rädsla och hjälpa patienten att känna trygghet på bästa sätt. När patienten upplever lidande på grund av vård, i detta sammanhang venpunktion uppstår vårdlidande och detta vårdlidande kan anestesisjuksköterskan förebygga. Syftet med studien är att beskriva anestesisjuksköterskors erfarenhet av mötet med vuxna patienter med stickrädsla. Åtta anestesisjuksköterskor intervjuades på fyra olika operationsavdelningar i Västsverige. Studien har en kvalitativ ansats och de utskrivna intervjuerna är analyserade med innehållsanalys. I resultatet framkom tre kategorier; stödjande faktorer och hindrande faktorer för anestesisjuksköterskan i mötet med den stickrädda patienten samt patientnära faktorer som påverkar mötet. Anestesisjuksköterskorna utför omvårdnadsåtgärder för att minska patientens vårdlidande och har som mål att göra det bästa för patienten. De ser och tolkar patienternas tecken på rädsla och bemöter dem utifrån dessa. Anestesisjuksköterskornas erfarenhet och kunskap gör att de blir trygga i sin yrkesroll och kan på så sätt skapa en trygghet hos patienten. / Program: Specialistsjuksköterskeutbildning med inriktning mot anestesisjukvård

Bakgrund: Idag utförs åtskilliga pediatriska operationer – i Sverige opererades omkring 90 000 barn mellan noll till fjorton år 2017. Att sövas och opereras är förmodligen bland det mest oroväckande ett barn kan vara med om inom sjukvården. Oro påträffas hos 50-75% av de barn som ska genomgå operation. Oro kan bland annat försvåra anestesin, ge ökat medicinskt behov och orsaka postoperativa komplikationer. Syfte: Syftet var att genom en systematisk litteraturstudie belysa strategier som förebygger och reducerar barns perioperativa oro. Metod: Systematisk litteraturstudie med kvantitativ ansats. Barn två till tolv år som skagenomgå eller har genomgått anestesi och operation. Artikelsökningar genomfördes i tre, för ämnesområdet, relevanta databaser. Resultat: Studien omfattar 25 resultatartiklar som visar på varierande strategier för att hantera barns perioperativa oro. Fem av dessa visade inte på någon överlägsen ororeducerande effekt i jämförelse med sedvanliga eller jämförande strategier. Information och distraktion utkristalliserades som huvudkategorier med tillhörande underkategorier. Multimedia var en framträdande underkategori som innefattade flera olika strategier. Några utstickande strategier var bland annat doftande inhalationsmasker och teaterframträdanden. Slutsats: Studien påvisar att det finns en variation i hur oro kan hanteras för att förebyggas och reduceras inom den pediatriska perioperativa vården. Strategierna inom underkategorin multimedia ter sig i denna studie mer framträdande vilket kan tyda på att de förekommer i större utsträckning inom denna vårdform. Det tydliggjordes dock att det inte finns en enda enskild strategi som anses vara vedertagen eller överlägsen andra. En icke-farmakologisk strategi skulle kunna föredras då den kan anses vara ett säkert, icke-invasivt och således behagligt alternativ till sedvanliga farmakologiska strategier såsom premedicinering. / Background: Today numerous paediatric surgeries are performed – In Sweden, 2017, approximately 90 000 children from zero to fourteen years of age underwent surgery/were operated on. To receive anaesthesia and have an operation is probably among the most disturbing and stressful a child can experience. Anxiety is found in 50-75% of children undergoing surgery. Anxiety can, among other things, complicate anesthesia, increase medical need and cause postoperative complications. Purpose: The aim was to elucidate strategies to prevent and reduce children’s perioperative anxiety through a systematic literature review. Method: A systematic literature review with quantitative approach. Children two to twelwe years of age who are to undergo or have undergone anesthesia and surgery. Article searches were carried out in three, for the subject area, relevant databases. Result: The study comprises 25 result articles that show varying strategies for dealing with children's perioperative anxiety. Five of these did not show any superior or reducing effect compared to conventional or comparative strategies. Information and distraction were distinguished as main categories. Multimedia was a prominent subcategory that included several different strategies. Some protruding strategies included scented inhalation masks and theater performances. Conclusion: There is a variation in how anxiety can be managed to be prevented and reduced in pediatric perioperative care. The strategies in the sub-category multimedia appear prominent in this study, which may indicate that these strategies occur to a greater extent within this form of care. It was made clear that there is no single individual strategy considered to be accepted or superior to others. A nonpharmacological strategy might be preferred as it can be considered a safe, non-invasive and thus pleasant alternative to conventional pharmacological strategies such as premedication.

O objetivo do estudo foi avaliar o efeito da escuta terapêutica na ansiedade pré-operatória e nos medos relacionados à cirurgia em pacientes hospitalizados para tratamento cirúrgico de câncer colorretal. Tratou-se de um ensaio clínico aleatorizado realizado em um hospital geral. Os participantes foram aleatorizados em dois grupos: experimental (GE) (n=25) e controle (GC) (n=25). No GE era realizada a escuta terapêutica, de modo que os pacientes tinham 30 minutos para falar com a pesquisadora sobre sua experiência com a hospitalização para o tratamento da doença. No GC os pacientes eram informados que teriam alguns dados coletados, em seguida a pesquisadora se ausentaria por 30 minutos e que, após este intervalo, a mesma retornaria para a conclusão da pesquisa. As variáveis dependentes (alfa-amilase, cortisol, frequência de pulso, frequência respiratória, pressão arterial, ansiedade estado e medos relacionados à cirurgia) foram coletadas antes e após a realização da intervenção no GE e antes e após o intervalo supracitado no GC. Na comparação das variáveis dependentes no GE em relação ao GC no momento pós-intervenção, não foram identificadas diferenças significativas para nenhuma das variáveis estudadas. Na comparação das variáveis no GE e GC nos momentos pré e pós-intervenção, constatou-se diferenças significativas apenas entre os momentos no GC para as variáveis cortisol (Z=-2,023; p=0,043), frequência de pulso (FP) (Z=-2,121; p=0,034) e medos relacionados à cirurgia (Z=-2,171; p=0,030), com redução dos valores destas variáveis. Na relação entre as variáveis estudadas obteve-se significância entre a ansiedade estado e as variáveis cortisol, idade, escolaridade e religião; os medos relacionados à cirurgia foram relacionados ao sexo, tempo de confirmação do diagnóstico de câncer colorretal, nível de escolaridade, cortisol, estado civil e à pressão arterial diastólica. Apenas a variável renda familiar mensal apresentou diferença significativa em suas distribuições no GE e no GC, no entanto, esta não teve influência sobre as variáveis dependentes. A maioria dos pacientes referiu satisfação quanto ao desenvolvimento da intervenção. Conclui-se que, no momento pré-operatório, nas condições investigadas neste estudo, os dados evidenciaram que a mensuração das variáveis imediatamente após a intervenção de escuta terapêutica de 30 minutos não evidenciou a redução esperada dos valores das variáveis estudadas; estudos com medidas dessas variáveis após um tempo para o paciente processar os efeitos da intervenção poderão confirmar se a mensuração imediata ou uma hora após a intervenção, por exemplo, conduziria a resultados distintos. Contudo, houve redução dos valores de cortisol, frequência de pulso e medos relacionados à cirurgia nos participantes do GC, o que pode ser atribuído ao contato da pesquisadora com tais participantes durante os momentos de coleta de dados / The aim of the study was to evaluate the effect of therapeutic listening on preoperative anxiety and fears related to surgery in patients hospitalized for surgical treatment of colorectal cancer. This is a randomized clinical trial conducted in a general hospital. Participants were randomized in two groups: experimental (n=25) and control (n=25). In the experimental group was performed therapeutic listening. The patients had thirty minutes to talk to the researcher about their experience with hospitalization for the treatment of disease. In the control group patients were informed that they would have some data collected, then the researcher would be gone for thirty minutes and after this range, she would return to complete the research. The dependent variables (alpha-amylase, cortisol, pulse rate, respiratory rate, blood pressure, anxiety state and fears related to surgery) were collected before and after the intervention in experimental group and before and after the break in control group. In comparing the dependent variables in the experimental group compared to the control group in the post-intervention time, no significant differences were identified for any of the variables studied. In comparing the variables in the experimental group and the control group in the pre and post-intervention, there was significant differences only between times in the control group for cortisol (Z=-2,023; p=0,043), pulse rate (Z= -2,121; p=0,034) and fears related to surgery (Z= -2,171; p=0,030), with reduced of these variables. In the relationship between the studied variables, there was a significant difference between state anxiety and the variables cortisol, age, education level and religion; the fears related to the surgery were related to sex, time of confirmation of the diagnosis of colorectal cancer, education level, cortisol, marital status and diastolic blood pressure. Only the variable monthly income showed a significant difference in their distributions in the experimental group and the control group, however, this had no influence on the dependent variables. Most patients report satisfaction with the development of the intervention. It was concluded that, in the preoperative period, under the conditions investigated in this study, the data showed that the measurement of the variables immediately after the intervention of 30 minutes of therapeutic listening did not show the expected reduction of the values of the studied variables; Studies with measures of these variables after a time for the patient to process the effects of the intervention could confirm whether the immediate measurement or one hour after the intervention, for example, would lead to different results. However, there was reduction of cortisol levels, pulse rate and fears related to surgery in the control group, which can be attributed to contact the researcher with these participants during times of data collection

Submitted by Ana Lúcia Torres (bfmhuap@gmail.com) on 2017-09-25T13:14:49Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Mestrado Alfredo Haack versão banca (1).pdf: 9768094 bytes, checksum: 3bdb2e65d438668333f45e16b3d76845 (MD5) / Approved for entry into archive by Ana Lúcia Torres (bfmhuap@gmail.com) on 2017-09-25T13:14:58Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Mestrado Alfredo Haack versão banca (1).pdf: 9768094 bytes, checksum: 3bdb2e65d438668333f45e16b3d76845 (MD5) / Made available in DSpace on 2017-09-25T13:14:58Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Mestrado Alfredo Haack versão banca (1).pdf: 9768094 bytes, checksum: 3bdb2e65d438668333f45e16b3d76845 (MD5) Previous issue date: 2016 / Universidade Federal Fluminense. Hospital Universitário Antonio Pedro / Fundamentos: Hemipelvectomia (externa ou interna) é uma cirurgia ortopédica de grande porte, indicada em sarcomas pélvicos primários do osso ou de tecidos conectivos. Devido à perda significativa de sangue e fluidos, extenso trauma tecidual, distúrbios da coagulaçã o e dor intensa pós-operatória, os cuidados perioperatórios e a anestesia são desafiadores. Objetivo: Analisar variáveis perioperatórias e as estimativas de sobrevida em cirurgias de hemipelvectomia. Métodos: Estudo retrospectivo de 35 pacientes consecutivos, submetidos a hemipelvectomia no Instituto Nacional de Câncer José Alencar Gomes da Silva entre 2000 e 2013. Foram analisadas variáveis perioperatórias. Realizada análise descritiva dos dados, expressos em médias±desvios-padrão e medianas. Para análise da sobrevida foram construídas curvas de Kaplan-Meier e realizada análise de regressão de Cox para identificar os preditores independentes de sobrevida. Resultados: Hemipelvectomia externa realizada em 23 (65,7%) pacientes. Dados pré-operatórios: mediana de idade 40 anos; peso mediano 70 kg; sexo masculino 68,5%; radioterapia pré-operatória 28,6%; quimioterapia pré-operatória 17,1%; tabagismo 42,8%; hipertensão arterial 25,7%; diabetes mellitus 5,7%; doença coronariana aterosclerótica 2,8%; asma 2,8%; insuficiência renal crônica 2,8%; refluxo gastroesofágico 2,8%; metástase pulmonar 11,4%; e depressão 5,7%. Anestesia geral combinada com regional realizada em 31 (88,57%) pacientes. Dados intraoperatórios: 23 (65,7%) pacientes apresentaram instabilidade hemodinâmica e medicamentos vasopressores foram necessários em 12 (34,2%); 6 (17,1%) apresentaram distúrbios da coagulaçã o. A mediana de infusão de cristaloides foi 3500 mL e a administração de coloides ficou entre 500 -1500 mL. Vinte pacientes (57,1%) receberam concentrado de hemácias e 4 (1,4%) necessitaram de outros hemoderivados. Trinta e três (94,2%) pacientes foram extubados na sala de operaçã o. Dados do pós-operatório: dor aguda intensa em 31,4% dos casos; 40% desenvolveram dor crônica. Dezessete pacientes (48,5%) foram transfundidos. Um paciente (2,8%) desenvolveu insuficiência renal aguda, 2 (5,7%) apresentaram distúrbios neurológicos, 1 (2,8%) apresentou arritmias e 9 (25,7%) apresentaram complicações de ferida operatória. A mediana do tempo de internaçã o após a cirurgia foi 6 dias. A média de sobrevida após a cirurgia foi 30,5±4,9 meses. Na análise bivariada, apenas estágio avançado da doença teve significância como preditor independente para morte (p=0,001, HR=6,0, IC95% para HR =2,03–17,6). Na análise multivariada ao nível de 5%, apenas os estágios avançados 3 e 4 da doença foram fator de risco independente para taxa de sobrevida reduzida. Conclusões: O tempo cirúrgico, o volume de fluidos e transfusões sanguíneas e o tempo até a alta foram menores quando comparados aos previamente reportados. A hemipelvectomia externa foi mais prevalente e apresentou menor sobrevida que a interna. Estágio avançado da doença foi preditor significativo para redução da sobrevida após hemipelvectomia / indicated in primary pelvic sarcomas of the bone or connective tissues. Due to significant loss of blood and fluids, extensive tissue trauma, coagulation disorders and severe postoperative pain, perioperative care and anesthesia are challenging. Objective: To analyze perioperative variables and survival estimates in hemipelvectomy surgeries.Methods: Retrospective study of 35 consecutive patients undergoing hemipelvectomy at Instituto Nacional de Câncer José Alencar Gomes da Silva between 2000 and 2013. Perioperative variables were analyzed. Descriptive data analysis was conducted. Data are expressed as mean±standard deviation and medians. For survival analysis, Kaplan-Meier curves were constructed and Cox regression analysis was performed to identify independent predictors of survival. Results: External hemipelvectomy was conducted in 23 (65.7%) patients. Preoperative data: median age 40 years; median weight 70 kg; males 68.5%; preoperative radiotherapy 28.6%; preoperative chemotherapy 17.1%; smoking 42.8%; hypertension 25.7%; diabetes mellitus 5.7%; atherosclerotic coronary artery disease 2.8%; asthma 2.8%; chronic renal failure 2.8%; gastroesophageal reflux 2.8%; lung metastasis 11.4%; and depression 5.7%. General anesthesia combined with regional anesthesia was employed in 31 (88,57%) patients. Intraoperative data: 23 (65.7%) patients presented hemodynamic instability and vasopressor agents were required in 12 (34.2%); 6 (17.1%) had coagulation disorders. The crystalloid infusion median was 3500 mL and colloids administration was between 500 - 1500 mL. Twenty patients (57.1%) received packed red blood cells and 4 (1.4%) of them required other blood products. Thirty-three (94.2%) patients were extubated in the operating room. Postoperative data: intense acute pain in 31.4% of cases; 40% developed chronic pain. Seventeen patients (48.5%) were transfused. One patient (2.8%) developed acute renal failure, 2 (5.7%) presented neurological disorders, 1 (2.8%) had arrhythmias and 9 (25.7%) had operative wound complications. Median length of hospital stay after surgery was 6 days. Mean survival after surgery was 30.5±4.9 months. In the bivariate analysis, only advanced stage of the disease had significance as an independent predictor of death (p=0.001, HR=6.0, 95% CI for HR=2.03-17.6). In the multivariate analysis at the level of 5%, only advanced stage of the disease (3 and 4) was an independent risk factor for reduced survival rate. Conclusions: Operation time, fluid and blood transfusion volumes and length of hospital stay before discharge were smaller than previous reports. External hemipelvectomy was more predominant and presented shorter survival than internal hemipelvectomy. Advanced disease stage was significant predictor for reduced survival after hemipelvectomy

O posicionamento cirúrgico é um procedimento que deve ser realizado com todo cuidado pela equipe cirúrgica e de enfermagem, pois implica em riscos para o paciente cirúrgico. Para sua execução é necessário o conhecimento das alterações anatômicas e fisiológicas decorrentes deste procedimento no organismo do paciente, dos equipamentos e dispositivos adequados para a implementação de intervenções efetivas para a prevenção de complicações que podem ocorrer devido à permanência prolongada do paciente em posição cirúrgica. Com o propósito de nortear a prática clínica do enfermeiro perioperatório, auxiliando na tomada de decisão sobre o cuidado do paciente durante o posicionamento cirúrgico, o presente estudo teve como objetivo geral a construção e validação da Escala de Avaliação de Risco para o Desenvolvimento de Lesões Decorrentes do Posicionamento Cirúrgico (ELPO) em pacientes adultos. Trata-se de pesquisa metodológica. A construção da ELPO foi fundamentada em evidências recentes sobre as implicações fisiológicas e possíveis complicações pós-operatórias relacionadas ao posicionamento cirúrgico do paciente no período intraoperatório. A escala tem sete itens (tipo de posição cirúrgica, tempo de cirurgia, tipo de anestesia, superfície de suporte, posição dos membros, comorbidades e idade do paciente) e cada item apresenta cinco subitens. O instrumento de medida foi submetido à validação de face e de conteúdo por 30 juízes provenientes de diferentes locais do Brasil. O Índice de Validação de Conteúdo da Escala foi igual a 0,88, assim pode-se inferir que houve consenso entre o comitê de juízes em relação ao que a ELPO se propõe a medir, demonstrando que aparenta ter cobertura da área de conteúdo que está sendo medida. A pesquisa de campo foi realizada em hospital geral, de médio porte, com amostra de 115 pacientes adultos, em contextos cirúrgicos heterogêneos. Por meio da aplicação do teste t de Student constatou-se validade de critério concorrente entre os escores da Escala de Braden e da ELPO. Para avaliar a validade de critério preditiva testou-se a associação da presença de dor e o desenvolvimento de úlcera por pressão com o escore da ELPO, sendo que os resultados do tratamento estatístico de regressão logística evidenciaram diferença estatisticamente significante. A confiabilidade interobservadores foi verificada por meio do Coeficiente de Correlação Intraclasse, cujo valor foi de 0,994, considerado excelente. A ELPO é um instrumento válido e confiável para a avaliação de risco para o desenvolvimento de lesões decorrentes do posicionamento cirúrgico em pacientes adultos. É um instrumento de fácil aplicação e pode ser útil na prática clínica. A avaliação da sua utilização depende da condução de novos estudos em diferentes contextos hospitalares. Espera-se que o presente estudo possa contribuir para a tomada de decisão do enfermeiro perioperatório, pois a sua condução teve como finalidade principal fornecer subsídios para a melhoria da assistência de enfermagem, bem como incentivar o desenvolvimento de protocolos de cuidados direcionados para o posicionamento cirúrgico do paciente / The surgical positioning is a procedure that must be carried out carefully by the surgical and nursing team, as it implies risks for surgical patients. For its execution, knowledge of the anatomical and physiological changes resulting from the procedure in patient\'s body, appropriate equipment and devices for the implementation of effective interventions for the prevention of complications that may occur due to patient\'s prolonged stay in surgical position, is necessary. This methodological research aimed to develop and validate the Risk Assessment Scale for the Development of Injuries due to Surgical Positioning (ELPO) in adult patients, with the purpose of guiding the clinical practice of perioperative nurses, helping on the decision making about patient care during surgical positioning. The construction of ELPO was based on recent evidences about the physiological implications and possible postoperative complications related to the surgical patient positioning during intraoperative period. It is a seven-item scale (surgical position, time of surgery, anesthesia, support surface, limb position, comorbidities and patient age) with five sub items for each item. The measuring instrument was submitted to face and content validation by 30 judges from different regions of Brazil. Scale\'s Content Validation Index was 0.88, which evidence that there was consensus among the committee of judges in relation to what ELPO proposes to measure, demonstrating it has coverage of the content area. The field research was performed in a midsized general hospital, with a sample of 115 adult patients in heterogeneous surgical settings. Concurrent validity between the Braden Scale and ELPO scores was evidenced through the use of Student t test. To evaluate predictive validity, association between the presence of pain and pressure ulcers development with ELPO scores was tested, and results of logistic regression evidenced a statistically significance difference. Inter-rater reliability was verified by the Intraclass Correlation Coefficient, whose value, 0.994, was considered excellent. ELPO is a valid and reliable instrument to assess the risk of developing injury resulting from surgical positioning in adult patients. It is an instrument easy to apply and can be useful in clinical practice. The assessment of its use in clinical practice depends on conducting new studies in different hospital settings. It is expected that this study can contribute to decision making of perioperative nurses, as its accomplishment had as main purpose to provide subsidies to improve nursing care, as well as to encourage the development of protocols of care directed to surgical patient positioning

Made available in DSpace on 2015-04-22T22:06:33Z (GMT). No. of bitstreams: 1 Ana Patricia Gomes Vasconcelos.pdf: 543917 bytes, checksum: 9391b06b87c7412f12b1f5c235e33002 (MD5) Previous issue date: 2012-10-08 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / This study intends to evaluate the surgical patient s view about the nursing pre-surgical visit made by the surgical center nurse, submitted to surgery at the University Hospital João de Barros Barreto. The conceptual bases used here were the nursing assistance systematization in the perioperative period and the pre-operative visitation from the surgical center nurse. It is a descriptive and exploratory study, with a quantitative analysis, using an interview technique applying a formulary. The place used for this research was the University Hospital João de Barros Barreto. In this study 130 patients were interviewed after surgery. The methods applied were description methods, which the data were tabulated through Microsoft Excel and the entire statistic processing happened under the computational support Epi-info, in which tables were developed and a critical analysis of the results was done. The obtained results were a predominance of the female sex, being represented by the 61% (79). Among the surgeries made in this period, the main occurrence was the cholecystectomy with the 42% (54). As about the question referred to the information in the pre-operative period, the care related to surgery and the 54, 62% (71) received VPOE made by the surgical center nurse. The investigation confirmed that the nursing pre-operative visitation realization brings benefit to the surgical patient being possible the adoption by the surgical center nursing service, inside the perioperative nursing assistance systematization theme. / Este estudo teve por objetivo avaliar a visão do paciente cirúrgico sobre a visita pré-operatória de enfermagem realizada pelo enfermeiro de centro cirúrgico, submetidos a cirurgia no Hospital Universitário João de Barros Barreto. As bases conceituais utilizada foram a sistematização da assistência de enfermagem no período perioperatório e a visita pré-operatória do enfermeiro de centro cirúrgico. Trata-se de um estudo do tipo descritivo, exploratório, com análise quantitativa, utilizando uma técnica de entrevista com a aplicação de um formulário. O local de pesquisa foi o Hospital Universitário João de Barros Barreto. No estudo foram entrevistados 130 pacientes após cirurgia. Os métodos aplicados foram descritivos, onde os dados foram tabulados através do programa Microsoft Excel e todo o processamento estatístico se realizou sob o suporte computacional Epi-info, onde foram desenvolvidas tabelas e realizada análise critica dos resultados. Os resultados obtidos foram predominância do sexo feminino, sendo representado por 61% (79). Dentre as cirurgias realizadas no período, a maior ocorrência foi a colecistectomia com 42% (54). Quanto à questão referente às informações no período pré-operatório os cuidados referentes ao ato cirúrgico e 54,62% (71) receberam VPOE realizada pelo enfermeiro do centro cirúrgico. A investigação confirmou que a realização da visita pré-operatória de enfermagem traz benefício ao paciente cirúrgico podendo ser possível sua adoção pelo serviço de enfermagem do centro cirúrgico, dentro da temática da sistematização da assistência de enfermagem perioperatória.

Breast cancer is the most common cancer among women in the United States with over 60% of cases diagnosed as early stage disease. For those women without prohibiting clinical or cosmetic concerns, a choice between breast-conserving surgery and mastectomy can be made. Either choice confers equivalent survival. The decision-making process also involves consideration of recurrence risk as well as management of the unaffected, contralateral breast for both future surveillance and risk reduction. In recent years, increasing rates of mastectomy with contralateral prophylactic mastectomy have been reported among women with unilateral, early stage breast cancer. If eligible for a choice among surgical options, a woman’s decision becomes one of personal preference. The decision-making process is complex and involves consideration of potential benefits and harms with each option. The purpose of this dissertation was to: 1) analyze the psychometric properties of the Anxiety Subscale of the Depression Anxiety Stress Scale, 2) critically review Decisional Conflict Scales and 3) prospectively identify demographic, clinical, cognitive and affective factors influencing a woman’s decision to choose either breast conserving surgery or mastectomy with contralateral prophylactic mastectomy and to identify self-reported sources of information in the surgical decision-making process. Three manuscripts make up the dissertation. A secondary data analysis was conducted to test the psychometric properties of the Anxiety Subscale of the Depression Anxiety Stress Scale (DASS). The results of this analysis supported the reliability and validity of the DASS anxiety subscale. A critical review of decisional conflict measures for use with early stage breast cancer patients making surgical treatment decisions was conducted. The results of this review supported the use of Decisional Conflict Scales from a clinical and research perspective. Existing Decisional Conflict Scales show moderate to acceptable reliability. The first two manuscripts provided background and support for the use of scales included in the research study described in the third manuscript. This study was a prospective, exploratory, cross-sectional, mixed-methods study describing factors influencing preference for surgical choice among women with early stage breast cancer. A sample of 78 participants enrolled in the study, 47 who chose breast conserving surgery and 31 who chose mastectomy with contralateral prophylactic mastectomy. Differences were tested between the groups. Women who chose mastectomy with contralateral prophylactic mastectomy were younger, more likely to work full or part-time, had larger tumors and participated in preoperative genetic counselling. Women who chose breast conserving surgery were more likely to have participated in preoperative breast magnetic resonance imaging. Overall, women choosing either surgery were not experiencing severe levels of distress, depression, anxiety or stress although there were individual variations. Women choosing mastectomy with contralateral prophylactic mastectomy were more anxious and had more frequent intrusive thoughts about the diagnosis. They also had less decisional conflict as compared to women choosing breast conserving surgery. Information sources were similar but the most influential information source differed among the two groups. In both groups, intention for surgical choice was matched by the final decision. There are many factors influencing surgical choice among women with early stage breast cancer. Previous work has focused on clinical, demographic and diagnostic processes influencing the decision. With this study, evidence regarding the influence of cognitive and affective factors is described.

The purpose of this dissertation was to evaluate the association of psychological distress with cardiac disease, events, and mortality. Specific aims were to: 1) to evaluate the association between hostility level and recurrence of acute coronary syndrome (ACS) and all-cause mortality in patients with coronary heart disease (CHD); 2) to evaluate the psychometric properties of the Brief Symptom Inventory (BSI) hostility and anxiety subscales in a group of incarcerated participants at high risk of cardiovascular disease; and 3) to evaluate the association of patient and caregiver psychological state with quality of life in both patient and caregiver, and postoperative complications after cardiac surgery. Specific aim one was addressed through a secondary analysis of data collected during the Patient Response to Myocardial Infarction following a Teaching Intervention Offered by Nurses trial to determine whether hostility was a predictor of ACS recurrence and mortality. Hostility was common after ACS and predicted all-cause mortality. Hostility did not predict recurrent ACS. Specific aim 2 was addressed in a secondary analysis of baseline data from a randomized controlled trial in male prisoners. Participants completed the BSI at baseline prior to the intervention. Internal consistency reliability was good for both subscales (Cronbach’s alpha - hostility 0.83, anxiety 0.81). Items from the two dimensions were analyzed together using exploratory factor analysis with varimax rotation. Two dimensions, anxiety and hostility, were identified. Construct validity was supported; those with high anxiety and hostility reported a greater number of days where their self-reported health was rated as fair or poor. Those prisoners with less perceived control had higher levels of anxiety and hostility. Specific aim 3 was addressed through a prospective, descriptive correlational study that measured patient and caregiver anxiety, hostility and depressive symptoms, at baseline to determine whether these predicted quality of life using a multilevel dyadic analysis; and to evaluate the association of baseline anxiety, hostility and depressive symptoms and quality of life with postoperative complications and mortality. Anxiety, hostility, and depressive symptoms were common in both cardiac patients and their caregiver. Psychological state influenced quality of life in both dyad members, but was not associated with complications.

Associations between patient and procedural factors on the nature and quality of the immediate in-home recovery from anesthesia following ambulatory orthopedic surgery are unknown. Further, there is a paucity of outcomes research quantitatively categorizing in-home patient recovery and safety following discharge from same-day orthopedic procedures. Tools are available, however, to shed light on outcomes in this population, and integration of such available measures is critical. Ambulatory orthopedic surgery is a burgeoning specialty, with growth expected over the foreseeable future. The expected increased patient caseload subsequent to implementation of the Affordable Care Act and aging Baby Boom generation suggests greater morbidity and mortality is on the horizon unless aggressive measures are taken at mitigating risk. Similarly, as the obesity epidemic expands, obesity-related comorbid conditions including obstructive sleep apnea (OSA) are likely to grow. The purpose of this research was to explore the relationship between ambulatory orthopedic patient-reported activities (quality of life metrics) and diagnostic factors (physical and perioperative care data) in the immediate postoperative period that are predictive of arterial oxygen desaturation. Data was obtained using a novel patient journal exploring sleep, pain, nausea, tobacco use, alcohol use, and appetite in conjunction with a valid and reliable portable, wrist-worn pulse oximeter. Additional assessment data was taken from the preanesthetic assessment. All participants were scored according to the STOP-Bang questionnaire, an accepted survey of OSA risk. Patients were recruited from a busy metropolitan ambulatory surgery center in Richmond, Virginia that sees approximately 500 cases monthly, and a 309-bed tertiary care hospital in West Burlington, Iowa. The target sample included 52 individual patients with data collected over the first two post-operative nights following discharge. Two patients were excluded. Negative binomial regression, log10 transformation, and least-squares regression examined the relationships the STOP-Bang questionnaire, quality of life data, and physical perioperative data had on postoperative desaturation events. Results suggested the STOP-Bang score predicted desaturation events and that age and BMI were significant individual predictors. Opiate pain medication treatment, a happy mood, and home CPAP use were associated with decreased events. This study provided a unique perspective in patient safety research, relating human behaviors and experiences with postoperative oxygen desaturation. Future research projects aligned with postoperative monitoring, pulse oximetry, patient safety, and obstructive sleep apnea are potential following the findings of this study.

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