Bakgrund Kroniska sår kan medföra lidande samt ha negativ inverkan på livskvalitet för individen som drabbas. Kroniska sår kan även innebära ökade kostnader för samhället. Kroniska sår drabbar särskilt äldre människor och kan ha sitt ursprung i flera faktorer. Vårdens primära mål för dessa sår är vanligtvis att uppnå läkning men för patienter med kroniska sår kan ett lindrat lidande vara lika viktigt. Det finns dock brister gällande kunskap inom vården hur behoven hos patientgruppen med kroniska sår ska uppnås. Att beskriva hur patienter med kroniska sår upplever lidandet kan ge ökad medvetenhet om faktorer som är betydelsefulla för denna patientgrupp och således bidra till ökad kunskap hos vårdpersonal när det gäller lidandet vid kroniska sår. Syfte Syftet var att beskriva patienters upplevelser av lidande vid behandling av kroniska sår. Metod En icke-systematisk litteraturöversikt där 17 vetenskapliga originalartiklar med både kvalitativ och kvantitativ ansats inkluderades. Artiklarna inhämtades i databaserna PubMed och CINAHL genom att använda sökordskombinationer och manuella sökningar. Artiklarna kvalitetsgranskades och en integrerad analys av de inkluderade artiklarna genomfördes. Resultat Två huvudrubriker identifierades med följande tre underrubriker var. Huvudrubriken “en smärta som är ständigt närvarande” med medföljande underrubriker: “sår och psykiskt lidande”; “påverkan på dagliga livet” och “procedursmärta och smärtlindring vid såromläggning”. Den andra stora huvudrubriken, med efterföljande underrubriker var “sjuksköterskans roll i att identifiera lidande”. Här ingick underrubrikerna: “vikten av kontinuitet”, “kommunikationens betydelse” och “vårdens kunskap och följsamhet”. Slutsats Litteraturöversikten visade att faktorer relaterade till att leva med kroniska sår och omvårdnaden av dessa påverkar patientens välmående och lidande. Denna kunskap och förståelse kan även vara av gagn i arbetet med att främja hälsa och välbefinnande hos patienter med kroniska sår. Såromläggningen nyttjades inte fullt ut som ett naturligt patientmöte, därmed kunde inte sjuksköterskor eller annan vårdpersonal identifiera och lindra patientens dagliga lidande. / Background Chronic wounds may cause suffering and a loss of quality of life for patients. These wounds may also bring added costs in a greater social aspect. Chronic wounds are mainly found in an older patient group and may have their origin in different factors. Though the primary goal in health care is wound healing, patients find it is of equal or more importance to reduce the suffering that these wounds entail. There is however a lack of knowledge in healthcare how the needs of this patient group is best met. To describe how these patients experience their suffering may bring a better understanding of what factors are of importance in this group and thus lead to better knowledge for the health care personnel concerning suffering associated with chronic wounds. Aim The aim was to describe how the patients suffering was affected when caring for chronic wounds Method A non systematic review that included 17 original articles. Both qualitative and quantitative articles were included. The articles were found in the databases PubMed and CINAHL with use of index terms and manual searches. The included articles were reviewed for quality and analyzed with an integrated analysis. Results Two main headlines were identified, with three subcategories respectively. The first main headline: “a constant presence of pain” had three subcategories: “ wounds and psychological suffering”; “effect on daily life” and “ procedure pain and analgesia in wound care”. The other main category was: “the nurses role in identifying suffering”. The three accompanying subcategories were: “the impact of continuity”; “the importance of communication” and “the knowledge and flexibility of the healthcare personnel”. Conclusions The review study found that the factors of living with chronic wounds as well as the nursing care associated with the wound affected the patients health and suffering. This knowledge can therefore be of use to promote health and well being in patients with chronic wounds. The wound care procedure where not always fully used as a natural patient meeting which could bring difficulties for the nurse to identify and aid the patients daily suffering.

Hydrogels are three-dimension networks of water-soluble polymer chains and have attracted interest in biomedical engineering, targeted drug delivery, tissue engineering, and regenerative medicine due to their ability to retain water coupled with their highly tunable physicochemical and biological properties. In the specific context of wound care, hydrogels can both maintain high wound hydration as well as absorb and manage wound exudate, both of which are major challenges in wound care. Hydrogel wound dressings can simultaneously deliver medication directly to the wound to suppress or treat infections, including antibiotic-resistant strains such as Methicillin-resistant S. aureus (MRSA). This thesis develops two wound care products that can address challenges in the selection and delivery of drugs to treat antibiotic-resistant strain infections: (1) in situ-gelling poly(oligoethylene glycol methacrylate) (POEGMA) hydrogel wound dressings containing self-assembled nanoparticles encapsulated with fusidic acid; and (2) an in situ calcium-crosslinked alginate scaffold produced using pressurized gas expanded liquids (PGX) technology impregnated with fusidic acid or tigecycline using supercritical adsorptive precipitation (sc-AP). The POEGMA hydrogel wound dressings helped supress MRSA infection and prevent systemic infection during the course of treatment, facilitating a 1-2 fold decrease in bacterial load in the wound bed. The sc-AP technology was shown to be compatible with loading clinically-relevant doses of both antimicrobial compounds, while the resulting wound dressings were effective in treating MRSA wound infections. In case of tigecycline loaded alginate scaffolds, the infection was completely cleared. In tissue engineering applications, injectable macroporous hydrogels are particularly limited by two factors: (1) their need for invasive administration, typically implantation; and (2) their generally weak mechanics. In the first case, reports of injectable hydrogels often involve toxic compounds or by-products that result in loss of cell viability. This thesis addresses this challenge by design and development of a POEGMA-based macroporous hydrogel scaffold based on a novel, non-cytotoxic pore forming emulsion based on perfluorocarbons. Use of the pore-forming emulsion significantly improved cell viability in vitro 14 days after injection and was well tolerated in vivo with minimal to no inflammatory response. In the second case, an interpenetrating “hard-soft” nanofibrous hydrogel network was fabricated by co-electrospinning POEGMA with poly(caprolactone) (PCL). The PCL phase significantly enhanced the mechanical properties of the electrospun POEGMA hydrogel scaffold making handling and manipulating the scaffolds possible, while the presence of the POEGMA phase significantly improved the biological properties of PCL scaffolds in terms of supporting significantly enhanced cell proliferation and delayed bacterial adhesion. Collectively, the advances made in this work address key challenges in the application of hydrogels in tissue engineering and wound care, with future potential to be applied to solve practical clinical challenges. / Dissertation / Doctor of Philosophy (PhD) / Hydrogels have been studied in various applications like targeted drug delivery, tissue engineering, regenerative medicine, and medical devices due to their tunable nature and their capacity to retain water. In many of these applications the pore size and porosity are the key to the performance of a hydrogel in a given application. In particular, the rate at which nutrients or wastes can move through a hydrogel, the stiffness of a hydrogel, and the interactions of a hydrogel with cells are all strongly dependent on the porosity of a hydrogel. Therefore, many techniques have been developed to produce hydrogels with well-defined pore sizes, in particular “macroporous” hydrogels that have larger pores at or above the size of a cell. However, the typical techniques used to make such hydrogels often require additives or manufacturing steps that make them challenging to implement in different applications. This thesis addresses challenges in the fabrication of controllable porosity of hydrogels for applications in wound care (including the treatment of antibiotic-resistant infected wounds) and regenerative medicine, in the latter case enabling minimally invasive injection of a macroporous hydrogel as well as enhancing its mechanics to better mimic native tissues. Each of these solutions aims to bring effective novel treatments to patients, offering alternative therapies for existing challenges in healthcare.

INTRODUCTION: Negative pressure wound therapy (NPWT) has proved to be a powerful tool in facilitating the healing of difficult wounds of a variety of etiologies. The pediatric experience with NPWT has been limited because of concerns about vascular compression and pain associated with treatment. METHOD: A retrospective review (2004-2014) was conducted at Shriners Hospital for Children-Boston to evaluate the therapeutic effect of NPWT on children with difficult wounds due to burns or soft-tissue trauma. Information was collected on patient demographics, wound size and depth, burn injury etiology, length of hospital stay, number of operating room visits, and other treatment procedures. NPWT was instituted in the operating room under general anesthesia using a commercially available system. NPWT was not initiated until all necrotic material had been removed from the wounds. A negative pressure varying between -50 and -125 mmHg was applied to the wound as continuous suction, with younger children being prescribed the lower negative pressures. NPWT dressings were changed every 5-7 days in the operating room. When wounds were clean and granulated, they were closed with split-thickness skin grafts. RESULTS: Twenty-nine children with an average age of 9.43 +/- 1.95 years (range 2 months to 18 years) were treated with NPWT. The average total wound size was 24.8 +/- 8.9% (range 0%-95%) of the body surface in patients who had suffered burns and non-burn injuries. Injury mechanisms were categorized as hot liquid (2 children), contact with hot object (4 children), electricity (7 children), flame (9 children), and other non-burn injuries such as abrasion and degloving (7 children). Over 90% of the patients required central venous or bladder catheters. Perceived benefits of the treatment included reduced numbers of dressing changes and more rapid wound granulation. There were no episodes of bleeding associated with NPWT. All patients healed their wounds, were successfully grafted, and survived. CONCLUSION: NPWT has a useful role in the pediatric burn unit in facilitating wound healing and improving quality of life. A significant correlation between the size of third-degree burn wounds and the number of negative pressure therapies suggests that NPWT may be more effective in treating complicated burn wounds. Overall, NPWT appears safe and effective when applied to well-debrided wounds, and the treatment does not seem to be associated with excessive bleeding or discomfort in children.

Wound care is a field with many treatment methods and products on the market. The healing period varies, some wounds become difficult to heal and chronic, in many cases a connection can be drawn to underlying diseases. Diabetes is a disease that could cause foot ulcers that are difficult to heal. Bioactive materials in wound care have not yet been studied to a greater extent, however it is of interest for development of new products with improved functions. Fibroblasts in the connective tissue have an important role in building and regenerating the tissue. Former studies show that the bio-ceramic calcium silicate (CS) induce tissue regeneration and promote reepithelization. It has also shown improvement of the biological functions of human epidermal stem cells and positive effects on cells in in vitro studies. The purpose of this project is to be a pre-study for further analysis of CS in wound care. The aim is to investigate additive material’s potential role in wound healing, one part will be a literature study to get an overview of the healing process of wounds and wound treatment. The other part of the study is based on three minor experiment to obtain information about how calcium silicate (CS) and CS/ β-tricalcium phosphate (β-TCP) effect human dermal fibroblasts. The method and results of literature study: The litterature study gathers information from literature and studies within the subject using the searchwords: wound, healing, biomaterials, calcium silicate, alamar blue, cell migration, recent trends, skin regeneration and diabetes. The results from the literature study demonstrates that the wound healing process is very complex and many factors must interact for good healing, some factors accelerate and inhibit healing. Furthermore, healing products with additives are already used for treatment of wounds with antibacterial and pain-relieving effects. However, only a little information about bioactive materials can be found which shows that there is lack of studies in this field. The method and results of experiments: Preparation of the two main samples: [1:10] CS in PBS together with pure water and [1:10] CS + β-TCP in PBS and pure water. The first experiment was the Inductively Coupled Plasma Optic Emission Spectroscopy (ICP-OES) made in an Optical Emission Spectrometer which detected the elements Ca 317,933 (mg/L) and Si 251,611 (mg/L) in the main samples. The second experiment was Alamar Blue which produce data about the cell survival in quantitative numbers to determine the toxicity of the diluted samples. One pre-test and two final tests (24 h apart) was made. The pre-test used the dilutions 1:2, 1:10, 1:100, and two Control Media, the pre-test indicated that CS diluted 1:2 is slightly toxic. The first final test used the dilutions 1:2, 1:10, 1:100, 1:1000, 1:10000 and one Control Media. The first final test indicated that CS diluted 1:2 is almost toxic. The second final used the dilutions 1:2, 1:10, 1:100, 1:1000, 1:10000 and one Control Media. The second final test indicated that CS diluted 1:2 is toxic. The third experiment was a Scratch Healing assay. This experiment struggled with learning how to count cells which made the analysis of this experiment difficult. The results of the Scratch healing assay shows cell migration through a before-picture right after the simulated scratch is made and a picture 24 hours after. In conclusion, two important parameters while investigating the direction of further research are toxicity and cell survival. CS as a bioactive material and additive in wound treatment could be possible but should be avoided when diluted 1:2 due to its toxicity shown in the Alamar blue test. The scratch healing assay showed that the fibroblasts migrate to some extent while interacting in solutions of CS.

Bakgrund: Världens befolkning ökar och blir allt äldre. Med stigande ålder ökar risken att drabbas av sår, och följaktligen förväntas också en global ökning av antalet människor som lever med sår. Samtidigt förväntas mängden vårdpersonal minska. För att lösa hälso- och sjukvårdens utmaning att med minskande resurser ta hand en ökande och åldrande befolkning föreslås patienters egenvård ta större plats. Positiva effekter av egenvård har påvisats vid flera långvariga sjukdomstillstånd. Egenvård av sår är dock ett relativt outforskat ämne, och lite är känt om hur patienter uppfattar fenomenet. Patienters uppfattningar är värdefulla att undersöka eftersom de kan fungera vägledande vid framtida planering av egenvård av sår. Syfte: Syftet var att beskriva patienters uppfattningar om egenvård av sår. Metod: En litteraturöversikt i vilken artiklar analyserades med tematisk syntes enligt Thomas och Harden (2008). Resultat: Studiens resultat baserades på tolv artiklar med kvalitativ design. Patienter såg egenvård som en positiv möjlighet som gjorde det möjligt för dem att leva ett mer självständigt liv. Anhörigas stöd lyftes fram som särskilt viktigt för att egenvård ska vara möjligt. Vårdpersonalens kompetens uppfattades i vissa fall som bristfällig, vilket ansågs försvåra utförandet av egenvård. Patienterna efterfrågade bättre information och utbildning om sårbehandling. Slutsats: Patienter såg egenvård av sår som en tilltalande möjlighet som kan realiseras genom stöd från anhöriga, bättre information och utbildning, god kompetens hos vårdpersonalen, samt genom en tillitsfull relation mellan patienter och vårdpersonal. / Background: The world’s population is growing and getting older. At the same time, the number of healthcare workers is expected to decrease. To solve the healthcare challenge of taking care of a growing and aging population with diminishing resources, patients’ self-care is suggested to take a bigger place. Positive effects of self-care have been shown in several long-term medical conditions. However, self-care of wounds is a relatively unexplored topic, and little is known about how patients perceive the phenomenon. Patients’ perceptions are interesting to investigate because they can serve as a guide in future planning of self-care of wounds. Aim: The aim was to describe patients’ perceptions of self-care of wounds. Method: A literature review that analyzed articles using thematic synthesis according to Thomas and Harden (2008). Result: The study’s results were based on twelve articles with qualitative design. Patients saw self-care as a positive opportunity that enabled them to live a more independent life. The support of relatives was highlighted as important for self-care to be possible. The healthcare staff's competence was perceived as flawed, which was considered to make it difficult to perform self-care. Patients requested better information and wound care education. Conclusion: The patients saw self-care of wounds as a positive opportunity that can be realized through support from relatives, better information and education, good competence of the healthcare staff, and through a trusting relationship between patients and healthcare staff.

Yes / To estimate the prevalence of wounds managed by the UK's National Health Service (NHS) in 2012/2013 and the annual levels of healthcare resource use attributable to their management and corresponding costs. METHODS: This was a retrospective cohort analysis of the records of patients in The Health Improvement Network (THIN) Database. Records of 1000 adult patients who had a wound in 2012/2013 (cases) were randomly selected and matched with 1000 patients with no history of a wound (controls). Patients' characteristics, wound-related health outcomes and all healthcare resource use were quantified and the total NHS cost of patient management was estimated at 2013/2014 prices. RESULTS: Patients' mean age was 69.0 years and 45% were male. 76% of patients presented with a new wound in the study year and 61% of wounds healed during the study year. Nutritional deficiency (OR 0.53; p<0.001) and diabetes (OR 0.65; p<0.001) were independent risk factors for non-healing. There were an estimated 2.2 million wounds managed by the NHS in 2012/2013. Annual levels of resource use attributable to managing these wounds and associated comorbidities included 18.6 million practice nurse visits, 10.9 million community nurse visits, 7.7 million GP visits and 3.4 million hospital outpatient visits. The annual NHS cost of managing these wounds and associated comorbidities was pound5.3 billion. This was reduced to between pound5.1 and pound4.5 billion after adjusting for comorbidities. CONCLUSIONS: Real world evidence highlights wound management is predominantly a nurse-led discipline. Approximately 30% of wounds lacked a differential diagnosis, indicative of practical difficulties experienced by non-specialist clinicians. Wounds impose a substantial health economic burden on the UK's NHS, comparable to that of managing obesity ( pound5.0 billion). Clinical and economic benefits could accrue from improved systems of care and an increased awareness of the impact that wounds impose on patients and the NHS.

No / High compression therapy, whether with bandage systems or hosiery, is the accepted treatment of lower limb venous ulceration. Compression has not only been shown to improve healing, it has been demonstrated to reduce oedema and improve tissue oxygen levels (Stacey et al, 1990), reversing some of the changes associated with chronic venous insufficiency (Vandongen and Stacey, 2000). The introduction of multilayer high compression bandage systems in the late 1980s, and subsequent improvements in bandage textiles and design, have undoubtedly improved outcomes for many patients. However, compression alone does not address the underlying pathology of venous ulceration, chronic venous insufficiency (CVI), and without treatment CVI continues to cause skin damage and increases the risk of recurrent ulceration. In 1999, Nelzen emphasised that compression treatment has been used since the days of Hippocrates and yet has not solved the problem of leg ulceration (Nelzen, 1999).

This study is an empirical work about healthcare in the process of transformation. The speciic healthcare concerns foot and leg wound care within the homecare. The theoretical frame of the study relies on the Activity theory applied onto the healthcare workers involved into the wound care of the hard healing leg and foot ulcers. The transformation process involving this activity is seen as the example of the expansive learning and which is part of the activity theory. The method used is known, according to the Engeström (the leading figure within the currunt Activity research) as "etnography of trouble". The focus is on identifying conflicts which take place within the work activity. The purpose of the study was to increase understanding of how the wound care business is performed in home care in light of expansive learning theory. Results show the need for the wound care within the homecare to develop at the subject level as much as the system level. There are two specific developmental areas in concern, the tehnical-instrumental (development of digital assistance) and interaction-communication dmension (development of a new communication channel on vertical level). Both solutions liberate individuals competens. In the question of communication channel connected to the leadership this would create conditions for tehnical solutions to appear quicker. / Detta studie är ett empiriskt arbete och handlar om vårdarbete i förändring. Det specifika vårdarbete som denna studie behandlar är vård av ben- och fotsår (svårläkta sår) inom hemsjukvården. Teosretiskt anlägger jag ett verksamhetsteoretiskt perspektiv på vårdpersonalens arbete med svarläkta sår. På den förändringen som sker i sårvårdens praktik tar jag det analytiska greppet att jag betratar den som ett möjligt exempel på expansivt lärande. metod har varit inriktad på det som Engeström kallar för "etnography of trouble". En viktig fokus har varit att komma åt motsättningar, spänningar, eller "gnissel" i vårdverksamheten. Insamlade data består av observationer, intervjuer och dokumentation. Syftet med studien har varit att öka förståelse för hur sårvårds verksamhet utförds inom hemsjukvården i ljuset av Expansivt lärande teori. Resultatet visar att sårvård inom hemsjukvården behöver utvecklas likaså på subjekt som på systemnivå. Två specifik utvecklingsfaktorer handlar om teknisk/instrumentell dimension (utveckling av en ny kommunikationskanal på vertikal nivå). Båda lösningar frigör individens kompetens. Skulle det öppnas en mer direkt kontakt med ledningen det skulle skapa förutsättningar för snabbare utveckling av nödvändiga tekniska lösningar.

Wound care is an important part of the daily work of nurses in all facilities like hospitals, institutes for long-term patients, social care institutions, or ambulances. In recent years, the treatment of wounds puts more and more emphasis on modern methods, mainly in the Czech Republic (CR) and Ireland. As already mentioned, nursing is constantly evolving, and possibilities for wound treatment are wide. Our aim will be to compare the ways and methods of wound treatment in three different countries. We will focus on the General Nurse, as a nursing care provider. In the theoretical part, the work was focused on characteristic of wounds, their distribution, general healing as well as concrete treatment in the countries concerned, specifically according to the competence of nurses. A major part was devoted to the education of nurses The main purpose of the research was focused on the way nurses treat wounds in Namibia, Ireland and the Czech Republic. Based on the research subject the following research questions and goals were set: Identify and describe how nurses treat wounds in the selected countries. How are wounds healed in Namibia, Ireland and the Czech Republic? How is the wound care in Namibia, Ireland and the Czech Republic? What kind of education does a nurse have to have in the countries concerned, in connection with the wound care? For the empirical part of the thesis, a qualitative approach was selected. A semi-structured interview with nurses from the selected countries was used. Further records of the wound treatment were used. These were obtained during the internship in Namibia, a personal visit to Ireland and my experience during my studies in the Czech Republic. Respondents were recruited by purposive sampling, the condition of which was wound care requiring hospital treatment. The interviews were conducted using a range of questions addressing nurses in those countries during their working hours and if needed, supplementing the required information via Skype. The research sample consisted of nine respondents - nurses from Namibia, Ireland and the Czech Republic and then records of the wound treatment of 9 patients from Namibia, the Czech Republic and Ireland were drawn. The countries have their competencies relating to this issue. In Ireland, Czech Republic there is a re-bandaging nurse, who creates a nursing plan and, if needed, consults everything with the physician. In Namibia, due to lack of nurses and physicians, only competences of local nurses which they acquired during their university studies, are sufficient. These competences lead to decisions and choice of care and wound treatment. In the Czech Republic, nurses shall consult the healing process and the course of treatment with the physician. In the area of education of nurses from the surveyed countries in connection with wound care the research investigation showed that university education is required in Namibia, in the Czech Republic as well as in Ireland. The third mentioned research question related to methods of care with clients suffering from acute or chronic wounds. Wound care in Namibia, Ireland, and in the Czech Republic does not differ in some specific procedures; however, in most cases it is very different. In severe cases of wounds, for many patients it is an unforgettable memory, which requires a professional approach, consisting of knowledge and experience. The nurse provides a unique support to the patient, education is therefore very important and unconditional in order to enable the patient coping with the situation. The results of this thesis can serve as information and study material to other grades of the surgical block and for further research on a similar topic.

Bakgrund: Svårläkta sår är ett globalt problem och innebär ökade kostnader för samhället. Sårvård är en stor del av distriktssköterskans arbete och innebär samverkan med patient och andra yrkeskategorier. Syfte: Att beskriva distriktssköterskans erfarenheter av samverkan vid vård av patienter med svårläkta sår i hemsjukvård. Metod: Metoden som användes var kvalitativ innehållsanalys med induktiv ansats. Datainsamling skedde genom elva kvalitativa, semi-strukturerade intervjuer med distriktssköterskor som har arbetat med sår inom kommunal hälso- och sjukvård. Resultat: Resultatet visar att distriktssköterskans upplevelse av samverkan vid sårvård kan liknas vid ett lagspel, där det finns möjligheter och hinder under spelets gång. Samverkan vid sårvård påverkas av olika spelregler, vilka som deltar och i vilken grad de tar sitt ansvar. Distriktssköterskornas kunskap skapar möjlighet till utveckling. Slutsats: Vilka möjligheter och hinder som distriktssköterskan stöter på under samverkan kring sårvård är avgörande för hur utgången blir för patienten med såret. Hinder kan vara både prövande och tidskrävande processer. Möjligheter skapas genom kunskap och kännedom om varandra som personer bakom vår yrkesroll. / Background: Wound Care is a global problem and involves increased costs for society. Wound care is a major part of the district nurse's work in the home care setting and involves collaboration with patients and other occupational categories. Aim: To describe the district nurse's experiences of collaboration in the care of patients with difficult-to-heal wounds in home health care. Method: A qualitative method was used in the study and the result was analyzed according to meaning analysis. Eleven district nurses were interviewed. The thesis used qualitative content analysis. Results: The result shows that the district nurse's experience of cooperation in wound care can be compared to a team game, where there are opportunities and obstacles during the course of the game. Collaboration in wound care is influenced by different rules of play, who participate and the degree to which they take their responsibility. The district nurses' knowledge creates opportunities for development. Conclusion: The opportunities and obstacles that the district nurse encounters during collaboration on wound care are decisive for how the outcome will be for the patient with the wound. Obstacles can be both trying and time-consuming processes. Opportunities are created through knowledge and knowledge of each other as people behind our professional role.