Nursing Care for Terminal Patients in Intensive Care Units by Pervell Dunbar Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University August 2015 Although the goal of the ICU has always been to save lives, ICU now additionally provides end-of life (EOL) care. The objective of this project was to provide ICU nurses with a comprehensive awareness of physical, emotional, and spiritual EOL care issues of patients and their families in order to be better equipped to handle EOL care. The framework used was Jean Watson's Caring model (10 Caritas). A literature review revealed a poster previously used by a major health organization as a conversation starter to facilitate decision-making among ICU nurses, EOL patients, and their families related to EOL issues. The purpose of this quality improvement initiative was to introduce and implement an educational EOL tool that would engage patients and family members in meaningful and useful conversations with ICU nurses. Twenty seven ICU nurses were selected by the unit's director to attend a PowerPoint presentation on the use of the EOL educational poster. Four ICU nurses were chosen by the director to be champions for this project. After the presentation, there was a period for questions and answers, and the ICU nurses were requested to give feedback on the presentation. The result from the feedback revealed that EOL care is outside previous practice and may require extra education and support. These comments substantiated similar conclusions from other researchers as described in this paper. With an increase in EOL training for ICU nurses and the implementation of EOL teaching tools like the poster used in this study, ICU nurses may be better able to have conversations with EOL patients and families, thus improving patient care.

Objectives: To describe the use of standardized protocols (SPs) in emergency departments (EDs) across Ontario for childhood asthma and analyze the association of SPs with hospital admissions, 7-day ED re-visits, and outpatient follow-up visits. Methods: Population-based retrospective cohort study using health administrative data and survey data. EDs were categorized as having the optimal, other, or no SP for each outcome. Associations were tested with generalized estimating equations. Results: Between 2006/04/14-2009/02/28, 46,510 children with asthma were seen in 146 EDs, with 43 (29.5%) having SPs. Children treated in EDs with the optimal SP compared to no SP had no significant differences in hospital admissions (AOR 1.17; 95% CI 0.91, 1.49) or ED re-visits (AOR 1.09; 95% CI 0.85, 1.40) but were more likely to have follow-up visits (AOR 1.27; 95% CI 1.02, 1.59). Conclusions: SPs for childhood asthma are not common in Ontario EDs and had little impact on outcomes measured.

Objectives: To describe the use of standardized protocols (SPs) in emergency departments (EDs) across Ontario for childhood asthma and analyze the association of SPs with hospital admissions, 7-day ED re-visits, and outpatient follow-up visits. Methods: Population-based retrospective cohort study using health administrative data and survey data. EDs were categorized as having the optimal, other, or no SP for each outcome. Associations were tested with generalized estimating equations. Results: Between 2006/04/14-2009/02/28, 46,510 children with asthma were seen in 146 EDs, with 43 (29.5%) having SPs. Children treated in EDs with the optimal SP compared to no SP had no significant differences in hospital admissions (AOR 1.17; 95% CI 0.91, 1.49) or ED re-visits (AOR 1.09; 95% CI 0.85, 1.40) but were more likely to have follow-up visits (AOR 1.27; 95% CI 1.02, 1.59). Conclusions: SPs for childhood asthma are not common in Ontario EDs and had little impact on outcomes measured.

The Motor Group of the European Council was commissioned in the autumn of 1997 to prepare a proposal for a new European Bus and Coach Directive. In the beginning, most of the Member States did not have the accessibility requirements as their main concern; still a smaller network with actors from the National delegations from Britain, Germany and Sweden would influence the other National delegations in the Council group to finally agree to retain the requirement of accessibility of the Directive. Within the EU decision process, the European Disability movement acted as a strong player during the whole negotiation process using the proposal to a new Bus and Coach Directive as a tool to influence key actors to go towards a Directive with a strong approach for accessibility. Policy Transfer and Policy Transfer Network are used as analytical tools to understand and structure the transfer of the question of accessibility during the negotiation process. Actors understanding how the bureaucratic process works within the EU decision system have a chance to contributing for the changes in the directions they wishes for within a range of policy areas. The principal aim of the Directive was to guarantee the safety of passengers and to provide technical prescription in particular to wheelchair users. In the end it turned out to be one of the most successful achievements for the European Disability movement in history.

ABSTRACT NOISE ASSESSMENT OF SHIPYARD WORKERS Can,&Ouml / zg&uuml / n M.Sc.,Department of Engineering Sciences Supervisor : Prof.Dr.G&uuml / lin Birlik May 2008,139 pages Noise is one of the most important health risks in workplaces worldwide and NIOSH identified noise as one of the 10 important occupational problems. In OSHA&#039 / s hearing conservation amendment it is stated that in U.S., more than 5 million workers are exposed to potentially hazardous levels of noise in manufacturing and utilities. In 1981 OSHA estimated that, at least one million workers in industry had undergone occupational hearing loss. Ship building has been one of the most promising and rapidly growing industries in Turkey in the recent years. It comprises many production techniques and activities, requires qualified personnel and compliance with several class institutions making the job interesting for the enthusiastic engineers and workers. However shipyard workers are subject to high levels of noise besides other health risks. The aim of this study is to figure out the effect of noise on shipyard workers. For this purpose 2 factories, namely Factory 1 and Factory 2 in a shipyard were chosen and two methods were adopted. The first method was the subjective evaluation of the workers through questionnaires distributed to them, whereas the second method involved the noise level measurement during their work hours. At all the points in Factory 1 where noise level measurements have been done, higher A-weighted values of noise than the limits stated in the legal regulations were found. In Factory 2, noise levels were all below the action value of 85 dBA .Dose measurements of the workers displayed the extremely variable acoustical conditions that the workers encountered. According to the &ldquo / Noise Regulation&rdquo / of Ministry of Labour and Social Security and &ldquo / The European Noise Directive&rdquo / , the employer seems to be obliged to measure periodically and to assess the level of noise exposure of workers in Factory 1 and take immediately the necessary precautions. Ear plug performance and speech interference conditions were also examined.

Advance Care Planning has been advocated for over 20 years as a way in which individuals who are no longer able to speak for themselves, may still convey their preferences regarding a wide of array of decisions, including medical care. Advance care planning may not be initiated by individuals for many reasons, and even when initiated, may not be specific enough to help guide decision making. Recent advance care planning models have utilized disease specific information to help guide end of life health care decision-making. Persons diagnosed with mild cognitive impairment face an increased possibility of developing dementia at some point in the future, but may retain decision making capability for a window of time, and thus the opportunity to participate in advance care planning. The advance care planning experiences of individuals with mild cognitive impairment have not been extensively studied. This study explored the advance care planning experiences of persons with mild cognitive impairment and their care partners' understanding and views of advance care planning, and if the diagnosis of mild cognitive impairment affects the advance care planning practices of these two groups. A convenience sample of 10 individuals with mild cognitive impairment and their 10 care partners (n=20) were recruited and interviewed. Using a grounded theory qualitative analysis approach, four themes were identified (1) decreased awareness regarding advance care planning from individuals with mild cognitive impairment versus a heightened awareness for the care partners; 2) the preference for comfort care measures only; 3) preferences for future end of life healthcare decisions largely influenced by previous end of life experiences with family and friends; and 4) lack of discussion of end of life healthcare decisions related to dementia and/or artificial nutrition and hydration by physicians or other healthcare providers. In addition two latent themes emerged including from the care partners, the importance of the mild cognitive impairment support group and lawyers for advance care planning and from both care partners and the mild cognitive impairment participants, trying to maintain autonomy, to `hang on' to self were identified. Study implications include the need for structured advance care planning interventions with individuals diagnosed with mild cognitive impairment to focus on common end of life scenarios, such as whether to use artificial nutrition and hydration, which will require future surrogate decision making.

Orientador: Cláudia Regina Castellanos Pfeiffer / Tese (doutorado) - Universidade Estadual de Campinas, Instituto de Estudos da Linguagem / Made available in DSpace on 2018-08-16T11:09:08Z (GMT). No. of bitstreams: 1 Silva_JoseRenato_D.pdf: 1198867 bytes, checksum: 1c4379de249098968aa9d28a3fb6fef4 (MD5) Previous issue date: 2010 / Resumo: O percurso de análises desta tese - inscrito na História das Idéias Lingüísticas articulada com a Análise do Discurso de Linha Francesa - teve o objetivo de compreender quais os sentidos que 'Educação', 'Ensino' e 'Língua' têm em textualidades jurídicas como as Constituições Nacionais Brasileiras e a Lei de Diretrizes e Bases da Educação de 1961 pensados como objetos discursivos, artefatos da linguagem. Dito de outra forma, o objetivo desta tese é, pensando discursivamente os sentidos de 'Educação', 'Ensino' e 'Língua', pensar a relação Língua/Conhecimento Lingüístico/Estado e, assim, realizar contribuições para o estudo da HIL na medida em que trata da história da construção da língua em espaços em que o Estado regula a Educação. Assim, a questão é recortada para o espaço institucional da Escola naquilo em que este espaço é pressuposto e afetado pelas políticas públicas de Educação/Ensino. Esta entrada no discurso histórico permite interrogar parte da construção de sentidos da brasilidade a partir da compreensão de parte da história da Educação/Ensino no Brasil - e suas relações com a língua - em momentos históricos particulares. E este percurso de análise, ao determinar uma articulação particular de parte da história da educação no Brasil, permite compreender a conformação do(s) sujeito(s) em certas condições histórico-ideológicas e a Constituição de um Estado Nacional Brasileiro / Abstract: This thesis analysis course - registered in Linguistic Ideas' History articulated with French Line of Speech Analysis - aimed to comprehend what are the meanings that 'Education', 'Learning' and Language' have in legal context as Brazilian National Constitutions and the Law Directives and Bases of Education created in 1961 and thought as discursive objects, language artifacts. In other words, this thesis's objective is, thinking about the meaning of 'Education', 'Learning' and 'Language' in a discursive way, try to think about the relationship between Language/ Linguistic Knowledge /State and, therefore, perform contributions to HIL study as well as it deals with the language construction history in spaces which the State regulates Education. This way, the question is focused in the institutional space of School and in what this space is prerequisite and affected by public Education/Learning politics. This admittance in historical speech allows interrogates part of 'brasilidade' meaning construction based on comprehension of the historical part of Brazil's Education/Learning - and their relation with the language - in particular historical moments. And this way of analysis, when a particular articulation in part of educational history in Brazil is determined, allow the comprehension of conformation of subjects in various historical-ideological conditions and the Constitution of a Brazilian National State . Key-words: Education, Learning, Language, Speech Analysis, Linguistic Ideas History, Constitutions, Law Directives and Bases of Education / Doutorado / Linguistica / Doutor em Linguística

O presente trabalho tem por escopo o estudo do princípio do respeito à autonomia do paciente à luz das recentes alterações trazidas pelo novo CEM Resolução do Conselho Federal de Medicina nº 1.931, de 17 de setembro de 2009 , que prestigia a autonomia do paciente e propõe um novo formato para a relação médico-paciente, impondo novas posturas tanto ao médico como ao paciente, e privilegia sua autodeterminação, ao mesmo tempo em que o obriga à tomada de decisões e à assunção de responsabilidade compartilhada quanto ao processo terapêutico. O objeto do estudo é a nova relação médico-paciente sob o enfoque da autonomia do último, ressaltando-se a responsabilidade compartilhada com o médico em relação à tomada de decisões atinentes ao processo terapêutico, às escolhas terapêuticas, bem como os limites e o conteúdo do poder de decidir e sua autonomia diante da enfermidade e da terminalidade da vida. Nesta hipótese, a reflexão concentra-se nos cuidados paliativos e na adoção de diretivas prévias estatuídas pelo paciente a serem observadas pelo médico e por eventual terceiro responsável por aquele, caso ele não possa manifestar sua vontade durante cuidados paliativos ou situações que revelem iminente terminalidade. / This proposal aims to study the principle of respect for patient autonomy in light of recent changes introduced by the new CEM Resolution of the Federal Medical Council nº 1931 of September 17, 2009 which honors the patients autonomy and proposes a new format for the doctor-patient relationship, imposing new attitudes to both the patient and physician, emphasizes self-determination and, at the same time that forces decision making and the assumption of shared responsibility as to the therapeutic process. The object of the study is the new doctor-patient relationship from the perspective of this autonomy, emphasizing shared responsibility with the physician regarding decisions pertaining to the therapeutic process, the therapeutic choices, and the limits of power and content and their autonomy to decide on the terminally ill and life. In this case, reflection focuses on palliative care and the adoption of policies laid by the previous patient to be seen by the doctor and by any third party responsible for that, if he can not express his desire for palliative care or situations that reveal impending finality.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2017-07-27T18:08:53Z No. of bitstreams: 1 rogeriataroccodossantos.pdf: 1861098 bytes, checksum: cbafa5d41ef8a487bd8dd5025ae65ce2 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-08-09T13:54:04Z (GMT) No. of bitstreams: 1 rogeriataroccodossantos.pdf: 1861098 bytes, checksum: cbafa5d41ef8a487bd8dd5025ae65ce2 (MD5) / Made available in DSpace on 2017-08-09T13:54:04Z (GMT). No. of bitstreams: 1 rogeriataroccodossantos.pdf: 1861098 bytes, checksum: cbafa5d41ef8a487bd8dd5025ae65ce2 (MD5) Previous issue date: 2012-08-20 / O presente trabalho tem como objetivo investigar as principais funções que os atos de fala diretivos e comissivos exercem na negociação de acordos em resoluções de conflitos. E, em particular, a relação desses atos com a produção de ameaças na formulação de acordos em audiências de conciliação, realizadas pelo órgão de defesa do consumidor, o PROCON. Para a análise, selecionamos cinco audiências intituladas: Banco Sul, Brasimac, Gesso, Ok veículos e Rui Pedreiro, estas foram gravadas em áudio e transcritas de acordo com as convenções da Análise da Conversa. Com base em uma perspectiva performativa da linguagem, formulada inicialmente pela Teoria clássica dos Atos de Fala (AUSTIN, 1962; SEARLE, 1969) e discutida por CASANOVA (1996), GARCIA (1997) e SALGUEIRO (2010), iniciamos a análise a partir da suposição de que diretivos e comissivos deveriam configurar uma mesma categoria, pois ambos os atos estão relacionados à obrigação. O primeiro se refere a obrigações impostas aos outros e o segundo, a obrigações assumidas pelo falante/escritor. Assim, buscamos investigar o papel dos: (i) diretivos nas negociações de conflitos e (ii) comissivos nas resoluções. Os dados foram analisados a partir de uma perspectiva qualitativa e interpretativa, seguindo as orientações teórico-metodológicas de perspectiva interacional pragmática. Alguns dos resultados demonstraram que: (i) os diretivos têm um relevante papel na produção dos diferentes enquadres construídos pelas partes oponentes; há sempre duas versões sendo disputadas (a do reclamado e a do reclamante), e é o uso dos diretivos que revela esses enquadres; (ii) os comissivos têm importância na resolução do conflito, só há resolução quando o reclamado se compromete com alguma ação que é do interesse do reclamante e (iii) a hipótese, que diretivos e comissivos estão intrinsecamente ligados, tem fundamento, visto que, durante as negociações, as partes fazem uso de ameaças do tipo diretivo-comissivas, que apresentam ao mesmo tempo uma parte diretiva e outra comissiva. Nas audiências analisadas, as partes apenas entram em acordo, após o uso de ameaça feita ou pelo mediador ou pelo reclamado. Não foram encontradas ameaças usadas pelos reclamantes que fossem eficientes na produção do acordo. / This study aims to investigate the main functions of directive and commissive speech acts in the negotiation of agreements in conflict resolution. And, specifically, the relation of these acts with the production of threats in the formulation of agreements in conciliation hearings, organized by the consumer defense organ, PROCON. For this analysis, we select five hearings entitled: Banco Sul, Brasimac, Gesso, Ok veículos and Rui Pedreiro record in audio and translated using the notations suggested by Conversation Analysis. Based on the theoretical assumptions of a performative perspective on language, formulated initially by the classical Speech Act Theory (AUSTIN 1962; SEARLE 1969) and applied by CASANOVA (1996), GARCIA (1997) and SALGUEIRO (2010) to specific issues, we started the analysis considering the supposition that directive and commissives must set the same category, because both acts are related to obligation. The first one refers to obligations imposed to other person and the second, assumed by the speaker/writer. Thus, we seek to investigate: the role of (i) directive acts in the negotiation of conflict and (ii) commissive in their resolutions. The data were analyzed from a qualitative and interpretative perspective, following the theoretical and methodological orientations of an interactional perspective in pragmatics. Some of the results found were: (i) the directives have a relevant role in the production of the different frames, constructed by the opponent parties: there is always two versions being disputed (the respondent one and the claimant one), and it is the use of directive which reveals these framings; (ii) the commissives are important to the conflict resolution: there is resolution only when the respondent undertake to do any action of claimant‘s interest and (iii) the hypothesis, that directives and commissives are intrinsically linked, is grounded, since, during the negotiations, the parties make use of threats of the directive-commissives types, which present, at the same time, a directive part and a commissive one. Most of the time, in the hearings analysed, the parties only reach any kind of agreement, after the use of threats by mediator or the respondent. There wasn‘t found any threat used by claimants which effectively has reached an agreement.

In the last years, world changes have affected people, organizations and nations in a drastic way. In a growing speed, are questioned the bases in what economic, social and politic theories were constructed. In attempt of their substitution, new theories are created, that also become, quickly overshot. Many authors say human civilization goes through a period of paradigm change. The sciences related to companies management are the most affected by this change. Information Era provided a growing availability of information and consequently an educational improve. This caused a growing population conscious about goods and services quality demand in all public sectors, including educational means. Federal Government, recognizing this new reality, accorded to the article 37of Ementa Constitucional nº 19/98, included in the Constituição Federal de 98, the efficiency, as Public Management principle. From this institutionalization, resulted another rules as: Complementary Law nº 101/00, the Fiscal Responsibility Law, that establishes practices with more efficiency in public expenses control. Thus, Government edited Law nº 10.861/2004 which pass Graduation Assessment National System - SINAES, which has ten lines that must be observed for all Graduation Institutions, to obtain their accredited by MEC. Therefore, these subjects are strategies for University Schools, then, should be associated with strategic projection, management for directives and consequently, with the institutional PDI. In this perspective, there was carried out a qualitative, bibliographical, descriptive inquiry of exploit character, in the Santa Maria Federal University UFSM in which is associated to the strategic projection pattern already existed in dimensions of SINAES. Considering that these dimensions are basic directives to any IES, a ramification was carried out in the institution in study. It was noticed that, with the ramification of these directives, the UFSM Manager, has an essential administrative tool for his management. / As mudanças ocorridas no mundo nos últimos anos vêm afetando de forma drástica pessoas, organizações e nações. Em uma velocidade crescente, são questionadas as bases nas quais se construíram as teorias econômicas, sociais e políticas vigentes. Na tentativa de substituí-las criam-se novas teorias, que também se tornam ultrapassadas rapidamente. Diversos autores afirmam que a civilização humana atravessa um período de mudança de paradigma. As ciências relacionadas à gestão das empresas estão entre as mais afetadas por essa mudança. A era da Informação proporcionou uma crescente disponibilização de informações, e conseqüentemente uma melhoria educacional. Isto provocou uma crescente conscientização da população na cobrança por bens e serviços de qualidade, em todos os segmentos do setor público, inclusive no meio educacional. O Governo Federal em reconhecimento dessa nova realidade, através do artigo 37 da Ementa Constitucional nº 19/98, realizou a inclusão na Constituição de Federal de 1998 a eficiência como princípio da Administração Pública. A partir dessa institucionalização surgiram outras normatizações como: a Lei Complementar no. 101/00, evocada de Lei de Responsabilidade Fiscal que determina práticas que resultem em maior eficiência na alocação e execução dos gastos públicos. Dessa forma o governo editou a lei no. 10.861/2004 que estabelece o Sistema Nacional de Avaliação Superior SINAES, que possui dez diretrizes que devem ser observadas por todas as Instituições de Ensino Superior para que obtenham o credenciamento ou descredenciamento junto ao MEC, portanto essas dimensões por serem vitais são estratégicas para as instituições de Ensino Superior, logo devem estar associadas ao planejamento estratégico, gerenciamento por diretrizes e consequentemente ao PDI das Instituições de Ensino Superior. Nesta perspectiva foi realizada uma pesquisa qualitativa, bibliográfica, descritiva de caráter exploratório, junto a Universidade Federal de Santa Maria UFSM na qual associou-se ao modelo de planejamento estratégico já existente as dimensões do SINAES. Sendo que essas dimensões são diretrizes fundamentais a qualquer IES foi realizado um desdobramento destas na instituição em estudo. Constatou-se que com o desdobramento dessas diretrizes o Gestor da UFSM possuir uma ferramenta administrativa essencial para a sua gestão.