Pain assessment continues to be poorly managed in the clinical arena. A review of the communication process in pain assessment is carried out and the hierarchical approach often recommended in the literature -with self-report as its "gold-standard," is criticized as limited and simplistic. A comprehensive approach to pain assessment is recommended and a model that conceptualizes pain assessment as a complex transaction with various patient and clinician dependant factors is proposed. Attention is then focused on the pediatric patient whose pain assessment is often dependent on nonverbal communicative action. The clinical approaches to pain assessment in this population -mainly the use of behavioral/observational pain scales and facial pain scales, are explored. The primal face of pain (PFP) is identified and proposed theoretically as an important link in the function of facial pain scales. Finally, the existence of the PFP is investigated in a sample of 57 neonates across differences in sex and ethnic origin while controlling for potentially confounding factors. Facial expression to a painful stimulus is measured based on the Neonatal Facial Coding System (NFCS) and applying an innovative computer-based methodology. No statistically significant differences in facial expression were found in infant display thereby supporting the existence of the PFP.

Bakgrund Demens är en progredierande sjukdom där den kognitiva nedsättningen påverkar patientens förmåga att förmedla och uttrycka smärta. Hos patienter med långt framskriden demens är underbehandling av smärta ett problem och skapar ett lidande för patienten. För sjuksköterskan kan det upplevas komplext att bedöma smärta och smärtbehandla patienter med demens. Syfte Denna litteraturöversikts syfte är att utforska sjuksköterskans upplevelser vid bedömningav smärta hos patienter med demenssjukdom. Metod En strukturerad litteraturöversikt med inslag av den metodologi som används vid systematiska översikter enligt riktlinjer av Högskolan Dalarna. Analysen genomfördes i steg för en innehållsanalys. Resultat Sjuksköterskans erfarenheter av smärtbedömning hos patienter med demens belyser en komplex process där observationsstrategier, erhållandet av information från anhöriga om tidigare smärtbeteenden samt inhämtandet av dokumentation utgör grunden i smärtbedömningen. Den komplexa processen påverkas även av organisatoriska strukturer med upplevd tidsbrist, teamsamarbetets prövningar och attityder samt betydelse av kunskap och erfarenhet vilka inverkar på smärtbedömningens process och utfall i smärtbehandlingen hos patienter med demens. Slutsats Att bedöma smärta hos patienter med demens är för sjuksköterskan en komplex uppgift med många faktorer som påverkar bedömningen. En ej tillförlitlig bedömning orsakar lidande för patienten, osäkerhet för sjuksköterskan, en påverkad arbetsmiljö samt kostnader för samhället. / Background Dementia is a progressive disease in which the cognitive impairment affects the patient's ability to mediate and express pain. In patients with advanced dementia, undertreatment of pain is a problem and creates suffering for the patient. For the nurse, assessing pain and pain treating patients with dementia can be complex. AimThe aim of this literature review is to explore the nurse's experiences in assessing pain inpatients with dementia. Method A structured literature review with elements of the methodology used in systematic reviews according to guidelines from Dalarna University. The analysis was carried out insteps for a content analysis according to Friberg (2017). Results The nurse's experience of pain assessment in patients with dementia highlights a complex process where observation strategies, obtaining information from relatives about previous pain behaviours and obtaining documentation form the basis of the pain assessment. The complex process is also influenced by organizational structures with perceived lack of time, the trials and attitudes of team collaboration, and the importance of knowledge and experience that affect the pain assessment process and outcomes in pain treatment inpatients with dementia. Conclusions Assessing pain in patients with dementia is for the nurse a complex task with many factors that influence the assessment. An unreliable assessment causes suffering for the patient, uncertainty for the nurse, an affected work environment and costs for society.

BACKGROUND: Pain assessment is a significant challenge in critically ill adults, especially those unable to communicate their pain level. At present there is no universally accepted pain scale for use in the non-communicative (cognitively impaired, sedated, paralyzed or mechanically ventilated) patient. Facial expressions are considered among the most reflexive and automatic nonverbal indices of pain. The facial expression component of pain assessment tools include a variety of facial descriptors (wincing, frowning, grimacing, smile/relaxed) with inconsistent pain intensity ratings or checklists of behaviors. The lack of consistent facial expression description and quantification of pain intensity makes standardization of pain evaluation difficult. Although use of facial expression is an important behavioral measure of pain intensity, precise and accurate methods for interpreting the specific facial actions of pain in critically ill adults has not been identified. OBJECTIVE: The three specific aims of this prospective study were: 1) to describe facial actions during pain in non-communicative critically ill patients; 2) to determine facial actions that characterize the pain response; 3) to describe the effect of patient factors on facial actions during the pain response. DESIGN: Descriptive, correlational, comparative. SETTING: Two adult critical care units (Surgical Trauma ICU-STICU and Medical Respiratory ICU-MRICU) at an urban university medical center. SUBJECTS: A convenience sample of 50 non-communicative critically ill intubated, mechanically ventilated adult patients. Fifty-two percent were male, 48% Euro-American, with mean age 52.5 years (±17. 2). METHODS: Subjects were video-recorded while in an intensive care unit at rest (baseline phase) and during endotracheal suctioning (procedure phase). Observer-based pain ratings were gathered using the Behavioral Pain Scale. Facial actions were coded from video using the Facial Action Coding System (FACS) over a 30 second time period for each phase. Pain scores were calculated from FACS action units (AU) following Prkachin and Solomon metric. RESULTS: Fourteen facial action units were associated with pain response and found to occur more frequently during the noxious procedure than during baseline. These included areas of brow raiser, brow lower, orbit tightening, eye closure, head movements, mouth opening, nose wrinkling, and nasal dilatation, and chin raise. The sum of intensity of the 14 AUs was correlated with BPS (r=0.70, P<0.0001) and with the facial expression component of BPS (r=0.58, P<0.0001) during procedure. A stepwise multivariate analysis predicted 5 pain-relevant facial AUs [brow raiser (AU 1), brow lower (AU 4), nose wrinkling (AU 9), head turned right (AU 52), and head turned up (AU53)] that accounted for 71% of the variance (Adjusted R2=0.682) in pain response (F= 21.99, df=49, P<0.0001). The FACS pain intensity score based on 5 pain-relevant facial AUs was associated with BPS (r=0.77, P<0.0001) and with the facial expression component of BPS (r=0.63, P<0.0001) during procedure. Patient factors (e. g., age, gender, race, and diagnosis, duration of endotracheal intubation, ICU length of stay, and analgesic and sedative drug usages, and severity of illness) were not associated with the FACS pain intensity score. CONCLUSIONS: Overall, the FACS pain intensity score composed of inner brow raiser, brow lower, nose wrinkle, and head movements reflected a general pain action in our study. Upper facial expression provides an important behavioral measure of pain which may be used in the clinical evaluation of pain in the non-communicative critically ill patients. These results provide preliminary results that the Facial Action Coding System can discriminate a patient’s acute pain experience.

Bakgrund: Vårdandets mål är att lindra eller förhindra lidande. Barn som vistas på sjukhus utsätts många gånger för onödigt lidande. Som barnsjuksköterska har man en viktig roll i mötet med barnet, där barnets perspektiv alltid ska vara i fokus. Syfte: Syftet med studien var att belysa barnsjuksköterskors erfarenheter av att bedöma smärta hos barn i åldern två till sju år. Metod: Semistrukturerade intervjuer med 8 barnsjuksköterskor vid en barnklinik i norra Sverige. Materialet analyserades med kvalitativ innehållsanalys. Resultat: Resultatet visade på ett ökat behov av utbildning och tydligare rutiner/riktlinjer. Samtliga barnsjuksköterskor ansågs använda den kliniska blicken i bedömningen av barnets smärta dock var det få som skattade smärta enligt smärtskattningsskala. Slusats: Mer utbildning efterfrågas om barn och smärta, samt i vilken omfattning smärtskattningsinstrument bör användas. / Background: The aim of the caregiver is to alleviate or prevent suffering. Children who are hospitalized are often subjected to unnecessary suffering. As a child nurse, one has an important role in the meeting with the child, where the child's perspective should always be in focus. Purpose: The purpose of the study was to highlight the nurses' experiences of assessing pain in children aged two to seven years. Methods: Semi-structured interviews were conducted with 8 child nurses’ at a children's clinic in the north of Sweden. The material was analyzed with qualitative content analysis. Results: The result showed an increased need for education and clearer routines / guidelines. All child nurses were considered to use the clinical look in the assessment of the child's pain, however, there were few who estimated pain according to the pain estimation scale. Conclusion: More education is required about children and pain, and to what extent pain assessment instruments should be used / <p>Betyg E, 190603.</p>

Adequate pain assessment is a pre-requisite for appropriate pain management. If pain remains untreated in critically ill young children, it can have dramatic short- and long-term consequences on their health and development. Apart from humanitarian reasons, the assessment of pain has been recognised in some parts of the world as the fifth vital sign and thus should be part of standard practice of pain management. The evaluation of pain in preverbal children is, nevertheless, challenging for health professionals, as they cannot rely on self-report when making their assessment. Observational pain instruments have been developed to facilitate this task, but none of these existing instruments are appropriate for the postoperative critically ill young child. The aim of this research was to provide a clinically valid pain instrument for health professionals to use in practice for the evaluation of the pain and the effectiveness of pain treatment in critically ill young children. This thesis presents research that was conducted in three phases to (a) describe pain, (b) develop, and (c) test the pain instrument. Conceptualisation of pain and psychometric theory informed the conceptual framework for this study. An observational design was used in Phase One of the study to define pain behaviour in critically ill infants. Correlational design was used in Phase Two and Three to determine the association between the newly developed pain scale and other pain assessment instruments. Phase One of the study was conducted in the paediatric intensive care units of two tertiary referral hospitals. Eight hundred and three recorded segments were generated from recordings of five critically ill infants, aged between 0 and 9 months, who had undergone major surgery. / Results indicated significant physiological and behavioural changes in response to postoperative pain and when postoperative pain was exacerbated by painful procedures. Using the pain indicators observed in Phase One, in Phase Two the Multidimensional Assessment Pain Scale (MAPS) was developed and tested for reliability and validity in 43 postoperative preverbal children from the same settings. Internal consistency and interrater reliability were moderate and good, respectively. Concurrent and convergent validity was good. In Phase Three, the MAPS' response to analgesics and clinical utility was demonstrated in a convenience sample of 19 postoperative critically ill children aged between 0 and 3 1 months of age at a tertiary referral hospital in Western Australia. Development of a pain instrument is a complex and lengthy process. This study presents the preliminary psychometric properties that support the validity and clinical utility of the Multidimensional Assessment Pain Scale. The MAPS is a promising tool for assessing postoperative pain in critically ill young children, and its clinical validity will be strengthened with further testing and evaluation.

Syftet med denna studie var att beskriva riktlinjer och PM angående smärtbedömning och behandling som finns att tillgå på olika akutmottagningar och sjukhus. Smärta är en av de vanligaste orsakerna till att människor söker sjukvård i Sverige, därför ställer detta krav på sjukvårdens kompetens och tillgänglighet till riktlinjer/ PM som stödjer den vård som ges. En förfrågan om att få ta del av sjukhusens riktlinjer/ PM skickades via ut mail. Dokumenten analyserades och innehållet delades därefter in i sju kategorier som beskrev dess kontext, Definition av smärta, Bedömning/ Skattning av smärta, Behandling, Mål, Utvärdering/ Dokumentation, Smärtombud och Övrigt. I kategorin övrigt tas bland annat den bristande referenshanteringen till riktlinjer/ PM upp. Dokumenten visade en stor variation gällande innehåll och utförande. För att säkerställa en trygg och säker vård av god kvalitet krävs evidensbaserad kunskap, en kunskap som kontinuerligt skall uppdateras och förnyas. Något som sjukhusen enligt lagstiftning har skyldighet att göra. / The purpose of this study was to describe guidelines/ PM regarding pain assessment and treatment that is available in various emergency rooms and hospitals. Pain is one of the most common reasons for seeking medical care in Sweden, therefore medical expertise is required and also access to guidelines/ PM that supports the care provided. A request was sent by email to the hospitals requesting access to their guidelines/ PM. The contents of the documents were analyzed using seven categories which describe its context. Definition of pain, Assessment / Measurement of pain, Treatment, Goals, Evaluation / Documentation, Pain and Other Outlets. The category other outlets include amongst others the lack of reference to the management guidelines / PM. The results showed that the documents varied greatly with respects to content and design. To ensure safe and high quality care, evidence-based knowledge is required, knowledge that is constantly updated and renewed. This is something which Swedish hospitals have a legal obligation to perform.

Pain is a very common problem experienced by the general population and children in particular. It goes beyond personal suffering and affects all dimensions of the quality of life and general functioning of both adults and children, be it the physiological, psychological or financial aspects. Children may suffer from pain that may either be chronic or acute, depending on the diagnosis. Assessment of pain in children is equally important as that of adults, except that they lack the verbal fluency and cognitive development to communicate their pain. Children’s experience of pain is similar to that of adults. Pain assessment is a key aspect in the nursing management of children and delivery of care within the Primary Health Care (PHC) setting. Effective pain assessment is thus reliant on comprehensive assessment of the child and his or her pain. The aim of this research was to explore and describe practices and perceptions of professional nurses working in a PHC facility regarding pain assessment of children under five years in the Mangaung Metropolitan Municipality and to formulate recommendations for professional nurses in PHC facilities to facilitate pain assessment in PHC settings. A qualitative study design was used and data was collected with the use of focus groups. A purposive sampling was conducted to select participants who represent the target population. The sample used for the study included all the professional nurses working in PHC facilities registered with the South African Nursing Council and that have at least one year of experience. The practical training of the researcher to conduct an interview was done prior to the actual research. A pilot focus group was conducted and the interview schedule was finalised. Semi-structured focus groups were used to obtain data from the participants. The researcher conducted 6 focus group interviews attended by 32 professional nurses. Data was collected until data saturation was achieved. Trustworthiness was ensured in accordance with the principles of credibility, transferability, dependability and confirmability. Data was captured on a digital voice recorder and transcribed verbatim. Field notes were taken during each focus group. Data analysis was done by means of content analysis by the researcher and an independent co-coder. After consensus and saturation, three major themes emerged. Each theme was identified and divided into sub-themes and was consequently discussed together with the relevant data obtained from literature. The findings indicated that professional nurses perceive the assessment of pain in children under five years as a challenge. The combination of signs and symptoms to make decisions with pain assessment was identified as an area of concern. The participants further p erceived the history provided by the parent as important in the process of pain assessment. The conclusions drawn are that the professional nurses acknowledge that they don’t take sufficient notice of pain in children under five, which means that children with pain are neglected. Professional nurses maintain that there is a need for sufficient pain assessment and the need for guidelines and tools to assess pain in children under five, especially in the PHC setting. These professional nurses support the availability of guidelines to assist them to conduct effective and comprehensive pain assessment. The research report concluded with the researcher’s recommendations for nursing education, nursing research and nursing practice with specific formulation of guidelines for the facilitation of professional nurses to truly render effective and comprehensive pain assessment in PHC settings. / Thesis (MCur)--North-West University, Potchefstroom Campus, 2013.

Pain is a very common problem experienced by the general population and children in particular. It goes beyond personal suffering and affects all dimensions of the quality of life and general functioning of both adults and children, be it the physiological, psychological or financial aspects. Children may suffer from pain that may either be chronic or acute, depending on the diagnosis. Assessment of pain in children is equally important as that of adults, except that they lack the verbal fluency and cognitive development to communicate their pain. Children’s experience of pain is similar to that of adults. Pain assessment is a key aspect in the nursing management of children and delivery of care within the Primary Health Care (PHC) setting. Effective pain assessment is thus reliant on comprehensive assessment of the child and his or her pain. The aim of this research was to explore and describe practices and perceptions of professional nurses working in a PHC facility regarding pain assessment of children under five years in the Mangaung Metropolitan Municipality and to formulate recommendations for professional nurses in PHC facilities to facilitate pain assessment in PHC settings. A qualitative study design was used and data was collected with the use of focus groups. A purposive sampling was conducted to select participants who represent the target population. The sample used for the study included all the professional nurses working in PHC facilities registered with the South African Nursing Council and that have at least one year of experience. The practical training of the researcher to conduct an interview was done prior to the actual research. A pilot focus group was conducted and the interview schedule was finalised. Semi-structured focus groups were used to obtain data from the participants. The researcher conducted 6 focus group interviews attended by 32 professional nurses. Data was collected until data saturation was achieved. Trustworthiness was ensured in accordance with the principles of credibility, transferability, dependability and confirmability. Data was captured on a digital voice recorder and transcribed verbatim. Field notes were taken during each focus group. Data analysis was done by means of content analysis by the researcher and an independent co-coder. After consensus and saturation, three major themes emerged. Each theme was identified and divided into sub-themes and was consequently discussed together with the relevant data obtained from literature. The findings indicated that professional nurses perceive the assessment of pain in children under five years as a challenge. The combination of signs and symptoms to make decisions with pain assessment was identified as an area of concern. The participants further p erceived the history provided by the parent as important in the process of pain assessment. The conclusions drawn are that the professional nurses acknowledge that they don’t take sufficient notice of pain in children under five, which means that children with pain are neglected. Professional nurses maintain that there is a need for sufficient pain assessment and the need for guidelines and tools to assess pain in children under five, especially in the PHC setting. These professional nurses support the availability of guidelines to assist them to conduct effective and comprehensive pain assessment. The research report concluded with the researcher’s recommendations for nursing education, nursing research and nursing practice with specific formulation of guidelines for the facilitation of professional nurses to truly render effective and comprehensive pain assessment in PHC settings. / Thesis (MCur)--North-West University, Potchefstroom Campus, 2013.

Der heute noch gängige Einsatz von Injektionsanästhetika bei Laborratten basiert zum großen Teil auf empirischen Daten. Auf der Grundlage des deutschen Tierschutzgesetzes sind Wissenschaftler verpflichtet, das nach dem derzeitigen Kenntnisstand schonendste Betäubungsmittel zu verwenden. Die wissenschaftlichen Daten zur intra- und postoperativen Belastung bei vielen Anästhetika sind lückenhaft. Daher wurden in dieser Studie im Sinne des „Refinements“ von Tierversuchen verschiedene Injektionsnarkosen bei 69 männlichen und weiblichen 6-8 Wochen alten Sprague-Dawley-Ratten im Rahmen einer stereotaktischen Gehirnoperation (OP) verglichen, bei der zumeist Injektionsnarkosen Verwendung finden. Die Ratten wurden entweder mit Chloralhydrat (CH: 3,6 %, 430 mg/kg intraperitoneal [i.p.] KGW), mit der vollständig antagonisierbaren Anästhesie (Medetomidin 0,15 mg/kg Körpergewicht [KGW], Midazolam 2 mg/kg KGW, Fentanyl 0,005 mg/kg KGW intramuskulär [i.m]) ohne (VAA-Gruppe) bzw. mit Antagonisierung (sog. VAA+A-Gruppe) zum OP-Ende (Atipamezol 0,75 mg/kg, Flumazenil 0,2 mg/kg, Naloxon 0,12 mg/kg subcutan [s.c.]) anästhesiert und nach Erreichen des Stadiums der chirurgischen Toleranz (cT), gekennzeichnet durch den Ausfall des Zwischenzehenreflexes an des Hintergliedmaße (ZZR hi.), einer 60-minütigen OP unterzogen. Eine weitere Gruppe erhielt eine i.p.-Bolusinjektion Propofol in einer Dosis von 120 mg/kg KGW, die sich im Rahmen von Vorversuchen als geeignet herausgestellt hatte, um bei Ratten eine Hypnose zu bewirken. Anschließend wurde Propofol zu Erzeugung und Aufrechterhaltung einer cT per Dauerinfusion i.v. (4 - 6 mg/kg/h) verabreicht. Kontrolltiere erhielten eine Injektion mit isotoner Kochsalzlösung (i.p.) ohne OP. Die Erfassung des KGWs erfolgte 3 Tage vor bis 2 Tage nach der OP. Im Vorfeld wurde jedes Tier über 3 Tage an das Tragen eines Pulsoximeterclips am Hals gewöhnt. Dies diente der Ermittlung von Basiswerte für die Atemfrequenz (AF), Herzfrequenz (AF) und die periphere Sauerstoffsättigung (SpO2)am wachen, freibeweglichen Tier am Tag der Anästhesie mittels MouseOx®-Pulsoximeter. In Narkose wurden die Tiere mittels Pulsoximeter, Reflextests (ZZR hi., Lid- [LR] und Cornealreflex [CR]) und Rektalthermometer überwacht. Die externe Wärmezufuhr wurde über eine elektrische Wärmeplatte (37 °C) vorgenommen Zu zwei Zeitpunkten erfolgten Blutabnahmen zur Bestimmung der Adrenalin- (A) und Noradrenalinwerte (NA) mittels HPLC. Der Verlust der cT wurde anhand festgelegter Kriterien bestimmt (ZZR hi. positiv, Zuckungen, lautes Vokalisieren, Zähneknirschen) und die Tiere ggf. nachdosiert. Prä- und postoperativ wurde immunreaktives Corticosteron (iCS) mittels ELISA aus Kotproben ermittelt. Zudem wurde die prä- vs. postoperative Belastung durch Etablierung eines nummerischen Scoresystems und Videoüberwachung der Tiere bewertet. 48 h nach der OP wurden die Ratten euthanasiert und relevante Organe und Gewebe für die histopathologische und immunhistochemische Untersuchung entnommen, um mögliche Anästhetika bedingte Irritationen sowie eine stressinduzierte Aktivierung von c-Fos-Proteinen in schmerz-assoziierten Gehirnregionen zu analysieren. Eine weitere Gruppe erhielt eine Inhalationsnarkose mit 3 % Isofluran (ISO) ohne OP und diente der Ermittlung von A und NA Basiswerten. Die AF lag bei 104 ± 1,05 Atemzüge/min, die HF bei 396 ± 2,10 Herzschläge/min und die SpO2 bei 95,7 ± 0,09 % (Angaben als Mittelwerte ± Standardfehler). Die Verwendung des MouseOx®-Pulsoximeters erwies sich als geeignete Methode zur Ermittlung von Wachwerten bei freibeweglichen Ratten. Alle CH-anästhesierten Tiere erreichten das cT-Stadium. Die Dauer der cT lag bei 49,14 ± 4,48 min, die Narkosedauer bei 155,66 ± 8,21 min. Während der Narkose zeigten die Tiere Tachykardie, Tachypnoe sowie eine geringgradig erniedrigte SpO2 und eine leichte Hypothermie. Erhöhte A/NA-Spiegel wiesen auf eine deutlich höhere intraoperative Stressbelastung in der CH-Gruppe hin. Auch iCS war in der CH-Gruppe im Vergleich zu VAA/VAA+A signifikant erhöht. Vom Tag der Anästhesie/OP auf den Folgetag verloren CH-Tiere durchschnittlich 9,4 g KGW. Postoperativ waren bei den Tieren keine bis geringe Anzeichen für Schmerz und/oder Disstress zu erkennen. Histopathologisch zeigten alle Ratten eine Peritonitis und Perihepatitis, 44 % der Tiere multifokale, akute Lebernekrosen und 22 % eine Perisplenitis. 95 % der mittels VAA anästhesierten Tiere erreichten die cT mit einer Dauer von 47,83 ± 7,05 min (VAA) bzw. 44,77 ± 5,27 min (VAA+A). Bei VAA-Tieren betrug die gesamte Narkosedauer 182,23 ± 20,58 min. Bei der VAA-Anästhesie insgesamt waren signifikante geschlechtsspezifische Unterschiede in der Latenzzeit bis zum Erreichen der 1. cT, der cT-Dauer und der Narkosedauer festzustellen. Die VAA-Anästhesie führte zu einer mittelgradiger Atemdepression und milden Hypothermie bei signifikant niedrigeren A/NA-Werten im Vergleich zu CH. Eine Nachdosierung ging mit einem vorrübergehenden signifikanten Abfall der SpO2 einher. Tiere der VAA+A-Gruppe erwachten 3,05 ± 0,21 min nach der s.c. Antagonisierung aus der Narkose. Anschließend zeigten sie starke Aufregung und Unruhe und ein verändertes Aktivitätsmuster, eine Stunde später teils Piloerektion sowie Ataxien. Die Körperkerntemperatur (KT) der VAA+A-Tiere sank innerhalb 1. Stunde nach der Antagonisierung signifikant ab. Einige Tiere wiesen eine Myositis als Folge der i.m. Applikation auf. Nach PROP-Anästhesie erreichten nur 36 % der Tiere das cT. Im Narkoseverlauf kam es bei diesen Tieren zu einer starken Beeinträchtigung der Atemfunktion. PROP-Tiere wiesen einen signifikanten Abfall der KT und Anzeichen verlängerter Sedation nach Wiedererwachen sowie die höchsten iCS-Gehalte auf. Insgesamt verstarben 4 von 11 Tieren wegen starker Atemdepression intra- oder postoperativ. Interessanterweise waren die nach ISO-Anästhesie ermittelten A/NA-Konzentrationen signifikant höher gegenüber allen Injektionsanästhesie-Gruppen. Die Ergebnisse dieser Studie belegen, dass die CH-Anästhesie mit gesteigerter Stresshormonfreisetzung einherging. Die Verwendung 3,6 %iger CH-Lösungen ist insbesondere wegen der massiven histopathologischen Befunde abzulehnen, obwohl die Tiere subjektiv ein scheinbar gutes Wohlbefinden aufwiesen. Die i.p. Applikation von Propofol erzeugte nur eine oberflächliche Anästhesie. Aufgrund der starken postanästhetischen Exzitationen sollte sie nur bedingt für kurze, nicht schmerzhafte Manipulation verwendet werden. Die initiale i.p. Propofol-Gabe mit anschließender i.v.-Infusion ist der reinen i.v. Gabe unterlegen und nicht empfehlenswert. Die VAA-Anästhesie ist für Ratten für stereotaktische OPs hingegen gut geeignet. Dabei ist eine exogene Wärmezufuhr auch nach der Antagonisierung zwingend notwendig, da das Thermoregulations-vermögen nach Wiedererwachen nicht ausreichend wiedererlangt wurde. Auf eine Belastung durch die unerwünschten Wirkungen der Antagonisierung wie Aufregung und Unruhe sowie durch die postanästhetische Hypothermie konnte nur anhand subjektiver Kriterien geschlossen werden. Hier sind weitere Untersuchungen nötig. Sofern kein Anästhesienotfall besteht, kann allerdings auf die Antagonisierung verzichtet werden, da in der Nachschlafzeit unter externer Wärmezufuhr (37 - 38 °C) kein wesentliches Risiko einer lebensbedrohlichen Hypothermie bzw. Kreislauf- und Atemdepression besteht. / Injectable anesthetics are still commonly used today, but mainly this is based on empirical data. In line with the German Animal Welfare Act, researches have to choose the least stressful anesthetic. However, scientific data about pain and distress during and after anesthesia are rare. To contribute to the refinement of animal experiments, we therefore investigated the suitability of different injectable anesthetics during a stereotactic surgery, for which kind of surgery injectable anesthetics are mostly used, in 69 male and female, 6 - 8 weeks old Sprague-Dawley rats. Rats were anesthetized with either chloral hydrate (CH: 3.6 %, 430 mg/kg intraperitoneal [i.p.]), with a complete reversible anesthesia (medetomidine 0.15, midazolam 2, fentanyl 0.0005 mg/kg intramuscular [i.m]) without (MMF) and with reversal (MMF with reversal) at the end of surgery (atipamezole 0.75, flumazenile 0.2, naloxone 0.12 mg/kg subcutaneous [s.c.]) or with propofol (PROP). The PROP-group received an i.p. bolus injection of propofol (120 mg/kg), shown to generate hypnosis in proceedings, followed by constant intravenous infusion (4 - 6 mg/kg/h) to achieve and maintain surgical tolerance (st). After reaching surgical anesthesia, indicated by loss of the pedal withdrawal reflex of the hind limb, a 60 minute surgery was undertaken. Rats with saline injection and without surgery served as control. Body weight of each rat was assessed 3 days before the surgery until 2 days after surgery. Over 3 days prior anesthesia and surgery, rats were adapted to wear a collar clip for MouseOx® pulse oximeter, used to gain basal of respiratory rate (RR), heart rate (HR) and peripheral oxygen saturation (pO2) values in awake and freely moving rats. During narcosis, monitoring was conducted via pulse oximeter, reflex tests (pedal withdrawal reflex, corneal and palpebral reflex) and rectal thermometer. All animals were placed on an electrical heating pad (37 °C). Levels of adrenalin and noradrenalin (A/NA) were analyzed at two designated time points via HPLC. Movement of the body or the extremities, audible vocalizations and teeth grinding were classified as defined criteria for the loss of st. If animals lost st during surgery, they received an additional anesthetic dose. Immunoactive corticosteron (iCS) in feces was determined by ELISA immunoassay before and after surgery. Moreover, different signs of pain and distress were scored by using a numerical pain scale and including video recordings. Rats were sacrificed 48 h after surgery for histopathological and immunhistochemical examination to analyze potential irritation on abdominal organs and tissue as well as stress-induced activation of c-Fos-protein in brain regions associated with pain. Furthermore, 5 rats were deeply anesthetized with 3 % isoflurane (ISO) and immediately sacrificed for reference values of A and NA. The RR assessed by MouseOx® pulse oximeter was 104 ± 1.05 brpm with a HR of 396 ± 2.10 bpm and an pO2 of 95.7 ± 0.09 % (results present the mean ± standard error). The MouseOx® pulse oximeter was found in the present study to be suitable to measure accurate values for awake and freely moving rats. All rats undergoing CH anesthesia reached st. The duration of the st was 49.14 ± 4.48 min, duration of narcosis was 155.66 ± 8.21 min. During the whole narcosis animal showed tachypnoea, tachycardia as well as minimal depressed pO2-levels and a slightly hypothermia. Elevated levels of A/NA indicated a high intraoperative distress. In addition, iCS levels were significantly elevated in comparison to the MMF-group. CH-rats lost 9.4 g of bodyweight from day of surgery to the following day. Overall, post-surgical little or no signs of pain and distress were observed after awakening from anesthesia, but all CH-rats exhibited peritonitis and perihepatitis, 44 % acute multifocal liver necrosis and 22 % perisplenitis. 95 % in the MMF-group reached satisfactory surgical anesthesia with duration of 47.83 ± 7.05 min (MMF) or 44.77 ± 5.27 min (MMF with reversal). Without reversal, MMF anesthesia lasted 182.23 ± 20.58 min. Gender-differences were noted in the latency to st, duration of st as well as duration of narcosis. Rats undergoing MMF anesthesia showed moderate depression of respiratory function and mild hypothermia. The A/NA levels were lower than in the CH-rats. Rats that received additional doses of MMF to maintain st showed a transient significant decrease of pO2. Core body temperature decreased significantly during 1 h after reversal. Post-mortem examination revealed myositis in some of the MMF-rats. MMF-rats with reversal awaked from anesthesia after 3.05 ± 0.31 min. Afterwards the rats were restless and agitated. After 1 h some of the rats exhibited piloerection and ataxic movements. Only 36 % of PROP-rats reached sufficient surgical anesthesia, accompanied by a pronounced respiratory depression. PROP-rats exhibited a significant decrease of core body temperature and signs of prolonged sedation after awakening from anesthesia. 4 of 11 rats died from respiratory failure during or after surgery. Surprisingly, levels of A/NA after ISO inhalation anesthesia were significantly higher compared to the injection groups. The results of this study indicate that CH anesthesia is associated with an increased liberation of stress hormones. The use of a 3.6 % solution of CH has to be refused especially because of the pathohistological findings, despite animals showed subjectively a good well-being. Propofol administered as an i.p. bolus produced only hypnosis. Therefore, i.p. injections are marely useful for short and non-painful procedures. However, post-anesthetic excitations represent limitations. The initial i.p. propofol bolus followed by intravenous infusion is therefore less suitable than an absolute intravenous administration. Thus, i.p. injections cannot be recommended. The complete reversible combination MMF is considered as suitable for stereotactic surgeries of Sprague-Dawley rats. There is an urgent need to continue heating after awakening, because thermoregulation is insufficiently restored after reversal of MMF anesthesia. Distress through the undesirable effects of the reversal like agitation and restlessness and through hypothermia was presumed only by subjective criteria. Further investigations are needed here. If there is no emergency situation, reversal should be avoided. In case of permanent external heating (37 - 38 °C) there is no major risk of life-threatening hypothermia or depression of respiratory or cardiovascular function during sleeping time.

Bakgrund: Smärta är en subjektiv upplevelse och bör uppmärksammas av distriktssköterskorna. Palliativ hemsjukvård innebär att distriktssköterskor ger patienten en smärtfri och god livskvalitet i livets sista dagar i hemmet med familj och vänner närvarande. Smärta är ett vanligt förekommande symtom vid palliativ vård, därför är det viktigt att smärtbedömningen grundar sig på ett personcentrerat förhållningsätt och att distriktssköterskor gör en adekvat smärtbedömning.    Syfte: Syftet var att belysa distriktssköterskors erfarenheter i att bedöma smärta i ett sent skede vid palliativ vård i hemsjukvården med fokus på användning av smärtskattningsinstrument.    Metod: För att få fram distriktssköterskors erfarenheter användes en kvalitativ intervjustudie med semistrukturerade frågor med en induktiv ansats. Studien resulterade i elva intervjuer. Bearbetningen av intervjuerna genomfördes via en kvalitativ innehållsanalys.   Resultat: Studiens resultat visade att distriktsköterskorna upplevde att utbildning skapade trygghet i att bedöma smärta, men uppgav att de saknade engagemang från organisationen gällande fortbildning i smärtbedömning. I de fall patienten inte själv kunde verbalt uttrycka sin smärta bedömde distriktssköterskorna smärtan med sin kliniska blick. Distriktssköterskorna uppgav att när den kliniska blicken och smärtskattningsinstrument kombinerades fick patienten den mest optimala smärtbedömningen.   Slutsats: Samtliga distriktssköterskor i studien poängterar att den mest gynnsamma bedömningen av smärta tillhandahålls genom att smärtskattningsinstrument används i kombination med en erfaren klinisk blick. För att uppnå detta måste ledningen skapa riktlinjer så att smärtskattningsinstrument implementeras i det vardagliga arbetet för distriktssköterskorna. / Background: Pain is a subjective experience and should be attended by the district nurse. Palliative home care means that the district nurse gives the patient a pain free and good quality of life in the last days of life at home with family and friends present. Pain is a common symptom of palliative care, so it is important that the pain assessment is based on a person-centered approach and that the district nurse makes an adequate pain assessment.  Aim: The aim was to highlight the experience of the district nurse in assessing pain at a late stage in palliative care in home care, focusing on the use of pain assessment instruments. Method: In order to obtain the district nurse's experience, a qualitative interview study was used with semi structured questions with an inductive approach. The study resulted in eleven interviews. The processing of the interviews was conducted through a qualitative content analysis. Result: The results of the study showed that the district nurses felt that education provided confidence in assessing pain, but stated that they lacked commitment from the organization regarding continuing education in pain assessment. In cases where the patient could not express his pain verbally, the district nurses assessed the pain with their clinical eye. District nurses stated that when the clinical eye and pain assessment instrument was combined, the patient received the most optimal pain assessment. Conclusion: All district nurses in the study emphasize that the most favorable assessment of pain is provided by using pain assessment instruments in combination with an experienced clinical eye. To achieve this, management has to establish guidelines so that pain assessment instruments are implemented in the everyday work of the district nurse.