Diss. Linköping : Univ., 2004.

Thesis (M.S.)--University of Michigan, 1999. / Includes bibliographical references.

Thesis (M.S.)--University of Michigan, 1999. / Includes bibliographical references.

Este estudo teve como objetivos analisar o conceito náusea em pacientes no período pósoperatório imediato; avaliar a validade de conteúdo e clínica do diagnóstico de enfermagem Náusea no período pós-operatório imediato, considerando-se o modelo de Fehring; identificar a incidência do referido diagnóstico em pacientes no período pós-operatório imediato; verificar possíveis associações entre os antecedentes de náusea obtidos na análise de conceito e os identificados nos pacientes com náusea no pós-operatório imediato e verificar a frequência de ocorrência das características definidoras principais e secundárias do diagnóstico Náusea. A pesquisa foi desenvolvida em três etapas: análise de conceito, validação de conteúdo e validação clínica. A análise de conceito seguiu as oito fases propostas por Walker a Avant: selecionar o conceito, definir o objetivo da análise, identificar a utilização do conceito, definir atributos definidores, desenvolver casos-modelos, desenvolver outros casos, identificar antecedentes e consequentes e verificar as referências empíricas. Essa etapa foi fundamental para a realização das etapas posteriores (validação de conteúdo e validação clínica), permitindo a construção de definições operacionais e a elaboração de instrumentos de coleta de dados mais direcionados ao cenário do paciente com náusea no período pós-operatório. Participaram da validação de conteúdo 52 expertos que responderam a um instrumento que continha dados de identificação profissional e de validação do diagnóstico de enfermagem Náusea (enunciado, definição, posição que ocupa na estrutura taxonômica e características definidoras, descritas em uma escala tipo Likert). A maioria dos expertos considerou o domínio 12 (Conforto), a classe 1 (conforto físico) e o enunciado (náusea) adequados ao diagnóstico. Foram sugeridas modificações na definição atual do referido diagnóstico de enfermagem. Quatro características definidoras foram consideradas principais (relato de náusea, salivação aumentada, aversão à comida e sensação de vômito) e oito foram denominadas secundárias (deglutição aumentada, gosto amargo na boca, palidez, taquicardia, diaforese, sensação de calor e frio, alterações da pressão arterial e dilatação pupilar). Na etapa de validação clínica, 106 pacientes foram incluídos na amostra. Para a coleta de dados, foram utilizados o questionário de avaliação pré, intra e pósoperatória e a Escala Hospitalar de Ansiedade e Depressão. A náusea foi avaliada em duas etapas: 1) análise das manifestações objetivas (dois enfermeiros simultaneamente) e 2) subjetivas (um enfermeiro). A incidência de náusea foi de 21,70% e, na maioria das vezes, de moderada intensidade. Os antecedentes associados à presença de náuseas no pós-operatório foram: sexo, idade, tipo de anestesia, presença de dor, movimentação e alimentação pósoperatória e odores nocivos. Na etapa 1, a característica definidora denominada principal foi relato de náusea, e as manifestações secundárias foram sensação de vômito, palidez e deglutição aumentada. O índice de concordância variou de 86,95% a 100,00%. Na etapa 2, as características consideradas principais foram relato de náusea e sensação de vômito, e as características definidoras secundárias identificadas foram salivação aumentada e sensação de calor e frio. Os escores totais do diagnóstico de enfermagem Náusea foram de 0,79 e 0,73 para as validações de conteúdo e clínica respectivamente, considerado válido para a Taxonomia da North American Nursing Diagnosis Association - International (NANDA-I). Concluiu-se que o relato de náusea, sensação de vômito, palidez, salivação aumentada, deglutição aumentada e sensação de calor e frio são fortes indicativos do diagnóstico de enfermagem Náusea. / The aims of this study were to analyze the nausea concept in patients during the immediate postoperative period; to assess the content and clinical validity of the nursing diagnosis nausea in the immediate postoperative period, considering Fehring\'s model; to identify the incidence of this diagnosis in patients during the immediate postoperative period; to check for possible associations between the nausea antecedents obtained in the concept analysis and those identified in patients with immediate postoperative nausea and to verify the frequency of the primary and secondary defining characteristics of the Nausea diagnosis. The research was developed in three phases: concept analysis, content validation and clinical validation. The concept analysis followed the eight phases proposed by Walker and Avant: select the concept, define the aim of the analysis, identify the use of the concept, define defining attributes, develop model cases, develop other cases, identify antecedents and consequences and check empirical references. This phase was fundamental to accomplish further phases (content validation and clinical validation), permitting the construction of operational definitions and the elaboration of data collection instruments that were better directed at the context of postoperative nausea patients. Fifty-two specialists participated in the content validation, who answered an instrument with professional identification data and the validation of the nursing diagnosis nausea (wording, definition, position in taxonomic structure and defining characteristics, described on a Likert scale). Most experts considered domain 12 (Comfort), class 1 (physical comfort) and the wording (nausea) adequate for the diagnosis. Modifications were suggested in the current definition of the referred nursing diagnosis. Four defining characteristics were considered primary (reported nausea, increased salivation, aversion toward food and gagging sensation), while eight were called secondary (increased swallowing, sour taste in the mouth, pallor, tachycardia, excessive sweating, feeling hot and cold, blood pressure alterations and pupil dilation). In the clinical validation phase, 106 patients were included in the sample. For data collection the pre, intra and post-operative assessment questionnaire and the Hospital Anxiety and Depression Scale were used. Nausea was assessed in two phases: 1) analysis of objective manifestations (two nurses simultaneously) and 2) subjective (one nurse). The incidence level of nausea corresponded to 21.70%, in most cases of moderate intensity. The following antecedents were associated with the presence of nausea and vomiting: gender, age, anesthesia type, presence of pain, postoperative movements and meals and harmful smells. In phase 1, the defining characteristic that was considered primary was reported nausea and the secondary manifestations were gagging sensation, pallor and increased swallowing. Agreement levels ranged between 86.95% and 100.00%. In phase 2, reported nausea and gagging sensation were considered primary characteristics, while increased salivation and feeling hot and cold were identified as secondary defining characteristics. The total scores of the nursing diagnosis Nausea corresponded to 0.79 and 0.73 for the content and clinical validations, respectively, which are considered valid for the Taxonomy of the North American Nursing Diagnosis Association - International (NANDA-I). In conclusion, reported nausea, gagging sensation, pallor, increased salivation, increased swallowing and feeling hot and cold are strong signs of the nursing diagnosis Nausea.

Aspiration of gastric content and delayed or failed intubation are the leading causes of anesthesia-related mortality and morbidity. In the recovery period, airway obstruction with subsequent hypoxia is a relatively common cause of morbidity, and is highly associated to the amount of opioids administered, especially in obese patients. The overall aim of this thesis was to study these risk factors for airway complications and postoperative hypoxia in obese patients, and to evaluate possible strategies for their prevention. In Study I, intubation times and incidence of failed intubation in obese patients were compared between direct laryngoscopy and videolaryngoscopy with the Stortz® C-MAC™. In Studies II and III, the effect of esmolol vs. remifentanil on the esophageal junction, and the possible analgesic properties of low-dose esmolol vs. placebo were evaluated using high-resolution manometry and the cold pressor test, respectively. Finally, in Study IV, the possible opioid-sparing effect of esmolol after laparoscopic gastric bypass surgery was evaluated. The use of videlaryngoscopy did not shorten intubation times, however appeared to reduce the incidence of failed intubation. Our results also show that esmolol has a favorable profile, compared to remifentanil, with regard to the protection against passive regurgitation and aspiration of gastric content. No analgesic effect of low-dose esmolol was however demonstrated. The intraoperative administration of esmolol instead of remifentanil also did not reduce the requirement of morphine for treatment of post-operative pain. The use of Stortz® C-MAC™ may be recommended for intubation of obese patients. Further studies are however required to clarify the possible role of esmolol in anesthesia.

Bakgrund: Pankreatikoduodenektomi är den enda kurativa behandlingen av pankreascancer och pankreasanastomosläckage (PAL) är en mycket allvarlig postoperativ komplikation. Metoder för att identifiera detta i ett tidigt skede behöver förbättras. Den postoperativa övervakningen består till stor del av vitalparametrar men sjuksköterskan observerar även andra tecken på försämring. Metod: 32 patienter som genomgått pankreatikoduodenektomi inkluderades i studie. Ett bedömningsformulär innehållande 14 parametrar togs fram och användes för att identifiera vad i sjuksköterskans observationer som kan identifiera tidiga tecken på PAL. Studien hade kvantitativ ansats. Syfte: Att identifiera tidiga tecken på PAL efter pankreatikoduodenektomi med hjälp av ett bedömningsformulär. Resultat: Bedömningsformuläret identifierade normalförloppet efter pankreatikoduodenektomi. Vid jämförelse mellan patienterna som drabbats av PAL och normalförloppet urskildes tre signifikanta skillnader. Patienterna med PAL hade innan det diagnostiserades ökat syrgasbehov, sjuksköterskan bedömde deras allmäntillstånd som dåligt istället för ganska gott och patienternas egenbedömning av allmäntillståndet visade att de mådde sämre för varje dag istället för bättre. Slutsatser: Studien indikerar att ökat syrgasbehov samt sjuksköterskans bedömning och patientens egenbedömning av allmäntillståndet är vägledande för upptäckten av pankreasanastomosläckage. / Background: Pancreaticoduodenectomy is the only curative treatment of pancreaticcancer and postoperative pancreatic fistula (POPF) is a very serious complication. Methods to identify this in an early stage must be improved. The postoperative monitoring is largely composed of vital signs, but the nurse also observes other signs of deterioration. Method: 32 patients how underwent pancreaticoduodenectomy were included in the study. An assessment form containing 14 parameters was used to identify what in the nurse's observation that can identify early signs of POPF. The study had a quantitative approach. Objective: To identify early signs of POPF after pancreaticoduodenectomy using anassessment form. Results: The assessment form identified the normal process after pancreaticoduodenectomy. In the comparison between the patients affected by POPF and the normal process, three significant differences were distinguished. The patients with POPF had before it occurred increased oxygen needs, the nurse assessed the general health as poor rather than pretty good and the patients self-assessed the general health worse by the day instead of better. Conclusions: This study indicates that increased oxygen needs and the nurse's assessment and the patient's self-assessment of general health can be indicative for the discovery of POPF.

Bakgrund: Smärta är en subjektiv känsla där varje individ lär sig betydelsen av ordet genom egna erfarenheter. Smärta är något nästan alla upplever efter ett kirurgiskt ingrepp och där otillräcklig smärtlindring i den akuta fasen kan leda till svåra komplikationer vilket skapar lidande för patienten samt stora samhällsekonomiska kostnader. Syfte: Att beskriva patienters upplevelse av postoperativ smärtbehandling. Metod: Litteraturstudie med deskriptiv design av 11 kvalitativa originalartiklar från databaserna PubMed, CINAHL och PsycINFO vars innehåll analyserades i fem steg. Resultat: Patienter var överlag tillfredsställda trots smärta. Det fanns delade åsikter om nyttan av NRS (numerisk skala). Patienter hade en rad föreställningar om läkemedel som ledde dem till att undvika analgetika. Information ansågs vara huvudsakligen hjälpsamt, framför allt skriftlig, dock upplevde patienter att informationen var bristfällig. Attityd, tillit och kommunikation spelade en viktig roll för relationen mellan personal och patient. Patienter som genomgått dagkirurgi och behandlade sin smärta ensamma i hemmet med mycket begränsad kontakt med vårdpersonal, upplevde svårigheter att ta beslut och följa sin smärtbehandlingsplan. Patienter uppskattade att bli inkluderade och delaktiga i sin vård, även om det kunde upplevas som en börda, och tog många egna initiativ och egna strategier under sin behandling, ofta för att slippa använda analgetika. Tidigare erfarenheter var också något som ofta hjälpte patienter i deras smärtbehandling. Slutsats: Patienter var ofta nöjda med sin smärtbehandling trots att de fortfarande upplevde smärta, viktigast för att uppnå detta var en känsla av trygghet. Viktiga faktorer för detta var utförlig skriftlig och upprepad information om smärta, smärtbehandling och analgetika samt ett gott, professionellt, inkluderande och individanpassat bemötande från vårdpersonalen. Brister inom dessa områden ledde till oro och rädsla för det okända, vilket försvårade smärtupplevelsen. Patienter upplevde sällan fullgod smärtlindring. / Background: Pain is a subjective feeling where each individual learns the meaning of the word through their own experiences. Pain is something almost everyone experiences after a surgical procedure and where insufficient pain relief in the acute phase can lead to severe complications, which creates suffering for the patient and large socio-economic costs. Aim: To describe patients' experience of postoperative pain management. Method: Literature review with descriptive design of 11 qualitative original articles from the databases PubMed, CINAHL and PsycINFO whose contents were analyzed in five steps. Result: Patients were generally satisfied despite pain. There were different opinions about the benefits of the NRS (numeric rating scale). Patients had a number of conceptions about drugs that led them to avoid analgesics. Information was considered to be mainly helpful, especially written, however patients felt that the information was deficient. Attitude, trust and communication played an important role in the relationship between staff and patient. Patients who underwent day surgery and treated their pain alone in the home with very limited contact with health care professionals experienced difficulties in making decisions and following their pain management plan. Patients appreciated being included and involved in their care, although it could be perceived as a burden, and took many own initiatives and strategies during their treatment, often to avoid using analgesics. Previous experience was also something that often helped patients in their pain management. Conclusion: Patients were often satisfied with their pain management even though they were still experiencing pain, most important to achieve this was a peace of mind. Important factors for this were detailed written and repeated information about pain, pain treatment and analgesics as well as a good, professional, inclusive and individualized response from the care staff. Deficiencies in these areas led to worrying and fear of the unknown, which made the pain experience more difficult. Patients rarely experienced adequate pain relief.

In der prospektiven Untersuchung bekommen 50 Patienten ein intraoperativ inseriertes ON-Q® PainBuster® Kathetersystem. Patienten der Verumgruppe erhalten über 72 Stunden postoperativ Ropivacain 0,375 % über das lokale Wundkathetersystem mit einer Flussrate von 5 ml/h, Patienten der Placebogruppe zum Vergleich Natriumchloridlösung 0,9 %. Als Basisanalgesie werden alle Patienten mittels eines oralen Nicht-opioid Analgetikum und intravenösem Piritramid therapiert. Im postoperativen Verlauf von 5 Tagen werden die visuell analoge Schmerzskala bei unterschiedlichen Aktivitäten und der Bedarf von intravenös applizierten Piritramid über die PCA-Pumpe als Ergebnisse evaluiert. Diese Ergebnisse werden mit den aktuellen Analagesieverfahren im Rahmen der Thorax- und Kardiochirurgie verglichen und diskutiert. Mögliche Alternativen werden abschließend aufgezeigt.:BIBLIOGRAPHISCHE BESCHREIBUNG 4 ABKÜRZUNGSVERZEICHNIS 5 1. DIE EINLEITUNG 7 1.1. DAS FAST-TRACK-THERAPIEKONZEPT 7 1.2. DAS POSTOPERATIVES SCHMERZMANAGEMENT 7 1.3. DIE ZIELSETZUNG DER ARBEIT 9 2. DAS MATERIAL UND DIE METHODEN 10 2.1 DAS STUDIENDESIGN 10 2.2 DAS NARKOSEVERFAHREN 10 2.3 DAS ON-Q® PAINBUSTER® KATHETERSYSTEM 13 2.4 DIE LABORANALYSEVERFAHREN 14 2.5 DIE STATISTISCHE AUSWERTUNG 14 3. DIE ERGEBNISSE 15 3.1. DAS PATIENTENKOLLEKTIV 15 3.2. DIE SCHMERZSCORE-ERGEBNISSE 16 3.3. DIE ERGEBNISSE DES PIRITRAMIDBEDARFES 20 3.4. DIE ERGEBNISSE DER ANGEFORDERTEN ZUSATZMEDIKATIONEN 21 3.5. DIE ERGEBNISSE DES ALPHA-1-SAURE-GLYKOPROTEINS UND DER ROPIVACAINSERUMSPIEGEL22 4. DIE DISKUSSION 23 4.1. DIE METHODENKRITIK 23 4.1.1 DAS STUDIENKONZEPT 23 4.1.2 DIE STICHPROBENMENGE UND DIE AUSFALLQUOTEN 23 4.1.3 DIE STATISTISCHE AUSWERTUNG 24 4.1.4 DIE KATHETERLAGE 25 4.1.5 DAS LOKALANÄSTHETIKUM ROPIVACAIN 26 4.1.6 DIE ZUSATZANALGETIKA 26 4.2. DIE ERGEBNISKRITIK 27 4.2.1 URSACHEN FEHLENDER WIRKSAMKEIT 27 4.2.2 DIE ROPIVACAINPLASMAKONZENTRATIONEN 30 4.3. VERGLEICH DER ERGEBNISSE MIT DER LITERATUR 31 4.3.1 DIE FAST-TRACK-KARDIOANÄSTHESIE 31 4.3.2 DAS PERIOPERATIVE SCHMERZMANAGEMENT 32 4.3.2.1 Die rückenmarksnahen Verfahren 33 4.3.2.2 Die peripheren Katheterverfahren 35 4.3.2.2 Die parenterale Opioidapplikation 38 4.3.2.4 Die orale Nicht-Opioidgabe 38 4.4. DIE FALSIFIZIERUNG DER ARBEITSHYPOTHESE 39 4.5. DER AUSBLICK 39 5. DIE ZUSAMMENFASSUNG UND DAS FAZIT 41 3 ANLAGEN 43 LITERATURVERZEICHNIS 44 ABBILDUNGS- UND TABELLENVERZEICHNIS 55 ERKLÄRUNG ÜBER DIE EIGENSTÄNDIGE ABFASSUNG DER ARBEIT 56 LEBENSLAUF 57 DANKSAGUNG 58

Bakgrund: För att sjukvården ska kunna upprätthålla patientsäkerheten krävs ett säkert sätt att överföra information mellan skifte av personal. För att kunna inkludera alla viktiga komponenter i en rapport krävs skicklighet i rapportering. Information som missas gör att patienter löper större risk att drabbas för vårdskador. Patienter som genomgår utsätts för sedering eller operativa ingrepp är redan sköra och löper större risk att drabbas av negativa konsekvenser. Syfte: Att undersöka innehållet i den muntliga överrapporteringen mellan anestesisjuksköterskor och postoperativ personal samt granskavad som kan påverka innehållet. Metod: En observationsstudie med kvalitativ och kvantitativ ansats utfördes på en intensivvårdsavdelning och en post-operativ avdelning. Resultat: Sammanställningen av 50 observationer visade att allergier, kirurgiska komplikationer, blodförlust och luftvägshantering var de mest frekventa punkterna som försummades. Innehållet jämfördes sedan med hur nöjda sjuksköterskorna som tog emot rapporten var gällandeinnehåll och struktur. Inga säkra slutsatser kunde dras av förhållandet mellan tid och innehåll, störningsmoment och innehåll, samt uppskattad nöjdhet med rapporten och innehåll. Vart rapporten sker har inverkan i hur stor utsträckning in-och utfarter samt operationsförband rapporteras. Störningsmoment har ingen inverkan på antal parametrar som tas upp. Konklusion: Resultatet visar att viktig information missas i olika utsträckning. Utifrån resultatet på studien dras slutsatsen att det behövs fortsatt forskning för att ge möjligheten att optimera och strukturera rapporterna så innehåll inte missas. / Background: If the health care is to maintain the patient security, a safe way to transfer information between staff changes is required. To be able to include all the important components in the report requires great skill. Information that is missed will expose the patient to a greater risk of care damage. Patients that undergo surgery or anaesthesia are already fragile and are at a greater risk of voluminous consequences. Objective: To examine the content of the oral report between the anaesthesia nurse and post-operative nurse, and what causes that could possibly affect the contents of the report. Method: An observation study with qualitative and quantitative method approach was adopted. The setting for the study was an intensive critical care unit and a post anaesthesia unit. Result: The findings in the 50 observations shows that allergies, surgical complications, blood loss and airway management were the most neglected points in the report. The amount of time the observations took were examined along with the content, structure and how satisfied the nurses that received the report were afterwards. No certain conclusions could be shown in the relationship between time and amount of content in the report. Neither was there a relationship between amounts of distraction and decreasing of content. These findings were compared with estimated satisfaction from the nurses that received the report. Where the report is held has impact on how much information about venous access, tubes and bandages is transferred. Disturbance had no effect on the amount of information being reported. Conclusion: The result shows that important information is missed to a certain degree. The study results show that there is still a need for more research to be able to find a way to optimize the oral report and the information transfer.

Sverige har blivit ett alltmer mångkulturellt samhälle vilket avspeglas i vården. Den interkulturella kommunikationen inom sjukvården kan vara utmanande för sjukvårdspersonalen speciellt när det kommer till smärtlindring. Syfte: Att beskriva specialistsjuksköterskors erfarenheter av interkulturell kommunikation vid postoperativ smärtlindring. Metod: Kvalitativ metod med semistrukturerade intervjuer. Resultat: Den manifesta analysen resulterade i fem huvudkategorier. Intervjuerna visar att språk och språkförbistring är faktor som kan påverka smärtskattning och smärtlindringen på postoperativa avdelningar. Andra erfarenheter är att kulturella uttryck vid smärta, fördomar och tidsbrist kan komplicera smärtlindringen ytterligare. Slutsats: Flera faktorer samverkar för att specialistsjuksköterskor upplever interkulturell kommunikation vid smärtlindring som extra utmanande och svårt. Att använda sig av smärtskalor är komplicerat utan gemensamt språk men andra strategier används för att bedöma patientens smärta. Det kan vara svårt att öppna upp för samtal på arbetsplatsen av rädsla eller oro att bli betraktad som främlingsfientlig men det finns ett behov av att diskutera skillnader och svårigheter för att ge patienter en mer personcentrerad vård.