Dissertations / Theses on the topic 'Dissertations – Anaesthesiology and critical care'

Thesis (DSc)--Stellenbosch University, 2013.
AFRIKAANSE OPSOMMING: Hierdie DSc is fundeer op ‘n aantal aspekte rondom ‘n sentrale tema naamlik die algemene en streeksfunksie van die normale hart of die hart blootgestel aan die risiko van miokardiale isgemie. Die werk is oor ‘n bestek van 25 jaar gedoen en sluit in eksperimentele werk in groot en kleindiere sowel as data verkry in pasiënte. Hoofstuk 1 handel met globale en streeksfunksie in die normale hart met die klem op die meer moderne benadering tot die koppeling van die hart met die sirkulasie en effek van middels op die twee komponente. Hierdie hoofstuk het waardevolle inligting gegee t.o.v. fisiologie maar ook gehelp om die middels te kies vir daaropvolgende studies. Hoofstuk 2 bevat navorsing wat verwys na die hart met kroonaarstenose. Onder andere word gesteun op ‘n dieremodel van kroonaarstenose. Die hoofstuk sluit data in wat , as eerste en unieke bydrae, gewys het dat inhalasie narkose middels die reperfusie besering van die hart kan verminder. Hierdie data het spesifiek bygedra om die kliniese praktyk van narkose vir hierdie pasiënte te verander. Hoofstuk 3 verwys na werk gedoen om die hart gedurende elektiewe chirurgiese arres te oksigeneer. Die effektiwiteit van verskillende kardioplegiese vloeistofsamestellings is ook krities ontleed. Die vierde hoofstuk handel met ‘n ernstige kliniese probleem naamlik akute pulmonêre hipertensie. By pasiënte met akute long besering is hierdie verskynsel baiemaal die oorsaak van dood en of moeitevolle oksigenasie. Die werk het gelei tot beter insigte t.o.v. pasiënt hantering tot die punt dat baie van die pasiënte vandag gered kan word.
ENGLISH ABSTRACT: This thesis is based on a number of aspects with a central theme of global and regional cardiac function in the normal heart and the heart at risk of ischemia. It summarizes work done over 25 years and includes experimental work in large and small animals as well as data obtained from human clinical practice. Chapter one deals with global and regional heart function and especially the physiological concept of ventriculo-arterial coupling as a mechanism to explain and understand the effects of inter alia commonly used drugs. Chapter 2 summarizes work done in hearts with a coronary artery stenosis. One of the interesting ,and at that time, unique findings was that inhalation anesthetic drugs are effective in limiting the reperfusion injury of the heart. This insight helped to redirect techniques used to anaesthetize patients with coronary artery disease. The third chapter examines methods to improve myocardial oxygenation during elective surgical cardiac arrest. It also includes data showing that not all the cardioplegic solutions are equally effective. Chapter four deals with a significant clinical problem i.e. acute pulmonary artery hypertension. This condition is often responsible for patient death, or contributes to, difficult oxygenation in patients with acute lung injury. The work in this chapter assisted in understanding the pathophysiology of the condition and improved the management thererof. This insight, combined with progress in other areas in the pathology or acute lung injury, has led to many of the patients today surviving their illness.

Thesis (MMed)--Stellenbosch University, 2014.
ENGLISH ABSTRACT: Case Report - A case is described of central oxygen pipeline failure that occurred at a large academic hospital and its subsequent implications for managing the situation. Literature review - The literature review undertaken focused on the current state of affairs with regards to anaesthetic staff's knowledge of and preparedness for the management implications of central oxygen pipeline failure. The events I describe below demonstrate a significant deficiency in the staff’s understanding of and training for the crisis, which should be remedied to improve patient safety. Specific measures are suggested in the literature to prevent such incidents and guidelines are available to manage central oxygen pipeline failure. These are reviewed in this study. Recommendations - This study attempts to bring together the most critical aspects that need to be addressed to safely manage similar future incidents. Prevention should include measures to implement clearly stated disaster management plans and increased awareness with regards to the medical gas pipeline system (MGPS), simulation training, efficient alarm systems, personally conducted routine evaluations of equipment and emergency backup systems by anaesthesiologists and effective communication between hospital staff. Careful planning and successful coordination during maintenance and modification of the medical gas pipeline system, using piston-type or air-driven, rather than oxygen-driven, ventilators and optimal design of the hospital bulk oxygen system can contribute to reduce risks. In the event of central oxygen pipeline failure a specific sequence of actions should be taken by the anaesthesiologist and a clear institutional operational policy is described.
AFRIKAANSE OPSOMMING: Gevalsbeskrywing - 'n Geval van sentrale suurstoftoevoerversaking, wat plaasgevind het by 'n groot opleidingshospitaal, word bespreek. Daar word ook gekyk na die praktiese gevolge met betrekking tot die hantering van die situasie. Literatuurstudie - 'n Literatuurstudie is aangepak met die doel om te fokus op die huidige toedrag van sake betreffende narkosepersoneel se kennis en paraatheid in die hantering van sentrale suurstoftoevoerversaking. 'n Wesenlike gebrek aan begrip en opleiding aangaande hierdie onderwerp is geïdentifiseer – areas wat, met die nodige aandag, verbeter kan word ten einde die welstand van pasiënte te verseker. Spesifieke voorkomende maatreëls en hanteringsriglyne word voorgestel deur die literatuur en word gevolglik hersien in hierdie studie. Aanbevelings - Hierdie studie poog om kernaspekte aan te raak ten einde soortgelyke toekomstige voorvalle veilig en optimaal te kan hanteer. Voorkomende maatreëls behels onder meer die daarstelling van duidelik verstaanbare noodplanne, verbeterde bewustheid aangaande die mediese gaspypsisteem, simulasie-opleiding, doeltreffende alarmstelsels, effektiewe kommunikasie tussen hospitaalpersoneel, sowel as narkotiseurs wat self roetine-evaluasies van hul narkosetoebehore en -noodtoerusting uitvoer. Noukeurige beplanning en neweskikking tydens herstelwerk of werk aan die mediese gaspypsisteem, die gebruik van suierventilators (of dan lugaangedrewe in plaas van suurstofaangedrewe ventilators) en die optimale uitleg van 'n hospitaal se suurstoftoevoer, kan bydra om die risiko's te beperk. In die geval van sentrale suurstoftoevoerversaking behoort die narkotiseur stapsgewyse aksie te neem. 'n Duidelike institusionele noodbeleid word ook omskryf.

In title 12, 22, 11 are in subscript.
Thesis (PhD)--Stellenbosch University, 2002.
ENGLISH ABSTRACT: The aim of this study was to test a synthetic protein-free surfactant preparation, LPM-l, with the same chemical composition as commercially available Exosurf (Glaxo Wellcome), but containing in addition, a sugar, trehalose (TRE). Towards this end, a study was designed to firstly test the hypothesis that the true difference in acute physiological effects between a mixture of oppe, tyloxapol, hexadecanol and trehalose (LPM-l), and Exosurf, (Oppe, tyloxapol and hexadecanol) is zero, in a surfactantdeficient animal model. A second study addressed the physiological effects of oppe, hexadecanol, tyloxapol and trehalose (LPM-l) compared to treatment with trehalose (TRE) or saline, in order to determine (1) the contribution of TRE to the mixture of oppe, hexadecanol and tyloxapol, and (2) to assess the effect of the LPM-l surfactant replacement on the epithelial lining fluid composition by means of analysing bronchoalveolar lavage fluid. Thirdly, the effects of TRE and / or calcium were studied on the surface properties of oppe suspensions, by in vitro analysis using the ring detachment method of Du Nouy The in vivo research comprised of two studies, performed in randomised controlled fashion. In the first study, 24 New Zealand White adult rabbits were randomised into 4 groups, while in the second study, 15 animals were randomised into 3 groups. In the first in vivo study, three synthetic surfactants, LPM-l, Exosurf and LPM-2, and a saline group were tested. LPM-l is a new formulation that consists ofa mixture of Df'PC, TRE, hexadecanol and tyloxapol. LPM-2 is a formulation with a composition equivalent to that of commercially available Exosurf, prepared on site. In both studies animals were subjected to repeated lavage with large volumes of warm saline (25 ml/kg) in order to establish surfactant deficiency and acute lung injury. Five minutes after the last lavage, vehicle, i.e. surfactants LPM-l, Exosurf, or LPM-2, or saline, in the first in vivo study, and LPM-l, TRE or saline in the second in vivo study, was instilled, and the course of the animals followed over the next 3 hours. Ventilator settings were standardized before and after lavage. The effects of surfactant treatment on gas exchange (arterial Pa02, oxygenation index (Ol), arterial-alveolar oxygen (a/A) ratio), percentage calculated shunt, and total dynamic respiratory compliance (CRSdyn), and histopathological changes were compared with changes in saline treated controls. Arterial blood gases in 100% oxygen and CRSdynwere measured before and after lavage, at 15 minute intervals for the first 30 min, then at 60, 90, 120, and 180 min after vehicle instillation. Oxygenation improved to a similar extent after LPM-l and Exosurf instillation, surpassing that of LPM-2 or saline. Overall, intratracheal instillation of both Exosurf and LPM-l, rapidly improved the gas exchange and reduced the intrapulmonary shunt, but did not restore the lung to its pre-lavage condition. From the 2nd in vivo study it was evident that trehalose-only, was inefficient as a lung surfactant, failing to improve oxygenation indices or the calculated percentage shunt, or influencing respiratory compliance. The addition of the sugar, trehalose (TRE), to the on-site 'Exosurf mixture (LPM-2) brought the activity of the resultant LPM-l to the same level as that of commercial Exosurf, but failed to raise the activity above that of Exosurf. These physiological improvements were sustained for up to 3 hours. Saline-treated animals had no improvement in gas exchange despite management with variable PIP (to maintain a tidal volume of -1 0 ml / kg) and constant PEEP of 5 cm H20. In-vitro results, obtained by the Ou Nouy tensiometer, showed higher mean ordinate surface tension values for the OPPC-only and DPPC + TRE mixtures, and the slopes of their respective graphs smaller in magnitude than those of the other formulations, suggesting that these formulations had less surface tension-lowering capability than the other surfactants. At 20°C (20 mg / ml DPPC-surfactants) the mean ordinate values of OPPC and OPPC + TRE, 70.13 and 69.47 dyne / cm, respectively, were not significantly different from each other. The mean ordinate values of LPM-l and the formulation containing OPPC + TRE + tyloxapol + CaCh were lower, but similar, as were the values of LPM-2 (on-site Exosurf) and LPM-2 + CaCho Thus, three internally homogeneous subgroups could be identified which differed significantly, namely: DPPC and DPPC + TRE, LPM-2 and LPM-2 + CaCh, and DPPC + TRE + tyloxapol + CaCh and LPM-l. Similar conclusions apply to the ordinate values of the surfactants at 37°C, and to the mean slope values at 20°C, with the exception that the subgroups, LPM-2 and LPM-2 + CaCh, and LPM-l and OPPC + TRE + tyloxapol + CaCh are not so clearly separated. A similar analysis of mean slope values was performed. Here too a significant difference between substances was found, OPPC alone or in combination with TRE, again being significantly different from the other surfactants. The most prominent light microscopy findings of the lungs of animals included general lymphatic dilatation, congestion and lung polymorphonuclear infiltration, with no difference between study groups. Hyaline membranes were present in all surfactant groups, but significantly more so in the saline treated group. In the first in vivo study, the presence of neutrophils in the lung interstitiwn as well as alveoli, was a common finding in all of the study groups towards the end of the study protocol. A significant increase in the BAL-fluid neutrophil count occurred in all animals, concurrent with a significant decrease in the BAL macrophage count. No significant change occurred in the peripheral neutrophil count during the 3-hour study, suggesting recruitment of neutrophils from storage pools. Treatment with synthetic surfactant (LPM -1) did not have a significant effect on modifying the inflammatory response, since there was no significant difference in the BAL-derived cell counts between the LPM-1 and -saline groups. Epithelial damage was a consistent finding in all groups. The damage was more evident by electron microscopy examination and included hydropic changes, most readily observed in the mitochondria. The airspaces of study subjects showed the presence of oedema fluid. This luminal oedema appeared to be more prominent in the control group and LPM-2 (on site 'Exosurf') group. Organellar debris, probably originating from lysis of epithelial cells, was present, despite treatment with synthetic surfactant. The electron microscopical appearance of the epithelial-lined substance ("hyaline membranes") in the present study showed a marked variability within groups as well as within the same case. The majority of cases showed a mix of membrane types with both granular and fibrillar materials present within the same membrane. In some cases there were layering of the membranes into distinct bands. The instillation of LPM-l resulted in the formation of a slightly different type of epithelial lining fluid after lavage, when compared to the prelavage composition. The most pronounced changes occurred within the fatty acids, whilst the phosphatidylcholine values remained unchanged. Palmitic acid concentrations (C16:0) increased significantly, suggesting enrichment of the epithelial lining fluid after instillation of LPM-l. This increase in C16:0 was concurrent with significant decreases in the percentage C16:1, C18:0, and C18:2. In contrast to previous studies, we describe higher levels for phosphatidyldimethylethanolarnine (PEA). An explanation may be that the lipid identified as PEA, was in fact partly phosphatidylglycerol (PG)-a lipid whose accurate identification was precluded for technical reasons. After surfactant instillation, the PC/SM ratio, a reflection of the lecithin / sphingomyelin (LIS), decreased significantly in the TRE-group between the first and final lavage, but remained statistically unchanged in the animals treated with LPM-l or saline. The change in ratio was mainly accounted for by a decrease in BAL-fluid PC content together with a rise in SM content. A poor correlation existed between the BAL-derived PC/SM ratio and indices reflecting oxygenation status (a/A ratio, Ol), as well as the CRSdynat the time of the final lavage. In conclusion, the primary hypothesis was accepted, LPM-l performed similarly to Exosurf in vivo, improving oxygenation, but not CRSdyn.None was clearly superior to the other. Some questions remain. The reason why LPM-l (LPM-2 + TRE) did not behave in a superior manner, in vivo, to Exosurf, is partly unclear. This finding was somewhat surprising since the chemical composition of Exosurf and LPM-2 did not differ, and the addition of TRE to LPM-2 (on-site Exosurf), did improve the in vivo activity of the resultant LPM-l, above that of LPM-2. A possible explanation for observed differences in performance include methodological issues, i.e. the preparation of the on-site formulations, especially that of LPM-2 (on-site Exosurf), may differ from the way in which true commercial Exosurf is prepared.
AFRIKAANSE OPSOMMING: Die doel van die studie was om 'n sintetiese proteïn vrye surfaktant te ontwikkel en die produk te vergelyk met 'n kunsmatige surfaktant reeds in kliniese gebruik. Die bekende uit die literatuur en die onbekende van die produk wat evalueer sou word, lei op tot die samestelling van die nul hipotese van die PhD naamlik dat geen verskil in longfunksie sou gewys word tussen die toetsproduk en reeds gebruikte kommersiële surfaktant nie. Die hipotese was dat 'n suiker (trehalose), in kombinasie met Dipalmitoiel fosfatidielcholine (DPPC), gaswisseling en longfunksies sal verbeter vir 'n long met 'n lae surfaktant konsentrasie. Vir die studie is jong volwasse wit New Zealand konyne gebruik en is hulle met 'n gestandaardiseerde en menslike manier gebruik in eksperimentele werk. Die diere is onder intraveneuse narkose geplaas en verskillende kardiovaskulêre en pulmonologiese aspekte is gemeet. Die long surfaktant is uitgewas deur middel van fisiologiese soutoplossing wat tot liggaam temperatuur verhit is en daarna is die diere prospektief gerandomiseer tot eksperimentele groepe. Met vooraf bepaalde tydsintervalle is die fisiologiese metings herhaal en was die metings toegespits daarop om longmeganiese funksie en gasoordrag vermoë te evalueer. Lig mikroskopiese en elektron mikroskopiese studies is ook op die longe gedoen en verder is brongoalveolêre vloeistof ook ontleed. Die groepe met ondersoek was: I. oppe, heksadekanol, tyloxapol en trehalose (LPM-I). 2. oppe, heksadekanol, tyloxapol (LPM-2 :. LPM-I sonder trehalose). Hierdie is 'n proteïnvrye surfaktant plaaslik berei ( dieselfde samestelling as Exosurf). 3. Exosurf®. (Kommersiële preperaat reeds in gebruik). Hierdie is 'n proteïnvrye sintetiese surfaktant. 4. Trehalose, 'n non-reduserende disakklaried van glukose. Addisioneel is daar ook in vitro studies gedoen waann die oppervlakte spanmngs aktiwiteite van die verskillende surfaktant oplossings vergelyk is. Die statistiese analise is gedoen in samewerking met Prof. J. Maritz wat 'n unieke metode ontwikkel en gepubliseer het om herhalende veranderlikes op 'n statisties verantwoordbare manier te ontleed. In die eerste van die studies, is LPM-I, Exosurf®, fisiologiese soutoplossing en 'n plaaslik bereide "Exosurf" (LPM-2), met 'n chemiese samestelling identies aan dié van kommersiële Exosurf®, evalueer. In 'n tweede studie is die fisologiese effekte van LPM-I vergelyk met trehalose of fisiologiese soutoplossing om die volgende te ondersoek: 1) Die bydrae van trehalose tot 'n mengsel van oppe, heksadekanol en tyloxapol (LPM-2). 2) Die gevolg van LPM-l surfaktant toediening op die konyn se brongo-alveolêre vloeistof samestelling. 'n Derde, in vitro studie, het die oppervlaktespannings-effekte van trehalose en of kalsiumbyvoegings tot DPPC-oplossings gemeet deur middel van die ring metode van Du Nouy, In die eerste in vivo studie verbeter oksigenasie en persentasie longaftakking tot dieselfde mate na LPM-l en Exosurf® toediening en word die hipotese van die proefskrif bevestig. In die breë gesien, is die tydsprofiele van LPM-l en Exosurf® ten opsigte van oksigenasie en persentasie longaftakking statisties betekenisvol beter en van 'n sneller aard, as die tydsprofiele van dieselfde indekse na die toediening van fisiologiese soutoplossing of LPM-2. Die tydsprofiel van dinamiese longvervormbaarheid, na die toediening van LPM-I of Exosurf®, is dieselfde, maar betekenisvol beter as die vervormbaarheid na toediening van LPM-2 of fisiologiese soutoplossing. Alhoewel die oksigenasie indekse in die geval van LPM-l en Exosurf® betekenisvol verbeter oor die studietydperk, vind volkome herstel tot die basislynwaardes (voor spoeling) nie plaas nie. Bykomend, geen van die surfaktante het na toediening enige noemenswaardige verbetering in longvervormbaarheid tot gevolg gehad nie. Die rede vir die swakker vertoning van LPM-2 en Exosurf is onbekend en sal in opvolg studie ondersoek word. In die tweede in vivo studie is dit duidelik dat trehalose op sy eie, 'n oneffektiewe surfaktant is aangesien die preperaat na toediening geen verbetering teweegbring ten opsigte van oksigenasie indekse, persentasie longaftakking, of long-dinamiese vervormbaarheid nie. Die toevoeging van trehalose tot LPM-2, om LPM-l te lewer, neem wel die aktiwiteit van LPM-l tot dieselfde in vivo vlak as dié van kommersiële Exosurf®, maar slaag nie daarim om 'n hoër fisiologiese in vivo aktiwiteit as dié produk te bereik nie. Die diere wat met fisiologiese soutoplossing behandel is toon geen verbetering in enige fisiologiese parameter nie. Die in vitro resultate wat verkry is deur die Du Nouy tensiometer toon hoër gemiddelde ordinaat oppervlaktespannings waardes vir 'n formule wat slegs uit DPPC bestaan, asook vir 'n mengsel van DPPC + trehalose. Die helling van die grafieke van hierdie oplossings is ook kleiner as die van die ander formulas wat daarop dui dat DPPC op sigself, en DPPC + trehalose, weinig vermoë het om oppervlaktespanning te verminder. Daarteenoor verlaag die volgende oplossings die oppervlaktespanning ten opsigte van gedistilleerde water betekenisvol en wel in In konsentrasie afhanklike manier by beide 21°C en 3rc: LMP-I-, LPM-2-, DPPC + trehalose + tyloxapol + CaCf2-, en LPM-2 + CaCf2. Die prominentste ligmikroskopiese bevindinge van die longe van die diere sluit in: Algemene limfvat dilatasie, stuwing, en long neutrofiel infiltrasie. Betreffende hierdie histologiese bevindinge is daar geen verskille aangetoon tussen die groepe nie. Hialienmembrane was teenwoordig in al die groepe, maar betekenisvol meer in die groep wat fisiologiese soutoplossing ontvang as vervangingsterapie. In die tweede in vivo studie is daar 'n betekenisvolle styging in die neutrofiel- en daling in makrofaagtelling, van die brongoalveolêre vloeistof spoeling in al drie die groep aangetoon. Terselfdertyd vind geen noemenswaardige daling in die perifêre (sistematiese) neutrofieltelling plaas nie. Hierdie bevindinge dui daarop dat die brongoalveolêre selveranderinge toegeskryf kan word aan verwerwing van neutrofiele vanuit 'n longstoringspoel eerder as rekrutering vanuit die sistemiese sirkulatoriese poel. Surfaktant (LPM-l), behandeling het geen betekenisvolle vermindering in long inflammasie teweeggebring nie. Epiteelskade was 'n algemene ligmikroskopiese bevinding in al die groepe. Die samestelling van die brongoalveolêre vloeistof verander na installering van LPM-I. Die prominentste verandering word waargeneem in die vetsuur samestelling terwyl die DPPC waardes onveranderd bly. Die vetsuur, palmitiensuur (palmitic acid), (CI6:0), verhoog betekenisvol na toediening van LPM-l. Daarteenoor verminder die konsentrasie van C16:1, C18:0 en C18:2. In kontras met vorige studies, beskryf die huidige studie hoër konsentrasies van fosfatidieletanolamien, moontlik as gevolg van tegniese verskille in die metingsmetodes. 'n Betekenisvolle verlaging in die fosfatidielcholine:sfingomiëlien (PC/SM) verhouding word waargeneem tussen die eerste en die finale longspoeling van die trehalose-groep, terwyl dit onveranderd bly in die diere wat LPM-1 of fisiologiese soutoplossing ontvang.

Dissertation (MD)--Stellenbosch University, 2000.
ENGLISH ABSTRACT: Acute renal failure still is, with the exception of cardiac deaths, the most important pathological process associated with perioperative mortality in patients operated for abdominal aortic aneurysms. The intraoperative change in renal blood flow (RBF) and glomerular function have been investigated in human and animal models, particularly over the past 15 years. Despite large variation in study populations, measurement techniques and study designs in general, a significant body of evidence has developed which suggests infrarenal aortic clamp-induced renal ischemia to be the cause of postoperative acute renal failure when this complication does occur. It is rather surprizing then that, despite some recent studies which have reported on various pharmacological interventions to prevent intraoperative renal ischemia (with variable success), very little has apparently been done to unravel the pathogenesis and exact pathophysiology of this potentially lethal complication. Although a number of investigators suggest the possibility of hormonal involvement (particularly reninangiotensin, antidiuretic hormone (ADH) and catecholamines) in the process, the exact role of these mediators have not been explored (or reported) in a structured fashion. In an initial human study, renal hemodynamics and function were measured from the preoperative period, during the intraoperative phase and at least until 4 hours after aortic unclamping. To investigate the possibility of a temporal relationship between renal changes and fluctuations in hormonal concentrations, plasma concentrations of relevant hormones were determined at every sampling period where renal parameters were measured. The decrease in RBF and glomerular filtration rate (GFR) which we demonstrated to coincide with infrarenal aortic cross clamping, is consistent with results previously published. We demonstrated persistence of the impairment of these parameters as long as 4 hours into the postoperative phase; which has previously only been reported for the period until immediately after aortic unclamping with the abdomen still open. The persistence of a depressed GFR until the time of discharge of patients is cause for concern, particularly in patients with compromised renal function prior to surgery. Of the measured hormones with a potential influence on RBF and nephron function, renin was the only mediator where changes in plasma concentrations coincided with the depression of RBF and GFR after aortic cross clamping. The design of our study did not allow us to conclude whether the concomitant increase in angiotensin II was primarily responsible for the change in renal hemodynamics, or whether the raised renin (and angiotensin) levels were stimulated by the decrease in RBF induced by another mechanism. In another patient group, we demonstrated that the combination of mannitol and dopamine provided no protection against the deleterious effects of aortic cross clamping. In fact, the high urine volumes produced under the influence of these agents (which did not correlate with RBF at the corresponding periods), is likely to prompt a false sense of security. Given the lack of any objective benefit afforded by these agents, their use in these clinical circumstances should be discouraged. The animal studies were aimed at elucidation of the exact role of angiotensin in the pathogenesis and pathophysiology of the renal changes associated with infrarenal aortic clamping, as well as the interaction of angiotensin with other modulators for which an interactive relationship had been described previously under other experimental and/or clinical circumstances. The first study showed that, although renin (and thus angiotensin) concentrations were high after aortic unclamping, the hormone had no pathogenic or pathophysiological role of significance in the observed renal changes during this period (since blocking angiotensin II activation by the prevention of renin release, or by inhibiting the conversion enzyme, did not prevent a substantial decrease in RBF or GFR during that period). Preventing angiotensin II activation did, however, prevent renal changes during aortic clamping. This beneficial effect did not establish a primary role for angiotensin during that period, since the favourable influence could also (at least partially) be explained by prevention of the permissive influence of angiotensin on other vasoconstrictors and/or other vasodilatory influences of ACE inhibition and [1- blockade which are unrelated to angiotensin. This study did indicate that (at least partially) different mechanisms are responsible for the renal changes seen during aortic clamping, and after aortic unclamping. The second study explored the role of calcium in the renal pathophysiological changes during aortic clamping and after unclamping. The protective influence effected by the administration of a Ca2 + -blocker suggest the dependence of the renal vasoconstrictive and glomerular pathophysiological process( es) on the cellular influx of Ca2 + through voltage-gated channels. It unfortunately provides no definitive insight into the primary instigators of these processes. However, it does offer a clinically useful method of preventing these changes and protecting the kidney against ischemic injury during abdominal aortic surgery. The third component of the animal studies demonstrates the importance of the protective effect of renal prostaglandins during the specific experimental (and probably also the clinical) circumstances. Again, it does not provide definitive information on the mediators responsible for the renal changes, since the deleterious effects of numerous endogenous substances have previously been shown to be counterbalanced by intrarenal synthesis of prostaglandins under various experimental and clinical circumstances. The extent of the pathophysiological and ultrastructural changes which occurred under the influence of a NSAID does, however, suggest that these drugs should not be used under these clinical circumstances. The last component of the study provides evidence that angiotensin only plays a secondary/supplementary role in the renal pathophysiological process even during aortic clamping. This may explain the contradictory evidence regarding the potential beneficial effect of ACE inhibition (on renal hemodynamics and glomerular function) during abdominal aortic surgery (Licker et al. 1996, Colson et al. 1992a). Based on our studies, ACE inhibition can not be supported for this purpose.
AFRIKAANSE OPSOMMING: Akute nierversaking is met die uitsondering van kardiale sterftes, steeds die belangrikste patologiese proses wat geassosieer is met perioperatiewe mortaliteit in pasiënte wat opereer word vir abdominale aorta aneurismes. Die intraoperatiewe veranderinge in renale bloedvloei (NBV) en glomerulêre funksie is die afgelope 15 jaar ondersoek en gerapporteer in pasiënte- sowel as diere-modelle. Ten spyte van groot variasies in studie-populasies, meettegnieke en ontwerp van studies in die algemeen, dui 'n wesenlike hoeveelheid getuienis daarop dat infrarenale klemming van die aorta renale isgemie induseer, wat die oorsaak is van postoperatiewe akute nierversaking wanneer hierdie komplikasie voorkom. Dit is verbasend dat, ten spyte van sommige onlangse studies wat rapporteer oor 'n verskeidenheid farmakologiese ingrepe om intraoperatiewe renale isgemie te voorkom (met wisselende sukses), baie min oënskynlik gedoen is om die patogenese en die presiese patofisiologie van hierdie potensieel dodelike komplikasie te ontrafel. Hoewel verskeie outeurs die moontlikheid van hormonale betrokkenheid (veral renienangiotensien, antidiuretiese hormoon en katekolamiene) in hierdie proses suggereer, is die presiese rol van hierdie mediators nog nie op 'n gestruktureerde wyse ondersoek (of rapporteer) nie. In ons aanvanklike pasiënte-studie is renale hemodinamika en -funksie gemeet vanaf die preoperatiewe periode, gedurende die intra-operatiewe fase en tot minstens vier uur na ontklemming van die aorta. Serumkonsentrasies van relevante hormone is bepaal tydens elke metingsperiode waar renale parameters gemeet is, ten einde die moontlikheid van 'n temporale verwantskap tussen renale veranderinge en variasies in hormoonkonsentrasies te ondersoek. Die vermindering in NBV en glomerulêre filtrasiespoed (GFS) wat ons aangetoon het om saam te val met infrarenale aortaklemming, stem ooreen met resultate wat tevore deur ander navorsers publiseer is. Ons het aangetoon dat die inkorting van hierdie parameters voortduur tot minstens vier uur na aorta-ontklemming. Hierdie veranderinge is tevore slegs rapporteer vir periodes tot kort na aorta-ontklemming voor sluiting van die buikwond. Die feit dat die GFS steeds verlaag is met ontslag van hierdie pasiënte, skep rede tot kommer, veral in pasiënte wat alreeds ingekorte nierfunksie het voor die chirurgiese prosedure. Van die gemete hormone wat moontlik 'n invloed sou kon uitoefen op NBV eh nefronfunksie, was renien die enigste waarvan verandering in plasmakonsentrasies saamgeval het met die onderdrukking van NBV en GFS na aortaklemming. Die ontwerp van ons studie het ons nie toegelaat om 'n besliste uitspraak te maak of die geassosieerde verhoging in angiotensien II primêr verantwoordelik was vir die verandering in renale hemodinamika, of dat die verhoogde renien (en angiotensien) bloedvlakke moontlik sekondêr stimuleer is deur die verandering in NBV wat deur 'n ander meganisme induseer is. In 'n ander pasiëntegroep het ons aangetoon dat die kombinasie van mannitol en dopamien geen beskerming verleen het teen die nadelige effekte van aorta-klemming nie. Die groot volumes uriene wat uitgeskei is onder die invloed van hierdie middels (wat nie korreleer het met NBV tydens ooreenstemmende periodes nie), het inderwaarheid 'n ontoepaslike gerustheid uitgelok. Weens die ooglopende gebrek aan objektiewe voordeel wat verleen word deur hierdie middels, behoort hulle gebruik tydens hierdie kliniese omstandighede ontmoedig te word. Die doel van die diere studies was die identifisering van die presiese rol van angiotensien in die patogenese en patofisiologie van die renale veranderinge geassosieer met infrarenale aortaklemming, sowel as die interaksie van angiotensien met ander modulators waarvoor 'n interaktiewe verwantskap voorheen beskryf is onder eksperimentele en/of kliniese omstandighede. Die eerste studie het getoon dat alhoewel renien (en dus angiotensien) konsentrasies hoog was na aorta-ontklemming, die hormone geen betekenisvolle patogenetiese of patofisiologiese rol in die waargenome renale veranderinge gedurende hierdie periode het nie (aangesien blokkade van angiotensien aktivering deur voorkoming van renien vrystelling, of deur inhibisie van angiotensien omsettingsensiem (AOE), nie 'n daling in NBV of GFS kon voorkom nie). Voorkoming van angiotensien II aktivering het egter wel renale verandering voorkom gedurende aortaklemming. Dié voordelige effek het nie 'n primêre rol vir angiotensien gedurende die periode bevestig nie, aangesien die gunstige invloed ook (ten minste gedeeltelik) verduidelik kon word deur die voorkoming van die fassiliterende invloed van angiotensien op ander vasokonstriktore en/of ander vasodilator-invloede van die onderdrukking van AOE en ïs-blokkers (wat geen verband het met angiotensien of die blokkade daarvan nie). Die studie het aangetoon dat (ten minste gedeeltelik) verskillende meganismes verantwoordelik is vir renale veranderinge wat gesien is gedurende aortaklemming en na -ontklemming. Die tweede studie het die rol van kalsium in die renale patofisiologiese veranderinge gedurende aortaklemming en na ontklemming ondersoek. Die beskermende invloed wat deur die toediening van Ca2 + -blokkers bewerkstellig is, het bevestig dat die renale vasokonstriktoriese en glomerulêre patofisiologiese prosesse afhanklik is van sellulêre influks van kalsium deur spannings-afhanklike kannale. Dit het ongelukkig geen definitiewe insig verleen ten opsigte van die primêre inisieerders van die proses nie. Dit verskaf nogtans 'n bruikbare kliniese metode om daardie veranderinge te voorkom en die niere teen isgemiese besering gedurende abdominale aorta-chirurgie te beskerm. Die derde komponent van die diere-studies demonstreer die belangrikheid van die beskermende effek van renale prostaglandiene tydens die spesifieke eksperimentele (en waarskynlik ook die kliniese) omstandighede. Weereens gee dit nie definitiewe inligting oor die bemiddelaars wat verantwoordelik is vir die renale veranderinge nie, aangesien die skadelike effekte van verskeie endogene stowwe voorheen aangetoon is om beperk of voorkom te word deur die intrarenale vrystelling van prostaglandiene. Die omvang van die patofisiologiese en ultrastrukturele veranderinge wat ontstaan het onder die invloed van nie-steroïed anti-inflammatoriese middels (wat gebruik is om prostaglandien sintese te inhibeer), dui aan dat hierdie middels vermy moet word onder soortelyke kliniese omstandighede. Die laaste komponent van die studie verskaf 'n sterk aanduiding dat angiotensien slegs 'n sekondêre/aanvullende rol speel in die renale patofisiologiese proses, selfs gedurende aortaklemming. Dit mag die weersprekende getuienis oor die potensiële voordeel van AOE onderdrukking (op renale hemodinamika en glomerulêre funksie) gedurende abdominale aortachirurgie (Licker et al. 1996, Colson et al. 1992a) verklaar. Gebaseer op ons studies, kan AOE onderdrukking nie ondersteun word vir hierdie doel nie.

Thesis (MMed)-- Stellenbosch University, 2013.
ENGLISH ABSTRACT: Introduction: Of the volatile anaesthetic agents, desflurane causes the greatest degree of potentiation of the neuromuscular blocking drugs (NMB). The purpose of this study was to determine whether desflurane prolongs the effects of 3xED95 doses of rocuronium and cisatracurium to the same degree. The two NMB represent potent and less potent classes respectively. Methods: Informed, written consent was obtained from 63 adult patients scheduled for routine surgery. They were randomly allocated to one of four groups to receive either desflurane-sufentanil (end-tidal partial pressure 4.0 kPa) or propofol-sufentanil anaesthesia and either rocuronium (0.9mg/kg) or cisatracurium (0.15mg/kg). All patients received a target-controlled sufentanil infusion (0.5 ng/ml). Neuromuscular blockade was recorded using accelerometry (TOFGUARD ®, Organon) while patients recovered spontaneously to a Train-of-Four ratio of 0.9 (TOFR0.9). Data were analysed using one- and two-way analysis of variance. The main effects were the types of anaesthetic and NMB on indices of recovery. Results: Compared with propofol-sufentanil anaesthesia, mean times to recovery to T125% and TOFR0.9, were prolonged by desflurane-sufentanil (p<0.01). There were no interactions. Mean prolongation of time to TOFR0.9 was 41 min (SD 36) for cisatracurium and 26.6 min (SD 39) for rocuronium. Discussion: Whereas previous studies did not reveal prolongation of the duration of action of rocuronium by desflurane, we demonstrated a statistically significant prolongation of the spontaneous recovery times of both rocuronium and cisatracurium by desflurane. From the data we could not conclude that there was a difference between the two NMB. A power study revealed that in order to detect a difference between times to recovery to TOF0.9, a sample size of 101 subjects per group would be required. Conclusion: Desflurane prolongs the mean time to spontaneous recovery from neuromuscular blockade after 3xED95 doses of both cisatracurium (a potent NMB) and rocuronium (a less potent NMB). There was wide inter-individual variation in times to spontaneous recovery. Any difference in the mean prolongations between the different types of NMB is unlikely to be of clinical importance.
AFRIKAANSE OPSOMMING: Inleiding Van al die vlugtige narkosemiddels veroorsaak desfluraan die grootste mate van potensiasie van die neuromuskulêre blokkeermiddels. Die doel van hierdie studie was om vas te stel of desfluraan wel die effek van driedubbel die ED95 dosis van rokuronium en cisatrakurium tot dieselfde mate sal verleng. Metodiek Geskrewe ingeligte toestemming is verkry van 63 pasiënte wat voorgedoen het vir roetiene chirurgiese prosedures. Pasiënte is lukraak in een van vier groepe ingedeel om of desfluraansufentaniel (eind-gety parsieële druk 4.0 kPa) of propofol-sufentaniel narkose en of rokuronium (0.9 mg/kg) of cisatrakurium (0.15 mg/kg) te ontvang. Alle pasiënte het 'n teiken-beheerde sufentaniel infusie (0.5 ng/ml). Neuromuskulêre blokkade is waargeneem met behulp van aksellerometrie (TOF-GUARD, Organon) terwyl pasiënte spontaan herstel het tot “reeks-van-vier” verhouding (Engels “Train-of-four” ratio) 0.9 (TOFR0.9). Data analise is gedoen met behulp van een- en tweerigting analise van variansie. Resultate Desfluraan-sufentaniel het die gemiddelde hersteltyd tot T125% en TOFR0.9 verleng in vergelyking met propofol-sufentaniel. Geen interaksies is waargeneem nie. Gemiddelde verlenging van TOFR0.9 vir cisatrakurium was 41 minute (standaardafwyking 36) en vir rokuronium 26.6 minute (standaardafwyking 39). Bespreking Vorige studies kon nie vasstel of desfluraan die werkingsduur van rokuronium verleng nie. Ons het in hierdie studie vasgestel dat desfluraan wel 'n statisties beduidende verlenging in die hersteltyd van beide rokuronium en cisatrakurium veroorsaak. Ons kon egter nie 'n verskil tussen die twee neuromuskulêre agente aandui nie. 'n onderskeidingsvermoëstudie het getoon dat ten minste 101 pasiënte per groep benodig sou word om 'n beduidende verskil tussen die hersteltye tot TOFR0.9 te verkry. Gevolgtrekking Desfluraan verleng die gemiddelde hersteltyd tot spontane herstel van neuromuskulêre blokkade na driedubbele ED95 dosisse van beide cisatrakurium en rokuronium. Daar was egter groot interindividuele variasie ten opsigte van spontane hersteltyd. Enige verskille in die gemiddelde verlenging is onwaarskynlik van kliniese belang.

Thesis (MMed)--Stellenbosch University, 2014.
ENGLISH ABSTRACT: BACKGROUND Post anesthesia discharge criteria scoring systems have been used successfully to aid discharge from the post anesthetic care unit (PACU) for over 40 years. They do not replace, but rather act in conjunction with good clinical judgment, and provide concise, standardized documentation of a patient’s readiness for discharge. 1,2,3,4,5 In order to improve patient safety, provide clear documentation and to aid future audit, a discharge criteria scoring system was developed for use in our PACU (Addendum A). It is a modification of the Aldrete Scoring System and the modified Post Anesthetic Discharge Scoring System (PADSS) proposed by Chung.1 There is a steadily increasing patient burden on the existing medical infrastructure in South Africa. Tygerberg Academic Hospital is no exception, and because of the high demand on our theatre services, optimal efficiency is essential. We speculated that our discharge criteria scoring system might increase the efficiency of our PACU when compared to the traditional time based system. The more healthy patients, undergoing minor procedures, could potentially spend less time in PACU, allowing the nurses to focus on problem cases. Increasing the speed of transit might also help prevent delays in theatre due to lack of bed space in PACU. Our primary endpoint was to compare the duration of time spent by patients in the PACU at Tygerberg Academic Hospital, from the moment they are admitted, to the time they are discharged to the ward, before and after the introduction of a discharge criteria scoring system. While planning the audit, one of the factors that staff identified as contributing to delayed discharge from PACU, was the time it took for the wards to collect their patients. A secondary objective, therefore, was to assess the amount of time that elapsed between calling the ward to collect the patient, and the patient leaving PACU. METHODS AND MATERIALS Prior to commencing the audit, approval was obtained from the Human Research Ethics Committee of the Faculty of Health Sciences of the University of Stellenbosch and Tygerberg Academic Hospital. The Audit, its purpose and possible benefits, was discussed with representatives of the nurses working in PACU, and written consent was obtained from those who would be involved in the data collection (Addendum B). Audit forms (Addendum C), collection boxes, and posters reminding staff to participate in the audit were prepared. Our first audit was performed over approximately a week in August 2012. During this period, the traditional time-based discharge system was still in operation. Data was captured from 327 patients. Audit forms were placed in a collection box, which was cleared daily by the primary investigator. The discharge criteria scoring system was introduced to the PACU staff in January 2013. The nurses were trained in its use, and a one month period was allowed for all involved to become accustomed to the new system. A second audit was performed in February 2013, again over a week, during which we gathered data from 313 patients. RESULTS The median value of the time spent by patients in the PACU decreased from 1 hour 25 minutes, to 1 hour 15 minutes, after introduction of the discharge criteria scoring system. This was statistically significant (p-value = 0.003). The median time between calling the ward to collect a patient, and the patient leaving recovery, was 15 minutes. CONCLUSION The main finding of the study was that the introduction of a discharge criteria scoring system decreased the median duration of time spent by patients in the post anesthetic care unit at Tygerberg Academic Hospital.
AFRIKAANSE OPSOMMING: AGTERGROND Puntestelsels as ontslag kriteria na narkose, word vir die afgelope 40 jaar suksesvol gebruik as maatstaf om pasiënte uit die herstelkamer te ontslaan. Hierdie kriteria vervang nie goeie kliniese oordeel nie, maar is ’n addisionele hulpmiddel om te bepaal of die pasiënt gereed is vir ontslag en om noukeurige, gestandardiseerde dokumentasie te verseker. 1,2,3,4,5 'n Nuwe puntestelsel vir ontslag is vir die herstelkamer van Tygerberg Akademiese Hospitaal ontwikkel om pasiëntesorg en dokumentasie te verbeter, asook om ouditering in die toekoms te vergemaklik (Addendum A). Hiervoor is die Aldrete Scoring System en die gemodifiseerde PADSS, voorgestel deur Chung, aangepas. 1 Die bestaande mediese infrastruktuur in Suid-Afrika beleef tans ‘n geleidelike toename in die getal pasiënte. Tygerberg Akademiese Hospitaal is geen uitsondering nie en as gevolg van die hoë aanvraag na ons teaterdienste, is uiterste doeltreffendheid noodsaaklik. Ons vermoede was dat hierdie aangepaste puntestelsel doeltreffendheid in die herstelkamer sou verbeter in vergelyking met die meer tradisionele tyd-gebaseerde sisteem. Gesonde pasiënte wat kleiner prosedures ondergaan, sal waarskynlik na ’n korter periode ontslaan kan word wat die verpleegpersoneel in staat sal stel om meer aandag aan probleem gevalle te gee. Bespoediging van die pasiëntvloei behoort onnodige vertragings van teatergevalle weens 'n tekort aan beddens in die herstelkamer, te beperk. Die primêre doel van die studie was om te bepaal of die gebruik van die aangepaste puntestelsel as ontslag kriteria in Tygerberg Akademiese Hospitaal, die tydperk wat die pasiënt in die herstelkamer deurbring, verkort. Die herstelkamer verpleegsters het beweer dat die saal personeel ‘n lang tyd gevat het om hulle pasiente in herstelkamer te kom haal. Vervolgens is 'n sekondêre doelwit ingesluit om die tydperk te bepaal vandat die saalpersoneel in kennis gestel word, totdat die pasiënt die herstelkamer verlaat. METODE Goedkeuring is verkry van die Menslike Navorsing en Etiese Komitee van die Gesondheidswetenskap Fakulteit van die Universiteit van Stellenbosch en Tygerberg Akademiese Hospitaal voor die aanvang van die studie. Die studie, asook die doel en moontlike voordele daarvan is vooraf bepsreek met verteenwoordigers van die herstelkamer verpleegpersoneel en skriftelike toestemming is verkry van al die deelnemers wat betrokke sou wees by die data versameling (Addendum B). Oudit vorms (Addendum C), versamelhouers en inligtingsplakkate vir die betrokke personeel is voorberei. Die aanvanklike oudit is in Augustus 2012 oor 'n periode van ongeveer een week uitgevoer. Tydens hierdie oudit is die tradisionele tydgebaseerde sisteem gebruik. Inligting van 327 pasiёnte is versamel. Die oudit vorms is in die versamelbokse geplaas en is daagliks deur die primêre navorser verwyder. Die aangepaste puntestelsel as ontslag kriteria, is in Januarie 2013 in die herstelkamer geïmplementeer. Die verpleegpersoneel het opleiding ontvang waarna die aangepaste puntestelsel vir een maand gebruik is om te verseker dat die personeel vertroud is daarmee. In Februarie 2013, is ‘n tweede oudit oor ‘n tydperk van een week uitgevoer, waartydens inligting van 313 pasiёnte versamel is. RESULTATE Na die implementering van die aangepaste puntestelsel as ontslag kriteria, het die mediane tyd wat pasiënte in die herstelkamer deurbring afgeneem van 1 uur en 25 minute tot 1 uur en 15 minute. Hierdie afname is statities betekenisvol (p-waarde = 0.003) Die mediane tyd vandat die saal in kennis gestel is totdat die pasiënt die herstelkamer verlaat, was 15 minute. GEVOLGTREKKING Die hoof bevinding van die studie is dat die mediane tydperk wat die pasiënte in die herstelkamer deurbring verminder is deur die implementering van die aangepaste puntestelsel as ontslag kriteria in Tygerberg Akademiese Hospitaal.

Malnutrition among hospitalized patients is prevalent and associated with adverse outcomes. At the health care facility for which this quality improvement (QI) initiative was developed, patients were not consistently fed within the nationally recommended 48 hours. The purpose of this project was to facilitate the early initiation of enteral feedings to prevent malnutrition in a vulnerable patient group by development of an evidence-based enteral feeding policy, algorithm, and nursing education module. The find, organize, clarify, understand, select, plan, do, check, and act model provided a systematic approach for development of the project. Validation of the QI initiative was through the use of Likert scale which was completed by 2 nurses and a head dietician. The content validity index average was 1.0 for the QI initiative products (policy, algorithm, educational module). Ten team members completed a summative evaluation of the educational module and presentation using a 7 item, Likert scale. Basic descriptive analyses were employed to analyze the data, revealing broad support for the module and the DNP student's leadership. A recommendation was made to conduct an audit using a formal software program to quantify the number of patients who were not being fed within the time frame of 48 hours. Implementing an evidence-based enteral feeding protocol can be a significant intervention that produces better patient outcomes.The implications for social change in this project relates to improvements within the critical care environment.

Increased levels of stress in the workplace have led the American Psychological Association to predict a looming public health crisis. Critical care nurses (CCNs) are highly exposed to stressors in the workplace, more than other nurses. Tens of billion dollars were reported lost in productive work time yearly due to ill health from depression alone. An important gap remains in understanding the relationships of stressors with the amount of stress. Supported by the biopsychosocial stress theory, the purpose of this study was to determine the relationship between frequencies of perceived stressors (IVs) as a source of perceived levels of stress (DV) or allostasis. The mixed-methods study included an online questionnaire and an e-mail interview of 400 hospital-based CCNs from professional nurses' associations in the United States. The Nursing Stress Scale was used to determine the kinds and frequencies of IVs, while the Psychological Stress Measure was used to assess the DV. Multiple regression analysis assessed the strength and direction of the relationships between IVs and DV. Interviews fell short of the minimum sample size for saturation and were not analyzed. Quantitative findings indicated workload as the most frequently perceived stressor, correlating positively with allostasis (p = .0005). Death and dying, conflict with other nurses, and lack of support for CCNs were also statistically significant (p < .05). Implications to practice and social change include promoting changes in policy with management support to reduce workload, death and dying, conflict with other nurses, and lack of social support for CCNs. Personal behavior changes like relaxation and physical exercises as coping methods may also reduce levels stress.

Compassion fatigue (CF), also known as secondary traumatic stress (STS), impacts critical care nurses (CCN) through exposure to pain, suffering, and loss of those for whom they provide care and results in a reduction of compassion satisfaction (CS). High incidence of CF and turnover (TO) rates at the project site were identified among CCNs. The institution's CCN TO rate was at 81% in comparison to peers in other areas at 29%–35%. The practice-focused question asked whether leadership education on CF might ameliorate CF at the project site. The purpose of the Doctor of Nursing Practice project was to reduce the incidence of CF and TO among CCN through leadership education. Watson's theory of human caring was used as a framework. Two hundred twenty-nine CCNs completed the Professional Quality of Life survey that measures CS, STS, and burnout (BO). Comparison of 28 nursing leaders' pretest scores to posttest scores indicated a statistically significant improvement (z = -4.625, p < .001) and knowledge acquisition. BO and CF taken together explained 86% (adjusted R2 = .86) of the variance in CS (F [2, 227] = 691.33, p < .001). Identifying the nursing units with the highest CF scores and providing CF education to the leadership provides a path to reduce turnover and provide needed support to CCNs, a positive social change.

Delirium is an acute change in cognition accompanied by inattention, which affects up to 88% of adult critical care patients. Delirium causes increased hospital complications, longer lengths of hospital stay, functional disability, cognitive impairment, and increased mortality. The purpose of this evidence-based quality-improvement project was to implement and evaluate a delirium screening process in adult intensive care units at a large medical center. This included education of nurses, implementation of a structured, validated tool, and review of tool use documentation. The implementation of this project was guided by an evidence-based practice model, Disciplined Clinical Inquiry© and Lewin's change theory. Evaluation of this quality-improvement project used audits of the electronic medical record. The audits included the presence and accuracy of delirium screening documentation in the patients' medical records. Results of 3 sequential documentation audits revealed a gradual adoption of this practice change by nurse clinicians. The percentage of charts with missing, incomplete, or inaccurate data decreased from 50% on the first week to 27.9% and 25.0% on the 2nd and 3rd weeks, respectively. These findings were an indication of practice change by validating the requirement for delirium screening on the units. In the first 3 weeks alone, 17 patient audits were positive for delirium, indicating the potential for poor short-term and long-term patient outcomes if not addressed promptly. Implementation of delirium screening ensures the dignity and worth of adult critical care patients by decreasing the poor outcomes associated with the diagnosis, which is an important contribution to positive social change.

The university classroom is an invaluable site for social activism. In this study, I focus on the university classroom in order to consider how university instructors care for students. More specifically, I consider what I call critical care--that is, care underscored by critical and critical communication pedagogy. I start by defining care, critical pedagogy, and critical communication pedagogy. Then, I focus on my own experiences autoethnographically to understand some of the ways I have come to understand care. After conducting interviews with teachers and those teachers' former students, I conducted dyad interviews between the teacher and the teacher's former student. I use the transcripts of these interviews as the data for an analysis of how these teachers and students understand care in their relationship. Because the teachers selected must have some background with critical and/or critical communication pedagogy, I also use the transcripts to build a case for critical care. I argue that critical care is the best way to build more humane and equitable classrooms.

Thesis (MCurr)--Stellenbosch University, 2012.
ENGLISH ABSTRACT: The increasingly complex role of the critical care nurse in an intensive care environment demands a much higher level of critical thinking and clinical judgment skill than ever before. Critical thinking in nursing practice may be defined as the cognitive ability to analyse, predict and transform knowledge, ensuring quality nursing care. To reason from a nurse’s perspective requires that we learn the content of nursing; this includes the concepts, ideas and theories of nursing. The aim and objectives of the study were to explore critical care nurses’ perspectives and experiences with regards to the concept of critical thinking, facets influencing the application of critical thinking skills in clinical practice and how these impact on the delivery of quality nursing care. A qualitative approach, using a case study design was utilised. A sample of six participants, who met the study inclusion criteria and consented to participate, were interviewed individually. Subsequently, five of these six participants took part in a focus group discussion to capture additional data to clarify and enrich the individual interview data. A field worker was present during the interviewing processes to note non-verbal data and later verify transcribed data. Feasibility of the proposed study was established by conducting a pretest which elicited relevant information. Ethical approval for the study was obtained from the Health Research Ethics Committee at the Faculty of Medicine and Health Sciences, Stellenbosch University. Permission and consent was obtained from the relevant hospital group to interview nurses working in the intensive care units. Qualitative content analysis, which focuses on the content or contextual meaning, was used to analyse interview data. Coding of the data through emergent themes and sub-themes was done by the researcher and supported through independent coding to verify and strengthen the analysis and interpretation of the researcher. . The results depicted how the participants personally understood the concept of critical thinking and the components influencing the application of critical thinking skill in clinical practice. The study of the participants’ perspective of the concept of critical thinking and portrayed how they experience analytical and independent thinking, competence and confidence, as well as knowledge, skill and expertise, to influence the quality of patient care. The data revealed several themes that facilitated critical thinking in critical care nurses. These themes were ‘team support’, ‘experience and exposure’ and ‘empowering the mind’. Emergent themes elaborating the limitations of critical thinking included ‘being stressed’, ‘professional boundaries’ and ‘being busy’. Several recommendations and suggestions for future research were offered.
AFRIKAANSE OPSOMMING: Die toenemende komplekse rol van die kritieke-sorgverpleegster in ’n intensiewe-sorg omgewing verg ’n veel hoër vlak van kritiese denke en ’n kliniese oordeelvaardigheid as ooit tevore. Kritiese denke in ’n verplegingspraktyk kan gedefinieer word as die kognitiewe vermoë om te kan analiseer, om vooruit situasies te kan bepaal en die vermoë om kennis te omskep sodat kwaliteit verpleegsorg verseker kan word. Om soos ’n verpleegster te kan dink, stipuleer dat die inhoud van verpleging geleer moet word wat konsepte, idees en teorieë daarvan insluit. Die doel en oogmerke van die studie is om die ervarings en perspektiewe van kritieke-sorgverpleegsters te ondersoek, met betrekking tot die konsep van kritiese denke, fasette wat die toepassing van kritiese denkvaardighede in ’n kliniese praktyk beïnvloed en die impak daarvan op die lewering van kwaliteit verpleegsorg. Die metodologie wat toegepas is, is ’n kwalitatiewe benadering deur middel van ’n gevalle-studie ontwerp. ’n Steekproefgrootte van ses deelnemers wat aan die inklusiewe kriteria voldoen het, is mee onderhoude individueel gevoer en daarna is met vyf van hierdie ses deelnemers in ’n fokusgroep onderhoude gevoer ten einde data op te neem wat andersins verlore kon geraak het. ’n Veldwerker was teenwoordig gedurende die proses van onderhoudvoering om die opgeneemde en getranskribeerde data te verifieer. Die data-insamelingsinstrument is in die vorm van ’n onderhoudsgids ontwikkel om die navorser gedurende die onderhoudvoering te help. ’n Loodsondersoek is uitgevoer om die haalbaarheid van die voorgestelde studie te ondersoek en is sodoende geskep om relevante inligting te onthul. Etiese goedkeuring vir die studie is verkry van die Gesondheidsnavorsing Etiese Komitee aan die Fakulteit van Geneeskunde en Gesondheidswetenskappe, Universiteit Stellenbosch. Goedkeuring en toestemming is van die hospitaalgroep aan wie die hospitaal behoort verkry, waar die studie onderneem is om sodoende onderhoude te kan voer met verpleegsters wat in die intensiewe-sorgeenhede werk. ’n Primêre, kwalitatiewe inhouds analise is gebruik om omderhoud data te analiseer wat fokus op die inhoud of kontekstuele betekenis daarvan. Kodering van die data deur die toepassing van die temas en sub-temas wat voorgekom het, is deur die navorser gedoen. Die data is onafhanklik gekodeer om die analise en interpretasie van die navorser te verifieer en te bekragtig ten einde die akkuraatheid en getrouheid in die formulering van die betekenis en interpretasie van gebeure met juiste weergawe daarvan, te verseker. Die resultate wat as hooftemas vanuit die individuele onderhoude voortgespruit het, asook die van die fokusgroep het die deelnemers se eie begrip van die konsep van kritiese denke en komponente wat die toepassing van kritiese denkvaardigheid in ’n kliniese praktyk beïnvloed, getoon. Die konsep van kritiese denke het die wyse waarop analitiese en onafhankilke denke, bevoegdheid en selfvertroue, asook kennis, vaardigheid en kundigheid die kwaliteit van pasiëntsorg beïnvloed, uitgebeeld. Die voortkomende data het daartoe aanleiding gegee dat die faktore wat die fasilitering en beperking van kritiese denke beïnvloed, bespreek kon word. Data rakende fasilitering het getoon hoedat die ondersteuning van die span, ervaring, blootstelling en die verruiming van die gees, kritieke-sorgverpleegsters positief kan beïnvloed om kritiese denke in hulle daaglikse verplegingsaktiwiteite effektief te kan toepas. Data wat verband hou met beperkings het getoon hoedat stres, professionele kwessies en besigwees kritieke-sorgverpleegsters negatief kan beïnvloed in die toepassing van kritiese denke gedurende daaglikse verplegingsaktiwiteite. Verskeie aanbevelings vir toekomstige navorsing is voorgestel.

The importance of nurse residency programs is addressed in the literature; however, a review of residency program outcomes and effectiveness is needed. Guided by Roy's adaptation model and Deming's plan-do-check-act model, the purpose of this quality improvement project was to assess the current state of a longstanding critical care nurse residency program in meeting organizational goals and objectives and to recommend modifications to the program related to external factors, internal challenges, and educational deficits of nurses entering the program. A review of the evidence-based literature and feedback from focus groups of leadership stakeholders were used to develop recommendations for residency program improvement. Using qualitative analysis of the focus group data, three common themes emerged related to external factors: financial resources, patient acuity, and generational differences that influence nurse satisfaction with the residency program. Three additional themes emerged related to organizational barriers to satisfaction with the program: preceptor availability and development, limited training hours due to productivity standards, and leader time to support novice nurses. Reality shock when starting to practice in the high acuity critical care area was the most frequently reported educational deficit among new nurses. Recommendations for program improvement included obtaining feedback from residency program participants and preceptors, initiating preceptor development pathways, reinstituting a dedicated cost center for nurse residents' training, and using competency assessment tools to customize training plans for residency program participants. This project has the potential for social change by increasing job satisfaction and retention of new nurses and improving health outcomes in critical care patients.

The purpose of this study was to examine the impact of clinical stress and burnout on health care professionals on critical care units. Thirty individuals who were employed at a local public hospital participated in the study. Participants completed a 25 item questionnaire on clinical stress and a 20 item questionnaire on burnout. A bivariate analysis was computed using Pearson's(r) correlation. The study found that there is a significant relationship between clinical stress and burnout.

Electronic nursing documentation systems can facilitate complete, accurate, timely documentation practices, but without effective policies and procedures in place, a gap in practice exists and quality of care may be impacted. This systematic review of literature examined current evidence regarding electronic nursing documentation quality. General systems theory and the Donabedian model of health care quality provided the framework for the project. Electronic databases PubMed and the Cumulative Index of Nursing and Allied Health were searched for articles addressing electronic nursing documentation practices. The Cochrane systematic review methodology was used to analyze the articles. Articles were excluded if published before 2001 or not in the English language. The search revealed 860 articles of which 35 were included in the final review. Most studies were quasi-experimental involving multiple interventions such as clinical decision support (CDSS), education, and audit and feedback specific documentation foci. The most reported outcomes were an improvement in documentation completeness and correctness. A multifaceted intervention strategy consisting of CDSS, education, and audit and feedback can be used to improve electronic documentation completeness and correctness. Policies and procedures regarding documentation practice should support the intended outcomes. Electronic documentation systems can improve completeness, but care should be taken not to depend on the quantity of documentation alone. Further research may shed light on the importance of concordance or plausibility, and the truth of documentation and ultimately how that can impact social determinates of health and social change.

Most nurses receive limited formal education regarding end-of-life (EOL) care, which affects their ability to meet dying patients' needs. Guided by Bandura's social learning theory, this explanatory correlational study examined the relationships between critical care nurses' personal and professional characteristics and their perceived knowledge and self-efficacy when providing EOL care at an academic medical center. Convenience sampling was used to recruit participants from the eligible adult, pediatric, and neonatal critical care nurses for this study. The 67 participants completed the End-of-Life Professional Caregiver Survey (EPCS) to assess EOL care knowledge and self-confidence. Total EPCS scores revealed only moderate levels of EOL knowledge and self-confidence. The Fisher's exact test indicated that higher EPCS scores were significantly associated with nurses' age and completion of advance directive. A 3-day workshop was designed to address deficits related to EPCS scores and advance directive completion, while educating younger nurses to gain confidence in their EOL discussions. Additional research is recommended to distinguish between nurses' actual knowledge and perceived knowledge about EOL care, the long-term effects of EOL care education on the quality of patient care, nurses' levels of moral distress and burnout, and nurses' communication skills with patients and other health care providers. The result of this research promotes positive social change through EOL education to improve the confidence of nurses working with dying patients and their families, as well as to understand the challenges of communicating difficult decisions regarding EOL care.

Critical care nurses often face the ordeal of witnessing a patient's death in a tense and stressful environment. Anecdotal stories shared among nurses reveal that unusual experiences often occur at the time of or after a patient's death. This hermeneutic phenomenological study explored the meaning of these experiences for critical care nurses. Using Parse's research method, in-depth interviews were conducted with six critical care nurses who described their experiences at the time of a patient's death as well as during the post-death period. These experiences brought a sense of peace and comfort to each individual as well as reinforced their individual belief patterns about life after death. A distinctive sense of nursing knowing at the time of death was also identified. The findings of this study indicate that the experiences of the phenomenon of death by critical care nurses have a significant impact on each individual and that further research and understanding of this impact is needed.
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Nurse-driven guidelines existed for the management of sedation in adult population; however, there is a lack of guidelines for the critically ill children. Nurses play significant roles in the management of sedation for mechanically ventilated patients in the Pediatric Intensive Care Unit (PICU), nonetheless, comprehensive guidelines for the management of sedation does not exist. The purpose of this systematic literature review was to evaluate and synthesize evidence-based research that can be used to adapt a pediatric clinical guideline for sedation management. The ACE star model and the evidence-based practice model were used as a framework to guide this review. The practice question focused on investigating the available best practices that can be used to support the nursing management practice of sedated patients in the PICU. This is important because inadequate sedation management can lead to multiple adverse outcomes for patients. The design of this project was a systematic literature review method. The sources of the data were gathered from Medline, PubMed, CINAHL, Joanna Briggs institute and Google Scholar. This review included 17 studies, of which 84.2% showed improvement with positive patient outcomes such as decreased sedation use, decreased length of stay, and improved nursing practice. The results also support recommendations for evidence-based practice guidelines in the clinical nursing practice setting. In conclusion, despite the recommendation for the use of sedation guidelines, this systematic review found that there are few studies comprehensively evaluating the impact of nurse-driven sedation management in the PICU. The social implication of this review is that more studies involving pediatric patients utilizing nurse-driven sedation protocol is needed, before it can be adopted in the PICU.

Every year, hundreds of thousands of patients have coronary angiograms performed in the United States. The Impella is a percutaneous ventricular support device that provides hemodynamic support for patients if hemodynamic instability occurs during the procedure. The critical care nurse is responsible for the recovery and management of the patient with the Impella device in place. The purpose of this scholarly project is to provide registered nurses (RN) who have not previously managed the Impella device with the appropriate education in order to demonstrate competency. The program demonstrated improved RN knowledge about the Impella and increased confidence when managing the Impella device and controller. King's goal attainment theory was used as a framework to develop nurse-patient collaboration. Kirkpatrick's 4-level training evaluation model provided the framework for evaluation of the RN educational program. The sources of evidence included literature and an expert panel that was recruited to evaluate the material prior to implementation of the educational program. The data were analyzed by comparing the results of the preeducational and posteducational questionnaires. The paired t test demonstrated statistical significance based on the scores from the pre- and post-tests taken by the RNs before and after the Impella educational program as p < .001. Increased RN confidence was demonstrated by p < .001, while a change in RN attitude towards the Impella established improvement by p < .001. Providing professional development opportunities has been shown to benefit RNs to allow the delivery of safe care while allowing for positive social change by impacting patient lifestyle and outcomes.

Foster care youth face significant challenges to postsecondary educational success, especially while enrolled at four-year institutions. Foster care youth are absent of family support that their non-foster peers receive throughout the college experience. Without family support, foster care youth encounter greater challenges to persevere through college and reach graduation. Postsecondary education provides a fundamental opportunity for foster care youth to achieve positive life outcomes. Policy makers, social welfare agents and educators continue to advocate on behalf of foster care youth and have made it possible for them to attend college; however, lack of preparedness and support prevent foster care youth from staying in college. Skills necessary for college success are often gained in early stages of life. For many foster care youth it is in this early stage of life that they have been separated from biological family and placed in the foster care system. This research sought to answer the question: how does the family milieu influence postsecondary educational success for foster care youth? According to research, parents play a significant role in the accrual of educational, social and cultural skills needed for children to have success in later stages of life. Additionally, research supports that schooling becomes increasingly complex as life success becomes increasingly dependent on college success.

Catheter-associated urinary tract infections (CAUTIs) are the most frequently reported hospital-acquired condition, affecting more than 560,000 patients each year. CAUTIs prolong hospital stays and increase health care costs, and they can result in patient morbidity and mortality. Nurses can be empowered by receiving education and knowledge to manage and identify urinary catheters that are not clinically indicated. The purpose of this project was to develop an education program on CAUTI prevention for critical care nurses using the teach-back method. The conceptual framework that guided this project was Knowles's adult learning theory. The theoretical model was based on 4 fundamental assumptions of self-concept development. A total of 32 critical care unit nurses participated in the evaluation of the teach-back method. Demographic data were collected from these 32 participants, and the results of a frequency analysis were obtained. Deidentified CAUTI data were provided by the organization prior to the educational intervention. The postintervention CAUTI rate and increase in nurses' knowledge level were evaluated 1 month after the educational intervention using a 1-sample t test. The finding was statistically significant (p < .001). The incidence of CAUTI was followed, and the outcomes indicated that the overall incidence of CAUTI in these patients was decreased. The education program was effective in improving critical care unit nurses' knowledge of evidence-based practices to prevent CAUTIs. Improving nurses' knowledge to decrease CAUTI rates is a strategy that may be effective in many healthcare settings. This educational intervention may create social change by improving the health of patients and serving as an educational resource for nurses.

Dissertation (PhD) -- University of Stellenbosch, 2001.
ENGLISH ABSTRACT: A thoughtfully planned learning program provides a blueprint for critical care nursing and gives direction to theory and clinical practice. The design of a learning program for critical care nursing that is adaptive, learner focussed and integrated, helps nurses acquire the necessary competencies (knowledge, technical skills and attitudes/values) needed for critical thinking. It also enables critical care nurses to grow professionally and to develop expertise in critical care nursing. Outcomes-based education has become the "new buzz word" in South Africa, and a paradigm shift from content-based to outcomes-based education has become essential. Institutions are concerned with efficient and effective approaches to critical care nursing delivery. The institution (nursing department) proves its worth by anticipating patient care needs and planning its learning program cognizant of the need to correlate activities with the institution's (nursing department) mission and outcomes. Planning that meets the learning needs of the critical care nursing learners not only provides the ability to meet job expectations, but also experiences for professional growth and satisfaction. In an age of nursing shortage, a well planned, integrated and outcomes orientated critical care learning program is essential. The outcome of the research was identified as a process of quality improvement for outcomes-based critical care nursing education, which included validated standards to facilitate quality critical care nursing education. This was researched by utilising an adapted Laing and Nish Model for Quality Assurance (1981) as the research strategy. Seven (7) steps were identified, namely: Step one included the identification and clarification of values; step two determined criteria, established standards for outcome, structure and process; step three ratified criteria and validated standards; step four identified and analysed factors influencing the results; step five selected appropriate actions to maintain or improve critical care nursing education; step six implemented the selected actions and in step seven, assessment (testing) was done. In steps two and three of the quality improvement process the Muller's (1996) Three Phase Model for Standard Development was implemented. Seven (7) standards were identified and formulated, namely: Standard one - Quality improvement; Standard two - Standard formulation; Standard three - Philosophy; Standard four - Legislative framework; Standard five - Curriculum development (learning program development); Standard six - Outcomes-based education; and Standard seven - Critical care nursing education. During the process of validation of the standards, standards five and six were combined and became Standard five - Outcomes-based learning program development. In step three the Delphi technique as part of the second phase of Muller's model (1996), was utilised to gain expert opinions / validation of standards. Operationalisation and assessment of the validated standards as part of a process of quality improvement for outcomes-based critical care education were done in a higher education institution. The results of this pilot study that was done supported the central theoretical assumption, namely that outcomes-based critical care nursing facilitates quality critical care nursing. The uniqueness of the research lies in the fact that in outcomes-based critical care nursing education there is no formal process of quality improvement for outcomes-based critical care nursing education. In this research, standards were developed and presented as part of a process of quality improvement for outcomes-based critical care nursing education. These standards should guide the developer of an outcomes-based critical care nursing education program during the development of the learning program (meso curriculum) and could be utilised to judge the quality of the current learning programs' quality. Five of the six standards are generic and could be utilised with minor adjustments in any higher education learning program.
AFRIKAANSE OPSOMMING: 'n Weldeurdagte leerprogram dien as 'n bloudruk vir kritiekesorg-verpleging, en rig beide die teorie en die kliniese praktyk. Die ontwerp van 'n leerprogram vir kritiekesorg-verpleging wat ge"integreerd,leerder-gefokus en aanpasbaar is, help verpleegkundiges om die nodige vaardighede (kennis, tegniese vaardighede en houdings/waardes) vir kritiese denke te ontwikkel. Dit stel kritiekesorg verpleegkundiges ook in staat om professioneel te groei en om kundigheid in kritiekesorg-verpleging te ontwikkel. Uitkoms-gebaseerde onderrig is die "nuwe wagwoord" in Suid-Afrika en het 'n paradigmaskuif van inhoud-gebaseerde- na uitkoms-gebaseerde onderrig genoodsaak. Instellings is begaan oor doeltreffende en effektiewe benaderings vir die lewering van kritiekesorg verpleging. Die verrnoe van 'n instelling (departement verpleging) om pasientsorq-behoeftes te voorspel en om die kritiekesorg leerprogram se aktiwiteite in ooreenstemming met die instelling (departement verpleging) se missie en verwagte uitkomstes te beplan, bewys die waarde van die instelling (departement verpleging). 8eplanning wat aan die leerbehoeftes van die kritiekesorg-Ieerders voldoen, bevredig nie aileen hul werksverwagtinge nie, maar het ook professionele groei en genoegdoening tot gevolg. In Goed-beplande, ge"integreerde en uitkoms-georienteerde kritiekesorg leerprogram is essensieel in 'n tyd waar verpleegtekorte aan die orde van die dag is. Ten einde gehalte-verpleegonderrig te fasiliteer, is die uitkoms van die navorsing as 'n proses van gehalteverbetering vir uitkoms-gebaseerde kritiekesorgverpleegonderrig, wat gevalideerde standaarde insluit, ge"identifiseer. 'n Aangepaste Laing en Nish Model vir Gehalteversekering (1981) is as navorsingstrategie vir hierdie navorsing gebruik. Sewe (7) stappe is ge"identifiseer, naamlik: Stap een sluit die identifisering en verduideliking van waardes in; stap twee bepaal kriteria en skep standaarde vir uitkoms, struktuur en proses; stap drie bekragtig en valideer die standaarde; stap vier identifiseer en ontleed faktore wat die resultate belnvloed; stap vyf selekteer toepaslike aksies om kritiekesorg-verpleegonderrig te handhaaf of te verbeter; stap ses implementeer die geselekteerde aksies en in stap sewe is assessering (toetsing) gedoen. Muller (1996) se Drie Fase Model vir Standaardontwikkeling is in stappe twee en drie van die gehalteverbeteringsproses ge"implementeer. Sewe (7) standaarde is ge"identifiseer en geformuleer, naamlik: Standaard een - Gehalteverbetering; Standaard twee - Standaardformulering; Standaard drie - Filosofie; Standaard vier - Wetlike raamwerk; Standaard vyf - Kurrikulumontwikkeling (Ieerprogramontwikkeling); Standaard ses - Uitkoms-gebaseerde onderrig; en Standaard sewe - Kritiekesorg-verpleegonderrig. Tydens die valideringsproses van die standaarde, is standaarde vyf en ses gekombineer as Standaard vyf - Uitkomsgebasseerde leerprogramontwikkeling. Gedurende stap drie is die Delphitegniek tydens die tweede fase van Muller (1996) se model gebruik om deskundige opinies te verkry I die standaarde te valideer. Operasionalisering en assessering van die gevalideerde standaarde as deel van In sisteem van gehalteverbetering vir uitkoms-gebaseerde onderring is in 'n hoeronderwysinstelling gedoen. Die resultate van hierdie toetsstudie het die sentrale teoretiese aanname, naamlik dat uitkoms-gebaseerde kritiekesorg-verpleging gehalte kritiekesorg-verpleging fasiliteer, ondersteun. Die uniekheid van hierdie navorsing is gelee in die feit dat daar in uitkomsgebaseerde kritiekesorg-verpleegonderrig, geen formele proses van gehalteverbetering vir uitkoms-gebaseerde kritiekesorg-verpleegonderrig is nie. In hierdie navorsing is standaarde ontwikkel en aangebied as deel van In sisteem van gehalteverbetering vir uitkoms-gebaseerde kritiekesorg-verpleegonderrig. Hierdie standaarde kan tydens die ontwikkeling van die leerprogram (mesokurrikulum), die ontwikkelaar van In uitkoms-gebaseerde kritiekesorgverpleegondderigprogram begelei, en kan gebruik word om die gehalte van huidige leerprogramme te beoordeel. Vyf van die ses standaarde is generies en kan, met minimale veranderinge in enige hoer onderwys leerprogram gebruik word.

Thesis (MCur (Nursing Science))--University of Stellenbosch, 2010.
Thesis presented in partial fulfilment of the requirements for the degree of Master of Nursing at Stellenbosch University
ENGLISH ABSTRACT: The trend towards specialisation in nursing has resulted in the development of the role of the Clinical Nurse Specialist (CNS) since the 1960s and 1970s in North America and the United Kingdom respectively. A Clinical Nurse Specialist should demonstrate excellent skills in leadership, communication, critical thinking, clinical and collaborative ethical decision-making, as well as mentoring. Research done internationally has shown that advanced practice nursing leads to higher patient satisfaction and compliance, fewer hospitalisations and shorter length of stays. The development of the CNS role in SA is slow in implementation. The South African Qualifications Authority has only recently published qualification rules for a master’s certificate and master’s degree in Nursing for advanced specialist nurses in SA. This situation led to the following research question: What is the expected role of the Critical Care Clinical Nurse Specialist in private hospitals in the northern and southern suburbs of the Cape Peninsula, South Africa? A non-experimental, explorative, descriptive study with a quantitative orientation was conducted in eight private hospitals in the Cape Peninsula. Through non-probability sampling 73 critical care health professionals (critical care professional nurses, clinical nurse specialists, nursing managers, unit managers, nurse educators, clinical facilitators, clinical coordinators and doctors) out of a population of 170 critical care health professionals participated in the study. A survey tool was designed and validated to collect the data. Quantitative data was analysed through Statistica® and qualitative data was analysed thematically. It was found that 81% of the participants agreed that Clinical Nurse Specialists should be appointed in the South African critical care environment as soon as possible to improve patient outcomes, to contribute to safer nursing care, to relieve work stress of shift leaders and bedside nurses and to improve the professional status of nursing. It is recommended that greater awareness regarding the Clinical Nurse Specialist should be developed. The relevant educational requirements should be finalised and a clear job description should be compiled. Nursing managers should appoint Clinical Nurse Specialists in each critical care unit as soon as possible.
AFRIKAANSE OPSOMMING: Die rol van die Kliniese Verpleegspesialis het as uitvloeisel van spesialisering in verpleging sedert 1960 en 1970 in Noord-Amerika en Groot-Brittanje onderskeidelik ontwikkel. `n Kliniese Verpleegspesialis behoort die volgende eienskappe te openbaar: uitmuntende vaardighede met betrekking tot leierskap, kommunikasie, kritiese denke, kliniese en etiese besluitneming en mentorskap. Internasionale navorsing het aangetoon dat gevorderde verpleegkunde tot `n hoër vlak van pasiënttevredenheid en nakoming van behandelingsvoorskrifte, minder hospitalisasie en korter hospitaalverblyf aanleiding gee. Die ontwikkeling van die rol van die Kliniese Verpleegspesialis in Suid- Afrika geskied langsaam. Die Suid-Afrikaanse Kwalifikasie-Outoriteit (SAKO) het eers onlangs die reëls vir `n meestersertifikaat en meestersgraad in Verpleegkunde vir gevorderde spesialisverpleegkundiges gepubliseer. Hierdie situasie het tot die onderstaande navorsingsvraag aanleiding gegee: Wat is die verwagte rol van die Kritiekesorg- Kliniese Verpleegspesialis in privaathospitale in die noordelike en suidelike voorstede van die Kaapse Skiereiland, Suid-Afrika? `n Nie-eksperimentele, beskrywende studie met `n kwantitatiewe benadering is in agt hospitale in die Kaapse Skiereiland onderneem. Deur nie-waarskynlikheids-, toevallige steekproefneming is 73 professionele betrokkenes by kritiekesorggesondheid (professionele kritiekesorgverpleegkundiges, kliniese verpleegspesialiste, verpleegbestuurders, eenheidsbestuurders, opvoeders in verpleegkunde, kliniese fasiliteerders, kliniese koördineerders en dokters) uit `n populasie van 170 professionele betrokkenes by kritiekesorggesondheid in die studie ingesluit. `n Vraelys is ontwerp en gevalideer vir die insameling van data. Kwantitatiewe data is deur middel van Statistica® ontleed terwyl die kwalitatiewe data tematies ontleed is. Daar is gevind dat die meerderheid van die deelnemers saamgestem het dat Kliniese Verpleegspesialiste so gou moontlik in die kritiekesorgomgewing in Suid-Afrika aangestel behoort te word. Die Kliniese Verpleegspesialis dra by om pasiëntuitkomste te verbeter, om tot veiliger verpleegsorg by te dra, om werkspanning van skofleiers en verpleegsters te help verlig en om die professionele status van verpleging te verbeter. Daar word aanbeveel dat daar groter bewusmaking aangaande die Kliniese Verpleegspesialis moet wees. Vereistes vir opleiding behoort gefinaliseer te word en `n duidelike werksbeskrywing moet opgestel word. Verpleegbestuurders behoort Kliniese Verpleegspesialiste so gou moontlik in die kritiekesorgomgewing aan te stel.

Physical, psychological, and social debilities are common among survivors of critical illness. Survivors of critical illness require rehabilitative services during recovery in order to return to functional independence, but the structure and access of such services remains unclear. The purpose of this qualitative study was to explore the vital issues affecting quality of life from the perspective of critical illness survivors and to understand these patients' experiences with rehabilitative services in the United States. The theoretical framework guiding this study was Weber's rational choice theory, and a phenomenological study design was employed. The research questions focused on the survivors' experiences with rehabilitative services following critical illness and post-intensive care unit quality of life. Participants were recruited using purposeful sampling. A researcher developed instrument was used to conduct 12 semistructured interviews in central North Carolina. Data from the interviews were coded for thematic analysis. The findings identified that aftercare lacked unity, was limited by disparate information, and overuses informal caregivers. In addition, survivors' recovery depended on being prepared for post-intensive care unit life, access to recovery specific support structures, and the survivors' ability to adapt to a new normalcy. Survivors experienced gratitude for being saved, which empowered them to embrace new life priorities. The implications for social change include improved understanding of urgently needed health care policies to provide essential therapies and services required to support intensive care unit survivors on their journey to recovery.

Thesis (MA)--University of Stellenbosch, 2002.
ENGLISH ABSTRACT: This assignment uses the theory of deconstruction to reflect on some discourses that underlie the practices of psychology and psychiatry. The language of the psychological professions is analysed in terms of its political implications. A number of linguistic power hierarchies that are central to the practice of psychology are deconstructed: the individual and the social, reason and unreason, normality and pathology, form and content, theoretical categories and real life, professional and lay views, and non-psychotic and psychotic language. The concepts of justice (as understood within the Derridian paradigm) and care are analysed, with specific emphasis on their practical implications in the interactions between therapists and patients in real life psychotherapeutic situations. This deconstructive process takes place in the intersection of my own story as an intern clinical psychologist with the stories of some of the patients I ' have worked with during this year. The outcome of this process is a deepening and broadening of the meaning of providing just and respectful mental health .' care to every patient.
AFRIKAANSE OPSOMMING: Hierdie werkstuk benut die teorie van dekonstruksie om te reflekteer oor sommige van die diskoerse onderliggend in sielkundige en psigiatriese praktyk. Die taal van die sielkundige professies word ontleed in terme van moontlike politieke implikasies. Daar is 'n dekonstruksie van 'n paar magshiërargieë wat sentraal staan tot die taal van die sielkunde: die individu en die samelewing, rasionaliteit en irrasionaliteit, normaliteit en patologie, vorm en inhoud, teoretiese kategorieë en "die regte lewe", professionele en leke-posisies, en die taal van nie-psigotiese en psigotiese pasiënte. Die konsepte van geregtigheid (soos verstaan binne 'n Derridiaanse paradigma) en sorg word ontleed, met spesifieke klem op die praktiese implikasies hiervan in die psigoterapeutiese interaksies tussen sielkundige en pasiënt. Hierdie proses van dekonstruksie vind plaas in die kruising tussen my eie storie as intern kliniese sielkundige en die stories van sommige van die pasiënte saam met wie ek hierdie jaar gewerk het. Die gevolg van hierdie proses is 'n verdieping en verbreding van die betekenis van geregtigheid en respek in die sisteem van geestesgesondheidsorg.

An Evidence-Based Educational Intervention to Improve Nursing Staff's Critical Thinking and Decision-Making Skills by Rene N. Kagan MSN, University of New Mexico, 2009 BS, University of Phoenix, 2000 Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University September 2016 Hospitalized patients in acute care settings are at a high risk of developing health complications that can eventually lead to failure to rescue (FTR) situations. The aim of this project was to deliver a structured comprehensive medical-surgical competency plan for acute care nurses to detect deterioration in a patient's condition through the triad of assessment model to promote clinical reasoning among acute care nurses. Data were collected using pretest surveys, a demographic sheet, and an evaluation survey. A convenient sample of between 22 and 29 nursing staff was recruited from three medical-surgical inpatient units at a VA Hospital. The pretest survey, administered simultaneously with the educational modules, assessed participants' baseline knowledge on components of the triad of assessment model and the processes involved in the prevention of FTR. The pretest scores for modules 1 to 6 were 2, 3, 3, 3, 2, and 3 respectively. The posttests scores for modules 1 to 6 were 4, 5, 5, 5, 4, and 5 respectively. The nurse's aides also recorded posttest scores of 4.6 for both Pulse Oximetry and orthostatic hypotension modules. The t-test (p<0.00) showed a significant difference between the pre and posttests scores, thus, indicating an improvement in nursing staff's knowledge regarding the triad of assessment model. Thus, it is important to adopt a comprehensive medical-surgical plan for acute care nurses institutional-wide. This project contributes to social change through identification of a medical-surgical intervention that improves nurses' critical thinking skills, thereby promoting patient satisfaction and safety. Because nurses play a significant role at the bedside, improved critical thinking skills will facilitate a significant reduction in FTR rates, heighten patient satisfaction, and enhance the nurse-patient relationship.

Thesis (MCur)--University of Stellenbosch, 2005.
ENGLISH ABSTRACT: The critical care nurse works in an environment where patient need often shifts the parameters within which she or he practices. It is expected of a skilled critical care nurse to be able to make independent decisions and take action regarding patient care based on her or his knowledge and skills without discounting the parameters of her or his scope of practice. Practice experience has indicated that the critical care nurse is often uncertain about whether her or his clinical activities are protected by the regulations provided by the Nursing Council. This is more specifically true in the private hospital industry where medical advice or assistance is not always easily available. This situation led to the following research question: Do the available professional and legal guidelines provide an appropriate foundation to guide the practice of the registered critical care nurse in the private hospital sector critical care environment? A non-experimental descriptive study with a qualitative orientation was conducted in 19 private hospitals in the Western Cape. Through nonprobability, random sampling, 71 registered critical care nurses were included in the study. A questionnaire was designed and validated to collect the data. Quantitative data was analysed through Excel® while qualitative data was analysed thematically. It was found that the legal and professional guidelines in place at present do provide a foundation for the clinical activities of critical care nursing in the private hospital sector. It is suggested that it is rather the critical care nurses’ interpretation of the Scope of Practice (No.R.2598 of 30/11/1984 as amended) that limits their practice as opposed to the wording of the regulations. It is recommended that critical care nurses must determine nursing care parameters based on patient need, using the regulations as a foundation for critical, analytical and reflective practice rather than as a set of rules to be followed. Key words: Scope of practice, critical care practice, ICU nursing care, private hospital nursing practice.
AFRIKAANSE OPSOMMING: Die kritiekesorgverpleegkundige werk in ‘n omgewing waar pasiëntebehoeftes gereeld die parameters waarin sy of hy praktiseer, verskuif. Dit word van ’n bekwame kritiekesorgverpleegkundige verwag dat sy of hy onafhanklike besluite en aksies met betrekking tot pasiëntesorg, gebaseer op haar of sy kennis en vaardighede, sal neem sonder om die parameters van haar of sy bestek van praktyk te oorskry. Praktykondervinding het getoon dat die kritiekesorgverpleegkundige dikwels onseker is oor watter van haar of sy optredes deur die Regulasies, soos deur die Raad op Verpleging gespesifiseer word, beskerm word. Dit is nog meer spesifiek van toepassing in die privaathospitaal-industrie waar geneeskundige advies en bystand nie altyd maklik beskikbaar is nie. Die situasie het tot die volgende navorsingsvraag aanleiding gegee: Voorsien die beskikbare professionele en wetlike riglyne ’n geskikte grondslag om die praktyk van ’n geregistreerde kritiekesorgverpleegkundige in die privaatsektor- kritiekesorgomgewing te rig? ’n Nie-eksperimentele, beskrywende studie met ’n kwalitatiewe oriëntasie is in 19 hospitale in die Wes-Kaap onderneem. Deur nie-waarskynlikheids-, toevallige steekproefneming is 71 geregistreerde kritiekesorgverpleegkundiges in die studie ingesluit. ’n Vraelys is ontwerp en gevalideer om inligting in te samel. Kwantitatiewe data is deur middel van Excel ontleed terwyl kwalitatiewe data tematies ontleed is. Daar is gevind dat die wetlike en professionele riglyne wat tans beskikbaar is, ‘n grondslag bied vir die kliniese aktiwiteite van kritiekesorgverpleegkundiges in die privaathospitaal.. Dit word voorgestel dat dit die kritiekesorgverpleegkundige se interpretasie van die Bestek van Praktyk (No.R.2598 of 30/11/1984 soos aangepas) is wat hulle praktyk beperk, eerder as die bewoording van die regulasie self.

Access to health care in rural communities is challenged by workforce shortages. Nurse practitioners (NPs) have been filling the gap created by physician migration into specialty areas. Flex hospital legislation allows critical access hospitals (CAHs) to staff the emergency department with NPs or physician assistants without on-site physicians. NP education often lacks emergency and trauma curriculum, resulting in gaps in education and practice expectations and leading to significant role transition stress and turnover. The purpose of this project was to construct an evidence-based transition-to-practice residency program to support NPs providing emergency department care in the CAH. Theoretical frameworks used to guide the project include rural health theory, novice to expert, and from limbo to legitimacy frameworks. Global outcomes include increased quality of care, patient safety, NP job satisfaction, and decreased turnover. The quality improvement initiative engaged an interprofessional team of institutional and community stakeholders (n = 10) to develop primary products including the residency program, curriculum modules, and the secondary products necessary to implement and evaluate the project. Implementation will consist of a pilot followed by expansion throughout the rural health network. Evaluation will involve the CAH dashboard to monitor patient outcomes, Misener NP job satisfaction scale, and employee turnover rates. The project expands understanding of the on-boarding needs of rural NPs. The results of this project will serve as a guide to publish outcome data and collaborate with higher education to develop programs to award academic credit for paid clinical experiences leading to academic degrees.

Thesis (Mcur)--Stellenbosch University, 2012.
ENGLISH ABSTRACT: A literature study showed that the topics of medication safety and medication error prevention have been studied in depth. Findings from the literature revealed that medication errors are reported to be common in neonatal and paediatric ICUs, that more than half of these errors are preventable and that risk reduction measures protect patients against untoward outcomes or adverse events (Clifton-Koeppel, 2008:72). If and when there is a failure in the process of safe medication administration, it results in a medication error, which is defined as a breach of one or more of the five rights of medication administration (Institute for Safe Medication Practices Alert, 2007:1). Medication administration, which is predominantly a nursing task, is of high risk and high volume in the intensive care unit (ICU). The accuracy of intravenous medication administration is critical for a neonatal and paediatric ICU patient since it can potentially heighten the patient’s vulnerability if further harm is caused. In view of the complexity of medication administration for neonatal and paediatric ICU patients, researchers confirm the diverse role of the registered nurse in safe medication administration practices. The purpose of the study was to describe the perceptions of registered nurses (RNs) regarding the factors that influence IV medication safety practice in the neonatal intensive care unit (NICU); paediatric intensive care unit (PICU); and paediatric cardiac intensive care unit (CSICU) in Saudi Arabia. The study objectives were set to describe the actual factors that have an influence on IV medication safety practices of RNs working in these ICUs; to determine the knowledge of registered nurses in the selected ICUs with regard to safe intravenous medication administration practices and to describe nursing medication administration strategies that are focused on medication error prevention. A quantitative research approach was selected for this study which had a descriptive, survey design. An 85% non-probability purposive sampling method was used to draw a sample (n=103) of the target population of NICU-, PICU- and CSICU-registered nurses (N=121) who were responsible for administering intravenous medication at King Faisal Specialist Hospital and Research Centre in Jeddah (KFSHRC-J). A self-administered questionnaire with closed-ended Likert and open-ended question was designed to describe the objectives under study. A pilot study was conducted to pre-test the questionnaire. A quantitative method was used to analyse the study data. MS Excel was used to capture the quantitative data after which it was analysed using descriptive statistics by means of STATISTICA 9 software. The open–ended questions (indicating “other” and Question 70) were also interpreted quantitatively after exploring the main aspects in the responses. The main findings were that multiple perceived factors influence the intravenous medication safety practices of RN’s working with neonatal and paediatric ICU patients in a particular Saudi Arabian tertiary hospital. It was found that these nurses’ had knowledge regarding safe medication administration practice that constitutes that all five medication rights have to be checked through nursing ‘double-checks’ in the steps of medication administration, as the method of checking as per hospital policy. However, from the findings, it is reflected that RNs perceptions of completely and correctly checking medication rights through complete and independent nursing ‘double-checks’, do not match the steps required by policy and that their knowledge is inadequate. It is evident from the perceptions of RNs that they are aware of the multiple factors influencing IV medication safety practice in this vulnerable patient setting. As perceived by RNs, it is possible to implement more safety strategies. Key recommendations on conclusion of the study include that there are more nursing medication administration strategies that could still be implemented for medication error prevention. These strategies relate to medication safety awareness, the role of the nurse and nursing managers, mandatory staff education, and review of knowledge and skills.
AFRIKAANSE OPSOMMING: Gebaseer op ʼn literatuurstudie blyk dit dat medikasieveiligheid en voorkoming van medikasiefoute reeds in diepte bestudeer are. Bevindings dui daarop dat medikasiefoute algemeen voorkom in neonatale en pediatriese intensiewesorgeenhede, dat meer as die helfte daarvan voorkombaar is, en dat maatreëls om risiko te vermindering pasiënte teen voorkombare uitkomste beskerm (Clifton-Koeppel, 2008:72). Indien en wanneer die proses vir veilige medikasietoediening faal, kom ʼn medikasiefout voor, wat gedefinieer word as die verbreking van een of meer van die vyf medikasieregte (Institute for Safe Medication Practices Alert, 2007:1). Medikasietoediening is hoofsaaklik ʼn verpleegtaak, wat ʼn hoërisiko- en hoëvolume-taak behels. Die akkuraatheid van intraveneuse medikasietoediening is kritiek vir neonatale en pediatriese intensiewesorgpasiënte, aangesien hul weerloosheid verhoog word indien verdere skade veroorsaak word. Omrede medikasietoediening vir neonatale en pediatriese intensiewesorgpasiënte kompleks is, bevestig navorsers dat geregistreerde verpleegkundiges se rol ten opsigte van veilige medikasietoediening veelsoortig is. Die doel van die studie was om die persepsies van geregistreerde verpleegkundiges aangaande die faktore wat medikasieveiligheid in die neonatale en paediatriese intensiewe eenhede in Saoedi-Arabië beinvloed, te beskryf. Studiedoelwitte is gestel om die spesifieke faktore te beskryf wat aanleiding gee tot medikasietoedieningsfoute in die genoemde intensiewesorgeenhede; om geregistreerde verpleegkundiges in die geselekteerde intensiewesorgeenhede se kennis van veilige medikasietoediening te bepaal; en die medikasietoedieningstrategieë wat op die voorkoming van medikasietoedieningsfoute fokus, te beskryf. ʼn Kwantitatiewe navorsingsbenadering is geselekteer vir die studie wat ʼn beskrywende navorsingsontwerp gehad het. ʼn 85% nie-waarskynlike gerieflikheidsteekproef is gebruik om ʼn steekproef (n=103) te selekteer vanuit die teikenpopulasie geregistreerde verpleegkundiges (N=121) wat verantwoordelik was vir medikasietoediening in die geselekteerde intensiewesorgeenhede by King Faisal Specialist Hospital and Research Centre, Jeddah (KFSHRC-J). ʼn Self-geadministreerde vraelys met geslote Likert- en oop-eindevrae is opgestel om die gestelde studiedoelwitte te ondersoek. ʼn Vooraf-toetsing van die vraelys is tydens die loodsstudie uitgevoer. ʼn Kombinasie van kwantitatiewe en kwalitatiewe metodes is gebruik vir die ontleding van die studie-data. Die kwantitatiewe data is op MS Excel ingevoer, waarna beskrywende statistiek deur middel van Statistica 9-sagteware gebruik is om dit te ontleed. Die studie het hoofsaaklik bevind dat veelvuldige faktore die veiligheidspraktyk ten opsigte van intraveneuse medikasie van geregistreerde verpleegkundiges wat met neonatal en pediatriese intensiewesorgpasiënte in ʼn spesifieke tersiêre hospitaal in Saoedi-Arabië werk, beïnvloed. Dit blyk dat hierdie verpleegkundiges se kennis voldoende is aangaande ‘n veilige medikasie toedieningspraktyk wat bestaan uit die kontrolering van al vyf medikasieregte deur verpleegkundige dubbel-kontrolering, soos beskryf is in die hospitaalbeleid. Volgens die bevindinge blyk dit egter dat die verpleegkundiges se persepsie van volledige and korrekte verpleegkundige dubbel-kontrolering, nie met die stappe volgens die hospitaalbeleid ooreenstem nie en dat hulle kennis onvoldoende is. Dit is duidelik dat die verpleegkundiges bewus is van die veelvuldige faktore wat intraveneuse medikasieveiligheidpraktyk vir weerlose pasiënte beïnvloed. Die verpleegkundiges se persepsie is dat daar meer verpleegkundige medikasietoedieningstrategieë is wat geïmplementeer kan word om medikasiefoute te voorkom, insluitende veiligheidsbewustheid ten opsigte van medikasie, die rol van verpleegkundiges en verpleegbestuurders, verpligte personeelopleiding, en hersiening van kennis en vaardighede.

Thesis (MCur)--University of Stellenbosch, 2011.
ENGLISH ABSTRACT: Agency-nursing work refers to nursing services provided by agency nurses employed on a casual, contracted basis. Agency-nursing has become more common in nursing practice in South Africa. This group of nurses play a significant role within the health care industry for both public and private sector. Given the pivotal role that nurses play in caring for the health of others, it is important to understand what motivates agency nurses in terms of job satisfaction. The aim of the study was to explore the perceptions of agency nurses regarding job satisfaction within critical care units in private health care institutions in the Western Cape. A qualitative research design with a phenomenological approach was applied. A sample size of n=10 was drawn from a total population of N=553, using random sampling technique. A semi-structured interview guide was designed based on the objectives of the study and validated by experts in the field before data collection. Ethical approval for the study was obtained from the Ethics Committee at the Faculty of Health Sciences, University of Stellenbosch. Permission to conduct the research was obtained from the participating nursing agency and consent was given in writing. The presentation of the results was categorised into themes and sub-themes emerged from the data analysis. The five clusters of themes that emerged were reasons for doing agency work, experiences with hospital staff, allocation of agency nurses, communication of information and staff development. The findings support Herzberg’s theory on motivation factors in terms of what motivates workers to excel in their performance. Agency nurses experienced both positive and negative aspects with regards to job satisfaction. The results of the study suggest the need to include revision and implementation of human resource policies and practices to include the nurses’ “voice” in an effort to provide a more supportive work environment. Further research is recommended. Key Words: Agency nurse, nursing agency, job satisfaction.
AFRIKAANSE OPSOMMING: Agentskapverplegingswerk verwys na verplegingsdienste wat voorsien word deur agentskapverpleegsters wat op ’n tydelike, gekontrakteerde basis in diens geneem word. Agentskapverpleging het meer algemene gebruik in die verpleegpraktyk in Suid-Afrika geword. Hierdie groep verpleegsters speel ’n belangrike rol in die gesondheidsbedryf vir beide die openbare en die private sektor. Gegee die deurslaggewende rol wat verpleegsters speel in die gesondheidsversorging van ander mense, is dit belangrik om te verstaan wat agentskapverpleegsters motiveer vanuit die oogpunt van werksbevrediging. Die doel van die studie was om die persepsies en ervarings van agentskapverpleegsters ten opsigte van werksbevrediging te ondersoek binne die waakeenhede in private gesondheidsorg-inrigtings in die Wes-Kaap. ’n Kwalitatiewe navorsingsontwerp met ’n fenomenologiese benadering is toegepas. ’n Monstergrootte van n=10 is geneem uit ’n populasie van N= 553 deur die ewekansige steekproeftegniek te gebruik. ’n Semi-gestruktureerde onderhoudgids was ontwerp en gebaseer op die doelwitte van die studie en was deur deskundiges op hierdie gebied, voor die insameling van data, gelding verklaar. Etiese goedkeuring vir die studie was verkry van die Etiese Komitee van die Fakulteit van Gesondheidswetenskappe, Stellenbosch Universiteit. Goedkeuring om die navorsing te doen, was verkry van die deelnemende agentskap en toestemming was op skrif geplaas. Die voorgelegde resultate was gekategoriseer in temas en subtemas wat uit die data-analise voortgespruit het. Die vyf groepe van temas wat hieruit gespruit het, is redes vir die keuse om agentskapwerk te doen, ervarings met hospitaalpersoneel, die toewysing van agentskapverpleegsters, kommunikasie van inligting en personeelontwikkeling. Die bevindinge het onthul dat Herzberg se teorie oor motiveringsfaktore werkers aangemoedig het om te presteer in die uitvoering van hulle pligte. Werksbevrediging is volgehou deur die agentskapverpleegster. Die bevindings dui op die behoefte om die hersiening en implementering van menslike hulpbronbeleidsverklarings en -praktyke in te sluit sodat die verpleegster se stem gehoor kan word in ’n poging om ’n meer ondersteunende werkomgewing te voorsien. Verdere navorsing word aanbeveel. Sleutelwoorde: Agentskapverpleegster, verplegingsagentskap, werksbevrediging.

Deconditioning occurs in critically ill patients as early as 4 days after entering the intensive care unit (ICU) resulting in a loss of up to 25% peripheral muscle tone and 18% body weight by the time the patient is discharged. Early mobility (EM) has been shown to reduce complications such as neuromuscular weakness, muscle wasting, pneumonia, and the effects of prolonged periods of time on the ventilator. No formal education on EM had been provided to nurses at the clinical site. The purpose of this project was to develop an educational program on EM to promote early ambulation of critically ill ICU patients. The theory of knowledge to action was used to guide the development of the educational program. The practice-focused question addressed whether an educational program would improve nurses' perceptions of their knowledge of EM and if they would promote the use of EM among ICU patients. After a literature review to identify evidence-based practices and a protocol on EM, an educational program was developed that included a 25-item Likert-style pretest and posttest to measure percent agreement with perceptions of knowledge gained and likelihood of behavior change related to the practice of EM. Participants included 60 ICU nurses. Results demonstrated improvement in perceptions of knowledge of EM (from 74% before education to 88% after) and in likelihood of behavior change related to EM (from 69% before education to 91% after). Findings may be used to integrate EM into the ICU setting to reduce complications such as neuromuscular weakness, muscle wasting, and pneumonia. Results may also include improved patient outcomes, reduced length of stay, and increased quality of life for patients and their families, and thereby promote positive social change.

The push to generate professional nurses has raised questions about the competency level of the novice nurses that are entering the workforce. Utilization of simulation laboratories is being viewed as an option for bridging the gap for the shortage of nurses, nurse educators, and clinical sites. The theory of goal attainment was used to guide this project, which aimed to develop and validate an ER simulation scenario that mimics a clinical setting as a tool for measuring nursing skills. An additional purpose, to be accomplished after graduation, will be to implement a pilot project to determine the impact of the validated simulation scenario within the nursing skills laboratories on the quality of care provided by novice nurses to patients. The validation of the ER simulation scenario was completed by having 10 local experts review the developed ER simulation scenario. The experts then completed a 5-question Likert-type scale survey. Descriptive analysis was used to evaluate the results of the survey and validate the simulation scenario tool. Results revealed that all experts strongly agreed that the ER scenario was visually appealing and had enough subject content. Most experts strongly agreed that it was easy to read and follow. Post-graduation and with the assistance of the education organization, the second part of this proposal will occur with a pilot study implementation. The significance of this project to the nursing practice is to utilize simulation as a bridge to real life practice settings. This project may contribute to the American Nurses Association Standards of best practice which works to improve patient safety as well as quality nursing care.

Thesis (MTh)--Stellenbosch University, 2012.
ENGLISH ABSTRACT: Pastors and congregations need to communicate the faithfulness and care of God within the real life contexts of the communities that they are a part of. The problem is that pastoral theology has been predominantly linked to individual psychology rather than to theory that facilitates a specifically Christian care for whole communities. This study asks how pastors can engage with the concrete realities of their communities, caring for real and practical needs, within the context of the specifically Christian focus of the Gospel. The chief goal is to make a clear contribution to the way in which Community Pastoral Care is thought about and carried out. This is a contribution that encourages engagement with the needs of the communities together with the Gospel. This requires a methodology that involves interdisciplinary understanding, calling for a hermeneutical study. The study engages firstly with Systems Theory, gaining an understanding of the way in which communities and groups function and change. Linked to this is the study of Communicative Action and Social Constructionism, these contribute understanding of the way in which communication functions within the community system. Thirdly, a study of Community Psychology, including Social Capital, emphasises the importance of focusing on the relationships within the community. Community care in this context is predominantly care for relationships and communication within the community. This includes the understanding that problems form within the relationships that make up the community, rather than individuals within the community. It also places the focus of care on building strengths rather than fixing pathologies. The specif cally Christian character of Community Pastoral Care is given through a study on sin/evil, the gospel and revelation. Th is introduces the action and communication of a faithful God. Community Pastoral Care is seen to incorporate the revelation of the Kingdom of God and its blessings, as well as the possibility of a direct relationship with Him that transforms the life of the community and individuals. Semi-structured interviews, with a small selection of pastors, give an empirical aspect to the study. This helps to ground the study in the actual experiences of pastors, giving a chance for their experience to add to and engage the theory study. The first two theory chapters suggest that the key to community care is developing positive relationships between the parts of the system. With the introduction of a relationship with a faithful God, the understanding of care expands. Revelation of His Kingdom, and the changed relationships that it brings, transforms the earlier Communicative Action into both an expression of and a communication of a faithful God and the promise of His Kingdom. What is concluded is that Community Pastoral Care is primarily the revelation of God to the community. This is carried out through relationship with the congregation including, and guided by, the ministry of the pastor. This is a Pastoral Care that is less about technique and more about mutual relationships of trust and open, positive communication with God, the congregation and the community.
AFRIKAANSE OPSOMMING: Predikante en gemeentes moet die trou en sorg van God kommunikeer binne die werklike lewens kontekste van die gemeenskape waarvan hulle deel is. Die probleem is dat pastorale teologie grootendeels verbind is aan individuele sielkunde eerder as teorie wat ‘n spesifi eke Christelike sorg vir hele gemeenskape fasiliteer. Hierdie studie vra hoe predikante kan betrokke raak by die konkrete realiteite van hulle gemeenskape en soedoende werklike behoeft es praktiese kan aanspreek binne die raamwerk van die spesifi ek Christelike fokus van die evangelie. Die hoefdoel is om ‘n duidelike bydrae te maak aan die teorie en praktyk van Gemeenskapspastoraat. Dit vra ‘n metodologie wat interdisiplinêr en hermeneuties van aard is. Hierdie studie gebruik eers Sisteem Teorie om te analiseer hoe groepe funksioneer en verander. In verband hiermee word die studies van Kommunikatiewe Aksie en Sosiale Konstruksie gebruik om te verstaan hoe kommunikasie funksioneer binne die gemeenskapsisteem. Derdens, word die lens van Gemeenskapssielkunde, veral die konsep van Sosiale Kapitaal, gebruik om die belang van verhoudings binne die gemeenskap te beklemtoon. Gemeenskapsorg in hierdie konteks is hoofsaaklik die sorg van verhoudings en kommunikasie binne die gemeenskap. Daaruit word daar geargumenteer dat probleme in die verhoudings binne die gemeenskap ontstaan eerder as in die individuë wat die gemeenskap vorm. Dit plaas die fokus van sorg op die uitbou van dít wat werk eerder as op die herstel van patologieë. Die besonder Christelike karakter van Gemeenskapspastoraat word uitgelig deur ‘n studie van sonde/ kwaad, die evangelie en openbaring. Dit stel die aksie en kommunikasie van ‘n getroue God voor. Gemeenskapspastoraat sluit in die openbaring van die konninkryk van God en die seëninge daarvan, sowel as die moontlikheid van ‘n direkte verhouding met Hom wat die lewe van die gemeenskap en die individu transformeer. Gedeeltelik-gestruktureerde onderhoude, met ‘n klein steekproef van predikante, het ‘n empiriese komponent aan die studie verleën. Dit help om die studie in die werklike ervaring van predikante te fundeer sodat hulle ervaringe in verband met die teorie gebring kan word. Die eerste twee hoofstukke stel voor dat die sleutel tot gemeenskapssorg is om positiewe verhoudinge te bou tussen die verskillende dele van die sisteem. Met die introduksie van ‘n verhouding met ‘n getroue God, word die verstaan van sorg uitgebrei. Die openbaring van sy Konninkryk, en die veranderde verhoudinge wat dit bring, omskep die vroeër kommunikatiewe aksie na ‘n uitdrukking van en kommunikasie van ‘n getroue God en die beloft e van sy Konninkryk. Die gevolgtrekking word gemaak dat Gemeenskapspastoraat primêr die openbaring van God tot die gemeenskap is. Dit word uitgedra deur die verhouding tussen God en die gemeente, insluitend en gelei deur die bediening van die predikant. Dit is dan ‘n soort pastoraat wat minder oor tegniek en meer oor getroue verhoudings en oop, positiewe kommunikasie met God, die gemeente en die gemeenskap gaan.

Schools of nursing educators are faced with redesigning nursing education to meet the complexity of implementing communication and patient- centered care to improve patient safety. This qualitative case study addressed the problem that teaching communication and patient- centered care were not threaded throughout curriculum, which left many new graduates nurses unprepared. The purpose of this study was to understand classroom experiences of new graduate nurses to meet performance outcomes. The research questions focused on understanding the classroom experiences of new graduates' of a nursing program by assessing the two concepts and how to address preparatory practices. The target populations were new graduates' of nursing programs who had been working in a hospital for less than 1 year and are registered nurses. Emergent themes regarding the new graduates classroom experiences strengths and areas of improvements were extracted from the 10 participants interview questions, and practice experiences from the journal recordings were manually coded, validated , triangulated, and member checked with eight themes that emerged from face-to-face interviews, theoretical frameworks, and the current literature. The researcher determined that the new graduates' nurses were self-motivated to implement communication and patient centered care, however incorporating the two concepts in the class instructions would be a safer preparatory experience. This study may contribute to positive social change through raising awareness regarding the overall standard of nursing education, which may lead to a reevaluation of nursing curricula and teaching strategies so that new graduate nurses may master the complexity of clinical practices resulting in positive performance outcomes

Thesis (MCurr)--Stellenbosch University, 2012.
ENGLISH ABSTRACT: Nurse managers are responsible to staff different hospital units and departments with sufficient, trained and experienced personnel. Most critical care units in the private healthcare in South Africa are staffed below maximum workload levels and additional staff is supplemented when needed. Current staffing management strategies comprises the application of the patient acuity score, the utilisation of contracted agency staff and ward staff who assist occasionally in the critical care unit (CCU). The aim of the study was to explore the experiences of critical care nurses regarding staffing management within critical care units in private health care institutions in the Western Cape. The following objectives were set to: - explore the experiences of CCNs regarding staffing management strategies such as o the patient acuity score o the employment of ad hoc agency staff and o the utilization of ward staff A descriptive design with a qualitative approach was applied. A sample size of n=15 was drawn from a total population of N=377, using purposive sampling technique. A pilot-test was also completed. The trustworthiness of this study was assured with the use of Lincoln and Guba’s criteria of credibility, transferability, dependability and confirmability. All ethical principles were met. The findings of the study demonstrated that nurses perceive the workload in critical care units as heavy. The utilisation of the acuity score does not really assist in relieving the workload as managers tend not to consider the staffing requirements as predicted by the acuity score due to budget constraints. The enrolled nurses who assist occasionally in the critical care unit require supervision as well as ongoing development to ensure safe and quality patient care. Yet agency nurses were perceived as either extraordinary good or incompetent.
AFRIKAANSE OPSOMMING: Verpleegbestuurders het die verantwoordelik om verskillende hospitaaleenhede en departemente met voldoende opgeleide en ervare personeel te voorsien. Die meeste kritieke sorgeenhede in Suid-Afrika word met minder as dan die maksimum werkladingsvlak beman en addisionele personeel word aangevul wanneer nodig. Huidige personeelbestuurstrategieë behels die toepassing van die pasiënt akuïteit telling, die gebruik van ingekontrakteerde agentskap-personeel en saalpersoneel wat per geleentheid in die kritiekesorgeenheid help. Die doel van die studie was om die ervaringe van kritieke-sorgverpleegsters ten opsigte van personeel bestuur binne die kritiekesorgeenhede in die privaat gesondheidsorginstellings in die Weskaap, te ondersoek. Die volgende doelwitte is gestel: - Om die ervaringe van kritieke-sorgverpleegsters aangaande personeelbestuur-strategieë te ondersoek, soos: o die pasiënt akuïteit telling o die gebruik van agentskapverpleegpersoneel en o die gebruik van saal personeel, te ondersoek ’n Beskrywende kwalitatiewe studie is toegepas. ’n Steekproef van n=15 is uit ’n totale populasie van N=377 getrek deur die doelgerigte steekproeftegniek te gebruik. ’n Loodstoetsing van die semi-gestruktureerde vraelys is ook gedoen. Die betroubaarheid van hierdie studie was verseker deur van Lincoln en Guba se kriteria vir geloofwaardigheid, oordraagbaarheid, betroubaarheid en bevestigbaarheid gebruik te maak. Daar is aan alle etiese vereistes voldoen. Die bevindings van die studie toon dat die verpleegpersoneel die werklading in die kritiekesorgeenheid as veeleisend ervaar. Die aanwending van die pasiënt akuïteit-telling dra nie werklik by tot verligting van die werklading nie, aangesien bestuurders weens begrotingsbeperkings neig om nie die personeelbenodigdhede soos deur die akuïteit-telling voorspel in ag neem nie. Die ingeskrewe verpleegsters wat per geleentheid in die kritieke-sorgeenheid hulp verleen, benodig toesig asook volgehoue ontwikkeling ten einde veilige en kwaliteit pasiëntsorg te verseker. Die agentskapverpleegpersoneel is egter as baie bekwaam of onbevoeg beskou.

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Bachelors
Nursing
Nursing

This study employed a heuristic -participant evaluation of the instruction of the web-based Essentials of Critical Care Orientation (ECCO) program using two research questions: (1) How well does the ECCO adhere to Bloom's theory of mastery learning and instruction; and (2) What effect, if any, does this have on the participant RN? Evaluation findings demonstrated that the ECCO is 66 hours of expository instruction with little to no meaningful feedback, correction, or enrichment activity, is not well aligned, and has significant design flaws related to objectives and transfer of instruction and to the processes of instruction. This results in the participant RN being left to his own devices to achieve mastery. Heuristic findings demonstrated the effect on the participant RN - feelings of frustration, resentment, fear, lack of confidence, and apprehension which in sum outweigh feelings of accomplishment and yield a compulsion to leave critical care practice. Discussion includes implications of findings and results, recommendations for the ECCO program improvement, and concludes with suggestions for future research.

Thesis (MNutr (Human Nutrition))--University of Stellenbosch, 2006.
INTRODUCTION: The primary objective was to determine whether acidified formulae (pH 3.5 and 4.5) decreased gastric and tracheal colonisation, as well as microbial contamination of the enteral feeding delivery system, compared with a non-acidified control formula (pH 6.8) in critically ill patients. Secondary objectives included tolerance of the trial formulae and mortality in relation to the administration of acidified formulas. DESIGN: The trial was a controlled, double-blinded, randomised clinical trial of three parallel groups at a single centre. METHOD: Sixty-seven mechanically ventilated, medical and surgical critically ill patients were randomised according to their APACHE II scores and included in the trial. Patients received either an acidified (pH 3.5 or 4.5) or control polymeric enteral formula via an 8-Fr nasogastric tube at a continuous rate. Daily samples were taken for microbiologic analyses of the enteral formulae at various stages of reconstitution and at 6-hour and 24-hour intervals during administration thereof (feeding bottle and delivery set). Daily patient samples included nasogastric and tracheal aspirates, haematological evaluation and gastro-intestinal tolerance. The trial period terminated when patients were extubated, transferred from the ICU, enteral nutrition became contraindicated, a patient died, or for a maximum of 21 days. RESULTS: Gastric pH showed no significant difference (p = 0.86) between the 3 feeding groups [pH 3.5 (n = 23), pH 4.5 (n = 23) and pH 6.8 (n = 21)] at baseline prior to the administration of enteral formulae. After initiation of feeds, the gastric pH decreased significantly (p< 0.0001) in the acidified formulae as compared to the control formula during the trial period. Patients who received acidified enteral formulae (pH 3.5 and 4.5) had significantly less (p < 0.0001) contamination from the feeding bottles and delivery systems in respect of Enterobacteriacea, and Enterococcus., The more acidified group (pH 3.5) showed significantly less gastric contamination (p = 0.029) with Enterobacteriacea, , but not for fungi. The 3.5 acidified group also had the lowest gastric growth in terms of colony counts (≤104) of these organisms, but not for fungi, when compared to the control group (≤105). Vomiting episodes were 22% and abdominal distension 12%, with a higher incidence in the control group. Adverse events occurred equally between the groups with a higher, but not significantly different incidence of 37% in the control group and 32% for the acidified groups. There was no evidence of gastro-intestinal bleeding in any patient. Overall, the mortality rate in this trial was 6%, with 6.5% for the acidified groups (n=46) and 4.8% for the control group (n=21), a statistically insignificant difference. CONCLUSION: Acidified enteral formulae significantly decrease gastric colonisation by preserving gastric acidity that decreases the growth of Enterobacteriaceaes organisms. Acidified formulae significantly decrease bacterial contamination of the enteral feeding system (bottle and delivery set) of Enterobacteriaceae and Enterococcus organisms. Acidified formulae are tolerated well in critically ill patients.

The prevalence of diabetes mellitus (DM) continues to be a global concern among health care practitioners. Without collaboration and interventions, this chronic disease, which poses a significant financial burden for health care institutions, will continue to be problematic. Promoting the use of glycemic control measures among diabetic patients is an intervention, which has the potential to reduce diabetic complications and improve outcomes. The purpose of this doctoral project was to explore available evidence through a systematic review of the best practices for glucose management. The chronic care model served as the theoretical framework. The evidence based practice question was, What is the current evidence supporting the utilization of a computer-based glucose management system (CBGMS) for inpatient diabetic adults in acute and critical care settings? A systematic review was conducted, yielding 532 studies in which 3 of the studies related to CBGMSs published from 2008 to 2017 were critically appraised. The John Hopkins Nursing Evidence Appraisal Tool with specific inclusion and exclusion criteria was utilized. Participants were adult patients (aged 18 and over) with DM in inpatient care settings who were English speaking. Interventions included the traditional paper-based sliding scale regimen versus the utilization of a CBGMS. Outcome measures included decreased length of stay, reduced cost, and glucose optimization. A conclusion was the implementation of a CBGMS has the potential to improve patient outcomes with additional research that exhibits overall benefits and implement into practice. Thus, implementation of a CBGMS can lead to positive social change by aiding in a change in practice that will ultimately ameliorate patient health outcomes.

Muscle weakness is the most common and persistent problem after a critical illness. Early mobilization of the critically ill patient, beginning with passive exercise and progressing to ambulation, may mitigate muscle effects of the critical illness. However, mobilization may produce adverse effects, especially early in the illness when risk for physiologic deterioration is common. If safe, introducing a mobility intervention early in the illness may facilitate ventilator weaning, shorten intensive care unit and hospitals stays, and improve functional status and quality of life for mechanically ventilated critically ill patients. The aim of this study was assess the cardiopulmonary and inflammatory responses to an early standardized passive exercise protocol (PEP) in mechanically ventilated critically ill patients. Using a quasi-experimental within-subjects repeated measures design, mechanically ventilated critically ill adults who were physiologically stable received a single standardized PEP within 72 hours of intubation. The PEP consisted of 20 minutes of bilateral passive leg movement delivered by continuous passive motion machines at a rate of 20 repetitions per minute, from 5-75 degrees, to simulate very slow walking. Physiologic parameters evaluated included heart rate (HR), mean blood pressure (MBP), oxygen saturation, and cytokine levels (IL-6 and IL-10), obtained before, during, and after the intervention. The Behavioral Pain Scale (BPS), administered before, during and after the intervention was used as a measure of participant comfort. The study sample was comprised of 18 (60%) males and 12 (40%) females, with a mean age of 56.5 years (SD 16.9 years), who were primarily Caucasian (N=18, 64%). Mean APACHE II scores for the sample were 23.8 (SD 6.2) with a mean predicted death rate of 48.8 (SD 19.8), indicating moderate mortality risk related to illness severity. Number of comorbidities ranged from 1-10 (X=4). All participants completed the intervention with no adverse events. Using repeated measures analysis of variance (rmANOVA), no significant differences were found in HR, MBP, or oxygen saturation at any of the four time points in comparison to baseline. BPS scores were significantly reduced (F(2.43, 70.42)=4.08, p=.02) at 5 and 10 minutes after the PEP was started, and were sustained at 20 minutes and for one hour after the PEP was completed. IL-6 was significantly reduced (F(1.60, 43.1)=4.351, p=.03) at the end of the intervention but not at the end of the final rest period. IL-10 values were not significantly different at any of the three time points, but IL-6 to IL-10 ratios did decrease significantly (F(1.61, 43.38)=3.42, p=.05) at the end of the PEP and again after a 60 minute rest period. Passive leg exercise was well tolerated by study participants. HR, MBP, and oxygen saturation were maintained within order set-specified ranges during and for one hour after activity, and patient comfort improved during and after the intervention. A downward trend in HR was noted in participants, which is contrary to usual HR response during exercise, and may represent clinical improvement in this population related to reduction in pain. Reduction of mean IL-6 values at the end of the PEP, but not after the rest period, suggests that the PEP was responsible for the initial IL-6 improvement. Improvement of IL-6 to IL-10 ratios from the end of the PEP to the end of the final rest period suggests that IL-10, although non-significant, may have had some effect, indicating that IL-10 increases may occur later than the time period of study. Passive exercise can be used as an approach to facilitating mobilization in mechanically ventilated critically ill adults until they are ready to participate in more active exercise. It could be that more frequent and aggressive exercise, such as passive cycling at faster rates, four times daily, will be tolerated in this population. While the understanding of clinical significance of cytokine profiles in critically ill patients is still evolving, cytokine levels may be useful in explaining benefits of mobilization in this population. Further study is required to replicate the impact of passive exercise on pain, and it may represent a novel approach to pain management in critically ill patients.
ID: 031001499; System requirements: World Wide Web browser and PDF reader.; Mode of access: World Wide Web.; Adviser: .; Title from PDF title page (viewed July 26, 2013).; Thesis (Ph.D.)--University of Central Florida, 2012.; Includes bibliographical references.
Ph.D.
Doctorate
Nursing
Nursing
Nursing

Thesis (MPhil (Curriculum Studies))--Stellenbosch University, 2008.
Background to the study: The Critical Care nursing programme at the Faculty of Health Sciences (Stellenbosch University) is a one-year programme. The practical component consists of practical procedures and case presentations. Students have limited time available in the clinical areas to reach competency in the practical skills. Students tend to use the majority of the clinical teaching time available to reach competency in these practical procedures, rather than discussing the patient and learning the skills to integrate and understand the patient’s condition and treatment, which they can acquire by doing case presentations. The end result of this misuse of clinical contact time is that some of the students, by the end of their programme, still have difficulty to integrate a patient’s diagnosis and treatment regime, although they have managed to complete the expected practical procedures. Summary of the work: A case study design was used. I wanted to investigate whether one could make use of simulation and the Clinical Skills Centre (CSC) to complete the majority of the practical procedures so that more time would be available in the clinical areas for the students to do case presentations. The study focuses on describing how the tutors and students involved experienced the use of simulation, as well as how it impacted on the available teaching time in the clinical areas. Conclusions and recommendations: Some of the most important issues that were highlighted in the study and needs to be mentioned are the following: · The students highly valued supervision by a Critical Care tutor when practising their skills in the CSC. · Students indicated that they valued the opportunity to practise some of the more risky procedures in simulation, because it presents no risk to patients. · Case presentations seem important to be added to the CSC’s practical sessions in order to attempt making the practical simulated scenarios even more realistic. · The teaching at the bedside in the clinical areas used to be done somewhat ad hoc. With the teaching in the CSC now being much more structured, this necessitates the teaching at the bedside to be revisited and to be structured to a certain extent. Summary of the results: The information obtained from the Critical Care tutors and the students indicated that these two groups were largely in agreement that simulation seems to be valuable and can effectively be used in a Critical Care nursing programme.

Thesis (MNutr (Interdisciplinary Health Sciences. Human Nutrition))--University of Stellenbosch, 2010.
ENGLISH ABSTRACT: Introduction Complications of severe infection or acute trauma include a cascade of immunological dysfunctions known as SIRS (Systemic Inflammatory Response Syndrome), that affect response to treatment, prolonging and complicating the course of illness and jeopardizing clinical outcome. Timing and the nature of nutritional support in the Intensive Care Unit (ICU) setting may influence this process. Against this background, and despite some trials demonstrating beneficial clinical outcomes for the use of immune-modulating diets (IMD), the findings of the US summit on immune-enhancing enteral therapy concluded that the currently available enteral immune-enhancing formulas are “first-generation products” which may not be appropriate in patients with SIRS or severe sepsis. This highlights a need for alternative nutritional products that target the specific needs of this patient population. As such, Intestamin® is designed for use in severely stressed patients as an immune-modulating enteral feed supplement which aims to improve maintenance of gut barrier integrity and immune response. Aim The aim of this pilot study was to investigate the effect of Intestamin® administration to critically ill patients, and in particular, to determine if administration would impact on nosocomial infections, ventilation days and the length of stay in the ICU. Methods The study design was an open label, retrospective case control, analytical study, of patients admitted to the ICU in The Bay Hospital, Richards Bay, between January 2002 and November 2003, who received Intestamin®. Patients were selected for the study from post-surgery and post-trauma patients at high risk of sepsis and SIRS, and critically ill patients with manifested SIRS or severe sepsis. Development of respiratory and urinary sepsis was used as surrogate markers for progression to severe sepsis and SIRS. Additionally, duration of ventilation and ICU stay were considered representative of the response to treatment and degree of clinical complications. Results The findings of the study demonstrated a significant difference in the rates of respiratory infection(p=0.05), positive sputum and tracheal aspirate cultures(p=0.03) and urinary catheter tip cultures(p=0.04). with statistically lower rates in the intervention group compared to the control group. There were no significant differences in the rates of urinary tract infection, septicaemia or in combined sepsis rates between the two groups. There were statistically significant higher rates of positive pus cell counts in the sputum(p=0.003) and urine(p=0.01) in the intervention group, compared to the control group. No corresponding reduction in ventilation days or ICU stay was observed. Conclusion In this patient population, early enteral nutrition with specially formulated IMD, (Intestamin®), did result in a significant reduction in respiratory infections, but not in other types of sepsis, ICU or ventilator days in critically ill ICU patients. This positive finding in some, but not all endpoints collected, may reflect confounding factors in the small patient population or the choice of clinical endpoints, rather than a genuine limitation in the benefit. IMD remains a tantalizing and scientifically plausible intervention in this patient population, with larger clinical trials necessary to confirm outcomes. The study supports the safe use of Intestamin by the nasojejenal route in this patient population.
AFRIKAANSE OPSOMMING:Inleiding Komplikasies van erge infeksie of akute trauma sluit ‘n kaskade van immunologiese disfunsie in, bekend as SIRS (Sistemiese Inflammatoriese Respons Sindroom), wat die respons op behandeling affekteer, die verloop van siekte verleng en kompliseer asook die kliniese uitkoms beïnvloed. Tydsberekening en die aard van die voedingsondersteuning in die Intensiewe Sorg Eenheid (ISE) mag hierdie proses beinvloed. Teen hierdie agtergrond, en ten spyte van sommige studies wat die voordelige kliniese uitkoms vir die gebruik van immuun-modulerende diete (IMD) toon, het die “US summit” oor immuunverbeterde enterale terapie tot die gevolgtrekking gekom dat die huidige beskikbare enterale immuun-verbeterde formules, “eerste-generasie” produkte is, wat moontlik nie toepaslik is vir pasiente met SIRS of erge sepsis nie. Dit beklemtoon ’n behoefte aan alternatiewe voedingsprodukte wat die spesifieke behoeftes van die genoemde pasient populasie teiken. Intestamin® is ontwerp vir gebruik in erge gestresde pasiente as ‘n immuun-modulerende enterale voedingssupplement doelgerig om spysverteringskanaal integriteit te onderhou en immuniteit te verbeter. Doel Hierdie loodsstudie se doel was om die effek van Intestamin® toediening aan kritiek siek pasiente te ondersoek, spesifiek om vas te stel of die toediening impakteer op nosokomiale infeksies, ventilasie dae en dae in ISE. .Metode Die studie ontwerp was ‘n oop, retrospektiewe, geval kontrole, analitiese studie van pasiente opgeneem in die ISE van The Bay Hospital, Richardsbaai, tussen Januarie 2002 en November 2003, wat Intestamin® ontvang het. Pasiënte is geselekteer vir die studie uit post-chirurgies en post-trauma pasiente wat hoë risiko was vir sepsis en SIRS, en kritiek siek pasiente wat reeds manifisteer het met SIRS of erge sepsis. Ontwikkeling van respiratoriese en urinêre sepsis is gebruik as surrogaat merkers vir die progressie na erge sepsis en SIRS. Addisioneel is duur van ventilasie en ISE verblyf beskou as verteenwoordigend vir die respons op behandeling en die graad van kliniese komplikasies. Resultate Die bevindinge van die studie het betekenisvolle verskille aangedui in die voorkoms van respiratoriese infeksies(p=0.05), positiewe sputum en trachiale aspiraatkulture(p=0.03) en urine kateterpunt-kulture(p=0.04) met statistiese laer voorkoms in die intervensie groep in vergelyking met kontroles. Geen statistiese verskille in die voorkoms van urineweg-infeksies, septisemia of in gekombineerde sepsis voorkoms tussen die twee groepe is gevind nie. Daar was statistiese betekenisvolle hoër voorkoms van etterselle hoeveelhede in die sputum(p=0.030 en uriene(p=0.01) van die intervensie groep in vergelyking met die kontrole groep. Geen ooreenkomstige vermindering in ventilasie dae of ISE verblyf is opgemerk nie. Gevolgtrekking In hierdie pasiënt populasie, het vroeë enterale voeding met spesifieke geformuleerde IMD (Intestamin®), ‘n beduidende vermindering in respiratoriese infeksies getoon, maar nie in ander tipes sepsis, ISE of ventilasie dae by kritiek siek pasiente nie. Hierdie positiewe bevindinge in sommige. maar nie al die versamelde eindpunte nie, reflekteer moontlike bydraende faktore in die klein pasiënt populasie of die keuse van kliniese eindpunte, eerder as a ware beperking in die voordele. IMD bly steeds ‘n uitdagende en wetenskapilik uitsonderlike intervensie in hierdie pasiënt populasie, wat groter kliniese studies benodig om die uitkoms te bevestig. Die studie ondersteun die veilige gebruik van Intestamin® via die nasojejenale roete in kritiek siek pasiënte.

Thesis (PhD)--Stellenbosch University, 2013.
ENGLISH ABSTRACT: Communication between doctors and patients in clinical settings is notorious for being difficult. This problem has inspired a wealth of empirical research from a variety of academic fields on the subject of doctor-patient communication. However, very little attention has been paid to the role of modern medicine's intellectual self-image as natural science in interactions within clinical medical settings. The aim of the current study was to philosophically investigate the influence of the medical profession's intellectual self-image on communication between doctors and patients. Jürgen Habermas' work on Universal Pragmatics was used to comment on doctor-patient communication as it is described in the existing empirical research literature. Michel Foucault's work on discourse and power was used to analyse and describe medical discourse and the nature of power in doctor-patient relationships. The outcome of this philosophical analysis leads to the conclusion that modern medicine's intellectual self-image has a pervasive and negative influence on communication between doctors and patients during clinical consultations. This is because medicine's positivist world-view results in an almost exclusive focus on the physical aspects of disease in clinical medicine. The patient's mind and his/her social world are not of great significance from the natural scientific perspective. Medical professionals may thus easily regard their clinical task solely as the physical treatment of physical disorders. They are very likely to consider many communicative activities as unrelated to their clinical task. Inadequate doctor-patient communication can easily affect the quality of medical care and patient outcomes in a negative manner, as well as diminish the quality of the doctor's occupational experience. For this reason I conclude that medicine's natural scientific intellectual self-image is not appropriate for the task of providing medical care to individual patients. Two additional reasons support this conclusion, namely the misidentification of clinical medicine as a natural science and the inappropriateness of a scientific conception of truth for the context of doctor-patient interactions. The implications of these conclusions are that the intellectual self-image and world-view of modern medicine should change to better agree with the nature of clinical practice and to make room for the psychological and social dimensions of the patient's life within health care. The medical profession should also revise its conception of science to a theory that acknowledges that interpretive reasoning and knowledge without guaranteed certainty are legitimate elements of science. I advocate for consciousness among the medical profession of the reality of medical discourse and its effects on doctors, patients and on their interaction with one another.
AFRIKAANSE OPSOMMING: Kommunikasie tussen dokters en pasiënte in kliniese omgewings is daarvoor berug om moeilik te wees. Hierdie probleem het 'n magdom empiriese navorsing vanuit 'n verskeidenheid van akademiese velde omtrent dokter-pasiënt kommunikasie geïnspireer. Baie min aandag word egter gewy aan die rol van moderne geneeskunde se intellektuele selfbeeld as 'n natuurwetenskap in interaksies in kliniese mediese omgewings. Die doel van die huidige studie was om die invloed van die mediese professie se intellektuele selfbeeld op kommunikasie tussen dokters en pasiënte filosofies te ondersoek. Jürgen Habermas se werk oor Universele Pragmatiek (Universal Pragmatics) is gebruik om kommentaar te lewer oor dokter-pasiënt kommunikasie soos wat dit beskryf word in die empiriese navorsingsliteratuur. Michel Foucault se werk oor diskoers en mag is gebruik om mediese diskoers en die aard van mag in dokter-pasiënt verhoudings te ontleed en te beskryf. Hierdie filosofiese ontleding gee aanleiding tot die gevolgtrekking dat moderne geneeskunde se intellektuele selfbeeld 'n deurdringende en negatiewe invloed op kommunikasie tussen dokters en pasiënte gedurende kliniese konsultasies het. Die rede hiervoor is dat geneeskunde se positivistiese wêreldbeskouing lei tot 'n byna uitsluitlike fokus op die fisiese aspekte van siekte in kliniese geneeskunde. Die pasiënt se verstand en gees (mind) en sy/haar sosiale wêreld is nie van groot belang vanuit die natuurwetenskaplike perspektief nie. Persone in die mediese beroep mag hul kliniese taak dus maklik as bloot die fisiese behandeling van fisiese afwykings beskou. Dit is baie waarskynlik dat hulle vele kommunikatiewe aktiwiteite as onverwant tot hul kliniese taak beoordeel. Ontoereikende dokter-pasiënt kommunikasie kan die kwaliteit van mediese sorg en pasiënte se gesondheidsuitkomste maklik negatief beïnvloed, en ook die kwaliteit van die dokter se ervaring van sy/haar beroep verlaag. Om hierdie rede maak ek die gevolgtrekking dat geneeskunde se natuurwetenskaplike intellektuele selfbeeld nie toepaslik is vir die opdrag om mediese sorg aan individuele pasiënte te lewer nie. Twee verdere redes ondersteun hierdie gevolgtrekking, naamlik die verkeerdelike identifikasie van kliniese geneeskunde as 'n natuurwetenskap en die onvanpastheid van 'n wetenskaplike konsepsie van waarheid vir die konteks van dokter-pasiënt interaksies. Die implikasies van hierdie gevolgtrekkings is dat die intellektuele selfbeeld en wêreldbeskouing van moderne geneeskunde moet verander om beter ooreen te stem met die aard van die kliniese praktyk en om ruimte te maak vir die sielkundige en sosiale dimensies van die pasiënt se lewe in gesondheidsorg. Die mediese professie moet ook haar konsepsie van die wetenskap hersien na 'n teorie wat erken dat interpreterende redenasie en kennis sonder gewaarborgde sekerheid, geregverdigde elemente van die wetenskap is. Ek pleit vir bewustheid onder die mediese professie van die realiteit van mediese diskoers en die effek daarvan op dokters, pasiënte en op hul interaksie met mekaar.

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Bachelors
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Thesis (MPhil (General Linguistics))--University of Stellenbosch, 2011.
Bibliography
ENGLISH ABSTRACT: This thesis is interested in textual features of websites which cover the same kind of content, but represent different organisations and address different kinds of audiences. Specifically, it investigates how information on HIV/AIDS is multimodally represented on the webpages of two non-governmental organisations (NGOs) and two governmental organisations. First, the websites of the national Department of Health and of a provincial Department of Health (Western Province) are scrutinised. Second, the websites of the Treatment Action Campaign (TAC) and Avert, NGOs with a special interest in the prevention and treatment of HIV/AIDS in southern Africa, are investigated. The aim of the research is to consider aspects of layout, the use of multimodality, and the introduction of selected themes and concerns foregrounded in the selected websites. The focus of the thesis is on the transmission of information, particularly through the electronic media, by investigating multimodal elements (language, images, sound, colours) and the layouts of websites, in order to identify possible interpretations which the intended audiences may afford the various texts. The analysis of the sites relies theoretically on the metafunctions developed by Halliday (1985) in his systemic functional linguistic framework. It also refers to an extension of Halliday’s work developed to allow multimodal discourse analysis that considers aspects of visual design and placement, developed by Kress and van Leeuwen (1996, 1998) and Kress (2003, 2005). These approaches focus on text, multimodal elements, the placements thereof on a page as well as the coherence between design of layouts and communicative modes that intend to send a convincing and meaningful message. The thesis also refers to Critical Discourse Analysis in that it considers matters of language and power in internet based communication. It seems that the governmental sites are set up with an audience in mind who needs to be informed on policy matters, while the NGO sites are set up with a more vulnerable audience in mind. One kind of web-communication is likely to alienate the exact people who should be receiving state support and treatment in the face of HIV/AIDS. Another is aimed more at supporting activism against the perceived lethargy of the state. A third supports various charities that reach out to communities where HIV-infection rates are particularly high. The interpretation of multimodal pages requires knowledge of website design for educational purposes as well as information on usage of the internet to get sufficient information. Further, access of the intended audience to electronic communication needs to be considered as this will determine whether the seriousness of the illness and possible prevention or treatment, is well communicated, especially to those who have been identified as most vulnerable to new infection. The thesis finds that electronic communication cannot be the first step to circulating information related to HIV/AIDS. Non-governmental and governmental institutions are still dependent on other forms of media than websites, thus on the printed media, radio and television, and on campaigns or community based projects to communicate with particular audiences. Electronic communication is complex in that it works with various modes (visual, verbal, audial) and requires some technical sophistication from producers and receivers of texts. Theories of communication and discourse analytic methodologies can assist in our understanding of how the internet succeeds or fails in circulating critical health care information. However, to gain a reliable understanding of how the internet functions in transmitting HIV-information to all interest groups, received knowledge of other areas of scholarly interest in health care communication, such as multilingualism, sociology, anthropology, behavioural sciences, cognitive psychology or brain research elaborations, would eventually have to be considered as well.
AFRIKAANSE OPSOMMING: Hierdie tesis stel belang in tekstuele kenmerke van webwerwe wat dieselfde tipe inhoud weergee, maar verskillende organisasies verteenwoordig en verskillende tipes gehore aanspreek. Dit ondersoek spesifiek hoe inligting oor MIV/Vigs multimodaal op die webbladsye van twee nie-regeringsorganisasies (NRO’s) en twee regeringsorganisasies aangebied word. Die webwerwe van die Nasionale Departement van Gesondheid en die Provinsiale Departement van Gesondheid (Wes-Kaap) word eerstens noukeurig ondersoek. Tweedens word die webwerwe van die Treatment Action Campaign (TAC) en Avert, NRO’s met spesiale belang in die voorkoming en behandeling van MIV/Vigs in suidelike Afrika, ondersoek. Die doel van hierdie navorsing is om oor aspekte van uitleg, die gebruik van multimodaliteit en die invoering van spesifieke temas en sake wat op die geselekteerde webwerwe beklemtoon word, na te dink. Die tesis se fokus in op die oordrag van inligting, veral deur die elektroniese media, deur multimodale elemente (taal, beelde, klank, kleur) en die uitleg van webwerwe te ondersoek, om sodoende verskillende moontlike interpretasies wat die bestemde gehoor aan die verskeie tekste mag heg, te identifiseer. Die analise van die webwerwe steun teoreties op die metafunksies wat deur Halliday (1985) ontwikkel is in sy grammatikale raamwerk, Systemic Functional Grammar. Dit verwys ook na ’n uitbreiding op Halliday se werk, wat deur Kress en Van Leeuwen (1996, 2005, 1998) en Kress (2003) ontwikkel is om multimodale diskoersanalise toe te laat wat aspekte van visuele ontwerp en plasing oorweeg. Hierdie benaderings fokus op teks, multimodale elemente, die plasing daarvan op ‘n bladsy en die koherensie tussen die ontwerp, uitleg en kommunikatiewe modusse. Dit kyk na hoe hierdie elemente saamwerk om ’n oortuigende en betekenisvolle boodskap uit te stuur. Hierdie tesis verwys ook na aspekte van Kritiese Diskoersanalise wat betrekking het op kwessies van taal en mag in internetgebaseerde kommunikasie. Dit kom voor asof die regeringswebwerwe ontwerp is met ’n gehoor in gedagte wat oor beleidskwessies ingelig moet word, terwyl die NRO-webwerwe ontwerp is met ’n meer weerlose gehoor in gedagte. Lg. gehoor word ingelig oor die siekte en behandelingsmoontlikhede eerder as beleid. Een soort web-kommunikasie sal waarskynlik dié mense wat juis regeringsondersteuning teen MIV/Vigs behoort te ontvang, vervreem. ’n Ander soort is meer daarop gerig om aktivisme teen die staat se vermeende traagheid te ondersteun. ’n Derde soort kommunikasie ondersteun verskeie liefdadigheidsorganisasies wat uitreik na gemeenskappe waar MIV-infeksiekoerse besonder hoog is. Die interpretasie van multimodale webwerwe vereis kennis van webwerf-ontwerp vir opvoedkundige doeleindes asook inligting oor die gebruik van die internet om voldoende inligting te bekom. Verder moet die bestemde gehoor se toegang tot elektroniese kommunikasie in ag geneem word, aangesien dít sal bepaal of die erns van die siekte en moontlike voorkoming of behandeling, goed weergegee word, veral aan dié wat s besonder blootgestel is en dus hoë risiko loop vir nuwe infeksie. Die tesis bevind dat elektroniese kommunikasie nie die eerste stap kan wees in die proses om inligting oor MIV/Vigs te sirkuleer nie. Nie-regerings- en regeringsorganisasies is steeds afhanklik van ander media as webwerwe, soos drukmedia, radio, televisie en veldtogte of gemeenskapsgebaseerde projekte, om met bepaalde gehore te kommunikeer. Elektroniese kommunikasie is kompleks omdat dit met verskeie modusse (visueel, verbaal, oudio) werk en tegniese sofistikasie van vervaardigers en ontvangers van tekste vereis. Teorieë van kommunikasie en diskoersanalise-metodologieë kan ons insig in hoe die internet daarin slaag (of nie) om belangrike gesondheidsorginligting te versprei. Om egter ’n betroubare begrip vir die werking van die internet as verspreider van MIV-inligting aan alle belange-groepe te verkry, moet kennis van ander areas van belangstelling in gesondheidsorg-kommunikasie, soos veeltaligheid, sosiologie, antropologie, gedragswetenskappe, kognitiewe psigologie of brein-navorsing, ook uiteindelik oorweeg word.

Thesis (MNutr)--Stellenbosch University, 2013.
ENGLISH ABSTRACT: Objectives: The objectives of this study were to determine the nutritional content/ contribution of intravenous (IV) fluid and electrolyte administration on the total feeding prescription of intensive care unit (ICU) patients. Methods: Retrospective review of ICU charts of consecutive patients (>18 years) with APACHE II scores ≥10 and on ≥72 hours nutrition therapy (NT) admitted to a medical/surgical ICU. Total fluid, electrolyte, energy and macronutrient intake from nutritional and non-nutritional sources were reviewed from ICU admission until discharge, discontinuation of NT or death for ≤7 days. Energy and protein delivery were compared to calculated targets of 25.4 – 28.6kCal/kg and 1.3 – 1.5g/kg respectively. Summary statistics, correlation coefficients and appropriate analysis of variance were used to describe and analyse the data. Results: A total of 71 patients (49% male), average age 49.2 ± 17.1, average APACHE II score 21.0 ± 6.1, 68% medical and 32% surgical, were included. Fluid and nutrient intake were reviewed over a mean of 5.7 ± 1.1 days. Mean daily fluid delivery was 3.2 ± 0.6L. IV fluid therapy (IVFT) contributed 32.0 ± 12.0% to total fluid delivery (TFD), whereas IV drug administration, including fluids used for reconstitution and dilution purposes, contributed 20.7 ± 8.1% to TFD. Balanced electrolyte solutions (BES) were the crystalloid of choice, prescribed in 91.5% of patients with a mean daily volume (MDV) of 0.5 ± 0.4L. Hypertonic low molecular weight (LMW) 130/0.4kD hydroxyethyl starch (HES) was the colloid of choice, prescribed in 78.9% of patients with a MDV of 0.2 ± 0.1L. Potassium salts were the most frequently prescribed IV electrolyte supplement (IVES), prescribed in 91% of patients (±20 – 60mmol per administration). NT was initiated within 14.5 ± 14.1 hours. The majority (80%) received enteral nutrition (EN). The mean daily energy delivered was 1613 ± 380kCal (25.1kCal/kg), meeting 93.6 ± 17.7% of mean target range (MTR). Mean daily protein delivery (PD) was 72 ± 22g (1.1g/kg), meeting 82.8 ± 19.9% of MTR. Non-nutritional energy sources (NNES), mostly derived from carbohydrate-containing IV fluids, contributed 10.1 ± 7.5% to total energy delivered (156kCal/d). Mean cumulative energy and protein balance was -674.0 ± 1866.1kCal and -86.0 ± 106.9g respectively. The majority (73%) received >90% of the minimum energy target but only 49% >90% of minimum protein target; 59% of those with energy intake 90-110% of target had adequate protein intake. A significant negative correlation was found between cumulative energy/protein balance and the time to initiation of NT (energy: r=-0.28, p=0.02; protein: r=-0.32, p=0.01). Conclusion: In this ICU BES are the crystalloid of choice and hypertonic LMW 130/0.4kD HES the colloid of choice for IVFT. Potassium salts are the most frequently prescribed IVES. NNES added significantly to energy delivery and should be included in the calculation of feeding prescriptions to avoid the harmful effects of overfeeding. Early initiation of EN with conventional products which are energy rich is insufficient to achieve adequate PD. EN formulae with a more favorable nitrogen to non-protein energy ratio could help to optimise PD during the first week of ICU care.
AFRIKAANSE OPSOMMING: Doelwitte: Die doelwit van hierdie studie was om die voedingswaarde/ bydrae van intraveneuse (IV) vog en elektroliet toediening tot die totale voedings voorskrif van pasiënte in ‘n intensiewe sorg eenheid (ISE) te bepaal. Metodes: Retrospektiewe bestudering van die ISE kaarte van agtereenvolgende pasiënte (>18 jaar) opgeneem in ‘n mediese/chirurgie ISE en met APACHE II tellings ≥10 en ≥72 ure voedingsterapie (VT). Totale vog, elektroliet, energie en makronutriënt inname vanaf voedingsverwante en nie-voedingsverwante bronne is vanaf ISE opname tot en met ontslag, staking van VT of sterfte, vir ≤7 dae hersien. Energie en proteiën inname is vergelyk met berekende doelwitte van 25.4 – 28.6kKal/kg en 1.3 – 1.5g/kg onderskeidelik. Beskrywende statisitiek, korrelasie koeffisiënte en toepaslike analises van variansie is gebruik vir data analise. Resultate: 71 pasiënte (49% mans), gemiddelde ouderdom 49.2 ± 17.1, gemiddelde APACHE II telling 21.0 ± 6.1, 68% medies en 32% chirurgie, is ingesluit. Vog en voedingstof inname is hersien oor ‘n gemiddelde tydperk van 5.7 ± 1.1 dae. Gemiddelde vog inname was 3.2 ± 0.6L/dag. IV vog terapie (IVVT) het 32.0 ± 12.0% bygedra tot totale vog inname (TVI). IV medikasie toediening, insluitende die herkonstruksie en verwatering van medikasie, het 20.7 ± 8.1% bygedra tot TVI. Die mees voorgeskrewe kristalloiëd en kolloiëd vir IVVT was gebalanseerde elektroliet oplossings (GEO), voorgeskryf in 91.5% van pasiënte (gemiddeld 0.5 ± 0.4L/dag), en hipertoniese lae molekulêre gewig (LMG) 130/0.4kD hidroksie-etiel stysel (HES), voorgeskryf in 78.9% van pasiënte (gemiddeld 0.2 ± 0.1L/dag), onderskeidelik. Die mees voorgeskrewe IV elektroliet supplement was kalium soute, voorgeskryf in 91% van pasiënte (±20 – 60 mmol per toediening). VT is binne 14.5 ± 14.1 ure geinisieër. Die meerderheid (80%) het enterale voeding (EV) ontvang. Die gemiddelde daaglikse energie inname van 1613 ± 380kCal (25.1kKal/kg) het 93.6 ± 17.7% van die gemiddelde doelwit rykwydte (GDR) bereik. Die gemiddelde daaglikse proteiën inname van 72 ± 22g (1.1g/kg) het 82.8 ± 19.9% van die GDR bereik. Nie voedings-verwante energie bronne (NVEB), meestal vanaf koolhidraat-bevattende IV vloeistowwe, het 10.1 ± 7.5% tot totale energie inname (TEI) bygedra (156kKal/d). Die gemiddelde kumulatiewe energie en proteiën balans was -674.0 ± 1866.1kKal en -86.0 ± 106.9g onderskeidelik. Die meerderheid (73%) het >90% van die minimum energie doelwit (ED) bereik. Slegs 49% het >90% van die minimum proteiën doelwit (PD) bereik. Opsomming: Die kristalloiëd en kolloiëd van keuse vir IVT is GEO en hipertoniese LMG 130/0.4kD HES onderskeidelik. Kalium soute word mees algemeen voorgeskryf. NVEB dra beduidend by tot TEI en moet inaggeneem word tydens die berekening van voedingsvoorskrifte ten einde oorvoeding te voorkom. Vroeë inisiëring van EV met konvensionele energie-ryke EV produkte is onvoldoende om genoegsame proteiën inname te verseker. EV produkte met ‘n gunstiger stikstof tot nie-proteiën energie verhouding sal help om proteiën inname gedurende die eerste week van intensiewe sorg te optimaliseer.Slegs 59% van pasiënte met genoegsame energie inname (90-110% van ED) het hul minimum PD bereik. Daar was ‘n beduidende negatiewe korrelasie tussen kumulatiewe energie/proteiën balans en die tyd tot inisiëring van VT (energie: r=-0.28, p=0.02; proteiën: r=-0.32, p= 0.01).

Les transfusions de plasma sont un traitement fréquent en réanimation, pour traiter ou prévenir un saignement. Or, des données observationnelles suggèrent que les transfusions de plasma sont associées à une augmentation de la morbidité et de la mortalité, sauf chez les patients qui souffrent d’hémorragie massive. Des données adultes suggèrent que les transfusions de plasma n’ont que peu d’effet sur les tests de coagulations.L’objectif de ce travail de thèse de sciences est d’effectuer quatre études préliminaires qui permettront ensuite de définir le protocole d’une étude randomisée contrôlée.La première étude présentée dans notre mémoire de thèse, une étude observationnelle dans 101 réanimations pédiatriques, a conclu que le plasma est souvent transfusé à des enfants qui ne saignent pas, et que, chez la grande majorité des patients, les transfusions de plasma n’ont que très peu d’effet sur les tests de coagulation. La deuxième étude a montré que les divers types de plasma actuellement sur le marché ont peut-être des effets différents, en terme de mortalité. La troisième étude a montré que les facteurs influençant la prescription de transfusions de plasma sont souvent des croyances non-fondées sur la capacité des transfusions de plasma à prévenir et arrêter le saignement. Et la quatrième étude a démontré que la mesure de la sévérité de la maladie, selon un score de défaillance multiviscérale, était adéquate dans une sous-population d’enfants recevant des transfusions de plasma. Ces quatre études nous ont donc permis d’esquisser le protocole de l’étude randomisée, qui permettra de comparer deux stratégies de transfusions de plasma
Plasma transfusions are frequently used to treat or prevent bleeding in critically ill children. However, little is known about the proper indications. Observational data both in children and adults indicate that plasma transfusions are associated with increased morbidity and mortality, except in massively bleeding patients. Adult data suggest that plasma transfusions have little effect on coagulation tests and that a large proportion of plasma transfusions are not given according to the international recommendations.The objective of this thesis is to perform four preliminary studies that will allow designing the protocol of a randomized controlled trial. This trial will evaluate the cost-benefit relationship of plasma transfusion strategies in critically ill children.The first study in this thesis, an observational study in 101 centers, concluded that plasma was often transfused to non-bleeding children and that plasma transfusions had little effect on coagulation tests. The second study showed that the different types of plasma products had different clinical effects, in terms of morbidity and mortality. The third study showed that unfounded beliefs on plasma’s ability to prevent or stop bleeding influenced the prescription of plasma transfusions. The fourth study showed that measuring the severity of the disease with a multiple-organ dysfunction score was appropriate in a sub-population of critically ill children requiring plasma transfusion.These four studies allowed designing the protocol for the randomized controlled trial, comparing plasma transfusion strategies

Atrial fibrillation (AF), the most common cardiac arrhythmia in persons over age 65, is associated with an increased stroke risk necessitating the need for long-term oral anticoagulation for risk reduction. With the introduction of direct thrombin and factor Xa inhibitors in the US since 2010, these novel oral anticoagulants (NOACs) are increasingly being prescribed, replacing the use of warfarin, a vitamin K antagonist. AF catheter ablation (CA), an elective procedure requiring femoral vascular access is a treatment for drug refractory and persistent AF. Bedrest, limb immobilization, and limited head of bed elevation are nursing measures utilized following femoral venous, and sometimes arterial, sheath removal and hemostasis. Limited research is available on the appropriate duration of bedrest to minimize bleeding complications associated with AF ablation in patients who use NOACs. The purpose of this quality improvement project was to compare and evaluate the effect of bedrest duration on post-procedure bleeding outcomes, urinary complaints, and back pain among patients taking NOACs while undergoing AFCA. Thirty patients undergoing elective AFCA on NOACs were orally consented to participate in the study and placed on shortened (8 hours) or prolonged (>8 hours) bedrest following vascular hemostasis. Outcome measurements included bleeding after ambulation, back pain, and urinary complaints. Fifteen patients (50%) were on shortened bedrest and 15 (50%) were on prolonged bedrest. No statistically significant difference in bleeding, urinary complaints, or back pain were found. Since there is no clear advantage to prolonged bedrest for patients on NOACS after an AFCA procedure, clinicians should consider this when deciding on bedrest duration for their patients.

Thesis (M.A.)--Northern Kentucky University, 2009.
Made available through ProQuest. Publication number: AAT 1465739. ProQuest document ID: 1827257541. Includes bibliographical references (p. 35-36)