Brain death in ICUs and associated nursing care challenges concerning patients and families.

In order to document the incidence and causes of brain death (BD) and the frequency of organ donation (OD) in a Swedish University Hospital, a retrospective review of deaths in a neurosurgical department and in the general intensive care units (ICUs), was carried out for the period 1988-1994. BD diagnosis was established in 197 (10.6%) of all deaths (n = 1843). The hospital records of all BD patients were examined in detail following a specific study plan. The majority of the BD patients (89%) were acute admissions to hospital, and among them 81 were transferred between hospitals often over a long distance. Among the BD patients the total number of OD was 65 (33%). The most common diagnosis leading to BD was spontaneous intracerebral bleeding and traumatic head injury. The BD diagnosis was established by neurological examination (60%) and by cerebral angiography (40%). Of the BD patients, 50% died within 48 hours in the ICU and the majority of requests for OD (67%) were made to the relatives of these patients. The findings are discussed with focus on the workload and psychological stress of ICU nurses when caring for BD patients and their families; a task which includes taking part in processes concerning BD diagnosis information and OD requests.

A comparison of the incidence of breast feeding two and four months after delivery in mothers discharged within 72 hours and after 72 hours post delivery.

OBJECTIVE: To compare breast feeding at two and four months after delivery in mothers discharged early (ED = before 72 hours post delivery) and late (LD = after 72 hours post delivery), and to explore the factors of greatest importance to the successful practice of breast feeding. DESIGN: Ex-post facto design. SETTING: In the country of Härryda, Sweden. PARTICIPANTS: All Swedish speaking women in the country of Härryda whose babies were born between 01.01.94 and 31.05.94 and who were registered at the Child Health Station (CHS) by the age of three months. One hundred and ninety women were invited to participate and 157 (83%) accepted. MEASUREMENTS AND FINDINGS: No significant difference was found in the breast feeding rates between the ED and LD group. However, ED mothers breast fed exclusively to a higher extent at two and at four months (exclusive breast feeding: at two months 89% and 86% respectively, and at four months 84% and 74% respectively, partial breast feeding: at two months 6% and 10% respectively, and at four months 5% and 12% respectively). If the woman considered that she had received encouragement and support while breast feeding for the first time, the probability of her breast feeding at two and at four months were about six times as great (Exp(B) 5.7594, df = 1, p = 0.0270; (Exp(B) 5.9781 df = 1, p = 0.0005 respectively). KEY CONCLUSIONS: The length of the hospital stay had no significant effect on the incidence of breast feeding at two and four months post delivery. The most predominant factors influencing breast feeding were seen to be the mother's first experience of breast feeding and the degree of support, help and encouragement she received. Less than half of the women received a visit from the CHS nurse after their return home from hospital. IMPLICATIONS FOR PRACTICE: The findings suggest that it is important that the midwife or nurse should prepare, support and encourage the mother when breast feeding for the first time. The midwife's or nurse's interventions are important for the incidence of breast feeding, at least during the first four months, and indirectly affect public health. This must also be taken into consideration when caring for mothers in the delivery ward and before discharge, i.e. that the breast feeding is working well, that the mother experiences it as working well, and also for planning follow-up after discharge.

Evaluating nurses' knowledge and patients energy intake after intervention.

The aims of this study were to describe and assess nutritionally at-risk patients' energy intake and nurses' knowledge and opinions of patients' need of energy during their hospital stay, before and after training and education. The effects of the intervention were evaluated by using a questionnaire, answered by the nurses before and after the intervention, and indirectly by measuring the patients' nutritional outcome, using a nutritional assessment form. A total of 230 matched patients and 171 nurses (86 before the intervention and 85 after) participated in the study. After the education, results indicated that a greater number of patients received increased levels of energy intake, an increased average intake of energy, and more dietary supplements. Nurses' knowledge about the content of energy in a standard portion of food had increased, and they found it easier to assess patients' need of energy. After the education, more nurses had the opinion that well-educated nurses in nutrition make it easier to motivate patients to reach a sufficient intake of energy.

Patients' experience of being critically ill or severely injured and cared for in an intensive care unit in relation to the ICU syndrome. Part I.

The intensive care unit (ICU) syndrome is regarded principally as a complex interaction of several contributory factors, all of which can be seen as partly responsible for the development of the syndrome. The purpose of this study was to describe and give a deeper insight into patients' experiences and memory recall, both during and after their stay in the ICU. Nineteen patients who had been respirator treated (ventilated), and had stayed at least 36 hours in the ICU, were interviewed about one week after discharge, and again 4-8 weeks after their discharge from the ICU. Patients' experiences are interpreted and related to previous views held concerning the syndrome, together with an awareness of other important and significant phenomena, i.e. a hermeneutic approach. This study partly confirms the findings of earlier studies concerning the ICU syndrome, but also reveals some new aspects, which have not previously been considered. The patients described themselves as experiencing some sort of state of chaos following the onset of their sickness, injury or accident, which resulted in feelings of extreme instability, vulnerability and fear, often experienced as prolonged inner tension. It was reported that even the most trivial events in circumstances or routines could trigger changes-either an increase or decrease-in patients' feelings of fear or inner tension. The caring relationship was perceived as providing an important degree of security and comfort. Nursing care actions can therefore be seen as vital factors in patients overcoming the accompanying horrific experiences to which they can be subjected. This state of chaotic feeling, and how it is combated and treated, appear to be one critical factor in the development and progression of the ICU syndrome.

The communication process with ventilator patients in the ICU as perceived by the nursing staff.

Intensive care unit (ICU) nurses (n = 27) were interviewed about their experiences and opinions of the communication process with ventilator treated patients. Nurses with limited ICU experience considered the initial contact with a new critically ill ventilated patient more frustrating than experienced nurses. The nurses thought that the content of the communication commonly requested by a patient was dominated by factors related to the clinical condition, prognosis and reassurance that the situation was under control. Factors considered to limit the communication and to create feelings of uncertainty and stress for nurses with an ICU experience of less than 5 years were: work overload, unstable condition of the patient, impaired communication with the patient, and their own personal problems or worries. For nurses with an ICU experience of more than 5 years stress was more commonly evoked by the presence of worried and anxious spouses/relatives, and by the feeling that something was wrong with the patient but they were unable to identify the problem. Failure to understand a ventilated patient could induce feelings of incompetence, stress and sometimes even despair. The present small scale study shows that there are many factors, in addition to ICU experience, that may influence the ability of an ICU nurse to establish and maintain a well functioning communication with ventilated patients and the likelihood of doing so.

Patients' experiences of postoperative respirator treatment--influence of anaesthetic and pain treatment regimens.

The influences of premedication, anaesthetic agents, and postoperative sedation and pain treatment regimens on the experiences of postoperative respirator treatment of surgical patients (n = 107) have been assessed. Of the patients, 55% recalled the respirator treatment. Administration of anticholinergic drugs and halogenated anaesthetic agents was found to impair the memory process and reduce the number of recallers, and sedation in the ICU with benzodiazepines was found to decrease the number of discomforts experienced by the recalling patients. Most of the patients who received treatment postoperatively for pain, mainly by epidural administration of local anaesthetic agents and/or morphine, recalled the respirator treatment period (85%), as compared to only 50% of the patients receiving intravenous opioids. The number and type of complaints experienced by patients receiving epidural pain treatment did not, however, differ from those reported by intravenously treated patients, and no significant adverse psychological reactions seemed to occur. It is concluded that the use of mainly regional techniques, when appropriate, for pain treatment of surgical patients needing postoperative ventilatory support seems advantageous. The primary aim of relieving pain from the wound area is achieved, allowing such light intravenous sedation and pain treatment that the possibility of communication and giving comforting reassurance is maintained. Such nursing care may be more efficient in helping the patient to cope with the stressful respirator treatment situation then heavy intravenous sedation and pain treatment regimens.

Assessment of patients' experience of discomforts during respirator therapy.

Patients (n = 158) who had been respirator-treated and who could remember the treatment were retrospectively (after greater than 2 months) interviewed about their experiences. Of all patients, 47% had felt anxiety and/or fear during the treatment. These feelings were intimately related to the experience of agony/panic (p less than .001) and insecurity (p less than .001). Inability to talk and communicate was found to be the dominating reason (p less than .001) for evoking such feelings and also made it difficult for the patients to sleep and rest (p less than .05); no correlation to pain was found. Difficulties to synchronize with the respirator in connection with suctioning also caused feelings of anxiety/fear (p less than .01), agony/panic (p less than .01), and insecurity (p less than .001). Even as long as 4 yr after respirator treatment, most patients (90%) who remember the treatment still recall the situation as unpleasant and stress-evoking. The isolation due to communication difficulties was a greater problem than direct airway-related nursing care activities. This relationship between communication difficulties and severe emotional reactions should be considered in the nursing care of respirator-treated patients.

Patient experiences during respirator treatment--reason for intermittent positive-pressure ventilation treatment and patient awareness in the intensive care unit.

Patient awareness of intermittent positive-pressure ventilation (IPPV) treatment in the ICU was studied in 304 patients. These ICU patients were divided into three groups: those treated for internal medical diseases (IMD; n = 129), patients admitted after major surgical procedures (MSP; n = 126), and patients treated for trauma (T; n = 49). All patients were interviewed 2 months to 4 yr after IPPV treatment. The IPPV period was recalled by 52% of all patients. The awareness of the treatment was similar in the IMD (51%) and MSP (59%) groups, but was significantly lower in the T group (37%; p less than .01). The ability to recall the IPPV treatment was reduced in patients with head injuries, those unconscious on admittance, and in elderly individuals. Treatment awareness was found to increase with the duration of the IPPV period in the IMD and T groups. Preoperative information of the treatment, given to elective surgical patients in the MSP group, did not increase treatment awareness.