Nursing Advocacy: A concept clarification in context of procedural pain care

The purpose of this study was to clarify the concept of advocacy in context of procedural pain care and to investigate the implementation of advocacy in that context. First, the concept of advocacy was described on the basis of a literature review (n = 89 empirical studies from 1990 to 2003). Then, the concept was described in the context of procedural pain care on the basis of interview data (n = 22 patients, 21 nurses) in a medical and surgical context. In the second phase, an instrument exploring the content of advocacy and the implementation of advocacy in context of procedural pain care was developed and validated. Then, the content of advocacy and implementation of it was explored in a sample of otolaryngeal patients (n = 405) and nurses (n = 118) in 12 hospitals. In the third phase, an update literature review (n = 35 empirical studies from 2003 to 2007) was conducted, and all data from phases one and two were reviewed in order to refine the elements the concept of advocacy, and the relationships between these elements. As a result of this study, advocacy in context of procedural pain care was defined as consisting of the dual aspects of patient advocacy and professional advocacy, and called nursing advocacy. It was divided into dimensions and subdimensions in which patient and nurse empowerment seems to play a vital role. All the data obtained lend support to this definition of nursing advocacy. Patients and nurses felt that nearly all of the activities that they considered as advocacy were implemented.

A Comparative Study of the Effectiveness of a Prefabricated Appliance and a Stabilization Appliance in the Treatment of Myofascial pain and Headache

The aim of this thesis was to evaluate the short- and long-term effectiveness of a prefabricated occlusal appliance (R) on patients with myofascial pain and headache by comparing it with the treatment of the stabilization appliance (S). Another aim was to evaluate the effect of appliance treatment on stress-related salivary parameters like cortisol and IgA, as well as on flow rate values in these patients. Sixty-five patients diagnosed with myofascial temporomandibular disorder (TMD) pain, of whom 94% suffered concomitantly from headache, at two centres for Stomatognathic Physiology, one in Sweden and one in Finland, were included in this randomized controlled trial using Research Diagnostic Criteria for TMD (RDC/TMD), with history questionnaires and clinical examinations performed at baseline and at 6- and 10-weeks, and 6- and 12-month follow-ups. Patients were randomly assigned either to the R or the S group. Treatment outcome was measured according to IMMPACT (Initiative on Methods, Measurements, and Pain Assessment in Clinical Trials), i.e. four chronic pain outcome domains: pain intensity, overall improvement, physical and emotional functioning. Changes in frequency and intensity of headache were recorded. Thirty-nine patients participated in the saliva study. Salivary analyses were performed at 6 and 10 weeks. The results revealed no differences between groups at baseline. At all follow-ups, all four outcome measures, as well as frequency and intensity of headache, showed statistically significant within-group improvement compared to baseline, without significant differences between groups. No treatment-induced changes in saliva parameters could be registered. In conclusion, the effectiveness of the prefabricated appliance seemed to be similar to that of the stabilization appliance in alleviating myofascial pain, and frequency and intensity of headache, in the short as well as the long term. However, no changes in salivary parameters were observed during treatment.

Pharmacokinetics of Oxycodone and Paracetamol in the Elderly. Clinical Pharmacokinetic Study on Orthopaedic Surgical Patients and Healthy Volunteers

The proportion of elderly people over 65 years of age in Finland is expected to grow to over 25% by the 2025. It has been estimated that elderly people today consume nearly 40% of all drugs. Age brings about number of physiological changes that may affect the disposition, metabolism and excretion of drugs. The function of heart, lungs, liver and kidneys decreases even in healthy people, as they get older. The proportion of total body water decreases and the relative fat percentage increases. Also several other factors such as concurrent diseases, concomitant medication and nutritional factors have an effect on drug therapy in elderly. Age increases the risk of adverse drug reactions, which most often are dose-dependent. Despite all this there are not enough studies involving the elderly people and the elderly are most often excluded from clinical trials. Oxycodone is a strong opioid analgesic, which is used to treat moderate or severe pain. Paracetamol is a widely used nonopioid analgesic, which has become popular in the treatment of pain in many patient groups. In this series of studies the pharmacokinetics of oral and intravenous oxicodone as well as intravenous paracetamol in the elderly and young adult patients were investigated. Also a study investigating the interaction of oral antibiotic clarityhromycin, a known cytochrome P450 (CYP) 3A4 inhibitor, with oxycodone pharmacokinetics and pharmacodynamics in elderly and young healthy volunteers was carried out. The pharmacokinetics of oxycodone showed a clear age depency. Patients over 70 years had 50-80% higher mean exposure to oral oxycodone and a twofold greater plasma concentration than young adults 12 h after ingestion of the drug. Elderly patients had 40-80% greater exposure to intravenous oxycodone and patients over 80 years had over twofold greater plasma concentrations 8 h post dose than the young adults. The elderly patients had also greater exposure to intra venous paracetamol compared to young adults. Clarithromycin increased the exposure to oral oxycodone in both young and elderly volunteers. The elderly had marked interindividual variation in the pharmacokinetics and pharmacodynamics when clarithromycin was given concomitantly with oxycodone. Because the pharmacokinetics of oxycodone and intravenous paracetamol depend on the age of the subject, it is important to titrate the analgesic dose individually in the elderly.

Postoperative Bowel Function and Related Factors in Enhanced Recovery Protocol with Patients Undergoing Hepatectomy

Patients’ bowel dysfunction is a major factor that weakens the results of surgical care as it can cause pain and weaken patients’ rehabilitation. Bowel dysfunction is a common postoperative problem, yet most incidents remain undocumented. The nursing profession has a significant role in enhancing the bowel function postoperatively. However, studies of postoperative bowel function after hepatectomy are scarce and somewhat incongruous. Enhanced recovery protocols are innovative models of care aiming for better outcomes of surgical care. Enhanced recovery protocols can improve gastrointestinal function after surgery, yet patients are also known to be satisfied with their care. The aim was to investigate if postoperative bowel function day varies between patients in terms of age, gender, ASA score, type of surgery, histology, patients’ experienced pain and experienced satisfaction three days after discharge and three months after operation in patients undergoing hepatectomy. The goal was to produce information for basis of scientific research, to give nurses in clinical setting more tools to work with hepatectomy patients undergoing enhanced recovery protocol and to produce information to nurse managers to use in process management of patients undergoing enhanced recovery protocol. The design of this study is descriptive. Data was collected retrospectively from hepatectomy patients (n = 134) undergoing enhanced recovery protocol within the first year of enhanced recovery protocol implementation. The data was based on registers and analyzed statistically. Mean age of patients was 62 years and mean day of discharge was 4. Main (n = 72) histology of the patients was colorectal liver metastases. Mean bowel function day was 3. Most of the patients were very satisfied or satisfied with the care three days after discharge (99%) and three months (90%) after operation. Most of the patients (72%) experienced moderate pain three days after discharge, but three months after operation 47% of the patients did not experience pain and 48% experienced moderate pain. There were no statistically significant differences in bowel function between different age groups, genders, ASA score groups or histologies. Neither were there statistically significant differences in postoperative bowel function in terms of experienced satisfaction or pain. There were statistically significant differences in postoperative bowel function between different types of surgery (p < 0.01). Nurses should take into consideration hepatectomy patients’ type of surgery and pay special attention in supporting major open hepatectomy patients’ postoperative bowel function. Nurses should educate patients undergoing major open hepatectomy about prolonged postoperative bowel function.