Coronary heart disease is a major physical illness and one of the main causes of death in Western society People who do not die an early and sudden death may have to consider a major surgical treatment, the most prevalent being coronary artery bypass graft surgery (CABG). More than 350,000 such operations are performed annually in the United States alone. This operation prolongs the life of patients in cases of triple-vessel disease It also improves patients’ quality of life), thus providing them with the opportunity for successful rehabilitation (Ben-Zur, 2000).
The postoperative complications of CABG include the following: high anxiety or depression, central nervous system damage (CNS), and atrial fibrillation. In this paper, we will discuss the postoperative complications of CABG and how they impact nursing practice. . During the first several weeks after CABG surgery, states of high anxiety or depression are usually observed (see, for example, Pick, Molloy, Hinds, Pearce, & Salmon, 1994; Trzcieniecka-Green & Steptoe, 1994).
In long-term research (that is, approximately one year after the operation), the results present a more positive trend in terms of elevation in positive moods (King, Porter, Norsen, & Reis, 1992; King, Reis, Porter, & Norsen, 1993), as well as an increase in quality of life (Kulik & Mahler, 1993). Such outcomes can be accounted for by illness severity factors. In addition, in recent years, the individual’s personality and coping characteristics have been investigated as important determinants of post-CABG patients’ emotional reactions and rehabilitation (Ben-Zur et al.
, 2000). Research studies indicate that depression is prevalent in approximately 20% of CAD patients, and has a significant effect on post-surgery morbidity and mortality. (Remedio, 2003). One major type of morbidity following CABG is central nervous system (CNS) dysfunction (. Barbut D, Hinton et al. 1985)]. Of all the adverse neurological outcomes that may be incurred postoperatively, stroke is one of the most serious.
However, due to technological and surgical improvements the incidence of stroke is now reported to be as low as between 0. 8 and 5. 8% [McCann GM, et al. 1997) Duke University Medical Center study published in 2001 indicated that fully half of people undergoing bypass surgery developed memory or thinking problems in the days following it, and that these problems were usually still evident five years later. (Bypass surgery and memory, 2005) Consequently, the rate of post-CABG stroke is no longer a sufficient index of CNS dysfunction.
Neuropsychological research suggests, however, that a considerable proportion of all patients who undergo CABG sustain some degree of cerebral damage and that this manifests as mild cognitive impairment. Although these cognitive deficits rarely disturb activities of daily living, they are still considered cause for concern. Therefore, it is these less severe forms of neurological injury, which are now targeted for reduction in what has been described as an age of quality improvement (Stump D. A. 1995; Stump D. A. , Rogers A. T. , and Hammon , J. W. 1996;].
Cognitive impairment following coronary artery bypass grafting, Neuropsychological tests are valuable tools in the assessment of brain dysfunction as they provide a method of systematically and quantitatively studying the behavioral expressions of this dysfunction (Lezak, 1995) .As there is now only a low risk of stroke following CABG, milder forms of cerebral damage have become a greater focus of concern. Consequently, neuropsychological assessment has become more important within the domain of cardiac surgery. The advantage of neuropsychological tests is that they are capable of detecting subtle changes in cognitive function.
In comparison, conventional neurological assessment techniques, such as the Mini-Mental State Examination, are less sensitive and therefore less able to detect subtle CNS changes In addition, neurological assessment techniques do not lend themselves as readily to quantitative analysis [Heyer E. J, et al. 1995) Cognitive decline has been observed by many researchers using batteries of neuropsychological tests, usually administered to patients before and after surgery. A patient’s pre- and postoperative scores are then compared. In this way, intersubject variability is minimized as the subjects act as their own controls.
While cognitive deficits have been consistently reported in the immediate postoperative period, some researchers have readministered test batteries in the immediate postoperative period, typically within 5–10 days of surgery (Aris A, et al, 1986; Clark et al. , 1995; . Newman MF, Croughwell ND, Blumenthal JA et al. 1994; Pugsley et al, 1994; Shaw PJ et al. 1986; Townes B. D. , Bashein G. , Hornbein T. F. et al. 1989; Symes et al, 2000).. Atrial fibrillation (AF), although t not life threatening, is one of the most common complications after CABG.
Hospital stays often are prolonged due to intermittent hemodynamic instability of thomboembolic complications. During AF, loss of synchronous atrial mechanical activity response, and inappropriately high heart rates may have adverse effects o n hemodynamic functions and cause hypotension and hear failure. Of all the complications associated with postoperative AF< the most serious are throboemboic complications, which cause permanent morbidity in many patients. Risk of postoperative stroke has been found to be significantly increased with postoperative atrial tacharrhymias.
Earlier studies shows that the incidence of AF can be as high as 50% in patients after the incidence of AF can be as high as 50% in patient after coronary artery bypass grafting (CABG), with a peak incidence on postoperative day 2 to 3. Atrial effective refractory periods (ERP) has been used a parameter to evaluate atrial repolarization and ERP and its dispersion are known parameters of atrial vulnerability that indicate enhanced atrial arrhythmogenesis, include a history spontaneous paroxysmal AF and easy inductility of atrial arrhthmias.
( Solyu et al). Pleural effusion occurs in up to 80% of patients during the first week after CABG. Most of these effusions are small, self-limiting and do not require interventions. However, chronic, persistent post-CABG effusions have been reported. The etiology of these persistent effusions remains unknown. ( Lee et al, 2001) Sleep disturbances is another big postoperative complication The purpose of a 1996 Schafer et al study was to describe the nature and frequency of sleep pattern disturbances in patients post coronary artery bypass (CABG) surgery.
An exploratory design using telephone interviews at one week, one month, three months and six months was used to describe the incidence and nature of sleep disturbances post CABG surgery. Forty-nine patients completed all four measurement times. More than half of the patients reported sleep disturbances at each measurement time. Sleep disturbances during the first month post CABG were reported to be the result of incisional pain, difficulty finding a comfortable position and nocturia. Although less frequent over time, these problems persisted for six months. . Miller et al (2004) discusses post CABG postoperative symptoms.
At 1 week post-CABG, symptoms were incisional pain, wound drainage, chest congestion, shortness of breath, dizziness, sweating, swollen feet, and loss of appetite; incisional pain and swollen feet were reported by a few patients at 6 weeks after CABG. The incidence and frequency of postoperative symptoms declined over time. There were several age-related differences in symptom reports prior to and at 1 and 6 weeks after the procedure (Miller et al, 2004. ). Nursing interventions A wide variety of interventions have been tested for recovery of CABG patients. These 19 studies tested 20 interventions.
Most of the interventions were educational in nature and dealt with preoperative or discharge instructions or counseling provided to patients. Preoperative interventions to affect in-hospital recovery included preparatory information about cognitive dysfunction following surgery, preparatory information and counseling about physical and psychologic recovery, and psychiatric counseling. Two of the studies[Rice VH, Mullin MH, Jarosz P.. 1992. ] compared the effectiveness of preadmission versus postadmission preparatory instructions, and one study [Barnason S, Zimmerman L, Nieveen J. 1995; Gortner SR, Gilliss CL, Shinn JA, Sparacino PA, et al.
1988); . compared the effects of music, relaxation, and structured rest on hospital recovery outcomes. One study tested the effect of in-hospital range-of-motion (ROM) exercises on arm ROM at discharge. Interventions for home recovery were delivered close to the time of discharge or within the first couple of weeks following discharge. Most of the studies involved tests of structured discharge preparatory information about home recovery using slide and tape programs,[ Gortner SR, Gilliss CL, Shinn JA, Sparacino PA, et al. 1988; Gilliss CL, Gortner SR, Hauck WW, Shinn JA, Sparacino PA, Tompkins C. 1993;.
] telephone follow-up and counseling,[ Gortner SR, Gilliss CL, Shinn JA, Sparacino PA, et al.. 1988;13:649-661. , Gilliss CL, Gortner SR, Hauck WW, Shinn JA, Sparacino PA, Tompkins C. 1993; Beckie T. 1989; Barnason S, Zimmerman L. 1995;] outpatient group teaching,[ Dracup; 1982. Dissertation. ,32] and homegoing audiotapes Interventions to promote risk factor modification behaviors included four studies[Dracup KA. 1982. ] that assessed the effect of structured versus unstructured teaching programs designed to increase knowledge of risk factors and enhance compliance with risk factor modification behaviors.
Another study tested an education program that included a behavioral component as well Various outcome variables have been used to evaluate CABG recovery. The most frequently used outcome was mood states; 10 of the 19 studies used mood states as an outcome measure. The most frequently used measurement point for hospital recovery outcomes was the first day following surgery and discharge. Home recovery outcomes were usually measured at 1, 3, and 6 months following discharge. Outcomes associated with risk factor modification most often were measured at 6 weeks and 3, 6, and 12 months following surgery.
What is the effectiveness of the interventions? Preparatory information was the intervention most frequently tested. In the two studies[Rice VH, Mullin MH, Jarosz P. 1992;, Anderson EA. 1987;] assessing its effectiveness to reduce analgesia use during hospital recovery, preoperative preparatory information was not found to be effective. Preoperative preparatory information was found to be effective in increasing patients’ comfort and control when experiencing postoperative delirium.
There was no support for the ability of preoperative preparatory information to reduce anxiety during in-hospital recovery] Discharge preparatory information also was found not to be effective in three of the four studies evaluating mood states during home recovery; this finding was noted even when individual counseling and telephone follow-up were added to the initial information provided Preadmission preparatory information about activity resumption during hospital recovery was found to be effective in one study (Cupples 1991. ] but not in another. [ Rice VH, Mullin MH, Jarosz P. 1992).
Activity resumption at home was found to be significantly increased by the provision of discharge preparatory information in two[Gilliss CL, Gortner SR, Hauck WW, Shinn JA, Sparacino PA, Tompkins C. 1993; Moore SM. 1996] 33 of three studies. Discharge preparatory information aimed at families was not found to be effective in improving family functioning (family cohesion and family communication) during the home recovery periodGiven the small number of studies addressing the effect of preparatory information on physiologic outcomes (blood pressure, heart rate, angina), no conclusions were made about its effectiveness on these variables.
Similarly, no conclusions were drawn about the effectiveness of ROM exercises, music, and visual imaging to enhance CABG recovery because of the small single studies testing each of these interventions. There was clear evidence that information interventions designed to increase individuals’ knowledge about managing recovery experiences during the first home recovery month and about coronary artery disease risk factor modification was effective; three of the four studies evaluating this intervention found significant effects.
Similarly, tests of the effectiveness of structured versus unstructured instruction indicated that structured information was more effective in increasing knowledge. Education to enhance compliance with medical regimens and risk factor modifications was found to be effective for some risk modification behaviors but not for others. It appears that information alone does not change behaviors. Allen’s[Allen. 1996;. ] study of an intervention to increase self-efficacy using both counseling and behavior modification techniques represented an important departure from previous interventions that were based solely on education and counseling.
Although Allen found a positive effect for only one of the risk modification behaviors studied (dietary intake), the addition of a behavioral component is an important change in cardiovascular health behavior modification interventions. Gender differences have been widely explored by nurses. Investigators have identified that gender can constitute a form a biculturalism (that is, women view surgery as a minor inconvenience, whereas men view it as a major life event). Postoperative symptoms vary, with males experiencing more fatigue, incisional chest pain, and atrial dysrythmias.
Conversely, women have more numbness and breast discomfort, heart failure, and functional impairment. The 2 areas wherein the most work has been done are pain and sleep. A number of descriptive studies have been done on patients’ self-report of pain, their satisfaction with treatment, and underuse of analgesics. Limited research on interventions to relieve pain has been reported. Despite these studies on pain outcomes, more exploratory work is required for pain associated with minimally invasive cardiac surgery, pain, and discomfort at discharge, and subsequently identification and trialing of interventions to provide pain relief.
The relationships between exercise behavior and functional status of men and women 5 to 6 years after CABG have not been examined in a representative patient sample. This study (Treat-Jacobson & Lindquist, 2004). compared the 5- to 6-year recovery in a cohort of 184 patients at the Minnesota site of the Post CABG Biobehavioral Study. Data were collected by telephone interview and self-administered questionnaires. Results showed that women had lower physical (p ? .004) and social (p = . 001) functioning scores; men were more likely to participate in regular exercise (p = .
01). Exercisers had higher functional status scores. ANCOVA demonstrated that differences in measures of functional status by exercise category were maintained even after controlling for age, sex, and symptom severity (p ? .01). In conclusion, individuals who exercised had more positive functional outcomes 5 to 6 years In general, nurse investigators have conducted sufficient studies within each of the generic outcome categories to allow for identification of cardiac surgery-specific outcomes that can be considered nurse sensitive.
Artinian (1993) demonstrated that in the early recovery phase, only 62% of women spouses felt they were prepared for discharge, with key concerns being the availability of social support, use of coping strategies, personal resources, and knowing what to expect. At 6 weeks after discharge, women’s concerns were most often regarding their husband’s self-care activities, uncertainty, and husband’s physical and mental symptoms. At 1 year after surgery, women reported less social support and greater role strain than they did at earlier time periods.
48 Other investigators have shown that positive psychosocial adjustment to illness is influenced both by the quality of the patient’s marriage and level of dysphoria. 49 Nursing interventions to improve family functioning have been reported by a number of investigators. Family members of ICU patients, who were recipients of care from nurses who attended educational sessions and who used checklists to assure provision of information and support, reported lower anxiety and higher satisfaction levels than did families not provided with this level of care.
50 Other reports of a controlled trial with a nurse-led psychoeducational intervention51 and follow-up phone calls33 demonstrated no differences in improving patients’ recovery or family functioning. Further research in this field should focus on determining if these findings persist across different demographic and economic groups Studies of functional status outcomes have focused on general activity and activities of daily living (ADLs). Specific findings have included that high levels of self-efficacy and decreased tension and anxiety at 4 weeks after surgery are predictive of greater activity at 8 weeks.
Women report greater disruption of ADLs at 1 than at 3 months, while disruption of their recreational activities is similar at both times. Need during home health visits include maximum assistance with meals and laundry but only partial assistance with bathing and dressing. One randomized controlled trial comparing usual care with supplemental hospital education and weekly telephone follow-up to improve self-efficacy demonstrated that patients in the experimental group developed higher expectations for walking, lifting, climbing stairs, and working than did patients in the control group.
(Whitman, 2004). Conclusion Coronary artery bypass graft (CABG) surgery is regularly performed in most major hospitals, reflecting the high prevalence of coronary artery disease in western countries. A number of studies have identified cohorts of patients undergoing CABG and other cardiac procedures who experience a higher than expected rate of mortality and morbidity. Increasing age, poor left ventricular function, urgent/emergency procedures, complex operations and reoperation procedures have all been identified as risk factors resulting in prolonged hospital stays and increased morbidity.
Subsequently, with current emphasis on both better clinical management and more cost-efficient practice, it is becoming increasingly beneficial to identify low-risk patients who can be safely ‘fast tracked’ to reduce postoperative management costs. The current, eclectic mix of topics studied reflects early resolution of specific issues. However, surgical procedures, recovery times, hospital length of stay, transitional care facility length of stay, use of home healthcare, and patient characteristics have changed dramatically during the last decade, suggesting that new functional outcome recovery trajectories evolved.
These new patterns for functional recovery and interventions merit new inquiry and reporting. The nursing studies have been well designed and have allowed the investigators to move, in many categories, through logical iterations of discovery (this is, from exploratory and descriptive work to predictive and correlational work and, finally, into interventional work). Future work in all categories needs to focus on moving through these stages and enhancing the current directions being taken so that patients achieve positive, optimal outcomes.
Such information can be used to plan the care of patients undergoing CABG, to prepare them for normal recovery, and to determine the need for symptom management by health care providers References Allen J. A. . (2000) Coronary risk factor modification in women after coronary artery bypass surgery. Nurs Res;45:260-265. Aris, A, et al.. Arterial line filtration during cardiopulmonary bypass. Journal of Thoracic and Cardiovascular Surgery1986; 91:526–533. Artinian N. (1993) Spouses’ perception of readiness for discharge after cardiac surgery. Appl Nurs Res. ;6(2):80-88 Barbarowicz P, Nelson M, DeBusk RF, Haskell WL.
A comparison of in-hospital education approaches for coronary bypass patients. Heart Lung. 1980;9:127-133. Barbut D. , Hinton R. B. , Szatrowski T. P. et al. Cerebral emboli detected during bypass surgery are associated with clamp removal. Stroke 1994; 25:2398–2402. Barnason S, Zimmerman L. (2000) A comparison of patient teaching outcomes among postoperative coronary artery bypass graft (CABG) patients. Prog Cardiovasc Nurs. ;10:11-20. Barnason S. , Zimmerman L. , Nieveen J.. Psychosocial aspects of cardiac care: The effects of music interventions on anxiety in the patient after coronary artery bypass grafting.
Heart Lung 1995;24:124-132. Beckie T. A supportive-educative telephone program: Impact on knowledge and anxiety after coronary artery bypass graft surgery. Heart Lung. 1989;18:46-55. Ben-Zur, Hasida, Rappaport, Batya, Ammar, Ronny, Uretzky, Gideon. Life Style Changes, And Pessimism After Open-Heart Surgery Health & Social Work, 03607283, Aug2000, Vol. 25, Issue 3 Bypass surgery and memory. (cover story) Harvard Heart Letter, Aug2005, Vol. 15 Issue 12, p1-2 Clark R E. et al. (1995).. Microemboli during coronary artery bypass grafting. Journal of Thoracic and Cardiovascular Surgery; 109:249–258.
Cupples S. A. Effects of timing and reinforcement of preoperative education on knowledge and recovery of patients having coronary artery bypass graft surgery. Heart Lung. 1991;20:654-660. Dracup K. A.. The Effect of a Role Supplementation Program for Cardiac Patients and Spouses on Mastery of the At-Risk Role. Ann Arbor, Ml: University Microfilms International; 1982. Dissertation. Gilliss CL, Gortner SR, Hauck WW, Shinn JA, Sparacino PA, Tompkins C. A randomized clinical trial of nursing care for recovery from cardiac surgery. Heart Lung. 1993;22:125-133.
Gortner SR, Gilliss CL, Shinn JA, Sparacino PA, et al (2000). Improving recovery following cardiac surgery: A randomized clinical trial. J Adv Nurs. 13:649-661. Heyer E. J. , Delphin E. , Adams D. C . et al. Cerebral dysfunction after cardiac operations in elderly patients. Annals ofThoracic Surgery 1995; 60:1716–1722. King, K. B. , Porter, L. A. , Norsen, L. H. , & Reis, H. T. (1992). Patient perceptions of quality of life after coronary artery surgery: Was it worth it? Research in Nursing and Health, 15, 327-334. King, K. B. , Reis, H. T. , Porter, L. A. , & Norsen, L.
H. (1993). Social support and long-term recovery from coronary artery surgery: Effects on patients and spouses. Health Psychology, 12, 56-63. Kulik, J. A. , & Mahler, H. I. M. (1993). Emotional support as a moderator of adjustment and compliance after coronary artery bypass surgery: A longitudinal study. Journal of Behavioral Medicine, 16, 45-63. Lee, Y. C. et al. (2001). Symptomatic Persistent Post-Coronary Artery Bypass Graft Pleural Effusions Requiring Operative Treatment. CHEST, Vol. 119 Issue 3, p795-801. Lezak M. D. Neuropsychological Assessment. 3rd edn.
New York: Oxford University Press, 1995. Lyon, William J. ; Baker, Robert A. ; Andrew, Marie J. ; Tirimacco, Rosy; White, Graham H. ; Knight, John L. (2003). Relationship between elevated preoperative troponin T and adverse outcomes following cardiac surgery.. ANZ Journal of Surgery 1/2, p40-44. Marshall J, Penckofer S, Llewellyn J. Structured postoperative teaching and knowledge and compliance of patients who had coronary artery bypass surgery. HeartLung. 1986;15:76-82. McKhann GM, Goldsborough MA, Borowicz LM et al. Cognitive outcome after coronary artery bypass: a one year prospective study.
Annals of Thoracic Surgery 1997; 63:510–515. Miller, K. H. ; Grindel, C. G, (2004). Comparison of Symptoms of Younger and Older Patients Undergoing Coronary Artery Bypass Surgery.. Clinical Nursing Research, 3, p179-193 Moore SM. (2002) The effects of a discharge information intervention on recovery outcomes following coronary artery bypass surgery. Int J Nurs Stud. 33:181-189. Munro I. Two-year follow up study of coronary artery bypass surgery. Psychologic status, employment status and quality of life. Journal of Thoracic and CardiovascularSurgery 1998; 97:78–85.
Newman M. F. , Croughwell N. D. , (1994). Blumenthal JA et al. Effect of aging on cerebral auto regulation during cardiopulmonary bypass – association with postoperative cognitive dysfunction. Circulation 90:243–249. Penckofer S, Llewellyn J. Adherence to risk-factor instructions one year following coronary artery bypass surgery. J Cardiovasc Nurs. 1989;3:10-24. Pick, B. , Molloy, A. , Hinds, C. , Pearce, S. , & Salmon, P. (1994). Post-operative fatigue following coronary artery bypass surgery: Relationship to emotional state and to the cathecholamine response to surgery.
Journal of Psychosomatic Research, 38, 599-607. Pugsley W, et al. (1994).. The impact of microemboli during cardiopulmonary bypass on neuropsychological functioning. Stroke; 25:1393–1409. Remedios, C. (2003). The role of medical, demographic and psychosocial factors in the incidence of depression among coronary artery bypass patients. Australian Journal of Psychology, Supplement, Vol. 55, p8-13 Rice V. H. , Mullin M. H. , Jarosz P. (2001) Preadmission self-instruction effects on postadmission and postoperative indicators in CABG patients: Partial replication and extension.
Res Nurs Health. 2; 15:253-259. Schaefer K. M. Swavely D, Rothenberger C, Hess S, Williston D. Sleep disturbances post coronary artery bypass surgery.. Prog Cardiovasc Nurs. 1996 Winter;11(1):5-14. Shaw P. J. , Bates D. , Cartlidge N. E. F. et al. Early intellectual dysfunction following coronary bypass surgery. Quarterly Journal of Medicine, New Series 1986; 58:59–68. Soylu, M. et al. (2003). . Increased Dispersion of Refractoriness in Patients with Atrial Fibrillation in the Early Postoperative Period after Coronary Artery Bypass Grafting.
Journal of Cardiovascular Electrophysiology, Vol. 14 Issue 1, p28-31 Stump D. A. Selection and clinical significance of neuropsychologic tests. Annals of Thoracic Surgery 1995; 59:1340–1344. Stump D. A. , Rogers A. T. , Hammon J. W. Neurobehavioural tests are monitoring tools used to improve cardiac surgeryoutcome. Annals of Thoracic Surgery 1996; 61:1295–1296. Stump DA, Rogers A. T. , Hammon JW, Newman SP. Cerebralemboli and cognitive outcome after cardiac surgery. Journal of Cardiothoracic and Vascular Anaesthesia 1996; 10:113–119. Symes, Emma; Maruff, Paul; Ajani, Andrew; Currie, Jon. (2000)
Issues associated with the identification of cognitive change following coronary artery bypass grafting: Australian & New Zealand Journal of Psychiatry, 5, p770-784, Taylor, S. E. , & Aspinwall, L. G. (1993). Coping with chronic illness. In L. Goldberger & S. Breznitz (Eds. ), Handbook of stress: Theoretical and clinical aspects_(pp. 511-531) (2nd ed. ). New York: Free Press. Townes BD, Bashein G, Hornbein T. yF. et al. Neurobehavioural outcomes in cardiac operations – a prospective controlled study. Journal of Thoracic and Cardiovascular Surgery 1989; 98:774–782. Treat-Jacobson, Diane; Lindquist, Ruth A. (2004).
Functional Recovery and Exercise Behavior in Men and Women 5 to 6 Years Following Coronary Artery Bypass Graft (CABG) Surgery. Western Journal of Nursing Research 5, p479-498, Vanninen R, Aikia M, Kononen M. et al. (1998). Subclinical cerebral complications after coronary artery bypass grafting: prospective analysis with magnetic resonance imaging, qualitative electroencephalography and neuropsychological assessment. Archives of Neurology; 55:618–627. Whitman, G. R. Nursing-Sensitive Outcomes in Cardiac Surgery Patients, The Journal of Cardiovascular Nursing: Volume 19(5) September/October 2004 p 293-298
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