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CHAPTER I11
Stress management Programme
Analysis of the Data
METHODOLOGY
'Thr rx1r1)ost' of the stu;i? was to test the efficacy of a Stress
rnanagernciit pr-ograrnrne i r ~ reducing stress and anxiety of
cardiac sul-gic.:rl patients. This chapter deals with research
design, sarnplc,. tools and prclcf,dures in detail.
Design of the Study
Prc tc.41 11ost test, control group design was used for the
study.
In tht. III-(. test - post test control group design, subjects
randomly assigncd to either thr control group or the experimental
group. Each g r o ~ ~ p i:; observed by pre test. One group received a
stress m:in;tgcnnmt programme, while the other did not. The
researcher 11-icn tcstrd the :wo groups again by post test to
determine t lie t,Slect nf the prl,grarnme.
Sample
The s;~mpic, consisted of 100 patients undergoing Cardiac
surgery sc,ict,t(~i from IVIedical College Hospitals of
Thiruvarlat 1 1 l~ : ip i i t -an~ and h.ortayam. The age of the sample
ranged l~ei\\c~c-r~ I 8 end 60 years. Male and female patients who
were to ~~ritic,t-gi~ i11x:ri heart c:r r:losed heart surgery were selected.
Criteria were ser for the !selection of samples to ensure
homogeneity and to exclude 1nt:ervening variables.
Criteria for the Section of Sample
Patients having h i s top r,f any debilitating diseases such as
hypertension, diabetes mellitus, tuberculosis, kidney diseases,
respiratory diseases, or livcr diseases were excluded from the
sample since these conditions affect the post-operative recovery.
The details of the sample are glven in tables 4.1 to 4.5.
Table 4.1: Age-wise ciistriburic~n of the sample
Table 4.2: Sex-wise classification of the sample
Total
24
76
100
S1. No Sex
"~! 1 Fe~nalc. i!-~-- 40
.-
- ~ - 14 .
36 ~. ~ ~ ~ ~ p p
50
Exper?mental group
Control group
Table 4.3: U~stribution of the sample based on educational qualifications
Table 4.4: L)istribution of the sample based on monthly income
s1. No.
1
2
Rs. \ iO 1 - 1000 ~ ~ ~- -
Rs. 100 1 - 150(
Above K s . 150 ~ ~ ~-
Table 4.5: Distribution of sample based on type of surgery
Edaueation
Upto S S L.C - -- - P.D C and above
--
Total
Experimental group
22 - - - -
2 8 - - --
SO
No
1
Control P U P ---
2 7 -
23
50
Total
49
5 1
100
Type of operation
Closed mitral
~- - -.-+ - -
Control group
26
Experimental group
14
2 -
3
Total
40 volvotomy
~-
Repair ol PDA 3 4 7 -- - ~ ~ - ~ -
Value replacement -~ --
4
5
Repail- of ASD --
Perical-din1 cystcc:lonl,
- --
Total SO 50 100 -
Tools
Tht investigator used the following tools to collect data.
1. Str-c,ss C'ht:c:k list: (SCL)-Constructed by the Investigator (1996)
2. Stat<, Trait Anxlety Invitntory-(STAI) Malayalam Version,
Das ,tnd Kumar, (1994)
3. Post oprratlve complic.3tion check list (POCCL). Developed
by the. i~ivestigator (1906)
4. Stress management programme (SMP), Developed by the
invesrigator (1096).
1. S t r e s s Check List (SCL)
The investigator herself designed the Stress Check List
based on r-c?vic:\\ of literature and consultation with experts.
Extensive rrview of literatun: contributed fifty items describing
signs and symptoms of stress on human body. These items
included phvsical arid psychological symptoms of stress and
strain. Thest-, fifty items werc listed from one to fifty in a table
and a separate answer sheet uias designed in which the client
... could mark his response a s Yes" or 'No'.
A scort of o t i c . was givrn to each Yes' response. When a
person got ; i srot-r. of I0 or rnorl- he was considered to be under
stress. Grnri-al instructions ior giving the response by putting (4)
mark in al~propl-late columr~s were included in the check list.
A modr/ (11' t11,:: stress check list and answer sheet is given
a s Appendlx I a n d 11.
2. State-Trait Anxiety Inventory (STAI)
Stat(,-TI-ail Anxiety Inventory developed by Spielberger,
Gorsuch and 1.~1shene (19ti81 was adapted into Malayalam by
Das and Kurnar (1994). This was used to collect state and trait
anxiety of the sr1ectc:d patients before and after cardiac surgery.
The inventory cornpr-jsed separate self report scales for measuring
two distinct anx~ety c:oncepts-xtate anxiety and trait anxiety. The
STAI-state anxietv consists ,of eighteen statements that ask
people to describe how they feel at a particular moment. The STAI-
Trait anxiety scalc also con:;ir,ts of eighteen statements. These
statements requirt, the su11jec.t to indicate how they generally feel.
These two scales are printed or opposite sides of a single form.
Reliability
Split-half Reliability
The split-hait 1-?liability c ~ f the inventory was found to be 0.89
for state arixict~. ar-id 0 75) for 1'r:iit anxiety. The test-retest reliability
obtained was 0 . 8 1 l i ~ r slate amitxtv and 0.70 for trait anxiety.
Validity
Thr i:orrelation coefficient obtained for state inventory was
0.84 and that for trait inventory was 0.86. These validated against
the ratings made by the prclgress scores show that the test ha s
high validity.
The test can also clain~ face validity, since the final scale of
the inventon was prepared after item analysis.
A model of the STAI is given as appendix I11 and answer
sheet a s apprnd~x IV.
Scoring
The rangc of possible scores of STAI varies from minimum
score of twent? t o a rnaximuln score of eighty in both state and
Trait subscules. Clients respond to each STAI items by rating
themselves o n a four-point scale as described below.
State anxiety - Trait Anxiety
1. Not at all 1. Almost never, -- --
2. S O ~ ( , ~ . h a t 2. Sometimes - ~ - ~~L -
3. Modt.ratt,ly so, and 3. Often, - ~
i f
4. V e n much so ! 4. Almost always A
3. Post-Operative Complication Check List (POCCL)
Thr. postr~perative complication check list was designed to
measure tlic post operative complications of the cardiac surgical
patients.
The post opcr;itive complication check list was designed on
the basis of the, rxptrience o f the investigator, consultation with
experts i11 t t i c . filcd of cardiac. surgery and review of literature.
The investigatc~r tiesigned the post-operative complication check
list for cai-tl~ac patie~lts und~:rgoing open heart and closed heart
surgery
Post-operative comp1ic:ations check list consisted of 2
sections, Sectioil A and Section t3. Section A involves identification of
data of the patic,nts, vital signs of patients-temperature, pulse rate,
respiratory latt.. t~l~)ot i pressurr, fluid intake and urine out put.
Vital signs were measured to assess general condition of the
patient. St-p;iratc. :;pace w a s included to mark the date of
admission. d:~tr. of surgery and date of discharge.
Sectio~~ H consisted of 3.L items of post-operative complications
and separatt, rolulnnr; were i~rovided to mark their response as
Yes or No in the, s i ~ r r l t . questicnilaire.
Administration and Scoring:-
Thr post opcrative cclmplication check list was filled u p by
the in vestige to^ based on the information obtained from her
observations ;ilid physical k~sscssment and measurements of vital
signs and (:hart review.
In thr IYICCL, 34 post-ojserative complications were numbered
from 1 to ;14. Minor complications which may not cost the life of the
patients and could bt: revel-terl t:5~ medical intervention, were listed a s
item numb(,^- I r o 18. A scc;rc of 1 was given to these items. The
items from 1Y lo 34, which ::re serious complications leading to
death of the patient!; or chrt~nic disabilities and handicaps, were
given a scot-c of 2 each.
Thr max~rnum score ala:; fifty. A score of zero indicated an
uneventful rec-ovt:rv with no complications. A score of one to two
was considrred ;is mild coml~lication. A score of 3 and above was
considered as serlou:; complication.
A motlel of the post-operative complication check list is
given as a p p r n d ~ x V
4. The Stress Management: Programme
The sr 1-r:ss inar-lagemel I t programme for the present study
was prepat-<.ti tbv thi: invesllg.itor for the patients undergoing
cardiac sui-gc.i-\. 'l'hc, pacl<agc programme is a comprehensive,
practical intt.rrrntion for ~~iallaging stress and anxiety before
surgery so that subsequent post-operative complications could be
prevented. l r ~iivolves three techniques-Deep breathing exercises.
Relaxation tec.tlnrques and Information about pre-operative
preparations aiid pos~.-operativr management of cardiac surgery.
This package takes car-e of the physical, psychological and cognitive
aspects of tlrc illness stress a r ~ d anxiety of the patient, resulting in
an uneventful, srr~ooth recovery rollowing cardiac surgery. This will
help to relax ttw rninti and body simultaneously, increase oxygen
intake and tklerrt~v increase physical vitality of patients. Information
about preoperative preparations and post-operative management
clears all dout~ts almut the stressful situation, enabling the
patients to prepare well aht:a~l. to deal with the pre-operative
anxiety and strr,ss which could have impeded their post-operative
recovery. A tictailed dcscriptic~n of each of the techniques is given
below.
1. Breathing Exercises (BE)
BI-eathrng c.xercises ena1)le the cardiac patient to absorb
more oxygc.11 1 o 1 the air tilry breath in and thereby increase
their oxyge~i;~tior~ and feelin:; of well-being. It will refresh their
body and 1 ~ c . I j 1 itl(,in to main t ;~ i l~ their lungs free of secretion post-
operativc,l> !! ilrll~s thc patic.i>t o feel more relaxed and refreshed.
Though tht,r-t: a n various rni.rhods of breathing exercises two
simple a n t i cftrctivc breatni~ig exercises are Diaphragmatic
breathing exc:rrist:s and Pursc?ii lip Breathing Exercises.
Diaphragmatic Breathing Exercises (DBE)
This is also termed a s abdominal breathing. In abdominal
breathing, the abdtrmen visibly rises during deep inhalation and
contracts during exhalation. U'it1-1 expiration the patient should feel
the abdomen muscles tightenctl. Tightening the abdominal muscles
helps the diaphragm to squeeze air out of the lungs. By placing
one hand on thy abdomen and the other on the chest, the patient
can feel whether he is breathing correctly while sitting up or
reclining.
Diaphragm 1s the most important respiratory muscle, the
paralysis of wh~ch will lead t o I-espiratory failure. Diaphragmatic
breathing exercises are practisrd to strengthen this vital muscle
so that the patlerlt could be 11-ained to breath slowly and deeply
without any d i s~rcss and pain during their post-operative period.
Since cardiac. surgery involves the chest wall, breathing will be
painful and distressing soon after surgery, for all the patients.
Patients oftrli suffer from inti-'cased bronchial secretions a s a
result of shallow br-cathing, 1'121:; in turn may lead to respiratory
complication^ sllclk 21s aspira~ici~i pneumonia, respiratory failure,
lung congestion rtc: By doing, tleep breathing exercises such as
diaphragmat~c brrathing exer~:ises secretion from lungs could be
brought out casilv, thereby r~rt'venting respiratory complication
and hastening postoperative rt:c:overy.
A detailed description oE ttle steps followed in Diaphragmatic
Breathing Exerclses is given bt:low
1) The patlent is placed i r l a comfortable and relaxed semi
fowlrr'5 posit Ion
2) The right hand of the paticmt is placed on his chest around
the lower I-ibs with fingers comfortably spread.
3 ) The left hand on the atldomen and instruct the patient to
sit straight so that the liings would remain in its natural
normal posillon.
4) The patient is asked to illhale through the nostrils slowly
(while relaxing the abdomen) and press his chest wall
inwardly with his right hand. By doing so the diaphragm is
being useti for breathinp,.
5) The patient 1s instructed to pause naturally and briefly a t
the erlt~i of rac:h inspiralinn. This effects a smooth pattern
of v e n t ~ l a t ~ o i ~ and an evt.n distribution of air into and out of
the l ~ ~ l ~ g s
6) Durulg rxliwlation, the patient is instructed to press the left
hand I i h t abdomcn inward and upward, while he
contracts his a1,dominal muscles. The patient is instructed
to purse t hr lips during exhalation.
NB:
I Ideally, the length of exhalation should be two or three
times longc~- than the time of inhalation.
I Do not rxc:rssively eniphasise the amount of exhalation
tirnt. If undue: effort is placed on counting, the patient
generally bccorr~es anxious and this may lead to dyspnoea.
I Afier thr patient has mastered this technique, instruct
him/ her t o practice it regularly for 50-60 iterns twice daily
during the preoperative and post-operative periods.
I Gratiuallv the patient learns to adjust to this controlled
breathing pattern, during pre-operative and post-operative
periods.
Pursed Lip Breathing (PLB):-
Purseti 11p breathing is another simple, effective and
practical breathing ex'-rcise tliat can be used by cardiac patients,
before and ; ~ S t c , r r e I t :lelps to control one's breathing by
pursing thc lips. 1 1 IIIL:I-eases rrsistance during exhalation, which
in turn for~t . ,311 the alveoli (lung unit) to expand and contract
effectively ro t i l t ' maximum. This method is very simple and
useful to thc cai-dxic patients and is being widely used among the
patients undergoing cardiothor,acic surgeries.
Purscti lip breathing allows the lung unit to expand
completely so that oxygen 11ptake and carbondioxide excretion
can be improved. Secretion:; that develop inside the lungs after
surgery could bc. easily broiigllt out of the lungs by pursed lip
breathing after- stcam inhalai.ion. This improves oxygenation and
refreshes the patient and inc:rrases his feeling of well being and
prevents post-operative lung i:omplications.
Steps Followed in Pursed Breathing:-
1) The paticnt is encouraged the patient to sit comfortably
with spinr straight.
2) The pat~rnt 1s instructrtl to breath in slowly through the
nose
3) Then patient is instructed to exhale slowly through pursed
lip. so that a 'blowin:<' effect occurs during exhalation.
1nstruc.t the patient to "t~low out a s if you were slowly blowing
on thc n;i~iic. (11' a burning candle without putting off the
flamt.' 'I'hr Irivest~gator herself demonstrated the procedure
along w11 h instruction
4) Thc p~itient 1s t:ncoura<rd to breath out through a pursed
lip slowlv and completely for a comfortable length of time.
Both thesr breathing exe,:cises were practiced a t the rate or
50-60 times, twicr daily pre-operatively and four hourly after the
surgery. 'I'his was also practiced just before and after guided
somatopsvch~c~ elax ax at ion.
2. Guided Somato Psychic Relaxation (GSPR)
Guided Somato Psychic Relaxation (GSPR), developed by
Sreedhar ( I c W 6 ) , 1s popular for its simplicity, and its unambiguous,
and definite and smooth steps. It is famous for its effectiveness in
giving mental relaxation along wlth physical relaxation. In GSPR
the relaxation 1s a totally guided one, starting from the soma to the
psyche. GSPR is found to be very practical and simple for cardiac
surgical patit:nts to practice, slnce it does not involve any strenuous,
sudden mo\.rrnrnr of body parts. The movements are slow and
steady and svstcmat~o in GSF'K.
Thr ptlrposr of GSPR i:j to reduce the stress and anxiety of
the cardiac S L I I - ~ I ~ ~ ~ patients bttfore and after undergoing cardiac
surgep
Matteso11 at1(1 Invancc~vii~h (1987) have reported that
successful reluauon results irl enhanced feelings of well-being,
peacefulness, a scrlsc of control and a reduction in felt tension and
anxiety. Phvsiologlc:ally it decrr;ises blood pressure, respiration
and heart rar t:.
GSPK 1s modified r m of Jacobson's Progressive
Muscular Rrlaxatlon (JPMR). 111 JPMR mental relaxation is not
given much importance tho& it is very effective in giving
physical relaxation. But in Crl5PR much attention is paid to
mental relaxation
Technique of GSPR
Guided Somato Psychic R'elaxation technique was developed
by Sreedhar (19Yb), Professr~r and Head of the Department of
Psycholog)/, University of Kera,:a. Trivandrum. The investigator has
obtained pcrrnisslon form Prof. Sreedhar for using the technique
for this rescarch The: invest1g;itor has undergone training from
Prof. Sreedhar in the :[node of administration of this technique.
Steps Followed in GSPR
a) Thc patwnt 1s instructxi to lie down on a comfortable cot
in a suplnt. position wll k l head slightly raised on a pillow.
b) 'The p;it~cnt is informeti that the relaxation has both physical
and irlental stages. In the physical stage there are ten steps.
In the mental stage there is a visualization process.
c) All doul~ts of the patients were clarified before starting
GSPK
d) The irrvest~gator de~nonstrated and described the following
ten steps for physical re1;lxation.
Physical Relaxation-Steps Used
The pati~~,rit is instructed to close his/her eyes from the
beginning t i l l thc cnd of GSPK and listen only to the directions
given and to avoid other distractions.
Step I - Hr~rlg both the feet parallel to each other and bend the
fert towards the bc~d:, a t the ankles. Feel the tension,
fccl the relaxation by brining the feet to normal position
whcn directed to RELAX ...........
Step I 1 Bring the fret parallel to each other, and push the toes
a\v;iy fi-oin the body as if pointing towards the wall. Feel
t t i ( . tci~sion, feel th,? relaxation by bringing the feet to
no1-m;11 position when directed to relax.
Step I 1 1 RI-irig thr feet par;~llel to each other, push the heels
I 1 downwarcis. without bending the knees, feel
tht. tr,lision, relax I putting the legs into normal
pos~tlorl when dii-ectt.ci to relax.
Relax the botlb p,irls lrom hlp 10 toes when directed to do so.
Step IV- Cler~ch both the fists a:j if trying to squeeze water out of
a spongcA. Feel the t8:nsion. Relax by putting hands to
nornlal position by o1)ening the fits slowly when directed
to rr1a.i.
Step V- C1enc.h both thc fists agaln and bend the elbows and let the
fists try ro to~lch [.he s.houlders and press down on the
shoulders. Feel the tension. Relax by putting hands back
to norrnal position after opening the fist when directed
to relax
Step VI- Arch both the should(~rs backwards by raising the chest
anti bre,ith~ng normally, feel the tension. relax and
assumt- normal posit~on when directed to do so.
Step VII- Arch both the shou lde~s to the front, feel the tension.
Reldx 11c .IssIJmlng the normal lying posltlon when
d l r~c tccl ( ( I tio 50
Relax body par-ts St-om shoulders to tip of fingers a s directed
Step VIII-Bring thr chin a 111tle down and push back the head
downu:ar-cis, feel thv rc.nsion, relax, by assuming normal
natur~rl position whrn directed to relax.
Step I X Raise thr eye brows and form wrinkles on the forehead
without opening the eyes. Feel the tension, relax by
assuming normal position when directed to relax.
Step X- Close the eyes tightlv, feel the tension of eye lids. Relax
by renioving tensior~ lrom eye lids slowly when directed
to do so ,
Relax the body parts from head to toes when directed to do so
Relaxation of Mind
For relaxation of mind the patient is instructed to visualize
as detailed t)elom.
1. Visualize a beautiful pond, filled with crystal clear water in
a vcrv c,alrn and peat:eiul environment during the dusk.
The water in the pond is clean, pure, serene, tranquil and
absol~itclv standstill.
2. Like tllr n7nter in the potid now the mind is also becoming
clearcr- ;lrid cltz;lrer.
3. Now il~~r mind is extrerrttly pure, serene, tranquil, transparent
anti ;~t)solu~cl\; stands:tll.
4. L(:t \ o i l r awareness get irito deeper and deeper layers of your
rnind. l>c:rp down the n ~ i r ~ d there exists a total silence. Be in
that si1rnc:c. until I call VOLI. RELAX (for 2mts)
5, The ~ r l ~ r r t l a r ~ d body art. now completely relaxed
Instructions for Coming out of Relaxation
The patient 1s instructed to come out of the relaxation by
counting 15 and by making him gradually open his eyes.
1. Open your eyes gradilally and slowly when you hear
counting from orie to fivtr.
2. Place yclur hands on the stomach with fingers held together.
3 Brlng the toes together and release them
4. Turn your hcad to the left side and then to the right side.
Frec the hands end slowly sit up a s usual
The hrart rate of the patients was monitored before and
after the rel;utation to assess whether the patient had relaxed
well. It was found that the hrar-t rate was considerably reduced
by guided somato-psychic relaxal~ion.
The invc-stig;itor lused an audio cassette for giving GSPR to
the selected r;-irdiar patients.
Information Module
Alorig wi t i l nlcntal and physical relaxation obtained from
undergoing (:St'K and E3E, one could be enabled to handle
knowledgr tiefic-~r rrgarding cardiac surgery, which is another
important stressor to cardiac surgical patients. A s evidenced by
several rescarc.tl studies stre:is and anxiety could be reduced to a
minimum tn 111-ovidi1lg adequate information about a procedure
or event as sur-grry. (John 1989) Awareness about a stressful
event helps thr ~ndividual to cope positively with the physical,
psycho1ogic:ai urld emotional problems. It is observed that post-
operative c.onipl~cations could be prevented by adequate
preoperative pl-cparations. Usually the patients would co-operate
better if t l l i , ~ ;irc provided wi~:h the why and what of the pre-
operative 121-c~ct.d~~res. Henct: clear, unambiguous, and correct
instructions ;?rr nc?edr:d for better co-operation from patients and
relatives. 'This would no doubt help to reduce stress and anxiety
among the patierits, thus bringin;: down post-operative complications.
The modulr: c:onsisted of section PL, B and C.
Sectlon A inlcii rriat~on regar dlng pre-operatlve procedures
Section B : Insrtuctic:,n while transferring patients to the operation
l l l i . ; i l 1 . 1 ~ .
Section C' I t i I ( 1 1 Iti.itron rcg~il ding Post-operative management
Thr i i~rlo~\~~rig details of the information module were taught
to the patit .11~~. ;r~tiividually.
Section A:- Information Regarding Pre-operative Preparation
Today, c;+rdiac surgery has developed to an extent that
doctors arc, ;iblt, to repair c:vcn the defects inside the heart
without rnuc.li io~nplications. Modern surgical procedures enable
the paticnts to lead a productive life without distressing signs
and symptorris such a s dyspno'ea, palpitation etc even after the
surgery.
Dcfei,ts 111 the heart such a s a hole in the septa1 wall
separating the chambers of heart, defects of heart valves and
blood vesscls can be repaired. Defective valves can be replaced by
prosthetic v;~~lvcs too, to save ; r life. The death rate among cardiac
patients hiis t1ct.11 I-educed to n~inimum as a result: of scientific
advancemrrit 111 the field of cardiac surgery. Yet there are
chances of ciiveloping some c:oinplications after cardiac surgery
which can br pwvented by proper pre-operative preparations.
Appi-oi~~iatr :ind timely pre operative preparations would enable
the patient 10 havc. a smooth, calm, and uneventful recovery from
cardiac ailrncmts after cardiac surgery. This also helps in the
prevention oi post-oper;itive complication. The patient's willingness and
Co-operatic111 :II-I. highly essential (i sr the pre operative preparations.
So xit tic,^^! '\ ~ I I r operative preparation can be successfully
done only wiih hls willingness and co-operation. The pre-operative
preparations (.orlsist of the f'o1lox;ing aspects of care.
A. Physicai preparations
B. Physiologic,al proparations
C. Psycholog~c.al preparations
D. Legal preparations
A. Physical Preparations
This iric1uilt.s assessment of the soma and making sure
that the persoil I S fit for surgery. Physical preparation includes
the following.
1. The following investigations have to be done to assess the
general c.oiitIition of the body and to detect the specific
defects.
a) Labor,ltory invest~gations of blood, sputum, Urine
.inti Stool
b) Kaiiiological anti other investigations l~ke X-ray,
Ectioc-ardiogram, tkigogram, ECG, MRI, and Stress Test.
I I disease other than cardiac ailments is detected
frorn rlrr tt~iult ~f these ic>.ts, it is treated and the homeostasis
of tht ' I ~ o t i \ 1s ~r(,gained bt,fore cardiac surgery.
2. The rt,rnprr-kttu~e of bod\:, rate of pulse and respiration,
Blooti pr(~,ssurc and weig11t of rhe patient will be monitored
a s a routrrirX, evtryday.
3. Any oihcr defects suc1-1 a s disease of the ear, diabetes
mellitus, hypert.ension, drntal caries or any other source of
infection ~nside the bod:$ will be treated prior to surgery so
that thesr abnormal it it:^ may not interfere with surgery
and its r-ecovery. For this purpose the patient need to
consult doctors from c:,ther departments on reference to
ensurc rhat tlr is free fi.c)rn any debilitating diseases other
than cardiac diseases.
4. Specific articles requi rd for surgery, such as prosthetic
valves, disposablr parts of cardiopulmonary bypass machine
etc., should he ar-ranged a:; listed by the doctors.
5. Arrangc adrcluat~. numb<-r- of blood donors before surgery.
6. Consult doctors ,:>I Anesthesia department and get certified
that the patient is fit for- surgery.
7 . Local preparation-The c:ht.st wall axilla and neck will be
shaved upto umt)ilical 1rvc.l. Shampoo the hair and have a
thorough bath sfter s h . ~ \ i n g on the evening of the day
befort, s ~ ~ t - g t ~ i i
8. Chaligr ~)c.r-sor~ul dress 1 0 white shirt and dothi prior to
surgrr-\
9. Braidr tht, hair into two (if it is long), fold and tie it a t the
sides and cove:[- the head with a cap provided from the
hospital
10. Removcz all metallic items from the body such a s ornaments,
watches rtc:., and entrust them to relatives.
1 1. Rcrnov~ pl-ustht:tic dentures, spectacles, and hearing aids
from the body and keerr them safe with relatives.
12. Removr nail polish if arly and cut short the nails.
B. Physiological Preparations
The physiological state of the human body is in equilibrium in
a healthy body Cardiac patient:^ need physiological preparation to
have an optlrnurn level of physiological functioning to undergo all
the physiologic:al and hernodynamic changes during and after
surgery. Phys~ological preparation of a cardiac surgical patient is
detailed bt-lo\c-
1. Any changrs in vital signs-pulse rate, respiration rate, blood
pressrir-t. rt.rnpt,rature or an imbalance of fluid intake and
outp1.11 w.111 tx~ treated artd corrected before surgery.
2. The p:~tic.tits need to f';is~ from 10 p.m. on wards, on the
night l,ef'ori: surgery. Evrn drinking sips of water should be
avoidrd. T h ~ s is to prrveilt complications during and after
anesthc.sia
3. On the night before surgery the patient need to take sedatives
for a co~nfortablr sleep. (IJs-dally it is given at 10 p.m.).
4. Physical assessment will be done by doctors and nurses to
ensurc fitness for surg<.n early in the morning on the day
of surge?.
5. J u s t before tak~ng to thr operating room, pre-medication
injections are give11 to minimise stress and anxiety.
Sometimes the patients feel drowsy and sleepy after these
injections and hence getting up and walking after these
pre-incdications should bc avoided.
6. Patients arc taken to the operating room in a trolley along
with a11 i~lvrstigation reports and medical records.
C. Psychological Preparations
Sincc rn~rld anti body :%I-e inter related, cardiac surgical
patients nerd adrcluate psyc:h~.,logical preparation to minimise
stress and wrix~r(v an'd furth1.r complications. A cardiac surgical
patient may hr p~-cljared psyrh~ilogically a s follows.
<;ivc. 1rcc:dorn of exprts5,ion to patient and clear all his
doubts to rnrnimise strc,ss and anxiety.
Givr training in guided somato psychic relaxation along with
deep breathing exercises a s mentioned earlier so that
patients could relax well.
Reassure about the positive outcomes after cardiac surgery,
showing mother cardiac surgical patient who is recovering
without cornp1ic;itions.
Promote religious prac:tices such a s prayer meetings to
relieve stress arid anxiet)
Infor~n that they will nevszr perceive any pain or discomfort
during surgery since they are given anesthetic drugs, prior
to surge?
Ensure that thic-y will be given pain killers if they feel the
pain soon after surgery, upon request.
Enco~~ragc soci,~l support from the other famlly members
Lct t h t : ixitien~: ventil;~tc: all his fears and anxiety in a
counsellirig ses:sion if required.
Makc arrangements f o ~ the patient to meet a patient who is
rrcovr~i-illg from similar surgery without any complications.
D. Legal Preparation
Eth~c.;il ;anti legal priiiciples need to be followed while
dealing with i11.1rnan beings allti their health problems. The legal
preparation oi ;i patient undel-going cardiac surgery involves the
following stt.ps
1 . Patients and relatives arc given adequate information about
the outcornc of the surgery and its complications.
2. The p . i t l e r ~ t .ind the relat~ves need to sign a written consent
agreelllg to undergo cardiac surgery, knowing all its
consecluyncrs.
Section B:- Instructions while Transferring Patients to Operating Room
Pat~ents will br shifted to the operating room in a trolley
along ~71th ~ 1 1 1 111s ~nvtstigation reports and records. The following
instruction5 -.:oulci be useful during the shifting period
=, Pra\ t o ( ;ocl Almighty. F3e calm and self confident
Do brc-atii~ng exercises calmly and quietly
Try t o vi\ualise a clam a r ~ d peaceful environment
Belivvt t l l l i t your life w~l l be safe in the hands of God
. Bc ~ .c ,~~r - ; ig~ . i ,us to face any difficulties
R e r ~ l t ~ n ~ b t ~ ~ that these problems and sufferings will be
redr~ct.d gradually day b j day.
Be optlrn~stic about thc outcome of the surgery
3 Belicvr that God is taking care of you safely through the
hands o f the doctors anti nurses, through out the surgical
proc:c.tiu~-t;
3 Think about a productivc: life after surgery, which is free of
all ihc distress~ng symptoms such as chest pain, dyspnoea
and palpitation etc.
T q T I ) relax the body, part by part, gradually a s demonstrated
whllr doing GSPR.
Rernc.tnt)er- that any emergency could be managed
sciailiifirally and effectively in the hospital with the help of
advanwd tc:chnology.
=. Wall patiently in the oper-ative room along with other surgical
pat.irilts, until jrour tun1 for getting operated comes.
Section C:- Post-operative Management
'I'hv ixr-diac surgical patient requires individualised,
comprrht:ns~v< ;trld cxpert nursing care soon after cardiac surgery
to prevrlll ; t l l possi1)le complications following surgery. For that
purposr the, [~;ii~t-nt need to be treated inside a modern, well
; ,,,' equipped c.;ir.d~uc. intensive ca$s unit for two to three days after
surgery.
Thr lollou-ing instrilctions regarding post-operative
management wcrc given to the selected patients.
i The pntirnrs need to bt: treated inside intensive care units
for 2 <1 days after surgery
I Relativt:~ ar-c not permitted to be with the patient inside the
Card~:ic, Sul-gical ICU.
I Paticrits will be constantl:~ monitored inside the 1CU using
moderil rcluipm(:nts, such a s ECG machine.
I Ventilators may be used for patients to assist breathing if
thew 1s airy tire;ithing difficulty.
I Therc \ % r i l l h(, some tubes attached to the patient's body,
such ;is iiltrr-costal drainage tube in the chest wall, urinary
ca1hetr.r~. ~i;isogastric tubes, intravenous infusion sets and
its cari~rl~is c,tc. All theso tubes will removed from the body
a s thc grliri-:il trc~ntlition o f the patient improves.
I Patictics rlr:i\ fitid breathing painful and difficult due to
inc:isioii i r i c i i ( . c:hrst wall a ~ i d intercostal drainage tubes. Slow
anti tic,c.[) L~rcathirlg exf,rc.ise, supporting the site of incision
wit11 l 1 i c . Ir,ii~d, could b 1 2 practised a s taught earlier.
I Irit~-avc~r~o~is iniusion of i:lucose will be given continuously
for 2 4 ~ IOLI I - s during the immediate post-operative days
and gl-adually it will be stopped to start oral fluids.
The pat~c,r~t may experience severe pain in the operated
area, whicll could be relieved by pain killer medications
and I-c,lax;rtion of chest w;all a s taught along with GSPR.
i In oriirr- to haziten wound healing and prevent infection,
many injrrtluns will be given such a s antibiotics and anti-
inflanimatory drugs.
i The p;iii>. sufferings, and other discomfort will decrease
gradu;illy a s the days pass on.
i Practisc t~r-eathing exel-cises a s taught earlier every four
hours ;it the rate of 50~60 times. This helps to prevent
resp~i-atorv c.omplicatior~s.
I Practlsc ( ;SPR a s and when you experience pain and agony
to rclic,vr p;iln 21nd re1a.x the body. The wound healing will
be rn~1<.11 iasler i f the muscles are relaxed.
Patieills itt.c.ti lo take stearn inhalation or medicated inhalation
e v 4 1 I S I3r1:athing ex(:rcise after inhalation helps to bring
out :\I1 tt1(. st.c.1-ctions froni the lungs and ease breathing.
Patients irt,rti to obey all the instructions given by doctors
and nL1rst.s in IC:U and co-operate well with them to have a
smooth arid uneventful recovery.
Food and fluid will be r::stricted for the first 24 hours soon
after surgttrv ;~nd latc?t. it will be given gradually a s
instrut.teti by the caregivers.
Patienis ulll be shifted from ICU to ward after two to three days.
Usually stit(:he$; a t the operation site will be removed on
the 8"; dw!. after su rgen i l ' there is no wound complication.
Patients \ \ ' i l l be discharged to home soon after removing
stitches troni the operation site.
Patients rr(,t.d ro clear all their doubts regarding follow u p
visits. i o o t l anti fluid restrictions, medications, rest and
activirv. ;iiid others, if an:, prior to discharge.
Usually, Ixitients need a follow up visit at cardiac surgery
dt:pal-tnit,~il onc month :after discharge. If any other problems
develol, .tftc-i o i 1 report to the nearest doctor
immciiiatt.l\
Post-Operative Complications
Though sclence and tect~nology have advanced to such an
extent to minimise the morbitiity and mortality rate of cardiac
surgical patients, occasionall?' there are chances of the following
post-operative i:omplications. The meaning of each post-operative
complication listed irl the post-operative complication check list
developed by thc investigator, I S detailed below.
2. Arrythmias
A condition in which the blood
pressure of the patient is below
90/60mm of Hg, detected by
checking blood pressure using
BP apparatus.
A condition in which there is
variation from the normal rhythm
of the heart beat , detected by the
auscultation of the chest, using
a stethoscope.
3. Myocal-d~;il 1rifnrctio11:- A condition in which there is
death of cells of the heart due to
5. Mediostirlal bleeding:
lack of blood supply to that area
due to coronary artery diseases.
A condition in which there is high
blood pressure above 130/90 mrn
of Hg., detected by measuring
blood pressure with a BP
Apparatus.
Bleeding from the middle part of
the chest where the operation is
done.
A disorder of blood clotting,
named a s clotting disorder.
7. Wound cornplicatio~ls:- Any complication of the wound
such a s infection, dehiscence,
gaping of wound or keloid
formation.
8. Sepsis: Presence of tissues, pathogenic
micro organism or their toxins
in blood, following surgery.
A disease condition in which there
is inflarnmabon of lungs with
exudation and consolidation.
10. Pulrnol~;lty ~omplications- Any diseases of the lungs or its
complications, associated with
cardiac surgery such as injury to
lung tissues, respiratory fdure,
respiratory arrest etc:.
11. Fever:
12. Strokc:
A condition in which there is
elevation of body temperature
above normal (37OC).
A condition due to acute vascular
lesions of the brain (haemorrhage,
embolism, thrombosis rupture of
aneurysm), whch Inay be marked
by herniplegia, hemiparasis, vertigo,
numbness, aphasia, dysarthria,
and often followed by permanent
neurological damage.
Inability of the kidney to excrete
metabolic waste products from
blood, marked by uremia,
olignria, hperkalemia and
pulmonary oedema.
14. Fluid ariti elt:c.tsolyte A condition in which there is an
imbalarl~.c.: imbalance between fluid intake
and urine output.
15. Hepatitis: Inflammation of the liver,
characterized by jaundice, purists,
dark urine and pale stools.
This condition is charactenized by
separation and liberation of
hemoglobin from red blood cells
and it appears in plasma
17. Transfusio~r reaction:. Allergc reaction manifested by
patients after introduction of whole
blood or blood components such
a s plasma or packed cells, directly
into blood stream through blood
transfusion
18. Vastulai- ~~rol) le~ns:- A condition associated with leak
of blood supply due to spasm,
thro~llbosis or embolism of blood
vcssels any where in the body.
--
19. Nerve r i ~iuiri,i A condition associated with
injury to nerve, in and around
operation site, due to surgical
manipulation or application of
tourniquet.
20. Post-operativt psqchosis - A condition in which patients
exhibit signs and symptoms of
psychosis-a mental illness-after
cardiac surgery.
21.Postoprrat1ve depression: A condition in which patients
develop psychotic depression
after cardiac surgery.
22. Paravasculai- 1cak:- A condition in which there is
leak in valves after reparative
surgery or replacement surgery.
A condition characterized by a
blockage of blood vessels due to
embolism anywhere in the body.
A condition in which there is
exudative and proliferative
inflammatory alterations of the
endocardium. I t is characterised
I ~y thc presence of vegetation On
I he surface of erldocardium
Involving the valves and inner
iining of the cardiac chambers.
25,Prostheti~:valvc malfunction: A condition in which the new
.artificial valve, placed inside the
patient's heart, replacing the
defectwe valve, does not function
effectively.
26. Haernolytic anaemia:-- A condition in which there is
reduction of number of erythrocytes,
quantity of haemoglobin or volume
of packed cells in blood, due to
shortened survival of mature
erythrocytes and inability of the
bone marrow to compensate for
their decreased life span.
27. Venrric.ii1ar rc.ptu1.e:- A condition in which the
ventricle of the heart breaks or
gapes after surgeq
28. Cardiac ~ i r r t \ l A condition characterized by
sudden stoppage of heart.
29. Post-olx.r-at~v' haemorrh;~gt::-Bleeding from the external or
internal wounds after surgery.
30. Drug scr1sitivitv:- Allergic reactions following
administration of any drugs.
3 1. Rap~d ar~d thready Pulse A condition characterized by
increased rate of heart and
pulse with less tension of pulse
than normal.
32. Cardingrnic shock:- A condition in which there is
disparity between blood volume
and blood space due to cardiac
diseases.
A condition characterized by loss
of ability to carry out familiar
purposeful movements in the
absence of motor or sensory
impairment. There will be inability
to use objects correctly.
34. Perical-cliotoriiv Syndromc: A condition following surgical
incision of pericardium
characterized by cardiac
tamponade and bleeding.
Procedure
The presrrit study was aimed a t finding out the efficacy of a
newly designed stress; rnanage~nent programme in relieving stress
and anxiety of cardiac: surgical patients. The stress checklist and
post-operative c:omplic:at:ion checklist, and the stress management
programme wrrt, developed by the investigator, which were not
tested on any population before. More over, the review of
literature f;iiled to provide anv systematic scientific data about
similar experimental studies conducted in Kerala. Hence the
investigator pi-opose~l to conduct a pilot study to test the
adequacy or st[-css check list (SCL), stress management
programmr (SMP) and post operative complication checklist
(POCCL) and also to assess the feasibility of the present study.
Pilot Study
Perln~ss~on WEIS obt;tiried from the authorities of the
Medical Collegc liottayanl anti Medical College TI-ivandrum for
conducting I l ~ t . p~lot study.
I n i t i l l , I invcstigatot- \.-isited the selected wards of the
hospital i t1 (11-dc.1 to cs,tablish rapport with the patients and the
hospital pet-sonirt~l Patients for the pilot study were identified
through cti;:ot i-c.view and ii1tc:rview by the investigator. The
purpose of t k ~ r . study was explained, voluntary risk-free
participatioil was r-rquested. Coiifidentiality of their response was
ensured. Thc paticnls who fulfiiled the criteria for selection were
selected for t hc pilot stucly.
Thirty paclrnts forrned tkit. sample for the pilot study. They
were randonlly d ~ v ~ d r t i into two groups of 15 each. One group
was treated ;is thr control group and the other, the experimental
group.
Both tllesc groups werc pre-tested for anxiety using STAI,
(Malayalam ddnptation) and SCL. The patients filled in the
answer shcczts ; in t i returned the same to the investigator. The
investigator- rhecked each answer sheet for errors and omissions.
The tools wri-e lound adequatc since the patients could respond
to these tools wlthout any practical difficulty.
The rxpet ini rn~;~l group:, was given the stress management
programme, ullich includetl GSPR, breathing exercise and
information tl~odiilr.
Thc or~r~tl-ol XI-oup was not given the SMP. They received
only routine prcuperative and post-operative hospital care.
Both thesc r o u l x were g~ven post-test on the seventh day
post-operativel\i. 'I'he STAI was (used to measure anxiety and SCL
was used to assess the stress post-operatively. The post-
operative complication check list was used to measure post-
I,, operative complicatiorls. Thesc tools were fond adequate for
/I
measuring post-oper;itive strrss, anxiety and post-operative
complicatior~s.
The following conclusions were drawn from the pilot study
1. The Strrss Check List State Trait Anxiety Inventory
(Malavd1;irn r2d:iptation) and Post-Operative Complication
Check Llst were found <idequate for the present study.
2. The Stress Marlagemen1 Programme was found adequate,
feasiblc and s,iniple f o ~ administration in the present
clinic;~l setting for cardiac. surgical patients.
3 . The study was found to l)e very useful and well appreciated
by th(, cl~n~c.al staff anci cardiac surgical patients.
4. The ; ipp~-~) [~r la t~? timinc,, I<,r data collection was found to be
hct\x:t~t ,~~ I 2 noon and ~ I . X p.m.
i , Thc lc.vi.,i ( I ! sir-es:; and allxlety was found to be considerably
lourel i t siu.gcty . than before surgery in the patients
belong111~ 10 i:xptri~nental group. There were only negligible
changc,s 111 ~trntrc~l group.
Sirlcc ihe ;iticqu:tcp of the tools and the stress management
programme was cstatilished through the pilot study, the final
study was <~ontiuc.ted without any changes in the tools and
techniques.
Perrnissior~ was obtained from the authorities of Medical College
Kottayarn anti Medical College Trivandrum for the present study.
Final Study
Pemmissior~ was obtaincd from the authorities of Medical
College Kottavain and Medical College Trivandrum for the present
study. The sutqrc.ts ur(:rt. taken from Medical Colleges of Kottayarn
and Trivandi-urn u s had been done for the pilot study.
S t .~b~c~.cs [ ( I I th,: final study were identified through chart
review anti int~rvi(:w by the irivt.stigator.
Huntit-cci patierits werv srlected for the final study a s per
criteria mc.ti!ioi~e.cl rarlier. Those patients who were taken a s
subjects 1~1 p~lot s t ~ . d y w c . ~ - ~ [lot included in the final sample.
The purpost, ot f t ~ i , srudy wras explained and participation of the
patients was I-equested. The cc>nlidentiality of their responses was
assured. Tht. pat~ent!s were \v~lling for voluntary participation
and were very co-operative.
The s:implc for the Enti1 study included 100 cardiac
surgical patients, 50 belonging to the experimental group and 50
to the control group.
Both the groups were pretested for anxiety and stress by
STAI (Malayalarrl version) and SCL.
The selcc:trd patients were given clear instructions
regarding self-administered questionnaire and they were asked to
read the ins1ruc:tions to ensure comprehension. Assistance was
given only upor1 rc.quest to clar~fy their doubts. Separate answer
sheets were used for STAI and SCL. The investigator checked
each form carefully for errors and omissions and got it filled
completely bv the cardiac surgical patients.
After pre testing, t.he expfrimental group was given training
in stress managemen],. programme and the control group was not
given a n specla! tn:atment. They received only the routine
hospital cart, pr-r operatively .ind post-operatively,
Sevr~i ii:r\-s aftc:r the cardiac surgery, the patients of both
the groups i\.r.rn give11 post test for measuring stress using SCL,
and anxietv u s ~ i i g S'TAI. 1'o:it-operative complications were
assessed by tht' ~~~ve>, t igator using post-operative complication
check list. The rcchni~ques uscti for Pilot study were followed for
final study also.
Analysis of Data
The diflet-ri-ic:c in score:; obtained in pretest and post test
for each patient, in tests measuring stress and anxiety, was
calculated sc:pa~-ately fbr bl)th the groups. The significant
difference between tht:st: two groups in each of the variables was
determined bv ' r ' test and pair-~d 't' test.
The tollowing chapter deals with details of analysis and
results.