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.