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8Acta Paul Enferm. 2013; 26(1):8-13.
Original Article
Myocardial revascularization:
strategies for coping with the disease
and the surgical process
Revascularização miocárdica: estratégias para o
enfrentamento da doença e do processo cirúrgico
Cintia Koerich1
Maria Aparecida Baggio1
Alacoque Lorenzini Erdmann1
Gabriela Marcellino de Melo Lanzoni1
Giovana Dorneles Callegaro Higashi1
Corresponding author
Cintia Koerich
Campus Universitário s/n, Trindade,
Florianópolis, SC, Brazil. Zip Code
88040-970
cintia.koerich@ig.com.br
Abstract
Objective: Knowing the strategies used by patients in coping with coronary heart disease and myocardial
revascularization surgical procedure.
Methods: The Grounded Theory method was used as a methodological framework for the reading of data from
a larger study entitled: Contextualizing the surgical experience and the living process of the patient undergoing
myocardial revascularization. Data collection was conducted from October 2010 to August 2011, through
semi-structured
interviews with three sample groups (patients, relatives of patients and health professionals) and 23
participants.
Results: The results indicate the strategies used by patients who underwent a surgical revascularization
process, which are: family, spiritual and professional support.
Conclusion: The experience of cardiac surgery modifies the living process of cardiac patients and the used
strategies make the experience less traumatic to them. Thus, these data provide the theoretical basis for
nursing care.
Resumo
Objetivo: Conhecer as estratégias utilizadas por pacientes no enfrentamento da doença cardíaca coronária e
do processo cirúrgico de revascularização miocárdica.
Métodos: Utilizou-se a Teoria Fundamentada nos Dados como referencial metodológico para a releitura dos
dados de um estudo mais amplo intitulado: Significando a experiência cirúrgica e o processo de viver do
paciente submetido à revascularização do miocárdio. A coleta de dados foi realizada de outubro de 2010 a
agosto de 2011, por meio de entrevista semiestruturada, com três grupos amostrais (pacientes, familiares de
pacientes e profissionais de saúde) e 23 participantes.
Resultados: Os resultados apontam as estratégias utilizadas pelos pacientes submetidos ao processo
cirúrgico de revascularização miocárdica, quais sejam: apoio familiar, espiritual e profissional.
Conclusão: A experiência da cirurgia cardíaca modifica o processo de viver do paciente cardíaco e as
estratégias utilizadas tornam a vivência menos traumática ao paciente. Logo, tais dados fornecem base
teórica para o cuidado de enfermagem.
Keywords
Myocardial revascularization; Coronary
disease; Nursing;Perioperative nursing;
Nursing care
Descritores
Revascularização miocárdica; Doença
cardíaca coronária; Enfermagem;
Enfermagem perioperatória; Cuidados
de enfermagem
Submitted
November 25, 2011
Accepted
February 21, 2013
1Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
Conflicts of interest: no conflicts of interest to declare.
9
Acta Paul Enferm. 2013; 26(1):8-13.
Koerich C, Baggio MA,Erdmann AL, Lanzoni GMM, Higashi GDC
Introduction
e myocardial revascularization surgery (CABG) is
dened as a process of restoration and preservation of
the vital capacities. It aims the return of the patient’s
physical, mental and social wellbeing.(1) In Brazil, in
2011, around 100 thousand cardiac surgeries were
performed. Among these, more than 50% were relat-
ed to myocardial revascularization, an index compa-
rable to international literature(2).
e discovery of coronary heart disease in most
cases can be interpreted by the patient as a synonym
of health loss and functional disability.(3) Facing the
indication of cardiac surgery some feelings emerge,
such as fear of death and rebellion against God, due
to the association made between the disease onset
and a superior power.(3) In this sense, the nursing
professionals with their knowledge and experience
can assist the patients in coping with coronary heart
disease and the myocardial revascularization surgical
process.
Human beings as complex forms of existence,
connected with their parts and their whole, estab-
lish relationships with themselves, with others and
with the environment in which they live. In order
to understand one being, it is necessary to consid-
er the established relationships, as well as respect the
internal and external inuences of this environment.
(4) e patient with coronary heart disease requires
full attention of the health team, since besides the
incidence and severity of the disease, social and en-
vironmental factors shall be known for professional
intervention.(1) Given this scenario, it is important
to seek knowledge about the coping strategies to
overcome diculties and negative feelings used by
patients who underwent the myocardial revascular-
ization surgery.(3)
us, the study aims to know the strategies used
by patients in coping with coronary heart disease and
the surgical process of myocardial revascularization.
Methods
is is a qualitative study of exploratory and descrip-
tive character which used the Grounded eory
method(5,6) as a methodological reference. e
study was conducted based on the reinterpretation
of data from a larger study, entitled: Contextualiz-
ing the surgical experience and the living process
of the patient undergoing myocardial revasculariza-
tion. In this larger study, the categories that com-
prise the results give visibility to a component called
‘strategies’, according to the study method.(6)
Data collection was developed at the Institute
of Cardiology of Santa Catarina, which specializes
in cardiac surgery, located in southern Brazil. e
study included patients who underwent CABG,
their relatives and health professionals, totalizing 23
participants divided into three sample groups. e
rst group consisted of eight patients. e second
group was formed by six health professionals and
the third group consisted of four patients and ve
relatives, totalizing nine subjects, respectively iden-
tied by the letters “E”, “P” and “F” to preserve
the identity of participants. e theoretical model
was validated by a group of patients who underwent
CABG surgery at the same institution.
Data collection was conducted between Oc-
tober 2010 and August 2011 through individual,
semi-structured interviews and digital voice record-
ing. For the beginning of the study with the group
of patients the interviews were opened with: tell me
about your experience regarding your CABG sur-
gery. e interviews were directed by the research-
ers, from the responses of participants. e process
of open, axial and selective coding was conducted
during the stages of collection and analysis, from
the comparison of data until reaching the study
phenomenon.(6)
e comparative analysis of data of the rst
sample group (patients) identied the hypothe-
sis that the health professionals who provide as-
sistance during patients hospitalization and after
their discharge participate in coping with the pro-
cess of surgical myocardial revascularization. e
analysis of the statements of health professionals
(second sample group) pointed out the hypothe-
sis that the relatives (third sample group) have a
complicating or facilitating role in coping with the
surgical process experienced by the patient with
coronary heart disease.
10 Acta Paul Enferm. 2013; 26(1):8-13.
Myocardial revascularization: strategies for coping with the disease and the surgical process
e data analysis allowed the identication of
three categories that sustained the phenomenon
“realizing the process of experiencing myocardial re-
vascularization surgery as an opportunity of mainte-
nance of life, associated with coping with signicant
changes in lifestyle”, which are: realizing the family
in coping with the disease and surgery; having faith
and hope; participating in the rehabilitation pro-
gram. e development of the study complied with
national and international ethical standards.
e study complied with national and interna-
tional ethical standards of researches that involve
human beings.
Results
e category called “realizing the family in coping
with the disease and surgery” is composed of two
subcategories. e rst subcategory, called “feeling
the presence and support of the family”, reveals that
the presence of family members during hospitaliza-
tion is motivating to patients; a joy when faced with
coping with the surgical process. Without family
members the patient would not even have the pow-
er to undergo surgery. is can be seen in the fol-
lowing statement:
ey [the family members] were very import-
ant; [...] made me happier (F9).
e patient, given his state of fragility after
the indication of cardiac surgery, needs the family
members in the sense of searching for security and
support in a strange environment, dierent than
the usual.
It means everything! I have my kids to help me.
It is better to be helped by my children than by the
hands of a stranger (E5).
e family support smoothes the acceptance of
surgery, with a consequent decrease in the anxiety
and stress generated at the moment of surgery in-
dication.
Without them [the family], I would have run
away because it is very sad to stay in one place and
not have the support of the family (F9).
According to health professionals, the family is
an important ally in coping with the surgical pro-
cess because it has the role to reassure the patient.
erefore, the family is inserted in the pre and post-
operative nursing guidelines to receive information,
from the perioperative period until recovery and re-
habilitation after discharge.
Most family members try to talk and leave the
patient calm... We [professionals] mention the im-
portance of that in the orientation (P6).
e family more or less knows how it is going
to happen... is participation in the preoperative
guidance is pretty cool. I say the family must be
together during treatment (P2).
e family relationships, when quarrelsome,
hinder the establishment of a family support net
for the patient. us, the interference of health pro-
fessionals is necessary. Sometimes the disease and
hospitalization are a means of reestablishing rela-
tionships and smoothing the resolution of family
issues. On the other hand, when this does not hap-
pen, these problems alter the emotional balance of
the patient.
No use in bringing problems [family], no good,
‘cause otherwise it will make the patient more anx-
ious, more worried (P6).
Sometimes at home the problem is not solved,
but as a family member is ill, it can be solved or
become a snowball that interferes even in patients
who often feel outraged, bothered with the situa-
tion (P3).
e second subcategory, called “family relation-
ship after surgery”, shows that the relationships of
family cooperation and care commonly increase after
hospital discharge. erefore they favor the recovery
of patients, but the autonomy with self-care is per-
ceived as an important factor to their rehabilitation.
After a month or so I [patient] was already here
doing rehabilitation and my son came along with
me. en, later I said: you can stay home, let me go
alone ‘cause I don’t want somebody following me
around for the rest of my life (F9).
Both patients and their families face changes in
family routine and in life habits after hospital dis-
charge, which often trigger situations of stress and
conict. Pressure from the family to the patients
regarding their health may reect in reduction of
their interactions and social life.
11
Acta Paul Enferm. 2013; 26(1):8-13.
Koerich C, Baggio MA,Erdmann AL, Lanzoni GMM, Higashi GDC
I [wife] always talk to him more calmly. I try no
to be aggressive in terms of pressure, ‘cause I know
it’s not helping... Sometimes he [patient] refrains
from going to places because people talk and nag;
he doesn’t participate ‘cause he doesn’t want to hear
it. I can tell he gets hurt (F4).
e category called “having hope and faith”,
through the subcategory called “using spiritual re-
sources”, identies that faith and belief in a Higher
Being help coping with the disease. Faith means hav-
ing hope and believing everything will be alright.
My guardian angel helps me a lot. If we don’t
hold onto him by our side, light a little candle and
say a prayer, we won’t make it (E3).
Health professionals nd in the faith of pa-
tients a subsidy to help them, which serves as an
incentive for them to use spiritual resources in
overcoming and coping with the diculties inher-
ent to the process of living the myocardial revascu-
larization surgery.
I pass this part of religiosity a lot that God is
there, present at the time [of the surgery], that He
is standing there and everything will be just ne,
they’ve got to trust (P3).
e category called “participating of the reha-
bilitation program” unleashed three subcategories.
e rst called “discovering the benets of cardiac
rehabilitation” refers to the possibility that family
and patients attend lectures given by health profes-
sionals. e patient is encouraged and stimulated to
engage in the cardiac rehabilitation program avail-
able at the institution.
I attended lectures promoted in the auditori-
um and it was like relaxing, having a behavior like
that... less stressful and it has helped me in a general
way (E6).
Besides oering cardiac patients the services of
monitoring and tness, the cardiac rehabilitation
service also favors and enables the socialization of
their experiences. It is considered that recently op-
erated patients feel insecure with their health con-
ditions and the new life habits to which they will be
conditioned. Social interactions can reduce anxiety
and prevent depression.
Sometimes here in rehabilitation I meet a lot of
nice people. Here we chat... Sometimes there are
people who have undergone surgery 20 years ago.
en I’m glad (F9).
e second subcategory, called “cardiac reha-
bilitation: medical monitoring as a reward to ad-
herence” comprehends an easier access to medical
monitoring. Consequently, the prescription of
medication and the request for exams are advan-
tages oered to patients who participate of the car-
diac rehabilitation program, which aims to main-
tain the number of adherents and the continuity
of the program.
I wanna go through a battery [of medical tests];
I wanna do everything because who is in rehabili-
tation can schedule exams and appointments very
easily there [at the hospital’s outpatient clinic] (F1).
e third subcategory called “dodging dicul-
ties of access to the cardiac rehabilitation program”
reports that many patients fail to attend the pro-
gram and receive the benets oered due to nan-
cial reasons, diculties of access, return to work
routine, lack of time or lack of motivation. ese
patients are advised to perform daily walks or join
other groups that deal with physical reconditioning,
according with the cardiac surgery and the clinical
condition.
It is near here where I do now... It is good here
because there is a gym..., even on rainy days we do it.
Yesterday we went [patient and wife]. Today we did
it in the gym because it was too cold outside (F2).
Discussion
e results showed data from the population of pa-
tients, family members and professionals of a high
complexity institution. However future studies may
include other subjects and scenarios of care with re-
vascularized cardiac patients.
e family represents the most important sup-
port network used by its members in cases of ill-
ness and hospitalization. It is considered the rst
instance of health assistance, a producer of care ac-
tions and whose relationships constitute strategies
for coping with the disease process.(7)
rough education in health, the professionals,
when involved with patients and family, may favor
12 Acta Paul Enferm. 2013; 26(1):8-13.
Myocardial revascularization: strategies for coping with the disease and the surgical process
changes in lifestyle and the exercise of autonomy
in self-care by the patient after hospital discharge.
(8,9) In this sense the presence of family is valued by
health professionals during perioperative orienta-
tion. erefore, it is possible for the family to un-
derstand the coronary cardiac disease and the sur-
gical process and consequently help the patients in
coping with all that is necessary.
After hospital discharge, even with an increase
in care and family cooperation aiming to favor the
recovery of the patient, situations of family conict
may happen and aect the course of treatment and
recovery of the revascularized patient. e return to
family routine can lead to family and patient anxi-
ety and fear of dealing with the new situation, away
from the cares of the healthcare team.(10) e family
member, in exercising the role of a caregiver outside
the hospital environment, can assume an inexible
behavior and impose very strict rules, increasing the
resistance or noncompliance with treatment by the
patient.(9)
According to another study, the family relation-
ships kept within their home settings have positive
eects in the health of its members, as the charac-
teristics of this context are directly associated with
the self-care behavior that the patient has.(11) is
statement reinforces the need for interaction and
partnership between health professionals and fam-
ily members to the success of treatment, recovery
and rehabilitation of the cardiac patient.
Besides the family support network, patients
have spiritual resources as a source of security, faith
and hope. Faith is considered important to the pa-
tient in coping with the cardiac disease and in the
search for quality of life,(12) and prayer is related to
fewer complications in the postoperative period of
cardiac surgery, as well as bringing positive results to
health(13,14) through belief.
e health professional, particularly in the nurs-
ing area, due to maintaining a closer contact with
patients during hospitalization, has to be alert, ap-
preciate and stimulate the spiritual resources in or-
der to promote the psychic wellbeing of the patient
and ensure a less traumatic experience.
Regarding the initiation of patients in cardi-
ac rehabilitation when they are still hospitalized,
the advantages of participating of this service are
explained to patients and families by health profes-
sionals, considering the importance of an early start of
physical activities. e cardiac rehabilitation program
aims a quick return to the productive and active life
of the patient, in the same way that the introduction
of educational moments is important in the patient’s
preparation since the preoperative period.(1)
Besides the physical reconditioning, the cardiac
rehabilitation program performed at the institution
of data collection or in other spaces broadens the
possibilities of socialization, interaction and ex-
change of experiences among patients in order to
avoid anxiety and prevent depression. Evidences
conrm this nding when it is veried that rehabili-
tation exercises based on specic and individualized
recommendations(15) have a positive eect on the
mental health of revascularized patients, in accor-
dance with the prognosis of depression during the
postsurgical period of these subjects.(16)
e actions of education in health should start
at the hospital but the services of primary health-
care have to continue this practice. It is necessary to
reinforce the importance of rehabilitation to the pa-
tient and encourage him in the practice of self-care.
Studies arm the need for patients in the cardiac
postoperative period to be monitored by a primary
healthcare team and these professionals should be
able to assess their recovery.(15,17)
us, it is appropriate that health professionals
of the hospitals work together with the healthcare
teams of primary care service in the sense that they
use the system of reference and counter-reference
for patients in process of recovery from myocardial
revascularization surgery.
Conclusion
e main strategies used by patients to cope with
coronary cardiac disease and the process of myocar-
dial revascularization are based on the presence and
support of the family, the quality of interfamily re-
lationships, the use of spiritual resources and partic-
ipation in rehabilitation programs that in addition
to physical tness, enable social interactions.
13
Acta Paul Enferm. 2013; 26(1):8-13.
Koerich C, Baggio MA,Erdmann AL, Lanzoni GMM, Higashi GDC
It appears that the experience of cardiac surgery
modies the process of living of the cardiac patient,
while the coping strategies used in this process make
the experience less traumatic and provide theoreti-
cal basis for the nursing care.
Collaborations
Koerich C; Baggio MA; Lanzoni GMM and Higashi
GDC declare to have contributed with the concep-
tion and design, analysis and interpretation of data;
drafting and writing the article, critical review of the
intellectual content. Erdmann AL contributed with
the nal approval of the version to be published.
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