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UBC Theses and Dissertations

Concerns of adult open heart surgery patients during the three to four weeks following discharge from… O’Loane, Brenda Maureen 1975

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CONCERNS OF ADULT OPEN HEART SURGERY PATIENTS DURING THE THREE TO FOUR WEEKS FOLLOWING CISCHARGE FROM HOSPITAL by SISTER BRENDA MAUREEN O'LOANE B.A., MOUNT SAINT VINCENT UNIVERSITY, 1966 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n the School of Nursing We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1975 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t o f the requirements f o r an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available f o r reference and study. I further agree that permission f o r extensive copying of t h i s thesis f o r sch o l a r l y purposes may be granted by the Head of my Depart-- ment or by his representatives. It i s understood that copying or publication of t h i s thesis f o r f i n a n c i a l gain s h a l l not be allowed without my written permission. _ The University of B r i t i s h Columbia Vancouver, Canada Department of i i ABSTRACT A DESCRIPTIVE STUDY TO EXPLORE THE CONCERNS OF ADULT OPEN HEART SURGERY PATIENTS DURING THE THREE TO FOUR WEEKS FOLLOWING DISCHARGE FROM HOSPITAL This d e s c r i p t i v e study was designed t o explore the perceived concerns of open heart surgery p a t i e n t s f o l l o w i n g t h e i r discharge from h o s p i t a l . The study was conducted by means of semi-structured i n t e r v i e w s of twenty p a t i e n t s who were convalescing from open heart surgery, who met a s e t of s p e c i f i e d c r i t e r i a , and who gave w r i t t e n consent t o par-t i c i p a t e i n the study. A l l twenty p a t i e n t s had undergone open heart surgery i n a l a r g e urban h o s p i t a l over a period of f o u r months. The p a t i e n t s were in t e r v i e w e d by the i n v e s t i g a t o r d u r i n g t h e i r t h i r d or f o u r t h week a t home i n order t o o b t a i n a f a i r l y accurate view of the concerns and d i f f i c u l t i e s faced by them e a r l y i n t h e i r convalescence. Subsequently, the i n v e s t i g a t o r was t o i d e n t i f y the common concerns. A s e m i - s t r u c t u r e d , v e r b a l i n t e r v i e w schedule was employed t o e l i c i t spontaneous responses about the p a t i e n t s 1 p h y s i o l o g i c a l , emotional and socio-economic concerns. P a t i e n t s were a l s o asked f o r some e v a l u a t i o n of the p r i n t e d Discharge G u i d e l i n e s they received p r i o r to h o s p i t a l d i s c h a r g e . The i n v e s t i g a t o r t r a n s c r i b e d the tape-recorded i i i i n t e r v i e w s and c o m p i l e d t h e d a t a n o t i n g s p e c i f i c common c o n c e r n s o f p a t i e n t s d u r i n g s a i d p e r i o d o f c o n v a l e s c e n c e . N i n e t y - f i v e p e r c e n t o f t h e p a t i e n t s e x p r e s s e d c o n c e r n s o f a p h y s i o l o g i c a l n a t u r e . The most common c o n -c e r n s i n t h i s a r e a were p a i n , d i f f i c u l t y s l e e p i n g , and c o n -t i n u e d w e akness and t i r e d n e s s . S e v e n t y - f i v e p e r c e n t o f t h e s t u d y g r o u p e x p e r i e n c e d e m o t i o n a l c o n c e r n s , t h e most common b e i n g f r u s t r a t i o n r e s u l t i n g f r o m a low t o l e r a n c e f o r p h y s i c a l a c t i v i t y , and f e e l i n g s o f d e p r e s s i o n . T h i r t y p e r -c e n t o f t h e p a t i e n t s e x p r e s s e d s o c i o - e c o n o m i c c o n c e r n s o f w h i c h o n l y one c o n c e r n , t h a t o f f i n a n c i a l n e e d , was common t o two o f t h e p a t i e n t s . A l l t w e n t y p a t i e n t s r e c e i v e d t h e D i s c h a r g e G u i d e -l i n e s i n t h e h o s p i t a l . N i n e t e e n o f t h e s e i n s t r u c t i o n s h e e t s were c o m p l e t e d , one was n o t . E i g h t y - f i v e p e r c e n t o f t h e p a t i e n t s r e c e i v e d some e x p l a n a t i o n o f t h e s e p r i n t e d i n -s t r u c t i o n s . T h i r t y - f i v e p e r c e n t o f t h e s t u d y g r o u p r e c e i v e d some w r i t t e n e l a b o r a t i o n o f t h e i n s t r u c t i o n s , i n c l u d i n g a s c h e d u l e f o r i n c r e a s i n g w a l k i n g a c t i v i t y . The s t u d y c o n c l u d e d w i t h r e c o m m e n d a t i o n s f o r b e t t e r p r e p a r a t i o n o f o p e n h e a r t s u r g e r y p a t i e n t s f o r h o s p i t a l d i s c h a r g e , and s u g g e s t i o n s o f a r e a s f o r f u r t h e r i n v e s t i -g a t i o n . i v TABLE OF CONTENTS Page LIST OF TABLES v i i i ACKNOWLEDGMENTS i x Chapter I INTRODUCTION TO THE STUDY 1 INTRODUCTION 1 THE PROBLEM 1 Statement of the Problem 1 Significance of the Problem 2 SPECIFICS OF THE STUDY 4 Purpose of the Study 4 Objectives of the Study 4 Limitations of the Study 5 D e f i n i t i o n of Terms 6 OVERVIEW OF THE REMAINDER OF THE STUDY 7 II REVIEW OF SELECTED LITERATURE 9 INTRODUCTION 9 DEVELOPMENT OF HEART SURGERY TO DATE 9 Correction of Coronary Artery 10 Disease Correction of Valvular Disease 13 v v i Chapter Page PREOPERATIVE CONSIDERATIONS 14 Physical Assessment 15 Psychological Determinants of Postoperative Well-being... 16 POSTOPERATIVE COURSE 18 Physiological Trauma of Open Heart Surgery 18 Psychological Trauma 21 CONVALESCENCE AND REHABILITATION 25 PREPARATION FOR DISCHARGE 28 RELATED STUDIES 32 SUMMARY 33 III RESEARCH DESIGN AND METHOD OF STUDY 34 SETTING 34 Cardiac Surgical Unit 34 Preoperative Orientation 34 Postoperative Teaching 35 SELECTION OF THE SAMPLE 36 I n i t i a l Contact with Patients 36 Interview Arrangements 37 COMPILATION OF DATA 39 SUMMARY 40 IV ANALYSIS OF DATA 41 DEMOGRAPHIC DATA 41 Mari t a l Status 41 Age 41 v i i Chapter Page Operative Procedures 41 Postoperative Complications 43 Interview Data 44 PATIENTS' EXPRESSED CONCERNS 45 Physiological Concerns 46 Emotional Concerns 51 Socio-Economic Concerns 52 DISCHARGE INSTRUCTIONS 54 Variety of Instructions 54 Adequacy of Discharge Guidelines 56 Patients' responses 56 Differences with varied instructions 57 POSITIVE ELEMENTS OF CONVALESCENCE...... 5^ FURTHER STUDY FINDINGS 59 Coping with Concerns 59 Patients' f e e l i n g s of Well-being ..... 61 Unexpected Elements of Convalescence.. 62 SUMMARY 63 V SUMMARY, .'CONCLUSIONS AND AREAS FOR -FURTHER INVESTIGATION 64 SUMMARY 64 Purpose of the Study 64 Methodology 64 Findings . 65 CONCLUSIONS.. 66 AREAS FOR FURTHER INVESTIGATION 68 v i i i BIBLIOGRAPHY 69 APPENDIXES 75 A. Consent Form 76 B. Discharge Guidelines 77 C. Patient P r o f i l e Sheet 81 D. Interview Schedule #2 E . Miscellaneous Physiological Concerns #3 F. Locations of Pain Reported by Patients # 4 G. Miscellaneous Emotional Concerns #5 H. Socio-Economic Concerns 56 I. Positive Aspects of Convalescence #7 J. Unexpected Aspects of Convalescence LIST OF TABLES Table Page I FREQUENCIES AND PERCENTAGES OF OPEN HEART SURGICAL PROCEDURES UNDERGONE BY THE TWENTY PATIENTS IN THE STUDY GROUP 43 II FREQUENCIES AND PERCENTAGES OF CONCERNS EXPRESSED BY TWENTY OPEN HEART SURGERY PATIENTS FOLLOWING HOSPITAL DISCHARGE 45 III COMMON PHYSIOLOGICAL CONCERNS OF PATIENTS IN THE STUDY GROUP EXPRESSED IN FREQUENCIES AND PERCENTAGES 50 IV C0I«M0N EMOTIONAL CONCERNS OF PATIENTS IN THE STUDY GROUP EXPRESSED IN FREQUENCIES AND PERCENTAGES 52 V FREQUENCIES AND PERCENTAGES OF AMOUNTS OF DISCHARGE INSTRUCTION RECEIVED BY STUDY GROUP PATIENTS 56 VI FREQUENCIES AND PERCENTAGES OF PERSONS ON WHOM PATIENTS RELIED TO HELP THEM COPE WITH CONCERNS 60 i x ACKNOWLEDGMENTS My thanks are expressed to my Committee chairman, Mrs. Ethel Warbinek and Committee member, Miss Elizabeth Cawston for t h e i r assistance during t h i s study; to Mrs. Sharon Johnson and the s t a f f of the Cardiac Surgical Unit f o r t h e i r help and cooperation; and f i n a l l y , to the members of the Sisters of Charity f o r t h e i r support and encouragement. x CHAPTER I INTRODUCTION TO THE STUDY INTRODUCTION Health education i s a r e s p o n s i b i l i t y of the h o s p i t a l that d e l i v e r s health care to patients. Because learning i s motivated by need i t becomes a r e s p o n s i b i l i t y of health professionals to asc e r t a i n the patients' needs f o r l e a r n -i n g . O n e tangible way of i d e n t i f y i n g patients' common learning needs i s to document the concerns and d i f f i c u l t i e s experienced by patients with s i m i l a r conditions. U n t i l t h i s type of documentation i s ava i l a b l e the content of health education programs r i s k s being somewhat i r r e l e v a n t to the patients' actual s i t u a t i o n s . This study was undertaken to explore the concerns and d i f f i c u l t i e s of a s p e c i f i c a l l y defined group of patients, although the larger need was recognized. THE PROBLEM Statement o f the Problem The factors which combined to give impetus to ^Carl R. Rogers, Freedom to Learn (Columbus, Ohio: Charles E. M e r r i l l Publishing Co., 1969), pp. 158-159. 1 2 i n i t i a t i n g t h i s study were the investigator's personal experience of having undergone open heart surgery and the dearth of documentation av a i l a b l e as to the d i f f i c u l t i e s and worries experienced by the open heart s u r g i c a l patient following his discharge from the h o s p i t a l . It seemed appro-pr i a t e , therefore, to i n v i t e patients to express t h e i r concerns; i . e . the events or f e e l i n g s that caused them d i s -comfort or anxiety or that raised questions during t h e i r f i r s t three to four weeks out of the h o s p i t a l . Significance of the Problem During the past twenty years open heart surgery has become commonplace i n the l a r g e r medical centers i n Canada. At the time of the study open heart surgery candidates from B r i t i s h Columbia and the Yukon T e r r i t o r y were referred f o r t h e i r operations to two medical f a c i l i t i e s i n Vancouver. In 4 one of the f a c i l i t i e s , the group of "out-of-town" patients comprised nearly one-third of the population i n the cardiac s u r g i c a l u n i t . These patients often returned to t h e i r homes immediately following discharge from h o s p i t a l and t h e i r l o c a l physicians guided t h e i r convalescent course. As A s p i n a l l pointed out, a planned postoperative teaching program was e s s e n t i a l to prepare these patients f o r d i s ^ . charge and to ensure co n t i n u i t y of care during the ensuing p convalescent period. 2Mary J o A s p i n a l l , Nursing-the Open-Heart Surgery  Patient (New York: McGraw-Hill C o . , 1 9 7 3 J , p . 2 2 2 . 3 Despite the f a c t that open heart surgery was now a r e l a t i v e l y common type of major surgery and the r i s k f a c t o r '3 was as low as two percent i n many cases, the patient often 4 saw himself with a mere f i f t y percent chance of s u r v i v a l , thereby unnecessarily increasing his anxiety l e v e l . ^ Pre-operative teaching programs which included information and instr u c t i o n s had been devised i n most cardiac s u r g i c a l units to help a l l a y the patients' anxiety and to promote t h e i r p a r t i c i p a t i o n i n t h e i r own care preoperatively and postop-5 e r a t i v e l y . Postoperative teaching and discharge prep-aration was a d i f f e r e n t matter. Pohl stated that i n common practice t h i s was an area which did not receive the emphasis i t deserved: 4 As a r u l e , convalescent patients are well motivated to learn because they want to return to t h e i r homes and resume t h e i r normal l i v e s . . . The teaching of the conva-lescent patient i s , unfortunately, often neglected. It i s unfortunate because t h i s i s the time when teaching and learning may be most e f f e c t i v e . . . when he and his family know that he i s safe and everyone's emotions are under c o n t r o l . " U n i v e r s i t y o f T o r o n t o I n t e r h o s p i t a l C a r d i o v a s c u l a r S u r g i c a l G r o u p , "The F i r s t 1000 C o r o n a r y A r t e r y R e p a i r O p e r -a t i o n s i n T o r o n t o ; " C a n a d i a n M e d i c a l A s s o c i a t i o n J o u r n a l . CXI (September 21, 1 9 7 4 ) , 525. 4 R i c h a r d S. B l a c h e r . "The H i d d e n P s y c h o s i s o f Open-H e a r t S u r g e r y , " J o u r n a l o f A m e r i c a n M e d i c a l A s s o c i a t i o n . C CXXII ( O c t o b e r 16, 1 9 7 2 ) , 3 06. ^ M a d e l e i n e L. L o n g , M a r y S c h e u h i n g , and J u d i t h L . C h r i s t i a n , " C a r d i o p u l m o n a r y Bypass,"' A m e r i c a n J o u r n a l o f  N u r s i n g . LXXIV (May, 1 9 7 4 ) , 363-365. ^ M a r g a r e t L . P o h l , The T e a c h i n g F u n c t i o n o f t h e  N u r s i n g P r a c t i t i o n e r (2d e d . ; Dubuque: Wm. C. Brown Co. P u b l i s h e r s , 1 9 7 3 ) , p p . 45 -A6 . 4 Many studies reported on the severe physical and psychological stresses of cardiotomy patients during the immediate postoperative period. Other studies reported the long-term r e s u l t s of open heart surgery and also the success i n r e h a b i l i t a t i n g these patients. The ear l y convalescent phase following h o s p i t a l discharge had apparently been a l -most neglected by the researchers and the problems and concerns of patients during t h i s period remained to be iden-7 t i f i e d more conclusively. Purpose of the Study The purpose of t h i s study was to explore the con-cerns perceived by patients who had undergone open heart surgery. This survey was to deal with the f i r s t three to four weeks following discharge from h o s p i t a l , and subse-quently the investigator was to i d e n t i f y the concerns common to these p a t i e n t s . Objectives of the Study The objectives of t h i s study were t o : 1. i d e n t i f y the p h y s i o l o g i c a l , emotional and socio-economic concerns of open heart surgery patients during the f i r s t three to four weeks following h o s p i t a l discharge; 2. i d e n t i f y concerns common to these patients; 7Sharon C. Wahl, "The Problems of Thirty-One Post-Operative Open Heart Surgery Patients a f t e r Discharge" (unpublished Master's t h e s i s , University of Oregon, 1 9 7 3 ) , P. 3. 5 3» determine the p a t i e n t s ' perceptions of the adequacy of the w r i t t e n i n s t r u c t i o n s received p r i o r to discharge; 4. note the p o s i t i v e elements i n the convalescent p e r i o d . L i m i t a t i o n s of the Study The study was l i m i t e d by: (1) the s m a l l s i z e o f the * * sample, (2) the l i m i t e d s e t t i n g , and (3) the predominance of males i n the sample p o p u l a t i o n . Some of these l i m i t a -t i o n s were unavoidable because of the i n v e s t i g a t o r ' s l i m i t e d time. Size of sample. Since the c o l l e c t i o n of data was by i n t e r v i e w , o n l y those p a t i e n t s who could be reached i n t h e i r homes were chosen f o r the sample. P a t i e n t s were asked t o p a r t i c i p a t e i n the study p r i o r t o t h e i r discharge from hos-p i t a l . Those who were discharged without the researcher's knowledge were not contacted f o r an i n t e r v i e w . Some pa-t i e n t s who signed the consent form could not be contacted f o r an i n t e r v i e w . The sample of twenty p a t i e n t s was not a random s e l e c t i o n but, r a t h e r , was based on a set of spec-i f i e d c r i t e r i a , as explained i n Chapter I I I . Limited s e t t i n g . During the time period of t h i s study at l e a s t o n e - t h i r d of the p a t i e n t s i n the c a r d i a c s u r g i c a l u n i t s e t t i n g were from r u r a l or s m a l l urban s e t -t i n g s . I t i s p o s s i b l e t h a t these persons perceived t h e i r 6 concerns d i f f e r e n t l y , s i n c e the expert help of the c a r d i o -l o g i s t was not r e a d i l y a v a i l a b l e . A l l p a t i e n t s i n t e r v i e w e d l i v e d i n o r near the Greater Vancouver area and t h e r e f o r e a l l were c l o s e t o expert medical help should they need i t . Predominance of males» Seventeen persons out of the twenty i n the sample were males. This number i s f a i r l y c o n s i s t e n t w i t h the predominance of men a f f e c t e d w i t h c o r -onary a r t e r y disease but may g i v e a d i s t o r t e d view when r e -p o r t i n g the concerns of open heart surgery p a t i e n t s as a groupo The r e s u l t s of t h i s study a p p l i e d o n l y t o the group s t u d i e d * DEFINITION OF TERMS Complications of Open Heart Surgery In t h i s study the term r e f e r s t o any event which caused (1) a r e t u r n t o the I n t e n s i v e Care U n i t a f t e r t r a n s -4 f e r t o the Cardiac Surgery U n i t , (2) a r e t u r n t o the Oper-a t i n g Room, and (3) a p r o l o n g a t i o n of the h o s p i t a l s t a y beyond t h i s study's average of s i x t e e n days. Concerns This r e f e r s to any occurrence or c o n d i t i o n t h a t was perceived by the p a t i e n t s as the cause of discomfort or worry, or t h a t r a i s e d questions which seemed important t o 4 4 °Marvin J . Goldman, "Medical. Acpects," The Cardiac  P a t i e n t : A Comprehensive Approach, ed. Richard G. Sanderson ( P h i l a d e l p h i a : W.B. Saunders Co., 1972), pp. 62-95» 7 them during the interviews. Discharge Instructions This r e f e r s to the printed Discharge Guidelines given to the patients before discharge from h o s p i t a l . It was the custom i n the Cardiac Surgical Unit used i n t h i s 4 4 study to have the c a r d i o l o g i s t , or more r a r e l y the surgeon, f i l l i n the two pages of printed i n s t r u c t i o n s as he or she saw f i t . Patients going home on anticoagulant therapy received a copy of the explanation of anticoagulants. These handouts are to be found i n Appendix B. Open Heart Surgery This term i s limited to s u r g i c a l procedures carried out using t o t a l cardiopulmonary bypass 0 OVERVIEW OF THE REMAINDER OF THE STUDY The remainder of the study i s as follows: Chapter II i s a selected review of the l i t e r a t u r e pertaining to open heart surgery: the present state of t h i s type of surgery, the p h y s i o l o g i c a l and psychological trauma associated with i t , and postoperative convalescence and r e h a b i l i t a t i o n . Consideration i s also given to the areas of planning f o r discharge and of teaching patients p r i o r to t h e i r discharge. Chapter III reports on the research design and the method-ology of the study. Chapter IV contains a discussion on the method of analysis and an in t e r p r e t a t i o n of the f i n d -ings. Chapter V contains the summary of the study, the conclusions, and the areas f o r further investigation,, CHAPTER II SELECTED REVIEW OF THE LITERATURE INTRODUCTION This chapter reviewed selected l i t e r a t u r e that pertained to the care of open heart surgery patients. Since i t would have been incomplete to consider one facet of open heart surgery i n i s o l a t i o n from the others the review covered f i v e major areas: (1) the development of open heart surgery to date, (2) the preoperative consider-ations of open heart surgery patients, (3) the physio-l o g i c a l and psychological trauma caused by open heart surgery, (4) the period of convalescence and r e h a b i l i t a t i o n and (5) planning and teaching f o r discharge from h o s p i t a l . DEVELOPMENT OF HEART SURGERY TO DATE It was just twenty-one years ago that Gibbon per-formed the world's f i r s t successful open heart surgery f o r correction of a congenital heart defect.^" By 1974 the diagnostic evaluation of patients had become more accurate with advances i n cardiac catheterization and coronary xJohn H. Gibbon, "Application-of a Mechanical Heart and Lung Apparatus to Cardiac Surgery," Minnesota Medicine. XXXVII (March, 1 9 5 4 ) , 171-180. 9 10 cineangiography. The s u r g i c a l techniques had kept pace with these diagnostic advances and open heart surgery was now carried out to correct congenital heart defects as w e l l as to r e p a i r the e f f e c t s of acquired heart disease. Today, complex congenital anomalies may be d e f i n -i t i v e l y repaired, damaged valves may be repaired or replaced, coronary a r t e r i e s may be repaired or bypassed, and even the heart i t s e l f can be replaced.3 Surgery to correct congenital defects was u s u a l l y performed on young ch i l d r e n . ^ Only a small percentage of adults had uncorrected congenital defects and s u r g i c a l 5 correction of these was advocated. The usual i n d i c a t i o n f o r open heart surgery on an adult was some form of acquired heart disease, such as coronary artery disease and va l v u l a r disease„ . -Correction of Coronary Artery Disease The s u r g i c a l correction of acquired coronary a r t e r y disease had received much attention i n both Canada and the John A. Crouch et a l , "Operative Rssults i n 1,426 Consecutive Cardiac Surgical Cases," Journal of Thoracic  and Cardiovascular Surgery. LXVII (October, 1974), 606. 3Richard G. Sanderson, "Surgical Aspects ?" The  Cardiac Patient: A Comprehensive Approach, ed.-Richard G. Sanderson (Philadelphia: W. B. Saunders Co., 1972), p. 107. ^Douglas M. Behrendt and W. Gerald Austen, Patient  Care i n Cardiac Surgery. (Boston: L i t t l e , Brown and Co., 1972), p . 1. - 5Barbara Rogoz. "Nursing Care of the Cardiac Surgery Patient," Nursing C l i n i c s of North America. IV (December, 1969), 632. 11 United States. The pathological problem was "a narrowing of the coronary a r t e r i e s which prevents adequate amounts of blood from reaching the heart muscle."^ It was commonly corrected by a coronary bypass operation using eith e r r e -versed segments of autogenous saphenous vein or, le s s f r e -4 quently, the i n t e r n a l mammary artery which was d i r e c t l y 7 anastamosed into the coronary artery. The usual i n d i c a t i o n f o r surgery was medically i n t r a c t a b l e angina pectoris with-out severe impairment of l e f t v e n t r i c u l a r function. Wilson commented that usual i n d i c a t i o n s f o r the coronary artery 4 4 bypass are crescendo, accelerated, unstable or 'pre-i n f a r c t i o n ' angina, and r e f r a c t o r y cardiogenic shock com-p l i c a t i n g an acute i n f a r c t i o n . The mortality figures f o r coronary bypass g r a f t i n g appeared to be more d i r e c t l y r e l a t e d to l e f t v e n t r i c u l a r function preoperatively than to any other s i n g l e f a c t o r . The University of Toronto Interhospital Cardiovascular Surgery Group reported that with good l e f t v e n t r i c u l a r status the h o s p i t a l mortality rate was le s s than 3 percent 4 4 * 6 R i chard G. Sanderson, "Anatomy, Embryology, Physiology and Pathology," The Cardiac Patient: A Compre- hensive Approach, ed. Richard G. Sanderson (Philadelphia: W. B. Saunders Co., 1972), p. 5 0 . ^Nicholas T. Kouchoukos and John W. K i r k l i n , - • "Coronary Bypass Operations f o r Ischemic Heart Disease,"' Modern Concepts of Cardiovascular disease. XLI (October, 1972), 47; see also W. Stan Wilson, "Aortocoronary Bypass Surgery II - An Updated Review," Heart and Lung III (May-June, 1974), 440-442. aWilson, p. 4 4 5 . 12 i n the one thousand patients operated on over a f i f t y - s i x month period and l e s s than 2 percent i n the l a s t twelve o months of the study. Kouchoukos and K i r k l i n reported a h o s p i t a l mortality rate of just over 6 percent i n 4&0 pa-t i e n t s with good l e f t v e n t r i c u l a r functioning who underwent surgery p r i o r to 1972. Wilson, defining the current status of aortocoronary bypass surgery, stated that almost a l l s u r g i c a l series reported 6 percent or l e s s s u r g i c a l mortality i n appropriately selected patients."^ The r e l i e f of angina pectoris was more rapid when reva s c u l a r i z a t i o n was carried out using a saphenous vein g r a f t , because blood was immediately supplied to ischemic 12 segments of myocardium. The anastamosis of the i n t e r n a l mammary artery i n i t i a t e d the establishment of a c o l l a t e r a l c i r c u l a t i o n and r e l i e f of angina pectoris was delayed u n t i l 13 t h i s c i r c u l a t i o n was established. J This f a c t had impor-tance i n planning f o r the convalescence of patients under-going a r e v a s c u l a r i z a t i o n procedure. ^University of Toronto Interhospital Cardiovascular Surgical Group, "The F i r s t 1,000 Coronary Artery Repair Operations i n Toronto," Canadian Medical Association Journal. CXI (September 21, 1974), 525. •^Kouchoukos and K i r k l i n , p. 43, i : LWilson, p. 435. 12 ' Mary R. Brogan, "Nursing Care of the Patient Experiencing Cardiac Surgery for-Coronary A r t e r y Bypass," Nursing C l i n i c s of North America. VII (September, 1972), 519. •^Rogoz, p. 633. 13 Long-term r e s u l t s of r e v a s c u l a r i z a t i o n procedures cannot be researched as yet. Morch et a l . followed up one hundred patients with coronary bypass grafts twelve to twenty-four months postoperatively (a mean of 19.7 months) 14 and found that 75 percent of the grafts were patent. Wilson reported that i n comparing patients treated conser-v a t i v e l y with those treated by vein bypass graft " s u r v i v a l from one year onward i s favorably influenced by vein bypass surgery...at l e a s t i n patients with multi-vessel or l e f t 15 main proximal disease." Correction of Valvular Disease Acquired v a l v u l a r disease was commonly found i n patients who had had one or more attacks of rheumatic fever, though there were other causes as w e l l . ^ The stan-dard s u r g i c a l treatment f o r severe congenital and acquired cardiac v a l v u l a r disease was t o t a l replacement of cardiac valves with homograft or heterograft valves, stinted or unstinted valves, or mechanical valves made from synthetic 17 materials. Crouch et a l . noted that of 247 patients ^"John Morch et a l . , "Late Results of Aortocoronary Bypass Grafts i n 100 Patients with Stable Angina Pectoris," Canadian Medical Association Journal. CXI (September 21, 1974), 530. : 15 ' Wilson, pp. 444 and 448. 16 -Sanderson, "Anatomy, Embryology, Physiology and Pathology," pp. 42-50 17 ' • Denton A. Cooley et a l . , "Ten Year Experience with Cardiac Valve Replacement:•Results with a•New M i t r a l Pros-t h e s i s , " Annals of Surgery.- CLXXVII (June, 1973), #18. 14 operated on f o r valv u l a r replacement, mechanical valves were inserted i n 234 of the patients and the o v e r a l l m o r t a l i t y 13 rate was only 5.6 percent. Barrett-Boyes reported a hos-p i t a l m ortality rate of 5.5 percent and a l a t e m o r tality rate of 3 percent using honograft a o r t i c valves i n patients 19 with severe a o r t i c valve disease. Various other open heart s u r g i c a l procedures were ro u t i n e l y performed i n les s e r numbers than the above-mentioned ones. They were not considered here because they were not relevant to the present study. PREOPERATIVE CONSIDERATIONS Brogan stated that: Preoperative preparation i s directed toward the attainment of maximum physical and psychologic s t a b i l -i t y i n order to a s s i s t the patient to withstand the stress of surgery. Long, Scheuhing and C h r i s t i a n noted that the preoperative care of a l l patients undergoing cardiopulmonary bypass was s i m i l a r and involved a thorough p h y s i o l o g i c a l and psycho-l o g i c a l assessment, as well as a great deal of teaching f o r ^Crouch et a l . , p. 607. -^B. G. Barratt-Boyes, "Homograft Replacement f o r Aortic Valve Disease," Modern Concepts of Cardiovascular  Disease. XXXVI (January, 1967), 1. 20 Rogoz, p. 632; see also Crouch et a l . , p. 60#. 2 lBrogan, p. 520. 15 22 both patients and f a m i l i e s . These three areas, physio-l o g i c a l and psychological assessment, and teaching were here considered with reference to selected l i t e r a t u r e . Physical Assessment Rogoz suggested that the preoperative medical work-up include: (1) medical h i s t o r y , (2) physical examination, (3) d a i l y weight, (4) observation of v i t a l signs twice a day, (5) measurement of intake and output, (6) low sodium d i e t , (7) laboratory tests relevant to any major surgery, (8) electrocardiogram, (9) chest X-ray, and (10) medications # as necessary f o r sleep, e l e c t r o l y t e s t a b i l i t y and d i g i t -23 a l i z a t i o n . Special examinations such as pulmonary func-t i o n studies, angiocardiography and cardiac catheterization should have been performed at t h i s time i f they had not 24 already been done. Other necessary measures noted i n '25 the l i t e r a t u r e included good skin care, prevention of •26 i n f e c t i o n , and pulmonary preparation, including the 22 •Madeleine L. Long, Mary Scheuhing, and Judith L. C h r i s t i a n , "Cardiopulmonary Bypass," American Journal of  Nursing, LXXIV (May, 1974), 363. 23 Rogoz, p. 636. 24 Mary Jo A s p i n a l l , Nursing the Open-Heart Surgery  Patient (New York: McGraw-Hill Co., 1973), p. 8 ; see also Rogoz, pp. 636-637. 25 •Aspinall, p. 8; see also Long, Scheuhing and Ch r i s t i a n , p. 864. 4 4 ' 2^Rogoz, p. 638; see also Sanderson, "Surgical Aspects," p. 99. 16 27 cessation of smoking. A l l dental work was to have been completed, e s p e c i a l l y i n patients who were to have pros-23 t h e t i c materials used i n t h e i r cardiac r e p a i r . Psychological Determinants of Postoperative Well-being It was the investigator's experience that open heart surgery patients endured the anxieties common to persons about to undergo major surgery. Additional anxiety stemmed from the emotional investment represented by the heart, as Blacher states: The anxiety t h i s type of surgery evokes i n both patient and s t a f f discourages a f r e e discussion of the emotional aspects of having one's heart cut open . . . It has become apparent that there i s a sense of awe surrounding the opening of the heart. It i s almost unbearable f o r most patients to conceive of t h e i r hearts being incised . . . . For t h i s reason the use of d e n i a l i s prominent both preoperatively and p o s t o p e r a t i v e l y . 2 " Abram reported that " . . . patients reacted to the operation as presenting not merely a symbolic but a r e a l i s t i c threat to l i f e . " 3 0 The symbolism and emotional overtones of 2?Sanderson, "Surgical Aspects;" pp. 93-99; see also William E. N e v i l l e and Robert D. Lynch; "The Coronary Pa-t i e n t f o r Myocardial Revascularization," Care of the Sur- g i c a l Cardiopulmonary Patient f ed. William E. N e v i l l e , (Chicago: Year Book Medical Publishers, 1971), p. 34; see also Brogan, p. 520. 23 Behrendt and Austen, p.3. 29 Richard S. Blacher, "Hidden Psychosis of Open Heart Surgery: With a Note on the Sense of Awe," Journal of the American Medical Association. CCXXII (October 16, 1972), 305-306. ^ H a r r y S. Abram and Benjamin F. G i l l , Predictions of Postoperative Psychiatric Complications," New England  Journal of Medicine f CCLXV (December 7, 1961), 1128. 17 "heart" were deeply ingrained i n many in d i v i d u a l s and thus 31 had a potent psychological impact. This may not have been consciously recognized by patients and s t a f f . Kennedy and Bakst i d e n t i f i e d anxiety as a f a c t o r common to a l l patients with heart disease. They observed that the causes of t h i s anxiety were the t e r r i f y i n g symp-toms such as chest pain and p a l p i t a t i o n s , the threat of death that i s inherent i n heart disease, and the actual or anticipated experience of physical l i m i t a t i o n s along with 32 the knowledge that these l i m i t a t i o n s are progressive. * In the open heart surgery patients they studied, the highest mortality rate was i n those preoperative patients with high anxiety l e v e l s and low motivation to recover. They concluded that the p a t i e n t s 1 preoperative p h y s i o l o g i c a l and psycho-l o g i c a l states were inseparable and both must be attended to 33 f o r optimal s u r g i c a l conditions. Henrichs et a l . reported that male non-survivors showed pronounced anxiety pre-operatively and female non-survivors were observed to have emotional o v e r c o n t r o l . ^ 31 Janet A. Kennedy and Hyman Bakst, "The Influence of Emotions on the Outcome of Cardiac Surgery," B u l l e t i n of the New York Academy of Medicine. XLII (October, 1966),812 32 Kennedy and Bakst, p. 826. 33 ' Kennedy and Bakst, pp. 842-845. •^Theodore F. Henrichs, James N. MacKenzie and Carl H. Almond, "Psychological Adjustment and Acute Response to-Open Heart Surgery," Journal of Nervous and Mental Disease T CXLVII (February, 1969") , 164. 18 Layne and Yudofsky studied f i f t y - e i g h t cardiotomy patients and twenty major vascular surgery patients who would not or could not express t h e i r anxiety preoperatively and these researchers found a high c o r r e l a t i o n between t h i s non-expression and postoperative psychotic episodes. Abrara and G i l l also found that the degree of preoperative anxiety experienced by open heart surgery patients was one of the factors related to the postoperative psychological 36 course. POSTOPERATIVE COURSE Physiological Trauma of Open Heart Surgery Besides postoperative d i f f i c u l t i e s such as shock and hemorrhage associated with general surgery, there were some problems that were unique to patients who underwent cardio-pulmonary bypass. These are considered below. Cardiac complications. Cardiac arrhythmias were f a i r l y common and appeared to be the r e s u l t of operative trauma, 37 acid-base imbalance, drug t o x i c i t y , hypotension or hypoxia. ' 3 5 0 t t i s L. Layne and Stuart C. Yudofsky, "Post-operative Psychosis -in Cardiotomy Patients," New England  Journal of Medicine. CCLXXXIV (March 11, 1 9 7 1 ) , 518-520. 36 Harry S. Abram and Benjamin F. G i l l , "Predictions of Postoperative Psychiatric Complications," New England  Journal of Medicine. CCLXV (December 7, 19ol), 1128. •^Long, Scheuhing and C h r i s t i a n , p. 866; see also George W. Barclay, "Possible Medical Problems Associated-with Cardiac Surgery," Texas Medicine. LXIX (July, 1973), 78. 19 Other possible cardiac problems to be aware of were cardiac output syndrome and cardiac tamponade. Sanderson noted that cardiac complications may have occurred separately, but they 3 8 were often i n t e r r e l a t e d . Pulmonary complications. Verderber reported that these may have occurred i n the face of a vari e t y of long-standing heart and lung problems. Ate l e c t a s i s could occur e a s i l y unless the lungs were hyperventilated i n t e r m i t t e n t l y during cardiopulmonary bypass and i n the immediate postoperative p e r i o d . ^ Post pump perfusion syndrome (pump lung) char-acterized by a t e l e c t a s i s , pulmonary edema and hemorrhage was observed to be becoming le s s common but was often f a t a l 40 when i t occurred. Bleeding complications. S i g n i f i c a n t changes took place i n patients' c l o t t i n g mechanisms. Patients were heparinized before being placed on the pump-oxygenator and r e v e r s a l of t h i s anticoagulation may have been imperfect i n the imme-diate postoperative period. Mechanical trauma damaged and decreased the p l a t e l e t s , prothrombin and fibrinogen causing c l o t t i n g abnormalities which contributed to bleeding 3 8 Sanderson, "Surgical Aspects," pp. 124-128. 39 Anne Verderber, "Cardiopulmonary Bypass: Post-operative Complications," American Journal of Nursing. LXXIV (May, 1974), 369. ^Verderber, p. 869. 20 problems.^ Inadequate hemostasis was a common cause of excessive bleeding and f a i r l y frequently required r e -operation to control the blood l o s s . ^ Fluid and e l e c t r o l y t e problems. The balance of f l u i d s and el e c t r o l y t e s may not have returned to normal f o r several days and patients were observed c l o s e l y f o r pulmonary edema, 43 congestive heart f a i l u r e and hypokalemia. Behrendt and Austen warned that great care must be taken to avoid hypo-44 natremia and a c i d o s i s . Renal complications. When cardiac output had been or was poor, o l i g u r i a could occur. At the same time, the renal tubules were coping with tissue-breakdown products and hemolyzed red blood c e l l s . For t h i s reason i t was neces-sary to maintain a urine output of at le a s t twenty m i l l i -l i t e r s per hour.^5 Fever and i n f e c t i o n . Patients could be f e b r i l e f o r several days following cardiopulmonary b y p a s s . ^ I f the fever ^Verderber, p. 868. ^ B a r c l a y , p. 76. ^Verderber, p. 868. 44 ' /• Behrendt and Austen, pp. 53 and 56. ^Behrendt and Austen, p. 57. ^Behrendt and Austen, p. 63. 21 lasted f o r more than a few postoperative days i t might have been caused by p e r i c a r d i t i s and further action was neces-47 sary. Kouchoukos and K i r k l i n noted that i n a small number of patients p h l e b i t i s occurred i n the lower extremity from 48 which the saphenous vein had been removed. Central nervous system complications. Verderber stated that cerebral edema and brain damage might occur following open heart surgery. Possible causes might be inadequate supply 4 4 of blood to the brain during surgery, a i r or f a t emboli, 49 calcium debris, or microemboli. Thromboemboli were considered to be the most dreaded complication of m i t r a l valve replacement according to Cooley et a l . ^ Psychological Trauma Psychosis or d e l i r i u m had been noted by many who observed or studied open heart surgery patients i n the e a r l y postoperative period. Layne and Yudofsky noted that t h i s psychosis was characterized by transient v i s u a l d i s t o r t i o n , v i s u a l and auditory h a l l u c i n a t i o n s , and d i s o r i e n t a t i o n and/or paranoid delusions. In some cases these were accom-panied by hyperventilation, tachycardia and anorexia, and 47 Barclay, pp. 79-80. 48 ' . Kouchoukos and K i r k l i n , p. 48. ^Verderber, p. 868. 50 ' Cooley et a l . , p. 826. 22 occurred a f t e r a b r i e f postoperative l u c i d interval. 5 1 Hazan stated that there was a higher incidence of psychi-a t r i c complications with open heart surgery than with gener-52 a l or closed heart surgery. Kornfeld, Zimberg and Malm reported a psychosis of acute organic v a r i e t y occurring i n 38 percent of ninety-nine adult, open heart surgery pat-53 i e n t s . Abramson and Block noted that most authors e s t i -mated the occurrence rate of open heart surgery postoper-ative psychopathology at 15 to 33 percent.^*" Many causes were postulated f o r t h i s psychosis. Egerton and Kay f e l t that the u n f a m i l i a r i t y of the Intensive Care Unit, with i t s simultaneous sensory deprivation and overstimulation, was responsible f o r patients becoming 55 d i s o r i e n t e d . Kornfeld, Zimberg and Malm also i d e n t i f i e d the major f a c t o r as the environment of the open heart Re-covery Room, which, they said, provided an atmosphere of 5^-Layne and Yudofsky, p . 518. 52 S.J. Hazan, "Psychiatric Complications Following Cardiac - Surgery." Journal-of Thoracic and Cardiovascular  Surgery, LI (March, 1966), 315. 53 Donald S. Kornfeld, Sheldon Zimberg and James R. Malm, "Psychiatric Complications of Open-Heart Surgery;" New England Journal of Medicine, CCLXXIII (August 5, 1965), 291. ^Ronald Abramson and Bernard Block, "Ego-Support-ive Care i n Open Heart•Surgery,"•International Journal of  Psychiatry i n Medicine, IV ( F a l l , 1973), 427. 5^ N. Egerton and J . H. Kay, "Psychological Disturbances Associated with Open Heart Surgery," B r i t i s h  Journal of Psychiatry, CX (May, 1964), 434-436. 23 56 s e n s o r y and s l e e p d e p r i v a t i o n . McFadden and G i b l i n c o n -c l u d e d , f r o m t h e i r s t u d y , t h a t o p en h e a r t s u r g e r y p a t i e n t s d e f i n i t e l y s u f f e r e d s l e e p d e p r i v a t i o n i n t h e I n t e n s i v e C a r e 57 U n i t . Abram s a i d t h a t p a t i e n t s o f t e n p e r c e i v e d t h e I n t e n -s i v e C a r e U n i t a s p s y c h o l o g i c a l l y t h r e a t e n i n g . Budd and Brown d e m o n s t r a t e d t h e p o s i t i v e e f f e c t o f a " r e o r i e n t a t i o n p r o c e d u r e " b e g u n i m m e d i a t e l y upon t h e p a t i e n t s ' r e t u r n t o 59 c o n s c i o u s n e s s • O r g a n i c c a u s e s were p o s t u l a t e d t o e x p l a i n p s y c h i c d i s t u r b a n c e s p o s t o p e r a t i v e l y . G i l b e r s t a d t and Sako, and G i l m a n s u g g e s t e d t h a t t h e r e were s i g n s o f c e r e b r a l d i s t u r -b a n c e o r damage i n o p e n h e a r t s u r g e r y p a t i e n t s w h i c h had o r g a n i c c a u s e s , p a r t i c u l a r l y p r o l o n g e d c a r d i o p u l m o n a r y 60 ' b y p a s s t i m e . E g e r t o n and K a y p r o p o s e d d e h y d r a t i o n , e l e c t r o l y t e i m b a l a n c e a n d d r u g s a s some o f t h e p r e c i p i t a t i n g 5 6 K o r n f e l d , Z i m b e r g and Malm, p . 292. 57 E i l e e n H. McFadden and E l i z a b e t h C. G i b l i n , • S l e e p D e p r i v a t i o n i n P a t i e n t s H a v i n g O p e n - H e a r t S u r g e r y , " N u r s i n g R e s e a r c h . XX (May-June, 1 9 7 1 ) , 2 5 3 . Abram, p . 6 6 6 . 59 Suzanne P. Budd and W i l l a Brown, " E f f e c t o f R e o r -i e n t a t i o n T e c h n i q u e on P o s t c a r d i o t o m y D e l i r i u m , " N u r s i n g  R e s e a r c h . X X I I I ( J u l y - A u g u s t , 1 9 7 4 ) , 342-346. 60 H a r o l d G i l b e r s t a d t and Y o s h i o Sako, " I n t e l l e c t u a l and P e r s o n a l i t y Changes F o l l o w i n g O p e n - H e a r t S u r g e r y , " A r c h i v e s o f G e n e r a l P s y c h i a t r y . XVI ( F e b r u a r y , 1 9 6 7 ) , 2 10-214; s e e a l s o S i d G i l m a n , " C e r e b r a l D i s o r d e r s a f t e r Open-H e a r t O p e r a t i o n s , " New E n g l a n d J o u r n a l o f M e d i c i n e . C C L X X I I (March 11, 1 9 6 5 ) , 498^ 24 61 factors f o r psychotic behaviour. Blachly and Kloster not-ed that increased cardiac output with r i s i n g catacholamine 62 l e v e l s preceded psychotic episodes. However, none of these authors appeared to have conclusive evidence i n sup-port of t h e i r reports. Layne and Yudofsky, and Abram and G i l l related the degree of preoperative anxiety to psychological problems following surgery. They observed that some patients r e -l i e d heavily on denial but the mechanism was not strong enough to allow them to cope with the trauma of surgery and the environment of the Intensive Care U n i t . ^ Once the mechanism f a i l e d , psychotic episodes were noted. Weiss observed that an ". . . in d i v i d u a l ' s reaction to surgery appears to be based i n large measure on his a b i l i t y to respond e f f e c t i v e l y to overwhelming psychological s t r e s s . " ^ Blacher viewed the sense of awe surrounding the opening of the heart as being a prominent feature among the ^E g e r t o n and Kay, pp. 435-436. 6? Paul H. Blachly and Frank E. Kloster, "Relation of Cardiac Output to Post-Cardiotomy Delirium," Journal of  Thoracic and Cardiovascular Surgery, LII (September, 1966), 427. ^Layne a n c j Yudofsky, p. 520; see also Abram and G i l l , p. 1128. ^Stephen M . Weiss, "Psychological Adjustment Following Open-Heart Surgery." Journal of Nervous and Mental  Disease. CXLIII (October, 1966), 367. 25 various factors leading to the psychosis and he stated: . . . Cthe3 unique role of the heart provides the background f o r the awe reaction; when the d e n i a l can no longer be sustained, the psychosis can be seen as de-fending against awareness of an awesome r e a l i t y . When r e a l i t y i s too much to bear, a psychosis may be one's only protection. ° 5 Egerton and Kay noted several personal predisposing f a c t o r s to postoperative d e l i r i u m such as marital i n s t a b i l i t y and overwhelming personal problems unrelated to the s u r g e r y . ^ CONVALESCENCE AND REHABILITATION Convalescence and r e h a b i l i t a t i o n following open heart surgery appeared to be dependent on the f a c t that the patients had suffered both physical and psychological trauma as a r e s u l t of the surgery. White described the r e h a b i l -itated cardiac patient as . .-. one who, v/ithin the physical l i m i t a t i o n s of his disease, has been psychologically oriented to accept the l i m i t a t i o n s , and who has been returned to a productive and g a i n f u l status i n his community with these l i m i -t a t i o n s , without fear or anxiety, and with a sense of usefulness i n hi s own eyes and those of his associates both at work and i n the community.°? This r e h a b i l i t a t i o n might be d i f f i c u l t f o r some cardiotomy patients as Kaplan pointed out by observing that i n many ^ E g e r t o n and Kay, p. 43# 6 6 B l a c h e r , pp. 306-307. 6?Paul D. White e t - a l . , Cardiovascular R e h a b i l i t a t i o n (New York: McGraw-Hill Co., 1957), p. 55 cited by Doris-Houser, "Outside the Coronary Care Unit," Nursing Forumf XII (1973), 97. 26 cases, patients had changed t h e i r patterns of l i v i n g as t h e i r heart pathology warranted that change. Following surgery they often had the opportunity of resuming t h e i r l i f e s t y l e but at that point i t became apparent that some patients had used t h e i r disease f o r psychologically adap-t i v e purposes.68 Kennedy and Bakst observed s i m i l a r occurrences and agreed that f o r those patients who found the secondary gains of i l l n e s s more s a t i s f y i n g than health, the motivations f o r r e h a b i l i t a t i o n might be unacceptable. They found that convalescence was bound up with the pa-t i e n t s ' postoperative somatic complications, and the high or low cost that they would have to pay i n "assuming the burden of . . . new-found freedom."69 Return to employment was used as an index of r e -h a b i l i t a t i o n . Finchum found that surgery was often p a l -l i a t i v e and not curative, with the r e s u l t that some symptoms reduced patients' motivation to work even though they were ph y s i c a l l y able. There was also a high c o r r e l a t i o n with the length of time unemployed p r e o p e r a t i v e l y B l a c h l y and o t tStanley M. Kaplan, "Psychological Aspects of Cardiac Disease: A Study of Patients Experiencing M i t r a l ' Commissurotomy," Psychosomatic Medicine. XVIII (May-June, 1956), 222-233. 69 ' Kennedy and Bakst, p. 824. 70 R. Newell Finchum, "Rehabilitation Following Cardiac Surgery," C i r c u l a t i o n , Supplement XLIII-XLIV (May, 1971), 1-157. 27 Blachly found t h i s same c o r r e l a t i o n i n t h e i r study of 329" open heart surgery patients. They found that 41 percent of these patients remained unemployed despite the f a c t that only 6 percent of the t o t a l group f e l t that they had r e -ceived l i t t l e or no benefit from the surgery. Eighty-two of the unemployed (57.8 percent) blamed health problems as the reason f o r not returning to work and the remaining unemployed patients had various other reasons. These investigators offered t h e i r "Law of the Year"; namely: " I f a person i s unemployed f o r any reason f o r a period exceed-ing one year, the chance of re-employment i s poor," as an explanation. They suggested coordinated pre and postoper-ative programs to counteract t h i s d i f f i c u l t y . They also advised r e a l i s t i c discussion with the patients and t h e i r f a m i l i e s to prevent disappointments . Expectations were too high or out of l i n e with what was possible. They appeared to recognize the patients' needs f o r support and knowledge a f t e r discharge by suggesting that a public health nurse could make home v i s i t s to i d e n t i f y the problems 71 patients took for granted. Zohman and Tobis recognized the need f o r counselling family members who would be able 72 to provide added support f o r patients. 7 1 P a u l H. Blachly and B. J . Blachly. "Vocational-and Emotional Status of 263 Patients a f t e r Heart Surgery," C i r c u l a t i o n . XXXVIII (September, 1968), 524-530. 72Lenore R. Zohman and Jerome S. Tobis, Cardiac  Re h a b i l i t a t i o n (New York: Grune and Stratton, Inc., 1970), pp. 187-189. PREPARATION FOR DISCHARGE 28 Recognizing the trauma that the open heart surgery patients endured and the variables connected with success-f u l convalescence and r e h a b i l i t a t i o n , i t was necessary to consider how patients might be helped to cope with d i f f i c u l t -ies during the f i r s t weeks following discharge from the ho s p i t a l . This included looking at the nurse's responsi-b i l i t y i n teaching patients p r i o r to discharge. Most of the l i t e r a t u r e i n t h i s area did not pertain d i r e c t l y to open heart surgery patients but could be applied to them. Wynn found that "inadequate help and planning i n t h i s phase (discharge, planning]of the patient's i l l n e s s were considered . . . to be responsible f o r excessive worry and d i s t r e s s . . . " i n 32 percent of four hundred male patients with ischemic heart disease.?3 Spiegel and Demone reported that out of 108 medical, s u r g i c a l , and o b s t e t r i c a l patients only 17 percent said they had received more than f i v e minutes of i n s t r u c t i o n related to carrying on t h e i r care at home. The other 65 percent stated they had r e -ceived no i n s t r u c t i o n at a l l . Frank et a l . had eight hundred cardiotoray patients respond to a questionnaire and 73Allan Wynn, "Unwarranted Emotional Distress i n Men with Ischemic Heart Disease," Medical Journal of A u s t r a l i a , II (November 4, 1967), 850. 74 Allen D. Spiegel and Harold W. Demone, "Questions of Hospital Patients- Unasked and Unanswered," Postgraduate  Medicine, XLIII (February, 1968), 216. 29 of these, 17 percent f e l t they had not been advised about 75 a c t i v i t y a f t e r discharge. J The method that should have been used f o r teaching appeared to be a matter of opinion among medical and nur-sing personnel. Spiegel and Demone, and Behrendt and Austen recommended a c h e c k l i s t f o r discharge i n s t r u c t i o n s so that the attending s t a f f knew what had been taught and what s t i l l remained to be taught. Mullen suggested that p r i o r to d i s -charge the physician should have reviewed the recovery plan with the patient and his/her family and prepared them f o r physical symptoms which were not serious but might cause anxiety once the patient was horae.7^ Zohman stated that i t was necessary f o r the physician to question patients and to evaluate physical performance, psychological function, s o c i a l r e l a t i o n s h i p s , and vocational capacity i n order to know what education was needed f o r both patients and f a m i l -ies.''7''' Powell and Winslow submitted that: The nurses' and doctors* lack of time-and lack of awareness of the patients' learning needs, and t h e i r 7-*Kenneth A. Frank, Stanley S. Heller and Donald S. Kornfeld, "A Survey of Adjustment to Cardiac Surgery," Archives of Internal Medicine. CXXX (November, 1972), 737. 7 6 P a t r i c i a - D . Mullen, "Health Education f o r Heart Patients i n C r i s i s , " Health Services Reports f LXXXVIII (August-September, 1973), 673. 77 Lenore R. Zohman, "Cardiac R e h a b i l i t a t i o n : Its Role i n Evaluation and• Management of the Patient with Coronary Heart Disease," American Heart Journal. LXXXV (May, 1973), 707-709. 30 f e e l i n g t h a t "someone e l s e w i l l e x p l a i n i t to the p a t i e n t " as w e l l as-the p a t i e n t s ' l a c k of aggressiveness i n a s k i n g q u e s t i o n s , a l l c o n t r i b u t e to the inadequacy of discharge teaching.'° They proposed u s i n g w r i t t e n discharge g u i d e l i n e s as an adjunct t o the nurses' t e a c h i n g . Stackman found t h a t a group of myocardial i n f a r c t i o n p a t i e n t s who re c e i v e d pre-discharge i n s t r u c t i o n s by a systematic t e a c h i n g program had much gr e a t e r understanding of t h e i r discharge orders than a c o n t r o l group who r e c e i v e d i n f o r m a l i n s t r u c t i o n . 7 ^ From her study of p a t i e n t s convalescing a f t e r myocardial i n -f a r c t i o n Royle concluded: When s p e c i f i c i n s t r u c t i o n s were given to p a t i e n t s and t h e i r spouses about p r e s c r i b e d t h e r a p e u t i c mea-sures, they experienced l e s s a n x i e t y d u r i n g the i n i t i a l p o s t h o s p i t a l p e r i o d . When i n s t r u c t i o n s were vague, increased a n x i e t y was shown.°0 She a l s o reported a need f o r a u t h o r i t a t i v e w r i t t e n m a t e r i a l to r e i n f o r c e and supplement t e a c h i n g , to provide a permanent source of r e f e r e n c e , and to decrease the p a t i e n t s ' need t o go to f r i e n d s and news media f o r i n f o r m a t i o n . ^ 78 ' Anne H. Powell and E l i z a b e t h H. Winslow, "The Cardiac C l i n i c a l Nurse S p e c i a l i s t : Teaching Ideas t h a t ' Work," Nursing C l i n i c s of North America. V I I I (December, 1973), 728-729. ^ J e a n n e F. Stackman, " E f f e c t s of a Systematic Teaching Program upon the Myocardial I n f a r c t i o n P a t i e n t ' s Understanding of His- Disease-and His Discharge Orders"' (unpublished Master's Thesis, U n i v e r s i t y of V/ashington, 1973), PP. 50-51. 80 Joan Royle, "Coronary Patients'and Their F a m i l i e s Receive Incomplete Care," Canadian Nurse. LXIX (February, 1973), 25. 8 1 R o y l e , p. 24. 31 The content of teaching should have r e f l e c t e d the i n d i v i d u a l patient's needs. A l l s u r g i c a l patients required i n s t r u c t i o n with regard to d i e t , elimination, exercises to be performed, a c t i v i t i e s to be l i m i t e d , and possible com-82 p l i c a t i o n s of which to be aware. Patients who had had heart surgery also should have received information about medications and eventual return to normal a c t i v i t y and to work.^3 To be relevant i t was obvious that t h i s teaching must be done i n l i g h t of each patient's age, sex, marital status, socio-economic group, and present l i f e s i t u a t i o n . Redman observed that i t was not clear who should carry out patient teaching i n order to achieve the desired e f f e c t s nor what kind of preparation t h i s teacher should h ave.^ Mullen saw the physician reviewing the recovery plan and adding to the nurses' teaching and she suggested 85 that former patients could provide extra support. Powell and Winslow viewed the nurse as the primary teacher, with the physician responsible f o r providing medical information 82 Joan Luckmann and Karen C. Sorenson.-Medical-Surgical Nursing: A Psychophysiologic Approach. (Philadelphia: W. B. Saunders Co., 1974), p. 340. 83 Mary A.-Brambilla, "A Teaching Plan f o r Cardiac Surgical Patients," Cardiovascular Nursing. V(February, 1969), 4. ^Barbara K. Redman, The Process of Patient Teaching  in Nursing (2d ed.; Saint Louis: The C.V.Mosby Co., 1972) 5. 8 5 M u l l e n , p. 673. 32 and recommendations f o r a c t i v i t y , etc.^^ Redman stated: Physicians r i g h t f u l l y control the prerogative to share information i n key areas such as diagnosis, prognosis, and often treatment plan. This information i s often a prerequisite to independent or follow-up teaching viewed as the prerogative of the nurse."' She suggested "Standing orders f o r educational therapy or educational experiences" which could be planned j o i n t l y by physicians and nurses and ordered by the physician when he saw f i t . Brambilla noted, i n t h i s regard, that teaching should r e f l e c t the p o l i c i e s of the physicians and surgeons 89 i f i t was to be of value. RELATED STUDIES One researcher had investigated the numbers and kinds of problems experienced by open heart s u r g i c a l pa-t i e n t s i n the immediate posthospital period. Wahl i n t e r -viewed thirty-one open heart s u r g i c a l patients s i x weeks to s i x months a f t e r discharge from the h o s p i t a l . Her findings were that the three most common areas of problems and/or questions were pain, mental-emotional d i f f i c u l t i e s 90 and complications. In a l l , there were t h i r t y - f i v e 87 'Barbara K. Redman, "Client Education Therapy i n Treatment and Prevention of Cardiovascular Diseases," Cardiovascular Nursing, X (January-February, 1 9 7 4 ) , p. 4. 88 Redman, "Client Education Therapy i n Treatment and Prevention of Cardiovascular Diseases," p. 4. 89 Brarnbilla, p . l . 90 Sharon C. Wahl, "The Problems of Thirty-One Post-Operative Open Heart Surgery Patients a f t e r Discharge" (un-published Master's t h e s i s , University of Oregon, 1 9 7 3 ) , 4 6 . 33 d i f f e r e n t problem areas expressed and questions in twenty-91 seven of these areas. This study by Wahl was not d i s -covered u n t i l a f t e r the present research was completed. It was of i n t e r e s t to compare the r e s u l t s of these two s i m i l a r studies. SUMMARY The chapter presented a review of selected l i t e r -ature pertinent to the needs of, and the trauma experienced by, open heart surgery patients. It explored the more common s u r g i c a l procedures f o r two types of acquired heart disease and pointed out t h e i r m o r tality rates which appeared to be l e s s than 5 percent, on the average. The physio-l o g i c a l and psychological considerations pertinent to open heart surgery patients i n the immediate postoperative period were discussed. Studies on the convalescence and the r e h a b i l i t a t i o n of the cardiac patient were reviewed. The need f o r discharge preparation, the content of the i n -s t r u c t i o n , and the question of who i s to do the teaching were reported from the l i t e r a t u r e . One study d i r e c t l y related to the present one was also outlined. Wahl, pp. 70-72. CHAPTER I I I RESEARCH DESIGN AND METHOD OF STUDY A d e s c r i p t i v e study exploring the concerns of open heart surgery patients following discharge from h o s p i t a l was conducted by means of semi-structured interviews of twenty patients convalescing from open heart surgery. SETTING Cardiac Surgical Unit The twenty patients' who were interviewed had under-gone open heart surgery i n a large metropolitan h o s p i t a l . They were admitted to a f i f t e e n bed Cardiac Surgical Unit, i n most cases three days p r i o r to surgery. This u n i t was staffed e n t i r e l y by registered nurses and each patient was under the medical care of a c a r d i o l o g i s t and a cardiac surgeon as well as the residents and interns on the cardiac s u r g i c a l s e rvice. Following t h e i r surgery, patients spent two to three days i n the Intensive Care Unit and then r e -turned to the Cardiac Surgical Unit u n t i l t h e i r discharge from the h o s p i t a l . Preoperative Orientation During the preoperative period patients and t h e i r f a m i l i e s received an o r i e n t a t i o n to the h o s p i t a l routine 34 and to the cardiac s u r g i c a l u n i t . This o r i e n t a t i o n included written material and a slide-tape presentation designed to prepare a l l s u r g i c a l patients f o r the events p r i o r to and immediately a f t e r t h e i r operations. Patients received one period of i n s t r u c t i o n and some supervised practice i n breathing exercises, coughing, and leg exercises from a physiotherapist assigned to the Cardiac Surgical Unit. Patients were also encouraged to attend and observe the d a i l y exercise classes held f o r postoperative cardiac sur-g i c a l patients i n order to know what to expect following t h e i r operations. Nursing i n s t r u c t i o n s to the patients, and to t h e i r f a m i l i e s i f they so desired, covered the d i s -ease process and the treatment pattern preoperatively and postoperatively. The treatment pattern included the trans-f e r s from one area to another following surgery (Recovery Room, Intensive Care Unit, return to Cardiac Surgical Unit) and what to expect i n each area. Patients and one family member or s i g n i f i c a n t other were taken, i f they wished, on a tour of the Intensive Care Unit. Postoperative Teaching Postoperative teaching by the nursing personnel on the Cardiac Surgical Unit did not have any apparent s t r u c -ture or o u t l i n e . Patients' queries were answered by the physicians or nurses as these questions arose. A physio-therapist reinforced the preoperative exercise i n s t r u c t i o n s and worked with i n d i v i d u a l patients to prevent and treat 36 pulmonary complications. An exercise- class was conducted each day f o r postoperative cardiac surgery patients and a l l patients were expected to attend these classes from t h e i r f i f t h postoperative day u n t i l discharge, unless t h e i r gen-e r a l condition prevented attendance. SELECTION OF THE SAMPLE I n i t i a l Contact with Patients The researcher's i n i t i a l contact with each patient in the sample was o r d i n a r i l y made a day or two p r i o r to the patient's discharge. In two cases i t was on the day of discharge. Only patients meeting predetermined c r i t e r i a were approached; therefore, the sample was not a random one. The c r i t e r i a f o r p a r t i c i p a t i o n i n the study were that the patient: (1) had undergone open heart surgery during the present period of h o s p i t a l i z a t i o n ; (2) understood and spoke English; (3) had no current diagnosis of mental i l l n e s s ; (4) would be convalescing within the Greater Vancouver area and (5) consented to p a r t i c i p a t e . Part way through the study, the fourth constituent of the c r i t e r i a was waived i n order to complete the twenty interviews within the l i m i t e d time a v a i l a b l e . However, only two patients l i v e d outside the i n i t i a l l y set geographical l i m i t s . The patients who met the above c r i t e r i a were asked fo r t h e i r consent to be interviewed by the i n v e s t i g a t o r . They were told that the investigator was carrying out a study of open heart surgery patients to ascertain the kinds 37 of questions and concerns patients had once they l e f t the h o s p i t a l . They were informed that the r e s u l t s of the study could be usefu l f o r planning the preparation other patients received p r i o r to discharge from h o s p i t a l . Patients who agreed to pa r t i c i p a t e signed a consent form provided by the inves t i g a t o r . They were t o l d they would be contacted by telephone i n approximately two weeks to arrange an i n t e r -view time. They were assured that t h e i r anonymity would be preserved i n the report of the study. Interview Arrangements Interviews were arranged by telephone, at le a s t two days before they took place. A l l patients except one were interviewed i n t h e i r own homes; the one patient was con-valescing at his daughter's home and was interviewed there. A l l patients were interviewed during t h e i r t h i r d or fourth week at home i n order to obtain a f a i r l y accurate view of the concerns and d i f f i c u l t i e s faced by the patients e a r l y in t h e i r convalescent period. Interviews The interviews were intended to evoke responses pertaining to any questions or concerns the patients had encountered i n d a i l y l i v i n g since t h e i r discharge. It was decided that, f o r t h i s type of study, a semi-structured verbal interview schedule was most l i k e l y to e l i c i t r e -sponses of a spontaneous nature. Kerlinger pointed out that open-ended questions were designed to supply the frame 3 3 of reference, with a minimum of r e s t r a i n t , f o r the i n t e r -viewees' responses. He stated, "While t h e i r [open-ended questions]] content i s dictated by t h e i r research problem, they impose no other r e s t r i c t i o n s on the content and manner of respondent answers. "^ -The interview was designed to touch on physiological, emotional and socio-economic concerns of patients. Consid-eration was given to a c t i v i t y , r e s t , sleep, pain, n u t r i t i o n , elimination, and medications when ph y s i o l o g i c a l concerns were discussed. Emotional considerations were mainly cen-tered on the fears, a n x i e t i e s , and f e e l i n g s of f r u s t r a t i o n and depression experienced by the convalescing patients. Socio-economic concerns included family i n t e r a c t i o n s , i n t e r -actions with f r i e n d s , neighbors and co-workers, and future employment plans. Discussion was also directed to a consid-eration of the printed Discharge Guidelines with regard to t h e i r adequacy i n meeting patients* needs f o r information. The outline of the interview i s shown i n Appendix D. There was no predetermined order to the interviews. The opening question u s u a l l y was "In general, how have you f e l t since you came home?" This question u s u a l l y sparked a f a i r l y detailed d e s c r i p t i o n of what had happened to the patient since discharge. When necessary, the investigator interposed questions to obtain c l a r i f i c a t i o n and/or •Fred N. Kerlinger, Foundations of Behavioral' Research, (New York: Holt, Rinehart and Winston, Inc., 1964), p. 471 39 elaboration of patients' statements. Patients were also questioned about any of the above-mentioned areas i f they did not mention these v o l u n t a r i l y . They were further asked about t h e i r f e e l i n g s with regard to the adequacy of the writ-ten Discharge Guidelines they had received. The f i n a l question asked of each patient was "What has been the most unexpected part of your convalescence at home?" The inves-t i g a t o r hoped that t h i s question would give some ins i g h t into the areas where most discharge teaching was needed. COMPILATION OF DATA A l l interviews, done over a period of four months, were tape-recorded with the consent of the patients. These were l a t e r transcribed by the investigator i n order to com-p i l e the data. A face sheet had been prepared f o r each patient u t i l i z i n g data from h o s p i t a l charts. A copy of t h i s face sheet i s i n Appendix C. The data transcribed from the tapes were l i s t e d i n si x sections on work sheets attached to the face sheet. The p i l o t study had revealed s i x common areas of discussion with patients: (1) concerns, ( 2 ) adequacy of Discharge Guidelines, (3 ) the posi t i v e aspects of convalescence since h o s p i t a l discharge, ( 4 ) means of coping with concerns, ( 5 ) general well-being since discharge and ( 6 ) the most unexpected part of convalescence at home. When a l l interviews had been completed the data from the worksheets were compiled under the above s i x 40 headings i n order to i d e n t i f y common elements. SUMMARY The d e s c r i p t i v e survey method of r e s e a r c h was used f o r t h i s study which was designed t o e x p l o r e the concerns o f open h e a r t s u r g e r y p a t i e n t s d u r i n g the e a r l y p o s t h o s p i t a l p e r i o d o f c o n v a l e s c e n c e . The study was c a r r i e d out by means of s e r a i - s t r u c t u r e d , t ape-recorded i n t e r v i e w s of p a t i e n t s . P a t i e n t s were i n i t i a l l y c o n tacted i n the h o s p i t a l by the i n v e s t i g a t o r to o b t a i n consents t o i n t e r v i e w them i n t h e i r homes. The data from i n t e r v i e w s were compiled a c c o r d i n g to s i x major headings and commonalities were noted. CHAPTER IV ANALYSIS OF DATA The purpose of t h i s chapter was to present the data derived from the interviews of convalescing open heart sur-gery patients and to discuss the implications of t h i s data. DEMOGRAPHIC DATA Study Population M a r i t a l status. There were twenty patients i n t e r -viewed. In t h i s sample there were seventeen males and three females. Seventeen of the subjects were married, two were single and one had been separated from her spouse f o r many years. One single subject l i v e d alone and another l i v e d i n a communal s i t u a t i o n . The separated subject l i v e d with a daughter and her family. A l l of the married subjects l i v e d with t h e i r spouses. Age. Patients ranged i n age from twenty-seven to seventy-two years with a mean age of 55.4 years. Only four patients interviewed were under f i f t y years of age. Six patients were r e t i r e d from t h e i r jobs but a l l of the re-maining fourteen persons had worked u n t i l at l e a s t four months p r i o r to surgery. Operative procedures. The operative procedures 41 42 undergone by these p a t i e n t s i n c l u d e d the r e p a i r o f an a t r i a l s e p t a l d e f e c t , s i n g l e , double and t r i p l e c o r o n a r y a r t e r y bypass g r a f t s , a o r t i c or m i t r a l v a l v e replacements, and the r e s e c t i o n of a s u b - a o r t i c muscular h y p e r t r o p hy. Table I shows the f r e q u e n c i e s and percentages o f these procedures. Two of the p a t i e n t s who had a o r t i c v a l v e replacements had undergone open h e a r t s u r g e r y p r e v i o u s l y and t h i s second s u r g e r y removed an i n f e c t e d p r o s t h e t i c v a l v e and r e p l a c e d i t w i t h a new p r o s t h e s i s . One o f these same p a t i e n t s had an e p i c a r d i a l pacemaker i n s e r t e d a t the time o f t h i s second v a l v e replacement* ( 43 TABLE I FREQUENCIES AND PERCENTAGES OF OPEN HEART SURGICAL PROCEDURES UNDERGONE BY THE TWENTY PATIENTS IN THE STUDY Surgical Procedures Frequencies Percentage Single Coronary Artery Bypass Graft Double Coronary Artery Bypass Graft T r i p l e Coronary Artery Bypass Graft Aortic Valve Replacement M i t r a l Valve Replacement Repair of A t r i a l Septal Defect Resection of Sub-aortic Muscular Hypertrophy 7 4 1 4 2 1 1 35.0 20.0 5.0 20.0 10.0 5.0 5.0 Total 20 100.0 Documentation showed that f i v e patients (25 percent) suffered post-operative complications during t h e i r hospit-a l i z a t i o n . One contracted pneumonia and another required the i n s e r t i o n of a drain into h is femoral i n c i s i o n . Two patients were returned to the Operating Room. One pa-ti e n t required the l i g a t i o n of several blood vessels to arrest postoperative bleeding, the second patient required a resuturing of his sternum on his twelfth postoperative day. One patient was sent back to the Intensive Care Unit f i v e days postoperatively because of tachycardia and c h i l l s which were eventually diagnosed as symptomatic of e i t h e r a v i r a l i n f e c t i o n or a drug s e n s i t i v i t y . After speaking with convalescing patients i t appeared that at lea s t three of them had experienced an episode of postoperative emo-t i o n a l c r i s i s while i n the h o s p i t a l . Two complained of being unable to r e c a l l or of " l o s i n g " as much as a week following t h e i r surgery. One other patient spoke of being very depressed and l e t h a r g i c f o r a week or more a f t e r surgery. Postoperative h o s p i t a l stays ranged from ten to forty-three days. The average stay was 16.4 days and only four patients (20 percent) were hosp i t a l i z e d f o r longer than seventeen days. It was i n t e r e s t i n g to note that a l l four of these persons had undergone a o r t i c valve replace-ments, two f o r the second time. Interview data Nineteen patients were interviewed i n t h e i r own homes and one patient was interviewed i n his daughter's home where he was convalescing p r i o r to returning to his own home. Eight patients were interviewed with only the investigator present. Eleven had t h e i r spouses with them and one had another family member present. Patients were 45 often prompted to express t h e i r concerns or were helped to remember incidents and related questions by the other person present. Family members also expressed t h e i r concerns at t h i s time. Interviews were conducted twenty to twenty-nine days following discharge from the h o s p i t a l with a mean of 21.4 days. Patients were, therefore, between four and a h a l f 4 weeks and nine weeks postoperative, with a mean of approx-imately f i v e and a half weeks. PATIENTS' EXPRESSED CONCERNS Patients expressed a t o t a l of f i f t y - f i v e d i f f e r e n t areas of concern. The most common area was p h y s i o l o g i c a l with a t o t a l of f o r t y separate concerns. Ten areas dealt with emotional concerns and f i v e areas were socio-economic i n nature. Table II i l l u s t r a t e s the frequencies and percen-tages of concerns expressed by the twenty patients. TABLE II FREQUENCIES AND PERCENTAGES OF CONCERNS EXPRESSED BY TWENTY OPEN HEART SURGERY PATIENTS FOLLOWING HOSPITAL DISCHARGE Concerns Expressed Frequencies Percentages Physiological 40 72.7 Emotional 10 18.2 Socio-economic 5 9.1 Total 55 100.0 46 Physiological Concerns Pain was the p h y s i o l o g i c a l problem voiced by the greatest number of patients. Sixteen patients (80 percent) complained of some type of pain ranging i n i n t e n s i t y from mild to severe. The most common s i t e of pain was the chest i n c i s i o n as evidenced by eleven complaints. The second most common s i t e of pain was the l e g from which the saph-enous vein had been removed. Five patients complained of pain i n that l e g . In a l l , among the sixteen patients who complained of pain, there were twenty-nine various complaints of the l o c a t i o n of the pain, including the shoulders, one or both arms, and the back. The complete l i s t i n g of these s i t e s i s given i n Appendix F. Wahl also found that pain was the most common problem, experienced by 68 percent of the patients she interviewed,^ The higher percentage of com-pl a i n t s i n the present study could perhaps be explained by the f a c t that Wahl's subjects were at l e a s t eight to ten weeks postoperative whereas ninety percent of the present sample were les s than seven weeks postoperative. Nine patients (45 percent) noted that one of t h e i r greatest concerns was that they f e l t so weak and t i r e d and, as a r e s u l t , t h e i r tolerance f o r physical a c t i v i t y was very l i m i t e d . This weakness and tiredness was a source of anx-xSharon C. Wahl, "The Problems of Thirty-One Post-Operative Open Heart Surgery Patients a f t e r Discharge" (Unpublished Master's t h e s i s , University of Oregon, 1973), p. 46. 47 i e t y f o r some who interpreted i t . a s a sign that they were not recovering from the surgery. For others, i t was a source of f r u s t r a t i o n since they f e l t well but when they t r i e d to do anything they t i r e d very e a s i l y and r a p i d l y . D i f f i c u l t y sleeping was common to nine patients (45 percent) at the time of the interview. Four of these persons could not get comfortable i n order to sleep or else they woke themselves when they attempted to turn over i n bed. Five patients found that they could not sleep without medication even though they had very l i t t l e pain or d i s -comfort. Most of these f i v e had not been i n the habit of taking sleeping medications p r i o r to t h e i r h o s p i t a l i z a t i o n and were not pleased to have to take them at t h i s time. There were no apparent reasons f o r the d i f f i c u l t i e s these persons were experiencing. Five patients questioned how much a c t i v i t y , such as ' * 4 4 walking, l i f t i n g objects, swimming, and mowing the lawn, they ought to be doing or when they could begin various physical exercises and a c t i v i t i e s . One patient, who had been receiving physiotherapy preoperatively f o r paralysis l e f t by a cerebral vascular accident, wished to know when she could resume her therapy. A l l of these patients had 4 4 experienced faintness, extreme weakness, or dizziness following some a c t i v i t y and were now very cautious as to what they should be doing. They a l l spoke of "overdoing i t " on at lea s t one occasion during the weeks a f t e r discharge. Another area df concern was related to what the 4* surgery had accomplished and what could possibly go wrong i n the future; e.g. heart attack, return of angina, or some other problem. One patient questioned as to how he could know that the surgery had been e f f e c t i v e . The patient who had received the pacemaker was very unclear as to i t s placement and operation. Two patients queried the cause of severe chest pain during t h e i r convalescence and neither had contacted the doctor though the pairi v/as stated to be severe. A l l these patients seemed to be seeking assurance that they were f i n e , that nothing could go wrong with t h e i r hearts at t h i s time and that t h e i r postoperative discomfort was normal and not a cause f o r alarm. Four out of f i v e of the patients who expressed these above concerns had been admitted f o r emergency open heart surgery. Redman explained that the psychosocial adaptation to i l l n e s s might be lengthy and that u n t i l the patients have passed through the stages from d i s b e l i e f to acceptance of the i l l n e s s they were probably too preoccupied with themselves to r e t a i n most of the information given to them. 2 Postoperatively the patients' attention spans may be short-ened because of the e f f e c t s of pain, medication and f a t i g u e . It would appear that the patients who had gone through open heart surgery with very l i t t l e warning had not worked 2Redman, Barbara K. The Process of Patient Teaching  i n Nursing. 2d. ed., (Saint Louis: The C.*~V. Mosby Co., 1972) PP. 36-37. 49 through the necessary stages of adaptation before inform-ation was given to them both preoperatively and postoper-a t i v e l y . Only at t h i s l a t e r date when the interview took place were they ready to seek out that information. Table III i l l u s t r a t e s the common ph y s i o l o g i c a l con-cerns according to frequencies and percentages of patients expressing them. There were also twenty-six miscellaneous phy s i o l o g i c a l concerns expressed by in d i v i d u a l s i n the study group. These are l i s t e d i n Appendix E. 50 TABLE I I I COMMON PHYSIOLOGICAL CONCERNS OF PATIENTS IN THE STUDY GROUP EXPRESSED IN FREQUENCIES AND PERCENTAGES Concerns expressed by patients Frequencies Percentages Pain 16 22.9 D i f f i c u l t y sleeping 9 12.3 Weakness and tiredness 9 12.*. How much a c t i v i t y and when allowed 5 7.1 Loss of appetite 4 5.7 Nausea 4 5.7 Shortness of breath 4 5.7 Overexertion 4 5.7 D i f f i c u l t y walking because of l e g discomfort 3 4.3 Slowness of recovery 3 4.3 Weight loss 3 4.3 Questioning reason f o r chest pain 2 2.9 Medications causing nausea 2 2.9 Swelling of l e g 2 2.9 Total 70 100.0 51 Emotional Concerns Fi f t e e n patients (75 percent) expressed one or more mental or emotional concerns. The largest group, nine patients, reported that they were f r u s t r a t e d . This f r u s -t r a t i o n seemed to stem from a combination of weakness and tiredness, and the i n a b i l i t y of patients to be as active as they wanted to be. They expressed t h e i r f r u s t r a t i o n i n § terms such as, " t i r e d of s i t t i n g around doing nothing", "frustrated with always f e e l i n g so t i r e d " , "wish I could manage to do more". The second common concern was depression. Five patients related that t h i s was an occasional occurrence, not a constant f e e l i n g . A l l of the patients who reported t h i s depression also noted t h e i r i n a b i l i t y to t o l e r a t e much a c t i v i t y without becoming very t i r e d . Long ;Scheuhing and C h r i s t i a n commented i n t h i s regard that there i s a " . . . c h a r a c t e r i s t i c postoperative depression which may be triggered by the patient's awareness of his weakness and fatigue following surgery." 3 This c e r t a i n l y appeared to be true f o r the patients who reported being depressed. I t seemed to the investigator, that there was often no d i s -t i n c t i o n between depression and f r u s t r a t i o n as described ^Madeleine L. Long, Mary A. Scheuhing, and Judith L. C h r i s t i a n , "Cardiopulmonary Bypass," American Journal  of Nursing. LXXIV (May, 1974), 867. by the patients and that f o r most of the patients e i t h e r term could have been used. The f i v e patients who underwent the open heart surgery on an emergency basis appeared to be more anxious, on the whole, than the other patients interviewed. Two of these patients complained that they could not remember what had happened during periods of t h e i r h o s p i t a l i z a t i o n . One person also commented several times that the whole experience s t i l l seemed very unreal to him. He was also very anxious with regard to the p o s s i b i l i t y of future problems. TABLE IV COMMON EMOTIONAL CONCERNS OF PATIENTS IN THE STUDY GROUP EXPRESSED IN FREQUENCIES AND PERCENTAGES Concerns expressed by patients Frequencies Percentages Fru s t r a t i o n 9 52.9 Depression 6 35.3 Memory Loss 2 11.3 Total 17 100.0 Socio-economic Concerns No problems were noted with regard to family r e -l a t i o n s or to contacts with friends and/or co-workers. Family members often seemed to accept the patients' disab-53 i l i t i e s more r e a l i s t i c a l l y than did the patients themselves since f a m i l i e s 1 expectations did not seem to be as high as the patients'. The impression gained by the investigator was that f a m i l i e s and friends considered s u r v i v a l as just short of miraculous and expected the patients to have a long convalescence. This attitude may l a t e r have led to problems of pampering patients, s h e l t e r i n g them, and pro-longing t h e i r convalescence. Wahl mentioned t h i s as a problem area^ but at the time of t h i s study most patients were s t i l l at l e a s t moderately incapacitated and uncom-for t a b l e from the surgery i t s e l f , so t h i s problem had not yet a r i s e n . In response to questioning about return to work, only four patients had any r e a l concerns. Two patients, both self-employed, were very eager to return to work and one, i n p a r t i c u l a r , was frustrated that the physician would not give him permission to work f u l l t i m e . One patient had no one to take over his job f o r him and was going to work p e r i o d i c a l l y f o r a few hours at a time. He stated that he f e l t g u i l t y about " s i t t i n g around and doing nothing" while the work pil e d up and people waited f o r important decisions to be made. A patient with a managerial p o s i t i o n disap-proved of the way some things were being done while he was away from work, but he said he was not overly concerned % a h l , pp. 72-73 54 about t h i S o Most patients apparently had not thought too much about t h e i r future employment or return to work. Some did mention that they had been promised easier jobs or "bench jobs" upon i n i t i a l return to work. It became evident that convalescing was the business at hand and since r e -turning to work was at l e a s t several months away there was no concern about i t that e a r l y i n the post-operative period. Two patients had drav/n a l l of t h e i r sick leave pay and benefits from t h e i r jobs and were reaching the end of t h e i r unemployment insurance b e n e f i t s . One patient had ap-plied f o r s o c i a l assistance and the other was e l i g i b l e to 5 apply f o r "Mincome". Neither patient seemed overly con-cerned about t h i s f i n a n c i a l s i t u a t i o n . Appendix H contains the miscellaneous socio-economic concerns reported. DISCHARGE INSTRUCTIONS Variety of Instructions A l l twenty patients received the ho s p i t a l ' s printed Discharge Guidelines, a copy of which i s i n Appendix B„ One patient had received the in s t r u c t i o n s but nothing had been f i l l e d i n on eithe r of the two pages. A l l of the other sheets were at l e a s t checked (/) under "Level of A c t i v i t y " , f i l l e d i n under "Medications" with the name and dosage of the medications, and marked f o r "Next Appointment with the -'A pension paid by the B r i t i s h Columbia Government to handicapped persons under 6 0 years of age and to persons 6 0 years and older who receive l e s s than the B r i t i s h Columbia minimum guaranteed income. Doctor". They were also marked i f patients were on a n t i -coagulants and needed a prothrombin time done. For seven patients (35 percent) there was further elaboration written on the i n s t r u c t i o n sheets concerning walking a c t i v i t y ( s p e c i f i c a l l y a graded schedule f o r d i s -tance to be walked), sexual a c t i v i t y and d r i v i n g an auto-mobile. These l a t t e r two were s p e c i f i e d according to the number of weeks before e i t h e r of these a c t i v i t i e s could be performed. These patients received the i n s t r u c t i o n s with the written additions as well as a verbal explanation from the c a r d i o l o g i s t . The remaining twelve patients (60 percent) received the marked ins t r u c t i o n s with no written elaborations. Of these patients, two stated they had received only the marked sheet with no verbal explanation. The patient who received the unmarked sheet reported he did not receive any verbal explanation. Explanations had been given to three patients by the registered nurses and to seven other patients by t h e i r c a r d i o l o g i s t or surgeon. Table V shows the frequen-cies and percentages by which patients i n the study group received varying amounts of discharge instruction,. 56 TABLE V FREQUENCIES AMD PERCENTAGES OF AMOUNTS OF DISCHARGE INSTRUCTION RECEIVED BY STUDY GROUP PATIENTS Frequencies Percentages Checked, written elaboration, verbal explanation by cardio-l o g i s t 7 35.0 Checked, verbal explanation by c a r d i o l o g i s t 7 35.0 Checked, verbal explanation by registered nurse 3 15.0 Checked, no explanation 2 10.0 Not checked, no explanation 1 5.0 Total 20 100.0 Adequacy of Discharge Guidelines Patients' responses. Patients were asked what they thought of the Discharge Guidelines and r e p l i e s were gen-e r a l l y i n a positi v e v ein. Twelve patients (60 percent) reported that they had found the f i r s t three paragraphs h e l p f u l because they included information as to what could be expected and what was "normal". Three patients suggested that a s p e c i f i c a c t i v i t y program would be of help. Two other patients thought that persons could be warned of signs that might precede common complications such as p h l e b i t i s . There was no discussion on the areas of sexual a c t i v i t y or d r i v i n g an automobile as these two a c t i v i t i e s were generally r e s t r i c t e d f o r s i x weeks a f t e r discharge. The area of d i e t seemed to pose l i t t l e problem since a l l but one patient had been sent home with instructions to maintain an unrestricted d i e t f o r at l e a s t one month and t h e i r d i e t s would be reassessed. Differences among patients r e c e i v i n g varying i n - structions . The main difference between those seven pa-t i e n t s who had received the i n s t r u c t i o n s , elaboration, and explanation, and the other t h i r t e e n patients, was that the l a t t e r persons, on the whole, appeared to be more f e a r -f u l and anxious about doing too much walking or other physical a c t i v i t y . Of the seven patients who received the whole gamut of i n s t r u c t i o n and explanation, only one was walking less than one-half mile per day and the other s i x were walking up to a mile. Of those t h i r t e e n who received no elaboration as to walking a c t i v i t y only f i v e patients were walking over one-half mile a day. It should be noted that three of those patients who were walking l e s s than one-half mile appeared too p h y s i c a l l y i l l to be expected to go any f u r t h e r . This cautious reaction i s i n keeping with Wynn's findings that when a c a r e f u l program of phys-i c a l a c t i v i t y was not planned f o r the convalescing patient "many patients were l e f t unsure of how much they could or 58 should do; many as a consequence, did too l i t t l e . " ^ Royle also reported on the f a c t that those patients who received s p e c i f i c i n s t r u c t i o n s with regard to a c t i v i t y , d i e t , and medications were l e s s anxious i n the posthospital period 7 than those who received vague i n s t r u c t i o n s . POSITIVE ASPECTS OF CONVALESCENCE A l l of the positive comments were spontaneous on the part of the patients. Nine patients (45 percent) noted that they were much stronger than they had been i n the h o s p i t a l or during t h e i r f i r s t week at home. By "stronger" they meant having a higher tolerance f o r a c t i v i t y and not t i r i n g as e a s i l y as they had e a r l i e r i n t h e i r convalescence. Nine patients also commented on t h e i r good or improved appetites and were pleased with t h i s sign of returning health. Other p o s i t i v e elements were also noted, though by fewer patients. Only one patient did not make some pos-i t i v e remarks about the period of convalescence at home. Appendix I l i s t s the posi t i v e aspects of the convalescent period• 6 A l l a n Wynn, "Unwarranted Emotional Distress i n Men with Ischemic Heart Disease," Medical Journal of A u s t r a l i a . II (November 4, 1967), f^Ol 7 Joan Royle, "Coronary Patients and Their Families Receive Incomplete Care," Canadian Nurse. LXIX (February, 1973), 25. ADDITIONAL STUDY FINDINGS 59 Some of the data acquired from the interviews of patients i n the study group was not relevant to the objec-ti v e s of the study. It was included here so that the information i t provided might be taken into account i n pre-paring open heart surgery patients f o r discharge from h o s p i t a l . Coping with Concerns Patients reported the d i f f i c u l t i e s and anxieties they had encountered during t h e i r period of convalescence but they also spoke of what they had done to cope with t h e i r concerns. By the time patients were interviewed, a l l of them had v i s i t e d t h e i r family physician i n his/her o f f i c e . This was according to the usual recommendation of the car-d i o l o g i s t that the patient see the family doctor two weeks a f t e r discharge from h o s p i t a l . Some patients had also seen the cardiac surgeon before the interview date. Both of these v i s i t s had afforded them the opportunity of asking questions and of r e c e i v i n g reassurance concerning t h e i r problems. Many of the patients said they had asked questions at that time and had voiced t h e i r d i f f i c u l t i e s to the doctor. Some patients, however, appeared to question the family physician's a b i l i t y to deal with problems they f e l t were d i r e c t l y related to t h e i r open heart surgery. At the same time they were reluctant to contact the "busy" 60 c a r d i o l o g i s t or cardiac surgeon i n case the problem was r e a l l y only a minor one or something that was normal f o r convalescing open heart surgery patients. Several patients spoke of being upset when they v i s i t e d the cardiac surgeon i n his o f f i c e . After l i s t e n i n g to t h e i r complaints, he t o l d them everything was "normal" though he had not examined them to t h e i r s a t i s f a c t i o n . Half of the patients had attempted to cope with t h e i r concerns by r e l y i n g on themselves and/or t h e i r spouses. In some cases t h i s simply meant doing nothing and hoping the d i f f i c u l t y or cause of anxiety would disappear on i t s own. Five patients had contacted t h e i r family physicians f o r help, three had gone to some family member other than t h e i r spouses, and two patients had waited f o r the investigator i n order to ask her assistance. Table VI shows on whom pa-t i e n t s r e l i e d to help them cope with t h e i r concerns. TABLE VI FREQUENCIES AND PERCENTAGES OF PERSONS ON WHOM PATIENTS RELIED TO HELP THEM COPE WITH CONCERNS Persons r e l i e d on Frequencies Percentages Self, or s e l f and spouse 10 50.0 Family physician 5 25.0 Family member 3 15.0 Investigator 2 10.0 Total 20 100.0 61 Patients' Feelings of Well-being The opening question of the interview, "In general, how have you f e l t since you came home?" yielded a v a r i e t y of responses. It appeared that these responses could be categorized into four l e v e l s of well-being: (1.) f e e l i n g w ell, (2) f e e l i n g f a i r l y w e l l , (3) noting a constant improvement, and (4) f e e l i n g quite i l l . Five patients (25 percent) stated that they were f e e l i n g very well and the investigator noted that they looked well and were also very p o s i t i v e i n t h e i r outlook. Some of t h e i r responses included: " f e e l l i k e a m i l l i o n d o l l a r s " , 4 " f e e l i n g so good and doing r e a l l y w e l l " , " r e a l l y good; no complaints". Nine patients (45 percent) reported that they were f e e l i n g f a i r l y well and gaining strength. Five of.these patients had expected to f e e l much better and therefore found i t d i f f i c u l t to see that they were making any progress i n recovering. One patient appeared to be quite depressed by t h i s occurrence. Responses from t h i s group were varied: "think I f e e l good f o r what I've been through", "good days and bad days", "on the whole, pretty good", " f e e l i n g stronger every day". The t h i r d group of patients saw some element of improvement, p a r t i c u l a r l y i n t h e i r physical c a p a c i t i e s , even though most of them did not f e e l too w e l l . A l l four 6 2 patients ( 2 0 percent) i n t h i s group had been quite severely-incapacitated p r i o r to surgery and even though they were not f e e l i n g too strong they could detect a d e f i n i t e im-provement i n t h e i r condition. The s i x t h patient had p h l e b i t i s at the time of the interview but despite t h i s he f e l t very much improved. These patients responded to the question with such comments as: "the a b i l i t y to walk further shows an element of improvement", "breathing much improved", " f e e l i n g much stronger each day", "don't need pain p i l l s any more". One patient i n t h i s t h i r d group was very frustrated over his slowness i n recovering but the r e s t of the patients appeared to be contented with whatever improvement had taken place. There were two patients who could f e e l no improve-ment and who, i n f a c t , f e l t worse than they had preoper-a t i v e l y . Both of these patients appeared to be very anxious and to have more concerns than the other patients. Unexpected Aspects of Convalescence Patients' responses to the question, "What has been the most unexpected part of your convalescence at home?"' were both p o s i t i v e and negative. Six patients (30 percent), although they had experienced some d i f f i c u l t i e s and anxiety, stated that nothing had been unexpected during t h e i r three or four weeks out of the h o s p i t a l . Three patients (15 per-cent) expressed t h e i r surprise at f e e l i n g so w e l l . They apparently had expected a much slower recovery. Three others reported that they had not expected to f e e l so i l l during t h e i r f i r s t week at home. They had f e l t f i n e i n the hos p i t a l but once they came home things seemed to s t a r t going amiss. A l l unexpected elements are l i s t e d i n Appendix J . SUMMARY This chapter reported the data gained from i n t e r -views of twenty posthospital open heart surgery patients. Seventeen men and three women were interviewed i n t h e i r homes between four and a h a l f weeks and nine weeks post-operatively. A l l but two patients reported that they were f e e l i n g improved. A l l but one expressed concerns of a phys-i o l o g i c a l nature, the most common one being pain. Seventy-f i v e percent of the patients expressed some emotional d i f f i c u l t i e s , mainly f r u s t r a t i o n and depression r e s u l t i n g from t h e i r physical l i m i t a t i o n s . Socio-economic concerns were small i n number. The amounts of discharge in s t r u c t i o n s that patients received were reported and differences between patients receiving the ins t r u c t i o n s were noted. The po s i t i v e e l e -ments of convalescence were taken from the interview data. Additional findings noted the patients' manner of coping with concerns, the patients' states of well-being, and the unexpected aspects of the early posthospital period. CHAPTER V SUMMARY, CONCLUSIONS, AND AREAS FOR FURTHER INVESTIGATION SUMMARY Purpose of the Study The purpose of t h i s study was to explore the concerns perceived by patients who had undergone open heart surgery. This survey was to deal with the f i r s t three to four weeks following discharge from h o s p i t a l and subsequently the i n -vestigator was to i d e n t i f y the concerns common to these patients. Methodology The investigator carried out a d e s c r i p t i v e study by means of a semi-structured interview schedule to obtain responses from twenty convalescent open heart surgery patients. Patients meeting a set of s p e c i f i e d c r i t e r i a were interviewed at home during t h e i r t h i r d or fourth week following discharge from h o s p i t a l . The interviewer ex-plored what had happened to these patients since t h e i r * 4 return home and, i n t h i s way, attempted to i d e n t i f y the phys i o l o g i c a l , emotional, and socio-economic concerns faced by these patients during the stated time period. Patients were also asked f o r some evaluation of the printed 64 Discharge Guidelines they had received. Interviews were tape-recorded and l a t e r transcribed i n order to compile the data. The interviewer compiled the data and noted s p e c i f i c common aspects of patients during said period of convalescence. Findings The study showed that there was a v a r i e t y of con-cerns encountered by convalescing open heart s u r g i c a l patients during t h e i r f i r s t three to four weeks at home. Ninety-five percent of patients expressed concerns of a ph y s i o l o g i c a l nature. The common concerns were pain, d i f f i c u l t y sleeping,- continued weakness and tiredness, questions as to the correct amount of a c t i v i t y , loss of appetite, nausea, shortness of breath on exertion, and overexertion. Seventy-five percent of the study group experienced emotional concerns, the most common being f r u s -t r a t i o n r e s u l t i n g from a low tolerance f o r physical act-i v i t y , and fe e l i n g s of depression. T h i r t y percent of the patients expressed socio-economic concerns of which only one concern, that of sick-leave pay and ben e f i t s , and un-employment insurance being used up, was common to two of the patients. One ha l f of the patients r e l i e d on themselves or on themselves and t h e i r spouses to cope with t h e i r concerns. The other ten patients looked f o r help or i n -formation from t h e i r family physicians, or other family members, or the in v e s t i g a t o r . 66 A l l twenty patients i n the study received the hospital's Discharge Guidelines which except i n one case, were completed. Fi f t e e n percent of the study group r e -ceived no explanation of these guidelines before t h e i r d i s -charge. Only t h i r t y - f i v e percent of the patients i n t e r -viewed received some written elaboration regarding the amount of a c t i v i t y they should do. Among the other s i x t y -f i v e percent of the patients who received no elaboration there appeared to be some reluctance to increase the length of d a i l y walks or to engage i n other l i g h t physical a c t i v -i t y . A l l but two patients could see some element of improvement i n t h e i r conditions. Many of them remarked that they found t h e i r recovery very slow. However, with regard to t h e i r convalescence, a l l but one patient had positi v e remarks to make. T h i r t y percent of the study group had experienced nothing that was of an unexpected nature during the stated period of convalescence. CONCLUSIONS The v a r i e t y of questions from and concerns of the patients was great and indicated a probable need f o r im-proved teaching i n preparing open heart surgery patients f o r discharge. The major concerns of these patients seemed to focus mainly on postoperative pain, d i f f i c u l t i e s with sleep, fatigue, and f r u s t r a t i o n stemming both from physical 67 fatigue and the i n a b i l i t y to be as active as they wanted to be. The present study revealed some patients who questioned whether or not the problems they were experi-encing were i n d i c a t i v e of complications. Such problems i n -cluded severe chest pain experienced by two patients and the pain and tenderness caused by p h l e b i t i s i n another patient. These incidents indicated that discharge teaching should provide information regarding the signs and symptoms of possible complications. Patients who did not receive any written elabor-ation regarding a c t i v i t y appeared to be somewhat reluctant to increase the extent of t h e i r walking and other l i g h t physical a c t i v i t i e s . Five patients questioned the amount of a c t i v i t y they should be doing and the appropriate time f o r c e r t a i n a c t i v i t i e s to be undertaken. Both of these findings pointed to the need f o r more s p e c i f i c Discharge 4 Guidelines, e s p e c i a l l y with regard to the amount and timing of a c t i v i t y suggested f o r each patient. The four patients who underwent emergency open heart surgery sought information concerning the e f f e c t i v e -ness of t h e i r operations, the p o s s i b i l i t i e s of future problems and the normalcy of t h e i r convalescent course. This suggested that patients who have undergone open heart surgery on an emergency basis should receive a more thorough b r i e f i n g on t h e i r condition p r i o r to discharge from h o s p i t a l . 68 Two patients waited f o r the investigator's v i s i t to seek help with p a r t i c u l a r p h y s i o l o g i c a l concerns. They evidently saw the nurse as someone who could provide r e l i a b l e information and help. For that reason i t i s suggested that at a determined time following discharge a nurse or nurses be assigned to contact patients by t e l e -phone to intervene by assessing concerns and providing encouragement, reassurance, and information. AREAS FOR FURTHER INVESTIGATION An experimental study u t i l i z i n g a v a r i e t y of i n -s t r u c t i o n a l techniques and methods should be carried out to determine the best means of preparing open heart surgery patients f o r discharge. The present study could be r e p l i c a t e d with the following changes: 1. employing a more structured interview guide to obtain more s p e c i f i c data on p a t i e n t s ' concerns; 2. c o n t r o l l i n g f o r the presence of those other than the patient at the interview; 3 . checking the r e l i a b i l i t y of the data analysis from the tape-recorded interviews. A study of the concerns of patients who return to t h e i r homes outside of the Greater Vancouver area should be carried out to determine i f these patients have concerns d i f f e r i n g from patients who l i v e i n closer proximity to the h o s p i t a l . SELECTED BIBLIOGRAPHY 69 70 SELECTED BIBLIOGRAPHY A. BOOKS As p i n a l l , Mary J. Nursing the Open-Heart Surgery Patient* New York: McGraw-Hill Book Co., 1973. Behrendt, Douglas M., and W. Gerald Austen. Patient Care  i n Cardiac Surgery. Boston: L i t t l e , Brown and Co., 1972. Kerlinger, Fred N.- Foundations of Behavioral Research. New York: Holt, Rinehart and Winston, Inc., 1964. Luckmann, Joan, and Karen C. Sorensen. Medical-Surgical  Nursing: A Psychophysiologic Approach. Philadelphia: W. B. Saunders Co., 1974. N e v i l l e , William E . (ed.). Care of the Surgical Cardiopulmonary Patient. Chicago: Year Book Medical Publishers, 1 9 7 1 . Pohl, Margaret L. The Teaching Function of the Nurse  P r a c t i t i o n e r . 2d ed. Dubuque: William C. Brown Co., Publishers, 1973. Redman, Barbara K. The Process of Patient Teaching i h ' Nursing. 2d ed. Saint Louis: The G. V. Mosby Co., 1972. Rogers, Carl R. Freedom to Learn. Columbus, Ohio: Charles E. M e r r i l l Publishing Co., 1 9 6 9 . Sanderson, Richard G. (ed.). The Cardiac Patient: A Comprehensive Approach. Philadelphia: W. B. Saunders Co., 1972. Zohman, Lenore R., and Jerome S. Tobis. Cardiac -R e h a b i l i t a t i o n . New York: Grune and Stratton, Inc., 1970. 71 B. PERIODICALS Abram, Harry S. "Adaptations to Open Heart Surgery: A Psychiatric Study of Response to the Threat of Death," American Journal of Psychiatry, CXXII (December, 1965), 659-668. Abram, Harry S., and Benjamin F. G i l l . "Predictions of Postoperative Psychiatric Complications," New England  Journal of Medicine. CCLXV (December 7, 19617] 1123-1128 Abramson, Ronald, and Bernard Block. "Ego-supportive Care i n Open-heart Surgery," International Journal of Psychiatry i n Medicine. IV ( F a l l , 1973), 427-437. Barclay, George W. "Possible Medical Problems Associated with Cardiac Surgery," Texas Medicine, LXIX (July, 1973), 74-S3. Barratt-Boyes, B.G. "Homograft Replacement f o r Aortic Valve Disease." Modern Concepts of Cardiovascular Disease. XXXVI (January, 1967), 1-5. Blacher, Richard S. "The Hidden Psychosis of Open-Heart Surgery: With a Note on the Sense of Awe," Journal  of the American Medical Association, CCXXII (October 16, 1972), 305-308. Blachly, Paul H. and B. J . Blachly, "Vocational and Emotional Status of 263 Patients a f t e r Heart Surgery," C i r c u l a t i o n . XXXVIII (September, 1968), 524-532. Blachly, Paul H. and Frank E. Kloster. "Relation of Cardiac Output to Post-Cardiotomy Delirium," Journal  of Thoracic and Cardiovascular Surgery, L i t (September, 1966), 422-427. Brambilla, Mary A. "A Teaching Plan f o r Cardiac Surgical ' Patients," Cardiovascular Nursing. V( January-February, 1969), 153-154 Brogan, Mary R. "Nursing Care of the Patient Experiencing Cardiac Surgery f o r Coronary Artery Disease," Nursing  C l i n i c s of North America. VII (September, 1972TJ 517-527. Budd, Suzanne P., and Willa Brown. "Eff e c t of Reorientation Technique on Postcardiotomy Delirium," Nursing  Research. XXIII (July-August, 1974), 341-348. 72 Cooley, Denton A., et a l . "Ten Year Experience with Cardiac Valve Replacement: Results with a New M i t r a l Prothesis," Annals of Surgery. CLXXVII (June, 1973), 818-826. Crouch, John A., et a l . "Operative Results i n 1,426 Consecutive Cardiac Surgical Cases," Journal of  Thoracic and Cardiovascular Surgery, LXVII (October, 1974), 606-610. Egerton, N., and J . H. Kay. "Psychological Disturbances Associated with Open Heart Surgery," B r i t i s h Journal  of Psychiatry. CX (May, 1964), 433-439. Finchum, R.-Newell. "Reha b i l i t a t i o n Following Cardiac Surgery," C i r c u l a t i o n , Supplement XLIII-XLIV (May, 1971), 1-151 - 1-158. Frank, Kenneth A., S. Heller, and Donald S. Kornfeld. "A Survey of Adjustment to Cardiac Surgery," Archives  of Internal Medicine. CXXX (November, 1972), 735-738. Gibbon, John H. "Application of a Mechanical Heart and Lung Apparatus to Cardiac Surgery," Minnesota Medicine. XXXVII (March, 1954), 171-180. " Gilberstadt, Harold and Yoshio Sako. " I n t e l l e c t u a l and Personality Changes Following Open-Heart Surgery," Archives of General Psychiatry. XVI (February, 1967), 210-214. Gilman, Sid. "Cerebral Disorders a f t e r Open-Heart Operations," New England Journal of Medicine. CCLXXII (March 11, 1965), 489-498. Hazan, S. J. " P s y c h i a t r i c Complications Following Cardiac Surgery;" Journal of Thoracic and Cardiovascular  Surgery. LI (March, 1966), 307-319. Henrichs, Theodore F., James W. MacKenzie, and Carl H. Almond. "Psychological Adjustment and Acute Response to Open-Heart Surgery," Journal of Nervous and Mental  Disease. CXLVIII (February, 1969), 158-164 Houser, Doris. "Outside the Coronary Care Unit," Nursing  Forum, XII (1973), 96-107. Kaplan, Stanley M. "Psychological Aspects of Cardiac Disease: A Study of Patients Experiencing M i t r a l Commissurotomy," Psychosomatic Medicine, XVIII (May-June, 1956), 221-233. 73 Kennedy, Janet A., and Hyman Bakst. "The Influence of Emotions on the Outcome of Cardiac Surgery,"-B u l l e t i n of the New York Academy of Medicine. XLII (October, 1966j, 811-845. Kornfeld, Donald S., Sheldon Zimberg, and James R. Malm. "Psychiatric Complications of Open-Heart Surgery," • New England Journal of Medicine. CCLXXIII (August 5, 1965),287-292. Kouchoukos, Nicholas T., and John W. K i r k l i n . "Coronary Bypass Operations f o r Ischemic Heart Disease," Modern Concepts of Cardiovascular Disease. XLI (October, 1972), 47-52. Layne, Ottis L., and Stuart C. Yudofsky, "Postoperative Psychosis i n Cardiotomy Patients," New England Journal  of Medicine. CCLXXXIV (March 11, 1971), 518-520. Long, Madeline L., Mary A. Scheuhing, and Judith L. Christian.- "Cardiopulmonary Bypass," American Journal  of Nursing. LXXIV (May, 1974), 860-867^ McFadden, Eileen H.,.and Elizabeth C. G i b l i n . "Sleep Deprivation i n Patients Having-Open-heart Surgery," Nursing Research, XX (May-June, 1971), 249-254. Morch, John, et a l . "Late Results of Aortocoronary Bypass Grafts i n 100 Patients with Stable Angina Pectoris," Canadian Medical Association Journal. GXI (September 21, 1974), 529-532. Mullen, P a t r i c i a D. "Health Education f o r Heart Patients i n C r i s i s H e a l t h Services Reports,, LXXXVIII (August-September, 1973), 669-675. Powell, Anne H,, and Elizabeth H. Winslow. "The Cardiac C l i n i c a l Nurse S p e c i a l i s t : Teaching Ideas that Work," Nursing C l i n i c s of North America. VIII (December, 1973), 723-733. Redman, Barbara K. " C l i e n t Education Therapy-in Treatment and Prevention of Cardiovascular Diseases,"-Cardiovascular Nursing, X (January-February, 1974), 1-6. Rogoz, Barbara. "Nursing Care of the Cardiac Surgery Patient f"•Nursing C l i n i c s of North America. IV (December, 1969), 631-644. Royle, Joan. "Coronary Patients and Their Families Receive Incomplete Care," Canadian Nurse. LXIX (February, 1973), 21-25. 74 Spiegel, Allen D., and Harold W. Demone. "Questions of Hospital Patients - Unasked and Unanswered." Postgraduate Medicine. XLIII (February, 1968), 215-218. University of Toronto Interhospital Cardiovascular Surgical Group. "The F i r s t 1,000 Coronary Artery Repair Operations in Toronto," Canadian Medical Association Journal. CXI (September 21, 1974), 525-528. Verderber, Anne. -"Cardiopulmonary Bypass: Postoperative Complications," American Journal of Nursing. LXXIV (May, 1974), Weiss, Stephen M. "Psychological Adjustment Following Open-Heart Surgery," Journal of Nervous and Mental  Disease. CXLIII (October, 1966), 363-368. : Wilson, W. Stan. "Aortocoronary Bypass Surgery I I - - an Updated Review," Heart and Lung, III (May-June, 1974), 435-454. Wynn, A l l a n . "Unwarranted - Emotional Distress i n Men with Ischemic Heart - Disease," Medical Journal of Australia« II (November 4, 1967), 847-851" : Zohman, Lenore R. "Cardiac R e h a b i l i t a t i o n : Its Role i n Evaluation and Management of the Patient with Coronary Heart Disease," American Heart Journal. LXXXV (May, 1973), 706-710. C. UNPUBLISHED WORKS Stackman, Jeanne F. "Eff e c t s of a Systematic Teaching Program upon the Myocardial Infar c t i o n Patient's Understanding of His Disease and His Discharge Orders;" Unpublished Master's t h e s i s , University of Washington, 1973. Wahl, Sharon C. "The Problems of Thirty-One Post-Operative Open Heart Surgery Patients - a f t e r Discharge." Unpublished Master's t h e s i s , University of Oregon, 1973. APPENDIXES 75 76 APPENDIX A CONSENT TO ACT AS A SUBJECT FOR STUDY S u b j e c t s Name: Date:_ I hereby consent to p a r t i c i p a t e i n a study being conducted by Si s t e r Maureen O'Loane and to be interviewed by S i s t e r O'Loane two weeks following my discharge from the open-heart s u r g i c a l u n i t at Saint Paul's Hospital. An explanation of the study has been given to me by S i s t e r O'Loane. I understand that there are no r i s k s involved and that no i d e n t i f y i n g information w i l l appear i n the completed study. I further understand that I am free to withdraw from the study at any time. (Subject's Signature) ST. PAUL'S HOSPITAL OPEN HEART SURGICAL AREA Discharge G u i d e l i n e s APPENDIX B DISCHARGE GUIDELINES 77 Although your primary heart problem has been c o r r e c t e d , do not expect to r e t u r n to "normal" f o r at l e a s t three months. You can expect v a r i o u s types of chest pain f o r some time. Dul l aching in the back or under the breasts i s common, e s p e c i a l l y on damp days and i s muscular in nature, a r i s i n g from your chest w a l l which was s t r e t c h e d at the time of surgery. Heat, in the form of a hot water b o t t l e or e l e c t r i c pad i s very h e l p f u l . Sometimes a sharp stabbing pain which l a s t s a second or two i s alarming - a g a i n , I t i s not s e r i o u s - perhaps a lung adhesion being freed from the chest w a l l i s to blame. If you develop a p e r s i s t e n t pain l i k e p l e u r i s y , which tends to be severe and i s worse on deep b r e a t h i n g , i t would be wise to report t h i s to your doctor. You may n o t i c e an o c c a s i o n a l " c l i c k i n g " noise from your sternum (breast bone), e s p e c i a l l y on deep breathing - t h i s i s of no consequence and w i l l disappear when the bones are f i r m l y healed. Do not be worried i f you have a poor a p p e t i t e f o r several weeks more. I t takes time f o r the body to "get over" heart surgery and the a p p e t i t e u s u a l l y returns in a month. Level of A c t i v i t y f o l l o w i n g Discharge from H o s p i t a l Week #1 - Carry on w i t h same amount of a c t i v i t y reached In h o s p i t a l Climbing s t a i r s permitted Yes \ I No f l Week #2 - Begin to increase the amount of walking and go outdoors i f weather permits .—> I Climbing s t a i r s permitted Yes j | No j \ S p e c i a l L i m i t a t i o n s , I f any: Sexual A c t i v i t y - may be resumed f o l l o w i n g heart surgery. You are encouraged to d i s c u s s t h i s subject w i t h your doctor, i f you wish. You are cautioned against d r i v i n g an automobile u n t i l you have been seen i n your doctor's o f f i c e . (2) M e d i c a t ions The m e d i c a t i o n s you w i l l be t a k i n g a t home, and the t imes you a r e t o t a k e them a r e as f o l l o w s : D i e t : D i e t i c i a n t o s e e | ' 1 Community R e f e r r a l A g e n c i e s to be u s e d : M e a l s on Wheels J~~"J V i c t o r i a n O r d e r o f N u r s e s r~j P u b l i c H e a l t h a n d / o r Home C a r e Program |_J Next A p p o i n t m e n t w i t h Doctor w i l l b e : S u r g e o n : C a r d i o l o g i s t : F a m i l y D o c t o r : I f you a r e r e c e i v i n g a blood t h i n n e r ( a n t i c o a g u l a n t ) you w i l l r e q u i r e a b l o o d t e s t ( p r o t h r o m b i n t ime) in d a y s . P l e a s e go to S t . P a u l ' s H o s p i t a l L a b o r a t o r y , o r the L a b o r a t o r y d e s i g n a t e d by y o u r d o c t o r f o r t h i s t e s t . Y o u r n u r s e w i l l g i v e you a r e q u i s i t i o n f o r t h i s t e s t , i f i t i s t o be done in S t . P a u l ' s H o s p i t a l . You do n o t need t o f a s t p r i o r to t h i s t e s t . YOU AND YOUR ANTICOAGULANTS 79 Your doctor has decided that you should r e c e i v e a n t i c o a g u l a n t medications when discharged from h o s p i t a l . We thought you would be i n t e r e s t e d i n knowing a l i t t l e about the a c t i o n of t h i s medication. Anticoagulants ( a l s o known as "blood t h i n n e r s " ) slow the c l o t t i n g prcesses of the blood. Normally, when the l i q u i d blood Is o u t s i d e the body i t w i l l form a s o l i d c l o t w i t h i n a few seconds. If an a n t i c o a g u l a n t has been added, the blood w i l l r e q u i r e more time to c l o t , and i f too much an t i c o a g u l a n t has been added, the blood may remain l i q u i d and never form a c l o t . You may have been given your a n t i c o a g u l a n t f o r a number of d i f f e r e n t reasons. Perhaps you have received a new a r t i f i c i a l heart v a l v e and your doctor wants to prevent blood c l o t s from forming on i t s surface. Perhaps you have had a bout o f t h r o m b o p h l e b i t i s , a form of inflammation of the veins o f the l e g s , from l y l n n in bed a long time, o r from pregnancy, and your doctor wants to prevent blood c l o t s from forming In the v e i n s . Perhaps you have a form of heart rhythm change which a l l o w s blood to stagnate and hence leads t o c l o t t i n g . Perhaps you have narrowed a r t e r i e s to the b r a i n and your doctor wants to keep your blood f l o w i n g f r e e l y through the narrow channels. There are many reasons f o r t a k i n g a n t i c o a g u l a n t s , but whatever the reason, I t Is necessary that you r e c e i v e j u s t the r i g h t dosage. No two people need Ju s t the same amount of a n t i c o a g u l a n t . If you do not take enough, you w i l l r eceive no b e n e f i t . I f you take too much, you may bleed spontaneously. Your doctor w i l l arrange f o r you to have your blood checked p e r i o d i c a l l y to determine j u s t how much an t i c o a g u l a n t you need. The blood t e s t i s c a l l e d a "prothrombin time". The t e c h n i c i a n takes a sample of your blood and determines how many seconds are required before your blood w i l l c l o t . She then compares t h i s time to a normal i n d i v i d u a l ' s prothrombin time, and w i l l report the r e s u l t s to your d o c t o r , both In seconds of time and In percentage of the normal. For i n s t a n c e , I f a normal person's blood c l o t s i n 13 seconds, and your blood c l o t s In 13 seconds, your r e p o r t w i l l read -" 1 3 seconds 100% of normal". On the other hand, i f your blood c l o t s i n 28 seconds -your report w i l l read - " 2 8 seconds 30% o f normal". Your doctor i s t r y i n g to keep your blood under 3 0 * of normal and he would be pleased w i t h such a reading. I f your blood c l o t s too soon and your percentage approaches the normal, he may ask you to take more a n t i c o a g u l a n t . On the other hand, i f your prothrombin time were l e s s than ]0%, he would ask you to take less a n t i c o a g u l a n t . At f i r s t , w h i l e you are i n h o s p i t a l , a blood t e s t f o r prothrombin time i s taken every day. Once you are " c o n t r o l l e d " your doctor w i l l decrease the number o f blood t e s t s to every other day, then once o week, and l a t e r perhaps, once every four to s i x weeks. As long as you are t a k i n g a n t i c o a g u l a n t s you w i l l r e q u i r e p e r i o d i c blood prothrombin times, f o r u n f o r t u n a t e l y the a c t i o n of the medications tends to change. Many things make the prothrombin time change. For example, i f you d r i n k a l c o h o l , you may need le s s a n t i c o a g u l a n t s than i f you do not. C e r t a i n drugs change the amount of a n t i -coagulant needed - e.g. a s p i r i n , s e d a t i v e s , a n t i b i o t i c s . This does not mean that you may not d r i n k a m a r t i n i , or take a s p i r i n f o r your headache - but i t does mean that i f you d r i n k more than you are accustomed to d r i n k , your prothrombin time may change and you may r e q u i r e more, or less a n t i c o a g u l a n t than at other times. The probthrombin time t e s t i s done e i t h e r In the h o s p i t a l or i n a nearby l a b o r a t o r y . Your doctor w i l l arrange f o r your f i r s t t e s t and t e l l you when and where to report f o r i t . You do not need to f a s t f o r the t e s t and It u s u a l l y j u s t takes a minute. Once your blood has been taken you may leave. The l a b o r a t o r y w i l l c a l l your doctor that day and give him the r e p o r t . He, or h i s s e c r e t a r y , should c a l l you that day or the next, and t e l l you whether or not the dosage of your a n t i c o a g u l a n t should be changed, and ask you t o return f o r another prothrombin time on a c e r t a i n date. I f you are not contacted by your doctor, please c a l l him. The report may have gone a s t r a y . 80 I f , In e r r o r , you take too many a n t i c o a g u l a n t t a b l e t s , you may bleed more e a s i l y than normal. You may see large b r u i s e s on your body, pass bloody u r i n e , or your t e e t h may bleed e x c e s s i v e l y a f t e r brushing. C a l l your doctor i f you n o t i c e any of these t h i n g s . If you cut y o u r s e l f w h i l e taking a n t i c o a g u l a n t s , ycu w i l l n o t i c e that you w i l l bleed more e a s i l y than at other times. If i t i s a small c u t , such as one caused by shaving, j u s t apply pressure over the cut f o r f i v e minutes and i t w i l l stop. If i t i s a l a r g e r c u t , and pressure does not h e l p , c a l l your d o c t o r . He may want to g i v e you vi t a m i n K which i s the an t i d o t e to your a n t i c o a g u l a n t . Never have an o p e r a t i o n w h i l e t a k i n g a n t i c o a g u l a n t s . T e l l your d e n t i s t and any new doctor u n f a m i l i a r w i t h your case that you are taking a n t i c o a g u l a n t s . They may wish to stop your a n t i c o a g u l a n t f o r two or three days before t a k i n g out your t o o t h , or may gi v e you an i n j e c t i o n of v i t a m i n K before t a k i n g out your appendix. It i s a good idea to c a r r y a l i t t l e - c a r d in your w a l l e t which s t a t e s that you are ta k i n g a n t i c o a g u l a n t s , In case you are in an auto a c c i d e n t . It may a l s o be wise to remind your doctor that you are on a n t i c o a g u l a n t s when new drugs are p r e s c r i b e d , e s p e c i a l l y a n t i b i o t i c s . A n t i c o a g u l a n t s taken by mouth are of many d i f f e r e n t types. The most popular types are Dicoumarol, W a r f a r i n , and Marcumar, but you may have been given a p r e s c r i p t i o n f o r s t i l l another v a r i e t y . Know which type you take and question any change In appearance o f the p i l l when you get your p r e s c r i p t i o n r e f i l l e d . December, 1973 APPENDIX C FACE SHEET Age: Sex: M a r i t a l Status: Occupation: Surgery: Postoperative Complications: Length of Postoperative H o s p i t a l i z a t i o n Surgeon: C a r d i o l o g i s t : Interview Data Location: Persons present: Days Postoperative: Days Postdischarge: Readmission to Hospital: Reasons: 6*2 APPENDIX D INTERVIEW SCHEDULE The interview f o r each patient was unstandardized as to format but was based on the following content: I. Patient's General Feeling of Well-being since Discharge A. Progress B. Questions that occurred C. Areas of concern D. Means of coping with concerns and questions I I . Physiological Considerations A. Present physical condition B. Complaints - most frequent most bothersome C. A c t i v i t y - type amount; how decided amount of sleep and rest d i f f i c u l t i e s with sleeping D. N u t r i t i o n - appetite at present s p e c i a l d i e t any d i f f i c u l t i e s with d i e t E. Elimination - constipation and s t r a i n i n g F. Medications - prescriptions dosages and schedules important side e f f e c t s known I I I . Emotional Considerations A. Worries B. Feelings about present state of health C. Feelings about worth of surgery IV. Socio-economic Considerations A. Family's treatment of patient since discharge B. Feelings about present r o l e i n family C. Acceptance of patient's condition by fr i e n d s D. Concern showed by f r i e n d s , work associates E. Expectations and plans re employment F. Person(s) most r e l i e d upon f o r knowledge of what one may do V. Feelings about pre-discharge teaching A. Successful Areas B. F a i l i n g s APPENDIX E MISCELLANEOUS PHYSIOLOGICAL CONCERNS Lack of balance i n early morning Cough Palpitations P h l e b i t i s i n one l e g Drainage from l e g i n c i s i o n Gout Cerebral vascular accident Loss of voice Tightening of chest Fractured c l a v i c l e queried Swelling above sternum When to resume r e h a b i l i t a t i o n that stopped preoperatively Effectiveness of surgery What was actual heart problem and how was i t repaired Placement and operation of pacemaker Early discharge from h o s p i t a l E r r a t i c pulse Poor c i r c u l a t i o n to lower extremities Medication causing insomnia Incompatibility of medications Weight gain Numbness i n arm Numbness around leg i n c i s i o n D i f f i c u l t y getting out of bed I n a b i l i t y to cough or deep breathe APPENDIX F LOCATIONS OF PAIN REPORTED BY PATIENTS Chest i n c i s i o n 11 complaints Leg i n c i s i o n 5 complaints Arms 4 complaints Legs 3 complaints Shoulder 2 complaints Chest (angina) 2 complaints Back 1 complaint Ribs 1 complaint APPENDIX G MISCELLANEOUS EMOTIONAL CONCERNS Unreality of the experience E a s i l y i r r i t a t e d Knowledge of surgery's l i m i t a t i o n s Distance from h o s p i t a l Number of physicians on the case Future problems that could occur Whom to contact f o r help APPENDIX H MISCELLANEOUS SOCIO-ECONOMIC CONCERNS P o s s i b i l i t y o f having t o change jobs D i s a p p r o v a l o f s u b s t i t u t e ' s h a n d l i n g o f job G u i l t about not working F e a r f u l t h a t f a m i l y p h y s i c i a n f e e l s g u i l t y about not d i s c o v e r i n g d e f e c t APPENDIX I POSITIVE ASPECTS OF CONVALESCENCE Feeling stronger Appetite good or improving Weight gain No pain Less shortness of breath on exertion Less pain Sleeping well No angina Improved c i r c u l a t i o n and color Greatly improved r e l a t i o n s with wife and children Able to keep weight down Adjusting to discomforts Doing better than wardmates who had also been discharged APPENDIX J UNEXPECTED ASPECTS OF CONVALESCENCE Nothing F e e l i n g so w e l l F e e l i n g so "rough" d u r i n g f i r s t week Weakness and t i r e d n e s s D i f f i c u l t i e s s l e e p i n g Slowness to pick up s t r e n g t h Severe chest pain -P h l e b i t i s Exacerbation of gout f o l l o w e d by c e r e b r a l v a s c u l a r a c c i d e n t 

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