Daniela Fraga de JesusI,II; Patrícia Figueiredo MarquesIII
IUniversidade Federal do Recôncavo da Bahia (UFRB), Cruz das Almas, BA, Brazil
IIUniversidade São Camilo, São Paulo, SP, Brazil
IIIMD. Universidade Federal do Recôncavo da Bahia (UFRB), Cruz das Almas, BA, Brazil
Work carried out at Universidade Federal do Recôncavo da Bahia (UFRB), Cruz das Almas, BA, Brazil.Correspondence To:
The study aimed to analyze the available evidence in the literature on nursing care in the hospital post-cardiac surgery. Data were collected from electronic databases LILACS, SciELO, MEDLINE, via DeCS thoracic surgery, hospital, nursing care, in the period 2001 to 2011. Ten articles were selected that showed the need to develop a plan of nursing discharge focusing on prevention of complications and coping with physical limitations resulting from heart surgery. Thus, the discharge should be considered from the time of admission, with carefully planned actions involving patient and family.
Keywords Cardiovascular surgical procedures. Nursing care. Patient discharge.
O estudo objetivou analisar evidências disponíveis na literatura sobre a assistência de enfermagem na alta hospitalar em pós-operatório de cirurgia cardíaca. Os dados foram coletados das bases eletrônicas LILACS, SciELO, MEDLINE, através dos DeCS cirurgia torácica, alta hospitalar, cuidados de enfermagem, no período de 2001 a 2011. Foram selecionados dez artigos que revelaram a necessidade de desenvolver um plano de alta de enfermagem com foco na prevenção das complicações e no enfrentamento das limitações físicas decorrentes da cirurgia cardíaca. Destarte, a alta hospitalar deve ser pensada desde o momento da admissão, com ações de cuidado planejadas envolvendo paciente e familiar.
Palavras-Chave Procedimentos cirúrgicos cardiovasculares. Cuidados de enfermagem. Alta do paciente.
LILACS: Literatura Latino Americana em Ciências de Saúde
MEDLINE: Medical Literature Analysis and Retrieval System Online
SciELO: Scientific Electronic Library Online
Cardiovascular diseases are the main cause of morbimortality of the Brazilian population . The diseases of the circulatory system with high level of morbimortality are: heart ischemic disease, cerebrovascular diseases, heart failure, and valvulopathies, especially of rheumatic origins, among others [2,3].
There is no single cause for those diseases, but there are several risk factors which increase the probability of their occurrence . Because of their several causes and complexity level, cardiac pathologies must have their course urgently interrupted with clinical and/or surgical treatment .
Since the treatment is complex, the institution must offer specialized material and human resources as well as a multidisciplinary team with technical-scientific expertise and skills to carry on the daily activities and the ability to see the individual as a whole . A multidisciplinary team should consist of clinicians, cardiologists, electrophysiologists, cardiac surgeons, vascular surgeons, anesthesiologists, cardiologists, nutritionists, physiotherapists, psychologists, and nursing staff .
Among the professionals in the multidisciplinary team, the nurse and the psychologist are extremely important because patients usually present symptoms such as anxiety, depression, negative thoughts about the future, and lack of confidence, especially in the postoperative period . The psychologist seeks to reduce feelings that may interfere with the patient's recovery as well as to prepare him throughout his hospitalization, with the goal of providing trust and peacefulness so that the patient can avoid feeling beaten and tortured .
In this context, the role of a nursing team is extremely important, once they assist the patient uninterruptedly during the hours following surgery and are responsible for setting up the unit as well as providing human and material resources . Besides having technical and scientific knowledge, the team is in charge of caring, controlling, and observing the patient by taking into account the complexity of the surgery in addition to the vitality of the organ system involved [2,11].
For this reason, the nurse should organize and plan the assistance based on the methodological steps of the nursing process in order to intervene in accordance with the individual needs of the patient . Hence, nursing practice should be guided by the scientific method as it enables the nurse to identify and meet the needs of the assisted person, through the patient's medical history, nursing diagnosis, planning, and correct implementation and evaluation. However, to meet the needs of patients, the nurse also needs skills, cognitive competence, and constructive technical, organizational and interpersonal relationships, both objectively and subjectively .
Despite the intensive care of the nursing team, the occurrence of complications after cardiac surgery is very common and is one of the main causes of morbidity and mortality in the postoperative period . Consequently, nursing care has to be planned systematically so that after discharge the patient does not fear or feel insecure about the new lifestyle, the limitations resulting from the procedure, changes in diet, and other relevant orientations according to the needs of the patient [15-17].
Guidance on discharge is commonly given mechanically and briefly, not taking into consideration the patient's condition and needs . That happens because nurses face difficulties in communicating with physicians. They are not informed about discharge, only becoming aware of it when the patient is leaving or after they have left the hospital . Thus, hospital discharge should be handled by an interdisciplinary team, mediated by the nurse, who will be the link between the professionals so that the specific needs of each patient are met .
Therefore, and to serve as a basis for the job of the nursing team, the present study set out to analyze the evidence available in the literature about nursing assistance at hospital discharge after cardiac surgery.
This is an integrative review whose methodological strategy is justified because it summarizes knowledge and incorporates applicable results of practical and meaningful studies [21,22].
In the process of making this integrative review, some operationalization patterns that contributed to the development of the study were followed: (1) the hypothesis was formulated and the problem was identified ; (2) inclusion and exclusion criteria for the selection of samples were established; (3) the analysis of relevant information extracted from the studies was done; (4) the studies included in the review were evaluated; (5) the results were interpreted; and (6) the review was presented, synthesizing the resulting knowledge [23,24].
The study was guided by the following question: what is the available evidence in literature about nursing assistance at hospital discharge after cardiac surgery?
The literature review was based on the LILACS (Literatura Latino Americana em Ciências de Saúde), SCIELO (Scientific Electronic Library Online), and MEDILINE (Medical Literature Analysis and Retrieval System Online) electronic databases. The descriptors (Decs) used for Health Science were: thoracic surgery, hospital discharge, and nursing care.
The criteria for sample inclusion were based on articles published in Portuguese, English, Spanish, and French, fully available, from 2001 and 2011. The articles were selected based on the analysis of their title and abstract. Those that did not address the issue anddid not meet the inclusion criteria above were excluded. Articles published twice were considered only once.
The instrument used for data collection was a grid, created specifically for this study, which was completed by each chosen item with information about identity Id (P1, P2, P3, ...), journal, article title, authors/year, authors' institution, authors' profession, QUALIS system, and considerations/themes.
After inserting the information into the grid, the studies selected were evaluated through careful reading, during which contributions were extracted, results were interpreted, discussions were presented descriptively, and information collected for each article was summarized (Table 1).
Regarding ethical aspects, the authors of this study were concerned with registering the necessary information to identify the authors of the articles investigated and not altering the available information in those documents. For this reason, the material was reproduced and analyzed impartially in order to avoid bias.
The review's final sample was comprised of ten articles, selected according to previously established inclusion criteria, available in the LILACS, SCIELO, and MEDLINE databases.
Nine (90%) out of the ten (100%) articles selected were from nursing journals and one (10%) from the Brazilian Journal of Cardiovascular Surgery. Based on the stratification of the Personnel Development Coordination for Higher Education (CAPES) for journals, five (50%) of the articles were published in Qualis A1 and A2 journals, four (40%) in Qualis B1 and B2, and only one (10%) in Qualis B3.
Regarding the time period of publication, from 2001 to 2011, five articles (50%) were published in 2006 and five (50%) between 2007 and 2011. In 2006, more professionals were willing to publish articles on this issue. In terms of the authors' institutions, seven authors (70%) were from public federal universities and three (30%) were from hospitals, which is positive since it highlights the production of knowledge in educational institutions. However, it is important that this new knowledge gets transmitted to the nursing professionals and put into practice in hospitals.
Regarding authors' occupations, eight (80%) articles were written by female nurses; one (10%), by a male nurse and a doctor; and one (10%), by two male nurses and a biologist. This partnership between nurses and other professionals is valid as a multi-professional outlook allows for different experiences in the healthcare area and improves the quality of the assistance offered.
The studies revealed that nurses are concerned with the guidelines provided to patients and their families in the hospital discharge [25-31]. However, guidelines should be developed with the participation of patients and their families in a way that is easy to understand. Accordingly, nursing care should be guided by a scientific methodology that fully meets the patient's needs. Still, studies claim that the nursing staff must develop new approaches to care with the application of nursing diagnoses and teamwork in order to have continuous care [32-34].
Among the new approaches in nursing care, a trusting relationship between nurse and patient must be readily established as it is necessary to prepare patients and their families with information about the need to undergo cardiac surgery so they can understand it and adapt to possible changes, especially in the postoperative period [23,31]. This is a tense moment, causing emotional stress, insecurity, and fear so the nursing staff must be prepared to guide patients and their families to reduce their anxiety and to comfort them.
Trust within the nurse-patient relationship should happen through a two-way communication because it builds an important foundation for the care to be carried out efficiently and effectively, and it provides understanding of the patient as a whole . These complications may be of cardiovascular, pulmonary, renal, gastrointestinal, and neuropsychiatric origins.
Due to the complexity of cardiac surgeries, the postoperative period is monitored by a multidisciplinary team through continuous monitoring and critical decision making and care. However, it is the nursing staff that monitors the patient full-time, providing specific care that aims at reducing complications and maintaining the balance of the organic system, through planned assistance . On the other hand, one study found that nurses still develop more technical care at the bedside, devoid of greater interaction with the patient and his family .
Essentially, the technical model of health care is still very present in the daily routine of health professionals. In nursing, this type of care is repeated in the postoperative period, through interventions aimed at preventing complications with the surgical incision and unidirectional guidelines preparing patients to return to their homes and their daily activities. There is no systematic care involving a discharge plan or the patient.
To change this reality, it is essential that the nursing staff make use of scientific knowledge and records of the multidisciplinary team to develop a discharge plan . That plan must be developed from the moment the patient is admitted so as to provide greater safety and reduce the risk of complications . The specific type of heart surgery should also be considered because the length of stay will vary according to the surgical procedure and the patient's condition. In addition, it may involve the temporary or permanent suspension of some activities, altering the lifestyle of the patient. To that end, it is necessary that the family and the patient follow specific care procedures after the surgery .
In this context, the discharge should be carried out with the help of a psychologist working with the family and the patient, in an attempt to help the patient understand the changes and adapt to a different lifestyle by developing new skills. Nevertheless, to make sure home care is provided and to avoid rehospitalization, discharge has to be planned and include the involvement and understanding of both patient and his family.
The discharge plan demands dedication from a multidisciplinary team, with interaction happening between all the professionals engaged in the health-disease process and aimed at minimizing fragmented care. Thus, solutions can be provided based on the patient's reality as the moment of discharge is the most expected by patients and their families. This moment is also marked by fear, insecurity, doubt, stress, and dependence upon the care of health professionals.
However, the problems mentioned should be solved during the hospitalization period by the nursing staff through continuous care and with planned, implemented, and evaluated actions. Since the discharge causes a feeling of incompleteness regarding the care, it is the responsibility of the nurse to reassure the patient during this recovery process . It is imperative that this professional show the patient how to take care of themselves, valuing their beliefs, feelings, actions, behaviors, and motivating them to feel able to safely develop self-care [29,31].
To this end, the nursing staff has a crucial role in providing educational activities for patients and their families by promoting knowledge and wellness, and enabling them to care for themselves. Self-care awareness is needed by the patient because it improves the practice of activities for their own benefit and quality of life. Self-care should be effectively performed and nurses should encourage it through scientific knowledge based on the General Theory of Orem Self Care. This theory emphasizes the value of engaging patients in self-care, encouraging them to participate actively in their recovery .
Based on this theory, educational activities that promote self-care in the postoperative period of cardiac surgery are conducted. These activities should contemplate aspects such as weight control, restriction of salt and fluids, medications, exercise, nutrition, and symptoms of worsening of the disease [27,29,31]. Besides, advice on the special care demanded by the disease and needed to handle the surgical incision and the specific conditions of each patient should be given . This can make them meet and/or greatly exceed any difficulties resulting from their physical limitations as well as reduce health risks .
In this regard, it is understood that nursing staff must consider how the patient undergoing cardiac surgery and his family prepare for the procedure, that is, the following must be taken into account: the causes of anxiety; the perception of what is more important to advise the patient on; and how much to advise when the patient is returning home. For that purpose, nursing guidance must be well-established in the patient's discharge plan, in a way that is clear and easy to understand.
In every discharge, it can be noticed that the fragile "thank you" pronounced by the patient comes along with expressions of doubt about the care he must follow after leaving the hospital. Consequently, we highlight the importance of the nursing staff in terms of care and advising patients about actions that will contribute to a better adaptation to daily life and that will minimize their doubts and expectations .
However, the lack of knowledge of patients about the disease and treatment will only be solved through the guidance and educational activities provided by nurses and the evaluation of the surgical patient in understanding the process of recovery from the time of the surgery and the implementation of post-discharge self-care. To do so, the time available and the expertise needed for the nurses to plan an individualized discharge, the availability of educational materials, and the monitoring needed to ensure the effectiveness of hospital discharge must be emphasized .
After the results discussed, researches must be done about nursing assistance at the hospital discharge of patients in the postoperative of cardiac surgery, with the objective of drawing them to patients' problem analysis which demand nursing specific actions, once scientific research is scarce in this field. These studies may contribute for the scientific development of the profession as well as its practical applicability in the health institutions.
However, nursing care actions towards patients of cardiac surgery must be planned and involve patients and family, and discharge has to be considered from admission so that care will not be fragmented.
Although we are referring to a nursing discharge planning, it is necessary to involve a multidisciplinary team and its records to set a discharge planning. So, the team must advise and develop education activities for patients and family. Moreover, the team is expected to hear and consider what participants say in order to reach their expectations and make their adaptation to a new lifestyle easier.
1. Jesus DF, Fonseca FA, Souza FM, Silva EAL. As facetas do HIPERDIA: o olhar da equipe multidisciplinar em uma unidade de saúde do município de Santo Antônio de Jesus-BA. In: XXIII Congresso Brasileiro de Cardiologia [CD]; 2011 Mai 12-14; Bahia. Anais CD. Salvador; 2011. p.76
2. Fernandes RA, Silva JA. Cuidados de enfermagem em pacientes no pós-operatório imediato (POI) de troca de válvula mitral: elaboração de um protocolo de atendimento. UNINGÁ Review. 2011;8(1):50-60.
3. Lopes CR, Brandão CMA, Nozawa E, Auler Jr JOC. Benefícios da ventilação não-invasiva após extubação no pós-operatório de cirurgia cardíaca. Rev Bras Cir Cardiovasc. 2008;23(3):344-50. [MedLine] [See article]
4. Brasil. Ministério da Saúde. Envelhecimento e saúde da pessoa idosa. Secretaria de Atenção à Saúde Departamento de Atenção Básica. Caderno de Atenção Básica nÂº 19. Brasília; 2006.
5. Pivoto FL, Lunardi Filho WD, Santos SSC, Almeida MA, Silveira RS. Diagnósticos de enfermagem em pacientes no período pós-operatório de cirurgias cardíacas. Acta Paul Enferm. 2010;23(5):665-70.
6. Gomes WJ, Almeida RMS, Braile DM. Abordagem multidisciplinar das doenças cardíacas: o paciente como prioridade na decisão médica. Rev Bras Cir Cardiovasc. 2010;25(4):VI-VII. [See article]
7. Sousa MR, Rocha RM, Paola AAV, Köhler I, Feitosa GS, Schneider JC, et al. Diretriz da Sociedade Brasileira de Cardiologia Sobre processos e Competências para a Formação em Cardiologia no Brasil. Arq Bras Cardiol. 2011;96(5 supl.1):1-24.
8. Costa VASF, Silva SCF, Lima VCP. O pré-operatório e a ansiedade do paciente: a aliança entre o enfermeiro e o psicólogo. Rev SBPH. 2010;13(2):282-98.
9. Finkel LA, EspíndolaVBP. Cirurgia cardíaca pediátrica: o papel do psicólogo na equipe de saúde. Psicol Am Lat. 2008;13. Available at: http://psicolatina.org/13/cirurgia.html
10. Ferreira FG, Silva RCG, Gonçalves CHB, Palomo JSH. Pós-operatório imediato de cirurgia cardíaca pediátrica: rotina de enfermagem para admissão do paciente na Unidade de Terapia Intensiva. Rev Bras Cir Cardiovasc. 2011;26(2):301-2. [MedLine] [See article]
11. Lamas AR, Soares E, Silva RCL. Desafios na assistência de enfermagem ao idoso no pós-operatório de cirurgia cardíaca. Rev Enferm UFPE. 2009;3(1):91-4.
12. Guimarães RCM, Rabelo ER, Moraes MA, Azzolin K. Gravidade de pacientes em pós-operatório de cirurgia cardíaca: uma análise evolutiva segundo o TISS-28. Rev Latino-Am Enfermagem. 2010;18(1):61-6.
13. Duarte SCM, Stipp MAC, Mesquita MGR, Silva MM. O cuidado de enfermagem no pós-operatório de cirurgia cardíaca: um estudo de caso. Esc Anna Nery. 2012;16(4):657-65.
14. Renault JA, Costa-Val R, Rossetti MB, Houri Neto M. Comparison between deep breathing exercises and incentive spirometry after CABG surgery. Rev Bras Cir Cardiovasc. 2009;24(2):165-72. [MedLine] [See article]
15. Almeida PFP, Junior RG. Gasparino RC. Dúvidas dos pacientes em pós-operatório de revascularização do miocárdio. Cogitare Enferm. 2009;14(4)675-81.
16. Jesus DF, Fonseca FA, Marques PF, Intervenções de enfermagem no pós-operatório de amputação de membro inferior - relato de uma experiência. In: Seminário Internacional de Pesquisa e Educação em Enfermagem [CD-ROM]; 2012 dez; Salvador, Brasil. p.86.
17. Gardetto NJ, Carroll KC. Management strategies to meet the core heart failure measures for acute decompensate heart failure: a nursing perspective. Crit Care Nurs Q. 2007;30(4):307-20. [MedLine]
18. Pompeo DA, Pinto MH, Cesarino CB, Araújo RRDF, Poletti NAA. Atuação do enfermeiro na alta hospitalar: reflexões a partir dos relatos de pacientes. Acta Paul Enferm. 2007;20(3):345-50.
19. Pereira APS, Tessarini MM, Pinto MH, Oliveira VDC. Alta hospitalar: visão de um grupo de enfermeiras. Rev Enferm UERJ. 2007;15(1):40-5.
20. Atwal A. Nurses' perceptions of discharge planning in acute health care: a case study in one British teaching hospital. J Adv Nurs. 2002;39(5):450-8. [MedLine]
21. Ursi ES, Galvão CM. Prevenção de lesões de pele no perioperatório: revisão integrativa da literatura. Rev Latino-Am Enfermagem. 2006;14(1):124-31.
22. Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein. 2010;8(1 Pt 1):102-6.
23. Silveira CS, Zago MMF. Pesquisa brasileira em enfermagem oncológica: uma revisão integrativa. Rev Latino-Am Enfermagem. 2006;14(4):614-9.
24. Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008;17(4):758-64.
25. Gasperi PD, Radunz V, Prado ML. Procurando reeducar hábitos e costumes: o processo de cuidar da enfermeira no pré e pós-operatórios de cirurgia cardíaca. Cogitare Enferm. 2006;11(3):252-7.
26. Razera APR, Braga EM. A importância da comunicação durante o período de recuperação pós-operatória. Rev Esc Enferm USP. 2011;45(3):632-7. [MedLine]
27. Romanzini AE, Jesus APM, Carvalho E, Sasaki VDM, Damiano VB, Gomes JJ. Orientações de enfermagem aos pacientes sobre o autocuidado e os sinais e sintomas de infecção de sítio cirúrgico para a pós-alta hospitalar de cirurgia cardíaca reconstrutora. Rev Min Enferm. 2010;14(2):239-43.
28. Dutra CMP, Coelho MJ. Implante de valva mitral mecânica: reflexões para cuidar e os cuidados de clientes após a alta hospitalar. Esc Anna Nery R Enferm. 2006;10(2):309-15.
29. Pereira APS, Tessarini MM, Pinto MH, Oliveira VDC. Alta hospitalar: visão de um grupo de enfermeiras. R Enferm UERJ. 2007;15(1):40-45.
30. Andrietta MP, Moreira RSL, Barros ALBL. Plano de alta hospitalar a pacientes com insuficiência cardíaca congestiva. Rev Latino-Am Enfermagem. 2011;19(6):1445-52.
31. Paul S. Hospital discharge education for patients with heart failure: what really works and what is the evidence? Crit Care Nurse. 2008;28(2):66-82. [MedLine]
32. Boaz MR, Bordignon R, Nesralla IA. A importância de medidas preventivas na profilaxia de infecções em pacientes submetidos a transplante cardíaco nos primeiros 30 dias de pós-operatório. Rev Bras Cir Cardiovasc. 2006;21(2):188-93. [See article]
33. Rocha LA, Maia TC, Silva LS. Diagnósticos de enfermagem em pacientes submetidos à cirurgia cardíaca. Rev Bras Enferm. 2006;59(3):321-6. [MedLine]
34. Galdeano LE, Rossi LA, Santos CB, Dantas RAS. Diagnóstico de enfermagem no perioperatório de cirurgia cardíaca. Rev Esc Enferm USP. 2006;40(1):26-33. [MedLine]
35. Soares GMT, Ferreira DCS, Gonçalves MPC, Alves TGS, David FL, Henriques KMC, et al. Prevalência das principais complicações pós-operatórias em cirurgias cardíacas. Rev Bras Cardiol. 2011;24(3):139-46.
36. Felix LG, Nóbrega MML, Fontes WD, Soares MJGO. Analysis from Theory of the Orem Self Care according to Fawcett criteria. Rev Enferm UFPE On Line. 2009;3(2):173-8.
Article received on april 7, 2013.
Article accepted on october 7, 2013.
No financial support.
DFJ: Study design, literature review, data collection, analysis of results and final considerations
PFM: Study design with literature review, data collection, literature review, analysis and discussion of results, and final considerations