Journal of Babylon University/Pure and Applied Sciences/ No.(2)/ Vol.(23): 2015
Determination The Level of Anxiety Among Patients
Scheduled for Diagnostic Cardiac Catheterization
Sahar Adham Ali
University of Babylon- College of Nursing
[email protected]
Abstract
Objective: presented study aimed to Determination the Level of anxiety among patients scheduled
for Diagnostic cardiac catheterization.
Methodology: descriptive design study was conducted at Cardiac Catheterization Center at
Marjan hospital in Al-Hillah city, data was gathered by using prepared form which consist tool for
measuring the level of the anxiety for patients admitted to the hospital from the period ( August 5
.2012 to December 20.2012) . The selected sample was 95 patients.
Results: the results shows that the higher percentage of the sample (54.7%) were male most of
them were smoker 64.2%, and 48.4% of the sample were hypertensive; 50.5% of the sample suffer
from moderate level of anxiety, according to the signs and symptoms which is associated with
anxiety most of the sample were suffering from headache and sleeping disturbance two days ago
before the procedure.
Recommendation: Patient education material is either sensory- or procedural-oriented should be
prepared. Procedural material describes the steps involved in the cardiac catheterization. Sensory
information focuses on what the patient will see, hear, feel, smell or taste during the procedure which
helps the patient reduce anxiety by communicating a better understanding of what to expect during
the procedure.
Keywords: Determination, cardiac catheterization, anxiety level .
‫الخالصة‬
. ‫ تهدف الدراسة إلى تحديد مستوى القلق لدى المرضى المزمع إخضاعهم إجراء قسطرة القلب التشخيصية‬:‫االهداف‬
‫تم إع ة ةةداد اس ة ةةت اصا تض ة ةةمصب سداة‬,‫ د ارس ة ةةة ميداصي ة ةةة وص ة ةةكية سجرة ة ةةب ة ة ة مر ة ةةز قس ة ةةطرة القل ة ةةب ة ة ة مستش ة ةةكى مرج ة ةةاة مديص ة ةةة الحل ة ةةة‬: ‫المنهجيةةةةة‬
‫ ل ة ة‬. 2012 ‫ ديسة ةةم ر‬20‫ إلة ةةى‬2012‫ سغسة ةةطت‬5‫لقية ةةات مسة ةةتوى القلة ةةق لة ةةدى المرضة ةةى عصة ةةد دخة ةةولهم المستشة ةةكى تة ةةم جمة ةةع ال يصة ةةة للكت ة ةرة مة ةةة‬
‫ مرةض‬95 ‫عدد ا راد ال يصة‬
%64.2 ‫ واة صس ة ة ة ة المة ة ةةدخصية اصة ة ةةب‬%54.7 ‫ال يصة ة ةةة ة ة ةةم مة ة ةةة ال ة ة ة ور صس ة ة ة ة‬
‫ م ة ة ةةصهم ي ة ة ةةاص م ة ة ةةة القلة ة ةةق مس ة ة ةةتوا‬%50.5 ‫ توصة ة ةةلب الد ارس ة ة ةةة إلة ة ةةى إة‬,‫ال ة ة ةةدم‬
‫ سشة ة ةةا رب صتة ة ةةاث ال حة ة ةةف ة ة ةةاة م ة ة ةةم إ ة ة ةراد‬:
‫النتةةةةةةة‬
‫ مة ة ةةصهم ي ة ة ةةاصوة مة ة ةةة ارتك ة ة ةةاإ ض ة ة ة‬%48.4 ‫واة صس ة ة ة ة‬
‫امة ةةا الصس ة ة ة الة ةةى ا ع ة ةراض وال المة ةةاب المصة ةةاح ة للقلة ةةق ت ة ةةية اة م ة ةةم ا ة ةراد ال يصة ةةة ي ة ةةاصوة مة ةةة ا م ال ة ةرات واضة ةةط ار اب الصة ةةوم‬. ‫المتوس ة ة‬
.‫ق ل يومية مة الكحص‬
‫ير ة ةةز علة ةةى ت ة ةاسر ح ة ةوات الم ة ةرةض‬
‫وال ة ة‬
‫ سوصة ةةب ال احسة ةةة اسة ةةتحداف رصة ةةام ت ليم ة ة ي خ ة ة ص ة ةةر ا عت ة ةةار الجاصة ةةب الحس ة ة‬: ‫التوصةةةةةي‬
‫إمة ةةا الجاصة ةةب اةخة ةةر يشة ةةمل الم لومة ةةاب عة ةةة الخط ة ةواب المت ة ةةة ج ة ةراء القسة ةةطرة‬. ‫خة ةةالخ إج ة ةراء القسة ةةطرة‬
‫ يحة ةةت‬,‫ يشة ةةم‬, ‫ ية ةةرى‬, ‫( مة ةةا يسة ةةمع‬
. ‫لتقليل مستوى القلق ومساعدة المرةض على هم وشرح ما يتوقع خالخ عملية القسطرة‬
‫ مستوى القلق‬, ‫قسطرة القلب‬, ‫ تحديد‬: ‫المفت حي‬
‫الكلم‬
Introduction:
Cardiac catheterization is a diagnostic and therapeutic procedure that allows a
comprehensive examination of the heart and surrounding blood vessels (Moton P.G,
et al: 2005).
National annual report in the United States estimated that, there were
45 million inpatient procedures during 2007 and 15 percent of these were
cardiovascular. Males aged 45–64 and 65 years and over had higher cardiac
catheterization rates than females in these age groups each year from 1997 to 2007.
Patients who undergoing coronary angioplasty and received coronary stents was
rose from 0% in 1994 to >80% in 2001, mortality rates at 5 years in the United
States relative to Canada (19.6% versus 21.4%) (Hall, et al: 2010) .Studies on
psychologica preparation have concluded that preparatory techniques specifically,
sensory-perceptual informational and modeling are beneficial in reducing patients'
anxiety in various situations, including cardiac catheterization (Mott, 1999).
Operationally anxiety defined as an unpleasant and uncanny experience perceived in
891
Journal of Babylon University/Pure and Applied Sciences/ No.(2)/ Vol.(23): 2015
this instance as a result of an environmental change and experienced as a threat to
one's security. This experience is verbalized with difficulty and is more readily
studied through its nonverbal manifestations. These manifestations include certain
psychological and somatic dysfunctions whose connection with the inciting incident
may be only temporal which can be observed (Videbeck: 2011). Anxiety alters the
patient’s vital signs; it results in physiological responses such as tachycardia,
hypertension, elevated temperature, sweating, nausea and a heightened sense of
touch, smell or hearing. A patient may also experience peripheral vasoconstriction.
Anxiety may cause behavioral and cognitive changes which can result in increased
tension, apprehension, nervousness and aggression. Some patients may become so
nervous and apprehensive that they cannot understand or follow simple instructions.
Some may be so aggressive and demanding that they require constant attention of
the nursing staff. Patients with low anxiety tend to adopt a joking attitude. Other
trends include displaying a calm and relaxed attitude during pre- procedure care so
they don't experience any sleeping disturbances. They also tend to make little effort
to seek more information about medical procedures. This may be due to the fact that
they are unaware of the potential threats, or it may just be because they have
succeeded in shutting themselves out and eliminating all thought of doubt and fear.
Patient with low anxiety usually deny apprehension about operational dangers.
The emotional tension is unrelieved because there are no real reassurances
available in the pre- clinical intervention stage. Patients with moderate anxiety may
experience minor emotional tension occasional worry and fear usually they suffer
from insomnia, and they respond well to mild sedatives. Their outward manner may
seem relatively calm and well controlled, except for small moments where it is
apparent to others that the patient is suffering from an inner conflict. They can
usually perform daily tasks, only becoming restless from time to time. These
patients are usually very motivated to develop reliable information from medical
authority in order to reach a point of comfortable relief.
Because the reassurances
given by hospital personnel were not effective, there aren’t any real reassurances
available to aid with the stress stimuli that are subsequently encountered. Patient
should be prepared previously, teaching or tours may be performed and accurate
information about the procedure relaxation therapy nurse-patient relationships
(Agarwal, et al: 2006). The anxiety experienced among patients may have various
causes, including not feeling cared about as an individual, too much waiting time
before the procedure begins, and physical discomfort. This review determines
nursing interventions that may effectively reduce anxiety prior to diagnostic cardiac
catheterization (Mc Caffrey and Taylor: 2005).
Objectives of the study:
1. To identify the characteristic of the participants
2. Determine the level of the anxiety depending on the Hospital Anxiety Scale (HADS)
3. Assessing changes in the physical parameters of the convenient sample
4. Find out the relationship between anxiety and demographical data (gender, age and
educational level).
Methodology
Design: Qualitative – descriptive design was used. The study included 95 consecutive
patients waiting for cardiac catheterization.
Setting of the study and Selection of the sample: This study was carried out during the
period between the periods August 5 to December 20. 2012 in cardiac catheterization center
in Marjan Hospital in Hillah city. The convenience sample consisted of (95) patient (43
female and 52 male) who admitted to the cardiac catheterization center for elective cardiac
catheterization. The inclusion criteria to select the sample were the following: Patients agree
892
Journal of Babylon University/Pure and Applied Sciences/ No.(2)/ Vol.(23): 2015
to participate in the study, oriented undergone cardiac catheterization for first time, not less
than 30 years old. Face to face interview performed with the patients during waiting time.
Methods: A data-collecting form includes three parts : first part consist of the following questions
about demographic features: (age , gender , area of residency ,marital status , educational levels and
occupation ) , second part depend on the Hospital Anxiety and Depression Scale (HADS) which
originally developed by Zigmond and Snaith , The HADS was prepared for detecting anxiety in
non-psychiatric patients from a medical department and is commonly used by health personals to
determine the levels of anxiety that a patient is experiencing , a score ranging from 1-24. Each item
has a choice of four fixed response statements (weighted 1-4). A score of 7-12 points indicates (mild)
borderline significance for either scale, 13-18 indicates (moderate), while 19-24 indicated (severe)
anxiety level, but less than 7 points is insignificant. In this study, a score of 7 categorized as a ‘case’
and less than 7 (1-6) as ‘non-case. While the third part of the form consist of six signs and symptoms
(physiological changes) which the patient may suffer from such as: headache, sleeping disturbance,
anorexia, diarrhea, constipation and gastric upset.
Statistical analysis: Data were analyzed through applying descriptive and inferential analysis
as; frequencies, percentage, mean score and chi-square
Result
Table 1: Distribution of Patients According to the Demographic data of the sample
Demographic data
Age:
30-40
41-50
51-60
61-70
Gender:
Male
Female
Marital status
Single
Marriage
Residence
Urban
Rural
Education Status:
Can't Read & Write
Primary
Intermitted
Secondary
Institution
Occupation :
Official work
Private work
Retire
Housewives
Total
Frequency
10
29
41
15
Percentage
10.5%
30.5%
43.2%
15.8%
52
43
54.7%
45.3%
1
94
1.1%
98.9%
95
0
100%
0
20%
33.7%
22.1%
17.9%
6.3%
19
32
21
17
6
23
23
15
34
24.2%
24.2%
15.8%
35.8%
95
100%
Table 1: presented that the highest percentage of the age were 41(43.2%) between (52-62)
age group, 52(54.7%) were male, according to the age the highest percentage 41(43.2%) were
between (52-62) age group, 32(33.7%) of the sample were within primary school, while the
highest percentage 34(35.8%) were housewives, the table shows that the 95(100%) were
urban area resident and 94(98.9%) of the sample were married.
893
Journal of Babylon University/Pure and Applied Sciences/ No.(2)/ Vol.(23): 2015
Table 2: Distribution of the patients According to chronic illness and Smoking
Chronic Illness
Frequency
Percentage
Diabetes Mellitus
Hypertension
Diabetes& Hypertension
21
46
17
22.1%
48.4%
17.9%
Free of chronic diseases
Smoker
11
61
11.6%
64.2%
Not Smoker
34
35.8%
Table 2: Shows that the highest percentage of the sample 49 (48.4 %) were hypertensive and
the highest percentage of the sample 61 (64.2 %) were smoker.
Table 3: Distribution of the patients According to their Family History
N= 95
Family History
Frequent
Percentage
Diabetes Mellitus
Hypertension
Diabetes& Hypertension
Free of family history for
chronic diseases
17
42
27
9
17.9%
44.2%
28.4%
9.5%
Table 3: Shows that 42 (44.2%) of the sample were with positive family history for chronic
disease (hypertension)
Table 4: Distribution of the Patients According to Anxiety Scale
Anxiety Levels
N=95
No
Items
Mild
Moderate
Severe
MS
L
F
%
F
%
F
%
F
%
I get a sort of frightened feeling as if
something bad is about to happen
20
21.0%
46
48.4%
34
35.8%
4
4.2%
2.4
HL
I can sit at ease and feel relaxed
22
23.1%
51
53.7%
28
29.4%
4
4.2%
2.3
HL
Worrying thoughts go through my
mind
I get a sort of frightened feeling like
butterflies in the stomach
I feel restless and have to be on the
move
13
13.7%
54
56.8%
36
37.9%
2
2.1%
2.4
HL
24
25.3%
46
48.4%
33
34.7%
2
2.1%
2.3
HL
21
22.1%
37
38.9%
42
44.2%
4
4.2%
2.4
HL
I get sudden feelings of panic
49
51.6%
37
38.9%
17
17.9%
3
3.1%
1.9
ML
Ms: mean score
HL: Highly level
ML: Moderate Level
Table 4: Shows that the highest percentage 48(50.5%) of the participants were records that
they have worrying thoughts according to the anxiety scale during waiting time for cardiac
catheterization.
894
Journal of Babylon University/Pure and Applied Sciences/ No.(2)/ Vol.(23): 2015
Table 5: Anxiety Level of the Patient According to Anxiety Scale (HADS)
Anxiety Levels
N=95
MS
L
F
%
NO Case ( 1-6)
14
14.7%
0.1
L
Mild (7-12)
32
33.7%
0.6
L
Moderate (13- 18)
48
50.5%
1.5
ML
Severe (19-24)
1
1.1%
0.04
L
Table 5: Shows that 48 (50.5%) of the sample recorded moderate level of anxiety during
waiting time for cardiac catheterization.
Table6: Relationship between Anxiety Level and Demographical Characteristics
(Gender, age, educational level) of the Sample
N=95
Anxiety
NO Case
( 0-6)
Characteristics
Gender
Male
Female
Mild
(7-12)
F
%
F
13
1
13.7%
1.1%
18
14
Moderate
(13- 18)
F
18.9%
14.7%
21
27
Severe (1924)
F
22.1%
28.4%
0
1
0
1.1%
χ : S
Age:
30-40
41-51
1
5
1.1%
5.3%
7
9
7.4%
9.5%
4
15
4.2%
15.8%
0
1
0
1.1%
52-62
6
6.3%
12
12.6%
22
23.2%
0
0
63-73
2
2.1%
4
4.2%
7
7.4%
0
0
χ :
NS
Education
Can't Read & Write
4
4.2%
4
4.2%
11
11.6%
0
0
Primary
3
3.2%
15
15.8%
14
14.7%
0
0
Intermitted
4
4.2%
5
5.3%
12
12.6%
0
0
Secondary
1
1.1%
7
7.4%
9
9.5%
0
0
Institution
2
2.1%
1
1.1%
2
2.1%
1
1.1%
χ : S
χ : P= P value
S: Significant
NS: None Significant
Table 5: Show that 27(28.4%) were female within moderate level of anxiety ( Chi-Square
:7.81 P ≤ 0.05) presented significant relation between anxiety level and gender , 22( 23.2%)
Chi- Square
895
Journal of Babylon University/Pure and Applied Sciences/ No.(2)/ Vol.(23): 2015
of the sample were between (52-62 ) age group who recorded moderate level of anxiety , no
significant relation presented ( Chi: 16.92 P ≤ 0.05) between anxiety and age , while
15(15.8%) of the sample were graduated from primary school shows mild anxiety level
significant relation (Chi: 16.92 P ≤ 0.05 ) ,between anxiety level and educational status clearly
presented .
Table 7: Distribution of the sample according to the physiological changes associated
with anxiety
Signs and Symptoms
MS
L
F
69
%
72.6%
F
26
%
29.4%
1.7
HL
Have sleeping disturbance two
days ago
69
72.6%
26
29.4%
1.7
HL
Anorexia
40
42.1%
55
57.9%
1.4
HL
Diarrhea
28
29.5%
67
70.5%
1.3
HL
Constipation
8
8.4%
87
91.6%
1.0
HL
Gastric upset
42
44.2%
53
55.8%
1.4
HL
Suffering from headache two days
ago
Yes
No
Table 7: shows that the highest percentage 69(72.6%A) of the sample were suffer
from headache and sleeping disturbance as physiological symptoms associated with
anxiety.
Discussion:
The results of the demographical data which presented in table (1) shows
that the higher percentage of the sample 41(43.2 %) were between (52-62) years of
age group and 52 (54.7 %) of the sample were male.
This results was parallel with the study which presented that the
demographic data for patients undergoing only diagnostic cardiac catheterization
procedures are shown that approximately two-thirds were male, whereas 56% of the
patients being 65 years of age or older and approximately 10% of the patients being
80 years of age or older (Dehmer et al :2010) .
"individual with low educational level, low economic status and married were
more label to expose to accidental cardiac disorder" (Norton: 2010) , this results
were agree with our finding which pointed on high percentage (33.7%) of the
sample were within primary education, (98.9%) were married and (35.8%) were
housewives also the table shows that the whole participant
(100%) were city
resident (Shavelle et al: 2006). The prevalence of cardiovascular risk factors was:
hypertension 32 (67%), smoking 19 (40%), diabetes mellitus 17 (35%),
hyperlipidemia 20 (42%), and family history of coronary artery disease 16 (33%).
This finding was clearly found in table (2) which presented that 46(48.4) were
within hypertension, 17(17.9) diabetes mellitus, 61(64.2) were smoker and the
results in table (3) found that 69(72.6%) were with positive family history of cardiac
disease (Chan &Cheung: 2003).
The results of table (4) presented the distribution of the sample related to the
anxiety scale, The Hospital Anxiety scale was prepared for detecting anxiety health
personals to determine the levels of anxiety that a patient is experiencing (Bjelland,2002).
896
Journal of Babylon University/Pure and Applied Sciences/ No.(2)/ Vol.(23): 2015
Table (5) presented that the 32(50.5%) recorded moderate level of anxiety, this
results supported by the study provides initial information about anxiety reduction
with education intervention among Chinese heart disease patients undergoing
cardiac catheterization. Anxiety of all subjects reached the highest level at the time
just before cardiac catheterization and recorded the lowest at the time following the
procedure. A lower level of anxiety was experienced by the experimental subjects
who received the education intervention when compared with the control subjects
who did not receive the education intervention before cardiac catheterization
(Garvin et al: 2003).
Women expressed greater anxiety than the men. However, the men and women
were similar at all levels of anxiety in their preference for information and control.
Women were significantly more anxious (p < 0.05). The search will help healthcare
providers design effective interventions to reduce anxiety among men and women.
These opinions agree with the results of table (6) which presented significant
relation (p=0.008) found between anxiety and gender (Okvat: 2002).
Anxiety and its pharmacological treatment can interfere with cardiac
catheterization an interventional cardiology center at an urban hospital in New
York, conducted on Seventy-eight patients (59 men, 19 women), and with a mean
age of 60.1 years who were scheduled for an elective, diagnostic catheterization
based on routine clinical practices. Mean anxiety scores on a 166 mm visual analog
scale. Massage therapy has been used primarily in nonmedical settings for
relaxation and stress reduction, and some research demonstrates its efficacy in
medical environments.
Table (6) presented significant relation between anxiety and patient's. According
to a study published "a lower education level" was a predictor of anxiety, people
"with at least some college-level education" were less likely to experience anxiety
than people without any college-level education (Bjelland: 2008).
The results of table (7) presented that most of the sample suffer from headache
and sleeping disturbance with gastric disorder. Anxiety is more than just a feeling.
As a product of the body’s fight-or-flight response, anxiety involves a wide range of
physical symptoms Anxiety takes several forms: phobia, social anxiety, obsessivecompulsive. The physical effects of anxiety may include heart palpitations,
tachycardia, muscle weakness and tension, fatigue, nausea, chest pain, shortness of
breath, headache, stomach aches, or tension headaches. As the body prepares to deal
with a threat, blood pressure, heart rate, perspiration, blood flow to the major
muscle groups are increased, while immune and digestive functions are inhibited
(the fight or flight response). External signs of anxiety may include pallor, sweating
( Videbeck: 2011).
Conclusion:
The presented study concluded the following:
1. Most of the convenient sample of the study was male, within age group (52-62),
graduated from primary school, housewives and city resident
2. Most of the sample were hypertensive, smoker.
Most of the participants within
moderate anxiety level, according to the signs and symptoms which are associated
with anxiety most of the sample were suffering from headache and sleeping
disturbance two days ago.
3. Significant relationship was clearly found between anxiety and gender, and
educational status.
Recommendation
 Patient education material is either sensory- or procedural-oriented should be
prepared. Procedural material describes the steps involved in the cardiac
897
Journal of Babylon University/Pure and Applied Sciences/ No.(2)/ Vol.(23): 2015
catheterization. Sensory information focuses on what the patient will see, hear, feel,
smell or taste during the procedure which understanding of what to expect during
the procedure.
 Information can be presented through different medias such as written pamphlets
and videos
 Face-to-face interaction between the patient and cath lab staff has an opportunity
to evaluate the patient’s comprehension of the information. Importantly, the
interview also provides a social visit with the patient which reducing anxiety.
 Proper time for education should be taken under consideration; simply best time
for education is as early as possible
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