bs_bs_banner
International Journal of Nursing Practice 2016; ••: ••–••
RESEARCH PAPER
Symptom management strategies of Jordanian
patients following coronary artery bypass grafting
surgery
Zaher Mohammed Al-Daakak RN,MSc
Medical Instructor, Department of Emergency and public Safety, Ministry of Interior General Head Quarters, Abu Dhabi, United Arab Emirates
Ali Ahmad Ammouri RN, MSN, PhD
Associate Professor, College of Nursing, Hashemite University, Zarqa, Jordan
Chandrani Isac RN, MSc
Lecturer, College of Nursing, Sultan Qaboos University, Muscate, Oman
Huda Gharaibeh RN, PhD
Associate Professor, College of Nursing, Jordan University of Science and Technology, Irbid, Jordan
Ibtisam Al-Zaru RN, PhD
Associate Professor, College of Nursing, Jordan University of Science and Technology, Irbid, Jordan
Accepted for publication 22 March 2016
Al-Daakak ZM, Ammouri AA, Isac C, Gharaibeh H, Al-Zaru I. International Journal of Nursing Practice 2016; ••: ••–
••
Symptom management strategies of Jordanian patients following coronary artery bypass grafting
surgery
The aim of this study was to explore the symptom management strategies utilized by post coronary artery bypass graft
(CABG) patients and its associations with demographic variables. A clear understanding of the use of symptom management
strategies following CABG surgery may help nurses in developing educational program and interventions that help patients
and their families during recovery period after discharge. A cross-sectional, descriptive design was utilized. A convenience
sample of 100 Jordanian patients post CABG surgery selected from five hospitals was surveyed between November 2012
and June 2013 using the Cardiac Symptom Survey. Chi squared analyses were used to examine the associations between
the symptoms management strategies and selected demographic variables. Frequency of symptom management strategies utilized by post CABG patients revealed that most frequently employed strategies were use of medications (79%), repositioning
(54%) and the rest (45%). Symptom management strategies utilized for poor appetite, sleeping problem and fatigue had significant associations with demographic variables. By providing information about the symptoms expected after surgery and
possible ways to manage them, will strengthen the patients psychologically and will make CABG experience within the realm
of self-management and coping.
Key words: CABG, coronary artery bypass graft, Jordanain, symptom management strategies.
Correspondence: Ali A. Ammouri, College of Nursing, Hashemite University, P.O Box 330127, Zarqa 13115, Jordan. Email: [email protected]
All authors met the authorship criteria and are in agreement with the content of the manuscript.
doi:10.1111/ijn.12445
© 2016 John Wiley & Sons Australia, Ltd
ZM Al-Daakak et al.
2
INTRODUCTION
Coronary artery disease (CAD) mortality rate was estimated at 7.4 million and continues to hold its reign as the
leading cause of death worldwide. The greater proportion
of the burden is experienced in the high income countries,
followed by upper middle countries.1 The morbid states
due to CAD were projected at 3 616 000 for the Southeast
Asian countries.1 In Jordan, the burden of CAD is representative of the world standards and has been reported by
World Health Organization (WHO)1 to be the highest
cause of death among Jordanian men and women.
Coronary artery bypass grafting (CABG) is a lifesaving
surgical procedure of choice for most patients with advanced CAD. The physical and psychological discomforts
experienced by patients after CABG have been comprehensively illuminated in literature.2 With the outset of the fast
tracked protocols in health-care delivery system, most patients carry home with them their discomforts. The manner
in which these symptoms are managed by post CABG patients has not been consistently or comprehensively explored internationally.3
BACKGROUND
Literature has consistently recorded the continuum of
symptoms experienced by the patients who undergo
CABG. The symptom experience in the physical domain includes shortness of breath, fatigue, trouble sleeping, pain
and swelling; the psychological domain is consisted of anxiety and depression.2 Empirical evidences on therapeutic
strategies and self-managed techniques instituted to prevent
and manage these symptoms have been reported by many
studies. The rest has been reported by post CABG patients
to overcome dyspnea,4 fatigue,5,6 sleep disturbances,7 anxiety and depression.8
Many studies quote the use of medications as the first
choice for reducing pain. Pain medication taken before
bed time has also been reported to improve sleep.7 Activities like short walk or riding a stationary bicycle every day9
were practiced by post CABG patients to enhance sleep. Altering routines was a prevalent practice among post CABG
patients. Balancing between activity and rest, sitting down
when doing of housework and using of a grocery cart when
shopping10 are techniques utilized by post CABG patients to
alleviate stress. Sleep restriction therapy11 has been reported by post CABG patient to improve their sleep quality
and quantity.
Behaviours used by post CABG patients to divert their
attention from anxiety were music therapy,12 listening to
© 2016 John Wiley & Sons Australia, Ltd
prayer8 and presence of family caregivers. Repositioning
techniques instituted by post CABG patients was mainly
to reduce leg swelling by keeping legs elevated in a chair.13
Literature reports the prevalent use of adjunct therapies for
many of the symptoms experienced by post CABG patients.
Using pillows to support incision during movement and applying heat or ice14 have been evidenced in literature to reduce chest incisional pain. Slow deep breathing exercises4
and cough manoeuvers by placing the palm of hands firmly
on the chest incision were found to decrease airway secretions.15 Wearing comfortable clothes and low heeled shoes
10
has been cited for fatigue reduction.
Use of massage therapy to improve sleep16,17 and reduce
anxiety and depression12 has also been magnified in literature. Use of compressive stocking18 to alleviate leg swelling
was also identified as an adjunct therapy among post CABG
patients. Behaviours involving a change in eating patterns or
foods consumed like limiting dietary restrictions, provision
of smaller and more frequent meals, snacks and supplements and changing of diet19 had significantly improved
the appetite of post CABG patients.
A clear understanding of the use of symptom management strategies following CABG surgery could help
nurses in developing educational programme and new interventions that help patients and their families during
recovery period after hospital discharge. No previous
study has investigated these phenomena in Jordan or
the region. Effective and efficient practice of these strategies can facilitate early recovery and reduce readmission
to the hospital. Giving patients the control and confidence to deal with their symptoms will foster independence and contribute vastly to an improvement in their
quality of life.
METHODS
Aims
The aim of this study was to explore the symptom management strategies utilized by post CABG patients. The study
empirically evidenced the strategies that were effective in
relieving post CABG discomforts and also directed healthcare providers to understand the tendency of specific demographic traits in utilizing these strategies.
Design
The design utilized for the study was descriptive, crosssectional design to assess symptom management strategies
utilized by patients after CABG surgery and there associations with selected demographic variables.
Symptom management strategies post CABG
Sample and setting
Non-probability convenient sampling of 100 Jordanian patients post CABG surgery was selected from five hospitals
in Jordan between November 2012 and June 2013. The
sample size was estimated according to Cohen20 formula,
with power = 0.80, α = 0.05, medium effect size. The results of the power analysis for chi-squared (χ 2) test at
df = 1 showed that the required sample size was 87 patients.
However, more patients were included to acquire more significant and reliable findings and to allow for an acceptable
dropout rate. Inclusion criteria were (i) 18 years or older,
(ii) have undergone CABG surgery for first time, (iii) oriented and able to hear and speak, (iv) have a telephone service. On the other hand, patients were excluded if they had
an active psychiatric diagnosis that might affect the ability of
the patients to response to the questionnaire.
The patients selected for the study had undergone CABG
in one of the five hospitals located in the capital city of
Amman and the second largest city Irbid. These hospitals included two teaching hospitals (Jordan University Hospital
and King Abdullah University Hospital) and three private
hospitals (Islamic Hospital, Amman Surgical Hospital and
Jordan Hospital). In these hospitals, the general protocol
is for post CABG patients to be nursed in the Intensive Care
Units for 2 days and then transferred to step-down units for
4 days before discharge.
Instruments
The Demographic Data Sheet was designed by the researchers to collect background information from both patients and medical records (gender, age, educational level,
income, working status, height and weight, smoking and
chronic diseases). The body mass index (BMI) for the participants was computed from their weight and height measurements (BMI = weight (kg)/[height (m)]2), and they
were categorized based on World Health Organization21
standards as normal weight (18.5–24.9 kg/m2), overweight (25–29.9 kg/m2) or obese (≥ 30 kg/m2).
To assess the discomforts symptoms experienced by patients who undergo CABG, the Cardiac Symptom Survey
(CSS) was utilized.22 Although this tool has three dimensions, the component, which measures the perception of
symptom presence, was alone considered for this study.
The Cronbach’s alphas for this instrument ranged from
0.85 to 0.98.23
The CSS questionnaire was rigorously translated back
and forth from English to Arabic language. The content validity of the tools was reviewed by three Doctorate experts.
3
A pilot study with a sample of ten patients post CABG
served as the medium to examine the reliability of the
CSS instrument. The results of pilot study indicated that
the Cronbach’s alphas for the instrument ranged from
0.83 to 0.99. In addition, questions required between
15–20 min to answer.
Symptom management strategies were measured using
the categories of symptom management strategies developed by Schulz et al.19 The categories were empirically formulated and utilized in a study on symptom management
strategies used by elderly patients after CABG surgery.19
The categories list nine strategies that include rest, medications, seek help, activity, alter routine, distraction, reposition, adjunct treatments and change diet. Content validity
of the categories was maintained by a nurse specialized in
cardiovascular nursing, and criterion validity was assessed
by comparing the categories to the guidelines of American
Heart Association and Society of Thoracic Surgeons.19
The definitions and the various ways by which these strategies are implemented were explained to participants.
Data collection
Formal consent was taken from the participants who
consented for the study. With the Demographic Data
Sheet, data related to the participants’ personal and medical
background were collected before hospital discharge. After
2 weeks of their discharge, each participant received a
phone call from the researcher who utilized the CSS to ascertain any symptom experienced by the participant. The
categories of symptom management strategies were used
as a framework to ascertain, if the patients who did experience discomforts during the 2 weeks utilize any strategy to
relieve their symptoms.
A total of 106 patients were invited to participate in the
study. Three patients refused to be contacted after hospital
discharge; one patient was feeling tired and refused to recall
later, and one contact number was out of service. One patient was excluded from the study because the patient
underwent a re-opening surgery during first week after discharge. The remaining 100 respondents (response rate
94.3%) were included in the study.
Ethical considerations
This study was approved by the human subject research
committee (reference no 14/2010/10) of Jordan
University of Science and Technology. Institutional permission from the teaching and private hospitals was also officiated before the conduct of the study. The study purpose
© 2016 John Wiley & Sons Australia, Ltd
ZM Al-Daakak et al.
4
was clarified to nursing administration, charge nurses and
patients who met the inclusion criteria. In addition, the importance of the study in improving of the quality of health
care was also explained. Patients’ names and telephone
numbers were written in separate cards and coded into
numbers for the Cardiac Symptom Survey. Written consent
forms were obtained from all patients at the day of discharge after assuring that their participation will be voluntary. Patients were also assured that they can withdraw
from the research at any time, information obtained will
be treated confidentially and aggregated data will be communicated if requested.
Data analysis
Data were analysed using SPSS version 19 (SPSS, Chicago,
IL, USA). A 0.05 criterion for statistical significance was
employed for the analyses. Demographic variables of the
participants and other study variables were analysed using
descriptive statistics including mean, standard deviations,
frequency and percentages. Chi-squared analysis (χ 2) was
used to examine the differences between symptom management strategies and demographic variables.
RESULTS
Sample characteristics
The majority of the participants were men (80%) (n = 80).
The number of participants, who were < 60 years of age
(55%) (n = 55), marginally dominated the group of participants. A more number of participants were educated
(83%) (n = 83) and employed (66%) (n = 66). A glimpse
at their previous health profile revealed that 78% (n = 78)
of them were smokers, 62% (n = 62) were overweight or
obese and nearly half (47%) (n = 47) of the participants
had diabetes, hypertension or both (Table 1).
Symptom management strategies utilized
by patients post coronary artery bypass
grafting surgery
The major symptoms elicited from the interview conducted
among post CABG patients during the 2 weeks following
their surgery were chest incisional pain (65%), leg swelling
(60%), poor appetite (56%), trouble sleeping (54%) and
leg incisional pain (52%) (n = 52). Symptoms that were
perceived by a minority of the respondents were fatigue
(43%) (n = 43), anxiety (32%) (n = 32) and shortness of
breath (29%) (n = 29). Symptoms like fluttering (15%)
(n = 15), angina (8%) (n = 8) and depression (3%) (n = 3)
were reported by a few participants.
© 2016 John Wiley & Sons Australia, Ltd
Frequency of symptom management strategies utilized
by post CABG patients revealed that most frequently
employed strategies were use of medications (79%), repositioning (54%) and rest (45%). Seeking help (27%), distraction (22%), activity (21%) and adjunct therapy (21%)
were used in moderation. Very few participants explored
change in diet (9%) and altering routines (2%) to impeded
their symptoms experiences after CABG.
Table 1 Demographic characteristics of patients post coronary artery bypass grafting surgery (n = 100)
Variable
Gender
Male
Female
Age
< 60 years old
60 or older
Educational status
Illiterates
Educated
Working status
Unemployed
Employed
Residency
City
Village
Monthly income
< 300 JD
300–500 JD
Smoking habits
Not smoker
Smoker
Body mass index
Normal
Overweight
Obese
Chronic diseases†
None
Hypertension
Diabetes
Hyperlipidemia
Heart failure
†
% (n)
Mean (SD)
Range
—
80% (80)
20% (20)
—
55% (55)
45% (45)
—
17% (17)
83% (83)
—
34% (34)
66% (66)
—
66% (66)
34% (34)
—
55% (55)
27% (27)
—
78% (78)
22% (22)
—
38% (38)
42% (42)
20% (20)
—
22% (22)
47% (47)
47% (47)
30% (30)
2% (2)
—
—
—
57.67 (9.70)
50.29 (5.35)
66.69 (5.06)
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
26.72 (3.46)
23.42 (1.18)
27.19 (1.35)
31.99 (2.05)
—
—
—
—
—
—
—
—
—
40–75
40–59
60–75
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
19.5–39.1
25–29.8
19.5–24.9
30–39
—
—
—
—
—
—
Not mutually exclusive.
Symptom management strategies post CABG
Symptom management strategies utilized
by patients post coronary artery bypass
grafting surgery
The most common symptom perceived by post CABG patients during the 2 weeks following their surgery was chest
incisional pain, which was primarily managed with medications (37%) and repositioning (32%). Leg swelling was predominantly managed with repositioning (38%) and
medications (25%). Seventy-five per cent of post CABG patients who had experienced poor appetite did not utilize any
strategy to relieve this discomfort. Meanwhile, changing
diet (16%) was principally used by those who initiated
symptom management strategy. The rest (63%)
outweighed all other strategies implemented by the study
participants to overcome fatigue. Distraction (31%) was
practiced more than activity (21%) by the post CABG patients who had experienced anxiety (Fig. 1).
Associations between demographic
variables and symptom management
strategies utilized by post coronary artery
bypass grafting patients
The results indicated that symptom management strategies
utilized by post CABG patients for poor appetite, sleeping
5
problem and fatigue had significant associations with demographic variables (Table 2). Chi-squared results indicated that
female (χ 2 = 9.37, df = 1, P < 0.01), patients aged more than
60 (χ 2 = 5.42, df = 1, P < 0.05) and patients with a history of
chronic disease (χ 2 = 5.80, df = 1, P < 0.05) had used more
strategies to manage poor appetite.
In the current study, a significant difference was found
between gender and strategies to manage sleeping disturbances (χ 2 = 24.710, df = 1, P < 0.001), which implied that
majority of the men did not utilize any strategy to manage
sleep disturbances. Also, a significant difference was found
between sources of health information and strategies to
manage sleep disturbances (χ 2 = 5.46, df = 1, P < 0.05).
The percentage of participants who did not access any
source of information but utilized strategies to manage sleep
disturbances was higher than those who did not use any
strategy (40 vs. 19).
The results of current study found that male participants
used strategies to manage fatigue more than female
(χ 2 = 8.32, df = 1, P < 0.01). In addition, participants with
fatigue who accessed health information used more strategies to manage sleep disturbances than who did not access
any source of health information (χ 2 = 3.92, df = 1,
P < 0.05) (Table 2).
Figure 1. Frequency distribution of symptom management strategies,
© 2016 John Wiley & Sons Australia, Ltd
ZM Al-Daakak et al.
6
Table 2 Significant associations between post coronary artery bypass grafting symptoms management strategies and demographic variables
(n = 100)
Variable
Yes % (n)
Gender†
Male
53 (9)
female
47 (8)
Age
< 60
29 (5)
≥ 60
71 (12)
Education
Illiterate
35 (6)
Educated
65 (11)
Source of information
Any source
59 (10)
No interest
41 (7)
Chronic disease†
No
5 (1)
Yes
95 (16)
Poor appetite
Sleeping problem
Fatigue
Strategies
Strategies
Strategies
No % (n)
χ2
Yes % (n)
No % (n)
χ2
Yes % (n)
No % (n)
χ2
86 (71)
14 (12)
9.37**
54 (20)
46 (17)
95 (60)
5 (3)
24.71***
95 (36)
5 (2)
71 (44)
29 (18)
8.32**
60 (50)
40 (33)
5.42*
54 (20)
46 (17)
56 (35)
44 (28)
0.03
50 (19)
50 (19)
58 (36)
42 (26)
0.58
13 (11)
87 (72)
3.16
27 (10)
73 (27)
11 (7)
89 (56)
3.18
16 (6)
84 (32)
18 (11)
82 (51)
0.56
76 (63)
24 (20)
2.10
60 (22)
40 (15)
81 (51)
19 (12)
5.46*
84 (32)
16 (6)
66 (41)
34 (21)
3.92*
26 (22)
74 (61)
5.80*
14 (5)
86 (32)
27 (17)
73 (46)
2.32
32 (12)
68 (26)
16 (10)
84 (52)
3.12
*P < 0.05. **P < 0.01. ***P < 0.001. †Fisher’s Exact test (expected frequency < 5).
DISCUSSION
The purpose of this study was to explore the symptom management strategies of Jordanian post CABG patients and
their associations with demographic variables. Chest
incisional pain, which had been reported as the most frequent discomfort among post CABG patients, is also resonated in many similar studies.24 This discomfort is
magnified by the respondents as it interferes with their
sleep, activities and mood.24 Leg swelling after a CABG
has been reported to limit the physical functioning of many
patients.2
The prevalence of sleep and appetite problems among
post CABG patients has been prevalently reported in literature.25,26 Both of these symptoms have been attributed in literature to the medications taken by these
patients during the recovery phase.24,25 The less frequently reported symptoms like fatigue and shortness
of breath have also been documented in literature in
similar frequency patterns.19 These less frequent symptoms have been reported in literature to diminish within
the recovery period.27
© 2016 John Wiley & Sons Australia, Ltd
Symptom management strategies of
Jordanian patients post coronary artery
bypass grafting for frequently reported
symptoms
In the present study, chest and leg incisional pain experienced by post CABG patients was predominantly relieved with medications. Literature showcases that
opioids were liberally utilized in the initial weeks after
surgery followed by the use of non-opioids in the weeks
of recovery.28 The prominent and distressful side effects
of these medications like constipation, drowsiness, nausea
and vomiting29 could have persuaded the participants of
the current study to rely on other non-pharmacological
strategies like rest or repositioning. Most of the study
participants had also resorted to seeking help to relieve
their pain. Watt-Watson et al.14 reported that post
CABG patients who were aware of the importance of
pain relief methods and the impact pain had on recovery
were prompt to report and request for pain medications.
This is a classic example of ‘seeking help’ as a strategy
to relieve pain symptoms.
Symptom management strategies post CABG
Most of the post CABG patients who participated in the
current study did not take any measures to relieve their loss
of appetite. The strategy, which was deemed helpful by the
few who practiced them, was changing their diet. Post
CABG patients should be encouraged to utilize appetite improving strategies like eating small meals, including
favourite foods, reducing seasoning and forcing themselves
to eat.19
Measures implemented by the post CABG patients sampled for the current study with difficulty in sleeping were
primarily with medications followed by distraction and altering routines. Redeker and Hedges26 reported that sleep
is disrupted strongly in the immediate postoperative period
because of the intense pain experienced by post CABG patients. During this phase, patients would have resorted to
medications, but with the reduction in pain over the following weeks,30 other measures like sleeping in a recliner,
changing positions, relaxation and listening to music would
have been instituted. 17
Fatigue, which was prevalent among the current study
participants, was most frequently tackled by rest and less
frequently by activity and adjunct treatments. This prompts
the researchers to exemplify the positive effects of increasing activities or scheduling rest between activities31 to the
current study participants. This emphasis will not only foster fatigue reduction, but will also prevent other postoperative complications of immobility like constipation, deep
vein thrombosis and atelectasis.
Anxiety was experienced by only a handful of the post
CABG patients interrogated for the current study. Although distracting oneself was the primary strategy
employed by the current study participants, problemfocused coping has been cited in literature to strongly diminish anxiety among post CABG patients. This strategy directs patients to focus on strategies to resolve their physical
problems, which reduces their perception of their emotional response.32
Associations between demographic
variables and symptom management
strategies utilized by post coronary artery
bypass grafting patients
In the current study, the symptom management strategies
for poor appetite, sleep problems and fatigue were statistically tagged to certain demographic traits that were consistent with previous studies.19
Study participants who were females, elderly and those
with chronic illness were prone to utilize strategies to
7
overcome their poor appetite. In the Islamic culture,
women’s health and competence is regarded most important by family members.33 The significance placed on the
health of women and the motivation from the family would
have persuaded female patients to practice strategies to improve their appetite. Elderly patients tend to possess greater
number of co-morbidities requiring them to take more
medications, which inevitably would cause them more intensity of appetite problems, forcing them to intervene.34
The trio of participant characteristics more interested to
overcome poor appetite conveys to health-care providers
that dietary consultation in the early postoperative days will
aid this population to make changes in their diet. Improvement in diet will accelerate energy levels and wound
healing, which are vital for resumption to pre-morbid activity levels and improvement in quality of life.
Findings from the current study reflect that sleep problems were significantly intervened by female patients and
those patients who did not seek any information about their
proposed surgical experiences preoperatively. Authors of
evidence-based literature postulate that women resume
their role and household activities early within the recovery
period and this increases their feelings of tiredness and decreases their day time sleep.33 These factors enhance their
sleep duration and quality. Sleep disturbances in post CABG
patients without any previous knowledge on their symptom
experiences could be largely attributed to their accelerated
anxiety levels. This could have prompted the study participant to seek help to resolve this distressing symptom.
Jalowiec, Grady and White-Williams35 concluded that post
CABG patients with increased anxiety levels had identified
that seeking help as the most frequently utilized strategy
to alleviate their concerns. Health-care providers are
reminded to incorporate the need to resume activities of
daily living within their energy levels, to improve their
sleep quality and quantity. Furthermore, a need to teach
proposed CABG patients about their forecasted experiences
will alleviate their anxieties and prevent sleeping difficulties.
Fatigue, which was experienced by post CABG patients
who participated in the current study, was statistically mediated by male patients and those who sort health information before surgery. Schulz, Zimmerman, Barnason and
Nieveen36 reported that men demonstrated higher mean
scores for physical functioning by the sixth week after
CABG compared with women. This justifies to the fact that
men tend to involve themselves in fatigue-reducing strategies in the early postoperative period. Utriyaprasit, Moore
and Chaiseri37 reported that patients who had received
© 2016 John Wiley & Sons Australia, Ltd
ZM Al-Daakak et al.
8
audiotaped information on Cardiac Home Information Program had a statistical reduction in their fatigue levels between 2 and 4 weeks after hospital discharge. These
interpretations signal to health-care providers to motivate
post CABG patients to initiate fatigue reducing strategies
as early as possible in the recovery phase and to provide information on these strategies through channels in which
they can repeatedly review these techniques like handouts
and audio tapes of video clips.
Implications for practice
This study aimed at exploring the symptom management
strategies among post CABG patients in order to prevent
re-admissions and also facilitated the improvement in quality of life post CABG surgery. The study findings provide
benefits for the preoperative and postoperative CABG patients. By providing information on the symptoms expected
after surgery and the possible ways to manage them, it psychologically strengthens patients that the CABG experience
is within the realm of self-management and coping. During
the postoperative period, the occurrence of symptoms
prompts patients to seek help at the earliest or to recall
and practice the strategies taught to them. In the home setting, the information provided guides them to initiate selfmanagement strategies consistently. Health-care providers
are prompted to equip themselves with these empirical facts
and prepare evidence-based health education sessions to inculcate these facts to their patients. Researchers are called
to explore best methods to disseminate these findings and
are also urged to explore the effectiveness of these strategies
in improving quality of life, recovery and resumption to
pre-morbid physical and psychological standards taking into
consideration demographic variables such as gender.
Study limitations
The authors wish to acknowledge that, although the study
was conducted taking into consideration the principles that
govern research, a few notable limitations were inevitable.
Descriptive nature of this study impedes the ability to infer
causal relationships between the study variables. Selfreported data could possess hidden biases related to recall.
Convenience sampling and small sample size may not be
truly representative of the Jordanian CABG patients.
CONCLUSION
The study has highlighted the symptoms experienced by
post CABG patients and the strategies utilized to relieve
them. With the advent of early discharge from the health© 2016 John Wiley & Sons Australia, Ltd
care settings, the evidences generated from this study direct
health-care providers to strengthen the cognitive resources
of their patients by providing them with information on effective strategies to reduce or relieve their post CABG patients. Furthermore, the demographic affiliation to utilize
strategies for selected discomforts should be captured, and
tailor-made information sachets are to be disseminated for
effective prevention of postoperative complications.
REFERENCES
1 World Health Organization (WHO). Noncommunicable
Diseases (NCD) Country Profiles, 2014, Jordan, 2014.Available from URL: http://www.who.int/nmh/countries/
joren.pdf?ua=1. Accessed 20 May 2010.
2 Cowper PA, DeLong ER, Hannan EL et al.. Trends in postoperative length of stay after bypass surgery. American Heart
Journal 2006; 152: 1194–1200.
3 Zimmerman L, Barnason S, Nieveen J, Schmaderer M. Symptom management intervention in elderly coronary artery bypass
graft patients. Outcomes Management 2004; 8: 5–12.
4 Westerdahl E, Lindmark B, Eriksson T, Friberg Ö,
Hedenstierna G, Tenling A. Deep-breathing exercises reduce
atelectasis and improve pulmonary function after coronary artery bypass surgery. Chest 2005; 128: 3482–3488.
5 Thomas L. Effective dyspnea management strategies identified by elders with end-stage chronic obstructive pulmonary
disease. Applied Nursing Research 2009; 22: 79–85.
6 University of Pittsburgh Medical Center. Heart Failure: Activity and Exercise, 2003. Available from URL: http://
www.upmc.com/HealthAtoZ/patienteducation/Documents/HeartFailureExercise.pdf. Accessed 20 May 2010.
7 The Society of Thoracic Surgeons. Patient Information: What
to Expect After Heart Surgery, 2008. Available from URL:
http://www.sts.org/sections/patientinformation/
adultcardiacsurgery/heartsurgery/index.html. Accessed 2
April 2010.
8 Ikedo F, Gangahar D, Quader M, Smith L. The effects of
prayer, relaxation technique during general anesthesia on recovery outcomes following cardiac surgery. Complementary
Therapies in Clinical Practice 2007; 13: 85–94.
9 American Heart Association. How Can I Recover from
Heart Surgery?, 2007. Available from URL: http://
www.americanheart.org/downloadable/heart/
1196355902375RecoverHeartSurgery.pdf. Accessed 2
April 2010.
10 University of California San Francisco. Tips for Conserving
Your Energy, 2010. Available from URL: http://www.
ucsfhealth.org/adult/edu/ConservingEnergy.html. Accessed
20 May 2010.
11 Montgomery P, Dennis J. Cognitive behavioural interventions for sleep problems in adults aged 60. The Cochrane
Database of Systematic Reviews 2003; 1: CD003161.
Symptom management strategies post CABG
12 Bauer BA, Cutshall SM, Wentworth LJ et al.. Effect of massage therapy on pain, anxiety, and tension after cardiac
surgery: a randomized study. Complementary Therapies in Clinical Practice 2010; 16: 70–75.
13 Soong C, Barros D. Lower limb oedema following distal arterial bypass grafting. European Journal of Vascular and
Endovascular Surgery 1998; 16: 465–471.
14 Watt-Watson J, Stevens B, Katz J, Costello J, Reid GJ, David
T. Impact of preoperative education on pain outcomes after
coronary artery bypass graft surgery. Pain 2004; 109: 73–85.
15 Fiore JF, Chiavegato LD, Denehy L, Paisani DM, Faresin SM.
Do directed cough maneuvers improve cough effectiveness in
the early period after open heart surgery? Effect of thoracic
support and maximal inspiration on cough peak expiratory
flow, cough expiratory volume, and thoracic pain. Respiratory
Care 2008; 53: 1027–1034.
16 Chan M, Chan E, Mok E. Effects of music on depression and
sleep quality in elderly people: a randomised controlled trial.
Complementary Therapies in Medicine 2010; 18: 150–159.
17 Reza H, Kian N, Pouresmail Z, Masood K, Sadat Seyed
Bagher M, Cheraghi M. The effect of acupressure on quality
of sleep in Iranian elderly nursing home residents. Complementary Therapies in Clinical Practice 2009; 16: 81–85.
18 Zohreh K, Farah AE, Mehrab M et al. Comparison of compression stocking with elastic bandage in reducing
postoperative edema in coronary artery bypass graft patient.
Journal of Vascular Nursing 2009; 27: 103–106.
19 Schulz PS, Zimmerman L, Pozehl B, Barnason S, Nieveen J.
Symptom management strategies used by elderly patients after coronary artery bypass surgery. Applied Nursing Research
2011; 24: 65–73.
20 Cohen J. A power primer. Psychological Bulletin 1992; 112:
155–159.
21 World Health Organization (WHO). Global Database on
Body Mass Index, 2006. Available from URL://apps.who.
int/bmi/index.jsp?introPage = intro_3. Accessed 20 May
2010.
22 Nieveen JL, Zimmerman LM, Barnason SA, Yates BC. Development and content validity testing of the Cardiac
Symptom Survey in patients after coronary artery bypass
grafting. Heart & Lung 2008; 37: 17–27.
23 Barnason SA, Zimmerman LM, Brey B, Catlin S, Nieveen JL.
Patterns of recovery following percutaneous coronary intervention: a pilot study. Applied Nursing Research 2006; 19:
31–37.
24 Parry M, Watt-Watson J, Hodnett E, Tranmer J, Dennis C,
Brooks D. Pain experiences of men and women after coronary artery bypass graft surgery. Journal of Cardiovascular
Nursing 2010; 25: E9–15.
9
25 Grap MJ, Savage L, Ball GB. The incidence of gastrointestinal
symptoms in cardiac surgery patients through six weeks after
discharge. Heart & Lung: The Journal of Acute and Critical Care
1996; 25: 444–450.
26 Redeker NS, Hedges C. Sleep during hospitalization and recovery after cardiac surgery. Journal of Cardiovascular Nursing
2002; 17: 56–68.
27 Keresztes PA, Merritt SL, Holm K, Penckofer S, Patel M.
The coronary artery bypass experience: gender differences.
Heart & Lung: The Journal of Acute and Critical Caren 2003; 32:
308–319.
28 Sethares KA, Chin E, Costa I. Pain intensity, interference and
patient pain management strategies the first 12 weeks after
coronary artery bypass graft surgery. Applied Nursing Research
2013; 26: 174–179.
29 MacMaster LM. Patients’ Pain Management at the end of the
First Week After Discharge Following Coronary Artery Bypass Graft Surgery, 2002. Available from URL: http://
search.proquest.com/docview/305489412?
accountid=27575. Accessed 2 April 2010.
30 Edéll-Gustafsson UM, Hetta JE, Arén CB. Sleep and quality
of life assessment in patients undergoing coronary artery bypass grafting. Journal of Advanced Nursing 1999; 29:
1213–1220.
31 Rubin G, Hotopf M. Systematic review and meta-analysis of
interventions for postoperative fatigue. British Journal of Surgery 2002; 89: 971–984.
32 Tung H, Hunter A, Wei J. Coping, anxiety and quality of life
after coronary artery bypass graft surgery [corrected] [published erratum appears in J ADV NURS 2008 Apr;62
(2):273]. Journal of Advanced Nursing 2008; 61: 651–663.
33 Naeeni NG. Islamic women studies is important and necessary. Procedia-Social and Behavioral Sciences 2010; 9:
1238–1243.
34 Jin H, Tang C, Wei Q et al. Age-related differences in factors associated with the underuse of recommended
medications in acute coronary syndrome patients at least
one year after hospital discharge. BMC Cardiovascular Disorders 2014; 14: 127.
35 Jalowiec A, Grady KL, White-Williams C. Predictors of perceived coping effectiveness in patients awaiting a heart
transplant. Nursing Research 2007; 56: 260–268.
36 Schulz P, Zimmerman L, Barnason S, Nieveen J. Gender differences in recovery after coronary artery bypass graft
surgery. Progress in Cardiovascular Nursing 2005; 20: 58–64.
37 Utriyaprasit K, Moore SM, Chaiseri P. Recovery after coronary artery bypass surgery: effect of an audiotape
information programme. Journal of Advanced Nursing 2010;
66: 1747–1759.
© 2016 John Wiley & Sons Australia, Ltd