CALIFORNIA S7ATE UNIVERSITY, NORTHRIDGE
A CURRICULUM FOR THE
I)
AORTOCORONARY .ARTERY BYPAS.S
SURGICAL PATIENT
A graduate project submitted in partial satisfaction
of the requirements for the degree
of
Master of Public Health
by
Mary Elizabeth Jorgensen
June, 1978
The graduate project of Mary Elizabeth Jorgensen
is approved:
--
----~------b
----h
------~
Robert W. 0 lat , M.D.
~6hn
T. Fodor. Ed.D.
G. B. Krish:namurty, Dr. P.H.,
Chairm~
California State University, Northridge
ii
DEDICATION
In memory of Mary Lorene Bailey Clayton
who cared
iii
ACKNOWLEDGEMENTS
Many assisted in the development of this project by
expressing interest and by offering suggestions.
However,
because of special contributions, individual recognition
and thanks are given to:
G.B. Krishnamurty, Dr.P.H., committee chairman, who
not only guided the project from the time of its inception
but provided the encouragement necessary for its
completio~
John T. Fodor, Ed.D., committee member, who gave
freely of his expertise and support in the structuring of
the project.
Robert W. Oblath, M.D., committee member, who
generously gave of his time to skillfully critique the
project.
Jane Simpson, R.N., who participated in the project
from the beginning and never failed to offer both positive
reinforcement and valuable comments.
The nurses who were directly involved in the
project:
Toni Oster, R,. N. , Annette Zimmerman, R.N. , and
Donna Talbott, R.N.
Kenneth Jorgensen who patiently read manuscript drafts
for style and accuracy.
Mercedes Kotelnicki who expertly assisted in the
final manuscript preparation.
iv
TABLE OF CONTENTS
Page
APPROVAL PAGE
ii
. iii
DEDICATION
ACKNOWLEDGEMENTS
iv
. . . vii
ABSTRACT
CHAPTER
I.
II.
INTRODUCTION
1
Background of the Problem
1
Statement of the Problem
5
Purpose of the Study
5
Limitations of the Study
6
REVIEW OF THE LITERATURE
Cultural Influence
7
Immediate Postoperative Period
7
Justification for Patient Teaching
I I I.
7
METHODOLOGY .
11
15
Procedures
15
Steps of Implementation . .
16
Target Population . .
16
Phase I:
Collection of Data .
17
Phase II:
Delineation of the
Program . . . . . . .
20
Evaluation
26
v
CHAPTER
Page
IV.
THE CURRICULUM
v.
31
Introduction to the Curriculum
31
Content Areas and Concepts
32
Preoperative Preparation
33
Surgical Intervention .
62
Postoperative Period
70
Preparation for Home
82
SUMMARY AND
RECO~WENDATIONS
.
91
REFERENCES
94
APPENDICES
99
A.
STUDY ANALYSIS FLOW CHARTS
B.
PATIENT HANDBOOK
.
. 10 9
c.
INTERVIEW QUESTIONS
.
. 142
vi
99
ABSTRACT
A CURRICULUM FOR THE
AORTOCORONARY ARTERY BYPASS
SURGICAL PATIENT
by
Mary Elizabeth Jorgensen
Master
of
Public Health
While attention has focused upon the selection and
management of the patients submitting to aortocoronary
artery bypass surgery, consideration of the cognitive needs
of the patients has tended to be extemporaneous and dependent upon the motivation of the nurses who have cared for
them.
An inadequate transfer of information from nurse to
patient has been the most commonly experienced outcome.
Therefore, a study was performed in a 500 bed community
medical center for the purpose of providing the registered
nurses with a ~lan for a structured teaching program designed for the patients who were admitted to the medical
center for aortocoronary artery bypass surgery.
A curriculum was developed with implementation
procedures, a plan of evaluation and a patient handbook.
The curriculum focused upon four areas of patient concern:
preoperative preparation, surgical intervention, postoperative care, and preparation for home.
It was based upon
concepts and contained performance objectives, evaluative
criteria, content, learning opportunities, and resources.
viii
CHAPTER
I
INTRODUCTION
BACKGROUND OF THE PROBLEM
Of the three major killers in the United States
today, heart disease is number one, and coronary artery
disease accounts for most cardiac fatalities.
(1: 8)
Furthermore, the disease process often becomes acutely
apparent during the most productive years.
(1:11)
This
catastrophic situation is being attacked by the Federal
Government via the Natitinal Institutes of Health research
programs and grants.
Voluntary national groups such as
the American Heart Association also demonstrate concern by
suppotting projects designed to seek solutions.
The busi-
ness community, because of its vested interest either as
the direct employer of the patient or as the third-party
payer, has also joined the campaign.
Coronary atherosclerotic heart disease, presenting as angina pectoris or
myocardial infarction, is a major health
problem affecting over 20 million people
in the United States. Each year more
than 600,000 persons die from myocardial
infarction and more than half of these
die suddenly before reaching medical care.
The total of illness, including lost income and payment for medical care, is
over $10 billion annually; over 50,000~000
man-days of production are lost each year
because of coronary atherosclerotic heart
disease.
It is no wonder that not only
patients, their families, and their physi-
1
2
cians but also employers, insurance
companies, and the economists fear
the consequences of myocardial infarction.
(47:104)
Patients with coronary artery disease have been
studied extensively.
Katz selected 390 individuals who
had suffered a first coronary occlusion and followed their
progress.
months.
Of these, about 23% died within the first 2
Two-thirds of the 285 survivors lived more than 5
years and 2/5 lived more than 10 years.
10 lived more than 15 years.
of the group was 8 years.
One out of every
The average life expectancy
In a study conducted by Master,
more than half of the patients lived more than 5 years and
75% of them returned to work.
Age is a critical factor
both with respect to whether patients return to work after
an infarction at all and to how rapidly they return.
(38:21)
The chance of a second attack, even in patients
with mild coronaries is significant.
Likoff found that of
100 patients who had a benign hospital course, 50% of those
who continued to have angina had another attack within 18
months.
Of those who were asymptomatic after the mild
coronary, 21.7% had another coronary within 24 to 46months.
He noted that neither the clinical course during the first
attack nor the extent of the infarction determined whether
the patient would have a subsequent episode.
(50:14)
3
This problem, then, is real and the underlying
disease,
ath~rosclerosis
poorly understood.
of the coronary arteries, is
As of now, there is no way known to
prevent or to cure coronary artery disease.
(1: 10)
While
basic research on the underlying problem continues, people
still become ill and die.
Therefore, admittedly pragmatic
programs have been initiated which focus upon palliation
rather than upon curing.
One of these approaches is that
of revascularization surgery.
Intended primarily to over-
come an existing myocardial perfusion deficit, it is not a
new concept.
Vineberg was the first to attempt to perform
myocardial revascularization in 1946 by detaching one end
of the internal mammary artery and inserting the open
artery into a tunnel forced through the cardiac muscle.
The results of this procedure were unpredictable and usually unsatisfactory.
(8:789)
However, the concept of
revascularization as applied today utilizes a bypass vein
graft which connects the aorta to the diseased coronary
artery distal to the obstruction.
One or more coronary
arteries may be bypassed during the surgical procedure.
Such surgery has become a routine procedure in many hospitals throughout the country.
The majority of these
operations are performed on an elective basis for patients
who have chronic forms of ischemic heart disease.
(11:869)
The development of aortocoronary bypass surgery has made
4
~o
available a physiologically rational surgical approach
coronary artery disease.
Surgical mortality is about 2
percent when the operation is performed by a capable, experienced team.
(14: 6)
Cardiac surgery is associated with pa1n and sufferlng at a cos~ which ranges between $12,000 and $15,000 per
patient.
(30:1)
Therefore, its limitations must be con-
sidered.
The grafts do not cure coronary artery disease
and sometimes grafts close.
For patients with a single
vein graft, there is a 23 percent chance of closure during
the first two-year period; the chance of both grafts closing during the same time period for those·~atients with 2
grafts is 5 percent; if three grafts .are implanted, the
chance of all three closing is 1 percent.
(33:2637)
De-
spite these and other problems, there seems to be the
development of consensus in the medical community that the
life span of the patient who has had aortocoronary bypass
surgery is probably prolonged.
(48:371)
(14:6)
(45:923)
(24:1)
The literature indicates that angina symptoms
are usually relieved and data show that up to five years
after surgery there has been minimal deterioration of left
ventricular function.
(25: 964)
In November, 1971, Dr. William Glenn, cardiac
surgeon, in his presidential address to the American Heart
Association emphasized that caution must be exercised in
I
5
the selection of patients for aortocoronary bypass surgery.
(13:373)
Thus while the physicians focus upon preoperative
selection of cardiovascular patients with the intent of
maximizing the benefits to be derived from such a major
intervention (2:209)
(26:235), programs to prepare the
nursing staff to assume the complex nursing management of
patients in the critical hours after surgery have proliferated across the country.
(18:37)
Professional prepara-
tion has led to relatively safe, effective surgery, but
the question of patient/family preparation, the focus and
scope of it, remains.
STATEMENT OF THE PROBLEM
While attention has focused upon the selection
and management of those submitting to aortocoronary bypass
surgery, consideration of the cognitive needs of the individual patients tends to be extemporaneous and dependent
upon the motivation of the nurses who care for them.
An
inadequate transfer of information from nurse to patient
is the most commonly experienced outcome.
(49:216)
PURPOSE OF THE STUDY
The purpose of the study was to develop a teaching
program for the aortocoronary artery bypass patient based
upon the assessment of patient and nursing staff need in a
community medical center and which included 1) a curriculum
guide with concepts, instructional objectives, evaluative
'
6
criteria, educational resources, and 2) a plan of program
implementation.
LIMITATIONS OF THE STUDY
The study was limited to the aortocoronary artery
bypass surgical patients and their families during the
preoperative and postoperative hospital periods at a 500
bed community medical center in Burbank, California.
It
was intended to be used by the registered nurses at the
medical center to help to optimize patient care.
CHAPTER II
LITERATURE REVIEW
While coronary artery surgery requires skilled
medical and nursing interventions, (8:785)
(18:37)
patient response to these interventions is influenced by
patient perception of surgery.
(12:825)
(17:33)
(37:108)
Two factors which influence perception are the patient's
cultural frame of reference and the patient's cognitive
expectations of the immediate postoperative period.
Because these factors are important to patient surgical
outcome, they merit further discussion.
CULTURAL INFLUENCE
The aortocoronary bypass surgical patient must
contend with the anxiety which confronts any surgical
patient, but (s)he also has problems which are unique to
the disease and operation.
Within Western society, the
heart has been conceptualized as the symbolic center of
being.
It is identified as the site of love, grief, and
religious devotion, e.g., faithful heart, broken heart,
sacred heart, etc.
The very thought of cardiac surgery
leads to a sense of increased tension and fear.
(48:376)
IMMEDIATE POSTOPERATIVE PERIOD
In the immediate postoperative period the patient
is confronted with a reality literally filled with noise,
7
8
pain, and equipment.
(18:37)
(S)He may awaken unable to
speak because an endotracheal tube (which is connected to
a controlled volume respirator) is in the trachea.
can't control the rate or depth of respirations.
(S)He
The
stomach is drained by a nasogastric tube which is coated
every hour with an antacid to prevent the development of a
stress ulcer.
(S)He is subjected to intravenous infusions
to maintain fluid and electrolyte balance and to serve as
portals for various drugs.
(18:37)
An arterial line is
maintained to give an instantaneous reading of arterial
blood pressure and to serve as a portal for the withdrawal
of arterial blood samples for various diagnostic tests.
(1:22)
(1:65)
Electrodes on the chest connect the patient
to equipment which continuously monitors the heart's electrical activity.
(1:266)
Chest tubes, inserted during surgery, drain air
and fluid from the chest.
The chest tubes help assure re-
expansion of the lungs but must be connected to an underwater drainage system which is attached to suction.
The
suction creates a noisy bubbling of water which is easily
heard by the patient and can be frightening if (s)he doesn't
understand it.
In addition, the chest tubes require fre-
quent stripping or milking to assist ventilation by
removing blood from the chest and to monitor the amount of
postoperative bleeding.
(6:249)
Most patients find chest
9
tubes painful, but the frightened patient finds them nearly
unbearable.
(41:2145)
Physiological assessments are routine.
They in-
elude peripheral pulses and urinary output which are
checked at least hourly (urine is obtained via a Foley
catheter placed in the urinary bladder).
In addition,
temperature and neurological checks are performed several
times per shift.
(6:39)
To awaken to such a situation is frightening.
It
is not surprising that some people temporarily experience
a psychotic episode which is related to preoperative
anxiety and postoperative sleep deprivation.
(48:378)
One patient who went for aortocoronary bypass
surgery with the routine preoperative preparation has
written:
I was on my way to trusting my life
to a surgeon I'd met an hour earlier,
a cardiologist I'd known a week and a
machine.
There had been little time
to think, but during that short fast
trip to the operating room, I seemed
to have ample time to review all the
events that led up to this extraordinary journey.
(41:2143)
*
*
*
A nurse leaned over me and spoke
loudly. Ms. Swan, your operation
is over.
Do you hear me?
Relief
flooded over me.
I turned my head
and tried to speak but couldn't.
I
wondered if something had gone
wrong and a tracheotomy had been
done.
But I had no strength to reach
up to my throat. It terrified me not
10
to know why.
Other times I woke when
my breath was completely shut off.
I
fought the nurses hovering over me
near panic.
I couldn't tell them I
couldn't breathe.
They were using
suction in my mouth ... I felt torn to
pieces and loosely mended like a
battered marionette.
I couldn't believe it when a nurse propped me into
a sitting position, gave me a pillow
to hug and said, "Cough." .... always
I had to keep coughing for the nurses
were quite stern if I produced nothing
from my tormented chest ... I was needled
to an intravenous bottle, wired to an
oscilloscope. Two tubes came out of my
side, one just under my right breast,
another a little farther down.
They
were equipped with some squeegee apparatus to press out draining fluid.
When
applied, it was torture.
I tried to
yell but couldn't.
(41:2145)
Despite literature to the effect that attachment of
equipment provides comfort to patients who are faced with
the threat of death, the unprepared find that the attachment to machines can also cause them to experience themselves as objects who have lost their value as human
beings.
They develop sensitivity to what is happening
around them.
Such patients often note even minimal changes
in the behavioral patterns of those caring for them and
read messages into staff conversations.
tations are often incorrect.
dep~ndency
This feeling of
and loss of control brings more fear, and fear
iptensifies pain.
i
(7:261)
Their interpre-
However, preoperative education helps
the patients understand what to expect and to have more
l'
11
positive and hopeful attitudes.
more confidence and less fear.
They approach surgery with
(12:825)
JUSTIFICATION FOR PATIENT TEACHING
Less anxiety is engendered when the patients are
given specific information on which to structure their perceptions of the impending surgery.
(49:215)
The patients
who understand the concept of the heart-lung machine are
not as frightened as the patients who think they will be
dead during surgery.
The patients who have been informed
about the routine use of the endotracheal tube, cardiac
monitor, and the intravenous and the arterial lines will
expect these.
They will not awaken terrified in the belief
that some catastrophic event has occurred.
(48:377)
Numerous reports support the value of preoperative
teaching as one of the most effective methods of reducing
anxiety and thereby encouraging postoperative behaviors
which inhibit the development of complications leading to
an extended length of stay in the hospital.
(48:371)
(35:223)
Egbert
(12:825)
(27:319)
notes that in a con-
trolled, study of randomly assigned patients those who were
told about their operations before the procedure remembered
the operation and its sequelae more favorably than those
who were not well informed.
He found that patients who
were told what to expect during the postoperatiye period
and were taught how to relax and how to deep breathe were
12
able to reduce the postoperative narcotic requirements by
half.
They were ready for discharge home about two days
earlier than the control group.
(12:827)
Other studies
support Egbert's findings and also link preoperative teaching to increased patient participation in postoperative
therapy, less preoperative/postoperative anxiety, less
postoperative urinary retention, less anesthesia, and a
more rapid return to oral intake.
Data indicate that when
patients are adequately informed and included in the educational process concerning their own care and treatment,
they have fewer hospital readmissions and shorter lengths
of stay.
(37:108)
(7:122)
(22:769)
Redman notes:
The age of patient education is
upon us, and we are not ready.
The
overwhelming feeling one gets about
patient education is normlessness,
a lack of boundaries or anything but
preposterously idealized goals for
care. As patient education makes
.the transition from being a nice
humane thing for which one is not
accountable, to a therapy for which
laws hold one responsible, the lack
of care standards becomes dangerous.
(31:19)
The question is not one of
if
teaching is of value
but how it should be done most effectively.
In a study by
Lindeman and Van Aernam (27:319) a comparative investigation of the effects of a structured program versus an
unstructured program was performed.
While the unstructured
program was beneficial and superior to no teaching, pa-
13
tients who were assigned to the structured program were
even more effective in their postoperative behaviors.
Data
supported the following:
1.
The ability of subjects to deep breathe
and cough postoperatively was significantly improved.
2.
The mean length of hospital stay was
significantly reduced by the implementation of the structured preoperative
teaching method.
3.
There was no significant difference
between the two teaching methods, i.e.,
structured versus unstructured, and
postoperative need for analgesia.
(26:332)
The development of a preoperative teaching/learning
program is justified because of existing evidence that such
a program:
1.
Includes the patient as a responsible
member of the health care team.
(35:223)
(49:213)
2.
Reduces anxiety and fear by presenting
the patient with a framework to build
realistic expectations, i.e., the endotracheal tube is routine and not the
result of the surgical mishap.
(48:377)
14
3.
Minimizes postoperative complications
because the patient performs postoperative behaviors more effectively, i.e.,
turning, coughing, deep breathing, and
ambulating.
These activities are
accepted and understood as therapies
which are based upon physiological
principles.
4.
(48:377)
Possibly lessens postoperative narcotic
requirements.
(12:827)
CHAPTER III
METHODOLOGY
PROCEDURES
A needs assessment survey was utilized as the
instrument for obtaining the data required for the aortacoronary artery bypass patient teaching program.
The de-
cision to employ the strategy of needs assessment and to
incorporate the data obtained from it into the program was
based upon the fact that program success depended upon the
participation and/or acceptance of four important groups:
medical staff, hospital administration, nursing staff, and
patients.
While the study was initiated in response to an
expressed need by a small group of critical care nurses,
its scope, focus, and limitations could be ascertained
only after a dialogue had been established with those who
would interface with the program.
The technique of direct communication, e.g., oneto-one interviews and small group discussions, was employed
by the writer as the needs assessment vehicle.
A semi-
structured communication format was adopted, i.e., both
closed and open-ended questions were posed.
(Appendix C)
Both factual and feeling-level information was sought.
Preliminary planning, prior to initiation of the
survey, included the identification and analysis of the
15
16
functions and the tasks that were identified by the writer
as important to the development of the program.
This
analysis took the form of flow charts (Appendix A) which
were used as guides during the study.
STEPS OF IMPLEMENTATION
Implementation was divided into two phases:
collection of data which was used for
the program.
1)
2) delineation of
Prerequisite to the first phase, i.e., data
collection, was the identification of the target population.
TARGET POPULATION
The target population consisted of the in-house
patients, male and female, who had been admitted for
aortocoronary bypass surgery at a community medical center
in Burbank, California.
This group was:
1.
Predominantly white
2.
Predominantly male
3.
Usually between the ages of 40
to 65 years
Work by Friedman and Roseman (20:1286)
(19:1030)
associated cardiac disease with these personality traits:
1.
Lacks life satisfaction;
achieve more;
continually tries to
seldom has leisure time;
any
leisure time is so full of activity, it becomes stressful.
2.
Is easily angered when frustrated.
3.
Has a strong sense of time urgency.
17
4.
Approaches work with intensity and competitiveness;
works many hours;
develops stren-
uous work habits.
5.
Commonly has family problems.
When 100 cardiac patients were interviewed by
Jackson,
(23:42) the following health profile emerged:
Exercise Habits
No exercise habits
Mild (two or three times per month)
Regular (at least weekly)
89
7
4
History of Hypertension
No hypertension
Hypertension
65
35
Cigarette Smoking
Smoking prior to cardiac admission
Stopped smoking 1 to 10 years
prior to cardiac admission
Never smoked
PHASE I:
65
12
23
COLLECTION OF DATA
PATIENT/F~IILY
POINT OF VIEW
Ten postoperative aortocoronary bypass patients
were interviewed by the writer just prior to their discharge home.
They stressed the importance of adequate
preparation, especially for the time spent in the intensive care unit during the immediate post surgical period.
Specifically, they urged:
1.
Be honest about pain.
Drugs only make it
possible to endure the pain ... drugs do not
18
take the pain completely away.
2.
Explain the tubes which will be in place when
one awakens.
3.
Stress how really special the ICU nurses
are ... they stay with the patient, are very
competent, and are experts in giving psychological support.
"They really give the patient
and his family a good feeling of security."
4.
Include the family in the teaching.
(Most men
commented that they didn't need teaching for
themselves, but it surely helped the wife.)
Four preoperative male patients were interviewed
and tended to emphasize that it was the wife who needed
support . .. after
all~
I'll be asleep.
However, these pre-
operative patients actively participated in any teaching
offered to them by the writer and demonstrated a high degree of motivation by working diligently at the breathing
and other exercises once they understood the importance
of them.
Patient families were anxious to obtain any information available.
The wives asked more questions and were
able to express their anxiety more easily than the patients
could.
They, i.e., the wives, usually confided that their
husbands were very frightened.
PHYSICIAN POINT OF VIEW
The cardiac surgeons at the medical center varied
19
in their attitudes toward patient teaching.
Some were
committed to preoperative preparation and wrote specific
orders for patient instruction by the nurse.
Others felt
instruction was of questionable value but wouldn't hurt
and that if the nurses wanted to teach, it was alright.
In the general sense, the physicians expressed the
view that since it was their responsibility to lead the
patient care team, any patient care, including teaching,
was to be approved by them.
ADMINISTRATION POINT OF VIEW
Administration at the medical center was oriented
toward an active education program.
It supported a well-
staffed nursing inservice department (an associate director
of nursing education, a secretary, and five instructors).
In addition, a consultant on patient education who answered
to the physician in charge of the department of medical
education was employed by the hospital.
Access to both
nursing inservice and the consultant was granted.
Financial support for the program, in view of
health care economics, was limited to the purchase of some
media materials.
NURSING POINT OF VIEW
The nurses who worked on the sub-intensive care
unit, the unit which admitted the patient before surgery
and accepted her/him from the intensive care unit after
surgery, were committed to preoperative patient teaching
20
and had initiated the request for a structured teaching
program.
Guided by their head nurse, they had been in-
volved in an informal instructional program for several
years.
However, it was unstructured and no evaluations
had been performed.
Each nurse decided what and when
(s)he would present information.
No media were utilized.
The result had been a lack of continuity and uniformity.
Interest was expressed by the nurses in having a
curriculum developed which incorporated their concepts.
During a series of group discussions and individual interviews, they were most cooperative and interested in discussing what should or should not be included in the
program.
PHASE II:
DELINEATION OF THE PROGRAM
BASE FOR PROGRAM CONTENT
The program had a support base at the medical
center, but if it were to succeed, recognition had to be
given to those who comprised the base by:
1.
Including the family as much as possible in
all aspects of the program.
2.
Discussing what to expect preoperatively
and postoperatively with patients.
3.
Discussing what was expected from the patient and family preoperatively and postoperatively.
21
4.
Stressing that a registered nurse would be at
the bedside during the hours postoperatively
and while the patient was dependent.
5.
Giving honest explanations, e.g., pain could
not be prevented but medication would be given
as needed and it would help to relieve the
pain.
6.
Forming a curriculum committee of the nurses
who were working on the sub-intensive care
unit.
7.
Obtaining physician approval of the curriculum.
8.
Presenting progress reports to the administration and obtaining approval of the curriculum.
PROGRAM PARAMETERS
The parameters which influenced the design of the
curriculum were primarily related to
b)
accessibility of participants, and
a) time limitations,
c) media (which
had a definite impact upon the variety of learning opportunities which could be devised.)
a)
Time Limitations:
patients were admitted on a
daily basis ... usually no more than one or two a day.
They
were admitted on the afternoon 3 days before surgery, i.e.,
if surgery were to be performed on a Thursday morning, the
patients would enter the hospital on a Monday afternoon.
They were usually discharged home one week postoperative.
22
b)
Patient/Family Accessibility:
visiting hours were
liberal and ranged from 11:00 a.m. until 8:00 p.m.
This
provided for staff contact with the family and patient.
The patient would be occupied at times with diagnostic tests
but was usually easily accessible during the hospital stay.
Nurse-Teacher Accessibility:
the nurse on the sub-
intensive care unit had the responsibility for the care of
6 to 8 patients.
Time was carefully budgeted among them.
Therefore, careful scheduling of the classes was necessary.
c)
Available Media:
a search of media indicated
very little appropriate material available for the patient
who was to have open heart surgery.
Letters to several
teaching centers, e.g., Stanford, UCLA, etc., were not
productive.
While need was recognized, little had been
done.
PROGRAM STRUCTURE
The program would be the responsibility of the
sub-intensive care unit nurses.
The medical center
inservice instructors and the consultant on patient education would be available in an advisory capacity but not as
primary teachers.
Instruction time was limited by the short preoperative inhouse stay.
much longer.
The postoperative period was not
This factor limited the opportunity for
group teaching of patients but small groups of 2 or 3
patients could be assembled.
The problem was further
23
compounded by the limited time available to the nurse for
teaching purposes.
Preoperative instruction would pro-
bably be limited to one orientation period lasting 45
minutes and to four teaching periods lasting 20 minutes
each.
Postoperative instruction would require two 20
minute periods.
Teaching would be scheduled on a one-to-
one and group basis.
The family would be included when
possible (they could be contacted on the day of admission
and invited to participate).
Classes would be conducted
on the day and afternoon shifts.
In order to compensate for lack of media and to
serve as a reinforcer to learning, a patient handbook was
developed (Appendix B).
OPERATIONAL REQUIREMENTS
Operational requirements were identified as those
factors which had to be considered before the program
could be presented.
They were
a) program facilitators,
i.e., the individuals and/or groups who controlled access
to the patients;
teachers; and
a)
b) the inservice needs of the nurse-
c) the classroom facilities.
Program Facilitators:
the program facilita-
tors were the medical center administration, i.e., the
hospital administrator, the assistant administrator for
nursing; the medical staff, i.e., the cardiac surgeons
and the cardiologists; nursing management, i.e., the
assistant director for the critical care units, and the
24
head nurses of the critical care units.
Administrative Approval:
as the program pro-
gressed, concurrent approval was sought from the medical
center administration by submitting written updates to the
assistant administrator of nursing.
Final administrative
approval was, of course, contingent upon the final report
being accepted by the hospital administrator.
Physician Approval:
while key physicians were in-
formed of the program during its development, official
medical approval required the formal submission of the
completed program to the appropriate medical committees
after administrative approval had been obtained.
Nursing Management Approval:
the writer worked
closely with the nursing management group during the study.
Each aspect of the program was submitted for approval.
b)
Nurse-Teacher Inservice:
provided for the nurse-teachers.
inservice would be
A series of workshops
would be given prior to the initiation of the program.
The day and evening sub-intensive care registered nurses
would be invited to attend.
Thereafter, the experienced
new employees could be introduced to the program during
orientation to the nursing department.
If the new nurses
were inexperienced in critical care nursing, they would be
taught at the conclusion of the regular critical care
classes.
25
the critical-care unit
Inservice Responsibility:
inservice instructors accepted the responsibility for the
inservice program and were informed of program development.
They agreed to evaluate the needs of the nurse-teachers,
e.g., since all sub-intensive care nurses had passed a
course in acute care nursing, emphasis would probably need
to be upon teaching methods rather than course content.
c)
Class Room Facilities:
individual patient/
family teaching could occur in the patient room.
Small
group teaching could take place in the sub-intensive care
unit patient suite when it was not occupied.
The nursing
conference room could be utilized as an alternative facility when the suite was in use.
Equipment Available:
a.
Teaching model of the heart:
on the nursing
unit
b.
Blackboard:
in the conference room
c.
Overhead Projector:
borrow from inservice
department
d.
Closed circuit television:
in process of
development, potential for near future
e.
Slide projector, 35 mm:
borrow from
inservice department
f.
Tape recorder:
unit
available on nursing
26
Supply Requirements:
the need for supplies should
be minimal and could be ordered by the head nurse.
The pa-
tient handbook (Appendix B) could be printed in the medical
center print shop and requisitioned as necessary.
EVALUATION
Three interdependent areas were identified as basic
to the evaluation of the program.
They were:
the purpose
of the evaluation; the scope of the evaluation; and the
evaluation structure or format.
PURPOSE OF EVALUATION
Justification for a program which focused upon the
cardiac surgical patient depended upon documentation that
the program contributed to the recovery and the well-being
of the target population.
The purpose, therefore, of a
planned evaluation was to obtain the documentation which
would permit program justification.
SCOPE OF EVALUATION
Evaluation was to consider three areas, i.e.,
assessment of patient/family needs; identification of program strengths and weaknesses; and the achievement of the
behavioral objectives.
Patient/Family Needs Assessment:
needs was integral to program development.
assessment of
During the
preliminary planning of the program, patient and family
needs were identified and incorporated into the curriculum
design.
Provisions to continue the patient/family needs
27
assessment were built into the evaluation structure for as
needs changed, the curriculum should change.
Program Strengths and Weaknesses:
if the aorta-
coronary artery bypass teaching program were to remain
viable, it should be assessed in terms of the competencies
of the teaching personnel, medical staff and administrative support, and the relevancy of its concepts,
objectives, learning opportunities, and content, i.e.,
does the program reflect currently accepted knowledge and
social attitude?
Achievement of Behavorial Objectives:
p~tient
ment of desired
upon therapy.
outcomes
achieve-
is dependent, in part,
A successful response to therapy is often
contingent upon the performance of specific patient behaviors .
Such behaviors were identified in the program.
Some of the behaviors were short term, e.g., deep
breathing and coughing postoperatively.
Others were long
term and included the ability of the patient to make
appropriate health decisions, e.g., when to seek immediate medical assistance.
Evaluation of patient be-
haviors, therefore, became an important part of the program evaluation.
EVALUATION STRUCTURE
In order to assess patient/family needs, program
strengths and weaknesses, and the achievement of behavioral objectives, a strategy of concurrent and annual
28
evaluation was employed.
The concurrent process focused
upon the patient and the family.
The data obtained from
the patient and the family would be utilized in the
annual process.
The annual evaluation examined the total
program, i.e., program relevancy, teaching personnel, and
key personnel attitudes.
The head nurse assumed the coordinator's role for
program evaluation but could obtain help as desired from
medical center personnel.
Concurrent Evaluation:
patients and families
would be interviewed and given questionnaires to learn
their opinions regarding the program, the environment, and
the areas which met and did not meet their needs.
Objec-
tive patient data, i.e., achievement or non-achievement of
the curriculum performance objectives (as measured by the
evaluative criteria), would be documented by the nurseteachers in the patient record.
In addition, randomly
selected patients could be observed in the intensive care
unit for immediate postoperative behaviors, i.e., coughing,
using blow bottles, intermittent pos,itive pressure breathing machines, etc.
A behavioral check list would be used
to document these behaviors.
Eventually, correlations
could be made between observed preoperative and postoperative behaviors and achievement of evaluative criteria.
Annual Evaluation:
annual evaluation would deter-
mine program relevancy and effectiveness over time, i.e.,
29
how groups of patients performed the expected behaviors;
if the nurse-teachers supported continuation of the program; if the nurse-teachers demonstrated the desired
competencies, and if key medical center personnel supported the program.
The methods to be employed in obtaining the annual
evaluation data included retrospective chart audits, a
review of the curriculum, interviews with key medical center personnel, and nurse-teacher interviews and observations.
Retrospective Chart Audits:
retrospective chart
audits would be performed by the nursing audit committee
to determine if patient behaviors delineated in the curriculum had been met.
Such audits are feasible and are
mandated by the Joint Commission on Hospital Accreditation
as partial fulfillment of accreditation criteria. Recommendations from the nursing audit committee would be sent
to the head nurse.
Curriculum Review: a panel of nurses led by the
head nurse would review the curriculum for relevancy and
content, e.g., was the curriculum reflective of current
health knowledge.
The panel would then recommend modifi-
cation of the curriculum as necessary.
Key Medical Center Personnel Interviews:
the
head nurse would sample the opinions of those who were
involved or who impacted upon the program, i.e.,
30
physicians, nursing supervisors, inservice instructors,
etc.
Nurse-Teacher Interviews and Observations:
the
head nurse, the assistant director for the critical care
units, and the inservice instructors would share in the
responsibilities of evaluating, e.g., direct observation,
the teaching skills of the nurse-teachers and of obtaining
data from the nurse-teachers regarding their feelings
about the program's effectiveness.
Analysis and Program Modification:
the head nurse
and a panel selected by her/him would receive and analyze
the data derived from the concurrent and annual evaluation
activities.
Program modification and updating would be
under their direction.
CHAPTER IV
THE CURRICULUM
INTRODUCTION TO THE CURRICULUM
The model delineated by Fodor and Dalis (15) serves
as the framework for the curriculum.
Inherent to the model
is the identification of key concepts which serve as organizers for the development of content, instructional objectives, evaluative criteria, and learning opportunities.
Such a model provides the instructor with the
rational, systematic organization of information.
Within
the hospital environment where time is limited, effective
teaching depends upon such an organized, cohesive approach.
A listing of content areas along with the key concepts identified within each content area is followed by an
overview of each content area, i.e., an introductory statement, the concepts, and the instructional objectives
organized under each concept.
A teaching guide is given
for each instructional objective and includes the suggested
evaluative criteria, content, learning opportunities, and
resources.
31
32
CURRICULUM
CONTENT AREAS AND CONCEPTS
PREOPERATIVE PREPARATION
An orientation period is one way of getting
acquainted, exploring feeling levels, offering support,
and reducing anxiety.
The cardiovascular system consists of 2 closely
related divisions:
the heart (pump) and the vessels
(conduits).
Coronary artery disease is a mechanical problem
and surgery may help alleviate it.
Preoperative routines include a number of tests,
treatments and expected behaviors.
SURGICAL INTERVENTION
Several incisions may be necessary in order to
perform aortocoronary bypass surgery.
During and after surgical intervention, a safe
physiological environment is maintained by monitoring and
stabilizing within predetermined parameters.
POSTOPE~~TIVE
PERIOD
The postoperative period is concerned with maintenance of physiological and psychological balance.
PREPARATION FOR HOME
Individual health responsibilities are assumed
during the last hospital week.
33
PREOPERATIVE PREPARATION OVERVIEW
Preoperative preparation involves the patient in
several important activities.
During a
2~
day time span,
(s)he will need to become oriented to the surroundings,
learn what to expect and what is expected from her/him.
CONCEPT:
AN ORIENTATION PERIOD IS ONE WAY OF GETTING
ACQUAINTED, EXPLORING FEELING LEVELS, OFFERING
SUPPORT, AND REDUCING ANXIETY
Instructional Objectives
1.
Following instruction, the learner will be
able to a) identify the nurse as a teacher,
b) identify the patient as a student, c) recall the name of the nurse-teacher.
2.
Following instruction, the learner will be
able to compare and contrast her/his own
presurgical concerns with those expressed
by the peer group, i.e., other aortocoronary
bypass patients.
3.
Following instruction, the learner will be
able to a) compare various given relaxation
techniques, b) decide which techniques are
appropriate to her/him, c) design her/his
own relaxation routine, d) demonstrate
her/his relaxation routine for the nurse.
34
4.
Following instruction, the learner will be
able to a) list the content areas to be
explored during hospitalization, b) explain
in own words why they merit consideration.
CONCEPT:
THE CARDIOVASCULAR SYSTEM CONSISTS OF 2 CLOSELY
RELATED DIVISIONS:
THE HEART (PUMP) AND THE
VESSELS (CONDUITS)
Instructional Objectives
5.
Following instruction, the learner will be
able to identify on a given diagram a) the
heart (atria, ventricles, valves, myocardium)
b) the vessels (vena cavae, pulmonary artery,
pulmonary veins, aorta, coronary arteries,
i.e., right, left, left anterior descending,
circumflex).
6.
Following instruction, the learner will be
able to describe in her/his own words the
relationship of the coronary arteries to the
myocardium.
CONCEPT:
CORONARY ARTERY DISEASE IS A MECHANICAL PROBLEM
AND SURGERY MAY HELP ALLEVIATE IT
7.
Following instruction, the learner will be
able to relate the obstruction of a coronary
vessel to the build-up of atherosclerotic
plaques and/or coronary thrombosis.
35
8.
Following instruction, the learner will be
able to discuss the rationale for coronary
artery surgery, i.e., perfusion of the
myocardium.
9.
Following instruction, the learner will be
able to indicate the placement of the bypass
graft or grafts.
CONCEPT:
PREOPERATIVE ROUTINES INCLUDE A NUMBER OF TESTS,
TREATMENTS, AND EXPECTED BEHAVIORS
Instructional Objectives
10.
Following instruction, the learner will be
able to discuss in her/his own words the purpose of diagnostic tests.
11.
Following instruction, the learner will be
able to discuss in her/his own words why
smoking is not permitted before cardiac
surgery.
12.
Following instruction, the learner will be
able to explain the rationale for and demonstrate the use of a) deep breathing and
coughing, b) sternal pillow, c) blow bottles,
d) IPPB (intermittent positive pressure
breathing).
13.
Following instruction, the learner will be
able to recall the purpose for a) taking
36
Phiso-Hex scrubs, b) having a Fleets enema
on the p.m. prior to surgery, c) having a
surgical prep on p.m. prior to surgery,
d) having an IV started on p.m. prior to
surgery.
CONCEPT:
AN ORIENTATION IS ONE WAY OF GETTING ACQUAINTED, EXPLORING FEELING LEVELS,
OFFERING SUPPORT, AND REDUCING ANXIETY
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
1.
Introductions
2.
Nurse-Teacher
3.
Patient-Student
Following instruction, the learner will be able to a)
identify the nurse as a teacher, b) identify patients
as students, c) recall the name of her/his nurse-teacher.
With an accuracy of 3 out of 3, the learner will identify on
a given list a) the nurse is a teacher, b) the patient is a
student, c) write the name of her/his nurse-teacher in the
provided space.
SUGGESTED LEARNING OPPORTUNITIES
The nurse will invite 2 or 3 newly admitted patients and
immediate family to the classroom.
(S)He will introduce her/himself as their teacher and
write her/his name on the blackboard. The nurse will
then ask those present to introduce themselves.
Each patient and family member will give her/his name
and volunteer any information (s)he desires.
The nurse will discuss her/his various roles as a nurse
and identify that of teacher as being one of the most
important.
The patients and families will join in the discussion
and identify the patients and nurse as students and
teacher.
tN
---.]
SUGGESTED CONTENT
SUGGESTED LEARNING OPPORTUNITIES
The nurse will give each patient a folder and explain that
hospital information will be given to each during the preoperative period. The folder will serve to hold this
information. Then (s)he will hand out the first of the
information ... a list of possible patient and possible
nurse roles and ask each patient to complete as the list
directs.
The patients will complete list.
The nurse will look at each completed list.
SUGGESTED RESOURCES
1.
Redman, Barbara K.
The Canadian Nurse.
2.
"Guideline for Quality of Care in Patient Education."
Vol. 71. No. 2.
(Feb., 1975). pp. 19-21.
Winslow, Elizabeth H. "The Role of the Nurse in Patient Education ... Focus:
The Cardiac Patient." The Nursing Clinics of North America. Vol. II. No. 2.
(June, 1976). pp. 213-222.
Vl
00
CONCEPT:
AN ORIENTATION IS ONE WAY OF GETTING ACQUAINTED, EXPLORING FEELING LEVELS,
OFFERING SUPPORT AND REDUCING ANXIETY
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
1.
Presurgical
Concerns
2.
Similarities
3.
Differences
Following instruction, the learner will be able to compare and contrast her/his own presurgical concerns with
those expressed by peer group, i.e., other aortocoronary
bypass patients.
The learner will recall at least 2 presurgical concerns identified by the group, will relate them to her/his expressed
concerns, and identify how (s)he is like the group and how
(s)he differs.
SUGGESTED LEARNING OPPORTUNITIES
The nurse will invite a postoperative patient who is
about ready for discharge home to join her/his group of
2 or 3 preoperative patients and their families in the
classroom.
The nurse will open the discussion by asking the preoperative patients how they feel and what particular concerns
they have.
The preoperative patients will express their feelings and
ask questions.
The nurse will ask the postoperative patient to explain
if this is how (s)he felt before surgery.
The postoperative patient will discuss with the group
how (s)he felt, will answer questions, and encourage the
group to talk.
t.N
1.0
SUGGESTED CONTENT
SUGGESTED LEARNING OPPORTUNITIES
Later, when the nurse makes rounds (s)he will give the
patient a chance to summarize her/his feelings and
analyze her/his concerns.
SUGGESTED RESOURCES
1.
Friedman, Barbara, et al. "Cardiac Surgery: Dependency and Apprehension Complicate Nursing Care." Nursing '74.
(December). pp. 33-36.
2.
Schmitt, Florence E. &Powhatan J. Wooldridge. "Psychological Preparation of
Surgical Patients." Nursing Research. Vol. 22. No. 2.
(March-April, 1973).
pp. 108-116.
3.
Winslow, Elizabeth H. "The Role of the Nurse in Patient Education ... Focus:
The Cardiac Patient". The Nursing Clinics of North America. Vol. II. No. 2.
(June, 1976). pp. 213-222.
+:0
CONCEPT:
AN ORIENTATION PERIOD IS ONE WAY OF GETTING ACQUAINTED, EXPLORING FEELING
LEVELS, OFFERING SUPPORT, AND REDUCING ANXIETY
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
1.
2.
3.
Following instruction, the learner will be able to
a) compare the given relaxation techniques, b) decide
which techniques are appropriate to her/him, c) design
her/his own relaxation routine, d) demonstrate her/his
relaxation routine for her/his nurse-teacher.
The patient will demonstrate her/his own relaxation routine
for her/his nurse-teacher and recall a), b), and c) in the
instructional objective.
SUGGESTED LEARNING OPPORTUNITIES
Purpose of relaxation Techniques
The nurse and 2 or 3 preoperative patients will discuss
how each of them relaxes.
a.
Reduce Anxiety
b.
Lessen Pain
Perception
The nurse will explain that there are a number of relaxation techniques available and ask if anyone is familiar
with them.
c.
Lower Metabolic Needs of
Body
Various Techniques
Available
Factors to Consider
in Selecting Techniques
The learners will discuss the topic and contribute any
information.
The nurse will summarize the patient discussion and
outline several methods which are appropriate for the
cardiac patient.
The patients will compare the methods, and each will
select 2 or 3 methods which suit her/him.
(S)He will
design a relaxation routine.
.j:>.
f-1
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED CONTENT
Later, the nurse will have the patient demonstrate
her/his technique.
(S)He will check BP and AP before
and after the demonstration. The nurse and patient
will then review the purpose of relaxation techniques.
At HS the nurse will note patient affect. If the
patient seems tense, (s)he will suggest that (s)he
demonstrate her/his relaxation routine again.
SUGGESTED RESOURCES
1.
Benson, H., MD.
2.
Egbert, L., MD, et al. "Reduction of Postoperative Pain by Encouragement &
Instruction of Patients." New England Journal of Medicine. Vol. 270. No. 16.
(April 16, 1968). pp. 825-827.
3.
Luthe, Wolfgang.
4.
Luthe, Wolfgang. Autogenic
Stratton. N.Y.
(1969).
5.
Suinn, R. "How to Break the Vicious Cycle of Stress."
Vol. 10. No. 7. (December, 1976). p. 59.
6.
Tart, Charles, Ed.
The Relaxation Response.
Autogenic Therapy.
Therapy~
Avon Books.
Vol. I.
Gune
N.Y.
& Stratton.
Medical Application.
Altered States of Consciousness.
(1975).
N.Y.
(1969).
Vol. II. Gune
&
Psychology Today.
Anchor Books.
N.Y.
(1972).
+>['-.)
CONCEPT:
AN ORIENTATION IS ONE WAY OF GETTING ACQUAINTED, EXPLORING FEELING LEVELS,
OFFERING SUPPORT, AND REDUCING ANXIETY
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
1.
Content Areas
2.
Rationale for
Content Areas
Following instruction, the learner will be able to a) list
the content areas (topics) to be explored during hospitalization b) explain in own words why they merit consideration.
The patient will list 4 of the 4 given content areas and will
explain in her/his own words that recovery is enhanced by
knowing what to expect and what is expected of her/him in the
hospital.
SUGGESTED LEARNING OPPORTUNITIES
The nurse will open the discussion by asking 2 or 3
newly admitted patients and their families what they
would like to understand about this hospital stay.
The learners will discuss areas of interest.
The nurse will list these on the blackboard and categorize them under the appropriate content areas, i.e.,
Preoperative Preparation, Surgical Intervention, Postoperative Period, Preparation for Home. (S)He will
explain that each of these topics will be discussed in
future classes, and will remind the learners to be sure
and ask anything which interests them about their care
during the classes.
The learners and the nurse will then discuss why it is
important to understand this hospitalization and why the
content areas are important to explore.
+:>
Vl
SUGGESTED CONTENT
SUGGESTED LEARNING OPPORTUNITIES
Later, when the nurse is making rounds, (s)he will ask
each patient to list the content areas and explain why
they are important.
SUGGESTED RESOURCES
1.
Schmitt, Florence & Powhatan J. Wooldridge. ''Psychological Preparation of
Surgical Patients". Nursing Research. Vol. 22. No. 2.
(March-April, 1973).
pp. 108-116.
.p.
.p.
CONCEPT:
THE CARDIOVASCULAR SYSTEM CONSISTS OF 2 CLOSELY RELATED DIVISIONS:
HEART (PUMP) AND THE VESSELS (CONDUITS)
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
1.
A Closed System
2.
Heart (Pump)
3.
THE
Following instruction, the learner will be able to identify on a given diagram a) the heart (atria, ventricles,
valves, myocardium) and b) the vessels (vena cavae, pulmonary artery, pulmonary veins, aorta, coronary arteries,
i.e., right, left anterior descending, and circumflex).
Given a diagram, the learner will identify without error each
of the above structures.
SUGGESTED LEARNING OPPORTUNITIES
The nurse and 2 or 3 preoperative patients and immediate
families will go to the classroom.
The nurse will discuss a model of the heart.
a.
Location
b.
Size
The learners will join discussion and ask questions as
they wish.
c.
Structures
The nurse will diagram the cardiovascular system on the
blackboard and explain the major structures.
Vessels
a.
Inflow (Veins)
The learners will take turns tracing the flow of blood
through the diagram.
b.
Outflow
(Arteries)
The nurse will show the video-tape, "The Heart." After
the video tape is completed, (s)he will summarize it and
the preceding discussion.
~
V1
SUGGESTED CONTENT
4.
SUGGESTED LEARNING OPPORTUNITIES
Coronary Arteries
a.
Location
b.
Right
c.
Left Anterior
Descending
d.
Circumflex
The learners will each be given a Programmed Instruction
on the anatomy of the cardiovascular system to take with
them.
The nurse will check the answers on the Programmed Instruction later when the patient has had time to read it.
SUGGESTED RESOURCES
1.
Andreoli, Kathleen, et al.
St. Louis.
(1975).
2.
Berne, R. MD &Matthew Levy
St. Louis. (1972).
3.
Heart Teaching Model.
4.
The Heart.
Comprehensive Cardiac Care.
MD.
C. V. Mosby Co.
Cardiovascular Physiology.
C. V. Mosby Co.
Available on Unit.
Video-Tape.
Color.
15 minutes.
I
I
ROCOM.
Available from inservice
department.
5.
Sanderson, R. G. MD.
delphia.
(1972).
The Cardiac Patient.
W. B. Saunders Company.
Phila-
~
01
~
CONCEPT:
THE CARDIOVASCULAR SYSTEM CONSISTS OF 2 CLOSELY RELATED DIVISIONS:
HEART (PUMP) AND THE VESSELS (CONDUITS)
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
1.
The Muscular
Pump
a.
Fuel (02)
b.
Nutrients
2.
The Mission of
the Coronary
Arteries
3.
Areas of Heart
Supplied by
Each Coronary
Artery
THE
Following instruction, the learner will be able to describe
in her/his own words the relationship of the coronary arteries to the myocardium.
The learner will include the following points in her/his discussion a) the heart is a muscular pump and requires fuel and
nutrients,b) the coronary arteries supply the required substances to the heart, c) without adequate coronary arteries,
the heart cannot function properly.
SUGGESTED LEARNING OPPORTUNITIES
The nurse will show the model of the heart to the 2 or 3
preoperative patients and their families.
(S)He will
state the heart is a muscle.
The nurse will explain the substances required by the
heart and how these substances are supplied.
The group will discuss the heart and identify the route
of each major coronary artery.
The nurse will give each learner a Programmed Instruction
which discusses the heart and the coronary arteries.
Later the nurse will check the patient answers in the
Programmed Instruction and answer questions.
..j:::.
---1
SUGGESTED RESOURCES
1.
Andreoli, K., et al.
(1975).
2.
Berne, R. MD &Matthew Levy MD.
St. Louis. (1972).
3.
Heart Teaching Model.
4.
Sanderson, R. MD.
(1972).
Comprehensive Cardiac Care.
C. V. Mosby Co.
Cardiovascular Physiology.
St. Louis.
C. V. Mosby Co.
Available on Unit.
The Cardiac Patient.
W. B. Saunders Company.
Philadelphia.
..j::.
00
CONCEPT:
CORONARY ARTERY DISEASE IS A MECHANICAL PROBLEM AND SURGERY MAY HELP
ALLEVIATE IT
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
1.
Definition of
Terms
a.
Atherosclerosis
b.
Coronary
Thrombosis
Following instruction, the learner will be able to relate
the obstruction of a coronary vessel to the build-up of
atherosclerotic plaques and/or coronary thrombosis.
Given a test question, the learner will write an answer which
includes each component listed above and identifies that a
direct relationship exists between antherosclerosis and myocardial infarction.
SUGGESTED LEARNING OPPORTUNITIES
The nurse and 2 or 3 preoperative patients and immediate
family will discuss atherosclerosis .
. The patients will explain what they understand of the
process.
The nurse will clarify and define as necessary.
The nurse will play the video-tape, Heart Disease.
2.
Etiology of
Atherosclerosis
The patients will discuss the film.
a.
Risk Factors
The nurse will give each patient a copy of the Programmed
Instruction on atherosclerosis.
b.
Pathophysiology
c.
Mechanical
Aspects
The patients will take the Programmed Instruction with
them to read individually and to answer questions it
proposes.
-f:::>
~
SUGGESTED CONTENT
SUGGESTED LEARNING OPPORTUNITIES
The nurse will check answers to Programmed Instruction
later.
SUGGESTED RESOURCES
1.
Andreoli, Kathleen, et al.
St. Louis. (1975).
2.
Heart Disease.
Video-Tape.
Patient Education.
Comprehensive Cardiac Care.
Color.
15 min.
C. V. Mosby Co.
Available from the Department of
tn
0
CONCEPT:
CORONARY ARTERY DISEASE IS A MECHANICAL PROBLEM AND SURGERY MAY HELP
ALLEVIATE IT
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
1.
What Coronary
Surgery is
2.
What Coronary
Surgery isn't
3.
Why Have Coronary
Surgery
Following instruction, the learner will be able to discuss
the rationale for coronary artery surgery, i.e., perfusion
of the myocardium.
The learner's discussion will include the relationship between
the coronary arteries and the oxygen supply to the heart
muscle.
SUGGESTED LEARNING OPPORTUNITIES
The nurse will open the discussion by asking 2 or 3 preoperative patients and their families how they perceive
their surgery.
The patients will discuss what they expect from the
scheduled surgery.
The nurse will join discussion to clarify if necessary.
The nurse will outline on the blackboard the rationale
for surgery.
The patients will discuss the outline and modify it if
they wish.
The nurse will give each patient the Programmed Instruction on coronary bypass surgery.
The patients will take it and read it later.
,_.
tn
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED CONTENT
After the patient has read it, the nurse will question
each patient regarding perfusion of the myocardium and
relate perfusion to surgery.
SUGGESTED RESOURCES
1.
Cooley, Denton, MD
Journal.
Vol. 21.
& Claudia
No. 5.
Wormuth, RN. "Direct Coronary Surgery."
(April, 1975). pp. 78 9- 79 4.
AORN
2.
Diethrich, Edward, MD. "Aortocoronary Bypass: Classification and Results."
Heart & Lung.
Vol. 4. No. 3. (May-June, 1975). pp. 381-389.
3.
Lee, Rose Marie, RN. "Surgery as Deterrent to Progression of Coronary Artery
Disease." AORN Journal. Vol. 22. No.6. (December, 1975). pp. 964-965.
4.
Likoff, William, et al.
1975). pp. 235-239.
5.
Siderys, Harry, MD et al.
"To Bypass or Not."
Emergency Medicine.
(November,
"The Bypass Surgery on Survival." The Journal of
Vol. 69. No. 2.
(February, 1976).
the Indiana State Medical Association.
pp. 85-8 7.
6.
Winslow, Elizabeth, MSN. "Coronary Artery Surgery: Operative Techniques and
Patient Education." Nursing Clinics of North America. Vol. 11. No. 2.
(June, 1976). pp. 371-383.
tn
N
CONCEPT:
CORONARY ARTERY DISEASE IS A MECHANICAL PROBLEM AND SURGERY MAY HELP
ALLEVIATE IT
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
Given a diagram, the learner will draw in the anticipated
bypass grafts without error.
SUGGESTED CONTENT
1.
Following instruction, the learner will be able to indicate the placement of the bypass graft or grafts.
Placement of
Aortocoronary
Bypass Grafts
SUGGESTED LEARNING OPPORTUNITIES
The nurse will diagram on the blackboard the heart and
aorta. Then (s)he will sketch in the placement of bypass
grafts.
The patients will be given diagrams and will sketch the
graft or grafts on it.
The nurse will check the diagrams.
SUGGESTED RESOURCES
1.
Likoff, William, et al.
1975). pp. 235-239.
"To Bypass or Not."
2.
Winslow, Elizabeth. ''Coronary Artery Surgery:
Education.'' Nursing Clinics of North America.
pp .. 371-383.
Emergency Medicine.
(November,
Operative Technique and Patient
Vol. 11. No. 2. (June, 1976).
V1
(.N
CONCEPT:
PREOPERATIVE ROUTINES INCLUDE A NUMBER OF TESTS, TREATMENTS, AND EXPECTED
BEHAVIORS
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
1.
Blood Tests
2.
Pulmonary Tests
3.
Chest X-Ray
4.
EKG
Following instruction, the learner will be able to discuss in her/his own words the purpose of diagnostic tests.
The learner will include in her/his discussion that the blood
tests, pulmonary tests, chest x-rays, and EKG are for the
purpose of establishing baseline data which will lead to indicated therapies before and/or after surgery.
SUGGESTED LEARNING OPPORTUNITIES
The nurse will visit the patient in her/his room and
review the diagnostic tests which the physician has
ordered.
The patient will ask any questions which (s)he may have
about any of the tests.
The nurse will answer questions and explain that these
tests are for the purpose of obtaining baseline data for
her/his physician.
The patient will explain why baseline data is necessary,
i.e., to initiate indicated therapy.
The nurse will give the Programmed Instruction on preoperative tests to the patient.
The patient will read the Programmed Instruction and
complete the questions in it.
U1
-1:::-
SUGGESTED CONTENT
SUGGESTED LEARNING OPPORTUNITIES
The nurse will check her/his answers later.
SUGGESTED RESOURCES
1.
Winslow, Elizabeth, MSN. "Coronary Artery Surgery: Operative Technique and
Patient Education." Nursing Clinics of North America. Vol. 11. No. 2.
(June, 1976). pp. 371-383.
VI
VI
CONCEPT:
PREOPERATIVE ROUTINES INCLUDE A NUMBER OF TESTS, TREATMENTS, AND EXPECTED
BEHAVIORS
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
Following instruction, the learner will be able to discuss
in her/his own words why smoking is not permitted before
cardiac surgery.
The learner will include at least 4 of 6 given reasons for not
smoking in the discussion.
SUGGESTED LEARNING OPPORTUNITIES
1.
Smoking and the
Lungs
The nurse will visit the patient in her/his room and
during the interview will ask about her/his smoking
habits.
2.
Smoking and the
Heart
(S)He will describe them.
3.
Smoking and the
Blood Vessels
Discussion will center upon the patient's understanding
of the effect of smoking on human physiology.
4.
Smoking and BP
The nurse will relate these physiological effects to the
demands made upon human physiology during surgery.
5.
Smoking and Carbon Monoxide
6.
7.
Smoking and the
Endocrine System
The patient will be given the Programmed Instruction on
smoking and surgery.
If desired, more information will be made available on
smoking and its control.
Smoking and Surgery
(Jl
0\
SUGGESTED RESOURCES
1.
, American Cancer Association pamphlets on smoking.
the Department of Patient Education.
Available from
2.
St. Pierre, R, Ed.D. & P. Scott Lawrence, Ph.D. "Reducing Smoking Using Positive Self-Management." The Journal of School Health. Vol. XLV. No. 1.
(January, 1975). pp. 7-9.
3.
Walker, Tish, RN, et al. Heart Attack! What Now. Georgia Heart Association,
Inc. Broadview Plaza, Level "C", 2581 Piedmont Road, N.E., Atlanta, Georgia,
30324.
VI
.....:(
CONCEPT:
PREOPERATIVE ROUTINES INCLUDE A NUMBER OF TESTS, TREATMENTS, AND EXPECTED
BEHAVIORS
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
Following instruction, the learner will be able to explain
the rationale for ~nd demonstrate the use of a) deep
breathing and coughing, b) sternal pillow, c) blow bottles,
and d) intermittent positive pressure breathing.
The learner will perform a), b), c) and d) listed above until
physician's orders have been met.
SUGGESTED LEARNING OPPORTUNITIES
1.
Role of the
Lungs
The nurse will visit the patient in her/his room and ask
what (s)he understands about the lungs, i.e., their role,
and the effect of open heart surgery upon them.
2.
Effect of Surgery on Lungs
The patient will respond to the question.
3.
4.
5.
The Effect of
Deep Breathing
on the Lungs
The nurse and patient will discuss the lungs.
The nurse will discuss why postoperative patient respiratory exercises are important to recovery.
Why a Sternal
Pillow
The patient will deep breathe and cough for the nurse.
Purpose of
Blow Bottles
The nurse will tell the patient about using a sternal
pillow.
The patient will deep breathe and cough using a sternal
pillow.
U"1
co
SUGGESTED CONTENT
SUGGESTED LEARNING OPPORTUNITIES
The nurse will describe how and how often the patient will
use blow bottles, or intermittent positive pressure
breathing (IPPB).
The patient will practice using the blow bottles or IPPB
and recall the frequency of use.
The nurse will evaluate the patient's performance and
express satisfaction when her/his responses fulfill
physician criteria. (S)He will then give her/him the
Programmed Instruction on respiratory exercises for open
heart patients.
SUGGESTED RESOURCES
1.
Sanderson, Richard, MD.
delphia. (1972).
2.
Storlie, Frances, RN, MS. Principles of Intensive Nursing Care.
Century-Crofts. New York.
(1972).
3.
Watson, Jeannette, RN, MScN. Medical-Surgical Nursing & Related Physiology.
W. B. Saunders Company. Philadelphia. (1972).
The Cardiac Patient.
W. B. Saunders Company.
Phila-
Appleton-
c..n
(.0
CONCEPT:
PREOPERATIVE ROUTINES INCLUDE A NUMBER OF TESTS, TREATMENTS, AND EXPECTED
BEHAVIORS
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
Following instruction, the learner will recall the purpose for a) taking Phiso-Hex scrubs (remove bacteria from
skin), b) having a Fleets enema on the p.m. prior to
surgery (G.I. tract sluggish after surgery), c) having
surgical prep on p.m. prior to surgery (bacteria cling to
hair), and d) having an IV started on p.m. prior to surgery (portal of entry for fluid and medications).
Given a list of preoperative treatments, the learner will
state the previously given purposes.
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED CONTENT
1.
Phiso-Hex Scrubs
2.
Fleets Enema
3.
Surgical Prep.
4.
Preoperative IV
The nurse will visit the patient in her/his room and
explain the purpose of each of the following:
a.
Phiso-Hex Scrub
b.
Fleets Enema
c.
Surgical Prep.
d.
Preoperative IV
(S)He will tell the patient when each is ordered and
ask her/him to tell what each treatment involves.
The patient will discuss the treatments and ask any
questions.
Q\
0
SUGGESTED CONTENT
SUGGESTED LEARNING OPPORTUNITIES
The nurse will give the patient the Programmed Instruction of preoperative treatments.
SUGGESTED RESOURCES
1.
Surgeon's Orders.
0\
I-'
62
SURGICAL INTERVENTION OVERVIEW
Patients talk about sZeeping through surgery, but
studies indicate that considerable anxiety is attached
to the actual surgical period.
One way to reduce this
anxiety is to give the patient some basic concept of what
is done and why.
Of particular interest is when the
tubes and lines which are inserted during the surgical
intervention will be removed.
CONCEPT:
SEVERAL INCISIONS MAY BE NECESSARY IN ORDER TO
PERFORM AORTOCORONARY BYPASS SURGERY
Instructional Objective
1.
Following instruction, the learner will be
able to
a) identify the locations of her/his
incisions,
b) explain why she/he will have
leg incisions.
CONCEPT:
DURING AND AFTER SURGICAL INTERVENTION, A SAFE
PHYSIOLOGICAL ENVIRONMENT IS MAINTAINED BY
MONITORING AND STABILIZING WITHIN PREDETERMINED
PARAMETERS
Instructional Objectives
2.
Following instruction, the learner will be
able to discuss in own words the concept of
the heart-lung machine.
3.
Following instruction, the learner will be
able to discuss in own words the purpose
63
of and when each of the following therapeutic
agents will be removed:
a) endotracheal tube,
b) nasa-gastric tube, c) chest tubes, d) peripheral IVs, e) Foley catheter, f) cardiac
monitor, g) arterial line.
CONCEPT:
SEVERAL INCISIONS MAY BE NECESSARY IN ORDER TO PERFORM AORTOCORONARY
BYPASS SURGERY
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
Following instruction, the learner will be able to a)
identify the locations of the incisions, b) explain why
(s)he will have incisions in her/his legs.
The learner will state that a) incisions will be mid-chest
and in the inner aspects of the legs, b) leg incisions are
necessary to obtain the vein grafts.
SUGGESTED LEARNING OPPORTUNITIES
1.
Chest Incision
The nurse will visit the patient in her/his room.
2.
Leg Incisions
The nurse will draw a diagram of the incisions which
will be made in surgery.
(S)He will explain why the
legs are used for the grafts.
The patient will ask any questions.
The nurse will explain that because of the leg incisions,
special attention must be given to the Phiso-Hex scrubs
on the legs as well as on the chest.
The patient will explain in her/his own words where
incisions are and why.
0\
~
SUGGESTED RESOURCES
1.
Winslow, Elizabeth. "Coronary Artery Surgery:
Education." Nursing Clinics of North America.
pp. 371-383.
Operativ~
Vol. 11.
Technique and Patient
No. 2.
(June, 1976).
0\
(J1
CONCEPT:
DURING AND AFTER THE SURGICAL INTERVENTION, A SAFE PHYSIOLOGICAL ENVIRONMENT IS MAINTAINED BY MONITORING AND STABILIZING WITHIN PREDETERMINED
PARAMETERS
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
Following instruction, the learner will be able to discuss
in her/his own words the concept of the heart-lung machine.
The learner discussion will include the following, a) the
heart-lung machine temporarily bypasses the heart and lungs,
b) the brain and the rest of the body continue to receive
blood the same as usual.
SUGGESTED LEARNING OPPORTUNITIES
1.
The Heart-Lung
Machine: What
The nurse will meet the patient and family in the patient's
room and ask them about the heart-lung machine.
2.
The Heart-Lung
Machine: Why
The patient, family and the nurse will explore patient/
family knowledges about the heart-lung machine.
3.
The Heart-Lung
Machine: How
The nurse will trace the flow of blood on a given diagram
and relate it to the flow of blood during heart-lung
bypass, and (s)he will explain as necessary.
The patient and family will recall the anatomy previously
discussed and relate the given diagram to the anatomy.
The nurse will give the patient the Programmed Instruction
on the heart-lung machine.
The patient will read the Programmed Instruction and answer the test questions.
"'
"'
I'I
SUGGESTED CONTENT
SUGGESTED LEARNING OPPORTUNITIES
Later, the nurse will check with the patient to ascertain
if (s)he fulfills the evaluative criteria.
SUGGESTED RESOURCES
1.
Sanderson, Richard, MD.
delphia. 1972.
2.
Winslow, Elizabeth. "Coronary Artery Surgery: Operative Technique and Patient
(June, 1976).
Education."
Nursing Clinics of North America. Vol. 11. No. 2.
pp . 3 71- 3 8 3 .
The Cardiac Patient.
W. B. Saunders Company.
Phila-
0'1
---J
CONCEPT:
DURING AND AFTER THE SURGICAL INTERVENTION, A SAFE PHYSIOLOGICAL ENVIRONMENT IS MAINTAINED BY MONITORING AND STABILIZING WITHIN PREDETERMINED
PARAMETERS
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
1.
Rationale of:
a.
Endotracheal
Tube
Following instruction, the learner will discuss in her/
his own words the purpose of and when each of the following therapeutic agents will be removed a) endotracheal
tube, b) nasa-gastric tube, c) chest tubes, d) peripheral
IVs and CVP line, e) Foley catheter, f) cardiac monitor,
and g) arterial line.
Learner discussion will include the previously g1ven purpose
and time factors for each of the interventions (a through g).
SUGGESTED LEARNING OPPORTUNITIES
The nurse will meet with the patient and family in the
patient's room.
The nurse will explain each of the listed tubes, lines,
of electrodes and draw a diagram explaining where each
is located.
b.
Nasa-gastric
Tube
c.
Chest Tubes
The patient and family will ask questions and discuss
the various lines and tubes as they wish.
d.
Peripheral
IVs & CVP
The nurse will give the diagram (s)he drew to the patient and ask her/him to explain each of the tubes,
lines, etc.
e.
Foley
Catheter
The patient will comply.
0\
00
SUGGESTED CONTENT
SUGGESTED LEARNING OPPORTUNITIES
f.
Cardiac
Monitor
The nurse will then tell the patient and family when
each tube, etc. will be removed.
g.
Arterial
Line
The patient will be given the Programmed Instruction to
study.
2.
Review Anatomy
3.
Removal of Tubes,
etc.
Later, the nurse will check the Programmed Instruction
test questions and question the patient to ascertain if
(s)he fulfills the evaluative criteria.
SUGGESTED RESOURCES
1.
Oster, Toni, Head Nurse, SUB-ICU.
Saint Joseph Medical Center, Burbank.
Available on nursing
Guide Lines for Preoperative Open Heart Patient Teaching.
unit.
2.
Oster, Toni, et al. Master Care PZan on Preoperative Care of the Open Heart
Patient.
Available on nursing unit.
0'1
1.0
70
POSTOPERATIVE PERIOD OVERVIEW
The immediate postoperative period presents the
patient with added concerns.
ICU is a strange and fright-
ening place for the uninitiated.
The patient can't speak
for a period of time (until the endotracheal tube is removed).
Considerable pain is present.
The patient who has been prepared for this exper-
ience copes more effectively because (s)he realizes the
environment, the equipment, and the tubes and lines are
routine and nothing went wrong in surgery.
It is helpful to introduce this content area by
talking about low anxiety producing topics such as visiting times, etc.
CONCEPT:
THE POSTOPERATIVE PERIOD IS CONCERNED WITH
MAINTENANCE OF PHYSIOLOGICAL AND PSYCHOLOGICAL
BALANCE
Instructional Objectives
1.
Following instruction, the learner will be
able to recall a) ICU is located on the second
floor, b) family and spiritual advisors may
visit at any time for about 5 minutes out of
the hour, c) aortocoronary bypass patients are
in ICU for about 24 to 48 hours.
2.
Following instruction, the learner will be
able to a) describe in her/his own words the
71
ICU environment, b) recall that (s)he may have
temporary personality changes, c) state that
when (s)he leaves ICU (s)he will soon recover.
3.
Following instruction, the learner will be
able to explain in her/his own words a) why
(s)he will be unable to speak while the endotracheal tube is in position, b) that as long
as (s)he is unable to speak an experienced ICU
registered nurse will be at the bedside, c)
when the endotracheal tube is removed,
(s)he
will do breathing exercises.
4.
Following instruction, the learner will be
able to recall a) chest tubes are uncomfortable, b) medication will be given and will
help control discomfort, c) discomfort will be
gone when the chest tubes are removed, d)
breathing exercises will shorten the time
chest tubes are required, e) chest tubes will
be connected to rather noisy bubbling suction.
5.
Following instruction, the learner will be
able to discuss control of postoperative incisional pain, i.e., medication will be given
and will help; relaxation routine can serve
as an adjunct to medication.
CONCEPT:
THE POSTOPERATIVE PERIOD IS CONCERNED WITH MAINTENANCE OF PHYSIOLOGICAL
AND PSYCHOLOGICAL BALANCE
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
1.
Location of ICU
2.
Visiting Regulations
3.
Time in ICU
Following instruction, the learner will be able to recall
that a) ICU is located on the second floor, b) family and
spiritual advisors may visit at any time for about 5
minutes out of the hour, c) aortocoronary bypass patients
are in ICU for about 24 to 48 hours.
Repeat information listed in a), b), and c) above.
SUGGESTED LEARNING OPPORTUNITIES
The nurse will invite 2 or 3 preoperative patients, immediate family, and 1 postoperative patient who is ready
for discharge horne to join her/him in the classroom.
The nurse will hand each patient an information pamphlet
re: ICU, location and philosophy.
The nurse will ask the postoperative patient to review
the pamphlet with the group.
The group will review the pamphlet and ask any questions.
Later, when (s)he makes patient rounds, the nurse will
ask the patient and family to tell about ICU location,
visiting regulations, and length of time the patient will
probably be there.
'-l
N
SUGGESTED RESOURCES
1.
ICU pamphlet, available from hospital storeroom.
-....]
lN
CONCEPT:
THE POSTOPERATIVE PERIOD IS CONCERNED WITH MAINTENANCE OF PHYSIOLOGICAL
AND PSYCHOLOGICAL BALANCE
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
1.
ICU Layout
2.
ICU Environment
3.
a)
Lights
b)
Noise
c)
Activity
d)
Equipment
Responses to
Following instruction, the learner will be able to a) describe in her/his own words the ICU environment, b) recall
that (s)he may have temporary personality changes, c) recall that when (s)he leaves ICU (s)he will soon recover.
The following facts will be included in learner discussion
a) in ICU lights will be on 24 hours a day; ICU is noisy
because of equipment and the numbers of people; there will be
considerable equipment in room; b) (s)he will be kept awake
most of the time in ICU; (s)he may become irritable, anxious,
angry and have strange dreams (normal responses to sleep
deprivation); and c) when (s)he leaves ICU, (s)he will sleep
and soon recover from effects of sleep deprivation.
SUGGESTED LEARNING OPPORTUNITIES
Present in the classroom: 2 or 3 preoperative patients
and immediate families, 1 postoperative patient who is
ready for discharge home, and the nurse.
The nurse will ask the learners what each knows about an
ICU.
The learners will draw upon own experiences to discuss
an ICU. The postoperative patient will relate her/his
ICU recollections.
The nurse will place a transparency of the Medical Center ICU floor plan on the overhead projector and explain
'--.J
+>-
SUGGESTED CONTENT
Sleep Deprivation
('
SUGGESTED LEARNING OPPORTUNITIES
it. Then the nurse will display several large photographs of ICU and discuss them.
The learners will participate in discussion.
The nurse will relate the ICU environment to sleep deprivation.
The learners will join discussion. Then the learners
will accept the Programmed Instruction on the environment in ICU from the nurse.
Later, the nurse will check with each patient to ascertain if evaluative criteria have been met.
SUGGESTED RESOURCES
1.
Benoliel, J, RN. "As the Patient Views the Intensive Care Unit and the Coronary
Care Unit." Heart & Lung. Vol. 4. No. 2.
(March-April, 1975). pp. 260-264.
2.
Friedman, B, RN. "Skilled Nursing During the Critical Postoperative Period."
Nursing '74. (December). pp. 34-40.
3.
ICU Photographs.
4.
ICU Transparency.
Available from Medical Center Photo-laboratory.
Available from Medical Center Photo-laboratory.
-....]
V1
SUGGESTED RESOURCES
5.
Oster, Toni, RN, Head Nurse SUB-ICU. Guide Lines for Preoperative Open Heart
Patient Teaching.
Available on Nursing Unit.
--..]
0\
CONCEPT:
THE POSTOPERATIVE PERIOD IS CONCERNED WITH MAINTENANCE OF PHYSIOLOGICAL
AND PSYCHOLOGICAL BALANCE
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
Following instruction, the learner will be able to explain in her/his own words, a) why (s)he will be unable
to speak while the endotracheal tube is in position, i.e.,
because it passes between his vocal cords, b) that as
long as (s)he is unable to speak an experienced ICU registered nurse will be at the bedside, i.e., to anticipate
needs, c) when the endotracheal tube is removed, (s)he
will do breathing ~xercises, i.e., deep breathing and
coughing using the sternal pillow and working with blow
bottles or IPPB.
The learner will include the information given in a), b) and
c) in the explanation.
SUGGESTED LEARNING OPPORTUNITIES
1.
Review Purpose of
Endotracheal Tube
Present in classroom: 2 or 3 preoperative patients,
family, 1 postoperative patient, and the nurse.
2.
Review Length of
Time for Endotracheal Tube
Nurse will review previously presented information about
the endotracheal tube.
3.
Relate Endotracheal Tube to
Speech
4.
Resumption of
Breathing Exercises
~)Hewill explain that the endotracheal tube prevents
speech because it passes between the vocal cords. The
postoperative patient will be asked to share experiences
with the group.
The postoperative patient will lead the group in discussion, and will answer questions.
·
-....]
-....]
SUGGESTED CONTENT
5.
SUGGESTED LEARNING OPPORTUNITIES
Role of ICU Nurse
The nurse will explain that the ICU nurse will be with
her/him while (s)he is intubated. (S)He will emphasize
that (s)he will not be alone at any time.
The postoperative patient will comment upon the role of
the ICU nurse and invite discussion.
The nurse will discuss resumption of breathing exercises
once the endotracheal tube is out.
SUGGESTED RESOURCES
1.
Friedman, B, RN. "Skilled Nursing During the Critical Postoperative Period."
(December). pp. 34-40.
Nursing '74.
2.
Swann, Joan.
"Coronary Bypass."
3.
Winslow, Elizabeth. "Coronary Artery Surgery:
Education." Nursing Clinias of North Ameriaa.
pp. 371-383.
AJN.
(December, 1975).
pp. 2142-2145.
Operative Techniques and Patient
Vol. 11. No. 2. (June, 1976).
-....]
00
CONCEPT:
THE POSTOPERATIVE PERIOD IS CONCERNED WITH MAINTENANCE OF PHYSIOLOGICAL
AND PSYCHOLOGICAL BALANCE
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
Present in classroom: 2 or 3 preoperative patients,
family, 1 postoperative patient, and the nurse.
Chest Tubes
a.
Review of
Purpose
b.
Review of
Removal
c.
Discomfort
Noise
d.
Relief of
Discomfort
Learner recall will include 5 of 5 given statements·
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED CONTENT
1.
Following instruction, the learner will be able to state
a) chest tube~ are uncomfortable, b) medication will be
given to help control discomfort, c) discomfort will be
gone when tubes are removed, d) breathing exercises will
shorten the time chest tubes are required, and chest tubes
will be connected to rather noisy bubbling suction.
The nurse will review previously presented information
on chest tubes and add that patients find chest tubes
uncomfortable and the suction noisy.
&
The group will discuss chest tubes and consider what
will help them to cope with problem.
The nurse will give each patient the Programmed Instruction on chest tubes.
The patients will read the Programmed Instruction and
answer the test questions.
The nurse will check with each patient to learn if
evaluative criteria have been met.
-....]
1.0
SUGGESTED RESOURCES
1.
Sanderson, Richard, MD.
delphia.
(1972).
2.
Winslow, Elizabeth. "Coronary Artery Surgery:
Education." Nursing Clinics of North America.
pp. 3 71- 3 8 3.
The Cardiac Patient.
W. B. Saunders Company.
Phila-
Operative Technique and Patient
Vol. 11. No. 2.
(June, 1976).
00
0
CONCEPT:
THE POSTOPERATIVE PERIOD IS CONCERNED WITH MAINTENANCE OF PHYSIOLOGICAL
AND PSYCHOLOGICAL BALANCE
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
1.
Postoperative
Incisional Pain
2.
Medication for
Pain
3.
Relaxation
Routine
Following instruction, the learner will be able to discuss control of postoperative incisional pain, i.e.,
medication will be given and will help; relaxation routine
can serve as an adjunct to medication.
Learner discussion will include 2 given control methods.
SUGGESTED LEARNING OPPORTUNITIES
Present in classroom: 2 or 3 preoperative patients,
families, 1 postoperative patient about ready for discharge home, and the nurse.
The nurse will introduce the topic of postoperative
pain and involve the group in the discussion.
The group will explore methods of pain control.
SUGGESTED RESOURCES
1.
Egbert, L.D. MD, et al. ''Reduction of Postoperative Pain by Encouragement and
Instruction of Patients." New EngZand JournaZ of Medicine. Vol. 270. No. 16.
(April 16, 1968). pp. 825-827.
00
.......
82
PREPARATION FOR HOME OVERVIEW
When the patient has major surgery, personal
responsibility for health care is arbitrarily taken from
her/him.
role.
(S)He is effectively regressed to a child's
It therefore becomes important to help her/him
assume once more the responsibility for her/himself as an
adult.
CONCEPT:
INDIVIDUAL HEALTH RESPONSIBILITIES ARE ASSUMED
DURING THE LAST HOSPITAL WEEK
Instructional Objectives
1.
Following instruction, the learner will be
able to a) identify each medication by sight
and recall when to take each, b) discuss the
desired effect, possible side effects, and
possible toxic effects, c) judge which medication effects should be reported to physician immediately and which may wait until
the regular visit.
2.
Following instruction, the learner will be
able to prepare a meal plan which is nutritionally balanced, acceptable to her/him,
and incorporates dietary limitations.
3.
Following instruction, the learner will be
able to develop a health program which incorporates the activities ordered by the physician.
83
4.
Following instruction, the learner will be
able to judge which cardiac symptoms require
immediate medical attention and which cardiac
symptoms do not require medical attention.
CONCEPT:
INDIVIDUAL HEALTH RESPONSIBILITIES ARE ASSUMED DURING LAST HOSPITAL WEEK
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
Following instruction, the learner will be able to a)
identify each medication by sight and state when to take
each, b) discuss the desired effect, possible side effects, and possible toxic effects, and c) judge which
medication effects should be reported to physician imntediately and which may wait until the regular visit.
The learner will perform a), b), c).
SUGGESTED LEARNING OPPORTUNITIES
1.
Physician Medication Plan:
What and When
The nurse will visit the patient in her/his room. (S)He
will bring a sample supply of medications ordered for the
patient.
2.
Medications:
"Show &Tell"
The nurse will ask the patient to tell about each medication, i.e., the name, the purpose, and time schedule for
taking.
3.
Effects of
Each Medication
The patient will discuss each medicine.
a)
Desired
The nurse will prompt, clarify, and inform as necessary.
b)
Side
The nurse will then differentiate between desired medication effect, side effects, and toxic effects.
c)
Toxic
The patient and nurse will discuss the common effects of
each of the ordered medications.
00
.j::>.
SUGGESTED CONTENT
SUGGESTED LEARNING OPPORTUNITIES
The nurse will then present several fictitious situations
which involve medication effects.
The patient will judge which of the fictitious situations
require an immediate report to the physician and which
may wait until later.
SUGGESTED RESOURCES
1.
Andreoli, Kathleen, et al.
Louis.
(1975).
2.
-------- , Physician Desk Reference.
3.
Physician Orders.
Comprehensive Cardiac Care.
C. V. Mosby Co.
Medical Economics, Inc.
New Jersey.
St.
(1976).
Available on patient chart.
co
t.n
CONCEPT:
INDIVIDUAL HEALTH RESPONSIBILITIES. ARE ASSUMED DURING THE LAST HOSPITAL
WEEK
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
1.
Prescribed Diet
2.
Use of Food Lists
3.
Writing a 24 Hour
Menu
Following instruction, the learner will be able to prepare a meal plan which is nutritionally balanced, acceptable to her/him, and incorporates dietary limitations.
Given the prescribed diet and an appropriate food list, the
learner will write a 24 hour menu which agrees with her/his
diet plan as ordered by the physician.
SUGGESTED LEARNING OPPORTUNITIES
The nurse will request that a dietitian visit the patient
and family.
The dietitian will review the prescribed diet with the
patient and family.
The dietitian will explain food lists and demonstrate
their use.
The patient will demonstrate usage of the food list
appropriate to her/his diet by writing a 24 hour menu.
The dietitian will check the menu for accuracy and clarify and correct if necessary.
The patient will write 24 hour menus for the remaining
hospital stay.
00
Cf\
SUGGESTED RESOURCES
1.
NutritionaZ MateriaZs Appropriate to Patient Needs.
Medical Center Dietitian.
Available and Selected by
00
-....J
CONCEPT:
INDIVIDUAL HEALTH RESPONSIBILITIES ARE ASSUMED DURING THE LAST HOSPITAL
WEEK
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
Given a list of physician's orders, the learner will plan a
daily program which includes each activity.
SUGGESTED CONTENT
1.
Ordered Activities
a)
Why
b)
When
c)
How
Following instruction, the learner will be able to develop
a health program which incorporates the activities ordered
by the physician.
SUGGESTED LEARNING OPPORTUNITIES
The physician will give the patient a list of home activity instructions.
The patient will read the list and question the physician
and/or nurse.
The nurse will discuss the orders with the patient and
ask her/him to plan a daily program which includes the
orders.
The patient will plan home activities and present the
plan to the nurse.
SUGGESTED RESOURCES
1.
Physician Home Orders.
00
co
CONCEPT:
INDIVIDUAL HEALTH RESPONSIBILITIES ARE ASSUMED DURING THE LAST HOSPITAL
WEEK
INSTRUCTIONAL OBJECTIVE:
EVALUATIVE CRITERIA:
SUGGESTED CONTENT
Following instruction, the learner will be able to judge
which cardiac symptoms require immediate medical attention (heavy pressure or squeezing pain in chest which may
spread to shoulder, arm, neck, or jaw and is not relieved
by resting and/or nitroglycerine or recurs frequently;
increased shortness of breath; fainting; very slow or very
rapid heart beat) and which cardiac symptoms do not require medical attention (chest pain, arm or hand discomfort or shortness of breath which disappear when activity
is stopped and/or nitroglycerine is taken).
Given 6 anecdotes (each dealing with the onset of cardiac
symptoms) the learner will decide which anecdotes require
immediate medical attention and which do not ... a~ accuracy
of 6 out of 6 is required.
SUGGESTED LEARNING OPPORTUNITIES
1.
Types of Cardiac
Symptoms
The nurse will ask the patient and family to describe
cardiac symptoms.
2.
Criteria for
Seeking Medical
Help
The patient and family will describe and discuss cardiac
symptoms.
Action to Take
The nurse will clarify, define, and inform as necessary.
Then (s)he will lead the group into a discussion of what
to do when symptoms occur.
3.
The patient and family will verbalize what they would do
and ~hen they would call the doctor.
co
1.0
SUGGESTED CONTENT
SUGGESTED LEARNING OPPORTUNITIES
The nurse will give the patient and family several anecdotes dealing with the onset of cardiac symptoms.
The patient and family will read the anecdotes and answer
questions which each anecdote proposes.
Later, the nurse will read the answers to the questions
to ascertain if the patient and family fulfill evaluative
criteria.
SUGGFSTED RESOURCES
1.
Walker, Tish, et al. Heart Attack! What Now. Georgia Heart Association, Inc.
Broadview Plaza. Level "C". 2581 Piedmont Road, N.E. Atlanta, Georgia 30324.
(1973).
'-0
0
CHAPTER V
SUMMARY AND RECOMMENDATIONS
Atherosclerotic coronary artery disease remains one
of the leading causes of mortality, especially in the middle-aged male in the United States.
Research continues in
the hope of finding a definitive solution, i.e., prevention of or a cure for the disease process.
Until such
prevention and/or cure are available, palliative measures
must be invoked.
One such measure, aortocoronary artery
bypass surgery has been generally accepted as a useful
therapy for selected cardiac patients.
While attention
has focused upon the selection and management of the
patients submitting to aortocoronary artery bypass surgery,
considera,tion of the cognitive needs of the patients has
tended to be extemporaneous and dependent upon the motivation of the nurses who have cared for them.
transfer of
inf~rmation
An inadequate
from nurse to patient has been the
most commonly experienced outcome.
Because of cultural attitudes and the complexity of
the surgery, the aortocoronary artery bypass patient has
a special set of needs and if these needs are met, patient
anxiety is reduced and recovery is enhanced.
As the result
of a needs assessment survey, a structured teaching program was designed for the patients admitted to a 500 bed
91
92
community medical center for aortocoronary artery bypass
surgery.
A curriculum was developed with implementation
procedures, a plan of evaluation, and a patient handbook.
The curriculum focused upon four areas of patient concern:
preoperative preparation, surgical intervention, postoperative care, and preparation for home.
An orientation
to the medical center and the roles of both the nurseteacher and the patient-learner were considered during the
preoperative preparation unit.
techniques were advocated.
Simple patient relaxation
A basic review of the cardio-
vascular system., atherosclerosis, coronary artery bypass
surgery, and the preoperative routines were then explored
in lay terms.
The unit on the surgical intervention
sought to reduce patient anxiety by explaining the lines
and monitoring devices which would be used during the
operation.
The locations of the incisions routinely
made for this type of surgery were identified.
The post-
operative unit focused upon the time in the intensive care
unit.
General information about the intensive care pro-
tocols was inserted as a mechanism for reducing anxiety
by focusing upon the intensive care unit location, visiting
periods, and the patient-nurse ratio.
After the patient was sufficiently recovered from
surgery to have been transferred from the intensive care
unit, the teaching program resumed by initiating the final
unit, preparation for home, which stressed the concept of
93
patient responsibility for resumption of self-management.
Home care plans which included medications, diet, and activity levels were stressed.
It is recommended that the teaching program and the
patient handbook be field tested, that evaluative data be
collected and analyzed.
Modifications which may become
apparent during the field testing could then be implemented
before the program is introduced on a continuing basis.
REFERENCES
Care~
1.
Andreoli, Kathleen, et al. Comprehensive Cavdiac
3rd ed. C. V. Mosby Co.
Saint Louis.
1975. ·
2.
Balasaraswathi, K. MD & A. A. El-Etr MD.
"Cardiovascular Preop Evaluation." AORN Journal.
Vol. 23.
No. 2.
(February, 1976)
209-211.
3.
Benoliel, Jeanne Quint RN & Susan Van De Velde RN.
"As the Patient Views the Intensive Care Unit and the
Coronary Care Unit." Heart and Lung.
Vol. 4.
No. 2.
(March-April, 1975)
260-264.
4.
Benson, H. MD.
N.Y. 1975.
5.
Berne, R. MD & Matthew Levy MD.
Cardiovascular Physiology.
C. V. Mosby Co.
Saint Louis.
1972.
6.
Beyers, M. RN MSN & Susan Dudas RN MSN.
The Clinical
Practice of Medical-Surgical Nursing.
Little, Brown
& Co. Boston. 1977.
7.
Conley, Leth & E. Graham.
''Valuation of Anxiety and
Fear in Adult Surgical Patients." Nursing Research.
Vol. 20.
No.2.
(March-April, 1971)
113-122.
8.
Cooley, Denton A. MD & Claudia E. Wormuth RN.
"Direct
Coronary Surgery." AORN Journal.
Vol. 21.
No. 5.
(April, 1975)
785-796.
9.
Crick, Eleanor RN.
"Patients Wait for Surgery in
'Twilight Zone.'" AORN Journal.
Vol. 22.
No. 6.
980-982.
(December, 1975)
The Relaxation Response.
Avon Books.
10.
Diethrich, Edward B. MD.
"Aortocoronary Bypass ...
Classification and Results." Heart & Lung.
Vol. 4 •
No. 3.
(May-June, 1975)
381-389.
11.
Effler, Donald B. MD.
"The Limitations of Emergency
Revascularization Surgery." Heart & Lung.
Vol. 4.
No. 6.
(November-December, 1975)
869-870.
12.
Egbert, Lawrence D. MD. et al.
"Reduction of Postoperative Pain by Encouragement and Instruction of
Patients." The New England Journal of Medicine.
Vol. 270.
No. 16.
(April 16, 1968)
825-827.
94
95
13.
Ehrilich, Ira B. MD.
"Patient Selection and Preoperative Evaluation." Heart & Lung.
Vol. 4. No. 3.
(May-June, 1975) 373-380.
14.
Favalora, Rene G. MD. Address before the American
College of Cardiology in Anaheim, California. March,
1978 as reported by Harry Nelson in the Los Angeles
Times.
Part II. March 9, 1978. 6.
15.
Fodor, John T., EdD & Gus T. Dalis, EdD. Health
Instruction.
Lea & Febiger. Philadelphia. 1971.
16.
Frerichs, Johanna M. & Nancy E. Vogel.
"A Comprehensive Approach to Teaching Cardiovascular Surgical
Patients." Cross Reference. Vol. 5. No. 10.
(November, 1975) 1-10.
17.
Friedman, Barbara. "Dependency and Apprehension
Complicate Nursing Care." Nursing '?4.
Vol. 1.
No. 12.
(December, 1974)
33-36.
18.
Friedman, Barbara. "Skilled Nursing During the Critical Postoperative Period." Nursing '?4.
Vol. 1.
No. 12.
(December~ 1974)
37-40.
19.
Friedman, Meyer MD, et al.
"Coronary-Prone Individuals (Type A Behavior Pattern). JAMA.
Vol. 212. No. 6.
(May 11, 1970) 1030-1037.
20.
Friedman, Meyer MD & Ray H. Roseman MD.
"Association
of Specific Overt Behavior Pattern with Blood and
Cardiovascular Findings." JAMA.
Vol. 169. No. 12.
(March 21, 1959) 1286-1296.
21.
Gordon, Marjory RN, PhD.
"Assessing Activity Tolerance." American Journal of Nursing.
Vol. 76. No. 1.
(January, 1976) 72-75.
22.
Holub, Nancy, et al. "Family Conferences as an
Adjunct to Total Coronary Care." Heart & Lung. Vol. 4.
No. 5.
(September-October, 1975)
767-769.
23.
"Cardiac Rehab il ita tion ... An
Jackson, Frank W. MD.
Alternative Approach." Pennsylvania Medicine. Vol. 76.
(July, 1973) 41-44.
24.
Lawrie,
College
1978 as
Times.
Gerald M. MD. Address before the American
of Cardiology in Anaheim, California. March,
reported by Harry Nelson in the Los Angeles
Part II. March 9, 1978. 1.
96
25.
Lee, Rose Marie RN. Surgery as Deterrent to Progression of Coronary Artery Disease." AORN Journal.
Vol. 22. No. 6.
(December, 1975) 964-966.
26.
Likoff, William MD.
Medicine.
Vol. 22.
964-966.
27.
Lindeman, Carol & Betty Van Aernam.
"Nursing Intervention with the Presurgical Patient: the Effects of
Structured and Unstructured Preoperative Teaching."
Nursing Research.
Vol. 20.
No.4.
(July-August,
1971) 319-332.
28.
Luthe, Wolfgang. Autogenic Therapy.
Vol. I and
Vol. II.
Gune & Stratton. N.Y. 1969.
29.
Murray, Ruth & Judith Zentner.
"Guidelines for More
Effective Health Teaching." Nursing '?6.
Vol. I.
No.2.
(February, 1976) 44-53.
30.
Pifarre, Roque MD. Address before the American College of Cardiology in Anaheim, California. March,
1978 as reported by Harry Nelson in the Los Angeles
Times.
Part II, March 9, 1978. 1.
31.
Redman, Barbara K. PhD.
"Guidelines for Quality of
Care in Patient Education." The Canadian Nurse.
(February, 1975) 19-21.
32.
Richards, Ruth F. "Patients are Learning." Health
Education Monographs~
SOPHE. Vol. 2. No. 1.
(Spring, 1974) 30-33.
33.
Rimm, Alfred A. PhD, et al.
"The Probability of
Closure in Aortocoronary Vein Bypass Grafts." JAMA.
Vol. 236. No. 23.
(Dec. 6, 1976) 2637-2640.
34.
Roberts, Sharon L. RN. "Systems Approach inAssessing
Behavioral Problems of Critical Care Patients." Heart
& Lung.
Vol. 4. No. 4. (July-August, 1975) 593-598.
35.
Roccella, Edward J. MPH. "Potential for Reducing
Health Costs by Public and Patient Education." Public
Health Reports.
Vol. 91. No. 3.
(May-June, 1976)
223-225.
36.
Sanderson, Richard MD. The Cardiac Patient.
Saunders Company. Philadelphia.
1972.
"To Bypass or Not." Emergency
No. 6.
(December, 1975)
W. B.
97
37.
Schmitt, Florence E. & Powhatan J. Wooldridge.
"Psychological Preparation of Surgical Patients."
Nursing Research. Vol. 22. No. 2.
(March-April,
1973) 108-116.
38.
Shapiro, Sam, et al.
"Return to Work After First
Myocardial Infarction." Arch. Environmental- Heal-th.
Vol. 24. No. 1.
(January, 1972) 17-26.
39.
Skiff, Anna W.
"Experiences with Methods for Patient
Teaching from a Public Health Service Hospital."
Health Education Monographs.
SOPHE. Vol. 2. No. 1.
(Spring, 1974) 48-53.
40.
Spodick, David H. MD DSc. "Aortocoronary Bypass
Surgery ... Emerging Triumph of Controlled Clinical
Trials." Chest.
Vol. 71. No. 3.
(March, 1977)
318-319.
41.
St. Pierre, R. EdD & P. Scott Lawrence PhD. "Reducing
Smoking Using Positive Self-Management. The Journalof School- Heal-th.
Vol. XLV.
No. 1.
(January, 1975)
7-9.
42.
Swan, Joan Todd. "Coronary Bypass." American Journalof Nursing.
Vol. 75. No. 12.
(December, 1975)
2142-2145.
43.
Tart, Charles, Ed. Altered States of Consciousness.
Anchor Books.
N.Y.
1972.
44.
Task Force on Patient Education for the President's
Committee on Health Education. "Concepts of Planned,
Hospital-Based Patient Education Programs." Health
Education Monographs.
SOPHE. Vol. 2. No. 1.
(Spring, 1974) 1-10.
45.
Vismara, Louis A. MD, et al.
"Improved Longevity Due
to Reduction of Sudden Death by Aortocoronary Bypass
in Coronary Atherosclerosis." The American Journal
of Cardiol-ogy.
Vol. 39. No. 5.
(May 26, 1977)
919-924.
46.
Walker, Tish RN, et al.
Heart Attack! What Now.
Georgia Heart Association, Inc. Georgia.
1975.
47.
Wegner, Nanette K. MD.
"The Rehabilitation of the
Coronary Patient." De ?-aware Medical Journal.
Vol. 44.
(April, 1972) 104-106.
98
48.
Winslow, Elizabeth Hahn & Horace MacVaugh, III.
"Coronary Artery Surgery: Operative Technique and
Patient Education." The Nursing Clinics of North
America.
Vol. 11. No. 2.
(June, 1976) 371-383.
49.
Winslow, Elizabeth Hahn.
"The Role of the Nurse in
Patient Education:
Focus on the Cardiac Patient."
The Nursing Clinics of North America. Vol. 11.
No. 2.
(June, 1976)
213-221.
50.
Zohrnan, Lenore R. MD.
Cardiac Rehabilitation.
& Stratton. N.Y. 1970.
Grune
APPENDIX A
STUDY ANALYSIS FLOW CHARTS:
PROFILE, IMPLEMENTATION
AND EVALUATION
99
STUDY PROFILE
JUSTIFY
PROGRAM
...
PLAN PROCEDURES,
IMPLEMENTATION
STEPS AND
EVALUATION
---
-----------···
---------~--------
4.0
3.0
2.0
1.0
DESIGN
CURRICULUM
WITIUN
IDENTIFIED
PARAMETERS
"'
-
---
- --
....
r
PRESENT
PROGRAM TO
NURSING
DEPARTMENT
~
----------------------
I-'
0
0
IMPLEMENTATION AND EVALUATION FLOW CHART
2.2
2.0
~
PLAN PRO EDURES,
IMPLEMENT1\.TION
STEPS AND
EVALUATI N
ASCERTAIN
PATIENT/
FAMILY
NEEDS
~
2.3
~
ASCERTAIN
PHYSICIAN
POINT OF
VIEW
r
2.7
~
2.4
~
2.1
4
IDENTIFY
TARGET
POPULATION
~
ASCERTAIN
ADMINISTRATION POINT
OF VIEW
DELINEATE
BASE FOR
PROGRAM
CONTENT
2.8
~
2.9
IDENTIFY
~D:EN'l'JFY
CURRICULUM
OPERATIONAL
PARAMETERS 1-l REQUIRFMENTS
~
r-)
2.5
ASCERTAIN
r--; NURSING
POINT OF
VIEW
~
2.10
2.6
~
ASCERTAIN
COMMUNITY
POINT OF
VIEW
~
~
PLAN
EVALUATION
2.11
PLAN UPDATING
AND REIMPLE- •
~ MENTATION
I-'
0
I-'
IMPLEMENTATION AND EVALUATION FLOW CHART
2.8
2.8.1
IDENTIFY
TIME
LIMITATIONS
IDENTI
CURRICULlJM
PARAME RS
..
~
2.8.2
...,
ASCERTAIN
PATIENT/
FAMILY
ACCESSIBILITY
2.8.5
SYNTHESIZE
INPUT
2.8.3
ASCERTAIN
NURSE-TEACHER
ACCESSIBILITY
2.8.4
IDENTIFY
AVAILABLE
MEDIA
.....
0
N
IMPLEMENTATION AND EVALUATION FLOW CHART
2.9
IDENTIFY
OPERATIONAL
REQUIREMENTS
I
j
----1'
2.9.u
IDENTIFY
PROGRAM
FACILITITATO
2.9.4
1
~
LIST
AVAILABLE
EQUIPMENT
2.9.2
DESIGN PLAN
TO OBTAIN
APPROVAL FROM
FACILITATORS
u
2.9.5
.•
LIST
REQUIRED
SUPPLIES
2.9.3
IDENTIFY
CLASSROOM
FACILITIES
,..
2.9.6
~
DELINEATE
INSERVICE
PROGRAM
2.9.6.1
1
·
~
ASSIGN
INSERVICE
RESPONSIBILITY
.......
0
IJ.1
IMPLEMENTATION AND EVALUATION FLOW CHART
2.10
PLAN
EVALUATION
2.10.1
_.,.
IDENTIFY
PURPOSE OF
EVALUATION
2.10.2
...
PLAN SCOPE OF
EVALUATION
2.10.3
FORMULATE
EVALUATION
SCHEME
--
f-1
0
~
IMPLEMENTATION AND EVALUATION FLOW CHART
2.10.1
IDENTIFY
PURPOSE OF
EVALUATION
2 .10.1.1
L----·---?1
ASSESS HEALTH
NEEDS OF
PATIENT AND
FAMILY
2 .10.1. 2
~
DETERMINE
PROGRAM
STRENGTHS
AND WEAKNESSES
...
2.10 .1. 3
ASSESS THE
ATTAINMENT
OF DESIRED
BEHAVIORS BY
PATIENT
I-'
0
(Jl
IMPLEMENTATION AND EVALUATION FLOW CHART
2.10.2
PLAN SCOPE OF
EVALUATION
_l__j
--,.
EVALUATE
PROGRAM
CONTENT
"
EVALUATE
PROGRAM
LEARNING
OPPORTUNITIES
EVALUATE
PROGRAM
OBJECTIVES
2.10.2.6
2.10.2.5
2.10.2.4
EVALUATE
-, PATIENT
RESPONSES
2.10.2.3
2.10.2.2
2.10.2.1
EVALUATE
...
F~IILY
RESPONSES
,...
EVALUATE
NlffiSE-TEACHER
RESPONSES
l..........-.---~
~
0
0\
IMPLEMENTATION AND EVALUATION FLOW CHART
2.10.3
FORMULATE
EVALUATION
SCHEME
l
I
2.10.3.1
PLAN
CONCURRENT
EVALUATION
2.10.3.2
_,
PLAN ANNUAL
EVALUATION
Z .lU. j.l.l
~
PERFORM STATISTICAL
EVALUATION
OF PATIENT
RESPONSES
2.10.3.2.1
r
PERFORM CLINICAL EVALUATIO~
OF PROGRA1v1
CONCEPTS
~
PERFORM CLINICAL EVALUATIOI'i
OF NURSETEACHER
RESPONSES
4
PERFORM CLINICAL EVALUATION
OF NURSETEACHER
COMPETENCY
2.10.3.2.2
.
..Joo
l.-.t
2.10.3.2.3
2.10. 3 .1. 2
1...-J
PERFORM CLINICAL EVALUATION
OF PATIENT/
FAMILY
RESPONSES
f-1
0
-.....]
IMPLEMENTATION AND EVALUATION FLOW CHART
2.11
PLAN UPDATING
AND REIMPLEMENTATION
j
2.11.1
ANALYZE
EVALUATION
-).j DATA
-
2.11.2
ASCERTAIN
WHICH ASPECTS
OF PROGRAM
REQUIRE
__j
2.11.3
MODIFY
AS
INDICATED
~DDIFICATION
I-'
0
00
APPENDIX B
PATIENT HANDBOOK
109
110
PATIENT HANDBOOK
OF
CORONARY ARTERY BYPASS SURGERY
BY MARY JORGENSEN
111
PATIENT HANDBOOK
Your physician has admitted you for cardiac
surgery.
He has explained to you the nature of your heart
problem and how he plans to help you.
Since you are probably trying to remember the
things you have been told and most likely have some
questions, this booklet has been prepared for you.
It will review things you
have already learned.
It will tell you some things to expect.
It will explain
why you are required to do certain things while you are
in the hospital.
But, most importantly, it should be
used to help you discuss your care with your doctor.
112
Your heart and the way it works will be considered
first.
Then the different phases of your hospitalization
will be discussed:
preoperative, operative (surgery), and
immediate postoperative.
The information is presented in such a way that
periodically there will be a few questions.
Take the
time to write the answers to the questions.
This way
you and those who are taking care of you will be able
to be sure that you understand what you have read.
113
INSTRUCTIONS
Some information will be presented.
be asked a question.
Then you will
The correct answer will follow so
that you will be sure that your answer is correct.
PLEASE READ THE INFORMATION
ANSWER THE QUESTION
CHECK YOUR ANSWER
Example:
When you are admitted to the hospital, a number
of people will work together as a team to provide you with
the individualized care you need.
your doctor.
dietician.
This team is led by
It will always include the nurse and the
It may include others ... the physical therapist
for example ..
Question:
Your hospital team will always consist of at
least
a.
A nurse
b.
A dietician
c.
Your physician
d.
All of the above
(Please circle the correct answer)
114
Answer:
d.
All of the above
IF YOU DO NOT UNDERSTAND OR HAVE ANY QUESTIONS, PLEASE
ASK YOUR NURSE FOR HELP.
*
*
*
WHAT ABOUT THE HEART?
The heart often is described as a pump.
A pump
may be defined as a machine or device for transferring a
liquid or gas from a source or container through tubes.
The most important pump, at least to most of us, is the
heart.
The tubes, of course, are the blood vessels.
Question (Please fill in the missing word):
If the heart could be thought of as a pump and the
blood vessels as tubes, then the liquid which is transferred through the vessels is the
115
Answer:
blood
Blood carries many important nutrients and regulating substences to the body cells, and oxygen is one of
the most important of these materials.
In order to
perform work, the cells must have an adequate supply of
oxygen.
The blood gives up its supply of oxygen and then
returns to the right side of the heart and is pumped
by the right side of the heart through the lungs where a
new supply of oxygen is obtained.
The blood then travels
from the lungs to the left side of the heart and is
pumped by the left side of the heart through the blood
vessels to the body cells.
116
The heart and blood vessels could be diagrammed
like this:
Cardiovascular System
Lungs
Right Side
Left Side
of Heart
of Heart
Body Cells
The heart and blood vessels form a closed system:
the pump and the delivery tubes.
117
Question (Match the following)
1.
Blood Vessels
a.
Pumps oxygen-rich
blood to the body
cells
2.
Right Side of Heart
b.
Carry the blood away
from the heart and
return it to the
heart
3.
Blood
c.
Sends the blood to
the lungs
- - -4.
Oxygen
d.
Carries the oxygen
- - -5.
Left Side of Heart
e.
Is used by the cells
to obtain energy
to do work
118
Answers:
b
1.
Blood Vessels
Carry blood away from the
heart and return it to
the heart
c
2.
Right Side of Heart
Sends the blood to the
lungs
d
3.
Blood
Carries the oxygen
e
4.
Oxygen
Is used by the cells
a
5.
Left Side of Heart
Pumps oxygen-rich blood to
the body cells
The heart has four chambers.
There are two cham-
bers on the right side of the heart and two chambers on the
left side of the heart.
One-way valves assure that the
blood will flow in the correct direction.
The heart pumps
by contracting or squeezing down upon the blood inside the
heart chambers and forcing the blood to move forward.
The heart muscle.is called the myocardium (myo=
muscle;
cardium= heart).
Question (Fill in the missing words)
Heart muscle is called the
Like all body muscle it performs work by
119
Answer:
Heart muscle is called the myocardium.
Like all
body muscle it performs work by contracting.
The myocardium receives its oxygen supply by
way of a special set of blood vessels ... the coronary
arteries.
The three major coronary arteries wrap around
the heart like a crown ... thus the name of coronary (from
the Latin word corona meaning crown).
The diagram illustrates the way that the coronary
arteries wrap around the heart.
\.)\J
l
AORT~
Key
/;\ Right Coronary
\1 Artery
~Left Coronary
"'\(/Artery
L~ Left Anterior
\()'Descending
Artery
/~Left Circumflex
WArtery
120
The left coronary artery is short and divides into
two major branches:
the left anterior descending artery
and the left circumflex artery.
The right coronary artery wraps around the
right side of the heart.
The three arteries, the left anterior descending
artery, the left circumflex artery, and the right
coronary artery
supply the right and left sides of
the heart with blood.
Normal cardiac function depends
upon an adequate flow of blood through these arteries
and their branches.
Question (Fill in the missing words)
The three major coronary arteries are:
1. ______________________________________________
2.
-----------------------------------------------
3.
----------------------------------------------
121
Answer:
1.
Left Anterior Descending Artery
2.
Left Circumflex Artery
3.
Right Coronary Artery
The diagram above identifies the aorta and the
pulmonary artery.
The pulmonary artery is the vessel which receives
blood from the right side of the heart and delivers the
blood to the lungs.
The aorta 1s the great vessel which receives the
oxygen-rich blood from the left side of the heart and
transports it via a series of vessels to the body cells.
122
The coronary arteries arise from the aorta at
the place where the left side of the heart and the
aorta meet.
Question (Select the correct answer)
The coronary arteries arise from the aorta:
1.
At the junction of the left side of the
heart and the aorta.
2.
Where the pulmonary artery and the aorta
join.
3.
Where the aorta joins the lungs.
4.
None of the above.
123
Answer:
The coronary arteries arise from the aorta:
1.
At the junction of the left side of the
heart and the aorta.
Like all cells, the cells of the heart must
have an oxygen supply in order to perform their specialized work ... pumping blood through the blood vessels.
If the coronary arteries do not deliver enough blood to
the myocardium, the portion of muscle which is deprived
of blood will not be able to function properly.
If the
blood supply is interrupted too long, a portion of the
deprived muscle may die (infarct).
When the coronary artery is unable to deliver
adequate amounts of blood, it is usually because the
artery has become narrowed or plugged.
due to atherosclerosis.
This commonly is
In atherosclerosis the walls of
the artery become rough and narrowed by fatty deposits.
This makes less room for the blood to flow.
The process
may be likened to the formation of lime deposits in a
water pipe.
Sometimes a blood clot will form on these
roughened spots and then the artery will probably be
blocked (occluded).
124
When the coronary arteries become narrowed, it
is possible, sometimes, to re-establish normal blood
flow to the myocardium by using a section of vein to
bypass the narrowed portion of the artery.
spoken of as a bypass graft.
This is
One end of the vein graft
is sutured (sewed) to the aorta and the other end is
sutured to the coronary artery just beyond the obstruction.
Sometimes several bypass grafts are used.
However, not everyone with atherosclerotic heart
disease would benefit from this surgery.
A doctor must
perform a careful evaluation before a decision can be
made.
The diagram on the next page illustrates two
bypass vein grafts which have been sutured to the
coronary arteries.
125
Question (Select the correct answer ... either True or False)
True/False
A portion of vein is used as a graft to bypass
the narrowed artery.
True/False
Several grafts may be used to bypass narrowed
coronary arteries.
True/False
Everyone with atherosclerotic heart disease
should have coronary artery surgery.
126
Answer:
~False
A portion of vein is used as a graft to bypass
the narrowed artery.
~False
Several grafts may be used to bypass narrowed
arteries.
True/~ Everyone with atherosclerotic heart disease
should have coronary artery surgery.
You have now reviewed some information about the
heart and should understand the importance of the
coronary arteries ... what they do and that they can develop atherosclerotic plaques.
You have also considered
one way to treat this problem, coronary artery bypass
surgery.
Since your physician has recommended this type
of surgery for you, it is now time to think about your
preoperative hospital period:
what needs to be done
to get you ready for your operation.
127
YOUR PREOPERATIVE CARE
Your doctor has ordered that a number of tests be
done before you have your surgery.
will require blood samples.
Some of the tests
The laboratory will send
a technician to obtain the blood from you.
may order breathing (respiratory) tests.
Your physician
Respiratory
tests may be done either in your room or in the Pulmonary Function Laboratory.
One or more EKGs (electro-
cardiograms) will be needed too.
x-ray taken also.
You will have a chest
By the time all of these tests are
completed, your physician will have an excellent, current
profile of your health ... especially your cardiac health.
This profile will provide the baseline data needed to
assure that you receive all the treatments and medications
necessary to aid you as you have surgery and recover from
it.
There are also some things for which you are
responsible.
One thing you must do is to stop smoking ...
if you haven't done so already.
There are three good
reasons why:
1.
Smoking paralyzes the hair-like structures
(cilia) in the lungs which help you remove
secretions.
128
2.
Smoking produces carbon monoxide.
The carbon
monoxide travels from the lungs into the blood.
Carbon monoxide displaces oxygen in the blood
and creates problems at a time when you need
all the oxygen you can get.
3.
Smoking has a direct effect upon the cardiac
blood vessels.
When you smoke, the blood
vessels tend to narrow.
This deprives the
myocardium even more of the blood it needs.
If you continue to smoke, you compound trouble.
Smokers always have more postoperative respiratory complications than nonsmokers.
If you leave smoking alone
during this period, you will enhance your recovery.
Who knows, you may kick the habit forever!
Question (Fill in the missing words)
There are three good reasons not to smoke.
include:
smoking paralyzes the
move the normal lung secretions;
They
which resmoking produces
which displaces oxygen
in your blood;
cardiac vessels.
smoking tends to
129
Answers:
There are three good reasons not to smoke.
include:
smoking paralyzes the
the normal lung secretions;
monoxide
tends to
cilia
smoking produces
which remove
carbon
which displaces oxygen in your blood;
narrow
They
smoking
the cardiac vessels.
It is because of the need to clear the secretions
in the lungs ... secretions which tend to pool during and
after surgery ... that your physician will order that the
nurses teach you how to deep breathe and how to cough
effectively.
It is very important to cough and deep
breathe after surgery so that your lungs will become fully
inflated and so that normal secretions will be brought up
and coughed out.
By coughing and deep breathing you will
help to prevent postoperative pneumonia.
Since you will have an incision in your chest, your
nurse will show you how to use a pillow to support yourself
when you cough.
(Don't worry about stitches ... they are
strong and will hold.)
The pillow is pressed against the
breast bone, the sternum.
When you use the pillow, cough-
ing will be more effective since the support helps to decrease the discomfort.
130
The doctor will order some type of breathing
treatments.
Perhaps he will order a breathing machine,
IPPB or intermittent positive pressure breathing.
he will have you use blow bottles.
Perhaps
Whichever he orders,
you will be helped to clear and inflate your lungs ... an
important postoperative consideration.
Question (Select the correct answer)
It is important to cough and deep breathe after
surgery because:
1.
Secretions tend to pool in the lungs after
surgery.
2.
If secretions are not removed from the lungs,
pneumonia may occur.
3.
Coughing and deep breathing help to inflate
the lungs.
4.
All of the above.
131
Answer:
4.
All of the above
Special attention must be given to your skin before
surgery in order to lessen the chance of infection.
Your
physician will order that you take special showers.
You
will probably use a cleansing material which will help
to remove bacteria from your skin.
Your nurse will tell
you when to take the showers and what areas of your body
to scrub.
The night before surgery, the surgical tech-
nician will shave the hair from your surgical sites.
is done to prevent bacteria from adhering to the hair
on your skin.
This
132
One more preoperative routine:
your doctor will
probably order an enema or suppository on the day of
surgery or on the night before surgery.
this is to clear the lower colon.
The reason for
Because of the enema
or suppository, you will not have to have a bowel movement
for a few days after surgery.
This will give you time
to be recovering from your operation and feeling better
before you need to move your bowels.
Question (Fill in the blank spaces)
The reason special showers are taken and the skin
is shaved before surgery is to remove
--------------------
This will lessen the chance of
You may be given an enema or suppository before
surgery.
The enema or suppository will
the
lower colon so that you will not have to have a bowel
movement for a few days after surgery.
133
Answers:
The reason special showers are taken and the skin
is shaved before surgery is to remove
This will lessen the chance of
bacteria
infection
------------------------------
You may be given an enema or suppository before
surgery.
The enema or suppository will
clear
the
lower colon so that you will not have to have a bowel
movement for a few days after surgery.
YOUR SURGICAL PERIOD
Now that you have learned about the preoperative
tests and treatments, let's consider the operating room
and what will happen there.
On the morning of your operation, you will be taken
to the second floor surgical suite.
The anesthesiologist,
who will have interviewed you before your operation, will
meet you there and will put you to sleep.
done gently and easily.
This will be
That will be the last you will
remember until your operation is completed.
However, while
you sleep, a number of lines and tubes will be inserted.
There will be IV (intravenous ... meaning into the vein)
tubes (usually called IV lines) to give you fluids and
medicines;
an arterial needle or cannula will be placed
134
in one. of your peripheral arteries and will be used to
monitor your blood pressure.
It will permit painless
withdrawl of arterial blood for blood gas measurements.
Chest electrodes will be placed on your chest so that your
heart's electrical activity can be watched.
A soft tube will be passed down your nose and into
your stomach.
It will keep your stomach empty so that you
won't be nauseated after surgery.
The stomach tube (nasa-
gastric tube) also permits the nurses to give you an antacid
after surgery.
This will keep your stomach coated and
protected until you are ready to eat again.
A catheter (a soft, flexible tube) will be passed
into your urinary bladder.
With the catheter in your
bladder, accurate measures of your urinary output can be
made.
This is an important measurement during the first
postoperative hours because it is one indication of your
response to surgery.
The anesthesiologist will insert a tube down your
throat into your trachea (wind pipe).
This way, your
breathing can be controlled in a very precise manner.
The endotracheal tube (the tube inserted into the trachea)
will probably be left in place for a few hours after
surgery is completed.
place.
You may wake up with this tube in
Remember, while it is in place, you will not be
able to talk, but during that period a nurse will remain
at your bedside and will be able to understand what you
135
want ... the nurses get very good at this type of understanding.
During the surgery, you will be connected to the
heart-lung machine.
The heart-lung machine was developed
to circulate blood around the heart and lungs ... to bypass
them.
The heart-lung machine adds the oxygen to your
blood which normally would be added by your lungs.
It
assures that blood is delivered to all parts of your body ...
it temporarily performs the pumping activity of your heart.
The heart-lung machine is used only while the surgeon is
working on your heart.
Once the bypass grafts are attached
to your coronary arteries, your blood is circulated through
your heart and lungs once more.
You will have incisions in your chest and legs.
The leg incisions will be made in order to remove a
portion of a vein which will serve as the graft.
These
incisions heal rapidly ... eventually only the scar will
remain.
As the surgery ends, tubes will be placed in your
chest.
These tubes, the chest tubes, are placed to a
special type of suction ... under water suction.
The tubes
are necessary to drain fluid and air from your chest cavity.
The water serves as a trap ... it permits the fluid and air
to escape from your chest but prevents the air from reentering your chest cavity.
This type of suction is rather
noisy because the water in the trap bubbles.
However, the
136
chest tubes will be taken out as soon as your lungs are
fully expanded ... and coughing and deep breathing will
speed the healing process.
Chest tubes can be somewhat uncomfortable.
they are removed, you feel much better.
CONCEPT OF UNDERWATER SUCTION
Once
137
Question (Match the following)
During surgery a number of lines and tubes will be inserted.
See if you can remember why each tube or line is used.
___ 1.
Nasogastric Tube (stomach)
a.
To maintain
precise control
of breathing
___ 2.
Endotracheal Tube (throat)
b.
To give fluids
and medicines
---3.
IV Lines (intravenous)
c.
To keep the
stomach empty
and comfortable
____4.
Catheter (urinary bladder)
d.
To drain the
chest and help
the lungs to
inflate
---5.
Arterial Lines (intraarterial) e.
To obtain an
accurate urinary
output measure
---6.
Chest Tubes (drain chest)
To monitor
blood pressure
and to obtain
blood samples
for blood gas
measurements
f.
138
Answers:
c
1.
Nasogastric Tube
To keep the stomach empty
and comfortable
a
2.
Endotracheal Tube
To maintain precise control
of breathing
b
3.
IV Lines
To give fluids and medicine
e
4.
Catheter (urinary)
To obtain accurate urinary
output measure
f
5.
Arterial Lines
To monitor blood pressure
and to obtain blood samples
for blood gas measurements
d
6.
Chest Tubes
To drain the chest and to
help the lungs to inflate
139
YOUR SURGERY IS OVER ... NOW WHAT?
After surgery, you will be taken directly to the
intensive care unit.
There are a number of things you
probably want to know:
where is intensive care;
are the visiting hours;
what
how long do you stay there?
The intensive care unit (ICU) is on the second
floor of the south building.
While you are in ICU, your
visitors will be limited to your immediate family.
How-
ever, if you wish to have your priest, minister, or rabbi
visit, he or she is welcome.
The visiting hours are usually
limited to about five minutes out of the hour ... every
hour ... around the clock.
just outside the ICU.
There is a family waiting room
It has chairs and couches for your
family.
You will be anxious to see your family ... and they
to see you.
Therefore, just as soon as you have been
admitted and settled, you will be permitted to visit with
them.
You will probably stay a couple of days in the ICU,
and by the time you leave it, most of your tubes will have
been removed.
In fact, the endotracheal tube is usually out
a couple of hours after surgery ... then you can talk and
COUGH and DEEP BREATHE and do your BREATHING EXERCISES!
Remember, the more you cough and deep breathe, the sooner
the chest tubes will come out.
140
What about pain?
Any type of surgery involves pain,
and so does cardiac surgery.
However, your doctor will
write orders for medicine to help with the pain.
The nurses
will watch you carefully and give you pain medication as you
need it.
led.
While pain cannot be avoided, it can be control-
So before you practice deep breathing and coughing
for the first time or before you get up in the chair, ask
for medication.
It will help you perform better.
In time
the pain will lessen, and you will not need any medicine
for it.
Your nurses have had special courses to prepare
them to take care of you before and after your surgery.
You will find them skilled and caring.
will be near you at all times.
that you cough and deep breathe.
In ICU one of them
However, they will insist
A pillow will be given
to help you support your chest when you cough.
When you leave ICU, you will be transferred to the
sub-intensive care unit.
progress toward recovery.
This means that you are
making
You are now entering the last
phase of your hospitalization:
convalescence.
Conval-
escense is a busy period for you will be preparing to go
home.
There are exercises to be done and tasks to be com-
pleted.
At times you may feel somewhat tired and depressed.
This is a normal response, and it will pass.
The sub-intensive care unit will be different from
the ICU.
In ICU a nurse is always at your bedside.
This
141
difference is part of your physician's plan of therapy.
Therefore, the nurses will be available when you need
them, but now their goal is to help you achieve your
preoperative independence.
Now is the time when you and
your family will work with the nurses and physicians to
plan your home activities so that when you leave the
hospital you will feel comfortable to do so.
APPENDIX C
INTERVIEW QUESTIONS
142
143
INTERVIEW QUESTIONS
POSTOPERATIVE PATIENTS
1.
Now that you are ready to go home, would you tell
me how you feel about this hospitalization?
2.
Did you receive preoperative teaching by the
nurses?
3.
Did preoperative teaching help you?
4.
Do you feel that your preoperative preparation
stressed the correct information?
Please tell
me what it should stress?
5.
What should be left out of preoperative teaching
or explanations?
6.
Did you practice breathing and coughing exercises
preoperatively?
7.
Do you feel that practicing your breathing and
coughing exercises helped or would have helped
you do them better after surgery?
8.
Do you think that preoperative teaching helps
patients to feel less anxious before surgery?
After surgery?
9.
Tell me what postoperative teaching you feel that
patients should have after cardiac surgery.
10.
Is there anything you would like to tell me that
would help other patients?
144
PREOPERATIVE PATIENTS
1.
Have your nurses explained anything to you about
what to expect from them while you are in the
hospital?
2.
If the nurses have told you about your surgery,
has it helped you and your family?
3.
What would you like to be told?
4.
Do you feel that you need to receive any special
information or explanations?
What about your
family?
5.
Would you tell me what we can do to help you
and your family at this time?
CRITICAL CARE NURSES
1.
What should the preoperative patients need to
know about:
cardiovascular anatomy?
physiology?
atherosclerosis?
2.
Is it important for the patient to be able to
explain what and why (s)he must have diagnostic
tests and treatments?
3.
What should (s)he know about the time in the
operating room?
4.
What do the patient and family need to know about
intensive care nursing?
5.
What do you tell the patient and family about the
practicing of coughing, deep breathing, and other
breathing exercises and treatments?