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Anxiety and open heart surgery.

Mrs. Miller, age 56, is noticeably upset because results of a cardiac catheterization led to a recommendation for open heart surgery due to coronary artery disease. Her mind races with multiple questions for her cardiologist and surgeon, and anxiety begins to mount. "How serious is this?" "Is it an emergency?" "How could this happen to me?" "What did I do wrong?" "Could I die during the operation?" The nurse must determine how to decrease Mrs. Miller's anxiety after the physicians explain her current heart condition and future surgery.

Anxiety

Anxiety is an unpleasant feeling that affects patients emotionally, psychologically, and physically (Smith, Kemp, Larson, Jaffe, & Segal, 2006). It is characterized by a feeling of foreboding, dread, or threat that could be real or imaginary (Moser et al., 2007). Anxiety in the medical setting is somewhat expected but can become a clinical issue (Cassem, Fricchione, Jellinek, Rosenbaum, & Stern, 2004) that can result in significant lifestyle impairment if left untreated. Anxiety can alter the way a person thinks, cause behavioral problems, and stimulate cognitive changes as well (Vaughn, Wichowski, & Bosworth, 2007). Anxiety after a major cardiac event can slow the patient's recovery and increase morbidity and mortality. During this time, the patient is confronted with awareness of his or her mortality, and has concerns regarding how open heart surgery will impact life, work, and relationship with others. The patient facing open heart surgery may have some normal anxiety-related behavior, but health care providers should monitor the patient's anxiety to preclude development an anxiety disorder (McCann, Fauerbach, & Thombs, 2005). Symptoms of anxiety can be physical or cognitive.

Physical Symptoms of Anxiety

Physical symptoms alone can be debilitating. Physical symptoms of anxiety reflect autonomic arousal, including headache, flushing, dry mouth, and nausea, or more intense symptoms such as chest pain, shortness of breathe, and heart palpitations (Cassem et al., 2004).

Chest pain. Chest pain, a common symptom of anxiety, often is described as localized, fleeting, and sharp. The chest pain can be described as visceral tightness that lasts greater than 30 minutes (Braunwald et al., 2005). Chest pain and anxiety in the patient who is preparing for open heart surgery are a reminder of the severity of the heart problem and the possibility that chest pain could indicate a fatal heart attack (Fitzsimons, Parahoo, Richardson, & Stringer, 2003).

Palpitations. Palpitations, common in the patient dealing with anxiety, can be a frightening symptom for a patient diagnosed with a heart condition requiring open heart surgery. Palpitations are defined as an awareness of the heart's beating, and often are described as pounding, fluttering, skipping beats, or a sensation the heart is stopping. Although palpitations can be caused by a cardiac arrhythmia, they are a common symptom of depression and panic disorders. The patient may wonder if the heart condition is worsening and whether emergency surgery may be needed. Palpitations can occur when the heart just is working hard or if a patient is becoming anxious. They are diagnosed by electrocardiogram (EKG) or a Holter monitor (Braunwald et al., 2005).

Shortness of breath. In a cyclical manner, anxiety can cause shortness of breath; the patient becomes more anxious, and the shortness of breath worsens. It is characterized by an abnormally uncomfortable awareness of breathing (Kahn & Smith, 2004). It is one of the cardinal symptoms of a pulmonary or cardiac disease but can result from other abnormalities which include anxiety. The health care provider's awareness of this symptom and its cause is critical to helping the patient avoid chronic shortness of breath.

Dizziness. Anxiety can be a predisposing factor to dizziness. A study done on chronic subjective dizziness assumed that balance functioning and emotion share a common neurologic pathway. The patient who complains of chronic imbalance frequently suffers from anxiety (Odman, 2008). Although this symptom has not been deemed serious, the patient who is preparing for open heart surgery may believe it is part of the heart problem and thus experience increased anxiety.

Psychological Symptoms

Fear and worry. Fear and worry are the primary psychological symptoms of anxiety (Smith et al., 2006). A patient facing open heart surgery may be consumed by fear of the unknown and worry regarding the recovery process, the uncertainty of the surgery's timing, and the physical incapacity after the surgery (Fitzsimons et al., 2003). This anxiety tends to cause other changes in the body due to the increase of adrenaline (Vaughn et al., 2007). Powerful catecholamines are released from the body when a person experiences anxiety. They cause increased heart rate, blood pressure, and cardiac output, which could cause myocardial ischemia. In a patient with known heart disease, catecholamines may cause a change in the EKG (Fitzsimons et al., 2003).

Preoperative Anxiety in Open Heart Surgery

A patient preparing for open heart surgery may have many anxieties. Most of them result from the concern about pain, poor or uncertain surgical outcomes, and surgery itself (Gallagher & McKinley, 2007). In one study, patients discussed their anxiety prior to surgery (Fitzsimons et al., 2003). Their descriptions included questions such as, "Will I even live to have the surgery?" and "Will I make it off the table?" Some even compared waiting for open heart surgery to being on death row waiting for execution.

Psychological concerns can manifest as fatigue, shortness of breath, chest pain, anxiety, and depression (Fitzsimons et al., 2003). A patient preparing for surgery goes through a crisis (Ivarsson, Larsson, & Sjoberg, 2004). During this time, the patient's ability to cope with the surgery depends on how much support he or she receives from family, friends, and health care professionals. The patient welcomes the support. As the patient prepares for surgery, the goal is a speedy recovery. For this to happen, the patient needs to be educated fully before surgery to enhance the opportunity for a complication-free postoperative period that is manageable for the patient, family, and health care professionals.

Postoperative Complications from Anxiety

Preoperative anxiety has been associated with slower wound healing, decreased immune response, fluid and electrolyte imbalance, and increased rate of infection. It also has been linked to increased postoperative pain (Scott, 2004). Anxiety can alter a patient's vital signs by releasing epinephrine in the blood stream, causing blood vessel constriction and increased heart rate (Vaughn et al., 2007). Abnormal vital signs can contribute to the development of other postoperative problems. If the deep somatic, cutaneous, and visceral pain of heart surgery is left untreated, the recovery process for the patient can be compromised (Kshettry, Carole, Henly, Sendeibach, & Kummer, 2006).

After surgery, the patient may face continued anxiety because of financial stress, uncertain health, and decreased ability to work (Karlsson, Johansson, & Lidell, 2005). In one study, 37% of patients experienced psychological distress and cognitive impairment after cardiac surgery (Tolmie, Lindsay, & Belcher, 2006). Even though these effects resolved some time after the operation, the patients had periods when psychological distress and cognitive impairment had detrimental effects on their rehabilitation process.

Nursing Interventions

Assess vital signs. Assessing a patient's vital signs can reveal a great deal about his or her condition, and may be the only option to make a quick diagnosis. Anxiety can alter a patient's vital signs by causing a negative impact on the body, such as an increase in blood pressure and heart rate. When the patient preparing for open heart surgery develops anxiety, epinephrine released in the blood causes vasoconstriction that results in chest pain. Anxiety can increase the patient's heart rate and cardiac contractility, leading to increased blood pressure and temperature, flushing, and sweating (Vaughn et al., 2007).

Preoperative education. Ku, Ku, and Ma (2002) found 76% of patients who underwent open heart surgery indicated their anxieties were relieved as a result of a pre-admission education program regarding the open heart procedure. The researchers noted that extensive preparation prior to cardiac surgery had a positive effect on patients' physical well-being and anxiety. Another study discussed surgical patients' anxiety from loss of control, uncertainty, and unpredictable postoperative stays in the ICU (Berg, Fleischer, Koller, & Neubert, 2006). Anxiety was found to contribute to postoperative conditions, such as delayed wound healing and an increased use of analgesics. Only 16% of patients indicated they were informed accurately and prepared for their postoperative hospitalization.

Relaxation techniques. Relaxation techniques can be offered to patients without a physician's order. Allowing the patient to express his or her feelings, and providing a quiet, serene setting, and a listening ear are strategies the nurse should use with the anxious patient. These techniques can assist the patient in tolerating anxiety and minimize escalating anxiety that can result from autonomic dyscontrol (Gorrol & Mulley, 2006).

Complementary and alternative therapies. Complementary and alternative medicine includes the use of massage, guided imagery, and music. These therapies evoke the relaxation response through stimulation of the parasympathetic nervous system, which is believed to decrease pain and anxiety. A recent study by Kshettry and colleagues (2006) found patients had a decreased heart rate, diastolic blood pressure, pretreatment and post-treatment pain, and tension scores as a result of complementary therapies such as touch and music.

Music can decrease anxiety and pain after surgery. Music intervention is used to change a specific behavior or feeling such as anxiety. Music therapy has positive physical and psychological effects prior to and after surgery. Music also has a positive effect on a patient's pain intensity and anxiety (Sendelbach et al., 2006).

Pharmacologic Treatment of Anxiety

Pharmacologic treatment of anxiety preoperatively and postoperatively may differ. Three classes of drugs are dispensed for anxiety: anxiolytics, antidepressants, and beta blockers. Although medications can help with anxiety, they carry risks of adverse effects, dependence, and withdrawal. For example, alprazolam (Xanax[R]) is an anxiolytic (benzodiazepine) commonly used for anxiety. A usual starting dose of alprazolam is 0.25-0.5 mg by mouth three times daily, increased as needed to a maximum daily dose of 4 mg. Dependence on the drug is possible, along with serious side effects, such as somnolence, confusion, lightheadedness, and dry mouth.

Another commonly used anxiolytic is buspirone (Buspar[R]). This drug is not related pharmacologically to alprazolam and does not appear to cause physical dependence. Buspirone is given initially in 5 mg doses three times daily, but dosing can be increased to as much as 20-30 mg daily; administration should not exceed 60 mg per day. This drug also can have side effects, such as lightheadedness, dizziness, and dry mouth. Prescribers must consider potential side effects compared to the potential harm of uncontrolled anxiety. Patients may need medications such as antidepressants that have a more long-term effect until they are able to resume their normal daily activities (DiPiro, 2003).

Loss of Control

Patients' loss of control over daily function can cause anxiety. In a recent study, patients who perceived they had more control had less anxiety; the patients who perceived they had less control developed higher levels of anxiety and experienced more complications (Moser et al., 2007). Patients' involvement in their treatment plans is important at all times but appears to be more significant when patients are dealing with open heart surgery due to the severity of the operation.

Conclusion

An estimated 7 million people underwent cardiovascular surgeries or other procedures in the United States in 2006 (American Heart Association, 2009). As this number continues to grow, nurses need to understand the impact of anxiety preoperatively and postoperatively. This anxiety can cause slower wound healing in patients, increased rate of infection, increased postoperative pain, and abnormal vital signs (Vaughn et al., 2007). As patients prepare for open heart surgery, they depend on health care professionals to explain the procedure and the perioperative expectations. If health care professionals consistently educate these patients, their anxiety will decrease and the postoperative recovery rate will improve.

References

American Heart Association. (2009). Heart disease and stroke statistics-2009 update. Dallas: Author.

Berg, A., Fleischer, S., Koller, M., & Neubert, T. (2006). Preoperative information for ICU patients to reduce anxiety during and after the ICU-stay: Protocol of a randomized controlled trial. BMC Nursing, 5(4). doi: 10.1186/1472-6955-5-4.

Braunwald, E., Fauci, A., Hauser, S., Jameson, J., Kasper, D., & Longo, D. (2005). Harrison's principles of internal medicine (16th ed.). New York: McGraw-Hill.

Cassem, N., Fricchione, G., Jellinek, M., Rosenbaum, J., & Stern, T. (2004). Massachusetts General Hospital handbook of general hospital psychiatry (5th ed.). Philadelphia: Mosby.

DiPiro, J., (2003). AHFS drug handbook (2nd ed.). Springhouse, PA: Lippincott Williams & Wilkins.

Fitzsimons, D., Parahoo, K., Richardson, S.G., & Stringer, M. (2003). Patient anxiety while on a waiting list for coronary artery bypass surgery: A qualitative and quantitative analysis. Heart & Lung, 32(1), 23-31.

Gallagher, R., & McKinley, S. (2007). Stressors and anxiety in patients undergoing coronary artery bypass surgery. American Journal of Critical Care, 16(3), 248-265.

Gorrol, A., & Mulley Jr., A. (2006). Primary care medicine office evaluation and management of adult patients (5th ed.). Philadelphia: Lippincott Williams & Wilkins.

Ivarsson, B., Larsson, S., & Sjoberg, T. (2004). Patients' experiences of support while waiting for cardiac surgery. A critical incident technique analysis. European Journal of Cardiovascular Nursing, 3, 183-191.

Kahn, S., & Smith, E. (2004). In a page: Signs and symptoms. Philadelphia : Lippincott Williams & Wilkins.

Karlsson, A., Johansson, M., & Lidell, E. (2005). Fragility-the price of renewed life. Patients experiences of open heart surgery. European Journal of Cardiovascular Nursing, 4, 290-297.

Kshettry, V., Carole, L., Henly, S., Sendelbach, S., & Kummer, B. (2006). Complementary alternative medical therapies for heart surgery patients: Feasibility, safety, and impact. The Society of Thoracic Surgeons, 81,201-206.

Ku, S., Ku, C., & Ma, F. (2002). Effects of phase I cardiac rehabilitation on anxiety of patients hospitalized for coronary artery bypass graft in Taiwan. Heart & Lung, 31(2), 133-140.

McCann, U., Fauerbach, J., & Thombs, B. (2005). Anxiety and cardiac disease. Primary Psychiatry, 12(3), 47-50.

Moser, D., Riegel, B., McKinley, S., Doering, L., An, K., & Sheahan, S. (2007). Impact of anxiety and perceived control on in-hospital complications after acute myocardial infarction. Psychosomatic Medicine, 69(1), 10-16.

Odman, M., (2008). Chronic subjective dizziness. Acta Oto-Laryngologica, 128(10), 1085-1088.

Scott, A. (2004). Managing anxiety in ICU patients: The role of preoperative information provision. Nursing in Critical Care, 9(2), 72-79.

Sendelbach, S., Halm, M., Doran, K., Miller, E., Hogan, E., & Gaillard, P. (2006). Effects of music therapy on physiological and psychological outcomes for patients undergoing cardiac surgery. Journal of Cardiovascular Nursing, 21(3), 194-200.

Smith, M., Kemp, G., Larson, H., Jaffe, J., & Segal, J. (2006). Anxiety attacks and disorders: Symptoms, types, and treatment. Retrieved October 1, 2007, from http://www.helpguide.org/mental/anxi ety_types_symptoms_treatment.htm

Tolmie, E., Lindsay, G., & Belcher, P. (2006). Coronary artery bypass graft operation: Patients' experience of health and well-being over time. European Journal of Cardiovascular Nursing, 5, 228-236.

Vaughn, E, Wichowski, H., & Bosworth, G. (2007). Does preoperative anxiety level predict postoperative pain? (Clinical report). AORN Journal Retrieved September 29, 2007, from http://www. encyclopedia.com/printable.aspx?id=1G1: 161011252

Joy Viars, MSN, NP-C, is a Nurse Practitioner, Bay Heart Group, Tampa, FL.
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Author:Viars, Joy
Publication:MedSurg Nursing
Article Type:Clinical report
Geographic Code:1USA
Date:Sep 1, 2009
Words:2472
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