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Palliative nursing care impact on anxiety outcomes in patients waiting for cardiac catheterization.

INTRODUCTION

Cardiac catheterization is an invasive diagnostic technique of cardiac disorder which presents important information about arterial coronary disease, congenital heart disease, vulvar disease and the function of cardiac ventricle. It is used to measure the pressure of inside the heart and the amount of oxygen in different chambers of the heart and cardiac output. In this method, cardiac cavities and the movement of cardiac walls would be seen through fluoroscopy of coronary arteries by injection of contrast [1].

By cardiac catheterization, it could be possible to evaluate heart and arteries position and to determine the area of arteries occlusion [2]. Cardiac catheterization has been done for about 2million patients in United States, and it is increasing with respect to being a valid and exact diagnostic method [3] in spite of being the most valid cardiac and arteries diagnostic test, cardiac catheterization can cause lots of patients' anxiety and fear [4]. To keep safe and save body and soul of the patients and to minimize the side effects before and after surgery are the main objectives of team of therapy in supervisions before invasive diagnostic methods, for anxiety would drastically affect the state and result of the method [5].

Anxiety as an effective factor on body health before surgery, not only would affect physiologic and endocrine reactions, but also should cause unpleasant results and severe side effects during diagnostic surgical operation and recovery stage after surgery [6]. Anxiety before and during diagnostic method can increase myocardial muscle need for oxygen and would cause ischemic pain.

As a result heart could endure more pressure which is effective on patients recovery and can cause lots of physiological side effects like increase in heart rate, respiratory rate and cardiac output which finally would lead to the failure of cardiac catheterization technique and consequently mistakes in patients' certain diagnosis [7].

Drug and non drug methods are used to treat anxiety. Common anti-anxiety drugs include Benzodiazepines, three cyclic anti depressant drugs, non Benzodiazepine anti-anxiety drugs (Baspiron), mono amino oxidase inhibitors, Carbamazepine, propranolol and hydroxyzine. Anti anxiety drugs have so many body physiological and psychological side effects; further more, there is the risk of addiction and drug dependency. Besides, there is drug side effects such as hypotension, weakening vital signs like breathing and heart rate, drowsiness, nausea, vomiting, constipation, sometimes allergic reactions, and even shock that increase threats during and after cardiac catheterization and also have varieties of body and soul side effects like dependence and resistance to drugs, and would impose high expenses to the country's health and treatment system [8].

In addition to drugs, there are lots of non drug methods to decrease anxiety of patients in need which are practical and useful, and do not have expense and side effects for users [5].

Prayers, massage therapy, exercise, cognition therapy, Benson muscle relaxation, meditation, music therapy, aromatherapy and guided imaging are among non drug treatments, which are used to tranquilize and relieve patients' anxiety.

Helping patients to use different kinds of relaxation techniques suitable and effective in is the important role of nurses [9]. Severe emphasis is on non drugs anti anxiety methods in recent years, for example, Benson muscle relaxation is the appropriate and economical method [8].

In fact, Benson muscle relaxation is an effective nondrug method to decrease anxiety level in patients awaiting invasive diagnostic surgeries like cardiac catheterization and it is one of the best methods of muscle relaxation. In this method there is no muscle stiffness because muscle contraction would lead to the increase of heart and breathing rate and cardiac load.

Benson muscle relaxation is very useful with easy instruction and no side effects for cardiac patients and they can use it independently.

This technique should be done in a quiet place, convenient position, mental concentration, by a positive attitude in order to have its real effect [10].

Hanifi et al study shows Benson muscle relaxation means severe decrease of body contraction in a physiological quality toward tension, it would lead to exterminate body and soul effects due to anxiety [11].

Regarding the previous studies conducted on high prevalence of anxiety in cardiac patients in general and those who are awaiting cardiac catheterization in particular, and with respect to unpleasant effects of anxiety on all body organs especially heart and arteries and also lots of side effects of anti anxiety drugs, drug resistance formation and reduction of drug's effect after a short while, and because Benson muscle relaxation is a non invasive and non drug treatment method suitable for reduction of anxiety level and amelioration of cardiac patients.

This study is carried out by the objective of defining to what extent Benson muscle relaxation would affect anxiety level in patients waiting cardiac catheterization.

Methodology:

This study is a two-group clinical trial whose sample includes patients waiting cardiac catheterization, admitted in post catheterization ward, CCU, medical cardiac wards of Tehran Imam Khomeini hospital from July to December 2008. The samples were selected by availability method, randomly divided into two groups of muscle relaxation (experimental) and control group. The two groups were matched in respect of age, sex, anxiety level one hour before cardiac catheterization.

Criteria of entering into the study include: the age between 18 to 60, having no hearing problem for listening to Benson muscle relaxation tape, using no tranquilizer and anti anxiety drugs during the research, having no known psychiatric disorder, first experience of cardiac catheterization technique, having no experience of performing similar courses of muscle relaxation, having no education in line with medical sciences or psychology, having no paralyze problem and understanding Persian language.

The sample size considering a=0.05, statistical coefficient of 80% is calculated 50 person in every group and with the expectation of possible mortality of samples is considered 70 person for each group. Data collection instrument in this research was questionnaire and visual analog scale (self reporting paper of anxiety level by patients).

To determine the validity of the questionnaire, the information report paper, content validity was used. In a way that after studying sources and related books with the topic of the research, data collection forms was provided and then needed amendments were done by the help of scientific sight of 10 nursing faculty members of the scientific board in Tehran Medical Science University.

A standard 10-point visual analogue scale was used for the first time in Iran by Imani pour in 2002 in a research as " a comparison on the effect of two methods of communication on anxiety level and satisfaction of coronary arterial bypass graft patients with intubation tube admitted in hospitals of Tehran Medical Sciences University", reliability coefficient of the instrument was calculated 85%. [12] This scale is also used in other researches [13].

To define the reliability of questionnaire and for data recording paper, test-re-test method and concurrent observation were used respectively.

Level of anxiety in this research refers to the point which patients under the study took from the 10-point visual analog scale of anxiety level before and after relaxation in Benson muscle relaxation group and one hour before and immediately before cardiac catheterization in control group, it is categorized in three level of low (0 to 3 points), middle (4 to 6 point), and severe (7 to 10 point).

Methodology was in a way that after getting permission from cardiologist, needed explanation was given to the patients, and then their satisfaction to attend in the research was taken. Patients were randomly divided into two groups of experimental and control. In Benson muscle relaxation group, the patient's anxiety level was measured and recorded one hour before cardiac catheterization by researcher. Further more this method was recorded in a tape and it was listened through a walk man and head-phone for 20 minutes.

Then the patients were asked to do the same as what the instruction in the Benson muscle relaxation tape says, so that the patient would lay in bed in the best relaxed position, closes his eye, and in this position chooses a comforter word (like: God, Love, Rain, Rainbow and the like).

Still then the patients start taking deep and regular breath. To inspirited with the nose and expiated with mouth, he should repeat the intended word in the mind, while relaxing muscles of tip toe. Indeed, the patient should do the same with upper muscles of the body until all muscles of the body reach to total expansion. After that, he would keep the position for 20 minutes then he would open his eye [11].

Immediately after doing Benson muscle relaxation, patients' level of anxiety would be measured and recorded again through visual analog scale (self-reporting paper). In control group, standard nursing cares and no other manipulations were done, one hour and immediately before the cardiac catheterization the patients' level of anxiety was measured and recorded. Relatives of the patients in two groups were next to them. Finally, data analysis was done by SPSS software and p<0.05 was statistically true. Statistical used tests include: K2, exact fisher test, wilcoxon, mann-witthny.

Result:

Findings suggest that most of the patients under investigation (88%) in Benson muscle relaxation group and (79.4%) in control group had the age range of 46-60. Males accounted for 66% of the experimental group receiving Benson muscle relaxation and 56% of the control group. Average of anxiety level of patients in experimental group one hour before cardiac catheterization was 6.32 [+ or -] 2.27, while it was 6.58 [+ or -] 2.18 in control group and mann-wittny statistical test did not show a relationship between two groups (p=0.3). So the two groups were matched in this point of view. (table1)

In Benson muscle relaxation group, the average of anxiety before manipulation was 6.32 [+ or -] 2.27, while the average of anxiety level after manipulation decreased to 3.96 [+ or -] 2.17 and based on the Wilcoxon test it was a relevant decrease (p<0.001). (Table 2)

In control group, level of anxiety immediately before cardiac catheterization (with the average of 9.14 [+ or -] 1.54) in contrast with their anxiety one hour before cardiac catheterization (with the average of 6.58 [+ or -] 2.1) had a remarkable increase, and based on the Wilcoxon test this increase was relevant (p<0.001). (table3).

As indicated in table 4, in contrast with the level of anxiety immediately before cardiac catheterization in two groups of experimental and control, based on the mann-wittny statistical test, there is a clear statistical difference between the anxiety of two groups (p<0.001), as anxiety in experimental group (with the average of 3.96 [+ or -] 2.17) in contrast with anxiety level of control group (with the average of 9.14 [+ or -] 1.54) had a remarkable decrease.

Discussion:

Results of the present study showed that muscle relaxation can decrease anxiety level of patients awaiting cardiac catheterization. This is considered as a glad tiding in using anti anxiety non-drugs nursing cares, and if patients like to use anti-anxiety methods, these non drug methods with low complications can be used in situations like waiting for diagnostic tests. As it was stated in findings, the average of anxiety level in the two groups of experimental and control was 6.32 with standard deviation of 2.27 and 6.58 with standard deviation of 2.18 respectively. This indicates high level of anxiety in all patients.

Lots of researches on this subject have been done in Iran and other countries, for example in Sherofi's research (2008) on "the effect of relaxation and music therapy on anxiety of patients admitted in cardiac care unit" have shown that the use of muscle relaxation would decrease anxiety of patients [14]. Moreover a remarkable statistical difference was observed between anxiety before and after manipulation (p<0.001).

In White and Van Dix hoom's (2005) research on the effect of using Benson muscle relaxation on rehabilitation and preventing cardiac Ischemic after muscle relaxation in experimental group. The result was reduction of resting heart rate, anxiety, depression, heart attack repetition, cardiac arrhythmia, cardiac ischemia, rate of death due to heart diseases and exercise tolerance improvement, increase of high density of lipoprotein, improvement in the extent of recovery and final result was that faster and better recovery of cardiac Ischemic which is an important aspect of cardiac rehabilitation which was received by muscle relaxation, but the results in control group were vice versa, verifying findings of the present study [10].

Also, Pour Memari's (1995) research on" the effect of applying Benson relaxation on anxiety and cardiac dysrhythmias of cardiac catheterization showed breathing rate increased in patients of control group in the second investigation [15].

In the study of Nikbakht Nasrabadi et al named as "a comparative study on the effect of Benson muscle relaxation technique and Zekr (rosary) on anxiety of patients awaiting abdominal surgeries, muscle relaxation should decrease anxiety of patients [6], so it would be concluded that muscle relaxation would decrease anxiety of patients awaiting cardiac catheterization and can be used for relaxation of patients in need.

Considering the results of the present study and confirming other studies, it is concluded that due to lack of non drug manipulation to remove or decrease anxiety in control group, anxiety level is rising, suggesting the importance of non drug and palliative nursing techniques to remove or decrease anxiety.

Besides, muscle relaxation is effective in reduction of anxiety level in patients specially patients awaiting cardiac catheterization. Nurses are important members of the team of therapy who have an important role in keeping safe and save body and soul of patients and one of their most important roles is to observe and investigate verbal and non verbal behavior of patients and to define their level of anxiety, as the most objective of therapy group is to preserve patients' health during and after surgeries and diagnostic techniques.

Conclusion:

It is hoped that methodology of this study with other methods of anti-anxiety treatments be used by nurses and doctors to control their patients' anxiety.

ACKNOWLEDGMENTS

We should express our sincere gratitude toward professors of Midwifery and Nursing Faculty in Tehran Medical Sciences University, nurses and people in charge in cardiac units of Tehran Emam Khomeini hospital and patients participated in the study.

REFERENCES

[1] Lewis, S., M. Heitkemper, S. Dirksen, 2004. Medical-surgical nursing. St. Louis: Mosby, pp: 770.

[2] Aramesh, K., 2001. [Translation of the most commons of Harrison's principles of international medicine] Harrison TR (Author). 1th ed. Tehran: Golban Publications, p: 135. (Persian).

[3] Aviles, R.J., A.W. Messerli, A.T. Askari, M.S. Penn, E.J. Topol, Introductory Guide to Cardiac

[4] Woods, S., E. Froelicher, S. Motzer, E. Bridge, 2005. Cardiac Nursing. 5th ed. Philadelphia: Lippincott Williams & Wilkins.

[5] Ilkhani, M., 2004. [Solacers]. 1th ed. Tehran: Golban Publications, p: 12. (Persian).

[6] McCaffrey, R., N. Taylor, 2005. Effective anxiety treatment prior to diagnostic cardiac catheterization. Holist Nurs Pract., 19(2): 70-3.

[7] Hanser, S., S.E. Mandel, 2005. The Effects of Music Therapy in Cardiac Health Care. Cardiology in Review., 13(1): 18-23.

[8] Twiss, E., J. Seaver, R. McCaffrey, 2006. The effect of music listening on older adults undergoing cardiovascular surgery. Nurs Crit Care., 11(5): 224-31.

[9] Morton, P.G., 2005. Critical care nursing: A holistic approach. 8th ed. Philadelphia: Lippincott Williams &Wilkins, p: 240.

[10] Van Dixhoorn, J., A. White, 2005. Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. Eur J Cardiovasc Prev Rehabil., 12(3): 193-202.

[11] Hanifi, N., F. Ahmadi, R. Memarian, M. Khani, 2005-2006 [Comparative study on two methods, Bensonrelaxation Vs premeditation, and their effect on respiratory rate and pulse rate of patients experiencing coronary angiography]. "Hayat" Journal of Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, 11(3-4): 47-54. (Persian).

[12] Imanipour, M., 2002. [Comparison of two methods of communication brmyzan anxiety and satisfaction with patients undergoing open heart surjery, tracheal tube admitted in Tehran University Medical Science hospitals]. MSc. Thesis, Health Faculty of Tehran University of Medical Science, (Persian).

[13] Valiee, S., 2008. [The effects of acupressure on the level of anxiety before surgery, abdominal Azamal]. MSc. Thesis, Health Faculty of Tehran University of Medical Science, (Persian).

[14] Shorofi, A., 1997. [The effect of relaxation and music therapy on anxiety of patients admitted in coronary care unit]. MSc. Thesis, Health Faculty of Iran University of Medical Science, (Persian).

[15] Pour Memary, M., 1995. [The effect of applying Benson relaxation on anxiety and cardiac dysrhitmies].MSc. Thesis, Health Faculty of Iran University of Medical Science, (Persian).

[16] Nikbakht Nasrabadi, A., T. Taghavi Larijani, M. Mahmoudi, F. Taghlili, 2005. [A comparative study of the effect of Benson's relaxation technique and Zekr (rosary) on the anxiety level of patients awaiting abdominal surgery]. "Hayat" Journal of Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, 10(23): 29-37. (Persian).

(1) Sima Hashemy, (2) Masoumeh Zakerimoghadam, (3) Leila Neisi

(1) MSc of nursing, Department of Nursing and Midwifery, Dezful Branch, Islamic Azad University Dezful, Iran.

(2) Medical and Surgical Nursing Department, Tehran University of Medical Sciences, Tehran, Iran

(3) Department of Nursing and Midwifery, Dezful Branch, Islamic Azad University Dezful, Iran (PhD student in Department of Health Services management, Collage of Management and Economics, Tehran Science and Research Branch, Islamic Azad University, Tehran, Iran)

ARTICLE INFO

Article history:

Received 26 December 2014

Received in revised form 26 January 2015

Accepted 20 February 2015

Available online 10 March 2015

Corresponding Author: Masoumeh Zakerimoghadam, Medical and Surgical Nursing Department, Tehran University of Medical Sciences, Tehran, Iran.
Table 1: Relative and absolute frequency of anxiety
level one hour before cardiac catheterization in two
groups of experimental and control in patients
awaiting cardiac catheterization admitted in Imam
Khomeini hospital in Tehran Medical Sciences University

Group                Muscle Relaxation  Control group
                     group

Level of anxiety     Number   Percent   Number   Percent

Low(1-3)             2        4         3        4.4
Moderate(4-6)        29       58        32       47.1
severe(7-10)         19       38        33       48.5
Total                50       100       68       100
Average              6.32               6.58
Standard deviation   2.27               2.18

Table 2: Relative and absolute frequency of anxiety level
before and after treatment in patients of experimental
group awaiting cardiac catheterization in Imam Khomeini
hospital in Tehran medical Sciences University

Time                 Before         After
                     manipulation   manipulation

Level of anxiety

Low(1-3)             2    4         27   54
Moderate(4-6)        29   58        14   28
severe(7-10)         19   38        9    18
Total                50   100       50   100
Average              6.32           3.96
Standard deviation   2.27           2.17

Table 3: Relative and absolute frequency of anxiety
level one hour before and immediately before cardiac
catheterization of patients in control group awaiting
cardiac catheterization in Imam Khomeini hospital in
Tehran Medical Sciences University

Time                 One hour          Immedbefore cardiac
                     before cardiac    catheterization
                     catheterization

Level of anxiety
Low (1-3)            3    4.4          2    2.9
Moderate (4-6)       32   47.1         6    8.8
severe (7-10)        33   48.5         60   88.2
Total                68   100          68   100
Average              6.58              9.14
Standard deviation   2.1               1.54

Table 4: Relative and absolute frequency of anxiety level
immediately before cardiac catheterization of patients
awaiting cardiac catheterization in two groups of
experimental and control in Imam Khomeini hospital
in Tehran Medical Sciences University

Group                Muscle             Control
                     Relaxation

Level of anxiety     Number   Percent   Number   Percent

Low (1-3)              27       54        2        2.9
Moderate (4-6)         14       28        6        8.8
severe (7-10)          9        18        60      88.2
Total                  50       100       68       100
Average               3.96               9.14
Standard deviation    2.17               1.54
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Author:Hashemy, Sima; Zakerimoghadam, Masoumeh; Neisi, Leila
Publication:Advances in Environmental Biology
Article Type:Report
Date:Mar 1, 2015
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