ORIGINAL RESEARCH

Myocardial revascularization surgery: individual life changes and self-care

Claudia Regina Maldaner^I; Margrid Beuter^II; Nara Marilene Oliveira Girardon-Perlini^III; Eliane Raquel Rieth Benetti^IV; Macilene Regina Pauletto^V; Matheus Souza Silva^VI

^I Nurse. Master in Nursing. Federal University of Santa Maria, University Hospital of Santa Maria. Rio Grande do Sul, Brazil. E-mail: claumaldaner@yahoo.com.br
^II Nurse. PhD in Nursing. Associate Professor, Federal University of Santa Maria. Rio Grande do Sul, Brazil. E-mail: margridbeuter@gmail.com
^III Nurse. PhD in Nursing. Adjunct Professor, Federal University of Santa Maria. Rio Grande do Sul, Brazil. E-mail: nara.girardon@gmail.com
^IV Nurse. PhD student in Nursing. Federal University of Santa Maria, University Hospital. Rio Grande do Sul, Brazil. E-mail: elianeraquelr@yahoo.com.br
^V Nurse. Master in Nursing. Federal University of Santa Maria, University Hospital of Santa Maria. Rio Grande do Sul, Brazil. E-mail: macipauletto@gmail.com
^VI Nurse. University Hospital of Rio Grande. Rio Grande do Sul, Brazil. E-mail: matheus_souza_silva@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2018.23747

ABSTRACT

Objective: to examine changes brought about by myocardial revascularization surgery (coronary artery bypass graft, CABG) and self-care by revascularized individuals. Method: in this qualitative study of ten individuals post-CABG at a teaching hospital in southern Brazil, data were collected by narrative interview and submitted to thematic analysis. Results: analysis revealed the category "changes caused by CABG, and revascularized individuals self-care" with the subcategories "now I take care of myself"; "care as two-way process"; "care as imposition"; "valuing life"; "changed attitude in relationships"; and "closest relatives". Conclusion: after surgery, individuals begin to rethink their attitudes to themselves and other people, valuing their life, health and family. Material possessions and everyday problems become less relevant, and individuals endeavor to act in ways that bring pleasure and well-being.

Descriptors: Nursing; myocardial revascularization; nursing care; cardiology.

INTRODUCTION

Coronary artery bypass grafting (CABG) has modified the survival of patients with significant reduction of morbidity and mortality after cardiovascular events¹. This surgery aims to reestablish perfusion of the coronary arteries and relieve anginal symptoms, with improvement of the quality of life of the re-vascularized individual ².

Both cardiovascular events and heart surgery interfere with the individual's way of life, since it is necessary to restructure the lifestyle, which demands coping strategies^3-4. Among the changes, there is a need for change of habits, withdrawal from work, health care and the continuous use of medications. In this sense, cardiac surgery determines new perceptions about life and way of life. This adaptation depends on individual characteristics, support networks and associated comorbidities. In this way, the surgical experience may be transformative for some, have little influence for others, and each one's way of coping determines the performance of self care.

Faced with the demands of care in the postoperative period, it is important that health professionals, especially nurses, know the changes that occur in the life of these individuals and the implications for self-care. The nurse can assist individuals in coping with the pathology and in the surgical process of CABG, because this professional is responsible for planning and organizing the care and for ensuring that the nursing team takes an individual and comprehensive approach⁵. Since nursing represents one of the links between the patient, the environment and the family, it is possible to qualify the care, both assistance care and health education, by providing guidance for self-care to individuals submitted to CABG.

In view of these aspects, the objective was to analyze the changes caused by the CABG and the self-care of re-vascularized individuals.

THEORETICAL FRAMEWORK

For Foucault, self-care is defined as an attitude toward oneself, towards others and towards the world, and it comprises the set of conditions of spirituality, transformations of oneself that constitute a condition for access to the truth⁶. The author emphasizes that the general rule of self-care is to take care of oneself, not to forget about oneself and to be careful with oneself.

In this study, self-care is set in the perspective of the re-vascularized subjects' autonomy. Autonomy is understood as something inherent to the human being or capable of being developed throughout life and it is important to overcome the daily difficulties in the recovery process. Caring for oneself is perceived as an attitude developed in all life situations, according to the subsjects' living conditions at each moment. In this sense, nursing can be present, using health education to guide individuals submitted to CABG in the performance of self-care.

METHODOLOGY

This is a qualitative and descriptive study carried out with 10 patients submitted to CABG attended at a university hospital in Rio Grande do Sul. Inclusion criteria were individuals who had undergone CABG, with a maximum of 120 postoperative days, enrolled at the outpatient clinic for cardiac surgery in the data collection period and who presented themselves lucid, oriented and able to express themselves verbally.

In order to select the participants, the consultation schedule was accessed, and those who met the inclusion criteria were identified in the records and invited to participate in the survey through telephone contact. The data were obtained from January to April 2013, through a narrative interview, which is characterized by participants' remembrance of what happened. These patients sequenced their experiences and were able to incorporate meaning and intentionality into their acts, relationships and social structures⁷.

The participants were informed about the research and signed the Informed Consent Form. The interviews were held in a private room, at a convenient time for the participant, and were recorded and later transcribed in full. The interviews were coded by the letter "P" from participant followed by the sequential number of the interviewees (Ex: P1, P2, P3), to ensure anonymity.

The content of the interviews was analyzed through the thematic analysis ⁸, characterized by two levels of interpretation: the fundamental determinations of the research, which observes the sociohistorical context of the social group in question; and the interpretative level, which represents the encounter with the empirical facts and seeks, in the informers' report, the meaning, the internal logic, the projections and interpretations⁸. The interpretative phase was divided into ordering and classification of the data⁷, giving rise to a category with six subcategories, analyzed in the next section.

The ethical principles of Resolution 466/2012 were respected and the study was approved by the Ethics Committee under no. 10993912.6.0000.5346.

RESULTS AND DISCUSSION

Seven men and three women, aged between 45 and 58 years, participated in the study. In relation to marital status, six were married, two divorced, one single and one widower. Six of the participants had children. As to the origin, six lived in the city of data collection. All participants were withdrawn from their work activities, four of them were retirees, three were receiving sick pay, two were carrying out household activities and one reported himself as unemployed.

From the analysis of the interviews, a thematic category emerged, namely Changes brought about by the CABG and the care of oneself of re-vascularized individuals, with the following subcategories: Now I take care of myself; The two-way process of care; Imposition of care; Valuing life; Change of attitude in relationships; and, The family becoming closer.

Now I take care of myself

After occurrence of a cardiovascular event and the need for CABG, self-care becomes a priority for the participants, since they have undergone life-threatening situations.

The speeches revealed that the shock, as they refer to the CABG, made them realize the need to take care of themselves. Before this event, they did not place themselves as the center of their lives, for they were more concerned with others than with themselves. In this sense, Foucault states that "you must attend to yourself, you must not forget yourself, you must take care of yourself"^6:6. Caring for oneself implies worrying about oneself, being an active and effective agent of one's own care.

It is also expressed the desire to recover and maintain health with the purpose of changing attitudes, employing self-care as a strategy.

Similar results indicate that experiencing a situation, such as cardiac surgery, brings significant changes to the lives of patients, ranging from physical to biopsychosocial transformations, which require the establishment of new habits of life⁹. In this sense, health professionals play an essential role in guiding and raising awareness of re-vascularized patients on aspects related to diet, physical exercise and lifestyle, in order to assist them in the changes necessary for a healthy life¹⁰. In addition, nurses can help patients by proposing spaces to exchange ideas, share experiences, minimize anguish, guide them for self-care and encourage them to rethink and acquire new behaviors.

The two-way process of care

Participants recognize and value the care received from professionals and others, but understand that the main attitude depends on them.

In the post-operative period of the CABG, the individuals perceive themselves as protagonists of care and they must be prepared for this. Nurses have a crucial role in guiding, encouraging autonomy and establishing care strategies. An individualized approach is recommended, in which nurses employ knowledge and skills to improve the quality of care and to obtain satisfactory results in the self-care of individuals¹¹.

The study participants understand that care cannot be unilateral and have stated that, in addition to other people's actions, the decision and commitment to care for oneself has to come from them.

Health professionals are perceived as someone who trusts patients' ability to care for themselves and, therefore, invest guidelines and expectations. Thus, when nurses demonstrate empathy in actions, they favor the verbalization of concerns, the construction of a care based on the individual needs and expands adherence to the treatment. In this way, teaching, guidance and education actions that aim at maintaining the life process and functioning of the human being encourage the protagonism of care^10,12.

In addition, when the guidelines are specific and based on the characteristics of a given population, it reduces the barriers of empirical and impersonal orientation, strengthens the focus on interesting patient-family strategies and increases safety, practicality and confidence in the performance of care¹².

Imposition of care

Participants reported that, at times, the care of family members was perceived as excessive and imposing, and that some activities could be carried out without assistance.

After the CABG, participants feel overprotected and report a reversal of roles. They point out that the relatives, in the attempt to help, at times exaggerate the care, which implies in the reduction of one's autonomy. In this sense, it is known that, with illness, a collective process of suffering emerges in which the family and individual suffer to deal with the problem and bilaterally share fears, uncertainties and concerns¹³.

In addition, the family component assumes importance as support, from diagnosis to coping with changes in the new life context¹⁴. Thus, it is important that professionals understand how the individual in the post-CABG period deals with the surgical process and with the return to the family environment, in order to favor the approach of those involved, stimulating care, but mainly the autonomy and independence of individuals.

Some re-vascularized individuals maintained an attitude of obedience to family members, while others became dissatisfied and took action to maintain autonomy for tasks they felt apt.

This manifestation corroborates with study results when affirming that, despite care and family cooperation to promote patient recovery, stressful situations can cause emotional, social and family interaction losses, especially due to changes in lifestyle¹⁵. For this reason, it is crucial that individuals acquire autonomy and gradually begin to perform daily life tasks, seeking continuity, although some trajectories need to be thought and resignified⁴. In view of this, it is necessary that health professionals provide guidance to the family members about the importance of the re-vascularized individual's autonomy, providing care for themselves and shared care.

Valuing life

Being submitted to the CABG signals that life is finite. This perception implies a greater appreciation of life after surgery.

Participants revealed their intention to change life habits, abandon addictions and overcome stressful factors from the daily routine. This willingness is in line with a research that evidenced the desire expressed by patients to take advantage of the good things life can offer and to perform others they had not yet given themselves the time to do after CABG⁹.

When realizing that the continuity of life can be threatened, and that to preserve it he needs to change habits, a participant demonstrates desire to take care of himself, to rethink some behaviors that can be harmful and to take advantage of the good things of life.

I know something unforeseen can happen. I have that awareness that I am no longer 'superman' as I thought I was; that it was not a silly thing that was going to take me away. It was these silly things that almost took me away. I did it myself, with unbalanced food, not taking care of me. That anxiety, anguish, it changed completely. There's a [Brazilian] song that says, 'I've been slow now because I used to be in a hurry...' (P10)

These actions include the desire to be close to the family, change in lifestyle, such as changes in smoking habits, stress management, diet, physical exercise and correct use of medication. This result corroborates that, in addition to visualizing changes, individuals also seek to re-signify their lives⁴. These data point to a rethinking of values and posture in relation to material goods, which became secondary after CABG.

Self-care seems to become a priority when reflection on the meaning of life and the values that must be preserved overlaps with the value attributed to material goods. Foucault points out that "you must not forget yourself" ^6:7. In this aspect, health professionals can reinforce the motivation manifested by individuals to take care of themselves and enjoy the good things in life. This will certainly imply a better quality of life and adherence to treatment.

Change of attitude in relationships

After CABG, individuals have changed their relationship with people and with everyday problems; they tried not to get stressed with small things and perceived themselves more loving.

The experience of CABG helped individuals to better understand and accept others and themselves, a result that corroborates that of a study that identified the expectations of re-vascularized patients at discharge⁴. This is also part of self-care, the quest to become better as a human being and as a citizen. This new conception of life points that individuals perceived the improvement in the relationship with the family after CABG, and demonstrated the desire to enjoy the day with them. In addition, they are more open, in the sense of seeking the recovery of bonds of affection, love, support and solidarity.

However, harmony in relationships is not a rule, because in opposition to this result, studies have verified the separation of the re-vascularized individual from family life, from children, grandchildren, friends, social gatherings and fraternizations¹⁶. Illness can interfere with leisure and social integration, hinder interactions between family members and with the social network¹⁷. Professionals should pay attention to these issues, stimulate the exercise of self-care of these individuals, so that they feel important when interacting with their social network, seeking leisure activities that provide satisfaction and pleasure.

The family becoming closer

The care received from family members was perceived as positive and associated with love, affection, companionship and closeness.

After the CABG, the participants perceived their relatives more caring and kind with them. Convergent results indicate that the family is seen as the most important source of support¹⁸. In this context, they point out that it is in difficult moments that they discover who is really important in life.

The cardiac event has an impact on the marital relationships and the stress caused by the disease can strengthen the bonds between the spouses and relatives. It was found that the families strengthened their ties after the CABG and that family members tried to stay close. Thus, family relationships interfere positively in the quality of life of patients undergoing CABG, mainly in the psychological aspect¹⁹. This reveals that the nurse, in addition to establishing strategies to encourage self-care, can help patient and family members to strengthen the bonds.

It should be emphasized that the nursing team has the knowledge, ability and communication skills and understanding to provide these guidelines, and that the nurse is a fundamental link in the search for actions aimed at comprehensive care²⁰. For this purpose, it is important to know the changes faced by re-vascularized individuals to understand the human actions and reactions, considering the factors that can interfere in the care of themselves.

CONCLUSION

After the CABG, there were changes in the lives of the individuals that made them rethink their attitudes with themselves and with other people. The perception of finitude allowed a different look at their lives, which triggered the desire to take care of themselves for health maintenance. The re-vascularized individuals perceived themselves as care protagonists, supported by the partnership with the health professionals; however, they pointed out the imposition of care sometimes submitted by their relatives, which impedes their freedom of choice and the performance of the care for themselves.

The results indicate a greater valuation of life after CABG, when compared to the problems of everyday life and material goods. In addition, it has improved relationships and the desire to live closer to the people with whom they have affinity, friendship and affection. Self-care manifests itself when they understand that they need to take an active and autonomous posture in all situations of their life, taking ownership of themselves and their care, taking on actions that bring them pleasure and well-being.

In view of these results, the importance of health professionals to know the changes in the lives of re-vascularized individuals is emphasized, so that they can help patients overcome their doubts, conflicts and fears. The nurse can promote discussion groups and also, in nursing consultations, encourage that these changes of attitude do not fade with the passing of the days and that the care of themselves is exercised with confidence, responsibility and autonomy.

The present study has as limitations the number of re-vascularized individuals and the time interval since the accomplishment of CABG; however, these findings are considered relevant for nursing care after this type of surgery and to increase nursing knowledge in this area.

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