Guidelines during the preoperative period of cardiac surgery to elderly patients: integrative review

Carina Regina Schmitz^I; Patrícia Klock^II; José Luis Guedes dos Santos^III; Alacoque Lorenzini Erdmann^IV
INurse. Member of the Group for Studies and Research in Nursing Administration and Health at the Federal University of Santa Catarina. Florianópolis, Santa Catarina, Brazil. E-mail: schmitz_enfermagem@hotmail.com
^IINurse of Neonatal intensive Care Unit of University Hospital Deepak Ernani de São Thiago of the Federal University of Santa Catarina. PhD student of the Graduate Program in Nursing at the Federal University of Santa Catarina. Scholar of the National Council of Technology and Scientific Development. Florianópolis, Santa Catarina, Brazil. E-mail: patynurse@hotmail.com
^IIINurse. Doctorate in Nursing Graduate Program in Nursing at the Federal University of Santa Catarina. Member of the Group for Studies and Research in Nursing Administration and Health. Scholar of the Coordinator of Improvement of  Upper Level students. Florianópolis, Santa Catarina, Brazil. E-mail: joseenfermagem@gmail.com.
^IVNurse. Doctor in Philosophy of Nursing. Professor of the Department of Nursing and the Graduate Program in Nursing at the Federal University of Santa Catarina. Researcher 1A of the National Council of Technology and Scientific Development.Florianópolis, Santa Catarina, Brazil.  E-mail: alacoque@newsite.com.br

ABSTRACT: The research aimed to identify and analyze what the preoperative cardiac surgery guidelines provided to elderly patients and those who are professionals in the health team responsible for them. It is an integrative review of 13 studies located in electronic databases, from 2001 to 2010, from the keywords: health education, preoperative period, preoperative care, elderly, nursing. Some guidelines are carried out more frequently than others, such as: anesthesia, surgical environment, risks, postoperative care, discharge date, vital signs, allergy, trichotomy, bath, jewelry, dental prosthesis, intimate clothes, nail enamel, gastrointestinal preparation and fasting. The doctor is the main responsible for the professional guidelines. It was noted that there are differences in the preparation of patients, and it is necessary to reevaluate and strengthen the role of the nurse in this scenario, creating innovative and creative possibilities of care in preoperative period of heart surgeries for elderly patients.

Keywords: Preoperative Period; Elderly; Health Education; Nursing. 

INTRODUCTION

The last five decades of the 20^th century were marked by a series of changes in the health profile of the Brazilian population and worldwide. By mid-1950, the infectious diseases predominated, accounting for 40% of deaths. With the expansion of the notions of hygiene and of knowledge about the transmitters and the etiological agents, the infectious diseases went down, thus decreasing the mortality of younger people. Accordingly, the number of individuals aged 65 years and more has doubled in the last 30 years, from 7% to 14% of the world's population. Consequently, the older population is a group of potential candidates for cardiovascular diseases (CVD)^1,2.

This profile change is related not only increasing in population of adults and the elderly, but also to changes in habit of life. The so-called risk factors, such as consumption of cholesterol-rich, not moderate intake of alcohol, smoking and frequent stressful situations, are factors that contribute to the emergence and growth of CVD^1-3.

The CVD are characterized by change in the functioning of the circulatory system, consisted of the heart, veins, arteries, capillaries and blood vessels, such as: Angina, Atherosclerosis, myocardial infarction, among others. The diagnosis and treatment of CVD have brought huge technological and surgical advances, which is contributing to the increase in the survival rate and quality of life of patients with heart problems. Heart diseases that usually has surgical indication are: diseases of the aorta, congenital heart defects or valvular, heart transplantation and heart disease angioplasty serious without indication^2,3.

Because they are highly complex surgeries, elderly patients represent a challenge to the health team, mainly in relation to the guidance in the preoperative period, because this age group demands and characteristics when compared to other age groups, such as senile dementia and the fears/concerns that are related to myths and symbolism inherent in a heart surgery^2,3.

The guidance in the preoperative period to patients who will undergo the surgical process should aim at the clarification of questions and possible situations to be experienced. When the patient has knowledge of such events, it can minimize or avoid complications in the postoperative period of cardiac surgery, in addition to allowing the patient to be quieter and encouraged to accept the facts. The guidelines still allow scientific or psychological needs to be met, contributing to a rapid improvement after surgery⁴.

The team in charge of the surgical treatment of patients with CVD is multidisciplinary, which is generally composed by the nurse, physical therapist, doctor, nutritionist and social worker. The patient should be evaluated preoperatively by one or more team members, with the goal of producing the best cardiology and clinical assessment of patients with indication of cardiac surgery⁵.

At that time, the nurses, as being responsible for management of care in the preoperative period, occupy an important space with a view to improving the quality of care. Among its tasks, it is important the development of health education activities with the goal of reducing the deficit of knowledge about the procedure and provide bio psychosocial support to the patient that will be submitted to heart surgery, as well as to their family members^5,6.

In the preoperative period, the nurse should know the possible fears and doubts of the patient, so that the guidelines and care does not occur so rapidly in relation to the surgical procedure, explaining situations that the patient does not want to know and leaving aside what really is important to highlight. The guidelines shall be elaborated clearly and objectively using a context with quality and not quantity of information, so a moment of interaction, dialogue and clarification⁷. In this sense, the visit of preoperative nursing must enable the knowledge of heart patient to prepare a systematization of individualized nursing care, respecting the differences of each one. The guide is a way to support patients, to be present, giving answers so it can occur early improvement⁸.

Therefore, whereas the preparation of the elderly patient for heart surgery is crucial to make him aware of the benefits of their participation in the recovery process, promoting self-care, the research questions formulated for this study were: what is the preoperative cardiac surgery guidelines provided to elderly patients? Who are the professionals of the health team responsible for this information? What is the participation of nurses and nursing staff in the performance of those guidelines?

In this way, outlined objective of the present study to identify and analyze what the preoperative cardiac surgery guidelines are provided to elderly patients and who are the professionals of the health team.

METHODOLOGY

It is an integrative review of the literature, using the Ganong method of analysis⁹. This method proposes a structure that guides the way of identifying and understanding relevant issues and differences in a particular field of literature.

In this sense, the six steps were adopted to the Constitution of the Integrative Literature Review: choice and definition of the theme, objectives, identify keywords; definition of inclusion criteria of the study and sample selection; information extraction, representation of selected studies in table format, considering all the features in common; critical analysis of the findings, identifying differences and conflicts; interpretation of results; and clearly report of the evidence found⁹.

Initially, to carry out the research, it was consulted the health and science descriptors (DECS) of the National Library of Medicine and it was decided on using the following key words: health education; preoperative period; preoperative care; elderly; nursing, with publications in Portuguese, English and Spanish languages.

The search for literature occurred in the month of March 2010, in the databases of the Virtual Health Library (VHL), in which several references were contemplated. It has been accessed the database of Latin American Literature and Caribbean Science and Health (LILACS), Scientific Electronic Library Online (SciELO), International Health Science Literature (MEDLINE), Databases in Nursing (BDENF) and the collection of the Library of the Pan American Health Organization (PAHO) using the keywords selected.

The inclusion criteria for selecting publications were: national texts available online for free, written by nurses or with participation of these professionals, published in the period from 2001 to 2010, on the preoperative cardiac surgery guidelines made by the health team related to the elderly patient.

In LILACS, 2.331 references were found, of which 13 texts were selected, being that they are compatible with the criteria for inclusion. In MEDLINE, 3.737 references were found, and 244 were totaled in PAHO, of which none text was selected, as well as on SciELO and BDENF, because they are not compatible with the integrative review criteria adopted in the study.

So, in the final sample included 13 productions^4,10-21, which were organized and analyzed in accordance with: the type of publication; the journal was published; the year of publication; and, the subject. It should be noted that all the selected productions are cited in the text and listed in the references.

RESULTS AND DISCUSSION

The results and discussion are divided into three parts. Initially, the characterization of selected studies and then the two categories established from the analysis of the texts:

Main orientations held the elderly patients in cardiac surgery preoperative and team Health Professionals responsible for guidelines.

Characterization of examinated scientific production

In relation to the type of publication, were selected 11 scientific articles^{4,10,11,13-15,17-21}, a Monography of the Nursing Graduation¹⁶  presented to the Federal University of Santa Catarina and a Nursing Master Dissertation¹² defended at the Federal University of Paraná. Also, it was found that they were published in 10 different magazines of healthcare and nursing. Only the State Nursing Magazine had two articles published in the period. It is good to note that, in relation to 2010, productions were not found, as shown in Figure 1.

The production related to guidelines made the elderly patients in cardiac surgery preoperative intensified throughout the study. This increase may be related to the growth of the life expectancy of the population and increased demand of elderly people for care in health services, which made this age group being a focus of many researches in the area of health and nursing.

Guidelines performed preoperative elderly patients of cardiac surgery

The guidelines on the surgical process are of fundamental importance to the patient face critical situations more easily, thus promoting and maintaining health, providing that the patient to interact in their treatment. Health education may intervene in knowledge and behavior through education and, in such a way that the preoperative guidelines minimize anxiety, fear and even postoperative complications¹⁴.

In this sense, in one of the studies analyzed, the participants were asked about receiving guidance about the surgical process and 71.4% of them claimed to have them received. Of this total, 60% of the patients reported have been told that they would undergo a surgical procedure and were told about catheters, pain, walking, change of decubitus, on-call time in the hospital, healing, rehabilitation, benefits of positioning in bed, ostomy, fasting, risk of death and complications of the procedure¹⁴.

Research on the main nursing care in preoperative period showed that the guidelines received by patients were compared to the surgical procedure, anesthesia, surgical environment, risks, postoperative care and discharge date, even though patients interviewed were told about preanesthetic medications, vital signs, allergy, trichotomy, bath, jewelry, dental prosthesis, other types of prostheses as glasses, clothing, intimate clothing, nail enamel, gastrointestinal preparation, fasting and transportation. Fasting had more patient-oriented index in relation to the reason, followed by gastrointestinal preparation and removal of nail enamel. The care that received less guidance in relation to the reason were bathing, transportation, the use of established clothing by the hospital, removal of intimate clothing, trichotomy and jewels²⁰.

However, three studies mentioned some guidelines that are important, but patients did not report having received or which are often relegated to a second plan by health professionals: using of surgical clothes, risks related to surgery, type of anesthesia, mechanical ventilation, intubation, use of catheters, cardiac monitoring, respiratory exercises, pain and symptom of pre-anesthetic medication. In addition, it is important to provide opportunities for a moment so that patients can expose their feelings, doubts, anxieties and fears, because the patients are afraid of the pain, anesthesia, from getting disfigured or incapacitated; afraid to show fear and many more fantasies and, above all, the fear of dying^15,17,19,20.

The guidelines to the elderly patient preoperatively are of the utmost importance, not only in relation to surgery, but also for routine tests requested by medical staff, since the preoperative period is the best time for the nurse deepens and makes the emotional preparation for the surgery that will be provided to the customer. Patients should know about their surgery to accept the changes, even if they are necessary and temporary. For this to be possible, it is necessary to be communication between nurse and patient, once that communication is effective in the therapeutic process¹⁴.

Thus, the health team plays an important role not only in helping, but with regard to support to patients, through conversations and explanations, so they are by their side, guiding them and reassuring them about the sensations and feelings that might arise. For this communication to flow effectively, nurses must listen, speak when necessary, offer time for questions, be honest, show respect, provide sufficient time for the conversation and show interest, among other habilities²¹.  A simple line that can be performed by the nursing staff is to provide the patient a visit to the Intensive Care Unit in the preoperative period, promoting familiarity with the location and also helping when the nurse is guide how to care¹⁵.

In addition to verbal communication, health education during the preoperative period involves aspects related to nonverbal communication, namely, the need to enhance attitudes like gestures, handshake, or even the act of flashing eyes as a way to interact with the professionals after surgery. These communication possibilities can be passed on to the elderly patients as a way to communicate. From the preoperative health education it is also possible to avoid possible unrest as well as psychomotor assist in surgical patient cooperation, because patients with the health team agree more calm and collaborative, demonstrating knowledge of what they experience²⁰.  The importance of these activities to be extended to family members of elderly patients, because the health care of the elderly should be structured in such a way as to encourage family support and contribute to the improvement of psychological aspects²².

For the care of the elderly with heart disease, it is essential that nurses use their scientific expertise and techniques, both for the organic functions and emotional balance, and help to coping and acceptance as to his state of health. The same study brings an assessment of elderly patients on the current hospitalization in which they stated that all the professionals of the health team provided a service with empathy, dialogue, questions clarification, as well as link creation, but do not report on what they were told, because it tackles the issue of humanization in this age group¹⁸. In this way, the suggestions are the development of a permanent education program to the health team, in order to minimize possible gaps in the performance of functions by the elderly patient, in addition to conducting new searches for education of elderly patients¹⁴.

In this line of thought, it is scoring the need of practice of nursing staff and health in the daily life of care respecting the completeness, the characteristics of patients, their life histories, their values and beliefs, striving for quality of care with an emphasis on humanizing and reception^23,24. Such a perspective emphasizes the integrality of care be creatively liberating, and going beyond the biomedical model paradigm-centered assistance health care²⁵.

The need to clarify and develop the different aspects involving the elderly guidelines on their preoperative cardiac surgery is an important aspect which facilitates health education^7,17. It is believed that it is of utmost importance, with sights to achieve a more individualized health education, watch appropriately, according to the perception and expectation, directing the guidelines according to their particularities and their ability to assimilate the information^16,12.  The encouragement in this area, therefore is to strengthen the integrity and motivate the construction and development of new care practices, involving the scientific community to direct and check rigorous investigations.

Team health professionals responsible for guidelines

In three studies were found evidence on what are the key health professionals responsible for preoperative guidelines or working/participating more actively in this process.

In two of these studies, the doctor was highlighted^17,20. One of them, with the aim to characterize the nursing care provided to patients in preparation for elective surgeries in the immediate preoperative period in two hospitals, showed that preoperative guidelines were held in greater numbers by the medical professional, being that only 5,6% were held by nurses²¹. In another investigation, when patients were asked about the professionals that guided preoperatively, it was found that 75% of them received medical guidelines, and only 5% mentioned the receiving team nursing guidelines¹⁷.

Despite having been a few studies that sought to relate the preoperative guidelines received by elderly patients and given by the professional it can be questioned how important that is assigned by the nursing staff to preoperative care guidelines to patients with cardiac changes and how these professionals have carried out these guidelines, since doctors' guidelines are the most cited by patients. This may be associated with the doctor's status as a professional more qualified and possessed of knowledge and the discontinuity of nursing care provided to the patient, because not always the same nurses that guide the preoperative patients will accompany them during the postoperative period, which makes the memories of medical guidelines are stronger/important to the pacientes²⁶. In addition, the nursing staff may be in doubt about what exactly it should be made clear to the patient, because the medical staff is responsible for the patient and, a priori, any information to be passed to him will know of this charge, in order not to polemicize the situation between the team and the patient²⁷.

It is stressed that the development of health education activities with older people is of utmost importance, as it may contribute to the cost reduction with hospitalizations and drug therapies for this clients²⁸. Therefore, it is noted the need for nursing staff, especially nurses, to participate more actively in the preoperative patient guidelines that will perform heart surgeries, and, above all, prepare/qualify to provide information that is meaningful to patients and minimize their doubts and anxieties. As more the preoperative guidelines provided by the health team, the better the prognosis and faster will be the recovery of patients.

FINALS CONSIDERATIONS

From this study, it was showed that some guidelines are carried out more frequently than others, such as: anesthesia, surgical environment, risks, postoperative care, discharge date, vital signs, allergy, trichotomy, bathing, removal of objects (jewelry, dental prosthesis, intimate clothes and nail enamel), gastrointestinal preparation and fast. The doctor appears in studies as the main responsible for the professional guidelines.

Thus, these results indicate that there are differences in the preparation of patients, and it is necessary to reevaluate and strengthen the importance of the role of the nurse in this context, enabling innovative and creative possibilities of care in preoperative period of heart surgeries for elderly patients.

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