RELATION BETWEEN STRESSORS AND SOCIODEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF PATIENTS HOSPITALIZED AT A CORONARY UNIT

Estudo descritivo, realizado com objetivo de correlacionar os estressores dos pacientes internados em uma unidade coronariana com suas características sociodemográficas e clínicas. Foram entrevistados 43 indivíduos internados em um hospital de grande porte. Para a avaliação dos estressores, foi utilizada escala tipo Likert de 4 pontos que avaliou a intensidade do estresse para 42 possíveis estressores, variando de 1 (não estressante) a 4 (muito estressante). Foram coletados dados para a caracterização sociodemográfica, clínica e relativos à unidade coronariana. Para análise dos dados foi utilizada estatística não-paramétrica com os testes de MannWhitney e de Kruskal Wallis e teste de correlação de Spearman. O nível de significância adotado foi de 0,05. Constatou-se maior estresse entre os pacientes mais jovens, do sexo feminino, não medicados com psicoterápicos, com presença de mais de dois equipamentos e sem internação anterior nesse tipo de unidade de tratamento intensivo.


RELAÇÃO ENTRE ESTRESSORES E CARACTERÍSTICAS SÓCIO-DEMOGRÁFICAS E CLÍNICAS DE PACIENTES INTERNADOS EM UMA UNIDADE CORONARIANA
Other discomforts are caused by the continuous monitoring of vital signs and cardiac activity, the absence of any type of recreation for patients, and subsequent interventions by the medical and nursing teams (1) .
Stressors are defined as stimuli that precede or precipitate change, and are classified as internal or external.Responses to stress are influenced by the intensity, duration and environment of the stress, as well as by the number of stressors present at a specific moment (2) .It has been suspected for a long time that acute and chronic mental stress states constitute risk factors for higher morbidity and mortality levels due to cardiovascular diseases .
Care delivery to cardiac patients hospitalized at coronary units is aimed at detecting possible complications deriving from the clinical situation, reestablishing hemodynamics and favoring the patients' recovery.Understanding how patients feel can help nurses and their team to define stressors at the unit, thus stimulating the construction of protocols to turn the sector more adequate and pleasant (4) .
Due to their complexity, coronary units are considered intensive therapy centers.Various studies have investigated stress among patients hospitalized at these units (4)(5) .The importance of assessing stress during hospitalization, with a focus on patients with heart diseases, is based on all of the physiological alterations, mainly in the cardiovascular system, caused by stress.Thus, eliminating sources of stress means guaranteeing a better recovery for cardiac patients hospitalized at coronary units.
As no specific studies have been published to assess stress at coronary units, we based ourselves on existing literature about stress at intensive therapy centers.We found that the humanization of these units is closely linked with health professionals' action upon stressors (6) .Nursing care is the key point in hospitalization at these units, as it permits the establishment of relations that contribute to the relief of stressors for patients and their relatives (7) .
One important point some researchers have highlighted is the existing difference in how patients and nursing professionals perceive stressors (5,(8)(9) .
Nurses tend to classify stressors as more intense and consider the following as the main sources of stress: feeling pain, having tubes in the nose and/or mouth, being tied up by tubes, not receiving explanations about treatment and not managing to sleep (6,10) .
Patients, on the other hand, indicate the following as the most stressful factors: feeling pain, not managing to sleep, having tubes in the nose and/or mouth and not having control over oneself (6) .
Therefore, this study aimed to observe how stress experienced by people hospitalized at a coronary unit and these patients' sociodemographic and clinical variables, as well as aspects of their hospitalization at the CCU.The Intensive Care Stressors Scale (ICSS) (8,11) was applied for stress assessment, using the version translated and validated for Portuguese (5)   .

OBJECTIVES
The ICSS consists of 42 questions and its aim is to identify factors causing stress in patients hospitalized in intensive therapy units.This is a four-point Likert 53.5%), followed by angina (11; 25.6%).We included the use of psychotropic medication on the medical prescription, on the day the interview was held, because the use of these drugs could affect the patient's perception about the stress caused by hospitalization.Thirty-one patients (72.1%) had not received any psychotropic drug during the 24 hours before the interview.The location of beds at the CCU under study was considered a possible stressor, because it places patients in more unfavorable situations in terms of visualizing other patients and the bed's proximity to the door, so that patients have to tolerate more noise and luminosity.Figure 1 shows the placement of the  3 represents the results of these characteristics.At data collection, 19 participants (44.2%) had been hospitalized for two days, 18 for between three and five days (41.9%) and the other patients for more than six days (14.0%).Thirty-three (76.7%) mentioned this was the first time they were hospitalized at the CCU or at another intensive therapy unit.In our sample, an average of 2.3 equipments and devices had been installed in patients (SD = 0.7), ranging combination of analgesics and sedatives improves critical patients' stress response, which is in line with our study.
The experience of being hospitalized at an ICU, whether associated or not with the disease process or the specialized environment exerts an important impact on patients' recovery and rehabilitation (15) .As we agree with this statement and believe that the frequency at which patients live this experience could affect their stress perception, we correlated the existence of earlier hospitalizations in intensive therapy units with the stress referred during the present hospitalization.In the study sample, patients who were hospitalized for the first time reported more intense stress than other patients, although we did not find any study about this correlation in literature.
As to hospitalization at the CCU in itself, other researchers (16)(17)(18) describe that most patients hospitalized at intensive therapy units are confined to a bed, many of whom have received a tube or tracheotomy and need mechanical ventilation.Besides assisted ventilation, which was not present in our patients, this study highlights the presence of arterial punctures, central venous lines, urinary catheter, as well as breathing and circulation monitoring by electrodes.These factors can cause the feeling of being tied up, which often causes fear.Our results demonstrated that, in the study sample, the more equipment patients use, the higher the stress levels they feel.
We found that patients hospitalized in bed (1)   at the CCU (Figure 1) indicated higher stress scores than patient who were hospitalized in more favorable beds in terms of privacy, more distant from other patients' noise and less illuminated.However, these results were not statistically significant either.

CONCLUSIONS AND FINAL CONSIDERATIONS
Although the results go against our initial perception about the stressing experience of being hospitalized at an intensive therapy unit, we believe this result can be justified by the small number of participants.
Hospitalization at the CCU was more stressful for younger female patients who had not received psychotherapeutic drugs during the last 24 hours before the interview and who were hospitalized for the first time at an intensive therapy unit.
Although we did not find a statistically significant correlation between stress, patients' sociodemographic and clinical variables and the CCU environment, we have observed that these differences do exist and can become statistically significant when a larger sample is used.However, due to the importance of minimizing stress in cardiac patients hospitalized in coronary units, with a view to preventing complications and aggravating their clinical situation, we believe further research is needed.
Nurses active at a CCU can advise patients who are hospitalized for the first time in an intensive therapy environment, with a view to decreasing perceived stress.Another aspect of nursing actions could be to modify the environment, minimizing noise and luminosity at the beds.

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Correlate stress referred by patients hospitalized at the CCU with their sociodemographic and clinical characteristics; -Correlate stress referred by patients with variables related to the environment of the Coronary Care Unit.METHODOLOGY This descriptive, correlational and crosssectional study was carried out at the CCU of a teaching hospital located in the interior of São Paulo State, Brazil.During the study period, between May and September 2004, 171 patients were hospitalized at this unit.Only 99 of these complied with one of the inclusion criteria, i.e. hospitalization at the CCU for at least 48 hours.This criterion was stipulated to guarantee that patients could spend sufficient time at the unit to experience all aspects addressed by the stress assessment instrument.Of these 99 patients, three passed away, resulting in 96 potential participants.Then, we constituted a convenience sample with 43 patients who complied with the other inclusion criteria: age over 21; clinical (physical and psychological) conditions to be interviewed by the researchers and agreement to participate in the study.The project was approved by the Research Ethics Committee at the study hospital.The study participants were properly informed about the research, both orally and in writing.Both patients and researchers signed the informed consent term.Data were collected through individual interviews with patients during their hospitalization at the CCU.Although the researchers offered the possibility for patients to fill out the data collection instrument themselves, only four of them (10.7%)actually did this.Most of them did not manage to fill out the instrument due to physical (deficient sight) or cognitive difficulties (not knowing how to read and/or write), and were interviewed by one of the researchers.The data collection instrument addressed the following sociodemographic variables: gender (female or male); civil status (married or living with somebody, single, widowed, disunited/divorced); education (years at education institutions); professional situation (active, retired, retired with paid activities, at home, unemployed/temporarily suspended from work).Age was calculated by means of the patient's birth date and interview date.The following clinical data were collected from the patient's medical file: medical diagnosis(es) when hospitalized at the CCU and medication prescribed during the last 24 hours.Other relevant data included in data collection were: existence of previous hospitalization experience at an intensive therapy unit (yes or no) and number of previous hospitalizations, bed occupied at the CCU and presence of equipment/devices during hospitalization (oral/nasogastric catheter, urinary catheter, venipuncture, arterial puncture, respirator, oral/nasotracheal tube, heart monitor, intra-aortic balloon).

Figure 1 -
Figure 1 -Disposition of beds at CCU
stressors at the CCU, Mann-Whitney's non-parametric tests were used.For example: gender (male/female); use of psychotherapeutic medication (yes/no); first hospitalization at the CCU (yes/no); number of equipment used (until two, more than two).Kruskal Only seven (16.3%) patients possessed more than eight years of formal education, which can justify the small number of patients who filled out the instruments alone.

Table 2 .
The most frequent diagnosis at the moment of hospitalization was Acute Myocardial Infarction (23;

Table 2 -
Clinical characterization of participants.