Nursing Consultation Protocol for Patients After Myocardial Revascularization: Influence on Anxiety and Depression

Francisca Elisângela Teixeira Lima Universidade Federal do Ceará Rua Alexandre Baraúna, 1115 Bairro: Rodolfo Teófilo CEP: 60430-160 Fortaleza, CE, Brasil E-mail: felisangela@yahoo.com.br 1 Trabalho extraído da tese de doutorado “Protocolo de consultas de enfermagem ao paciente após a revascularização do miocárdio: avaliação da eficácia” apresentada a Faculdade de Farmácia, Odontologia e Enfermagem da Universidade Federal do Ceará, CE, Brasil. Projeto CNPq No 306149/2006-0. 2 Enfermeira, Doutor em Enfermagem, Professor Adjunto, Faculdade de Farmácia, Odontologia e Enfermagem, Universidade Federal do Ceará, CE, Brasil. E-mail: felisangela@yahoo.com.br. 3 Enfermeira, Doutor em Enfermagem, Professor Assistente, Faculdade de Farmácia, Odontologia e Enfermagem, Universidade Federal do Ceará, CE, Brasil. E-mail: thelmaaraujo2003@yahoo.com.br. 4 Enfermeira, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, CE, Brasil. Mestranda, Faculdade de Medicina, Universidade Federal do Ceará, CE, Brasil. E-mail: edilmacasimiro@yahoo.com.br. 5 Enfermeira, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, CE, Brasil. E-mail: iresl.custodio@gmail.com. O objetivo foi verificar a influência do protocolo de consultas de enfermagem nos aspectos relacionados à ansiedade e à depressão em pacientes após revascularização miocárdica, utilizando a escala de HAD (Hospital Ansiety and Depression). Ensaio clínico, randomizado, desenvolvido no ambulatório de um hospital público, Fortaleza, CE. Compôs a população 146 pacientes nos quais foi realizada revascularização miocárdica, constituindo a amostra 39 pacientes do grupo controle (GC) e 39 do grupo de intervenção (GI). Os resultados foram apresentados em tabelas. A ansiedade teve média no GC de 5,41 e mediana de 5 e, no GI, teve média de 5,21 e mediana de 4. A depressão predominou no GC, com média 4,82 e mediana de 4, enquanto o GI teve média de 3,79 e mediana de 3. Constatou-se que as pessoas acompanhadas de acordo com o protocolo de consultas de enfermagem tiveram menor percentual de ansiedade e depressão, após seis meses de acompanhamento.


Introduction
Among the studies developed in the area of health, an interest can be observed in chronic diseases, defined as health problems with symptoms or associated disabilities that require long-term treatment.
By contributing significantly, as a causal group, to the rate of mortality in all regions of Brazil, cardiovascular diseases stand out among the chronic disorders.
Furthermore, they constitute one of the principle causes of prolonged hospital stay and are responsible for the allocation of public resources in hospitalizations in Brazil.The economic burden of cardiovascular diseases has grown exponentially in recent decades (1) .
Based on these considerations, the necessity to develop strategies to increase the practice of self-care was perceived in order to control risk factors, minimize cardiovascular complications after surgery and to promote improved quality of life of patients.Among the work strategies, the nursing consultation was chosen, due to Lima FET, Araújo TL, Serafim ECG, Custódio IL.
it being an effective strategy for early detection of health disorders and for monitoring the imposed measures, which address the welfare of the people involved.It is an action that is distinguished among the various ways to care because it enables the person to person approach, establishing the interpersonal relationship of concrete help in the face of cultural variables (2) .
After myocardial revascularization surgery, the patient must go through the rehabilitation process, which is dynamic, health-oriented and able to help them achieve the highest possible level of physical, mental, spiritual and emotional health.The rehabilitation process helps the person achieve an acceptable quality of life with dignity, self-esteem and independence (3) .
Among the most common emotional disorders following heart surgery, anxiety and depression are prominent.For their assessment, it is important that health professionals use a validated scale such as the Hospital Anxiety and Depression Scale (HAD) which evaluates the changes as separate constructs.This is a simple tool, but with the power to reveal cases of mood disorders that could go unnoticed by the treatment team (4) .Given these considerations, the goal of this study was to verify the influence of the nursing consultation protocol in aspects related to anxiety and depression, six months after myocardial revascularization surgery, using the HAD scale and comparing to a control group.

Materials and Methods
The study was a randomized clinical trial, developed in the outpatient clinic of a public hospital, a reference in Cardiology, located in the city of Fortaleza, CE.In this study, for a period of six months, a nursing consultation protocol was applied to people who had undergone myocardial revascularization surgery (MR), for further observation of its effects in relation to another group of patients, who also underwent MR without being accompanied by the protocol.
Adult and elderly patients of both sexes who met the following inclusion criteria participated in the study: to be the first myocardial revascularization surgery, regardless of the type and number of grafts (saphenous vein or mammary), to perform the surgery in the period of data collection in the above-mentioned hospital and to consent to participate in the proposed follow-up by the nurse during the rehabilitation period.
And as exclusion criteria: to undergo other surgery concomitant to the MR, to have gone through another surgical procedure in the first month after surgery and to live outside the metropolitan area of Fortaleza, since the movement of patients resident in other cities or other states is very expensive.
It was also necessary to define the criteria for discontinuation in the study, which were: to die during the monitoring period, to change residence from the metropolitan area of Fortaleza to another city, to decide not to continue participating in the study, to acquire a disability that prevented attendance of the consultations at the outpatient clinic, or to not attend two consecutive visits.
During the period of data  real needs of the patient.The main goals were: to gain the confidence and trust of the patient, to raise nursing problems, to evaluate the physical and psychological conditions of the patient, to explain about the surgery and related questions, to raise awareness about the ongoing therapy and to solve or minimize changes in health.
On the day of the last visit, in addition to the evaluation carried out by the researcher, all patients were referred to a nurse of the institution for further evaluation using the Hospital Anxiety and Depression (HAD) scale.The evaluation of the clinical nurse was carried out with all patients (IG and CG), without her knowing to which group the patient belonged, thus avoiding biased results.
As mentioned, the HAD scale was used, which contains two subscales: One for anxiety and the other for depression.This scale has seven multiple-choice questions for each subscale, each question containing four items with values 0 (zero), 1 (one), 2 (two) and 3 (three), zero being the best score and the three worst.
The use of this instrument was chosen for the following reasons: it is intended to detect mild degrees of affective disorders in a non-psychiatric environment, it is short and can be completed quickly, it evaluates anxiety and depression separately, and when validated in Brazil, it was found that in clinical practice, the use of HAD could assist in the detection of cases of mood disorders that require treatment (4) .
The results were analyzed descriptively and presented using tables.

Characterization indicators
By comparing the two study groups in relation to

Indicators of aspects relative to anxiety and depression, according to the HAD scale
Because the HAD scale addresses anxiety and depression as different issues alternately, both were analyzed separately.Initially, the average number of patients who felt anxiety after six months of surgery was determined.
Anxiety was assessed at the end of the study and had a mean in the CG of 5.41 and a median of 5, while the IG had a mean of 5.21 and a median of 4. between the CG and IG was found, after six months of monitoring.
Considering the data in Table 1, although no significant difference was found between the groups, there was a predominance in all indicators of anxiety for people in the CG.
In relation to the presence of depression after six months of surgery, the mean of patients that presented depression was also established and, subsequently, each indicator was examined individually.
According to the analysis, indicators of depression were more present in the CG, with a mean of 4.82 and standard deviation of 4.62, while the IG had a mean of 3.79 and standard deviation of 3.06.It was found that the people monitored according to the nursing consultation protocol had a lower percentage of depression after six months of monitoring.However, there was no significant difference (p>0.05) between groups.Nevertheless, according to the findings, the group monitored with a greater frequency (IG) showed lower rates of depression.

Discussion
The evaluation of anxiety and depression was carried out at just one moment, that is, six months after hospital discharge, with the application of the HAD scale by a clinical nurse.As previously discussed, the results of the indicators of anxiety showed no significant difference between the two groups, however, in the analysis of depression, one indicator showed a significant difference, looking forward with enjoyment to things, and there was a higher percentage of people of the CG having a decreased interest in personal appearance.
No studies were found on the implementation of the HAD scale in revascularized patients, after six months of discharge.However, in a transversal study of psychiatric evaluation a 39% prevalence of mood disorders (20.5% of "cases" of anxiety and 33% of "cases" of depression) was found among 78 patients from a medical clinical ward after 48-72h of hospitalization In a study conducted in São Paulo, 17% of heart operation patients had some psychological disorder that persisted with varying intensity until one year after surgery, where changes were: memory deficit, difficulties in problem solving, attention and concentration deficit, delirium, crying spells, insomnia, depression, behavioral disorders and intellectual changes (5) .
Another study noted that hospital discharge often cause much anxiety, since it involves doubts, for both the patient and the family.The individual is in the process in which they are leaving a place where they were offered assistance by trained professionals, to return home, the place where a family member will have to develop the role of caregiver (6) .
Given this reality, nurses and other health professionals because what is being carried out is not sufficient for the elimination of the fraction of potentially preventable disease.If preventive measures were adopted more vigorously, the epidemiology of cardiovascular diseases could be drastically modified in the next fifty years (7) .
The nurse must, however, also establish strategies to help the patient and the family to set realistic and attainable goals for the individual and the family at each different moment, stimulating them in the continuation of the effort to seek and achieve new goals that are being established, each at their own time (6) .
The inclusion of the family in the care is based on a study conducted in the city of Goiânia, GO, with people who had experienced myocardial revascularization surgery, in which it was observed that the family was an important source of emotional and social support, and contributed to the confrontation of both, problems related to the health process and illness, as well as other social problems that involve the quotidian life of these people (8) .
Moreover, it is necessary that health professionals support the patient and family, which requires the involvement and commitment of the professionals with the subjects and their needs.
It is therefore necessary to promote the support and to construct bonds with the assisted individuals, because, as is understood, it is not possible to accommodate the health needs of people, listening to and understanding them, without making compromises (9) .
A warning is important here: periodic attendance of medical consultations for patients with cardiovascular with an average total of 204.3 minutes/patient over six months (10) .In accordance with the norm, the cost of one hour of nursing time is R$15.00,i.e. the total cost per patient during this period is R$51.08.Therefore, this cost is negligible and can not constitute an impediment to the nurses' performance in the implementation of the nursing consultation protocol.
Finally, in recent years, strong emphasis has been placed on the identification of treatments that may produce an impact on morbidity and mortality in ischemic cardiopathy.However, the scientific evidence has not been translated into clinical practice in many institutions (11) .

Conclusions
As evidenced using the HAD scale, the nursing consultation protocol influenced the control and/or reduction of aspects related to anxiety and depression.
As verified, the IG had a lower percentage of people with anxiety and/or depression, after six months of monitoring, than the CG, and, although there was no significant difference between the groups, the control group had a higher prevalence of indicators of anxiety and depression in its patients.
whereby, in addition to the researcher's evaluation, on the day before or the day of hospital discharge, they also received guidance on self-care activities for the recovery of health and the prevention of complications, emphasizing the need to maintain a healthy lifestyle.The subsequent consultations were implemented by the researcher at one, two, four and six months.After hospital discharge, patients in the IG were monitored by doctors of the institution in the same way as those of the CG.In the nursing consultation protocol for patients after myocardial revascularization surgery, there are targets and interventions that should be met, conforming to the Rev. Latino-Am.Enfermagem 2010 May-Jun; 18(3): 331-8.
who care for individuals after myocardial revascularization should be alert to the features of mood change, among them anxiety and depression.The evaluation of these factors could contribute to the detection of individuals with more rehabilitation difficulties, because anxiety and depression may reflect feelings of inability to change and maintain behaviors conducive to cardiovascular health, such as: adoption of a healthy diet, practicing physical exercise and cessation of smoking.The Ministry of Health has adopted various initiatives to reduce the impact of non-transmissible diseases in the Brazilian population, especially cardiovascular diseases.However, it emphasizes the need to develop permanent and continuing strategies for the entire population, intervention, such as myocardial revascularization, is vital for the evaluation of health status, especially of heart function, and for them to receive their prescriptions.Likewise, monitoring is essential in nursing consultations, focusing on the orientation and supervision of drug and non-drug treatment, such as control of the changes in lifestyle by encouraging the practice of self care.All this can be facilitated with the implementation of the nursing consultation protocol.Regarding the cost of this, although the actual amount spent on its realization has not been calculated, the average cost was low compared with the benefits gained.In one study, in which the cost was measured by time spent by the nurse on orientation on reducing risk factors, it was found that the time used to orient patients who underwent nursing interventions varied from 80 to 240 minutes,

From
these results, the importance of the nursing consultation to the patient that underwent myocardial revascularization was noted.It is believed that satisfactory results were only possible because of the use of the nursing consultation protocol, which made possible a systematic evaluation of the patient, raising their real problems for the planning and implementation of nursing interventions, establishing priorities in the adoption of measures, principally those that involve changes in behavior, habits and lifestyle, understanding the patient in a holistic manner, in the physical, social, spiritual and emotional dimensions.Moreover, aiming at greater efficacy, it is recommended that evaluations be repeated periodically and successively, allowing a precise comparison of the patient's progress, determining if there was progress or regression.This individualized approach, through nursing consultation, for the care of the patient, requires of the nurses the employment of their time, knowledge, expertise and planning to improve the quality of care and obtain satisfactory results in the maintenance or restoration of the health of the patient.Despite the satisfaction obtained from the results, it is considered appropriate to conduct further studies with a larger sample and with more control over the variables, thus, providing a more consistent experimental basis to the current study, promoting the standardization of nursing care to this group of clients in the control of anxiety and depression.

Table 1 -
Distribution of participants in the intervention and control groups, according to the questions of the HAD scale that assess anxiety.Fortaleza,CE, 2006Lima FET, Araújo TL, Serafim ECG, Custódio IL.

Table 2 -
Distribution of participants in the intervention and control groups, by the evaluation of depression, according to the HAD scale Fortaleza,CE, 2006

Table 2 -
Continuation A higher prevalence of indicators of depression in the patients in the control group was detected.