الفهرس 
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Abstract
Cardiac surgery is considered an effective way and the gold standard treatment of severe forms of cardiovascular diseases that cannot be treated by medical treatment or cardiac interventions. If patients are not well prepared for this experience, they may develop a range of adverse consequences.
Prehabilitation is an approach of care incorporating psychological intervention as well as functional capacity, nutritional optimization and life style modification that can be implemented while the patient is waiting for cardiac surgery.This can result in increased functional reserve and ability to cope with stress associated with surgery, improved cardiac and respiratory functions and makes patients fit for surgical intervention. This in turn improves quality of life and reduces effect of comorbidities on postoperative surgical outcomes.
Surgical intensive care nurses can support their patients by performing preoperative visits, providing continuous and repeated explanations to patients and their families concerning the postoperative sequence of events. However, standardized multimodal prehabilitation program is lacking. In addition, there is a gap in studies investigated the effect of prehabilitation interventions inpatients undergoing cardiac surgery. Therefore, this study is conducted to investigate the effectiveness of prehabilitation interventions on the physiological, psychological, cognitive outcomes of patients undergoing cardiac surgery.
Aim of the study
A quasi experimental research design was used to investigate the effectiveness prehabilitation interventions on the physiological and psychological outcomes of patients undergoing cardiac surgery
Materials & Method
This study was conducted in the department of cardiothoracic surgery of Alexandria Main University Hospital, and the open heart intensive care unit of the New University Hospital of Alexandria.
Patients who were admitted to the cardiothoracic department to undergo elective open heart surgery for valve replacement, coronary artery bypass graft or both constituted the subjects for this study.
Data collection took approximately 7 months starting from April 2019 to November 2019.
To accomplish the aim of the current study; one tool ’’psychological, physiological, clinical, cognitive and behavioral outcome assessment tool’’ was used to assess the patients’ responses to prehabilitation intervention.
The study design was accomplished as follow:
An official letter from the faculty of nursing was delivered to the hospital authorities in the Main University Hospital and approval to conduct this study was obtained after providing explanation of the aim of the study. An informed consent was obtained from patients. It included the aim of the study, potential benefits, risks and discomforts from participation in this study. The anonymity, confidentiality and privacy of responses, voluntary participation and right to withdraw from the study were emphasized before inclusion in the study sample.
The developed tool was tested for content validity by five experts in the field of the study. A pilot study was carried to assess the clarity and applicability of the tool and the necessary modifications were done prior to data collection. The reliability of the tool was assessed using Cronbach’s alpha test and its result was 0.812 which is acceptable.
The list of patients scheduled for surgery within one week was checked to recruit the subjects. Data were collected first from the control group and after its completion, it was collected from the study group to prevent the contamination between the control and study group that might affect the study results.
The bio-demographic data such as age, sex, level of education, occupation, marital status, diagnosis, type of surgery and comorbidities the was obtained and recorded. Patients’ level of stress, anxiety and depression was assessed for each patient individually and recorded three times; on admission, on the day before surgery and in the second day postoperative.
Patients in the control group were left to receive the routine hospital care which includes preoperative information about surgical procedure provided by resident physicians and surgeons. Patients in the study group were subjected to prehabilitaton intervention one week before the elective cardiac surgery.
The prehabilitation interventions implemented include psychological interventions in form of verbal and written instruction related to cardiac surgery, circulation and arm exercise, respiratory muscle training including deep breathing and training to use spirometers. In addition to education about importance of appropriate nutrition particularly protein and carbohydrate intake and salt restriction in diet.
Outcome assessment include assessment of the cognitive status of postoperative patients was assessed to detect occurrence of delirium after discontinuation of sedative medications for two consecutive days postoperatively. Physiological and clinical related outcome were measured within 48 hours postoperatively and recorded. It include vital signs such as MAP, pulse rate and RR, blood glucose level, the highest pain intensity experienced by the patient daily, oxygenation and ventilation parameters including duration of mechanical ventilation and tracheal intubation, mean oxygen saturation (SaO2), method used to deliver oxygen therapy and depth of breathing on incentive spirometer and functional capacity indicators reflected in ability of patients to move out of bed, ambulate, eat, and toilet independently
Results of the study
Approximately more than half of the studied patients aged 50+ years. An 86.7% of patients in the study group and 83.3% of the control group were married compared. 30% of patients in the study group were not working compared to 36.7% of patients in the control group. A 43.3% of patients in the study group diagnosed with valvular disorder and 40 % diagnosed with coronary artery disease compared to 46.7% of patients in the control group diagnosed with valvular disorders and 46.7% diagnosed with coronary artery disease.
There was statistically significant difference between the mean score of depression, anxiety and stress in the study and control group. Also, there was statistically significant difference between the mean pulse rate and respiratory rate of the study and the control group P= 0.051* and P= 0.000*
The mean score described pain intensity was lower in the study group than the control group with significant difference between the two groups. Regarding oxygenation and ventilation parameters, there was statistically significant difference between SaO2 in the study and the control group P= 0.003*. However, there was no significant difference between the two groups regarding duration of mechanical ventilation
There was significant difference between the two groups regarding the need for non-invasive CPAP after extubation and the need for oxygen therapy where P= 0.005* and P= 0.000*. Regarding depth of breathing, patients in the study group were two groups P= 0.000*. In addition, there was no significant difference between the two groups in relation to occurrence of delirium and mean blood glucose levels.
Moreover, patients in the study group stayed fewer days in the postoperative ICU and cardiothoracic ward than patients in the control group with significant difference between the two groups P= 0.030* and P= 0.024*. Regarding behavioral recovery indicators, patients in the study group mobilize to chair and ambulate more frequently than those in the control group P= 0.001* and P= 0.000* however, there was no significant difference regarding the need to assist in eating and toileting.
Conclusion
It can be concluded from this study that the implementation of prehabiltation interventions in form of psychologically prepare patients for the coming open heart surgery, promoting physical fitness and enhancing their capacities help patients to anticipate the sequence of events associated with surgery, alleviate the stress of unknown, preoccupation with postoperative health state in term of mobility, postoperative complications, return to normal life after surgery, prepare patients physiological function to withstand the stress associated with the surgical intervention.
Recommendations
Surgical intensive care nurses should conduct a baseline assessment of patients who are scheduled for elective open heart surgery for psychological disturbance.
Establishing an effective nurse patient interaction is an important prerequisite for the acceptance and compliance of patients waiting cardiac surgery with the instructions and interventions provided by nurses.
The content lecture of cardiac surgery must emphasize the importance of the art of caring that nurses in the multidisciplinary team can provide for patients undergoing cardiac surgery. Nurses should not merely depend on surgeons’ consultation about patients.
Policies and protocols should be established according to standardized interventions for prehabilitaton.
Standardized guidelines and interventions must be available in an educational handout that can be easily understood by patients and contain illustrative images. These instructions must be provided to patients by nurses while they are waiting for open heart surgery.
Psychological assessment scale must be included in nursing flow sheet both before and after surgery.
Further studies are needed to confirm the current study results in the clinical routine monitoring.