Necessidades de aprendizagem e estratégias educacionais para pacientes adultos no pré-operatório de revascularização do miocárdio: scoping review
DOI:
https://doi.org/10.5294/aqui.2022.22.3.7Palavras-chave:
Período pré-operatório, educação do paciente, revascularização miocárdica, equipe de saúde, enfermagemResumo
Objetivo: identificar e mapear as necessidades de aprendizagem e estratégias educacionais para pacientes adultos no pré-operatório de revascularização do miocárdio. Materiais e método: scoping review realizada entre março e abril de 2021, em bases de dados nacionais e internacionais para identificar registros publicados em periódicos científicos e na literatura cinzenta, sem recorte temporal. Resultados: a amostra selecionada foi de 35 registros, compostos, em sua maioria, de artigos (32; 91,42 %), publicados de 1990 a 2021. As necessidades de aprendizagem dos pacientes antes da cirurgia foram categorizadas em sistema cardiovascular e doença arterial coronariana; cuidados, procedimentos e rotinas antes, durante e após a cirurgia. Além disso, identificaram-se diversas estratégias educacionais implementadas nos diferentes contextos dos estudos. Conclusões: as necessidades de aprendizagem identificadas podem contribuir para o planejamento e a implementação de estratégias educacionais centradas no paciente antes da realização da cirurgia.
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Referências
World Health Organization (WHO). Cardiovascular Diseases (CVDs); 2017. Available from: https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)
Centers for Disease Control and Prevention (CDC). Coronary Artery Disease (CAD); 2019. Available from: https://www.cdc.gov/heartdisease/coronary_ad.htm
Golaghaie F, Esmaeili-Kalantari S, Sarzaeem M, Rafiei F. Adherence to lifestyle changes after coronary artery bypass graft: Outcome of preoperative peer education. Patient educ couns. 2019;102(12):2231-7. DOI: https://doi.org/10.1016/j.pec.2019.07.019
Chandrababu R, Nayak BS, Pai VB, N R, George LS, Devi ES, George A. Effects of foot massage and patient education in patients undergoing coronary artery bypass graft surgery: A randomized controlled trial. Complement Ther Clin Pract. 2020;40:101215. DOI: https://doi.org/10.1016/j.ctcp.2020.101215
Lai V, Ho KM, Wong WT, Leung P, Gomersall CD, Underwood MJ et al. Effect of preoperative education and ICU tour on patient and family satisfaction and anxiety in the intensive care unit after elective cardiac surgery: A randomised controlled trial. BMJ qual saf. 2021;30(3):228-35. DOI: https://doi.org/10.1136/bmjqs-2019-010667
Rushton M, Howarth M, Grant MJ, Astin F. Person-centred discharge education following coronary artery bypass graft: A critical review. J. clin nurs. 2017;26(23-24):5206-15. Available from: https://doi.org/10.1111/jocn.14071
Joanna Briggs Institute (JBI). Manual for evidence synthesis. The Joanna Briggs Institute; 2020. Available from: https://wiki.jbi.global/display/MANUAL/Downloadable+PDF+-+current+version
The Joanna Briggs Institute (JBI). The JBI Approach. Grades of recommendation. Levels of Evidence. The Joanna Briggs Institute; 2014. Available from: https://jbi.global/sites/default/files/2019-05/JBI-Levels-of-evidence_2014_0.pdf
Mahler HI, Kulik JA. Preferences for health care involvement, perceived control and surgical recovery: a prospective study. Soc Sci Med. 1990;31(7):743-51. DOI: https://doi.org/10.1016/0277-9536(90)90169-S
Lepczyk M, Raleigh EH, Rowley C. Timing of preoperative patient teaching. J Adv Nurs. 1990; 15(3):300-6. DOI: https://doi.org/10.1016/0277-9536(90)90169-S
Mahler HI, Kulik JA. Effects of preparatory videotapes on self-efficacy beliefs and recovery from coronary bypass surgery. Ann Behav Med. 1998;20(1):39-46. DOI: https://doi.org/10.1007/BF02893808
Arthur HM, Daniels C, McKelvie R, Hirsh J, Rush B. Effect of a preoperative intervention on preoperative and postoperative outcomes in low-risk patients awaiting elective coronary artery bypass graft surgery. A randomized, controlled trial. Ann Intern Med. 2000;133(4):253-62. DOI: https://doi.org/10.7326/0003-4819-133-4-200008150-00007
Shuldham CM. Pre-operative education for the patient having coronary artery bypass surgery. Patient Educ Couns. 2001;43(2):129-37. DOI: https://doi.org/10.1016/S0738-3991(00)00160-9
Shuldham CM, Fleming S, Goodman H. The impact of pre-operative education on recovery following coronary artery bypass surgery. A randomized controlled clinical trial. Eur Heart J. 2002;23(8):666-74. DOI: https://doi.org/10.1053/euhj.2001.2897
Watt-Watson J, Stevens B, Katz J, Costello J, Reid GJ, David T. Impact of preoperative education on pain outcomes after coronary artery bypass graft surgery. Pain. 2004;109(1-2):73-85. DOI: https://doi.org/10.1016/j.pain.2004.01.012
Kayhan N, Reinerth G, Albers J, Hagl S, Vahl C. Präoperative Aufklärung über neue Operationsstrategien: Interaktive Software zur Verbesserung der Patienteninformation. Z Herz- Thorax- Gefasschir. 2005;19(1):13-24. DOI: https://doi.org/10.1007/s00398-005-0463-7
Martin CG, Turkelson SL. Nursing care of the patient undergoing coronary artery bypass grafting. J Cardiovasc Nurs. 2006;21(2):109-17. DOI: https://doi.org/10.1097/00005082-200603000-00006
Parthum A, Weinzierl A, Grässel E, Koppert W. Preoperative pain training. No influence on postoperative pain perception in patients undergoing cardiac surgery. Schmerz. 2006;20(4):315-26. DOI: https://doi.org/10.1007/s00482-005-0441-8
Sørlie T, Busund R, Sexton J, Sexton H, Sørlie D. Video information combined with individualized information sessions: Effects upon emotional well-being following coronary artery bypass surgery-A randomized trial. Patient Educ Couns. 2007;65(2):180-8. DOI: https://doi.org/10.1016/j.pec.2006.07.006
Krannich JH, Weyers P, Lueger S, Faller H, Schimmer C, Deeg P, et al. The short- and long-term motivational effects of a patient education programme for patients with coronary artery bypass grafting. Rehabilitation. 2008;47(4):219-25. DOI: https://doi.org/10.1055/s-2007-1004598
Krannich JH, Herzog M, Weyers P, Lueger S, Faller H, Bohrer T et al. Patients’ needs during hospitalization in a cardiac surgery unit before and after coronary artery bypass graft surgery. Thorac Cardiovasc Surg. 2009;57(1):22-4. DOI: https://doi.org/10.1055/s-2008-1038725
Galdeano LE, Rossi LA, Spadoti Dantas RA. Deficient knowledge nursing diagnosis: Identifying the learning needs of patients with cardiac disease. Int J Nurs Terminol Classif. 2010;21(3):100-7. DOI: https://doi.org/10.1111/j.1744-618X.2010.01155.x
Ozer N, Akyil R, Yurttas A. The effect of education on the stress levels in patients undergoingcoronary artery bypass graft surgery. Pak J Med Sci. 2010;26(2):282-7. Available from: https://www.researchgate.net/publication/228657287_The_effect_of_education_on_the_stress_levels_in_patients_undergoing_coronary_artery_bypass_graft_surgery
Zhang CY, Jiang Y, Yin QY, Chen FJ, Ma LL, Wang LX. Impact of nurse-initiated preoperative education on postoperative anxiety symptoms and complications after coronary artery bypass grafting. J Cardiovasc Nurs. 2012;27(1):84-8. DOI: https://doi.org/10.1097/JCN.0b013e3182189c4d
Lee J, Jung J, Noh JS, Yoo S, Hong YS. Perioperative psycho-educational intervention can reduce postoperative delirium in patients after cardiac surgery: A pilot study. Int J Psychiatry Med. 2013;45(2):143-58. DOI: https://doi.org/10.2190/PM.45.2.d
Veronovici NR, Lasiuk GC, Rempel GR, Norris CM. Discharge education to promote self-management following cardiovascular surgery: an integrative review. Eur J Cardiovasc Nurs. 2014;13(1):22-31. DOI: https://doi.org/10.1177/1474515113504863
Varaei S, Shamsizadeh M, Cheraghi MA, Talebi M, Dehghani A, Abbasi A. Effects of a peer education on cardiac self-efficacy and readmissions in patients undergoing coronary artery bypass graft surgery: a randomized-controlled trial. Nurs Crit Care. 2017;22(1):19-28. DOI: https://doi.org/10.1111/nicc.12118
Uyar IS, Akpınar MB, Şahin V, Abacıla AF, Uç H, Varol R et al. Preoperative education may attenuate anger scores of patients after cardiac surgery. Turk Gogus Kalp Dama. 2014;22(3):547-52. DOI: https://doi.org/10.5606/tgkdc.dergisi.2014.9411
Højskov IE, Moons P, Hansen NV, Greve H, Olsen DB, Cour SL et al. Early physical training and psycho-educational intervention for patients undergoing coronary artery bypass grafting. The SheppHeart randomized 2 × 2 factorial clinical pilot trial. Eur J Cardiovasc Nurs. 2016;15(6):425-37. DOI: https://doi.org/10.1177/1474515115594524
Lai VK, Lee A, Leung P, Chiu CH, Ho KM, Gomersall CD et al. Patient and family satisfaction levels in the intensive care unit after elective cardiac surgery: Study protocol for a randomised controlled trial of a preoperative patient education intervention. BMJ Open. 2016;6(6):e011341. DOI: https://doi.org/10.1136/bmjopen-2016-011341
Nowicka-Sauer K, Jarmoszewicz K, Trzeciak B, Roszak K, Zemla A, Beta S et al. Constructivism in patient education: using drawings to explore preconception of coronary artery disease. Kardiol Pol. 2018;76(8):1274-6. DOI: https://doi.org/10.5603/KP.2018.0165
Mousavi Malek N, Zakerimoghadam M, Esmaeili M, Kazemnejad A. Effects of nurse-led intervention on patients’ anxiety and sleep before coronary artery bypass grafting. Crit Care Nurs Q. 2018;41(2):161-9. DOI: https://doi.org/10.1097/CNQ.0000000000000195
Macleod, CE. Emergency coronary artery bypass grafting: An overview. Nurs crit Care. 2019; 14(3):8-13. DOI: https://doi.org/10.1097/01.CCN.0000554831.89961.bc
Niknejad R, Mirmohammad-Sadeghi M, Akbari M, Ghadami A. Effects of an orientation tour on preoperative anxiety in candidates for coronary artery bypass grafting: A randomized clinical trial. ARYA Atheroscler. 2019;15(4):154-60. DOI: https://doi.org/10.22122/arya.v15i4.1806
Højskov IE, Moons P, Egerod I, Olsen PS, Thygesen LC, Hansen NV et al. Early physical and psycho-educational rehabilitation in patients with coronary artery bypass grafting: A randomized controlled trial. J Rehabil Med. 2019;51(2):136-43. DOI: https://doi.org/10.2340/16501977-2499
Salzmann S, Salzmann-Djufri M, Wilhelm M, Euteneuer F. Psychological Preparation for Cardiac Surgery. Curr Cardiol Rep. 2020;22(12):172. DOI: https://doi.org/10.1007/s11886-020-01424-9
Rizkallah SG. The health education needs of the patient and family upon discharge after a myocardial infarction [dissertação]. Durban: University of Natal; 2002. Available from: https://researchspace.ukzn.ac.za/handle/10413/4806?show=full
Galdeano LE. Validação do diagnóstico de enfermagem conhecimento deficiente em relação à doença arterial coronariana e à revascularização do miocárdio [tese]. São Paulo: Universidade de São Paulo; 2007. Disponível em: https://www.teses.usp.br/teses/disponiveis/83/83131/tde-19032008-163504/pt-br.php
Mclaughlin PA. Development and usability evaluation of preoperative teaching materials for CABG/Valve Surgery Patients [projeto acadêmico]. Baltimore: University of Maryland; 2017. Available from: https://archive.hshsl.umaryland.edu/bitstream/handle/10713/6526/McLaughlin_TeachingMatsForCABGPatients_2017.pdf?sequence=1
Şahin B, İlgün G. Risk factors of deaths related to cardiovascular diseases in World Health Organization (WHO) member countries. Health Soc Care Community. 2020;00:1-8. DOI: https://doi.org/10.1111/hsc.13156
Zhao D, Liu J, Wang M, Zhang X, Zhou M. Epidemiology of cardiovascular disease in China: Current features and implications. Nat Rev Cardiol. 2019;16:203-12. DOI: https://doi.org/10.1038/s41569-018-0119-4
Turk-Adawi K, Sarrafzadegan N, Fadhil I, Taubert K, Sadeghi M, Wenger NK et al. TURK-ADAWI, Karam et al. Cardiovascular disease in the Eastern Mediterranean region: epidemiology and risk factor burden. Nat Rev Cardiol. 2018;15:106-19. DOI: https://doi.org/10.1038/nrcardio.2017.138
Volgman AS, Palaniappan LS, Aggarwal NT, Gupta M, Khandelwal A, Krishnan AV et al. (2018). Atherosclerotic cardiovascular disease in South Asians in the United States: epidemiology, risk factors, and treatments: A scientific statement from the American Heart Association. Circulation. 2018;138(1):e1-34. DOI: https://doi.org/10.1161/CIR.0000000000000580
Yun JS, Ko SH. Current trends in epidemiology of cardiovascular disease and cardiovascular risk management in type 2 diabetes. Metab. 2021;123:1548382. DOI: https://doi.org/10.1016/j.metabol.2021.154838
Yuyun MF, Sliwa K, Kengne AP, Mocumbi AO, Bukhman G. Cardiovascular diseases in Sub-Saharan Africa compared to high-income countries: An epidemiological perspective. Glob Heart. 2020;15(1):1-18. DOI: https://doi.org/10.5334/gh.403
Faria L, Oliveira-Lima JA, Almeida-Filho N. Medicina baseada em evidências: breve aporte histórico sobre marcos conceituais e objetivos práticos do cuidado. Hist Ciênc saúde-Manguinhos. 2021;28(1):59-78. DOI: https://doi.org/10.1590/s0104-59702021000100004
Ribeiro AL, Oliveira GMM. Toward a Patient-Centered, Data-Driven Cardiology. Arq Bras Cardiol. 2019;112(4):371-3. DOI: https://doi.org/10.5935/abc.20190069
Li M, Zhang J, Gan TJ, Qin G, Wang L, Zhu M et al. Enhanced recovery after surgery pathway for patients undergoing cardiac surgery: a randomized clinical trial. Eur j cardiothorac surg. 2018; 54(3):491-7. DOI: https://doi.org/10.1093/ejcts/ezy100
Noale M, Limongi F, Maggi S. Epidemiology of cardiovascular diseases in the elderly. Adv exp med biol. 2020;1216:29-38. DOI: https://doi.org/10.1007/978-3-030-33330-0_4
Ren J, Zhang Y. Targeting autophagy in aging and aging-related cardiovascular diseases. Trends pharmacol. sci. 2018;39(12):1064-76. DOI: https://doi.org/10.1016/j.tips.2018.10.005
Serino A, Salazar G. Protective role of polyphenols against vascular inflammation, aging and cardiovascular disease. Nutrients. 2019;11(1):1-23. DOI: https://doi.org/10.3390/nu11010053
Mussi FC, Teixeira JB. Fatores de risco cardiovascular, doenças isquêmicas do coração e masculinidade. Rev Cubana Enferm. 2018;34(2):1-13. Disponível em: http://www.revenfermeria.sld.cu/index.php/enf/article/view/1613
Vainshelboim B, Chan K, Chen Z, Myers J. Cardiorespiratory fitness and cancer in men with cardiovascular disease: Analysis from the Veterans Exercise Testing Study. Eur j prev cardiol. 2021;28(7):715-21. DOI: https://doi.org/10.1177/2047487320916595
Amiri P, Mohammadzadeh-Naziri K, Abbasi B, Cheraghi L, Jalali-Farahani S, Momenan AA et al. Smoking habits and incidence of cardiovascular diseases in men and women: Findings of a 12 year follow up among an urban Eastern-Mediterranean population. BMC public health. 2019;19(1):1-10. DOI: https://doi.org/10.1186/s12889-019-7390-0
Banharak S, Zahrli T, Matsuo H. Public Knowledge about Risk Factors, Symptoms, and First Decision-making in Response to Symptoms of Heart Attack among Lay People. Pacific Rim International Journal of Nursing Research. 2018;22(1):18-28. Avaliable from: https://he02.tci-thaijo.org/index.php/PRIJNR/article/view/93505
Salzwedel A, Heidler MD, Meng K, Schikora M, Wegscheider K, Reibis R et al. Impact of cognitive performance on disease-related knowledge six months after multi-component rehabilitation in patients after an acute cardiac event. Eur j prev cardiol. 2019;26(1):46-55. DOI: https://doi.org/10.1177/2047487318791609
Fredericks S, Yau T. Clinical effectiveness of individual patient education in heart surgery patients: A systematic review and meta-analysis. Int j nurs stud. 2017;65:44-53. DOI: https://doi.org/10.1016/j.ijnurstu.2016.11.001
Kathania D, Singh NV, Kaur S, Kumar R. Patients perception about Coronary Artery Bypass Graft (CABG) surgery during waiting period: A phenomenological study. Nursing and Midwifery Research Journal. 2021;17(1):31-7. DOI: https://doi.org/10.33698/NRF0330
Pereira DA, Ferreira TM, Silva JI, Gomes ET, Bezerra SMMS. Learning needs about cardiac surgery from the perspective of patients and nurses. Rev SOBECC. 2018;23(2):84-8. DOI: https://doi.org/10.5327/Z1414-4425201800020005
Martins LM, Kazitani BS, Bolela F, Maier SRO, Dessotte CAM. Sintomas de ansiedade, depressão e ansiedade cardíaca pré-operatórios segundo o tipo de cirurgia cardíaca. REME rev min enferm. 2020;25:1-8. DOI: https://doi.org/10.5935/1415-2762-20210002
Knihs NS, Valmorbida AP, Lanzoni GMM, Roza BA, Ghellere A. Path taken to heart surgery: needs and expectations in preoperative preparation. Av enferm. 2017;35(1):30-41. DOI: https://doi.org/10.15446/av.enferm.v35n1.60753
Meadows K, Gibbens R, Gerrard C, Vuylsteke A. Prediction of patient length of stay on the intensive care unit following cardiac surgery: A logistic regression analysis based on the cardiac operative mortality risk calculator, EuroSCORE. J cardiothoracic vasc anest. 2018;32(6):2676-82. DOI: https://doi.org/10.1053/j.jvca.2018.03.007
Oliveira MC, Andrade AYT, Turrini RNT, Poveda VB. Negative pressure wound therapy in the treatment of surgical site infection in cardiac surgery. Rev Bras Enferm. 2020;73(5):e20190331. DOI: https://doi.org/10.1590/0034-7167-2019-0331
Andrade LS, Siliprandi EMO, Karsburg LL, Berlesi FP, Carvalho OLF, Rosa DS et al. Surgical Site Infection Prevention Bundle in Cardiac Surgery. Arq Bras Cardiol. 2019;112(6):769-74. DOI: https://doi.org/10.5935/abc.20190070
Akhlaghi E, Babaei S, Mardani A, Eskandari F. The effect of the neuman systems model on anxiety in patients undergoing coronary artery bypass graft: A randomized controlled trial. The Journal of Nursing Research: JNR. 2021;29(4):pe162. DOI: https://doi.org/10.1097/JNR.0000000000000436
Velikanov AA, Stoljarova AA, Protasov EA, Zelenskaya IA, Lubinskaya EI. Dynamics of psychoemotional characteristics in patients with coronary heart disease after coronary artery bypass graft surgery: Russian sampling specifics. RUDN Journal of Psychology and Pedagogics. 2020;17(2):310-29. DOI: https://doi.org/10.22363/2313-1683-2020-17-2-310-329
Kamenshchikov NO, Mandel IA, Podoksenov YK, Svirko JS, Lomivorotov V, Mikheev SL et al. Nitric oxide provides myocardial protection when added to the cardiopulmonary bypass circuit during cardiac surgery: Randomized trial. The J of Thor and Card Surgery. 2019;157(6):2328-36. DOI: https://doi.org/10.1016/j.jtcvs.2018.08.117
Hussain SMA, Harky A. Complications of coronary artery bypass grafting. Int J Med Ver. 2019;6(1):1-5. DOI: https://doi.org/10.29252/IJMR-060101
Landoni G, Lomivorotov VV, Nigro Neto C, Monaco F, Pasyuga VV, Bradic N et al. Volatile anesthetics versus total intravenous anesthesia for cardiac surgery. N Engl J Med. 2019;380(13):1214-25. DOI: https://doi.org/10.1056/NEJMoa1816476
Jiao XF, Lin XM, Ni XF, Li HL, Zhang C, Yang CS et al. Volatile anesthetics versus total intravenous anesthesia in patients undergoing coronary artery bypass grafting: An updated meta-analysis and trial sequential analysis of randomized controlled trials. PLos ONE. 2019;14(10):e0224562. DOI: https://doi.org/10.1371/journal.pone.0224562
Oh TK, Song IA. Total Intravenous Anesthesia was associated with better survival outcomes after coronary artery bypass grafting: A retrospective cohort study with 3-year follow-up in South Korea. J cardiothoracic vasc anest. 2020;34(12):3250-56. DOI: https://doi.org/10.1053/j.jvca.2020.07.025
Pagnucci N, Tolotti A, Cadorin L, Valcarenghi D, Forfori F. Promoting nighttime sleep in the intensive care unit: Alternative strategies in nursing. Intensive crit care nurs. 2019;51(1):73-81. DOI: https://doi.org/10.1016/j.iccn.2018.11.010
Santos NC, Lima CJFS, Rosa Junior SLR, Silva GF. Nursing care in the post-operatory of cardiac surgery. Res, Soc and Devel. 2020;9(11):e629119535. DOI: https://doi.org/10.33448/rsd-v9i11.9535
Gimpe D, Fisher R, Khan Z, McCormack DJ. Primary care management of chest pain after coronary artery bypass surgery. BMJ. 2019;365:l1303. DOI: https://doi.org/10.1136/bmj.l1303
Javaherforooshzadeh F, Abdalbeygi H, Janatmakan F, Gholizadeh B. Comparing the effects of ketorolac and Paracetamol on postoperative pain relief after coronary artery bypass graft surgery. A randomized clinical trial. J Cardiothorac Surg. 2020;15(1):80. DOI: https://doi.org/10.1186/s13019-020-01125-y
Tüfekçi H, Akansel N, Sivrikaya SK. Pain Interference with Daily Living Activities and Dependency Level of Patients Undergoing CABG Surgery. Pain manag nurs. 2021;3(20):1-8. DOI: https://doi.org/10.1016/j.pmn.2021.03.002
Greaves D, Psaltis PJ, Ross TJ, Davis D, Smith AE, Boord MS et al. Cognitive outcomes following coronary artery bypass grafting: a systematic review and meta-analysis of 91.829 patients. Int J Cardiol. 2019;289:43-9. DOI: https://doi.org/10.1016/j.ijcard.2019.04.065
Lima AMC, Piagge CSLD, Silva ALO, Robazzi MLCC, Mélo CB, Vasconcelos SC. Tecnologias educacionais na promoção da saúde do idoso. Enferm Foco. 2020;11(4):87-96. DOI: https://doi.org/10.21675/2357-707X.2020.v11.n4.3277
Amini K, Alihossaini Z, Ghahremani Z. Randomized Clinical Trial Comparison of the Effect of Verbal Education and Education Booklet on Preoperative Anxiety. J Perianesth Nurs. 2019;34(2):289-96. DOI: https://doi.org/10.1016/j.jopan.2018.06.101
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