Functional capacity after cardiac surgery in elderly patients.

OBJECTIVES: This study was performed to determine whether cardiac surgery improves functional capacity in patients > 70 years of age and to identify factors associated with good and poor functional results in this age group. BACKGROUND: Cardiac surgery has been used increasingly among older patients, but the effectiveness of surgery in this age group remains controversial. METHODS: Self-reported functional capacity was assessed by the Duke Activity Status Index preoperatively and again 1 year after coronary artery bypass or valve replacement surgery in a total of 199 patients with a mean age of 76 years (range 70 to 91). RESULTS: Functional capacity improved significantly after surgery (mean Duke Activity Status Index 27.9 at baseline vs. 36.8 at 12 months, p < 0.001), with improvements in most patients (74%). Six preoperative factors were independent predictors of less improvement in functional capacity between baseline and 1 year: smoking, female gender, higher Charlson comorbidity index, syncope, previous cardiac operation and older age. Postoperative complications were also a highly significant predictor of lower functional capacity at 1 year. CONCLUSIONS: Most older patients have meaningful improvements in functional capacity after cardiac surgery, and clinical factors appear to modify the degree of improvement attainable.

Daily physical activity levels in congestive heart failure.

To determine the level of daily physical activity routinely performed by patients with congestive heart failure (CHF) and the ability of clinical and laboratory assessments of function to predict peak daily activity levels, 45 patients with CHF were evaluated in the laboratory and during 2 days of usual activity. Subjects performed symptom-limited treadmill exercise tests with respiratory gas analysis and wore a Vitalog activity monitor with continuous measurement of heart rate and body motion. Mean maximal oxygen uptake for this sample was 16.8 ml/kg/min. Peak daily physical activity involved walking on a flat surface (44%), or general activities (housework/yardwork, 42%). Most subjects were asymptomatic (49%) during daily physical activity, 22% noted dyspnea, 16% fatigue and 13% sore muscles/joints. Perceived intensity of peak daily physical activity (mean = 4.19, SD = 2.21) was similar to perceived exertion (mean = 3.73, SD = 1.37) reported at ventilatory threshold measured during treadmill exercise testing. Subjects may control their peak daily physical activity to minimize symptoms experienced. It was further observed that current methods of assessing functional capacity in these patients were inadequate for estimating the peak level of daily activity. In conclusion, daily physical activity levels are low in patients with congestive heart failure and a gap exists between exercise capacity and actual performance of daily physical activity.

Predictors of physical activity in patients with chronic heart failure secondary to either ischemic or idiopathic dilated cardiomyopathy.

To identify predictors of physical activity levels in patients with chronic heart failure, 43 patients, aged 33 to 91 years, who had well-compensated heart failure were asked to perform a symptom-limited exercise treadmill test and to complete activity logs for 2 consecutive days while wearing an ambulatory heart rate activity monitor. Activity logs included information on the type of activity, duration, rating of perceived exertion, symptoms experienced, and the intensity of symptoms. Subjects also completed the Duke Activity Status Index, a brief self-administered questionnaire that assesses physical functioning, and a self-efficacy for general activity questionnaire. Simultaneous multiple regression analysis was used to predict physical activity levels from a model that included: personal variables of physical fitness (peak oxygen consumption); knowledge, attitudes, and beliefs including self-efficacy for general activity, and rating of perceived exertion during daily activity; and environmental factors such as social support (marital status). The overall model explained 38% of the variance (p < 0.001). Self-efficacy (p = 0.015) was the strongest predictor of physical activity in this group. From this initial descriptive study, we conclude that self-efficacy is a better predictor of performance of physical activity than measures of physical fitness or rating of perceived exertion during activity. Additional studies are needed to examine other behavioral and physiologic mediators as well as behavioral strategies that may be used to increase participation in physical activity programs. Particularly promising are strategies to enhance self-efficacy for exercise.

Events leading to the treatment of coronary artery disease: implications for nursing care.

The selection of a particular treatment for CAD was found to be related to the severity of illness, patients who were more severely disabled by angina elected surgical treatment after vessel blockage was documented by angiography. Differential access to treatments was not described by study subjects and therefore cannot be evaluated as a contributing factor to the selection of treatment. Although most subjects participated in a therapeutic pharmacologic regimen, few patients in either group employed dietary or exercise programs to ameliorate CAD. Most patients received information about CAD and about surgery as a treatment option. This educational communication was directed by the cardiologist for a large majority of patients. Nurses were cited as information sources for surgical subjects only. In retrospect, more than half of the surgical subjects indicated a need for additional information. The decision regarding which type of treatment to have was made autonomously by most subjects, unlike the usual decision-making styles of families of surgical patients. A significantly greater proportion of surgical patients identified their family as a source of support during the elected treatment. Both groups described family changes specific to the illness and selected treatment.

A randomized clinical trial of nursing care for recovery from cardiac surgery.

OBJECTIVE: To determine the efficacy of a psychoeducational nursing intervention in patients who receive coronary artery bypass graft and valve repair surgery. DESIGN: A cluster-randomized controlled trial design. SETTING: Two hospitals in the western United States--a large community hospital with an active cardiovascular surgery practice and a health-sciences research center. SUBJECTS: 156 patients between 25 and 75 years of age, 125 (81.1%) men, and 31 (19.9%) women, all with primary care givers. OUTCOME MEASURES: Self-efficacy expectations, activities (behavior performance), quality of life, mood state. INTERVENTION: Supplemental in-hospital education followed by telephone contact from discharge to eighth week after discharge. RESULTS: Patients in the experimental group reported significantly greater self-efficacy expectations for walking and behavior performance for walking, lifting, climbing stairs, general exertion and, where applicable, for working. CONCLUSION: This trial suggests that a low-intensity psychoeducational nursing intervention can promote self-efficacy expectations for walking in recovery and is associated with more self-reported walking and lifting behavior after cardiac surgery.

(Mis)conceptions and reconceptions about traditional science.

"Traditional" science (ie, scientific work that has evolved from the natural sciences) is still said to rely on theory-neutral facts, quantitative data, and the search for universal laws. This depiction of science is incongruent with much contemporary thinking. This article examines three shifts in recent philosophy that are relevant for nursing science philosophy: the move from foundationalism to an understanding of the fallibility of science, the shift in emphasis from verification to justification of knowledge claims, and the recent examination of explanation by scientific realists. It is suggested that scientific realism may be a fruitful area of inquiry for philosophers of nursing science.

Nursing's syntax revisited: a critique of philosophies said to influence nursing theories.

Lodged within the syntax of a discipline are the value systems and research constraints that influence theory development and research strategies. Humanism and postmodern philosophy have challenged natural science philosophical influences on nursing's syntax. This paper examines the construction of nursing's syntax from empiricist, hermeneuticist, feminist, and critical social theory views. In this critique, two requirements are placed on the world views: (1) they must accommodate theoretical (realist) terms important to nursing; and (2) they should provide explanatory power for these terms within nursing's disciplinary substance. Arguments are continued for a "within-the discipline" structure, a substantive and syntactical structure for the discipline of nursing that recognizes the centrality of biobehavioral processes in the practice of nursing [Gortner, IMAGE: J. Nurs. Scholarship 22, 101-105 (1990)].

Historical development of doctoral programs: shaping our expectations.

The history of doctoral education for nurses in the United States is reviewed with emphasis on the nurse scientist training model, changing student characteristics, and developing scientific perspectives and programs. Recommendations are made for cross-disciplinary training in a revised nurse scientist model and for greater research emphasis on fundamental processes (for example, host factors) to understand human ecology in health and illness.

Women's short-term recovery from cardiac surgery.

Cardiac surgery is becoming more prevalent in women. Previous knowledge and understanding regarding the process of recovery following cardiac surgery have been based predominantly on what has been known about men. Knowledge is needed regarding factors which may be particular to women's recovery from cardiac surgery and which include both biophysical and psychosocial components. A longitudinal study was conducted to describe, from both objective and subjective perspectives, women's short-term recovery from cardiac surgery. Preoperative (baseline) data were collected from 31 women who presented for cardiac surgery at two Northern California hospitals. Following discharge from the hospital, 27 women were followed monthly by telephone for three months to obtain subjective responses regarding postoperative symptoms, perceptions of recovery, activity, and health status. The findings indicate that women's perceptions of recovery are independent of NYHA functional classification, and these perceptions improve before other more objective measures of activity or health state demonstrate improvement.

The road to recovery for elders after CABG.

One year later, 88% of these octogenarians said they would undergo CABG again. Here's how nursing care set them on the right course.

Management of an elderly, multi-center cohort: strategies for conducting longitudinal research.

This paper describes a longitudinal study in which a cohort of cardiac surgery elders from several hospital sites has been followed. Issues related to retention of the cohort over time are identified. Low-cost and reliable strategies for cohort management are suggested.