Evidence based practice
Also known as a heart attack, myocardial infarction (MI) is a dramatic and life changing event. The victim does not know how to resume a normal life post MI, so the nurse plays a pivotal role as an educator regarding the resumption of a normal lifestyle. However, much controversy exists in the literature as to best practice guidelines, and when the appropriate time frame is for teaching. This paper will explore the best practice guidelines and time frame for post-MI education, exercise, proper diet, and resumption of sexual activity.
Education is a vital component of care for patients after myocardial infarction. By informing patients about the disease process of MI, it helps to reduce anxiety and aid recovery, as the underlying cause of MI is related to lifestyle. Nurses need to provide education on lifestyle change with regards to minimizing the reoccurrence of MI. A change in diet is one of the most important aspects of nursing teaching for post MI patients. A heart healthy diet is recommended to reduce LDL and blood pressure. Heart healthy diet guidelines include limiting total calories from fat less than 30%, limiting total calories from saturated fats to 8-10 % and limiting cholesterol to intake to less that 300mg per day. According Grundy (2003) in a diet and re infraction trial carried on 2033 men who had suffered from MI. They were divided into two groups. Half were advised to reduce fat intake, increase dietary fiber, increase fatty fish intake. The other half received no dietary advice. The prescribed diet was reported to provide about 500-800mg/d of every long chain N-3 fatty acids. Patients who received the prescribed amount of fatty fish had a 29% reduction in all cause mortality over the period of study. Much of the benefit was attributed to diet's higher content of N-3 fatty acids. Nurses need to educate patients based on patients' unique concerns, thus, standard protocol regarding post-MI teaching need to be tailored to each individual patient. Every patient has various experiences and a wide range of emotions, and needs the appropriate methods pertaining to teaching the client when he/she is ready to listen. Bores & Sinclair (2009) mention how crucial it is to have post-MI education and programs individualized to each patient's specific needs, and to examine the organizational factors influencing their performance on the patient teaching role.
Thompson & Lewin (2000) describe how exercise may have significant protective effects in post-MI patients. As a nurse, it is important to encourage the client to identify what they felt may have been the cause of their MI and if the client is associating this as psychological distress. Thompson & Lewis (2000) also mention that initial distress predicts outcomes for return to work and for some other aspects of quality of life outcome, lifestyle changes, and compliance with medical care. Every patient should be helped to develop an individualized and concrete plan for recovery in the weeks following the MI (Thompson & Lewis, 2000). It is also important that the patient's partners be advised to alter family routines as little as possible except for lifestyle changes, such as smoking or diet, which should begin immediately (Thompson & Lewis, 2000). The patient and partner's understanding of the advice should be checked during the course and at the end of each session, by asking them to summarize the advice imparted, it may be helpful if information provided was written or tape recorded for review throughout the rehabilitation phase.
There is a strong correlation between proper diet, exercise and improving post-MI outcomes. According to Skinner, Cooper, & Feder (2007), who have summarized some recommendations from the National Institute for Health and Clinical Experience (NICE) on effective secondary prevention in patients with post-MI, nurses can utilize this information, by taking into account the recommendation of lifestyle advice that should be consistent and take into consideration the patients' current habits. Patients should be advised to increase physical activity, quit smoking, eat a Mediterranean-style diet, consume at least seven grams of omega 3 fatty acids a week, keep weekly alcohol consumption within safe limits, achieve and maintain a healthy weight if obese, and advise patients against taking supplements containing carotene, vitamin E or C supplement and folic acid supplements (Skinner, et. al, 2007).
Education about exercise post-MI is vital to relieving anxiety and resumption of activity. Another recommendation by NICE regarding exercise is to advise patients to return to work and to get involved in activities of daily living while taking into account the his/her physical and psychological status, and the nature of his/her work. Exercise has been shown to increase myocardial oxygen delivery, and improvements are seen on changes in the oxygen utilization of the peripheral skeletal muscles, resulting in decreased demand placed on the myocardium at any given workload (Nolewajka, Kostuk, Rechnitzer, & Cunningham, 1979). Furthermore, Luszczynska (2006) found that the promotion of an active lifestyle after eight months post-MI can help patients to increase their sessions of moderate physical activity.
The resumption of sexual is an area of great concern for post MI patients. Often, patients are more preoccupied and greatly concerned with feelings of inadequacy and disempowerment due to their compromised physiological condition. Nurses often feel awkward addressing the issue, and are not sure how to begin the education process. Fortunately, the literature for the past two decades has shown the positive effects of counseling and education. It is interesting to note that the exertion required for sex is only equivalent to climbing up two flights of stairs (Steinke, 2000). With this kind of information at hand, the nurse can easily use a conversation on exercise as a spring board for a discussion of the resumption of sexual activity.
Research by Steinke & White (2006) reveals attention to sexual concerns of MI patients before and after hospital discharge results in improved patient outcomes. There is a strong link between heightened anxiety and decreased sexual satisfaction with post MI patients. Therefore nurses, in particular coronary care nurses, play an important role in counseling patients in this area (Crumlish, 2004). However, Crumlish (2004) asserts this is a frequently neglected area. It seems logical that there is a strong link between anxiety and feelings of sexual inadequacy post MI, which brings the question as to whether there are also gender and cultural differences. Research by Moser, Dracup, McKinley, Yamasaki, Kim, Riegel, Ball, Doering, An, & Barnett (2003) demonstrate that although women have higher levels of anxiety post MI, this relationship is independent of age, education level, marital status, or presence of co-morbidities. Whether these variables influence the effectiveness of post MI teaching remains to be investigated.
The best practices in sex education post MI have changed over the past two decades. In the early 1990s, research and education was focused on dispelling the myths and fears of sexual dysfunction (Boone & Kelley, 1990), whereas in the 2000s the focus has changed to the effects of anxiety (Steinke & White, 2006). Both decades show the need for counseling, however in the 2000s, the nurse is the key educator, rather than the physician. Fortunately, there are several approaches to post MI sex education that can be used by the nurse to decrease anxiety. For instance, the hypothesis that MI patients who receive both written instructions and a videotape to view at home about sex education will resume sexual activity more quickly than the patients who receive only written instructions was tested in a two group randomized clinical trial (Steinke & Swan, 2004). They found significant improvements in the experimental group after only one month, indicating that video tape intervention is an effective means of providing post MI sex education. The nurse who incorporates these teaching approaches can address the sensitive topic of resumption of sexual activity in an appropriate and effective manner.
Controversy exists as to when the best timing is for patient teaching about the resumption of sexual activity. For example, some researchers recommend waiting until the patient is psychologically ready. Others believe it is dependent on the physician's assessment of the degree of readiness. While Gentz (2000) asserts that it is actually safe to resume sexual activity after only seven to ten days post-MI. Regardless of the controversy, it is obvious that the nurse plays a key role as the patient educator to provide counseling on the best practice guidelines to assist the patient to safely resume sexual activity.
The future practice in nursing about education in secondary prevention of MI should focus on the discharge planning of the client. Effective communication between the acute care nurses and the community nurses can bridge the gaps when transferring the clients from hospital to home or long term care setting and can ensure the clients are receiving excellent nursing care in services across setting. Also, nurses should ensure interpreters are used and translated written materials are available when conducting family meeting about discharge, teaching with clients and family members. This can ensure that information is delivered to clients correctly and the clients will understand the purpose and meaning of the teaching. Moreover, the hospital can implement a telephone system for follow up to discharge clients to reinforce the teaching especially the detail of medication and plan of emergency incident. At last, nurses should integrate cultural-ethical content into teaching and provide holistic care which can help the health care providers to work effectively with diverse populations.
Although controversy exits in the literature regarding when to begin post MI teaching, it is evident that the nurse plays a critical role in education. Post-MI teaching needs to be individualized to meet the needs, goals, hopes and values of each patient. Education regarding lifestyle modification, diet, exercise, anxiety, and resumption of sexual activity has been show to be beneficial to assist the patient to adjust to his/her new lifestyle. Although the resumption of sexual activity is associated with anxiety and fear of coital death, according to best practice guidelines, patients can resume within seven to ten days post-MI. Overall, the role of the nurse is to educate the patient about MI and its treatment, lifestyle changes (drugs, diet, exercise), self-monitoring and management (especially the early detection and treatment of chest pain), coordination of care with other health care providers, and provide rehabilitation support. By educating the clients about secondary preventions such as pharmacotherapy, health education and psychological support in developing lifestyle medications, clients are able to develop coping strategies for treating and preventing MI and ultimately yield to better health outcome and restore their function in normal daily living activities.