Page 802 - Cardiac Nursing

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778 PA R T V / Health Promotion and Disease Prevention
with others and enhance perceived support. 145 For patients with emotional arousal and increase parasympathetic response should be
few social ties or ties perceived to be unsupportive, Friedwald emphasized for patients with hostility and anger. 128 Patients should
et al. 146 suggest referral to a cardiac rehabilitation program or to be encouraged to record their thoughts and feelings to become
Mended Hearts, a national nonprofit organization that offers more aware of their hypercritical view of others as incompetent or
support services to patients with heart disease, may increase com- untrustworthy. Such generalizations can be gently questioned so
munity contacts. Having a pet may also be beneficial. Patients re- that patients’ assumptions can be evaluated from a neutral perspec-
ferred to cardiac rehabilitation programs benefit by observing tive. Also, they can be questioned about the function of their anger
other patients recover and by maintaining contact with health care and hostility, 152 and they can also learn when anger is justified and
staff. Many CHD patients in rehabilitation programs develop last- when it is not. 113
ing friendships with their counterparts. Such ties serve buffer the The interventions used in most studies have involved group
stresses of daily life. therapy programs with educational and behavioral strategies to as-
Patients with existing support networks are likely to benefit by sist patients in identifying and modifying their behaviors. One
having family or significant others involved during their recovery such strategy is the “Hook Intervention” 153 taught to patients
in the hospital. Like CHD patients, spouses and significant oth- with high autonomic reactivity to life’s daily hassles, such as wait-
ers are likely to distort and make false assumptions about the re- ing in lines and being delayed in traffic. These patients frequently
covery process during and after the medical emergency. Spouses react to the unfairness of the external environment and unsuc-
can be significantly distressed by the hospital admission for several cessfully try to gain control over that environment through overt
reasons: lack of control, fear of the unknown, fear of change in or covert impatient and hostile behaviors, which lead to further
roles, self-blame for the event, and fear of loss. 147–149 Also, pro- frustration and physiological arousal. Through practice, patients
viding information before procedures occur and during rehabilita- learn that daily hassles are hooks; they can choose to bite or they
tion can decrease the fear of uncertainty. Educating a spouse about can ignore the bait, thus controlling their arousal levels. For exam-
his or her partner’s MI, the course of treatment, and the recovery ple, a patient might identify routine behaviors such as speeding up
process can decrease over-protectiveness and over-involvement when approaching a yellow light or passing cars or multitasking.
when the patient is discharged from the hospital. 150 Behavioral Such patients can be instructed to modify their behavior or con-
strategies that allow patients and families to rehearse or model ex- duct experiments by driving in the slow lane, standing in a longer
periences are useful. For example, treadmill exercise testing before line, or doing one task at a time.
discharge from the hospital, if observed by the spouse, has been Patients who are hostile and angry tend to have unsatisfactory
shown to enhance the patient’s self-esteem and to reduce spousal relationships and may have difficulty maintaining relationships. 154
anxiety. 151 Rather than being overprotective in the recovery period, Interventions can nurture social connectedness in these patients
the spouse can provide positive support. who either lack the skills to connect or fear the cost of these social
connections, such as the risk of rejection and or diversion from
Intervention Strategies for goal-oriented activities. 128 These patients learn (a) to recognize
Hostility and Anger their internal reactions in an interpersonal environment, (b) to
practice expressing their feelings and listening in a reflective and
Hostility can often be an ingrained trait and resistant to change. empathetic way, (c) to practice assertiveness skills, such as saying
In some cases, referral to a mental health specialist may be re- no and delegating to others, and (d) to learn the difference between
quired. Hostile patients may be less compliant with risk factor assertive and aggressive responses. 155 These programs, although
modification and medical regimens. For example, when patients costly and time consuming, have been shown to reduce hostility
smoke to relieve episodes of anger or frustration, quit rates are ratings. 156
lower than if they are able to control their expression of anger. 26
Evaluating adherence to health care recommendation and problem-
solving strategies is important in all coronary patients, but they PHARMACOLOGICAL
may be particularly important in people to excessive hostility and INTERVENTIONS FOR
anger.
After establishing rapport with hostile or angry patients, nurses PSYCHOSOCIAL RISK
can teach them about the physiological effects of emotions. So- FACTORS IN CHD
cratic questioning works well: “Do you think that you often are an-
grier than others in similar situations or that you stay resentful for Besides interventions mentioned above, patients with psychosocial
longer periods?” or “How do you think your anger and resent- risk factors should also be evaluated for psychopharmacological in-
ments affect your heart or your blood pressure?” This approach terventions after a thorough assessment. The efficacy of antide-
gives a nurse insight into a patient’s understanding, to determine pressants in treating clinical depression is well established. The
how best to share information without provoking anxiety, and to Agency for Health Care and Policy Research’s treatment guidelines
assess the patient’s readiness to receive information. Eliciting feed- recommend that moderate to severe depression and recurrent de-
back from patients also helps to assess how they are processing the pression should be treated with antidepressants and psychother-
information. apy. 125 Antidepressant treatment may also decrease anxiety and
Hostile or angry patients should be informed about the effects hostility, and is sometimes used to help patients stop smok-
of heightened cardiovascular and neuroendocrine responses that ing. 3,157–161 Given the availability of so many antidepressants and
increase cortisol levels and plasma lipid levels. The effect of angry the potential side effects and drug interactions for CHD patients,
assumptions, thoughts, and behaviors in decreasing parasympa- consulting a psychiatrist is recommended. The empirically based
thetic response should also be addressed. The benefits of exercise medical consensus 162 is that selective serotonin reuptake in-
and relaxation training to decrease physiological arousal, decrease hibitors cause fewer side effects and have fewer contraindications