RES EARCH PAPER

Symptom management strategies of Jordanianpatients following coronary artery bypass grafting

surgery

Zaher Mohammed Al-Daakak RN,MScMedical Instructor, Department of Emergency and public Safety, Ministry of Interior General Head Quarters, Abu Dhabi, United Arab Emirates

Ali Ahmad Ammouri RN, MSN, PhDAssociate Professor, College of Nursing, Hashemite University, Zarqa, Jordan

Chandrani Isac RN, MScLecturer, College of Nursing, Sultan Qaboos University, Muscate, Oman

Huda Gharaibeh RN, PhDAssociate Professor, College of Nursing, Jordan University of Science and Technology, Irbid, Jordan

Ibtisam Al-Zaru RN, PhDAssociate Professor, College of Nursing, Jordan University of Science and Technology, Irbid, Jordan

Accepted for publication 22 March 2016

Al-Daakak ZM, Ammouri AA, Isac C, Gharaibeh H, Al-Zaru I. International Journal of Nursing Practice 2016; ••: ••–••

Symptommanagement strategies of Jordanian patients following coronary artery bypass graftingsurgery

The aim of this study was to explore the symptom management strategies utilized by post coronary artery bypass graft(CABG) patients and its associations with demographic variables. A clear understanding of the use of symptom managementstrategies following CABG surgery may help nurses in developing educational program and interventions that help patientsand their families during recovery period after discharge. A cross-sectional, descriptive design was utilized. A conveniencesample of 100 Jordanian patients post CABG surgery selected from five hospitals was surveyed between November 2012and June 2013 using the Cardiac Symptom Survey. Chi squared analyses were used to examine the associations betweenthe symptoms management strategies and selected demographic variables. Frequency of symptom management strategies uti-lized by post CABG patients revealed that most frequently employed strategies were use of medications (79%), repositioning(54%) and the rest (45%). Symptom management strategies utilized for poor appetite, sleeping problem and fatigue had sig-nificant associations with demographic variables. By providing information about the symptoms expected after surgery andpossible ways to manage them, will strengthen the patients psychologically and will make CABG experience within the realmof self-management and coping.

Key words: CABG, coronary artery bypass graft, Jordanain, symptom management strategies.

Correspondence: Ali A. Ammouri, College of Nursing, Hashemite University, P.O Box 330127, Zarqa 13115, Jordan. Email: aliammouri@yahoo.comAll authors met the authorship criteria and are in agreement with the content of the manuscript.

International Journal of Nursing Practice 2016; ••: ••–••

doi:10.1111/ijn.12445 © 2016 John Wiley & Sons Australia, Ltd

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INTRODUCTIONCoronary artery disease (CAD) mortality rate was esti-mated at 7.4 million and continues to hold its reign as theleading cause of death worldwide. The greater proportionof the burden is experienced in the high income countries,followed by upper middle countries.1 The morbid statesdue to CAD were projected at 3 616000 for the SoutheastAsian countries.1 In Jordan, the burden of CAD is represen-tative of the world standards and has been reported byWorld Health Organization (WHO)1 to be the highestcause of death among Jordanian men and women.Coronary artery bypass grafting (CABG) is a lifesaving

surgical procedure of choice for most patients with ad-vanced CAD. The physical and psychological discomfortsexperienced by patients after CABG have been comprehen-sively illuminated in literature.2 With the outset of the fasttracked protocols in health-care delivery system, most pa-tients carry home with them their discomforts. The mannerin which these symptoms are managed by post CABG pa-tients has not been consistently or comprehensively ex-plored internationally.3

BACKGROUNDLiterature has consistently recorded the continuum ofsymptoms experienced by the patients who undergoCABG. The symptom experience in the physical domain in-cludes shortness of breath, fatigue, trouble sleeping, painand swelling; the psychological domain is consisted of anx-iety and depression.2 Empirical evidences on therapeuticstrategies and self-managed techniques instituted to preventand manage these symptoms have been reported by manystudies. The rest has been reported by post CABG patientsto overcome dyspnea,4 fatigue,5,6 sleep disturbances,7 anx-iety and depression.8

Many studies quote the use of medications as the firstchoice for reducing pain. Pain medication taken beforebed time has also been reported to improve sleep.7 Activi-ties like short walk or riding a stationary bicycle every day9

were practiced by post CABG patients to enhance sleep. Al-tering routines was a prevalent practice among post CABGpatients. Balancing between activity and rest, sitting downwhen doing of housework and using of a grocery cart whenshopping10 are techniques utilized by post CABG patients toalleviate stress. Sleep restriction therapy11 has been re-ported by post CABG patient to improve their sleep qualityand quantity.Behaviours used by post CABG patients to divert their

attention from anxiety were music therapy,12 listening to

prayer8 and presence of family caregivers. Repositioningtechniques instituted by post CABG patients was mainlyto reduce leg swelling by keeping legs elevated in a chair.13

Literature reports the prevalent use of adjunct therapies formany of the symptoms experienced by post CABG patients.Using pillows to support incision during movement and ap-plying heat or ice14 have been evidenced in literature to re-duce chest incisional pain. Slow deep breathing exercises4

and cough manoeuvers by placing the palm of hands firmlyon the chest incision were found to decrease airway secre-tions.15 Wearing comfortable clothes and low heeled shoes10 has been cited for fatigue reduction.Use of massage therapy to improve sleep16,17 and reduce

anxiety and depression12 has also been magnified in litera-ture. Use of compressive stocking18 to alleviate leg swellingwas also identified as an adjunct therapy among post CABGpatients. Behaviours involving a change in eating patterns orfoods consumed like limiting dietary restrictions, provisionof smaller and more frequent meals, snacks and supple-ments and changing of diet19 had significantly improvedthe appetite of post CABG patients.A clear understanding of the use of symptom manage-

ment strategies following CABG surgery could helpnurses in developing educational programme and new in-terventions that help patients and their families duringrecovery period after hospital discharge. No previousstudy has investigated these phenomena in Jordan orthe region. Effective and efficient practice of these strat-egies can facilitate early recovery and reduce readmissionto the hospital. Giving patients the control and confi-dence to deal with their symptoms will foster indepen-dence and contribute vastly to an improvement in theirquality of life.

METHODSAims

The aim of this study was to explore the symptom manage-ment strategies utilized by post CABG patients. The studyempirically evidenced the strategies that were effective inrelieving post CABG discomforts and also directed health-care providers to understand the tendency of specific demo-graphic traits in utilizing these strategies.

DesignThe design utilized for the study was descriptive, cross-sectional design to assess symptom management strategiesutilized by patients after CABG surgery and there associa-tions with selected demographic variables.

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Sample and settingNon-probability convenient sampling of 100 Jordanian pa-tients post CABG surgery was selected from five hospitalsin Jordan between November 2012 and June 2013. Thesample size was estimated according to Cohen20 formula,with power=0.80, α=0.05, medium effect size. The re-sults of the power analysis for chi-squared (χ2) test atdf=1 showed that the required sample size was 87 patients.However, more patients were included to acquire more sig-nificant and reliable findings and to allow for an acceptabledropout rate. Inclusion criteria were (i) 18years or older,(ii) have undergone CABG surgery for first time, (iii) ori-ented and able to hear and speak, (iv) have a telephone ser-vice. On the other hand, patients were excluded if they hadan active psychiatric diagnosis that might affect the ability ofthe patients to response to the questionnaire.The patients selected for the study had undergone CABG

in one of the five hospitals located in the capital city ofAmman and the second largest city Irbid. These hospitals in-cluded two teaching hospitals (Jordan University Hospitaland King Abdullah University Hospital) and three privatehospitals (Islamic Hospital, Amman Surgical Hospital andJordan Hospital). In these hospitals, the general protocolis for post CABG patients to be nursed in the Intensive CareUnits for 2days and then transferred to step-down units for4days before discharge.

InstrumentsThe Demographic Data Sheet was designed by the re-searchers to collect background information from both pa-tients and medical records (gender, age, educational level,income, working status, height and weight, smoking andchronic diseases). The body mass index (BMI) for the par-ticipants was computed from their weight and height mea-surements (BMI=weight (kg)/[height (m)]2), and theywere categorized based on World Health Organization21

standards as normal weight (18.5–24.9kg/m2), over-weight (25–29.9kg/m2) or obese (≥ 30kg/m2).To assess the discomforts symptoms experienced by pa-

tients who undergo CABG, the Cardiac Symptom Survey(CSS) was utilized.22 Although this tool has three dimen-sions, the component, which measures the perception ofsymptom presence, was alone considered for this study.The Cronbach’s alphas for this instrument ranged from0.85 to 0.98.23

The CSS questionnaire was rigorously translated backand forth from English to Arabic language. The content va-lidity of the tools was reviewed by three Doctorate experts.

A pilot study with a sample of ten patients post CABGserved as the medium to examine the reliability of theCSS instrument. The results of pilot study indicated thatthe Cronbach’s alphas for the instrument ranged from0.83 to 0.99. In addition, questions required between15–20min to answer.Symptom management strategies were measured using

the categories of symptom management strategies devel-oped by Schulz et al.19 The categories were empirically for-mulated and utilized in a study on symptom managementstrategies used by elderly patients after CABG surgery.19

The categories list nine strategies that include rest, medica-tions, seek help, activity, alter routine, distraction, reposi-tion, adjunct treatments and change diet. Content validityof the categories was maintained by a nurse specialized incardiovascular nursing, and criterion validity was assessedby comparing the categories to the guidelines of AmericanHeart Association and Society of Thoracic Surgeons.19

The definitions and the various ways by which these strate-gies are implemented were explained to participants.

Data collectionFormal consent was taken from the participants whoconsented for the study. With the Demographic DataSheet, data related to the participants’ personal and medicalbackground were collected before hospital discharge. After2weeks of their discharge, each participant received aphone call from the researcher who utilized the CSS to as-certain any symptom experienced by the participant. Thecategories of symptom management strategies were usedas a framework to ascertain, if the patients who did experi-ence discomforts during the 2weeks utilize any strategy torelieve their symptoms.A total of 106 patients were invited to participate in the

study. Three patients refused to be contacted after hospitaldischarge; one patient was feeling tired and refused to recalllater, and one contact number was out of service. One pa-tient was excluded from the study because the patientunderwent a re-opening surgery during first week after dis-charge. The remaining 100 respondents (response rate94.3%) were included in the study.

Ethical considerationsThis study was approved by the human subject researchcommittee (reference no 14/2010/10) of JordanUniversity of Science and Technology. Institutional permis-sion from the teaching and private hospitals was also offici-ated before the conduct of the study. The study purpose

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was clarified to nursing administration, charge nurses andpatients who met the inclusion criteria. In addition, the im-portance of the study in improving of the quality of healthcare was also explained. Patients’ names and telephonenumbers were written in separate cards and coded intonumbers for the Cardiac Symptom Survey.Written consentforms were obtained from all patients at the day of dis-charge after assuring that their participation will be volun-tary. Patients were also assured that they can withdrawfrom the research at any time, information obtained willbe treated confidentially and aggregated data will be com-municated if requested.

Data analysisData were analysed using SPSS version 19 (SPSS, Chicago,IL, USA). A 0.05 criterion for statistical significance wasemployed for the analyses. Demographic variables of theparticipants and other study variables were analysed usingdescriptive statistics including mean, standard deviations,frequency and percentages. Chi-squared analysis (χ2) wasused to examine the differences between symptom manage-ment strategies and demographic variables.

RESULTSSample characteristics

The majority of the participants were men (80%) (n=80).The number of participants, who were< 60years of age(55%) (n=55), marginally dominated the group of partic-ipants. A more number of participants were educated(83%) (n=83) and employed (66%) (n=66). A glimpseat their previous health profile revealed that 78% (n=78)of them were smokers, 62% (n=62) were overweight orobese and nearly half (47%) (n=47) of the participantshad diabetes, hypertension or both (Table 1).

Symptom management strategies utilizedby patients post coronary artery bypass

grafting surgeryThe major symptoms elicited from the interview conductedamong post CABG patients during the 2weeks followingtheir surgery were chest incisional pain (65%), leg swelling(60%), poor appetite (56%), trouble sleeping (54%) andleg incisional pain (52%) (n=52). Symptoms that wereperceived by a minority of the respondents were fatigue(43%) (n=43), anxiety (32%) (n=32) and shortness ofbreath (29%) (n=29). Symptoms like fluttering (15%)(n=15), angina (8%) (n=8) and depression (3%) (n=3)were reported by a few participants.

Frequency of symptom management strategies utilizedby post CABG patients revealed that most frequentlyemployed strategies were use of medications (79%), repo-sitioning (54%) and rest (45%). Seeking help (27%), dis-traction (22%), activity (21%) and adjunct therapy (21%)were used in moderation. Very few participants exploredchange in diet (9%) and altering routines (2%) to impededtheir symptoms experiences after CABG.

Table 1 Demographic characteristics of patients post coronary ar-

tery bypass grafting surgery (n=100)

Variable % (n) Mean (SD) Range

Gender — — —Male 80% (80) — —Female 20% (20) — —

Age — 57.67 (9.70) 40–75< 60 years old 55% (55) 50.29 (5.35) 40–5960 or older 45% (45) 66.69 (5.06) 60–75

Educational status — — —Illiterates 17% (17) — —Educated 83% (83) — —

Working status — — —Unemployed 34% (34) — —Employed 66% (66) — —

Residency — — —City 66% (66) — —Village 34% (34) — —

Monthly income — — —< 300 JD 55% (55) — —300–500 JD 27% (27) — —

Smoking habits — — —Not smoker 78% (78) — —Smoker 22% (22) — —

Body mass index — 26.72 (3.46) 19.5–39.1Normal 38% (38) 23.42 (1.18) 25–29.8Overweight 42% (42) 27.19 (1.35) 19.5–24.9Obese 20% (20) 31.99 (2.05) 30–39

Chronic diseases† — — —None 22% (22) — —Hypertension 47% (47) — —Diabetes 47% (47) — —Hyperlipidemia 30% (30) — —Heart failure 2% (2) — —

†Not mutually exclusive.

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Symptom management strategies utilizedby patients post coronary artery bypass

grafting surgeryThe most common symptom perceived by post CABG pa-tients during the 2weeks following their surgery was chestincisional pain, which was primarily managed with medica-tions (37%) and repositioning (32%). Leg swelling was pre-dominantly managed with repositioning (38%) andmedications (25%). Seventy-five per cent of post CABG pa-tients who had experienced poor appetite did not utilize anystrategy to relieve this discomfort. Meanwhile, changingdiet (16%) was principally used by those who initiatedsymptom management strategy. The rest (63%)outweighed all other strategies implemented by the studyparticipants to overcome fatigue. Distraction (31%) waspracticed more than activity (21%) by the post CABG pa-tients who had experienced anxiety (Fig. 1).

Associations between demographicvariables and symptom management

strategies utilized by post coronary arterybypass grafting patients

The results indicated that symptom management strategiesutilized by post CABG patients for poor appetite, sleeping

problem and fatigue had significant associations with demo-graphic variables (Table 2). Chi-squared results indicated thatfemale (χ2=9.37, df=1, P< 0.01), patients aged more than60 (χ2=5.42, df=1, P< 0.05) and patients with a history ofchronic disease (χ2=5.80, df=1, P< 0.05) had used morestrategies to manage poor appetite.In the current study, a significant difference was found

between gender and strategies to manage sleeping distur-bances (χ2=24.710, df=1, P< 0.001), which implied thatmajority of the men did not utilize any strategy to managesleep disturbances. Also, a significant difference was foundbetween sources of health information and strategies tomanage sleep disturbances (χ2=5.46, df=1, P< 0.05).The percentage of participants who did not access anysource of information but utilized strategies to manage sleepdisturbances was higher than those who did not use anystrategy (40 vs. 19).The results of current study found that male participants

used strategies to manage fatigue more than female(χ2=8.32, df=1, P< 0.01). In addition, participants withfatigue who accessed health information used more strate-gies to manage sleep disturbances than who did not accessany source of health information (χ2=3.92, df=1,P< 0.05) (Table 2).

Figure 1. Frequency distribution of symptom management strategies,

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DISCUSSIONThe purpose of this study was to explore the symptomman-agement strategies of Jordanian post CABG patients andtheir associations with demographic variables. Chestincisional pain, which had been reported as the most fre-quent discomfort among post CABG patients, is also reso-nated in many similar studies.24 This discomfort ismagnified by the respondents as it interferes with theirsleep, activities and mood.24 Leg swelling after a CABGhas been reported to limit the physical functioning of manypatients.2

The prevalence of sleep and appetite problems amongpost CABG patients has been prevalently reported in lit-erature.25,26 Both of these symptoms have been attrib-uted in literature to the medications taken by thesepatients during the recovery phase.24,25 The less fre-quently reported symptoms like fatigue and shortnessof breath have also been documented in literature insimilar frequency patterns.19 These less frequent symp-toms have been reported in literature to diminish withinthe recovery period.27

Symptom management strategies ofJordanian patients post coronary arterybypass grafting for frequently reported

symptomsIn the present study, chest and leg incisional pain expe-rienced by post CABG patients was predominantly re-lieved with medications. Literature showcases thatopioids were liberally utilized in the initial weeks aftersurgery followed by the use of non-opioids in the weeksof recovery.28 The prominent and distressful side effectsof these medications like constipation, drowsiness, nauseaand vomiting29 could have persuaded the participants ofthe current study to rely on other non-pharmacologicalstrategies like rest or repositioning. Most of the studyparticipants had also resorted to seeking help to relievetheir pain. Watt-Watson et al.14 reported that postCABG patients who were aware of the importance ofpain relief methods and the impact pain had on recoverywere prompt to report and request for pain medications.This is a classic example of ‘seeking help’ as a strategyto relieve pain symptoms.

Table 2 Significant associations between post coronary artery bypass grafting symptoms management strategies and demographic variables

(n=100)

Variable Poor appetite Sleeping problem Fatigue

Strategies Strategies Strategies

Yes % (n) No % (n) χ2 Yes % (n) No % (n) χ2 Yes % (n) No % (n) χ2

Gender†

Male 53 (9) 86 (71) 9.37** 54 (20) 95 (60) 24.71*** 95 (36) 71 (44) 8.32**female 47 (8) 14 (12) 46 (17) 5 (3) 5 (2) 29 (18)

Age< 60 29 (5) 60 (50) 5.42* 54 (20) 56 (35) 0.03 50 (19) 58 (36) 0.58≥ 60 71 (12) 40 (33) 46 (17) 44 (28) 50 (19) 42 (26)

EducationIlliterate 35 (6) 13 (11) 3.16 27 (10) 11 (7) 3.18 16 (6) 18 (11) 0.56Educated 65 (11) 87 (72) 73 (27) 89 (56) 84 (32) 82 (51)

Source of informationAny source 59 (10) 76 (63) 2.10 60 (22) 81 (51) 5.46* 84 (32) 66 (41) 3.92*No interest 41 (7) 24 (20) 40 (15) 19 (12) 16 (6) 34 (21)

Chronic disease†

No 5 (1) 26 (22) 5.80* 14 (5) 27 (17) 2.32 32 (12) 16 (10) 3.12Yes 95 (16) 74 (61) 86 (32) 73 (46) 68 (26) 84 (52)

*P< 0.05. **P< 0.01. ***P< 0.001. †Fisher’s Exact test (expected frequency< 5).

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Most of the post CABG patients who participated in thecurrent study did not take any measures to relieve their lossof appetite. The strategy, which was deemed helpful by thefew who practiced them, was changing their diet. PostCABG patients should be encouraged to utilize appetite im-proving strategies like eating small meals, includingfavourite foods, reducing seasoning and forcing themselvesto eat.19

Measures implemented by the post CABG patients sam-pled for the current study with difficulty in sleeping wereprimarily with medications followed by distraction and al-tering routines. Redeker and Hedges26 reported that sleepis disrupted strongly in the immediate postoperative periodbecause of the intense pain experienced by post CABG pa-tients. During this phase, patients would have resorted tomedications, but with the reduction in pain over the follow-ing weeks,30 other measures like sleeping in a recliner,changing positions, relaxation and listening to music wouldhave been instituted. 17

Fatigue, which was prevalent among the current studyparticipants, was most frequently tackled by rest and lessfrequently by activity and adjunct treatments. This promptsthe researchers to exemplify the positive effects of increas-ing activities or scheduling rest between activities31 to thecurrent study participants. This emphasis will not only fos-ter fatigue reduction, but will also prevent other postoper-ative complications of immobility like constipation, deepvein thrombosis and atelectasis.Anxiety was experienced by only a handful of the post

CABG patients interrogated for the current study. Al-though distracting oneself was the primary strategyemployed by the current study participants, problem-focused coping has been cited in literature to strongly di-minish anxiety among post CABG patients. This strategy di-rects patients to focus on strategies to resolve their physicalproblems, which reduces their perception of their emo-tional response.32

Associations between demographicvariables and symptom management

strategies utilized by post coronary arterybypass grafting patients

In the current study, the symptom management strategiesfor poor appetite, sleep problems and fatigue were statisti-cally tagged to certain demographic traits that were consis-tent with previous studies.19

Study participants who were females, elderly and thosewith chronic illness were prone to utilize strategies to

overcome their poor appetite. In the Islamic culture,women’s health and competence is regarded most impor-tant by family members.33 The significance placed on thehealth of women and the motivation from the family wouldhave persuaded female patients to practice strategies to im-prove their appetite. Elderly patients tend to possess greaternumber of co-morbidities requiring them to take moremedications, which inevitably would cause them more in-tensity of appetite problems, forcing them to intervene.34

The trio of participant characteristics more interested toovercome poor appetite conveys to health-care providersthat dietary consultation in the early postoperative days willaid this population to make changes in their diet. Improve-ment in diet will accelerate energy levels and woundhealing, which are vital for resumption to pre-morbid activ-ity levels and improvement in quality of life.Findings from the current study reflect that sleep prob-

lems were significantly intervened by female patients andthose patients who did not seek any information about theirproposed surgical experiences preoperatively. Authors ofevidence-based literature postulate that women resumetheir role and household activities early within the recoveryperiod and this increases their feelings of tiredness and de-creases their day time sleep.33 These factors enhance theirsleep duration and quality. Sleep disturbances in post CABGpatients without any previous knowledge on their symptomexperiences could be largely attributed to their acceleratedanxiety levels. This could have prompted the study partici-pant to seek help to resolve this distressing symptom.Jalowiec, Grady and White-Williams35 concluded that postCABG patients with increased anxiety levels had identifiedthat seeking help as the most frequently utilized strategyto alleviate their concerns. Health-care providers arereminded to incorporate the need to resume activities ofdaily living within their energy levels, to improve theirsleep quality and quantity. Furthermore, a need to teachproposed CABG patients about their forecasted experienceswill alleviate their anxieties and prevent sleeping difficulties.Fatigue, which was experienced by post CABG patients

who participated in the current study, was statistically me-diated by male patients and those who sort health informa-tion before surgery. Schulz, Zimmerman, Barnason andNieveen36 reported that men demonstrated higher meanscores for physical functioning by the sixth week afterCABG compared with women. This justifies to the fact thatmen tend to involve themselves in fatigue-reducing strate-gies in the early postoperative period. Utriyaprasit, Mooreand Chaiseri37 reported that patients who had received

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audiotaped information on Cardiac Home Information Pro-gram had a statistical reduction in their fatigue levels be-tween 2 and 4weeks after hospital discharge. Theseinterpretations signal to health-care providers to motivatepost CABG patients to initiate fatigue reducing strategiesas early as possible in the recovery phase and to provide in-formation on these strategies through channels in whichthey can repeatedly review these techniques like handoutsand audio tapes of video clips.

Implications for practiceThis study aimed at exploring the symptom managementstrategies among post CABG patients in order to preventre-admissions and also facilitated the improvement in qual-ity of life post CABG surgery. The study findings providebenefits for the preoperative and postoperative CABG pa-tients. By providing information on the symptoms expectedafter surgery and the possible ways to manage them, it psy-chologically strengthens patients that the CABG experienceis within the realm of self-management and coping. Duringthe postoperative period, the occurrence of symptomsprompts patients to seek help at the earliest or to recalland practice the strategies taught to them. In the home set-ting, the information provided guides them to initiate self-management strategies consistently. Health-care providersare prompted to equip themselves with these empirical factsand prepare evidence-based health education sessions to in-culcate these facts to their patients. Researchers are calledto explore best methods to disseminate these findings andare also urged to explore the effectiveness of these strategiesin improving quality of life, recovery and resumption topre-morbid physical and psychological standards taking intoconsideration demographic variables such as gender.

Study limitationsThe authors wish to acknowledge that, although the studywas conducted taking into consideration the principles thatgovern research, a few notable limitations were inevitable.Descriptive nature of this study impedes the ability to infercausal relationships between the study variables. Self-reported data could possess hidden biases related to recall.Convenience sampling and small sample size may not betruly representative of the Jordanian CABG patients.

CONCLUSIONThe study has highlighted the symptoms experienced bypost CABG patients and the strategies utilized to relievethem. With the advent of early discharge from the health-

care settings, the evidences generated from this study directhealth-care providers to strengthen the cognitive resourcesof their patients by providing them with information on ef-fective strategies to reduce or relieve their post CABG pa-tients. Furthermore, the demographic affiliation to utilizestrategies for selected discomforts should be captured, andtailor-made information sachets are to be disseminated foreffective prevention of postoperative complications.

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