Journal of Biology, Agriculture and Healthcare ISSN 2224-32 ! "#a$er% ISSN 222&- '3( ")nline% *ol.3, No.

+,, 2 +3

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Impact of a Designed Nursing Intervention protocol on Myocardial Infarction Patient's Outcome at a selected University Hospital in Egypt
+. 2. 3. 4. A-delha.eed /ahrosA-delha.eed+0, 1arda 2oussef /oha.ed2, 2ousria A-d 3l-sala. Selo.a3, Hanan 3l-sayed 4aghla4, 5linical Instructor of 5ritical 5are and 3.ergency Nursing, 6aculty of Nursing, #rof. of 5ritical care and 3.ergency Nursing, 6aculty of Nursing, 7ecturer of 5ritical 5are and 3.ergency Nursing, 6aculty of Nursing, 7ecturer of 5ritical 5are .edicine 6aculty of /edicine, 0 3-.ail of the corres$onding author8 a-delha.eed.ahros9yahoo.co.

Abstract ac!ground8 /yocardial infarction is a life threatening disease that influences the $hysical, $sychological and social di.ensions of the indi:idual. I.$ro$er lifestyle is one of the causes of this disease. ;he designing and i.$le.enting of nursing inter:ention $rotocol for /I $atients could -e one of the i.$ortant and funda.ental ste$s in i.$ro:ing /I $atients outco.es. Aim8 ;he ai. of this study was to e<a.ine the i.$act of a designed nursing inter:ention $rotocol on .yocardial infarction $atient=s outco.es as indicated -y higher $ost total .ean >nowledge scores, higher $ost total .ean $ractices scores and high le:el of co.$liance to lifelong instruction. "esearc# #ypot#eses$ H+. #atients who will -e e<$osed to a designed nursing inter:ention $rotocol will ha:e a higher $ost total .ean >nowledge scores? H2. #atients who will -e e<$osed to a designed nursing inter:ention $rotocol will ha:e a higher $ost total .ean $ractices scores? H3. #atients who will -e e<$osed to a designed nursing inter:ention $rotocol will ha:e a high le:el of co.$liance to lifelong instruction. Design$ A @uasi-e<$eri.ental research design was utiliAed in this study %ample$ A con:enience sa.$le of 4 adult .ale and fe.ale /I $atients. %etting8 ;he cardiac care units at a selected 5airo Bni:ersity Hos$ital were recruited to fulfill the ai. of this study. &ools8 6our tools were for.ulatedC tested to collect data $ertinent to the study? Socio-de.ogra$hic and .edical data sheet, #reD#ost >nowledge @uestionnaire sheet, an )-ser:ational chec>list and 5o.$liance assess.ent sheet. Structured inter:iew, re:iewing .edical records and direct o-ser:ation were utiliAed for data collection. "esults$ ;he study results re:ealed that the $ost total .ean >nowledge scores of the studied su-Eects is increased significantly with :alue of tF 2 .G at $F . , higher $ost total $ractice scores a.ong the studied su-Eects with tC $ :alues "tF&.G at $F . % also, studied su-Eects had .ild to high co.$liance le:el regarding the lifelong instructions. 'onclusion$ It can -e concluded that, enrich.ent of $atientsH >nowledge and $ractices in relation to their condition and utiliAation of the effecti:e nursing inter:ention $rotocol as an a$$roach of care could ha:e a $ositi:e i.$act u$on i.$ro:e.ent of $atientsH outco.e. "ecommendations$ ;he study reco..ended 5onduction of further studies in order to assess the effecti:eness of the designed $rotocol on $atientsH outco.e regarding different cardiac disorders with re$lication of this study on a larger $ro-a-ility sa.$le fro. different geogra$hical locations at the Ara- Ie$u-lic of 3gy$t, in addition to esta-lish.ent of cardiac reha-ilitation center in the different heath care organiAations. (ey)ards: Nursing inter:ention $rotocol, /yocardial Infarction, )utco.es, 5ardiac care units. Introduction )ne of the goals of nursing care is health $ro.otion and $re:ention of disease. 5ardiac reha-ilitation achie:es these goals as it a co.$rehensi:e $rogra. that $re$ares the $atient to full, :ital and $roducti:e life in the ter.ination i.$osed on hi. -y the cardiac disease. It is a $rocess for restoring and .aintaining a $atient at his o$ti.al $hysiological, $sychological, and social status. #atient .o:es fro. co.$lete de$endence to inde$endence in his acti:ities of daily li:ing "AJ7% "Nair, 2 '%. ;he $attern of coronary care has changed, as ha:ing treat.ent $hiloso$hies, early hos$ital discharge is a .aEor force. Su$er:ised $rogra.s of e<ercise, education and lifestyle changes ha:e i.$ro:ed outco.e for client who ha:e coronary artery disease, .yocardial infarction "/I%, and other se:ere cardio:ascular conditions "Hoe.an, 2 2%. Kulanic> C /ayers "2 ++% added, ;he A.erican Heart Association and A.erican 5ollege of cardiology ha:e de:elo$ed treat.ent guidelines for $atients with unsta-le angina and Non S; seg.ent ele:ation /yocardial infarction, as well as for S; seg.ent ele:ation .yocardial infarction. 3ach guidelines addresses initial and ongoing drug thera$y, indication for fi-rinolytic and #ercutaneous coronary inter:entions, and discharge consideration. 6or $atient with /I, the thera$eutic goals are to esta-lish re$erfusion, to reduce infarct siAe, to $re:ent and treat co.$lications, and to $ro:ide e.otional su$$ort and education. Ieco:ery fro. unsta-le angina is shorter than with .yocardial infarction -ecause only ische.ic, not infracted, tissue occurs. /ore than !&L of $atients e<$eriencing *+

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Journal of Biology, Agriculture and Healthcare ISSN 2224-32 ! "#a$er% ISSN 222&- '3( ")nline% *ol.3, No.+,, 2 +3

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.yocardial infarction return to full acti:ity le:el. Ac>ley, 7adwig, Swan C;ucher "2 '% re$orted that, 5ardiac disease self-.anage.ent are $ersonal actions to .anage heart disease and $re:ent disease $rogression which are? re$ort sy.$to.s of worsening disease? $erfor.s treat.ent regi.en as $rescri-ed? li.its sodiu. inta>e? follows reco..ended diet? $artici$ates in s.o>ing cessation $rogra.? $artici$ates in reco..ended e<ercise $rogra. and uses war.ing signs to see> health care. ;rials ha:e esta-lished that se:eral ty$es of inter:ention can reduce the ris> factors for cardio:ascular disease? i.$ro:e $sychosocial well--eing, and $atient >nowledge? and reduce .or-idity and .ortality "Hanestad, Hanssen C Nordrehaug , 2 4%. Nurses should $ro:ide the $atient with an e<ercise instruction such as instructing the $atient to record his heart rate -efore and after each $hase of e<ercise and whene:er he feels anything unusual during and after each e<ercise. #atient .ay increase s$eed of wal>ing day -y day, and increase the length of wal>ing distance. At the end of G-! wee>s $atient should -e a-le to engage in -ris> wal>ing for &>.Dhr. $atient .ay -e ad:ised to a:oid static e<ercise "lifting, carrying, $ushing hea:y o-Eects%" Nair 2 '%. In 3gy$t, cardiac reha-ilitation, usually, is not a $art of the routine $atient care after acute .yocardial infarction, so ;he designing and i.$le.enting of nursing inter:ention $rotocol for /I $atients could -e one of the i.$ortant and funda.ental ste$s in i.$ro:ing /I $atients outco.es. %ignificance of t#e study 6ro. clinical o-ser:ation in the cardiac care and critical care units, it was o-ser:ed that the nu.-er of $atients with A5S has increased o:er the last years and these $atients re@uire intensi:e colla-orati:e care to sa:e their li:es and they are at ris> for se:eral conse@uences. ;hese conse@uences in turn .ay ha:e negati:e i.$act on the $atientHs $hysical and $sychological condition, and will $rolong $atientHs hos$ital stay, and increase hos$ital costs, ;hat is why there is an interest to conduct such ty$e of research which .ight safeguard this category of $atients against these serious conse@uences, In addition, scattered researches where done in this area es$ecially on the national le:el. 6urther.ore, this research could $ro:ide health $rofessionals with an in de$th understanding related to this category of $atients which could -e reflected $ositi:ely on the @uality of $atientsH life, ;he study as well could su$$ort the i.$ortant role of the nurse in the $atientsH care through assessing the $atientHs and $ro:iding the re@uired care and teaching regarding the .yocardial infarction, Also it is ho$ed that findings of this study .ight hel$ in i.$ro:ing @uality of $atient care and esta-lish e:idence -ased data that can $ro.ote nursing $ractice and research. Aim of t#e study ;he ai. of the study is to assess the i.$act of nursing inter:ention $rotocol on .yocardial infarction $atientHs outco.es at the cardiac care units- 5airo Bni:ersity hos$itals. .+ "esearc# #ypot#eses ;o fulfill the ai. of this study, the following research hy$otheses were for.ulated8 H+. #atients who will -e e<$osed to the nursing inter:ention $rotocol will ha:e a higher $ost total .ean >nowledge scores. H2. #atients who will -e e<$osed to the nursing inter:ention $rotocol will ha:e a higher $ost total .ean $ractices scores. H3. #atients who will -e e<$osed to the nursing inter:ention $rotocol $lan will ha:e a high le:el of co.$liance to .edication regi.en, diet, e<ercises, and follows u$ a$$oint.ents. /+ %ub0ects and Met#ods$ 5.1 Research Design A @uasi-e<$eri.ental research design was utiliAed in this study 5.2 Setting ;his study was carried out at the cardiac care units affiliated to 5airo Bni:ersity Hos$itals, in 5airo go:ernorate. It is one of the largest educational uni:ersity hos$itals in 3gy$t in this field. It recei:es the cardiac $atients all o:er the day. It recei:es .ore than +& /I $atients $er year. 5.3 Subjects A con:enient sa.$le of 4 adult .ale and fe.ale $atients ad.itted to cardiac care units at 5airo uni:ersity hos$itals with acute .yocardial infarction for the first ti.e and willing to $artici$ate in the study. -+ ,+

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Journal of Biology, Agriculture and Healthcare ISSN 2224-32 ! "#a$er% ISSN 222&- '3( ")nline% *ol.3, No.+,, 2 +3

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5.4 Tools 6our tools were de:elo$ed to collect data $ertinent to the study. ;hese tools are8 +-Sociode.ogra$hic and .edical data sheet "A$$endi< A%8it is a sheet co:ering two .ain sections8 the first section is related to sociode.ogra$hic data which includes age, gender, occu$ation, .arital status, le:el of education, socioecono.ic le:el, nutritional ha-its, s.o>ing ha-its etc. and ;he second section co:ers .edical data such as date of ad.ission and discharge, diagnosis, :ital signs, $ast .edical historyC co-.or-idities such as dia-etes, hy$ertension%, routine .edications, fa.ily history, and -ody .ass inde< 2- #reD#ost >nowledge @uestionnaire sheet "A$$endi< B%8 ;his sheet was for.ulated to assess $atientsH >nowledge a-out ris> factors, .anifestations, treat.ent, co.$lications of acute .yocardial infarction, warning signs of recurrent attac>s, acti:ities, and life style .odificationsM.etc. 3- )-ser:ational chec>list "A$$endi< 5%8 ;his sheet was de:elo$ed to assess $atientHs $ractices regarding $atientsH a-ility to $ractice $eri$heral $ulse counting, rela<ation techni@ue? dee$ -reathing techni@ue and filling a diet record. 4- 5o.$liance assess.ent sheet "A$$endi< J%8;his sheet was designed to e:aluate su-EectsH adherence to the $rescri-ed regi.en. It includes si< .ain areas including a% adherence to the life-long $ost discharge instructions? -% adherence to $rescri-ed follow u$ syste.? c% adherence to $rescri-ed .edications regi.en? d% adherence to $rescri-ed diet regi.en? e% adherence to $rescri-ed e<ercise regi.en and f% adherence to stress .anage.ent techni@ues. It is a rating scale which is co.$osed of 4 $oints "always, so.eti.es, rarely and ne:er%. Ethical consideration An official $er.ission to conduct the study was o-tained fro. the ethical co..ittee of research and *ice Jean for Higher 3ducation and Iesearch- 6aculty of Nursing and directors of 5ritical 5are Bnits. *er-al consents were o-tained fro. head nurses of these units. In addition, $atientsH agree.ents to -e included in the study were o-tained for.ally after e<$lanation of the nature and $ur$ose of the study. 3ach $atient was free to either $artici$ate or not in this study and ha:e the right to withdraw fro. the study at any ti.e without any rational? also, $atients were infor.ed that data will not -e included in any further researches without another new consent if they do not .ind. 5onfidentiality and anony.ity of each su-Eect were assured through coding of all data. 5.6 Techniques or data collections Structured inter:iew, re:iewing .edical Dnursing records ,direct $atients o-ser:ation and follow u$ -y $hone calls were utiliAed to fill out the study tools. 5.! "rocedure ;he current study was carried out on two $hases, designation and i.$le.entation $hases which are8 5.!.1 Designing #hase: It was concerned with the construction and $re$aration of the different data collection tools and instructional -oo>let in addition to o-taining .anagerial arrange.ent to carry out the study. 5.!.2 $%#le%entation #hase: ;he researchers :isited the cardiac care units on daily -ases once they find the $atient who .et the criteria of selection? socio-de.ogra$hic and .edical data sheet "tool +% was fulfilled. As well the >nowledge assess.ent sheet "tool 2% and o-ser:ational chec>list sheet "tool 3% were filled out for the whole grou$ as a control grou$. ;he whole grou$ was e<$osed to the routine hos$ital care. ;hen the whole grou$ was su-Eected to the designed nursing inter:ention $rotocol on a daily -ase till discharge as a study grou$. ;hen all su-Eects were su$$lied with the $redeter.ined instructional -oo>let. ;he co.$liance assess.ent sheet "tool 4% was filled out for all su-Eects during the first .onth after discharge. /ainly follow u$ was done through the o$en channel of co..unication with the in:estigator through the tele$hone call to answer their @uestions, reinforce infor.ation, correct .isunderstanding and .onitor the $atientHs adherence to the gi:en instructions. 5.& Statistical data anal'sis Jata o-tained fro. the study tools were categoriAed, ta-ulated, analyAed and data entry was $erfor.ed using the S#SS software "statistical $ac>age for social sciences :ersion2 . %. Jescri$ti:e statistics were a$$lied "e.g. .ean, standard de:iation, fre@uency and $ercentage%. ;ests of significance were $erfor.ed to test the study hy$otheses "i.e. $aired and un$aired t- test, chi s@uare test and AN)*A test%. #earsonHs correlation coefficient was a$$lied -etween @uantitati:e :aria-les. A significant le:el :alue was considered when $N . &.;he s.aller the #- :alue o-tained, the .ore significant is the result. ;he #- :alue is -eing the $ro-a-ility of error of the conclusion. 1+ "esults 6indings of the current study are $resented in three .ain sections? section "+% related to sociode.ogra$hic data, .edical data "ta-le+ and figures+,2,3,4,&,G,,C!%, section "2% is concerned with testing the research hy$othesis "figure ',+ C++% and section "3% is concerned with the additional findings"ta-le2C3%

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Journal of Biology, Agriculture and Healthcare ISSN 2224-32 ! "#a$er% ISSN 222&- '3( ")nline% *ol.3, No.+,, 2 +3

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Section +8 6igure "+% shows that, &2.& L of study sa.$leHs age ranged fro.O& toG& years, and 3,.&L of the. were aged -etween 3&to& years. 6igure "2% shows that, .ore than three fourths of the studied su-Eects ",! L% were .ales. 6igure "3% shows that, !&L of studied su-Eects ca.e fro. ur-an areas and figure "4% shows that "4 L% of the studied su-Eects were o:erweight and 3 L were .oderate o-ese. 6igures "&%C "G% shows that, ",2.&L% of the studied su-Eects were s.o>ers and "3,.'L% of the. were s.o>ing + to 2 cigarettes $er day. In addition that, figure ",% shows that .ore than half "&&L % of the studied su-Eects were diagnosed as S;3/I while "44L %of the. diagnosed NS;3/ and figure"!% shows that "3,.&L% of the. ha:e not any co-.or-idity diseases. ;a-le "+% re:ealed that .ore than one third "3,.&L% of the studied su-Eects were a-le to read and write and "! L% of the. were ha:ing a wor>. In addition that, "4,.&L% of the studied su-Eects were used to eat foundry and fatty diet and ",2.&L% dose not drin> coffee."',.&L% of the studied su-Eects does not $ractice any s$orts. 6inally only "+&L% of the studied su-Eects has $ositi:e fa.ily history for the cardiac disease. Section "2%8 6igure "'% indicating higher total >nowledge scores a.ong the studied su-Eects, ran>ed as satisfactory to good le:els. Howe:er, all of the studied su-Eects "+ L% re.ained with an unsatisfactory >nowledge le:el -efore recei:ing the designed $rotocol which is su$$orting the first hy$othesis which stated P#atients who will -e e<$osed to a designed nursing inter:ention $rotocol will ha:e a higher $ost total .ean >nowledge scoresP. 6igure "+ % shows that "+ L% were ha:ing unsatisfactory le:el of $ractice -efore recei:ing the designed $rotocol, this $ercentage decreased to -e "4&L%after recei:ing the designed $rotocol, the other "&&L% of the studied su-Eects were ha:ing satisfactory "2&L% and good "3 L%le:el of $ractice and this is su$$orting the second hy$othesis which stated P#atients who will -e e<$osed to a designed nursing inter:ention $rotocol will ha:e a higher $ost total .ean $ractices scoresP. finally, it a$$ears fro. figure"++%that, "& L% of the studied su-Eects has .ediu. total co.$liance le:el to the lifelong instructions, while "4,.&L% of the. has low le:el of total co.$liance, and shows also the different su-total co.$liance scores ran>ing fro. low to high le:el of co.$liance which could $artially su$$ort the third hy$othesis which stated P#atients who will -e e<$osed to a designed nursing inter:ention $rotocol will ha:e a high le:el of co.$liance to lifelong instructionP. Section "3% ;a-le "2% re:ealed that, there is a significant $ositi:e statistical correlations -etween total >nowledge scores and total $ractice scores, total $ractice scores and total co.$liance scores and total co.$liance scores and total >nowledge scores "r F .&G', $ F . %, "r F .& ', $ F . +% and "rF .33! ,$F . 33% res$ecti:ely. ;a-le "3% Je.onstrates that, there is a highly significant statistical difference was found -etween educational le:el and total .ean >nowledge, $ractice and co.$liance scores of the studied su-Eects. 2+ Discussion ;he $resent study delineated that .ore than three fourths of the cases are .ale and .ore than half of the study sa.$leHs age ranged -etween O& -G& years old. ;his agreed with Bare, 5hee:er, Hin>le C S.eltAer "2 + % who .entioned that ris> factors for the de:elo$.ent of coronary artery diseases Q5AJR increases with age and .ale gender. In accordance with these results, Bos-Schea$, Haut:ast, Heester.ans, 1it CB.ans "2 ++% re$orted in a $u-lished study entitled as PNursing role to i.$ro:e care to infarct $atients and $atients undergoing heart surgeryP that ",&L% were .ale. ;his study results is si.ilar to the study of Angerud ,Brulin , 3liasson C Naslund "2 +3% in an analysis of 42GG /I $atient which re:ealed that a-out two third of the studied su-Eects were .ale with .ean age of G+.! years, and Haw-oldt, #earce C 2oung "2 + % in a study on 34G /I $atients found that, their .ean age was G&.3 years and G&.&L of the. were .ale. /oreo:er, Ahrens, Slin$ell C #rentice "2 + % found that A5S is .ore $re:alent in older $ersons than in younger $ersons, the condition de:elo$s earlier in .en than in wo.en. Holle, Sirch-erger, Such, /eisinger, SeidlC 1ende "2 + % also confir.ed that aged $atients ha:e a high $re:alence of /I. ;he study results also su$$orted -y the results of Haw-oldt, #earceC 2oung "2 + % which studied 34G /I $atients, showed that the .ean age of $atients was G&.4 years and al.ost two-thirds were .ale. Another study done -y 3liasson, Isa>sson ,Jansson , 7und-lad , NaslundC 4ing.ar> "2 ++% studied !G3 with a first /I and showed that a-out three fourths of the studied su-Eects were .ale with .ean age of &&.& years. In contrast with our study, the study of Aurige..a, 5hiri-oga, 6ornasini, Kold-erg, Kore, 7essard, S$encerC 2arAe-s>i "2 '% that studied G334 /I $atients showed that the .ean age of the studied su-Eects was ,+ years and &GL were .en. ;he de.ogra$hic data of $resent study also delineated that the .aEority of the studied su-Eects ca.e fro. ur-an areas. As 5airo Bni:ersity hos$itals is one of the largest educational uni:ersity hos$itals in 3gy$t in this field which recei:es the cardiac $atients fro. all o:er the country. ;his .ay -e due to the unhealthy lifestyle which the ur-an $eo$le ha:e co.$aring to the rural $eo$le lifestyle. ;his study results is si.ilar to the

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Journal of Biology, Agriculture and Healthcare ISSN 2224-32 ! "#a$er% ISSN 222&- '3( ")nline% *ol.3, No.+,, 2 +3

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study of Angerud ,Brulin, 3liasson C Naslund "2 +3% in an analysis of 42GG /I $atient which re:ealed that a-out two thirds of the studied su-Eects ca.e fro. ur-an areas. ;he $resent study re:ealed that a-out three fourths of the study su-Eects were s.o>ers, that is why, s.o>ing .ay -e the .ost $ro-a-le ris> factor for the .aEority of /I e:ents. ;his is agreed with Kulanic> C /ayers "2 ++% who re$orted that s.o>ing causes :asoconstriction and reduces .yocardial o<ygen su$$ly , ris> for de:elo$ing 5AJ is 2 to G ti.es greater in cigarette s.o>ers and ris> is $ro$ortional to nu.-er of cigarettes s.o>ed. Howe:er the study carried out -y Angerud , Brulin , 3liasson C Naslund "2 +3% showed that a-out one third only of the study su-Eects which was 42GG /I $atients were s.o>ers.In accordance to this study, the study of 3liasson, Isa>sson , Jansson , 7und-lad , NTslund C 4ing.ar> "2 ++% which studied !G3 with a first /I and showed that 3'.GL of the study su-Eects were s.o>ers./oreo:er, Haw-oldt, #earce C 2oung "2 + % found that .ore than one third of the studied su-Eects "34G /I $atients % were current s.o>ers. ;he re:iewed .edical data sheet of current study su-Eects showed that .ore than half of the. were diagnosed S;3/I. ;his result is si.ilar to the results of Aurige..a, 5hiri-oga, 6ornasini, Kold-erg, Kore, 7essard, S$encerC 2arAe-s>i "2 '% study titled Q5onte.$orary trends in e:idence--ased treat.ent for acute .yocardial infarctionR which showed that the .aEority of the studied su-Eects were S;3/I. In contrast with this study the study of 2oung, Haw-oldt C #earce "2 + % which studied 34G /I $atients found that, the .aEority of the study su-Eects diagnosed NS;3/I. Iegarding B/I the current study showed that .ore than one third of the studied su-Eects were o:erweight and .ore than one forth of the. were o-ese, ;hat=s why, the o-esity .ay -e one of the ris> factors for /I. In this regards, Bru-a>er, Sa.insyC 1haley "2 2% re$orted that o-esity is docu.ented in a$$ro<i.ately 4 L of $eo$le with 5AJ $atients. In accordance with these results, BucholA, 5han, Jone, Iathore, Sru.holA, Ieid, IichC S$ertus "2 +2% in a study titled QBody .ass inde< and .ortality in acute .yocardial infarction $atientsR done on study sa.$le G3&' /I $atients re$orted that one third of the studied su-Eects were o-ese. Iegarding the co-.or-idities the current study re:ealed that co-.or-idities was a-sent in one third of the study su-Eects, while al.ost one fourths of the studied su-Eects had hy$ertension $lus dia-etes .ellitus and one fifth of the studied su-Eects had dia-etes .ellitus only. Kulanic> C /ayers "2 ++% also .entioned that eighty $ercent of dia-etic $atients ha:e cardio:ascular disease. In addition that High -lood $ressure is .aEor ris> factor for 5AJ as Nair "2 '% re$orted that the stress of constantly ele:ated -lood $ressure can increase the rate of atherosclerosis de:elo$.ent. In this regard, Aurige..a, 5hiri-oga, 6ornasini, Kold-erg, Kore, 7essard, S$encerC 2arAe-s>i "2 '% re$orted that a-out one third of the study sa.$le ha:en=t any co-.or-idities, while .ore than one fourth of the study sa.$le had had +-2 co-.or-idities and a-out one third of the. had 3-4 co.or-idities. Also BucholA et al. "2 +2% re$orted in a study done on G3&' /I $atients that around two- thirds of the sa.$le had hy$ertension, and .ore than one third of the. had dia-etes .ellitus. /oreo:er, Haw-oldt, #earce C 2oung "2 + % found that .ore than one fourth of their study su-Eects had had dia-etes .ellitus, while .ore than half of the. had hy$ertension. As regards to the #atientHs Snowledge, the current study results delineated, a higher statistically significant difference -etween $atient=s >nowledge score $re and $ost e<$osure to the designed $rotocol, indicating higher total and su-total .ean $ost >nowledge scores a.ong the studied su-Eects, ran>ed as satisfactory to good le:els. Howe:er, all of the studied su-Eects were ha:ing an unsatisfactory >nowledge le:el -efore recei:ing the designed $rotocol. ;he rational for >nowledge i.$ro:e.ent .ight -e related to the $ro:ision of educational -oo>let and D or :er-al instructional infor.ation. Also, the curiosity of the studied su-Eects as this is the first heart attac> for the. and .any concerns are $resent. Iesults of $resent study showed that there was a significant difference -efore and after the inter:ention in the studied su-Eects. ;herefore, a$$lying discharge $lan could ha:e $ositi:e effects on the lifestyle of $atients with /I. Si.ilar to the results of this research, another study -y Jiang, SitC 1ong "2 ,% indicated that, a nurseled cardiac reha-ilitation $rogra. can significantly i.$ro:e the health -eha:iors and cardiac $hysiological ris> factors in coronary heart disease $atients. Based on these findings, it is necessary to consider the role of nurses in a cardiac reha-ilitation $rogra.. Jallec>, 7ue>erC Sch.idt "2 ++% re$orted that, $artici$ation in cardiac reha-ilitation $rogra.s had $ositi:e changes in :arious ris> factors li>e -lood $ressure, cholesterol, triglyceride, HJ7 and 7J7 cholesterol +,,+! energy e<$enditure, fat, and stress. 6ollowing u$ the client=s -eha:ior at ho.e hel$ed -etter controlling the heart disease. ;his reduced the fre@uency of their re-hos$italiAation, cost of hos$italiAation and .ortality rate. 6ran>lin, Kordon 7eightonC Sal.on "2 2% also showed a reduction in ris> factors of $atients with /I, 5ABK, #ercutaneous coronary inter:ention, or angina after $artici$ating in traditional cardiac reha-ilitation, cardiac reha-ilitation with $hysician su$er:ision, and a co..unity--ased e<ercise $rogra. run -y e<ercise $hysiologists. In addition, A-edi, Ah.adi, Arefi ,6aghihi-AadehC Khofrani$our "2 &% re$orted that, continuous care .odel has $ositi:e effects on the @uality of life of $atients after 5ABK and heart failure, in all $hysical,

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e.otional and general di.ensions. ;his .odel was effecti:e in the reduction of the hos$italiAation $eriod and chest $ain in $atients with coronary :ascular diseases. Howe:er, the study carried out -y Hosseini, /oha..adi, IahgoAarC ;aherian "2 G% ai.ing to deter.ine the effect of a$$lying cardiac reha-ilitation at ho.e on the @uality of life of $atients with /I showed that the reha-ilitation $rogra. consisting of training sessions regarding /I disease and its co.$lications, dietary and .edicinal regi.e, ris> factors of the disease, etc. at ho.e had no $articular effect on :arious di.ensions of the @uality of life of this grou$ of $atients and there was no significant difference -etween grou$s. Khahra.anian, KolchinC Iosta.i "2 ++% showed that, education $rogra.s and follow-u$ -y tele$hone ha:e $ositi:e effects on >nowledge, self-care -eha:iors, a disease sy.$to.s of $atients with cardiac failure. #atients forget the thera$eutic reco..endations gradually after discharge fro. the hos$ital? therefore, it is necessary to $ro:ide such infor.ation. )n the other hand, the nu.-er of healthy undesira-le -eha:iors of $atients with /I increases if it is not followed-u$ at ho.e. Since the $atients= $artici$ation in cardiac reha-ilitation $rogra.s after an acute /I is low, they re@uire education and follow-u$ regarding the control of sy.$to.s, .edicinal infor.ation, and i.$ro:e.ent of lifestyle. 5hris C5harlie "2 4% agreed with this findings as they studied the PInfluence of written infor.ation on $atientHs >nowledge of their diagnosisP on G4 $atients in )<ford Bni:ersity found that $atients recei:ing an infor.ation sheet were twice as li>ely to -e correct with their .ain diagnosis "&'L :s 3+L% co.$ared with the control grou$. ;here was a tendency for $atients recei:ing a sheet to ha:e increased >nowledge of $re:ious .edical $ro-le.s. 6inally, $atients recei:ing a sheet were significantly .ore satisfied with the infor.ation gi:en a-out their diagnosis in hos$ital co.$ared with the control grou$. As regards to the relationshi$ -etween >nowledge and educational le:el, the current study re:ealed that there was significant statistical correlation -etween educational le:el and .ean >nowledge scores a.ong studied su-Eects. In this regard, Alghani. C Alnaif "2 '% agreed with our findings in a $u-lished research article entitled as P$atients= >nowledge and attitudes towards health education8 i.$lications for $ri.ary health care ser:icesP in Saudi Ara-ia in which they found, res$ondents with a higher le:el of education had a significantly higher .ean score "3.G3% of >nowledge a-out dia-etes than those with a lower le:el of education "3.2!% "t-test F 3.GG&, $N . +%. 5ontradicting this, Selo.a "2 + % re$orted in an un$u-lished doctorate thesis entitled asR I.$act of utiliAation of a designed nursing clinical $athway guidelines on the $atientsH outco.es with cardiac $acing at the critical care units, 3l-/anial Bni:ersity Hos$italR that there was no significant statistical correlation -etween educational le:el and .ean >nowledge scores a.ong study and control grou$ su-Eects throughout the different assess.ent $eriods e<ce$t during assess.ent $eriod -efore $ace.a>er insertion. As regards to $atient=s $ractice, the current study results re$orted that there was a significant statistical difference -etween $atient=s $ractice .ean scores $re and $ost e<$osure to the designed $rotocol, the .aEority of study su-Eects had higher $ost total and su-total .ean $ractice scores, ran>ed as satisfactory to good le:els. Howe:er, all of the studied su-Eects had an unsatisfactory $ractice scores -efore recei:ing the designed $rotocol .;hese findings .ay -e as a result of continuous de.onstration, rede.onestration, follow u$ and $ractical content of the instructional -oo>let which was gi:en to the studied su-Eects with the continuous e<$lanations, reinforce.ent and feed-ac>. In the $resent study, there was a significant statistical correlation -etween $atients .ean $ractices scores and their le:el of education in different assess.ent $eriods a.ong studied su-Eects -efore and after the inter:ention. In addition to, there was a significant statistical $ositi:e correlation -etween total >nowledge and total $ractices scores a.ong the studied su-Eects. 5ontradicting this, Selo.a "2 + % re$orted that there was no significant statistical correlation -etween $atients .ean $ractices scores and their le:el of education in different assess.ent $eriods a.ong study and control grou$ su-Eects. Howe:er, there was a significant statistical $ositi:e correlation -etween total >nowledge and total $ractices scores a.ong the study and control grou$ su-Eects throughout the different assess.ent $eriods. In accordance with the study findings, Iefaii "2 + % in an un$u-lished doctorate thesis entitled as Pthe i.$act of a designed nursing clinical $athway guidelines on acute .yocardial infarction $atientsH outco.esP on G $atients "3 study and 3 control% at Benha Bni:ersity Hos$itals in 3gy$t found that, an incre.ent of study grou$ $ost .ean $ractices scores as co.$ared to control grou$ after i.$le.entation of a designed nursing clinical $athway with a highly significant statistical differences -etween the two grou$s during the two follow u$ assess.ent "i..ediately $ost and three .onths later% with the following (2 C$ :alues"(2 F2+.,2 at $F . + C (2 F 4.+&! at $ F . + res$ecti:ely%. As well, 3l Hadary "2 '% in an un$u-lished doctorate found that there was a higher statistically significant difference -etween the study and control grou$ su-Eects in different assess.ent $eriods, indicating higher .ean :alues of a:oiding cardiac stress acti:ities, cli.-ing stairs as ad:ised and arranging acti:ityDrest ti.e throughout the follow u$ :isits a.ong the study grou$ as co.$ared to the control grou$ ones, with high significant statistical differences -etween the. "6F 2&.+4 at $F . +, 6F&3.3' at $F . +C6F3 ., at $F . +%./oreo:er, /oha.ed "2 G% in a study entitled asP effect of counseling on

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$atientHs co.$liance with thera$eutic regi.en after artificial :al:ular heart re$lace.ent surgeryP on + $atients at the cardiothoracic surgery de$art.ent at Ain Sha.s Bni:ersity hos$ital in 3gy$t, in an un$u-lished doctorate thesis found that, none of the $atients in the study and control grou$s were $erfor.ing radial $ulse .easuring, nec>, shoulder and el-ow e<ercises $re-$rogra. i.$le.entation. Howe:er $ost $rogra. i.$le.entation? a$$ro<i.ately one third had satisfactory $erfor.ance, with a highly significant statistical difference -etween study and control grou$ su-Eects As regards to $atient=s co.$liance, the current study indicated a statistically significant difference -etween the studied su-Eects regarding to total and su-total co.$liance scores $ost discharge and during follow u$ :isits. ;he studied su-Eects showed different le:els of co.$liance ranging -etween -eing low, .ediu. and high co.$liance le:els. ;his .ay -e due to continuous contact with the studied su-Eects through o$en channel of tele$hone co..unication -etween the researcher and the studied su-Eects. 1al, Jaars.a, /oserC*eeger "2 G% .entioned that in order to i.$ro:e co.$liance, an incre.ent of >nowledge and a change of $atientHs -eliefs -y education and counseling are reco..ended. 3<tra attention should -e $aid to $atients with de$ressi:e sy.$to.s. In this regard, 3l Hadary "2 '% su$$orted these result when re$orting that study grou$ su-Eects showed a higher .ean co.$liance scores regarding following $rescri-ed .edications and following $rescri-ed acti:ity regi.en as co.$ared to control grou$ su-Eects with significant statistical differences -etween the two studied grou$s "6F2&.G at $F . +C 6F G'. 2 at $F . +%.Also, 1al, Jaars.a, /oserC*eeger "2 G% in a $u-lished research article entitled as P5o.$liance in heart failure $atients8 the i.$ortance of >nowledge and -eliefP in Bni:ersity of Kroningen, data were collected in a cohort of & + heart failure $atients. ;hey found that o:erall co.$liance was ,2L in this older heart failure $o$ulation. 5o.$liance with .edication and a$$oint.ent >ee$ing was high "O' L%. In contrast, co.$liance with diet "!3L%, fluid restriction ",3L%, e<ercise "3'L%, and weighing "3&L% was .ar>edly lower. 5o.$liance was related to >nowledge ")IF&.G,? 5I 2.!,-++.+'%, -eliefs ")IF+.,!? 5I +.+!-2.G'%, and de$ressi:e sy.$to.s ")IF .&3? 5I .3&- .,!%. Adding to that, 4erwic "2 ,% stated that, the co.$liance to the thera$eutic regi.en was $ro.oted -y nursing clarification and e<$lanation. ;herefore, the infor.ation $ro:ided through nursing inter:ention .ust -e sufficient to increase $atientHs desire and encourage the. to co.$ly with $rescri-ed thera$eutic regi.en after discharge. ;he $atient who are oriented with e:ery-thing a-out their disease are .ore li>ely to engage in acti:ities that $ro.ote changing their -eha:iors, $ro.ote $hysical well--eing and enhancing the co.$liance with thera$eutic regi.en than those who are not oriented. 3+ 'onclusion 5onsidering the results of the $resent study and the a:aila-le e:idence, it can -e concluded that, $atients who were e<$osed to the designed nursing $rotocol for the .yocardial infarction $atients showed a relati:e i.$ro:e.ent in their conditions than those who were e<$osed to the routine hos$ital care only. ;his i.$ro:e.ent was .anifested in the incre.ent in the $ost total .ean >nowledge scores, $ost total .ean $ractice scores and the .ean co.$liance scores as regards to the i..ediate, life-long and follow u$ instructions. Ieha-ilitation centers also could a$$ly this .odel to follow the $atients after /I.

4+ "ecommendations Based on the findings of the $resent study, the following reco..endations are suggested8 Ieco..endations related to $atients8 - 3sta-lish.ent of $atientsH educational centers in hos$itals e@ui$$ed -y suita-le related .aterials, .edias and audio-:isual aids for teaching all .yocardial infarction $atientsH how to li:e with their .edical condition. - 5ardiac reha-ilitation centers can -e esta-lished and encouraged. - Iegular follow u$ for all $atients with .yocardial infarction to e:aluate their health conditions and to detect co.$lications early. Ieco..endations for furthers researches8 - Ie$lication of the study on a larger $ro-a-ility sa.$le selected fro. different geogra$hical areas in 3gy$t is reco..ended to o-tain .ore generaliAa-le data. - 6urther studies ha:e to -e carried out in order to assess the effecti:eness of nursing inter:ention $rotocol a$$lications on $atientsH outco.es regarding different cardiac disorders. - 6urther studies ha:e to -e carried out in order to assess nursesH >nowledge and $ractices regarding $ro:iding a nursing inter:ention $rotocol for .yocardial infarction $atients. Ac!no)ledgment ;his research article would not ha:e -een $ossi-le without the su$$ort of .any $eo$le. ;he authors wish to e<$ress their gratitude to all $eo$le who share or hel$ in this research.

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"eferences Ac>ley, B. J., 7adwig, K. B., Swan, B. A. C ;ucher, S. J. "2 '%. 3:idence-Based nursing care guidelines. 5anada, 3lse:ier /os-y, $.$. +4 -+4!. A-edi, H.A., Arefi, S.H., Ah.adi, 6., 6aghihi-Aadeh, S. C Khofrani$our, 6. "2 &%. 3ffect of continuous consultation care .odel on re hos$italiAation and chest $ain in $atients with coronary artery disease. J UaA:in Bni: /ed Sci? 3&"'%8 ''-+ 3. Ahrens, ;. S., Slein$ell, I. /. C #rentice, J., "2 + %. 5ritical care nursing certification, Singa$ore, /cKrewHill, $.$ G&-,&. Alghani., S.A., Alnaif, /.S. "2 '%. #atientsH >nowledge and attitudes towards health education8 I.$lications for $ri.ary health care ser:ices in Saudi Ara-ia. #u-lished thesis? *olu.e 8 +G, Issue 8 +, $.$. 8 2,-3 Angerud, S.H., Brulin, 5., 3liasson /. C Naslund, B. "2 +3%.7onger $re-hos$ital delay in first .yocardial infarction a.ong $atients with dia-etes8 B/5 cardio:ascular disorders2 +3,+38 G. Aurige..a, #., 5hiri-oga, J., 6ornasini, /., Kold-erg, I.J., Kore, J./., 7essard,J., S$encer, 6.A C2arAe-s>i, J."2 '%. 5onte.$orary trends in e:idence- -ased treat.ent for acute .yocardial infarction. A/ J /ed.2 + ?+23"2%8 +GG. Bru-a>er, #. H., Sa.ins>y, 7.A., C1haley, /.H., "2 2%. 5oronary artery diseases, essentials of $re:ention and reha-ilitation $rogra.s. Bnited states of A.erica, -y Hu.an >inetics, $.$. 2'+-32G. BucholA, 3./., 5han, #.S., Jones, #.K., Sru.holA, H./., Iathore, S.S., Iich, /.1.C S$ertus, J.A."2 +2%. Body .ass inde< and .ortality in acute .yocardial infarction Jallec>, 7.5., 7ue>er, I. C Sch.idt, 7.S."2 ++%. 5ardiac reha-ilitation outco.es in a con:entional :ersus tele.edicine--ased $rogra. ? +,"&%8 2+,-2+. 3l Hadary, S. "2 '%8 I.$act of BtiliAation of a Nursing 5linical #athway Kuidelines on the Heart 6ailure #atientsH )utco.es at the 5ritical 5are Bnits, 3l-/anial Bni:ersity Hos$ital8 Joctorate thesis. 3lison, /., Isa>sson, I./., Jansson, J.H., 7und-ald, J., Naslund, B.C 4ing.ar>, S. "2 ++%. 6ran>lin B.A., Kordon N.6., 7eighton, I.6. C Sal.on, I..J. "2 2%. 3ffecti:eness of three .odels for co.$rehensi:e cardio:ascular disease ris> reduction. A. J 5ardiol? !'"++%8 +2G3-!. Khahra.anian, A., Kolchin, /. C Iosta.i, H. "2 ++%3ducational needs of .yocardial infarction $atients. J Br.ia Nurs /idwifery 6ac 2 ++? '"3%8 +&,-G3. Kulanic>, /. and /yers, J.7. "2 ++%. Nursing care $lans",th ed.%. Bnited states of A.erica,3lse:ier /os-y, $.$ 2 '-2+ . Haw-oldt, J.J., #earce, N.J. C 2oung, S.1. "2 + %. Bse of e:idence -ased thera$y at discharge for $atients with A/I.5J#H-*)7 G3"3%82 ,-2++. Hoe.an, S. #. "2 2%. Ieha-ilitation nursing "3rd ed.%. Bnited states of A.erica, /os-y, $.$. ,23-,3&. Holle, I., Sitch-erger, I., Such, B., /eisinger, 5., Seidi, H. C 1ende, I."2 + %. Nurse -ased case .anage.ent for aged $atients with /I8 study $rotocol of a rando.iAed controlled trial. B/5 Keriatrics 2 + , + 82'. Hosseini, /.A., /oha..adi, 6., IahgoAar, /. C ;aherian, A."2 G%. 3ffect of ho.e--ased cardiac reha-ilitation on @uality of life in the $atients with .yocardial infarction. Iran Ieha-il J 2 G? ,"3%8 ++-'. Jiang, (., Sit, J.1.C 1ong, ;.S. "2 ,%. A nurse-led cardiac reha-ilitation $rogra..e i.$ro:es health -eha:iours and cardiac $hysiological ris> $ara.eters8 e:idence fro. 5hengdu, 5hina. J 5lin Nurse 2 ,? +G"+ %. Nair, B.I. "2 '%. ;e<t-oo> of .edical surgical nursing "+st ed.%. India, Jay$ee Brothers .edical #u-lishers, $.$ 4&-43 . Selo.a, 2.3. "2 + %. I.$act of utiliAation of a designed nursing clinical $athway guidelines on the $atientsH outco.es with cardiac $acing at the critical care units, 3l-/anial Bni:ersity Hos$ital8 Joctorate thesis.

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"A% 6igures

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5igure 6**7$ Differences in total and subtotal compliance score levels of t#e studied sub0ects8 post receiving t#e designed protocol 6n9.:7$

Compliance scores
low compliance medium compliance high compliance
95% 87.5% 70% 50% 47.5% 66% 55% 45% 22.5% 10% 2.5% 12.5% 0% 7.5% 5% 2.5% 2.5%

20%

total compliance

Patient's Patient's Patient's compliance to compliance to compliance to life-long regular follow up me ication instructions regimen

Patient's ! Patient's compliance to compliance to iet regimen e"ercise regimen

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"B% ;a-les8 &able 6*7$ Distribution of t#e educational level; Occupation; Diet nature; 'offee inta!e; practicing sports and family #istory for cardiac diseases for t#e studied sub0ects 6n9.:7+ Ite.s - Illiterate - 5an read and write - Secondary education - High education - JoesnHt wor> - 1or>erD 3.$loyer - 7ow salt - 7ow fat - 6oundry and fatty - Not s$ecificP usualP - No - 2es - No - 2es - No - 2es No , +& +2 G ! 32 2 + +' +' 2' ++ 3' + 34 G L +,.& 3,.& 3 . +&. 2 . ! . & 2.& 4,.& 4& ,2.& 2,.& ',.& 2.& !&. +&.

3ducational le:el

)ccu$ation

Jiet nature

5offee inta>e #ractice s$orts 6a.ily history

&able 6,7$ 'orrelation 'oefficient et)een total !no)ledge scores; total practice scores; and total compliance scores of t#e studied sub0ects 6n9.:7+ ;he Ite.s +-;otal >nowledge scores and total $ractice scores 2- ;otal $ractice scores and total co.$liance scores 3- ;otal co.$liance scores and total >nowledge scores 0Significant at the $ N . & $ro-a-ility le:el rD:alue .&G' .& ' .33! NSF not statistically significant "D:alue . 0 . +0 . 330

&able 6-7$ One )ay ANO<A test for comparison of total mean !no)ledge scores; total mean practice score and total mean compliance scores in relation to educational =evel of t#e %tudied %ub0ects 6n9.:7+ *aria-le • f $ . 0 . &0 . ++0

3ducational le:el + .+ o 3ducational le:elD total .ean >nowledge scores &.3 o 3ducational le:elD total .ean $ractice scores 4.2 o 3ducational le:elD total .ean co.$liance scores 0Significant at the #N . & $ro-a-ility le:el 0NSF not statistically significant

3&

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