Wiyatno ER, et al. Belitung Nursing Journal.

2017 August;3(4):360-369
Accepted: 17 May 2017
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© 2017 Belitung Nursing Journal

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ORIGINAL RESEARCH ISSN: 2477-4073

EFFECT OF ACCUPRESSURE ON QUALITY OF SLEEP AND PULSE

RATE IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION
Eko Rustamaji Wiyatno*, Rr. Sri Endang Pujiastuti, Titin Suheri, Djenta Saha

Program Pascasarjana Magister Terapan Kesehatan Keperawatan, Politeknik Kesehatan Kementrian Kesehatan
Semarang

*Correspondence:
Eko Rustamaji Wiyatno
Program Pascasarjana Magister Terapan Kesehatan, Politeknik Kesehatan Kementrian Kesehatan Semarang
Jl. Tirto Agung, Pedalangan, Banyumanik, Kota Semarang, Jawa Tengah, Indonesia (50268)
E-mail: ekorustamaji2004@gmail.com
ABSTRACT
Background: Patients with acute myocardial infarction have a change in sleep pattern. Acupressure is identified
as a therapy with the principle of healing to deal with sleep changes.
Objective: To analyze the effect of acupressure on sleep quality and pulse rate in patients with acute myocardial
infarction.
Methods: This study employed a quasi-experiment study with non randomized pretest-posttest with control
group design. There were 50 respondents selected in this study, with 25 assigned in the intervention and control
group using consecutive sampling. Quality Sleep Questionnaire and bedside monitor were used to measure sleep
quality and pulse rate. Accupressure in combination of Neiguan point (PC 6), Shenmen (HT7), Sanyinjiao
(SP6), Yintang (EX3) and Tay (EX5) was given as the nursing intervention in this study. Data were analyzed
using paired t-test and independent t-test.
Results: There was statistically a significant increase of quality of sleep and significant decrease of pulse rate in
the intervention group with p-value 0.000 (<0.05).
Conclusion: Accupressure has a significant effect on the increase of sleep quality and the decrease of pulse rate
in patients with acute myocardial infarction. Thus, it is suggested that accupressure could be one of the nursing
intervention for AMI patients to increase sleep quality and decrease of pulse rate.

Key words: Acupressure, acute myocardial infarction, sleep quality, pulse rate

INTRODUCTION
Changes in lifestyle are major factors (WHO) data in 2012 showed that heart
thought to influence susceptibility to disease was the leading cause of death in
many diseases. Degenerative diseases are the world, causing 17.5 million deaths and
often linked with the way people live their is expected to continue to increase to 22.2
life such as heart disease, stroke, and million by 2030.2 Acute myocardial
obesity.1 World Health Organization infarction (AMI) disease is a type of

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coronary heart disease that has high during hospitalization the number of
morbidity and mortality rates. Data on the patients who had poor sleep quality was
top ten causes of death in the world 45.6%, and after undergoing treatment
showed that ischemic heart disease is the patients who had sleep quality was
highest, which was 7.4 million deaths in decreased by 57.4%.
2012. The Center for Data and Sleep has an important role in
Information Ministry of Health explained cardiovascular function, and sleep
that the prevalence of coronary heart deprivation can lead to intensive anxiety,
disease in 2013 based on medical irritability, and anger that increase heart
diagnosis and symptoms was 1.5% or rate and myocardial oxygen need, which
2,650,340 people, while the number of may result in recurrence.7 Hemodynamic
patients with coronary heart disease in manifestations in AMI patients may be
East Java was 1.3% or 375,125 people.2 tachycardia or bradycardia.8 Heart rate
The medical record data of ICCU in experienced tachycardia caused by acute
the Hospital of Dr. Iskak Tulungangung pain and anxiety that increase the
indicated that from January to August stimulation of the sympathetic nerve and
2016 AMI case was ranked first, with the adrenal hormones so that the pulse
number of inpatients in ICCU room as increases.9
much as 43% with an average of 27 Decreased sleep quality needs to be
patients per month.3 Based on the given serious attention in dealing with
preliminary study with 8 patients AMI patients. Pharmacologic and non-
diagnosed with myocardial infarction pharmacological methods can be used to
stated that they have low quality of sleep. control sleep disorders. The
Literature stated that critical patients pharmacological therapy used today is the
admitted to intensive care have a tendency benzodiazepine drug class, however the
to have sleep problems and circadian use of drugs has side effects such as
patterns are impaired due to both hemodynamic decline, memory deficits,
psychological and environmental factors.4 drug resistance and dependence when
Patients with acute coronary have a used over a long period, whereas
change in sleep patterns, with difficulty nonpharmacologic therapy is safer.7 Many
starting and maintaining sleep, increasing non-pharmacologically independent
reactive responses to stimuli, and nursing interventions can be given to
decreased total sleep time, early stage of overcome sleep disorders as well as the
deep sleep (Slow Wave Sleep) and REM negative impact felt by AMI patients such
sleep. Sleep disorders in ICCU patients as dhikr,10 murotal,11 and acupressure.7,12
can be caused by interaction of patient Acupressure is a simple, cheap, easy
care, disease severity, noise, mechanical to do, safe, and no side effects because it
ventilation, pain, medication, or changes is not an invasive action.13 Acupressure is
in circadian rhythm. very practical because it does not require
The results of study of Schiza et al5 any equipment and enough with the hands
indicated that revealed that approximately or fingers.14,15 Manual stimulation at the
56% of patients with sleep deprivation acupressure point is proven increasing
and acute myocardial infarction on the serotonin and endorphin production and
first day of hospitalization had low sleep contributing to increased serum cortisol
quality in the first three days of regulation. Endorphin is a natural opiate
hospitalization. Lei et al6 revealed that produced in the body, which triggers a

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calming and stimulating response in the Shenmen (HT7), Sanyinjiao (SP6),
body, has a positive effect on emotions, Yintang (EX3) and Tay (EX5) as the
reduces anxiety, causes relaxation, nursing intervention in patients with
improves sleep quality and normalizes decreased sleep quality and pulse
body function,14 whereas serotonin has the elevation in AMI patients in ICCU.
function of regulating mood and sleep.16 Therefore, this study aims to determine
Empirical evidence of the effect of the effect of accupressure on quality of
acupressure has been performed in several sleep and pulse rate in patients with acute
studies. Masoumeh et al7 study revealed myocardial infarction.
that that acupressure can have a
therapeutic effect in improving sleep METHODS
quality in ACS patients and has no side Design
effects with p <0.001 and effect size 1.14. This study employed a quasi-experimental
The intervention given in this study was study with non-randomized pretest-
the acupressure at the point of Fengchi posttest with control group design,
(GB 20), shenmen (HT7), yongquan conducted in the ICCU of Dr. Iskak
(KL1), ying-tang (EX-3) with a duration Tulungagung hospital, East Java,
of 18 minutes performed 1 times daily for Indonesia on January - February 2017.
3 days.7
Another study conducted by Shariati Population and Sample
15
et al indicated that acupressure in The target population in this study is all
combining shenmen point (HT7), Hegu patients with acute myocardial infarction
Li4) and Sanyinjiao (SP6) in 15 minutes (AMI) treated in the ICCU at Dr. Iskak
for 3 times a week for 1 month showed Tulungagung hospital. Consecutive
that there was a difference in sleep quality sampling was used to select the sample.
between acupressure group and control There were 50 respondents selected in this
group in hemodyalisis patients with p study, with 25 assigned in the intervention
<0.001 and effect size 1.15. and control group. The inclusion criteria
Based on the results of literature in this study were: 1) AMI patient aged ≥
review on acupressure therapy, it is 26 years, 2) able to communicate verbally,
obtained that acupressure at 5 points with 3) had been treated at least 1 x 24 hours,
combining the heart point of shen men and 4) did not take a sedative drug 4-5
(HT-7), the point of the neiguan heart hour before the intervention. The
lining (PC-6), and the spleen point of san exclusion criteria were: 1) Patient in
yin jiao (SP -6) has an effect on emergency/critical condition (shortness,
improving the quality of sleep for those hypotension, shock, acute phase), 2)
who have difficulty getting into sleep and unconscious, 3) patients with
other sleep disturbances; and the special contraindications of acupressure: injured
point of tay point (EX-5) and yintang skin, swelling and bone / fractures /
(EX-3) gives a relaxed feeling.17 Selection fractures.
of such intervention points is practical,
easier to do, and the location of the Intervention
selected point is easy to find and be Research was conducted by the researcher
applied by the nurse. However, little is and an enumenerator who have the
known about the accupressure in competence to perform acupressure and
combination of Neiguan point (PC 6), certified by the Association of

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362
Chiropractors and Akupresur Seluruh technique, which is a circular motion
Indonesia (ACASI). Accrupressure was opposite to the clock direction. The total
performed at the point of Neiguan (PC 6), amount of massage time was ± 18 minutes
Shenmen (HT7), Sanyinjiao (SP6), given 1 time a day before sleep at night
Yintang (EX3) and tay (EX5) in the right between 20.00 to 22.00 pm for 2 days.
and left body, so that the total number is 9 The control group in this study only
accupressure points (See Figure 1). Each received treatment according to the
point was performed for 2 minutes with standard of procedure of the ICCU in the
the thumb of the right hand and sedation hospital.

Figure 1. Acupressure point for sleep quality improvement and pulse rate17

Instruments was detected. For the pulse rate, the

Quality Sleep Questionnaire was used for bedside monitor was used, which was
this study. This questionnaire is modified connected to the patients. The pulse value
from the Pittsburgh Sleep Quality Index in the monitor represents the pulse
(PSQI) and St.Mary's Hospital (SMH)18 frequency of the patient within a minute.
sleep questionnaire adopted from Karota's
study. Content validity of Quality Sleep Ethical consideration
Questionnaire had been analyzed by 3 The study has met the ethical
experts in Psychological Nursing, Sleep requirements of the Health Research
and Medical & Gerontological Nursing Ethics Committee (K.EP.K) of Health
from Prince of Songkla University, Polytechnic of Ministry of Health
Thailand. Internal consistency of (Poltekkes) of Semarang with No. 284 /
Cronbach's Alpha Coefficient of this KEPK / Poltekkes-Smg / EC / 2016. Prior
questionnaire was 0.89.19 To distinguish to the research, respondents were given
between good and poor sleep, researcher informed consent to provide information
examined seven items of questions about the purpose, benefits and research
including total hours of sleep at night, procedures.
bedtime, frequency of awakened due to
sleep disturbance, tired feeling of Data analysis
drowsiness, wake up feeling fresh, sleep Data were processed and analyzed using
depth and sleep satisfaction. A good or SPSS. Mean and frequency distribution
bad score of sleep was identified by were described. Because data were in
summing the score of items 1-7. If the normal distribution, paired t-test was
score was ≤ 5, a good sleep quality was performed for paired group, and
detected; if it was > 5, a poor sleep quality

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independent t-test for unpaired group with them in the treatment and control group
significant value <0.05. were males (88%; 84%), had elementary
school background (52%; 60%), and
RESULTS working in the private sectors (48%:
Table 1 shows that the majority of the 40%). The homogenuity test showed p-
respondents aged 41-59 years, which was value >0.05 in each variable, which means
60% in the treatment group with mean that there was no significant difference of
59.76 years old and 56% in the control respondents characteristics in the
group with mean 59.88 years old. Most of intervention and control group.

Table 1. Homogeunity and distribution of respondents based on gender, age,

education, and job and working status
Intervention Control
Variable p-value
n % n %
Age (years)
41-59 15 60.0 14 56.0
0.179
> 60 10 40.0 11 44.0
(Mean ± SD) (59.76 ± 10.647) (59.88± 8.880)
Gender
Male 22 88.0 21 84.0 0.425
Female 3 12.0 4 16.0
Educational level
Elementary school 13 52.0 15 60.0
3 12.0 3 12.0 0.739
Junior high school
Senior high school 7 28.0 5 20.0
Graduate level 2 8.0 2 8.0
Job
Not working 2 8.0 2 8.0
Farmer 8 32.0 12 48.0
0.563
Private 12 48.0 10 40
Civil servants, 3 12.0 1 4.0
Military/Police

Table 2. Frequency distribution of respondents based on the quality of sleep in patients

with AMI
Intervention Control
Sleep Quality Pretest Posttest Pretest Posttest
n % n % n % n %
Good 0 0 18 72.0 0 0 0 0
Poor 25 100.0 7 28.0 25 100.0 25 100.0
(Mean±SD) 10.52±1.327 5.00±1.225 10.40±1.414 9.92±1.441

During pretest, both intervention of them had a good sleep quality and 28%
and control groups had poor sleep quality had a poor quality. However, there was no
(100%). But, there was a sharply change change of sleep quality in the control
of sleep quality during posttest in the group.
intervention group. Of total patients, 72%

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 Table 3. Frequency distribution of pulse rate in patients with AMI
Group n Mean±SD Minimum Maximum
Intervention group
Pretest 25 89.68±11.142 70 108
Posttest 25 79.04±5.719 68 89
Control group
364
Pretest 25 89.04±9.650 70 104
Posttest 25 86.60±6.916 70 96

As shown in the table 3, it can be pulse rate was 68 and the highest was 89.
seen that the pulse rate before given While there was no change of the pulse
intervention was 89.68 ± 11.142 with the rate during pretest and posttest in the
lowest score was 70 and the highest was control group with the mean value of
108. There was a change in pulse rate posttest was 86.60±6.916, with the lowest
after given intervention with a mean value value was 70 and the highest was 96.
of 79.04 ± 5.719 with the lowest value of

Table 4. Quality of sleep in the intervention and control group using paired t-test
Group Quality of
n Mean SD t p-value
Sleep
Pretest 25 10.52 1.372
Intervention 22.461 0.000
Posttest 25 5.00 1.225
Pretest 25 10.40 1.414
Control 1.953 0.063
Posttest 25 9.92 1.441

Table 4 shows that there was no significant increase of the sleep quality
statistically significant increase of quality in the control group with p-value 0.063
of sleep in the intervention group with p- (>0.05)
value 0.000 (<0.05). However, there was

Table 5. Pulse rate in the intervention and control group using paired t-test
Group Pulse rate n Mean SD t p-value
Pretest 25 89.68 11.142
Intervention 6.725 0.000
Posttest 25 79.04 5.719
Pretest 25 89.04 9.650
Control 2.672 0.013
Posttest 25 86.60 6.916

Table 6. The difference in mean of sleep quality and pulse rate in posttest in the
intervention and control group using independent t-test
Posttest
Variable
n Mean ± SD t p-value
Sleep quality
Intervention group 25 5.00±1.225
13.008 0.000
Control group 25 9.92±1.441
Pulse rate
Intervention group 25 79.04±5.719
4.212 0.000
Control group 25 86.60±6.916

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 As shown in the Table 5, it is stimulus is sent to the center of the pons to
indicated that there was statistically the midbrain (periaquedectus), then the
significant decrease of pulse rate in the stimulus received by the periaquedectus
intervention group and control group with conveyed to the hypothalamus, and from
p-value 0.000, 0.013 (<0.05) respectively. this hypothalamus through the descending
However, the decrease of the value of nerve pathway of the endorphin hormone
pulse rate in the intervention group was secreted to blood vessels that provide
(10.64) was higher than the pulse rate in a sense of calm, comfort and
the control group (2.44). relaxation.14,20 Thus, this calm condition,
Independent t-test as shown in the comfortable and relaxation will make
table 6 shows p-value 0.000 (<0.05), respondents have the desire to sleep and
which indicated that there were significant can achieve long and deep sleep duration
differences in sleep quality and pulse rate (NREM 4th stage sleep).9 On the other
between intervention and control group. hand, another effect of acupressure is to
stimulate the release of serotonin hormone
DISCUSSION that regulates mood, sleep, and muscle
The results of this study revealed that contraction. Serotonin will act as a
there was a significant effect of neurotransmitter that carries signals to the
accupressure on the increase of the quality brain to activate the pineal gland
of sleep in patients with acute myocardial producing the hormone melatonin, which
infarction. This is consistent with the will affect the suprachiasmatic nucleus
study in the increase of sleep quality in (SCN) in the anterior hypothalamus of the
acute coronary syndrome patients (ACS) brain in circadian rhythm settings,
after given acupressure intervention at resulting in decreased sleep latency,
Fengchi point (GB 20), shenmen (HT7), nocturnal awakening, and an increase in
yongquan (KL1), ying-tang (EX-3 ) with a total sleep time and sleep quality.16
duration of 18 minutes for 3 days.7 Acupressure is a therapy with the
Similar results with the study conducted principle of healing touch that shows
by Shariati et al15 indicated that there was more caring behavior on the respondents,
an increase of sleep quality in 44 so as to provide feelings of calm,
hemodialysis patients who were given comfortable, feelings that are more
acupressure at combining shenmen point attention that can close the therapeutic
(HT7), Hegu (Li4) and Sanyinjiao (SP6) relationship between researchers and
for 15 minutes 3 times a week for a respondents. From the psychological
month. In addition, literature stated that aspects, acupressure helps reducing
the combination of the heart point of the anxiety of respondents.16
shen men (HT-7), the neiguan heart lining Additionally, acupressure as
(PC-6), and the spleen point of san yin Chinese healing art and science is based
jiao (SP-6) could decrease anxiety, and on the theory of equilibrium, which is a
improve the sleep quality. While the other harmonious and proportional balance
points of the tay (EX-5) and the yintang between the yin and yang elements.
(EX-3) points provide a relaxed feeling.17 Acupressure interventions at the point of
The increase of sleep quality in this cardiac, spleen and heart rest as well as
study because the stimulation of sensory the intervention in this study will
nerve cells at the acupressure point strengthen the energies of the spleen yin
stimulates the nerve receptor in which the element and weaken the heart and heart

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366
membrane elements. The occurrence of McFadden et al,23 acupressure yields
the energy balance of the body will reduced heart rate greater (p = 0.043) and
optimize the function and system of faster (p = 0.002) significantly more than
organs so that there can be health placebo acupressure during treatment.
improvements including sleep quality,
prevention, healing and recovery from CONCLUSION
illness.17 Based on the results of this study, it can
Besides, findings of this study also be concluded that accupressure has a
revealed there was a significant decrease significant effect on the increase of sleep
of pulse rate after given accupressure quality and the decrease of pulse rate in
intervention. In this regard, acupressure patients with acute myocardial infarction.
can promote blood circulation and Qi, Thus, it is suggested that accupressure
harmony of yin and yang, and the could be one of the nursing intervention
secretion of neurotransmitters, thereby for AMI patients to increase sleep quality
maintaining normal functioning of the and decrease of pulse rate. Further
human body and providing comfort.15 research is needed to determine the
Furthermore, manual stimulation of duration of effectiveness of acupressure in
acupressure points has been shown to AMI patients.
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