ASSESSMENT OF KNOWLEDGE OF PATIENTS WHO HAVE

UNDERGONE MECHANICAL VALVE REPLACEMENT ABOUT

HOMECARE MANAGEMENT

PROJE_CT REPORT

Submitted in partial fulfillment of requirements for Diploma in Cardiovascular and Thoracic Nursing.

RAKHI RAJENDRAN CODE NO: 5879

SREE CHITA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND TECHNOLOGY TRIVANDRUM

2009

CERTIFICATE FROM SUPERVISORY GUIDE

This is to certify that Miss.Rakhi Rajendran has completed the project work on

the 'Assessment of knowledge of patients after mechanical valve replacement about

homecare management' under my direct supervision and guidance for !he partial

fulfillment of the Diploma in Cardiovascular and Thoracic Nursing in the university of

SCTIMST, Trivandrum.

It is also certified that no part of the report has been included in any other thesis

for procuring any other degree by the candidate.

Dr. P.P.Saramma

Senior Lecturer in Nursing

SCTIMST

Trivandrum

October 2009

CERTIFICATE FROM THE CANDIDATE

This is to certify that the assessment of knowledge of patients after mechanical

valve replacement about homecare management is a genuine work done by me, at

SCTIMST Trivandrum under the guidance of Dr.P.P.Sarainma. It is also certified that

this work has not been presented for award of degree, diploma or other recognition.

Trivandrum

October 2009

Miss.Rakhi Rajendran

Code No: 5879

SCTIMST

APPROVAL SHEET

This is to certify that Miss.Rakhi Rajendran bearing the code no: 5879 has been

admitted to the Diploma in Cardiovascular and Thoracic Nursing in January 2009 and has

undertaken the project entitled 'Assessm_ent of knowledge of patients after mechanical

valve replacement about the /zomecare management' which is approved for the Diploma

in Cardiovascular and Thoracic Nursing awarded by SCTIMST, Trivandrum, and it is

found satisfactory.

Examiners:

Guide:

Trivandrum October 2009

ACKNOWLEDGEMENT

First of all let me thank God almighty for the unending love, care and blessing

especially during the tenure of this study.

I take this opportunity to express my sincere gratitude to Dr. Saramma.P.P, Senior

Lecturer in Nursing, SCTIMST, Trivandrum for the guidelines she provided for

executing this study. Her advice regarding the concept, basic guidelines and analysis of

data was very much encouraging. Her contributions and suggestions have been a great

help for which I am extremely grateful.

With profound sentiments and gratitude I acknowledge the encouragement and

help received from the following persons for the successful completion of the study.

I am thankful to all the sisters in the Cardiac Surgical ICU and wards for their

constant support and encouragement.

I am extremely grateful to the participants of the study, who gave their valuable

time during data collection.

I thank all my friends and colleagues who directly or indirectly supported me in

completing this study.

CONTENTS

-Chapter No TITLE Page No

I INTRODUCTION 1

1.1 Introduction 1 .

1.2 Background of the study . 4

1.3 Need and significance of the study 6

1.4 Statement of the problem 7

1.5 Objectives of the study

7

1.6 Operatim:ml definitions 8

1.7 -. . Delimitations 9

1.8 Study setting

9

1.9 Study method 9

1.10 Sampling 9

1.11 Sample size 9

1.12 Tool 10

1.13 Organization 10

II REVIEW OF LITERATURE 11

2.1 Knowledge assessment of patients regarding valve

11 - replacement

2.2 Diet and warfarin therapy 12

2.3 Prevention of complications after mechanical valve 13

replacement

2.4 Discharge planning and follow up 16

III METHODOLOGY 20

3.1 Introduction 20

3.2 Research approach 20

3.3 Setting of the study 20

3.4 Study population 20

3.5 Sample and sampling technique 20 --

3.6 Exclusion criteria 21

3.7 Inclusion criteria 21

3.8 Development of the tool 21

3.9 Description of the tool 21

3.10 Pilot study 22

3.11 Data collection procedure 22

3.12 Plan of analysis 22

3.13 Summary 22

IV ANALYSIS AND INTERPRETATION 23

. 4.1 Introduction 23

Distribution of samples according to the 4.2 24

demographic data

Distribution of samples according to the type of 4.3 27

. surgery

Distribution of samples according to the knowledge 4.4 28

score

4.5 Analysis and interpretation 31

4.6 Summary 33

v SUMMARY, CONCLUSION, 34

DISCUSSION AND RECOMMENDATIONS

5.1 Summary 34 .

-5.2 Major findings of the study 35

5.3 Limitation 35

5.4 Conclusion 35

5.5 Discussion 36

5.6 Recommendation 37

BIBLIOGRAPHY 38

APPENDIX 1 41

APPENDIX2 44

LIST OF TABLES

.

Table No TITLE Page No

1 Keywords 19

2 Distribution of samples according to the age 24

.3 Distribution of samples according to sex 25

4 Distribution of samples according to the educational 26

status

5 Distribution samples according to the type of surgery 27

6 Distribution of samples according to the knowledge score 28

7 Distribution of samples according to the specific 29

know ledge on home care management

Mean, standard deviation and p value with the age

8 31 group by the know ledge score

Mean, standard deviation and p value with sex by the 9 31 knowledge score

10 Mean, standard deviation and p value with the 32

educational status and the knowledge score

11 Mean, standard deviation and p value with the type of 32

surgery and the knowledge score

LIST OF FIGURES

Figure No TITLE Page no

1 Bar diagram showing distribution of data according 24 to the age

2 Pie diagram showing the distribution of data 25 according to sex

3 Bar diagram showing distribution of data according 26 to the educational status

4 Pie diagram showing distribution of data according to 27 the type of surgery

5 Bar diagram showing distribution of data according 28 to the knowledge score

6 Bar diagram showing distribution of data according 30 to the specific knowledge

1.1 Introduction

1

CHAPTER-1

INTRODUCTION

Valvular heart disease is a significant health problem in United States although it

is far less common than coronary artery disease. It is characterized by impaired function

of one or more of the four cardiac valves. Either or both of the two functional

abnormalities may be present: stenosis or regurgitation, Finkelmeier.B.A. (2000).

Primary valvular heart disease ranks well below coronary heart disease, stroke,

hypertension, obesity and diabetes as major threats to the public health. Nevertheless, it is

the source of significant morbidity and mortality. Rheumatic fever is the dominant cause

of valvular heart disease in developing countries. Its prevalence has been estimated to

range from as low as 1.01100000 school age children Costa Rica to as high as 150/100000

in China. RHD accounts for 12 to 65 % of hospital admissions related to cardiovascular

diseases and 2 to 10 % hospital discharges in some developing countries. Prevalence and

mortality rates vary among communities even within the same country as a function

crowding and the availability of medical resources and population wide programmes for

detection and treatment of Group A Streptococcal pharyngitis. In economically deprived .

areas, tropical and subtropical climates particularly on Indian subcontinent, Central

America and Middle East, Rheumatic valvular disease progresses more rapidly than in

more developed nations and frequently causes serious symptoms in patients less than 20

years of age. This accelerated natural history may be due to repeated infections with more

virulent strains of rheumatogenic Streptococci. Tricuspid stenosis, as relatively

1

2

uncommon valvular lesion in North America and Western Europe is more common in

tropical and subtropical climates especially in Southern Asia and in Latin America.

As the year of 2000, worldwide death rates for RHD approximated 5.5/ 100000

population with the highest rates reported from Southern Asia. Although there have been

reported cases of isolated outbreaks of Streptococcal infection in North America, valve

disease in developed countries is now dominated by degenerative or inflammatory

processes hat lead to valve thickening, calcification and dysfunction. The prevalence of

VHD increases with age. Important left sided valve disease may affect as many as 12 to

13% of adults over the age of 75. The incidence of Infective Endocarditis has increased

with the aging of the population, the more widespread prevalence of valve grafts and

intra cardiac devices, the emergence of more virulent multi drug resistant

microorganisms, and the growing epidemic of diabetes. I.E. has become a more frequent

cause of acute valvular regurgitation. Bicuspid aortic valve disease affects as many as 1 to

2 % of population, and an increasing number of childhood survivors of Congenital Heart

Diseases present later in life with valvular dysfunction: The past several years have

witnessed significant improvements in surgical outcomes with progressive refinement o.f

relatively less- invasive techniques; Bonow et al (2006) Circulation 114: 450.

The results of replacement of any valve are dependent primarily on ( 1 ). The

patients' myocardial function and general medical condition at the time of surgery;

(2). Technical abilities of the operative team and the quality of the postoperative care;

and (3). The durability, haemodynamic characteristics and thrombogenicity of the

prosthesis. Increased perioperative mortality is associated with advance age and co

morbidity ( eg: pulmonary or renal disease, the need for nonvalvular cardiovascular

2

--~ ·--------·--··--··-~-~---------··-··----·--------,------

3

surgery, diabetes mellitus) as well ad with greater levels of preoperative functional

disability and pulmonary hypertension. Late complications of valve replacement include

paravalvular leakage, thromboemboli, bleeding due to anticoagulants, structural

deterioration of the prosthesis and infective endocarditis.

The considerations involved in the choice between a bioprosthetic (tissue) and

artificial mechanical valve are similar in the mitral and aortic positions and in the

treatment of stenotic or regugitant or mixed lesions. All patients who have undergone

replacement of any valve with a mechanical prosthesis are at risk of thromboembolic

complications and must be maintained permanently on anticoagulants, a treatment that

imposes a hazard of hemorrhage. The primary advantage of bioprostheses over

mechanical prostheses is the virtual absence of trromboembolic complications 3 months

after implantation, and except for patients with chronic AF; with their use. The major

disadvantage of bioprostheses is their structural deterioration, the incidence of which is

inversely proportional to the patients' age. The deterioration results in the need·to replace_

the prosthesis in up to 30% of patients by 10 years and in 50% by 15 years. Rates of

structural valve deterioration are higher for aortic prosthesis. The plfenomenon may be

due to the greater closing pressure to which mitral prosthesis is exposed, WHO (2001).

Traditionally, a mechanical prosthesis was considered preferable for a patient

under the age of 65 who could take anticoagulation reliably. Bioprostheses were

recommended for older patients (>65years) who did not otherwise have an indication for

anticoagulation (e.g.: AF). A mechanical prosthesis is reasonable for aortic or mitral

valve replacement in patients < 65 years without a contraindication to anticoagulation.

Bioprosthesis is equally reasonable for aortic or mitral valve replacement in patients < 65

3

4

years who elect this strategy for lifestyle with full knowledge of the likely need for

reoperation overtime.

1.2 Background of the study

The valves of the heart control the flow of blood through the heart into the

pulmonary artery and aorta by opening and closing in response to the blood pressure

change as the heart contracts and relaxes through the cardiac cycle. The atrioventricular

valves separate the atria from the ventricles and include the tricuspid valve; which

separates the right atrium from the right ventricle and the mitral valve separates the left

atrium from the left ventricle. The tricuspid valve has three leaflets; the mitral valve has

two. Both valves have chordae tendinae that anchor the valve leaflets to the papillary

muscles and the ventricular wall. The semi lunar valves are located between the

ventricles and corresponding aretes. The pulmonic valve lies between the right ventricle

and the pulmonary artery; the aortic valve lies between the left ventricle _and the aorta.

When any of the heart valve s do not close or open properly, blood flow is

affected. When valves do not close completely, t4e blood flows backward through the

valve in a process called regurgitation. When the valves do not open completely, a

condition called stenosis, the flow ofblood through the valve is reduced.

Disorders of the mitral valve fall into the following categories; mitral valve

prolapse (i.e., the stretching of the valve leaflet into the atrium during systole); mitral

regurgitation and mitral stenosis. Disorders of the aortic valve are categorized as aortic

regurgitation and aortic stenosis. These valvular disorders may require surgical repair or

replacement of the valve to correct the problem, depending on the severity of the

4

5

symptoms. Tricuspid and pulmonary valve disorders also occur, usually with fewer

symptoms and complications. Regurgitation and stenosis may occur at the same time in

the same or different valves.

The indications for the aortic valve operations are dictated by severity of the

disease and symptoms produced. The most common symptoms include, dyspnoea on

exertion, chest pain, and lightheadedness or dizziness usually with sudden change of

position, such as standing quickly. Although patients with symptoms certainly require

correction; there are indication for valve replacement or repair for aortic stenosis in

patients who are asymptomatic i.e. in patients who have excessively high gradients or

valve areas below 0.75-squire em. When this situation exists, a very carefully performed

treadmill or exercise test can be performed to evaluate the patients' myocardial response

to a light form of exercise. For aortic valve regurgitation, obviously echo cardio graphic

findings and symptoms help determining the operation. If the patients' LV function starts

to fail or becomes dilated, it is appropriate to rec~mmend an operation. For stenosis,

similar events are tantamount to recommending valve replacement. Repair of aortic

stenosis has been tried with variqus forms of decalcification; ultra sonic debridement can

be recommended in these cases. There are incidents of fulminate scarring which caused

the leaflets to retract and these patients then turned with rather significant and sever aortic

regurgitation requiring reoperation and valve replacement.

Mitral regurgitation occurs especially from myxomatous disease or ruptured

chordae are ideal situations for valve repair. The presence of severe mitral regurgitation

alone has become the indication for valve repair because of the late effects on survival

and left ventricular function if the regurgitation is left to progress until symptoms or

5

6

severe cardiomegaly develops. Any acute infection requires the removal of all infected

tissue which limits repair when there is large area of valve replaced with vegetations.

Tricuspid valve rarely requires replacement except in s3everal extenuating

circumstances; e.g. carcinoid involvement, endocarditis, where replacement of tricuspid

valve is required. Significant dilatation from long standing tricuspid valve regurgitation

and even more frequently from device trapping and tethering of leaflets is and indication

for valve replacement.

1.3 Need and significance of the study

The incidence of valve replacement surgery and its complications are high in

United States and also in India. The lack of personal hygiene, adequate knowledge of

patient and care givers are the important factors in developing the complications such as

wound infections, thromboembolism, endocarditis etc. The study assesses the knowledge

of patients who have uiidergone v~lve replacement in SCTIMST, Trivandrurn about the

horne care management. In SCTIMST, 212 patients carne for valve replacement either

aortic or rnitra! or double valve replacement in the year of 2008.

Mechanical valve shares the advantage of long-term durability but have increased

risk of thromboembolism and the risk of bleeding secondary to the need of

anticoagulation to prevent thromboembolism. Temporary discontinuation of

anticoagulants increases the risk of valve thrombosis and embolism. It is necessary to

discuss the importance of maintaining good oral hygiene with daily care and regular trips

to the dentist. The patient must be instructed on anticoagulation therapy and the

importance of not taking over the counter medications without consulting the physician.

6

7

Importance must be give to the patient to discuss the allowances and limitations with

respect to the occupation, recreation and activities. If the patient is taking anticoagulants,

emphasize the need for adhering the schedule for prothrombin and international

normalized ratio laboratory tests and subsequent medication dosing. Effective prevention

of infectious and embolic complications requires thorough patient and family education.

Persons with mechanical valves and with valvular diseases complicated by atrial

fibrillation require detailed instruction on proper use of warfarin anticoagulation.

Intravenous heparin may be associated with a higher incidence of hemorrhage; a

randomized trial is needed to provide the best evidence regarding early postoperative

anticoagulation after mechanical valve implantation.

1.4 Statement of the problem

Assessment of knowledge of patients who have undergone Valve Replacement

abourhome care_ management.

1.5 Objectives

+ To assess the knowledge level of patients who have undergone valve replacement

about home care management.

+ To identify the relationship between knowledge levels of patients after valve

replacement and selected variables i.e. age, sex, educational status, and the

surgery done.

7

8

1.6 Operational definitions

KNOWLEDGE:

A state of awareness or understanding with conscious mind. In this study the

knowledge about home care management after valve replacement. In this study the

investigator assessing the knowledge by asking a validated questionnaire.

PATIENTS:

In this study, patients refer to the persons who have undergone valve replacement

in Sree Chitra Tirunal Institute For Medical Sciences And Technology.

VALVE REPLACEMENT:

The surgery performed to replace the diseased valve by an artificial valve or

bioprosthetic valve. The valve may be either mitral or aortic or double valve replacement.

HOME CARE MANAGEMENT:

Home care management is the health care or supportive care provided in the

patients home by family and friends, health care professionals or the patient himself.

8

9

1.7 Delimitations

The study is limited to

+ Patients who have undergone mechanical valve replacement, who are in cardiac

surgical wards and intensive care units.

+ Patients who are more than 18 years of age

+ Patients who understand and speak Malayalam

+ Patients who are willing to participate in the study

+ The data collection period is limited to one month

+ The study area is limited to only in SCTIMST, Trivandrum.

1.8 Study setting

Location: tlie cardiac surgical intensive care units and cardiac surgical wards in

SCTIMST, Trivandrum.

1.9 Study method

The study was conducted in patients who have undergone mechanical valve replacement

either aortic or mitral or double valve replacement. Consecutive sampling done in 30

patients at the third or fourth postoperative day.

1.10 Sampling

Consecutive sampling was used to collect the data.

1.11 Sample size

30 patients

9

10

1.12 Tool

In this study the investigator assess the knowledge level of patients after

mechanical valve replacement by asking a self-prepared questionnaire. The questionnaire

contains 1 0 numbers of questions about the medications, diet, physical activity, and rest

and blood investigations. Knowledge assessment was performed on the third or fourth

postoperative day of surgery in cardiac surgical intensive care unit and cardiac surgery

wards.

1.13 Organization

The report is organized with the introduction, background of the study, need and

significance of the study, objectives, operational definitions, delimitation, and

methodology.

10

11

CHAPTER-2

REVIEW OF LITERATURE

The review of literature relevant to this study is presented in following sections:

1.Knowledge assessment of patfents regarding valve replacement

2.Diet and warfarin therapy

3.Discharge planning and follow up and

4.Prevention of complication after mechanical valve replacement

2.1 Knowledge assessment of patients regarding valve replacement

Hu Amanda and Chow-Chi- Ming (2006) conducted a study to determine the

influence of both in hospital teaching practices and socio economic status and

demographic variables on patients' knowledge of warfarin therapy. The researchers

performed a telephone survey among 1 00 patients 3 to 6 months after mechanical heart

valve replacement. A twenty-item questionnaire was used to measure the knowledge of

patients about warfarin therapy, its side effects, and vitamin K food sources. They

concluded that 61% of participants had insufficient knowledge of warfarin therapy

compared to employed or self employed and they have improve their knowledge scores

after a post discharge counseling.

11

12

2.2 Diet and warfarin therapy

Bach et al (1996) conducted a study to find out whether Vitamin K is required to

convert specific glut amyl residues in a limited number of proteins to gamma­

carboxyglutamyl residues with the response of various measures of vitamin K

insufficiency to the administration of 1 mg/d of the vitamin K antagonist warfarin. The

researchers studied in two groups of nine older (55-75 y) or younger (20-28 y) subjects.

They concluded that the concentration of serum under-gamma-carboxylated osteocalcin

was lower when subjects consumed 1 mg vitamin K than when they consumed their

normal diet.

Rohde et al (2007) conducted a study to evaluate the potential interaction of

dietary vitamin K and coagulation stability in elderly patients. Recent perspective

evidences suggested that the dietary intake more than 250 microg/day was shown to

decrease warfarin sensitivity in anticoagulated patients consuming regular diets. In a

randomized crossover study brief periods of changes on vitamin K intake had significant

effects on coagulation parameters. Dietary records that for each increase in 1 00 microg of

vitamin K intake would reduce the INR by 0.2 estimated it. A recent study demonstrated

that over the counter multivitamin supplements contain enough vitamin K1 to

significantly alter the coagulation parameters.

Sconce et al (2005) conducted a study to evaluate the effectiveness of dietary

intake of vitamin K in patients with unstable control of anticoagulation compared to

patients with stable control of anticoagulation. Study was conducted in twenty-six

patients with unstable and twenty-six with stable control of anticoagulation and they

completed dietary records of all foods and drinks consumed on a daily basis for two

12

13

consecutive weeks. The mean daily intake of vitamin K in unstable patients was

considerably lower than that for. stable patients during the study period. They concluded

that daily supplementation with oral vitamin K in unstable patients could lead to a more

stable anticoagulation response to warfarin

Hu et al (2006) conducted a study to determine the influence of knowledge

regarding the warfarin therapy in patients after mechanical valve replacement in hospital

teaching practices as well as socioeconomic status and demographic variables on patients'

knowledge of warfarin therapy. A telephone survey was conducted among 100 patients 3

to 6 months after mechanical heart valve replacement. A previously validated 20-item

questionnaire was used to measure the patient's knowledge of warfarin, its side effects,

and vitamin K food sources. They concluded that gender, ethnicity, and warfarin therapy

before surgery were not related to warfarin knowledge scores. Multivariate regression

analysis revealed that understanding the concept of International Normalized Ratio,

knowing the acronym, age, and receiving community counseling after discharge were the

strongest predictors of warfarin knowledge Gender, ethnicity, and warfarin therapy

before surgery were not related to warfarin knowledge scores.

2.3 Prevention of complication after mechanical valve replacement

Puri et al (2009) conducted a study to assess the complications related to the

anticoagulation treatment after mechanical valve replacement. Anticoagulation is started

soon after mechanical valve replacement, as the risk of thromboembolic complications is

especially high during the first six months after surgery. The authors conducted the study

in a total of 503 patients who underwent mechanical valve replacement surgery at the

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14

authors institute between July 2001 and October 2006. The patients were allocated to

three comparable groups, depending on the anticoagulation regime administered. Group

A patients (n = 221) received only oral anticoagulation from the first postoperative day;

group B patients (n = 159) received oral anticoagulation plus low-molecular weight

heparin; and group C patients (n = 123) received unfractionated heparin within 12 h of

surgery in addition to oral anticoagulation. There were incidents of reinsertion of

additional intercostal drains for collections, cardiac tamponade, valve thrombosis, and re­

explorations for excessive drainage. The authors concluded that early oral anticoagulation

alone provided optimum anticoagulation and is associated with minimum complications.

Early supplementation with heparin increased the risk of hemorrhagic complications but

without reducing the thromboembolic risk.

Heras et al (1995) studied the rate of thromboembolism in patients undergoing

bioprosthetic replacement of the aortic or mitral valve, or both, at serial intervals after

operation and the effects of anticoagulant or anti platelet treatment and risk facrors. The _

rate of thromboembolism was studied at three time intervals after operation: one to ten

days, eleven to ninety days and after ninety days. The study was ~onducted in 816

patients who underwent bioprosthetic replacement of the aortic or mitral valve, or both, at

the Mayo Clinic from January 1975 to December 1982.The authors evaluated the effect

of antithrombotic therapy with warfarin, aspirin and dipyridamole alone or in

combination. They concluded that thromboembolic risk was especially high for aortic and

mitral valve replacement for 90 days after operation, and increased with lack of

anticoagulation, mitral valve location, previous thromboembolism and increasing age.

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15

Anticoagulation reduced thromboemboli and appeared to be indicated in all

1atients as early as possible fm: 3 months and thereafter in those with risk factors and

teeded prospective testing.

Konagai et al (2006) conducted a study to evaluate the coagulant activity after

nechanical heart valve replacement. PT-INR and TAT evaluated the coagulant activity.

~o evaluate whether coagulant activity was fully suppressed by the target range of 1.5 to

~.5; coagulant activity was evaluated by measuring thrombin antithrombin3rd complex

evels and valve related complications were enrolled in this study. The investigators

ound that under adequate warfarin control, there was no significant correlation between

>T~INR and TAT, however nine patients who exhibited a PT-INR of less than 2.0 had

righ levels of TAT. They finally concluded that monitoring of TAT was useful in

letecting potential coagulation factors and to determine the therapeutic range of warfarin

hat could normalize coagulant.

Brueck et al (2006) conducted a study to evaluate the necessity of the antiplatelet

herapy by ASA with no postoperative antiplatelet therapy in terms of survival, major

>leedings and cerebral thromboembolism of patient~ undergoing biological aortic valve

·eplacement without thromboembolic risk factors. From January 2001 to December 2003,

~88 consecutive patients were selected with sinus rhythm and no other thromboembolic

'isk factors underwent single biological A VR with porcine or bovine pericardia! valves

without concurrent coronary artery bypass graft surgery. By surgeons' preference, 100

ng ASA was given to 132 patients, and 156 patients received no antiplatelet therapy. The

mthors concluded that patients without thromboembolic risk factors undergoing

>iological A VR admirristration of ASA confer no advantage compared to no antiplatelet

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16

therapy. Functional status, thromboembolic events and survival were not adversely

affected by withholding any antiplatelet, therapy.

2.4 Discharge planning and follow up.

Naylor et al (1994) conducted a study to assess the effects of the discharge

planning and home follow up intervention on elders hospitalized with common medical

and surgical cardiac conditions. The authors collected data from 202 patients of 65 years

of age and above admitted for heart failure, myocardial infarction, CABG, angina, or

valve replacement. The authors performed a 24 week post discharge follow up

programme and concluded that high risk elders with significant problems might benefit

from a care programme and medical patients in the interventional group required fewer

multiple readmissions than in surgical group.

Theobald (2004) conducted a study to examine the post discharge issues, concerns

and needs of patients after CABG and -their family after discharge. A two-phase

naturalistic inquiry was performed in 35 patients and their carers for four to five weeks

after CABG. The findings sugge~ted that the periodic follow up and mechanisms of

mutual support and comparin~ experiences of cardiac patients and their carers need

further research for evaluation. Almost half of the patients experienced variety of changes

including pain, life style implications and financial implications.

Jaeger et al (1994) conducted a study to determine whether cardiac surgery

improves functional capacity in patients greater than 70 years of age. Self reported

functional capacity was assessed by Duke activity status index preoperatively and also

one year after CABG or valve replacement; in a total of 199 patients with a mean age of

16

,-~-----'-- ,_ -·-- _,--~-- __ , __ -----·--

17

76 years. Functional capacity improved significantly after surgery (mean Duke Activity

Status Index 27.9 at baseline vs. 36.8 at 12 months, p < 0.001), with improvements in

most patients (74%). Six preoperative factors were independent predictors of less

improvement in functional capacity between baseline and 1 year: smoking, female

gender, higher Charlson co morbidity index, syncope, previous cardiac operation and

older age. Older patients had meaningful improvements in functional capacity after

cardiac surgery and clinical factors appeared to modify the degree of improvement

attainable.

Davoodi et al (2009) conducted a study to evaluate the postoperative quality of

life in those who have undergone short and midterm results of triple valve surgery. The

authors reviewed 107 patients with multiple valve disease who underwent triple valve

surgery at Tehran University Heart Center from January 2002 through December 2007,

100 patients with complete, recorded the data were enrolled into the study. The authors

considered the demographic and ~linical characteristics and in hospital postoperative

complications. In quality of life assessment, suitable physical and social activities were

reported in 65.!)% and 60.6% of patients respectively. The researchers concluded that

despite patients' satisfaction with early outcomes of triple valve surgery and their

acceptable midterm survival rates, the improvement of quality of life is still far from

ideal.

Koertke et al (2009) conducted a study to evaluate INR self-management to

reduce severe thromboembolic and hemorrhagic complications following mechanical

heart valve replacement. Beginning anticoagulation therapy immediately in the

postoperative period further reduce anticoagulant-induced complications. The authors

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18

collected the data from the first 600 surviving patients (from a total study sample of 1200

patients) who completed follow-up of at least 2 years. Patients were randomly divided

into a self-management group and a control group. INR self-management reduced severe

hemorrhagic and thromboembolic complications (P=0.018). Nearly 80% of INR values

recorded by patients themselves, regardless of educational level, were within the target

therapeutic range of INR 2.5-4.5, compared with 62% of INR values monitored by family

practitioners. Only 8.3% of patients trained in self-management immediately after

surgery were unable to continue with INR self-management. The results differed slightly

between patient groups with different levels of education. The authors concluded that all

patients for whom anticoagulation is indicated were candidates for INR self-management

regardless of education level.

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TABLE 1

KEYWORDS

KEYWORDS NUMBER OF ARTICLES

Knowledge assessment of patients after 16

mechanical valve replacement

Diet and warfarin therapy 108

Prevention of complications after 84 -mechanical valve replacement

Discharge planning and home follow up 2

19

3.1 Introduction

20

CHAPTER-3

METHODOLOGY

This chapter contains research approach, study design, the sample and sampling

technique, development and description of the tool, pilot study, data collection and plan

of analysis.

3.2 Research approach

Survey approach was used in this study.

3.3 Setting of the study

The study was conducted in cardiac surgical intensive care units and cardiac

surgical wards of Sree Chitra Tirunal Institute For Medical Science and Technology,

Thiruvananthapuram.

3.4 Study population

Population of the study are the patients m cardiac surgery ICU and wards of

SCTIMST, those who have undergone mechanical valve replacement either aortic valve

or mitral valve or double valve replacement.

3.5 Sample and sampling technique

Consecutive sampling is done for this study; 30 samples collected. The pilot study

was done in 7 patients. The total period of study is one month from September to October

2009.

20

21

3.6 Exclusion criteria

+ Patients who understand language other than Malayalam are excluded.

• The study is limited to SCTIMST Trivandrum.

3. 7 Inclusion criteria

Patients who have undergone aortic valve replacement or mitral valve

replacement, or double valve replacement with a mechanical prosthesis and those who

are willing to study are included in the study.

3.8 Development of the tool

Self-prepared questionnaire developed to assess the knowledge of patients who

have undergone valve replacement in SCTIMST Thiruvananthapuram. Several journals

and textbooks helped to develop the tool and experts in SCTIMST Trivandrum approved

it. The self-prepared questionnaire contain 10 questions regarding several aspects of

home care management after valve replacement about the medication, diet, rest and

physical activity, and blood investigations.

3.9 Description of the tool

The tool used in this study contains the following parts:

• Demographic data

• Questions about the different aspects of the home care of patients after

mechanical valve replacement.

21

22

3.10 Pilot study

Pilot study was conducted on the month of September 2009 after obtaining

permission from the authorities of hospital management. The study was conducted in 7

patients both male and female between the age group of 29 to 69 years of age with a self­

prepared questionnaire. After pilot study assessment has been done on the third or fourth

post operative day of mechanical valve replacement after making necessary corrections in

the questionnaire.

3.11 Data collection procedure

Formal permission obtained from the authorities for the collection of data. The

period of data collection was from September to October 2009. The data was collected

from the cardiac surgical intensive care units and cardiac surgical wards of SCTIMST

Trivandrum. The investigator first introduced her and explained the need and purpose of

the study, the knowledge level assessed aftergetting consent from the patients.

3.12 Plan for analysis

The investigator developed the plan of analysis after the pilot study. The data

obtained from the samples was analyzed by using descriptive statistics.

3.13 Summary

This chapter contains research approach, settings, population, sample and

sampling technique, development and description of the tool, data collection and plan of

analysis.

22

23

CHAPTER4

ANALYSIS AND INTERPRETATION OF DATA

4.1 Introduction

Analysis is categorizing, ordering, manipulating and summarizing the data to an

intelligible and interpretable form so that the research problem can be studied and tested

including the relationship between different variables.

This chapter deals with the analysis and interpretation of the data collected from

30 patients who have undergone mechanical valve replacement in SCTIMST

Trivandrum.

The findings of the study were arranged and analyzed under the following sections.

1. Distnoution sample according to the demographic data

2. Distribution of sample according to the type of surgery

3. Distribution of sample according to the knowledge score

23

---·----··----·-····--~-----········

.•

24

4.2 Distribution of sample according to the demographic data

Distribution of the data according to the age

Age of sample ranged from 29 to 69 years of age with a median of 40, and mean

age of 42.56. The data presented in the table denotes maximum number of patients was

under the age group of 31 to 50 years.

Table 2: Distribution of the data according to the age

Age in years Frequency Percentage

<30 4 13.3

31 to 50 19 63 .3

51 to 70 7 23.4

Same data shown in bar diagram: Figure 1

70

60

50

40

30

20

10

0

< 30 yrs 31-SO v rs 5 1 -70 y rs l 24

--1 -; _= ~ '}il- '---"I_' _:_ill --~-~ -

25

Distribution of samples according to sex

Data presented in the table denotes that males 66.7% greater than females.

Table 3:Distribution of samples according to sex

Sex Frequency Percentage

Male 20 66.7

Female 10 33.3

Data shown in pie diagram:

Figure 2

Male Female

25

--~ . '"'" ~:. ' .~ ,_ _;;.~- = ===--=- ~

26

Distribution of samples according to the educational status

The data presented in the table denotes the maximum (46.67%) of patients have

secondary education.

Table 4: Distribution of samples according to the educational status

Educational status Frequency Percentage

Illiterate 2 6.67

Primary 9 30

Secondary 14 46.67

Graduation 5 16.66

Same data shown in bar diagram: Figure 3

50 45

Ill 40 Q)

Q. 35 E Ill 30 Ill -0 25 Q) Cl 20 Ill -c::: 15 Q) (J .. 10 Q)

a.

26

-

-. ~~ - - _, ~- -·-·

27

4.2 Distribution of samples according to the type of surgery

The data presented in the table denotes maximum percentage of patients have

undergone Mitral Valve Replacement.

Table 5: Distribution of samples according to the type of surgery

Type of surgery Frequency Percentage

A.V.R. 9 30

M.V.R. 17 56.7

D .V.R. 4 13.3

The same data shown in pie diagram

Figure 4

~ AVA oMVR oDVR

27

28

4.3 Distribution of samples according to the knowledge score

The data presented in the table denotes maximum percentage of patients

has average level of knowledge about the home care management after mechanical valve

replacement.

Table 6: Distribution of samples according to the knowledge score

Score Frequency Percentage

0 to 3 9 30

4 to 7 12 40

8 to 10 9 30

Same data shown in bar diagram

Figure 5

The knowledge score ranges from 0 to 10 with a mode of 7, median of 6.5 and

40% of patients have average knowledge regarding the homecare after valve replacement.

28

--=------------ -. - ____ ·-- - -==-

- - -~ Ltil ' -

29

Table 7: Distribution of samples according to the specific knowledge on homecare

management

No Questions Answers Percentage

I Knowledge related to the medication Correct Wrong Correct Wrong

Ql The ideal time for 16 . taking anticoagulant 14 53.3 46.7

Q2 Duration of anticoagulant therapy 18 12 60 40

Q3 Precautions while taking anticoagulant 15 15 50 50

Q4 Time for taking diuretic 15 15 50 50

Q5 Precaution for taking 12 18 40 60 Digoxin

II Knowledge about diet

Q6 Diet that can be

20 10 66.7 33.3 included

Q7 Diet that must avoid 29 1 96.6 3.3

III Regarding physical activity and rest

Q8 Time taken for 7 23 23.3 76.7 restoration of activities

Q9 Time taken to resume

29 1 96.6 3.3 work

QIO INR value 9 21 30 70

29

30

Same data shown as bar diagram

Figure 6

90 .-----------------------------------------80 +------------70 +-----------60 +------------GO 40 30 20 10 0

Medications Diet Rest and physical blood activity investi gations

I • correct • wrong I

The data presented here denotes patients have good knowledge regarding the diet

(81.7%)and the physical activity (60%) and less knowledge regarding the blood

investigations (30%) and the medications (50.7% ).

30

--- ·- ~-----,;c------~c~:. - ---

--

31

4.4 Analysis and interpretation:

Table: 8 Mean, standard deviation and p value with the age group by the knowledge

score

Age group Frequency Mean Standard deviation P value .

<30 4 7.25 3.59

30 to 50 19 4.84 2.43 0.059

51 to 70 7 7.14 1.77

There was an increase in the mean total knowledge score in patients with increase

in age. However this increase was not found to be statistically significant at 0.05 levels in

ANOV A test. (p= 0.059)

Table: 9 Mean, standard deviation and p value with sex by the knowledge score

Sex Frequency Mean Standard

P value deviation

Male 20 6.0 2.79 0.39

Female 10 5.1 2.33

There was no significant statistical relationship between the sex and the knowledge score

of patients (p=0.39)

31

32

Table: 10 Mean, standard deviation and p value with the educational status by the knowledge score

Educational status Frequency Mean Standard deviation P value

Illiterate 2 3.5 0.71

Primary 9 3.88 1.76

Secondary 14 6.07 2.56 0.001

Graduation 5 8.8 0.83

There was an increase in the mean total knowledge score with increase in educational

level and found that there was significant statistical relationship between the educational

status and the knowledge score (p=O.OOl).

Table: 11 Mean, standard deviation and p value with the type of surgery and the knowledge score

The type of surgery Frequency Mean Standard deviation P value

A.V.R. 9 6.88 2.71

M.V.R. 17 5.35 2.45 0.24

D.V.R. 4 4.5 3.0

32

33

There is no significant statistical relationship between the type of surgery and the

knowledge scere (p= 0.24).

4.5 Summary

This ·chapter contains distribution of samples according to the demographic data

and the knowledge score, analysis and interpretation of the data collected.

33

34

CHAPTERS

SUMMARY, CONCLUSION, DISCUSSION AND

RECOMMENDATIONS

5.1 Summary

The study is to assess the knowledge level of patients who have undergone

valve replacement about home care management.

The objectives of the study was:

1. To assess the knowledge level of patients who have undergone valve

replacement about home care management.

2. To identify the relationship between knowledge levels of patients after valve

replacement and selected variables i.e. age, sex, educational status, and the

surgery done.

The study has been done in- SCTIMST Trivandrum with the permission from

authorities. A self-prepared questionnaire approved by the experts of SCTIMST used for

assessing the knowledge of patients who have undergone valve replacement either aortic

or mitral or double valve replacement. Pilot study conducted on the september2009 in

seven patients and sample collections has been started after making necessary corrections

in the questionnaire. The samples were collected from the cardiac surgical ICU and

postoperative wards of SCTIMST Trivandrum. The period of study was from·September

to October 2009. Thirty samples collected and their knowledge regarding the home care

assessed. Data analysis done and 40% patients have average knowledge regarding home

care after mechanical valve replacement.

34

35

5.2 Major findings of the study

The sample size was limited to 30 patients even though the maximum percentage

of patients has average level of knowledge regarding the homecare management after

valve replacement. Most of the patients have good knowledge regarding the diet and the

rest and physical activity and less knowledge regarding the blood investigations and

medications to be taken after valve replacement. The study revealed that there is

significant statistical relationship between the educational status and knowledge and also

some significant relationship was found with the age of the samples.

5.3 Limitation

The study to assess the knowledge level of patients who have undergone

mechanical valve replacement is limited to SCTIMST Trivandrum. The period of study

was only one month. The sample size is also limited to thirty. The samples were collected

from tlfe cardiac ~urgical ICU and cardiac surgical wards and those who are coming in

the review department are avoided.

The study conducted only in those who were willing to the study and those who are

speaking Malayalam.

5.4 Conclusion

The study concluded that most of the patients have good knowledge regarding the

diet and physical activity and rest: especially about the diet that must avoid and the time

to resume their work.

5.5 Discussion

35

36

The study was aimed to estimate the knowledge regarding the medications, diet, need

of rest and physical activity and the follow up after mechanical valve replacement. In

addition the study revealed positive association between the knowledge of homecare

management and the educational level. The study discussed the importance ofknowledge

of homecare management regarding the medications, diet, rest and physical activity and

the investigations to be done. The data entered in Microsoft excel and descriptive

statistics done in Epi info Version 3.2.The study revealed that 70% of patients had

insufficient know ledge regarding the homecare management.

Throughout the world, 95% of all valve replacements are performed for mitral or

aortic valves. There are approximately 225,000-heart valve procedures world wide each

year. According to American College of Cardiology/ American Heart Association

guidelines for the management -of patients with prosthetic heart valves the following

International Normalized Ratios are recommended for bileaflet valves. For the first 3

_months after valve replacement: INR= 2.5 to 3.5.Three or more months after valve

replacement:INR= 2 to 3 (Aortic Valve Replacement), INR= 2.5 to 3.5 (AVR with risk

factors), INR= 2.5 to 3.5 (Mitral Valve Replacement).

The risk factors of anticoagulation therapy include atrial fibrillation, left

ventricular dysfunction, previous thromboembolism and hypercoagulable condition. Food

and alcohol also affect the anticoagulation level.

Bacteria may enter the blood stream during dental and some medical procedures and

causing bacterial endocarditis in the tissue surrounding the artificial heart valve.

Antibiotic prophylaxis should be taken before these procedures to avoid endocarditis.

36

37

he knowledge of the patients is average regarding the homecare after mechanical valve

!placement. The complications of the valve replacement surgery can be avoided by

iving adequate knowledge regarding the homecare management after the surgery.

5.6 Recommendation

• The study has been performed in other hospitals.

• The study can be performed with a large sample size.

• The samples can be selected from the patients who are coming to the review

department can also include for this study.

37

38

BIBLIOGRAPHY

1. Bonow.R.O. et al, (2006) Guidelines for the Management ofpatients with

valvular heart disease: Executive Summary.Circulation: 114-450.

2, ACC foundation and American heart Association. (2002). ACC/ AHA 2002

guideline update for exercise testing: A report of the ACC/ AHA Taskforce on

practice guidelines. Available at: htt_p://www.acc.org/clinicallguidelines/exercise.

3. Bayer, A.S., Bolger, A.F., Taubert, K.A., Wilson, W., Stecklberg, J., Karchmer,

A.W., et al. (1998). Diagnosis and management of infective endocarditis.

Circulation, 96(1), 358- 366.

4. Murphy. (Ed.). (2007). Mayo clinic Cardiology Review (3rd edn). Philadelphia:

Lippincot Williams And Wilkins.

5. Mcttale, D.J., and Carlson, K.K. (2001). AACN Procedure manual for critical

care (4th edn).

6. Finkelmeier, B.A. (2000). Cardiothoracic Nursing (2nd edn. pp.l69- 188).

Philadelphia: Lippincot Williams Wilkins.

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39

7. Feldman. Grossman. (2006) Profiles in VHD. In Baim.D.

Grossman's Cardiac Catheterization, angiography and

Intervention, 7th edn. Lippincot Williams AND Wilkins.

8. Bonow, R.O., Valvular Heart Diseases, In P Libby et al (eds) Brunwald's Heart

Disease, 8th edn. Philadelphia, Saunders, 2008.

9. Hargrave, K., Kothari, M.J., 2006 Neurological Sequelae of

InfectiousEndocarditis.http://www.Emedicine.com/neuro/topic264htm.

10. Hudak, C.M.Gallo, B.M., &Mortan, P.G. (1998). CriticalCare Nursing: A Holistic

Approach (7th edn). Philadelphia; Lippincot-Raven.

11. Wikipedia. Cardiovascular Diseases. Retrived on October 4, 2009, from

http:/ I en. wikipedia.org/wiki/C ardiovascular disease.

12. lung B, Gohlke-Ba··rwolfC, Tomos P, Tribouilloy C, Hall R, Butchart EG,

Vahanian A. Recommendations on the management of the asymptomatic patient

with valvular heart disease. European Heart Joumal2002; 23:1253-1266

13. Gohlke-Ba··rwolfC, Acar J, Oakley C, Butchart EG, Burkhardt D, Bodnar E,

Hall R, Delahaye JP, Horstkotte D, Krayenbuhl HP, Krzeminska-Pakula M,

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40

Kremer R, Samama M. Guidelines for the prevention of thromboembolic events in

valvular heart disease. European Heart Journal i 995; 16:1320-1330.

14. Massel D, Little SH. Risks and benefits of adding antiplatelet therapy to warfarin

among patients with prosthetic heart valves: a meta-analysis. Journal of American

College of Cardiology 2001; 37:569-578.

15. Cappelleri JC, Fiore LD, Brophy MT, Deykin D, Lau J. Efficacy and safety of

combined anticoagulant and antiplatelet therapy versus anticoagulant

monotherapy after mechanical heart valve replacement: a metaanalysis.

American Heart Journal1995; 130:547-552.

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41

APPENDIX 1

Demographic data

1. Name of the patient

2. Age

3. Sex

4. Marital status

5. Educational status

6. Socioeconomic data (category)

7. Surgery done

8. Source of information

41

42

. A QUESTIONNAIRE REGARDING THE HOME CARE MANAGEMENT OF

PATIENTS AFTER MECHANICAL VALVE REPLACEMENT

(Choose the correct answer for the questions from the following options)

KNOWLEDGE REGARDING THE DRUG THERAPY

1. What is the ideal time for taking anticoaguiant?

(A) With food

(B) One hour before food or one hour after taking food

(C) In empty stomach

2. For how long will you continue anticoagulant?

(A) For 6 months

(B) For 5 years

(C) Life long

3. What will you do if you forget to take one dose of anticoagulant?

(A) Take the drug same dose, at the time when you remember

(B) Take the double dose the next day

(C) No harm if you withhold the drug for one day

4. When will you take the drug LASIX?

(A) One hour after food

(B) Every morning before food

(C) Every night

5. What is the precaution to be taken before taking the drug DIGOXIN?

(A) Check blood pressure

(B) Check blood sugar

. (C) Check pulse rate

42

KNOWLEDGE REGARDING DIET

6. Item to be included in diet!?

(A) Fish and fish products

(B) Cabbage and potato

(C) Green leafy vegetables

7. Item to be excluded from diet?

(A) Milk

(B) Fruits

(C) Ghee

43

KNOWLEDGE REGARDING PHYSICAL ACTIVITY AND REST

8. How many months will you take rest after operation?

(A) Up to 3 months

(B) For 4 to 6 months

(C) More than 6 months

9. After how long can you resume your work?

(A) At 3 months

(B) After 3 to 6 months

(C) Only after 6 months

KNOWLEDGE REGARDING BLOOD TESTS

10. At what range should you keep the INR level?

(A) 1

(B) 2.5 to 3.5

(C) 3 to 4

43

44

APPENDIX2

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45

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46