ࡱ> [ bjbj xΐΐ/      8U|,*PLIIII mOoOoOoOoOoOoO$RjUJOQ v"O  II-OT*T*T* I ImOT*mOT*T*)K0NI^f(jYL$YOO0*P}LU(UHNU NT*OOT**PU :  SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION SUBMITTED TO: RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES IN PRATIAL FULFILLMENT OF M.Sc(N)IN MEDICAL SURGICAL NURSING SUBMITTED BY: MR. RAGHAVENDRA D T 1ST YEAR M.Sc NURSING UNDER THE GUIDANCE OF : MR. P. SIVAMARAN PRINCIPAL H O D MEDICAL SURGICAL NURSING SHEKAR COLLEGE OF NURSING. NO.93, H D HALLI,BANNERGHATTA MAIN ROAD, GOTTIGERE POST, BANGALORE-570083 PERFORM FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1 NAME OF THE CANDIDATE AND ADDRESS MR.RAGHAVENDRA D T 1ST YEAR M.Sc NURSING. SHEKARA COLLEGE OF NURSING, NO 93,H D HALLI, BANNERAGHATTA MAIN ROAD, GOTTIGARE POST,BANGALORE-560083.  2 NAME OF THE INSTITUTION SHEKARA COLLEGE OF NURSING, NO 93, H D HALLI, BANNERAGHATTA MAIN ROAD, GOTTIGARE POST, BANGALORE-560083.  3 COURSE OF THE STUDY AND THE SUBJECT MASTER DEGREE OF SCIENCE NURSING, MEDICAL-SURGICAL NURSING  4 DATE OF ADMISSION TO THE COURESE 15/06/2011  5 TITLE OF THE TOPICA STUDY OF ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING VALVE REPLACEMENT AND ITS MANAGEMENT AMONG PATIENTS UNDERGONE VALVE REPLACEMENT SURGERY AT SELECTED CARDIAC HOSPITAL IN BANGLORE.  6. INTRODUCTION: Blood is pumped through the heart in only one direction. Heart valves play a key role in this one-way blood flow, opening and closing with each heartbeat. Pressure changes on either side of the valves cause them to open their flap-like "doors" (called cusps or leaflets) at just the right time, then close tightly to prevent a backflow of blood. In the UnitedStates, surgeons perform about 99,000 heart valve operations each year.Nearly all of these operations are done to repair or replace the mitral or aortic valves. These valves are on the left side of the heart, which works harder than the right. They control the flow of oxygen-rich blood from the lungs to the rest of the body1. Valvular heat disease is a common medical condition. In developing countries rheumantic and degenerative valve disease as well endocarditis play a major role in the development of valvular heart disease. The disease of rheumatic valve disease had declined in industrialized countries because of the development of streptococcus infection prophylaxis. However the increase in life expectancy of caused degenerative valve disease to become more prevalent2. Valvular heart disease is disabling and if untreated leads to congestive heart failure and death. Valve replacement has remained and procedure of choice for advanced valve disease. Many of the patients will need anticoagulation therapy for the rest of their lives to prevent thrombus formation. Anticoagulant therapy itself poses a risk of major bleeding. The key to minimizing both risks are patient adherence to medication. Diet and medical follow up3. Omission, poor control withdrawal of anticoagulation substantially increase the incidence of thromboemboli in patients with mechanical valves. In addition the poor knowledge regarding long term management and noncompliance increase the rate of problems.2 There on a Structured teaching and self management programme for patients receiving oral anticoagulation concluded that education programme results in improved accuracy of anticoagulation control and in the treatment related quality of life measures2 6.1 NEED FOR THE STUDY: Valve problems can be present at birth or caused by infections, heart attacks, or heart disease or damage. Some valve problems are minor and do not need treatment. Others might require medicine, medical procedures or surgery to repair or replace the valve. Surgery is needed for the following reasons if the valve does not work properly4. A valve that does not close all the way will allow blood to leak backwards. This is called regurgitation. A valve that does not open fully will restrict blood flow. This is called stenosis. Changes in your heart valve are causing major heart symptoms, such as chest pain (HYPERLINK "http://www.nlm.nih.gov/medlineplus/ency/article/001107.htm"angina), shortness of breath, HYPERLINK "http://www.nlm.nih.gov/medlineplus/ency/article/003092.htm"fainting spells (syncope), or heart failure. Tests show that the changes in your heart valve are beginning to seriously affect your heart function. Your doctor wants to replace or repair your heart valve at the same time as you are having open heart surgery for another reason. Your heart valve has been damaged by infection of the heart valve (HYPERLINK "http://www.nlm.nih.gov/medlineplus/ency/article/001098.htm"endocarditis)4. You have received a new heart valve in the past, and it is not working well, or you have other problems such as blood clots, infection, or bleeding. According to the American heart association s(AHA) 2006 heart and stroke statistical update, valvular heart disease is responsible for nearly 20000 deaths each year in the United states and is a contributing factor in about 42000 deaths.1 Valvular heat disease has been identified has one of the major problems in developing and developed countries. In developing countries Rheumatic heart disease is the cause in 99% of cases. Because of the decline of the acute Rheumatic fever and the increase in life expectancy, degenerative valve disease has become the predominant cause of valvular heart disease in industrialized nations. Treatment of Valvular heart disease still relies on surgical prosthetic technology5. China has been reported in the elderly calcific valvular heart disease incidence rate is about 3.64%, more than 60 years of age was 8.62%. Foreign reports, at 65 years of age or older the incidence of aortic stenosis in the rate of 2% to 3%, the most common reason is the degeneration senile calcific. In the U.S., calcified aortic stenosis has become the third cause of cardiovascular disease. Aortic valve calcification more common in male to female ratio was 4:1; and mitral annular calcification more common in women, male to female ratio was 1:46. The first successful replacement of cardiac valve in the humans were done by Nine Braun wald and colleague haskes and co workers and star Edwards in1960. Life long anticoagulation therapy is required for those who received mechanical valve to prevent clot formation. Monitoring is critical, since low level of anticoagulation foe even, which may break away when warfarin levels are increased to a therapeutic range.2 Thrombo embolic and haemorrhagic complications were the most significant problems in patients treated with oral anticoagulants after implication of artificial valvular prosthesis of the heart. Bharath. V(1999) reported that after mechanical heart valve replacement, sub therapeutic anticoagulation was the key factor for thrombotic complications. Some of the commonly used drugs and diet rich in vitamin K interfere with anticoagulation causing thrombus in those who were prone. He suggested that education of primary care giver as well as patients is required to reduce life threatening thromboembolic complications.2 Patients with mechanical valve prostheses need to receive chronic therapy with oral anticoagulants in order to reduce the occurrence of thromboembolic events(1). Treatment with oral anticoagulants consists of maintaining the International Normalized Ratio (INR), which allows one to evaluate the plasma clotting time within the therapeutic range values. The INR therapeutic values for aortic valve prosthesis are between 2.0 and 3.0 and between 2.5 and 3.5 for mitral valve replacement, according to the World Health Organization(2-4). Nevertheless, this therapy has limitations in clinical practice due to the difficulty for health professionals of keeping patients INR values within therapeutic specifications. National and international data indicate that 40% to 50% of patients undergoing oral anticoagulant therapy do not meet the target values, which leads to an increased risk of bleeding or thrombotic events4. The investigator noticed that even with antisoagulation therapy, the patients have a high risk of thromboembolic events and haemorrhagic problems. The international Normalized Ratio(INR) values of most of the patients were not in the normal range. Diet rich in vitamin K, use of other prescription and over the counter medications affect warfarin and aggravate the problem. Lack of knowledge and noncompliance to treatment leads to physical problems, thromboembolic episodes, bleeding and infection7. Usually after valve replacement patients remain physically inactive. They feared about returning to work, producing excessive and financial problems. It was in this context the investigator decided to take up this study it identify the problems of patients with valve replacement and to prepare a structured teaching programme, STP will enhances the knowledge of the patients. 6.2 REVIEW OF LITERATUTRE: Review of literature is an essential component of the research process. Review literature helps the researcher to build on existing work, he or she should understand what is already known on a topic8. The review of the literature is sub divided in to two heading: Review of literature related to knowledge regarding heart valve replacement Review of literature related to management after heart valve replacement. Review of literature related to knowledge regarding heart valve replacement A study was conducted to assess the knowledge about long-term electrocardiographic changes after Fallot. Measurements were performed on electrocardiograms recorded preoperatively, postoperatively, and during annual follow-up in 35 Fallot patients included in three groups: G1 if they received no patch (n = 7), G2 if they received a transannular patch (n = 13), and G3 if they received a pulmonary homograft (n = 15). PR interval increased over the study period in all groups (Z-score: from 0.9 1.1 to 1.3 0.9 in G1, 0.9 1.2 to 1.7 1.6 in G2, and 0.7 0.7 to 1.4 1.3 in G3). The QRS duration increased during the follow-up at a rate of 1.78 msec/year in G1, 2.34 msec/year in G2 despite pulmonary valve replacement in 10 patients, and 1.81 msec/year in G3 despite conduit replacement in 9. At the later follow-up, the QRS duration was significantly increased (Z= 4.5 3.6 in G1, 5.7 1.4 in G2, and 4.6 1.9 in G3). One patient in each group had QRS duration of 170 msec or longer and the one in G3 had a history of serious ventricular arrhythmia. Three patients had a QTc duration above 460 msec9. A study was conducted to assess the knowledge about Aortic stenosis is a common valvular pathological finding in older adults. Currently, aortic valve replacement is the gold-standard treatment for severe symptomatic aortic stenosis. However, patients with advanced age and multiple comorbidities carry a significant operative risk. Transcatheter aortic valve implantation (TAVI) was developed with the goal of offering a less invasive alternative to symptomatic high-risk patients with aortic stenosis. Since the first successful TAVI procedure in 2002, TAVI has been used as a treatment option for patients at very high or prohibitive surgical risk in clinical feasibility trials, registries, and in ongoing randomized controlled trials. There are 2 transcatheter valves in widespread clinical application, with several others in different stages of development. This article provides an overview of TAVI outcomes including insertion options, procedural outcomes, morbidity, valve durability, short- to medium-term survival, and quality of life to guide nursing care interventions. Enhancing nurses' knowledge of the risks, benefits, and potential complications of TAVI will empower nurses in their role as patient advocates and educators and improve patient outcomes. Gaps in the current TAVI research literature are identified10. A study was conducted to assess knowledge on procedural outcomes and complication rates following TAVR in a large sequential patient cohort using a balloon expandable valve according to the new VARC definitions. Three hundred and ten consecutive patients undergoing TAVR were assessed, including patients forming our early historical series at the infancy of TAVR. All complication rates were re-evaluated according to VARC definitions. Mean age was 82.2 8.1 years and the Society of Thoracic Surgeons score was 9.4 5.7%. Transfemoral 30-day mortality was 6.8% (3.8% in the second half of the cohort) and transapical 30-day mortality was 13.7% (9.4% in the second half of the cohort). Cardiovascular 30-day mortality was 7.4% and the composite safety endpoint at 30-days was 18.4%. Device success was 80% (post-procedural valve area d" 1.2 cm2 in 9.7%). Failure to deliver and deploy a valve occurred in only 3.5%, with 82% (nine cases) occurring in the first half of the experience. Of those who did not meet echocardiographic criteria for device success (valve area d" 1.2 cm2, transaortic gradient e" 20 mmHg or e" moderate aortic incompetence), 90% achieved a New York Heart Association class I/II. Life threatening bleeding complications occurred in 8.4%. In 7.7% of patients, red blood cell transfusions were given without evidence of overt bleeding. Major strokes occurred in 2.3% and acute kidney injury occurred in 6.5%11. A cross-sectional study was conducted to assess the knowledge on mechanical heart-valve patients (because of congenital heart disease or acquired heart-valve defects) have about oral anticoagulation therapy included 57 patients. Knowledge was measured using the Knowledge of Oral Anticoagulation Tool. Adherence was assessed with a visual analogue scale and the Swiss HIV Cohort Study Adherence Questionnaire.Patients poorly understood symptoms relevant to over-anticoagulation and the effects of alcohol and vitamins on oral anticoagulants. The knowledge level of patients with congenital heart disease and acquired heart-valve defects did not differ significantly. Three-quarters of patients claimed to be 100% adherent to oral anticoagulant therapy12. A study was conducted to assess the knowledge on cost-effectiveness of homograft valve. Cost-effectiveness of homograft valve replacement with mechanical valve replacement surgery. Our samples were selected from 200 patients that underwent homograft and mechanical heart valve replacement surgery in Imam-Khomeini hospital (2000-2005). In each group we enrolled 30 patients. Quality of life was measured using the SF-36 questionnaire and utility was measured in quality-adjusted life years (QALYs). For each group we calculated the price of heart valve and hospitalization charges. Finally the cost-effectiveness of each treatment modalities were summarized as costs per QALYs gained. Forty male and twenty female participated in the study. The mean score of quality of life was 66.06 (SD=9.22) in homograft group and 57.85 (SD=11.30) in mechanical group (P<0.05). The mean QALYs gained in homograft group was 0.67 more than mechanical group. The incremental cost-effectiveness ratio (ICER) revealed a cost savings of 1,067 US$ for each QALY gained in homograft group13. A study was conducted on Factors influencing patient knowledge of warfarin therapy after mechanical heart valve replacement. 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. Sixty-one percent of participants had scores indicative of insufficient knowledge of warfarin therapy (score < or = 80%). Age was negatively related to warfarin knowledge scores (r = 0.27, P = .007). Patients with family incomes greater than $25,000, who had greater than a grade 8 education, and who were employed or self-employed had significantly higher warfarin knowledge scores (P = .007, P = .002, and P = .001, respectively). Gender, ethnicity, and warfarin therapy before surgery were not related to warfarin knowledge scores. Furthermore, none of the in-hospital teaching practices significantly influenced knowledge scores, whereas receiving postdischarge community counseling significantly improved knowledge scores (P = .001). 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. Accessing postdischarge counseling resulted in significantly improved warfarin knowledge scores. Because improved knowledge has been associated with improved compliance and control, our findings support the need to develop a comprehensive postdischarge education program or at least to ensure that patients have access to a community counselor to compliment the in-hospital education program14 Review of literature related to management after heart valve replacement. A study was conducted on Heart valve replacement in the elderly. From January 1973 to December 1976, 70 operations for heart valve replacement were performed on 68 patients aged 65--75 years. These comprised 40 aortic valve replacements, 27 mitral valve replacements, and three aortic and mitral valve replacements. Three patients died within 30 days of operation (early mortality 4.3%), and five died 12 weeks to three years after operation. Four patients showed no improvement. The results were excellent or good in the remaining 56 patients. Valve replacemnt can restore to a useful independent life elderly patients who would otherwise be a burden on costly social and medical domiciliary services. The indications for valve surgery in the elderly should therefore be the same as in any other age group15. A study was conducted on Coronary artery disease and its management: Influence on survival in patients undergoing aortic valve replacement. Data from 1,156 patients e"30 years of age who underwent aortic valve replacement alone or with coronary artery bypass grafting from 1967 through 1976 (early series) and 227 similar patients operated on during 1982 and 1983 (late series) were reviewed. In the early series, 414 patients (36%) had preoperative coronary arteriography (group 1): group 1A (n = 224) did not have coronary artery disease, group 1B (n = 78) had coronary artery disease but did not undergo bypass grafting and group 1C (n = 112) had coronary artery disease and underwent bypass grafting. The 742 patients in group 2 did not have preoperative arteriography. Operative mortality rates (30 day) in groups 1A, 1B, 1C and 2 were 4.5, 10.3, 6.3 and 6.3%, respectively (p = NS). The 10 year survival in both groups 1 and 2 was 54%; in groups 1A, 1B and 1C it was 63, 36 and 49%, respectively (1A and 1B, p < 0.01).In the late series, the 227 patients were divided into similar groups (group 1A, n = 73; 1B, n = 32; 1C, n = 99), and 90% had preoperative coronary arteriography. Operative mortality rates (30 day) for groups 1A, 1B and 1C were 1.4, 9.4 and 4.0%, respectively; that for group 2 (no preoperative arteriography, n = 23) was 4.3%16. A study was conducted on Antithrombotic therapy in patients with mechanical and biological prosthetic heart valves. 1. Permanent therapy with oral anticoagulants offers the most consistent protection in patients with mechanical heart valves. 2. Antiplatelet agents alone do not consistently protect patients with mechanical prosthetic heart valves, including patients in sinus rhythm with St. Jude Medical valves in the aortic position. 3. Levels of oral anticoagulants that prolong the INR to 2.0 to 3.0 appear satisfactory for patients with St. Jude Medical bileaflet and Medtronic-Hall tilting disk mechanical valves in the aortic position, provided they are in sinus rhythm and the left atrium is not enlarged. Presumably, this is also true for the CarboMedics bileaflet valve, based on the observation of no clinically important difference in the rate of systemic embolism with this valve and the St. Jude Medical bileaflet valve. 4. Levels of oral anticoagulants that prolong the INR to 2.5 to 3.5 are satisfactory for tilting disk valves and bileaflet prosthetic valves in the mitral position. 5. Experience in patients with caged ball valves who had prothrombin time ratios reported in terms of the INR is sparse, because few such valves have been inserted in recent years. The number of surviving patients with caged ball valves continues to decrease. It has been suggested that the most advantageous level of the INR in patients with caged ball or caged disk valves should be as high as 4.0 to 4.9. However, others have shown a high rate of major hemorrhage with an INR that is even somewhat lower, 3.0-4.5. The problem is self-limited, however, because few such valves are being inserted. 6. In patients with mechanical heart valves, aspirin, in addition to oral anticoagulants, has been shown to diminish the frequency of thromboemboli. The risk of bleeding is somewhat increased if the INR is 2.0 to 3.0 or 2.5 to 3.5. However, if the INR is 3.0 to 4.5, the risk of bleeding becomes excessive with aspirin. There are no investigations in which aspirin 80 mg/d in combination with oral anticoagulants was evaluated. 7. Data are insufficient to recommend dipyridamole over low doses of aspirin in combination with warfarin. Whether dipyridamole plus aspirin is more effective than aspirin alone when used with warfarin is undetermined. 8. Patients with bioprosthetic valves in the mitral position as well as patients with bioprosthetic valves in the aortic position may be at risk for thromboemboli during the first 3 months after operation. 9. Among patients with bioprosthetic valves in the mitral position, oral anticoagulants at an INR of 2.0 to 2.3 were as effective as an INR of 2.5 to 4.0 and were associated with fewer bleeding complications during the first 3 months after operation.10. Aspirin may reduce the long-term frequency of thromboembolism in patients with bioprosthetic valves17. A study was conducted on Five to Eight-Year Follow-up of Patients Undergoing Porcine Heart-Valve Replacement. To evaluate the clinical course after porcine heart-valve replacement, we followed 128 patients for five to eight years after surgery. Aortic-valve replacement was performed in 47 patients, mitral-valve replacement in 62, and combined aortic-valve and mitral-valve replacement in 19. Four patients died within 30 days of surgery (operative mortality, 3 per cent), and 20 died later (16 per cent); the actuarial probability of survival at eight years for all patients was 804 per cent (mean S.E.M.). Thromboemboli were found in two of 43 patients after aortic-valve replacement, in nine of 62 after mitral-valve replacement, and in four of 18 after combined aortic-valve and mitral-valve replacement. Valve dysfunction resulted from bacterial endocarditis in five patients (4 per cent) and from primary valve dysfunction in another five18. A cross-sectional study was carried out between October 2007 and February 2008 in an outpatient clinic specializing in cardiology in two hospitals in Porto Alegre, RS, Brazil. Users of the Single Health System, 18 years old or older, with mechanical valve prostheses, taking oral anticoagulation medication and who attended consultations in the clinic were included in the study. All patients included in the study were accompanied in this clinic and underwent valve replacement in the same studied institutions. No patients were excluded from the study. Data collection was carried out through an instrument composed of 11 questions: the ten first questions addressed knowledge and the last one the level of patient satisfaction regarding information received concerning oral anticoagulation medication. A total of 110 patients were evaluated. The internal consistency, evaluated through Cronbachs alpha, was 0.627. Average age was 50.310.7 years old and 58.2% were female; average of years of schooling was 6.072.98 years and 44.5% of the patients were retired. Mitral valve replacement (62.7%) and the use of warfarin as anticoagulant (64.5%) predominated19. STATEMENT OF THE PROBLEM; A study of assess the effectiveness of structured teaching programme on knowledge regarding valve replacement and its management among patients undergone valve replacement surgery at selected cardiac hospital in Bangalore. 6.3 OBJCTIVES OF THE STUDY: To assess the pretest knowledge regarding valve replacement and its management. To evaluate the effectiveness of planned teaching programme on the knowledge regarding valve replacement and its management To compare the mean score of pretest and post test knowledge regarding valve replacement and its management among patients undergone valve replacement surgery in selected cardiac hospitals. To assess the association between knowledge regarding valve replacement and management with selected demographic variables. 6.4 HYPOTHESIS: H1: There will be significant change in pretest and post test knowledge on management of patients undergone valve replacement after implementing structured teaching programe. H2: There will be a significant associations between knowledge of patient after valve replacement with selected demographic variables . 6.5 OPERATIONAL DEFINITION: Assess: It is the organized, systematic and continues process of collecting data and the statistical measurement of knowledge regarding management of patients after valve replacement by structured questionnaire. Effectiveness: It refers to the extent to which the structured teaching programme is helpful in gaining knowledge of patients regarding valve replacement and its management after structured teaching programme. Structured teaching programme: It is systematically developed programme with teaching aids, designed to impart knowledge, regarding valve replacement and its management among patients under gone surgery. Knowledge: It refers to the awareness and understanding regarding valve replacement and its management among patients under gone surgery as evaluated by structured questionnaire. Valve replacement: Is the excision of defective mitral or aortic valve or both and replacement with mechanical or biological valve. Cardiothoracic unit: It is one of the specialized department of surgery which deals with the surgical correction of heart as well as other thoracic problems. Surgery : It is the branch of science that treats disease by operative measures. Cardiac Hospitals :Is a place where patients are admitted and undergoing investigations and treatment for cardiac problems . 7.0 MATERIALS AND METHODS: 7.1 SOURCES OF DATA 7.2.1, Research Design : Quasi- experimental One group pre test and Post test design 7.2.2, Setting of the study : Selected hospitals at Bangalore 7.2,3, Population : peoples of age 20 years and above 7.2.4, Sampling technique : purposive sampling technique will be used 7.2.5, Sample size : Sample size will be 40 7.2,6,Sampling criteria Inclusion Criteria Patients after valve replacement in the age group 20 years and above. Patients after valve replacement who can either understand Kannada or English. Patients after valve replacement willing to participate in the study. Exclusion Criteria Patients who have other cardiac diseases. Patients who are not available at the time of study. 7.2.8, METHOD OF DATA COLLECTION : After obtaining the permission from the concerned authorities the investigator will introduce himself to the study subjects and explains the purpose of study. The data will be collected by using structured questionnaire. Description of the tool : Structured questionnaire Tool-1 Part-A : Performa for collecting demographic data Part-B : structured questionnaire to assess the knowledge of the patients regarding heart valve replacement and its domiciliary management. Tool-2 : structured teaching programme on knowledge regarding heart valve replacement and its domiciliary management. 7.2.8,Method of data analysis and interpretation: Pre and post test scores of knowledge and awareness will be analyzed through the following technique. Descriptive statistics: Mean, standard deviation, range and mean score percentage will be used to quantify the level of knowledge before and after STP. Inferential statistics: Paired t-test will be use to examine the effectiveness of STP by comparing the pre- test and post- test score. Chi-square test will be worked out to determine the association of socio-demographic factors of people with pre-test and post-test knowledge. Duration of the study : 6 weeks. 7.3Does the study require any investigation or intervention to be conducted on the patients or other human being or animals? If so please describe briefly. No 7.4Has Ethical Clearance been obtained from your institution in case of the above? Yes 8.0 LIST OF REFERENCES: 1. HYPERLINK "http://www.who.int"www.who.int 2. Abernthy WS Wills. Thromboembolic complication of rheumatic heart disease. Journal of cardiovascular nursing 1989;5(132):1972 3. Crowther MA, Ageno W, Garcia D, Wang L, Witt DM., Clark NP,et al, Oral Vitamin K versus placebo to correct Excessive anticoagulation in patients receing warfarin. Ann intrn med.2009:150(5):293-300. 4. Kulik A, Bedard P, B-khanh L, RuBens FD Hendry P J, Masters RG, et al, Mechanical versus bioprosthethic valve Replacement in middle aged patients. Eur J Cardiothorac surg. 2006;30(3):485-91. 5. Kunicki TJ, Kritzig M, Annis DS, valvular heart disease. Am J cardiol 1997:89:1939-43. 6. Tang EO, Lai CS, Lee KK. Wong RS, Cheng G, Chan TY. Elderly calcific valvular heart disease. Ann pharmacother.2003:37(1):34-9. 7. Koertke H Breymann Th, minami K, seifert D, Arusoglu L, Koerfer R. early start of INR self-management (INR-s) after mechanical valve replacement. Eur heart J,2000:21 suppl:266. 8. Polit D.F and B.P Hungler, Textbook of nursing research principles and methods Lippincott publications page no 57. 9. Massin MM, Malekzadeh-Milani SG, Schifflers S, Dessy H, Verbeet T.Division of Pediatric Cardiology, Queen Fabiola Children's University Hospital, Brussels, Belgium. martial.massin@huderf.be .Ann Noninvasive Electrocardiol. 2011 Oct;16(4):336-43. doi: 10. McRae ME, Rodger M.Marion E. McRae, MScN, NP, RN, CCRN-CSC-CMC, ACNP-BC, CCN(C), ACNPC Nurse Practitioner-Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Adjunct Clinical Faculty, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Ontario, Canada. Marnie Rodger, MN, NP, RN, CCN(C) Nurse Practitioner-Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Ontario, Canada. J Cardiovasc Nurs. 2011 Jul 13. 11. Gurvitch R, Toggweiler S, Willson AB, Wijesinghe N, Cheung A, Wood DA, Ye J, Webb JG. Department of Cardiology and Cardiothoracic Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, Canada. EuroIntervention. 2011 May;7(1):41-8. 12. Van Damme S, Van Deyk K, Budts W, Verhamme P, Moons P. Division of Congenital and Structural Cardiology, University Hospitals of Leuven, Leuven, Belgium. Heart Lung. 2011 Mar-Apr;40(2):139-46 13. Yaghoubi M, Aghayan HR, Arjmand B, Emami-Razavi SH. School of Management and Medical Information Science, Iran University of Medical Sciences, Tehran, Iran. Cell Tissue Bank. 2011 May;12(2):153-8. Epub 2009 Dec 2. 14. Hu A, chow CM, Dao D, Errett L, Keith M., Factors influencing patient knowledge of wafarin therapy after mechanical heart replacement , J cardiovasc nurs.2006 may-jun;21(3):169-75;quiz176-7. 15. A H De Bono, T A English, and B B Milstein, heart valve replacement in the elderly, Br med j 1978 septermber30;2(6142):917-919. 16. Charles J. Mullany, lila R Elveback, Robert L. et.al coronary artery disease and its management : Influence on survival in patients undergoing aortic valve replacement Journal of the American college of cardiology volume 10, issue1,july 1987.page66-72. 17. Stein PD, Alpert JS, Bussey HI, dalen JE, Turpie AG, Antithrombotic therapy in patient with mechanical and biological prosthetic heart valves chest. 2001 jan:119(1 suppl):220s-227s. 18. 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