Rajiv Gandhi University of Health Sciences Karnataka

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|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 |

| | |A STUDY OF ASSESS THE EFFECTIVENESS |

|5 |TITLE OF THE TOPIC |OF STRUCTURED TEACHING PROGRAMME |

| | |ON KNOWLEDGE REGARDING VALVE REPLACEMENT AND IT’S 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 United States, 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 (angina), shortness of breath, 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 (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:

1. Review of literature related to knowledge regarding heart valve replacement

2. Review of literature related to management after heart valve replacement.

1. 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 ≤ 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 ≤ 1.2 cm2, transaortic gradient ≥ 20 mmHg or ≥ 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  ................
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