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Asian Journal of Research in Nursing and Health
3(1): 33-41, 2020; Article no.AJRNH.53445
Effect of Health Education on Knowledge Regarding
Post-operative Care among Patients with
Mechanical Valve Replacement:
A Quasi-Experimental Study
Roheeda Amanullah Khan
1*
, Bakhtiar Ali Shah
1
, Nusrat Noreen
1
,
Riaz Anwar Khan
1
and Nasreen Ghani
1
1
Institute of Nursing Sciences, Khyber Medical University (KMU), Peshawar, Pakistan.
Authors’ contributions
This work was carried out in collaboration among all authors. Author RAK designed the study selected
the title literature review analysis proof done and wrote the first draft of manuscript. Authors BAS
helped in data collection and also helped in data Analysis. Author RAK helped out in identifying the
patients, manage and organize the patients for data collection in the study. Author NG was the
supervisor for the study. All authors read and approved the final manuscript.
Article Information
Editor(s):
(1) Dr. Fernanda Jorge Guimaraes, Universidade Federal de Pernambuco, Centro Academico de Vitoria, Brazil.
(2) Dr. Abdel-Hady El-Gilany, Mansoura University, Egypt.
(3) Dr. Alexandrina Cardoso, Escola Superior de Enfermagem do Porto, Portugal.
(4) Dr. Priscilla Sibongile Dlamini, University of Swaziland, Eswatini.
Reviewers:
(1) Egle Tamuleviciute-Prasciene, Lithuanian University of Health Sciences, Lithuania.
(2) Rajathi Sakthivel, The Tamil Nadu Dr. M. G. R. Medical University, India.
(3) Attahiru Adamu, Gombe State College of Nursing and Midwifery, Nigeria.
Complete Peer review History:
http://www.sdiarticle4.com/review-history/53445
Received 02 February 2020
Accepted 07 April 2020
Published 20 May 2020
ABSTRACT
Introduction:
Mechanical valve replacement is a necessary procedure for patients with valvular
heart disease. The potential for morbidity and mortality from a valvular prosthesis remains as long
as the valve is in place globally. Post-Operatively the patients are more prone to develop severe
complications i.e. wound infection, oral anticoagulation related disorders like Thromboembolic
events, bleeding, infective endocarditis, periprosthetic leak, and anemia and valve failure.
Materials and Methods: One group pretest-posttest (Quasi-Experimental) study was conducted in
Lady Reading Hospital, a tertiary care government hospital in Peshawar. Data were collected from
Original Research Article
Khan et al.; AJRNH, 3(1): 33-41, 2020; Article no.AJRNH.53445
34
35 patients through an adopted questionnaire. Data analysis for descriptive statistics and inferential
statistics were done through SPSS version 22.
Results: The knowledge of the study patients regarding rest, exercise, personal hygiene and
medications after mechanical heart valve replacement was insufficient (< 40%). After the education
session regarding the exercise, personal hygiene and medications, the knowledge improve due to
93%. The knowledge enhanced from 60% to 100% after intervention (P-value < 0.001). Similarly,
knowledge of patients regarding overdose of anticoagulants increased (P-value < 0.001). Likewise,
before the intervention, the knowledge of the patients was 42% and after the intervention, it
increased to 64% as evidenced by 54.3% of the patients replied correct answers.
Conclusion: Nursing education plays an important role in the improvement of patient’s knowledge
regarding complications of mechanical valve replacement. Knowledge of patients regarding post-
operative care was satisfactory after the intervention. Efforts may be needed to further improve
awareness among patients to enhance post-operative care to prevent complication.
Keywords: Knowledge; nursing education; post-operative mechanical valve replacement.
1. INTRODUCTION
Valvular Heart Disease (VHD) affects more than
100 million people worldwide and is associated
with significantly high morbidity and mortality [1].
The mortality rate of cardiovascular diseases is
very high. Cardiovascular diseases are the
leading cause of death, accounts for nearly
610000 deaths per year which are one out of
three deaths in the United States (US) [2]. More
than 65 million deaths worldwide are caused by
cardiovascular diseases [3]. Globally around
30% to 40% of deaths are due to cardiovascular
diseases [4,5].
There are many cardiovascular diseases which
are responsible for the morbidity and mortality in
which one of the major categories of
cardiovascular diseases is Valvular Heart
Disorders [6]. Heart valve replacement is the
most effective and appropriate management for
Valvular Heart Disorders [7]. Most common
causes of Valvular heart disease (VHD) are
Rheumatic heart diseases, myxomatous
degeneration, aortic sclerosis, infective
endocarditis and congenital anomalies. The
mostly mitral and aortic valve is effected which
results in either stenosis of the valve or
regurgitation or leakage of the valve or mix
lesions [1,8].
In the last 50 years, the epidemiology of valvular
disorders has drastically changed, with a marked
reduction in the incidence and prevalence
of rheumatic heart disease and a substantial
increase in the prevalence of degenerative valve
diseases. Currently, the overall age-adjusted
prevalence of mitral or aortic valvular heart
disease is estimated to be 2.5% in the general
population of the United States, with a
prevalence exceeding 10% in subjects over 75
years of age [6].
Surgical treatment of VHD began early in the 20
th
century, before the availability of
cardiopulmonary bypass, with isolated attempts
to dilate stenotic valves. Surgical valve
replacement (or repair of mitral valves) is
currently the standard of care for treatment of
valvular heart disease in patients at low and
intermediate risk for surgery [9]
.
The major type of morbidity associated with the
presence of prosthetic cardiac valve is valve
failure due to per-prosthetic leak or mechanical
dysfunction of the mechanical prosthesis,
thromboembolism, anticoagulant related
hemorrhage and endocarditis. Despite
successful surgery and regular hospital visits,
long-term survival was compromised by
anticoagulation-related complications [10].
Prosthetic valve replacement is usually done
when the cardiac valve is unable to perform its
function. There are several complications of
valve replacement in which one and the most
important one is the thrombotic event [11,12].
The patients should have sufficient knowledge
regarding the post-operative mechanical valve
replacement care to overcome the dangerous
complications. Education plays an important role
in the improvement of patient’s knowledge
regarding complications of mechanical valve
replacement. There is a dearth of study on
knowledge of patients regarding post-operative
care among patients with mechanical heart valve
replacement. The current study is therefore
designed to fill the knowledge gap and its hope
that the study will have implications for health
professional and policymakers.
Khan et al.; AJRNH, 3(1): 33-41, 2020; Article no.AJRNH.53445
35
2. MATERIALS AND METHODS
This was a Quasi-Experimental (pretest-posttest)
study conducted in Lady Reading Hospital
(LRH), a major tertiary care hospital in
Peshawar, Khyber Pakhtunkhwa Pakistan. The
study patients were recruited from September
2018 to December 2018. The study participants
were those who undergone Aortic valve
replacement (AVR) or mitral valve replacement
(MVR) or double valve replacement (DVR) and
were selected from Cardiac Surgical Ward and
Cardiac Surgery Intensive Care unit of LRH
hospital. Post-operative mechanical valve
replacement patients who fulfilled the inclusion
criteria were included in the study.
2.1 Objective
To assess the knowledge level of the
patient about the homecare after prosthetic
valve replacement.
To assess the effectiveness of health
education among patients after prosthetic
valve replacement.
2.2 Limitation of the Study
The study is limited to patients who are admitted
or coming for follow up care in the single tertiary
care LRH Peshawar and Patients willing for the
study admitted for prosthetic valve replacement
in LRH Medical Teaching Institute. Adult patients
(>18years old) only are included.
2.3 Sampling
A consecutive sampling technique was used to
select 35 patients who had undergone either
AVR or MVR or DVR.
Data collection Tool: Twelve items adopted and
validated questionnaire was used for data
collection. The questionnaire consists of two
sections. Section-1 consists of demographic data
including the name of the patient, age, sex,
category, education, name of the surgery and
day of the postoperative period. Section-II
contains 12 questions about different aspects of
post-operative care after mechanical heart valve
replacement.
2.4 Inclusion and Exclusion Criteria
Inclusion: Patients who are undergone either
AVR or MVR or DVR with a mechanical
prosthesis (>18years old)and willing for the study
are included in this study.
Exclusion: Patient who are admitted with other
cardiac problem and critically ill patients who
cannot answer the questionnaire wereare not
included in this study.
2.5 Data Analysis
Data were analyzed using SPSS version 22.
Frequencies and percentages were calculated
for categorical variables including age, sex,
marital status, education and employment. Chi-
square test was applied to see the statistical
difference in the knowledge level of the patients
before and after the intervention.
3. RESULTS
A total of 35 patients were included in the study
from LRH Peshawar, Khyber Pakhtunkhwa. The
majority (33%) of the patients were from the age
group 29-39 years while 6% of the patients were
from the age group for more than 50 years. 74%
ofthe study patients were married followed by
11% unmarried and only 1% divorced. More than
half (60%) patients were male while 40% were
female. Only 5% study patients were primary
education and 34% were high secondary level of
education. 37% study participants were
employed and 14% were students (Table 1).
Fisher’s exact test and chi-square test was
applied, the data to identify the significant
difference in the knowledge of participants before
and after the intervention. There was a significant
difference found in the knowledge level of
participants after the intervention. Significant
improvement in the knowledge regarding sleep
was observed after the intervention (P-value <
0.001). Similarly, knowledge of participants
regarding surgical wound care after bath
significantly increased to 91% (P-value < 0.001).
Knowledge of participants regarding the care of
the wound after surgery increased from 11% to
29% with intervention.
There is a significant increase in the knowledge
of the participants regarding the question of
whether the clients can detect the wound
infection. The knowledge enhanced from 60% to
100% after intervention (P-value < 0.001) (Table
2). Similarly, knowledge of participants regarding
overdose of anticoagulants increased (P-value <
0.001). Likewise, before the intervention, the
Table 1.
Demographic profile of the population, (n=35)
Age (years)
18-28 years
29-39 years
40-50 years
> than 50 years
Marital Status
Married
Unmarried
Death of wife
Divorced
Gender
Male
Female
Education
Primary
Middle
Higher Secondary
FA/FSC or Higher
Employment Status
Employed
Unemployed
Retired
Student
Table 2. Knowledge of participants regarding the detection of infection
Variable
Chest pain
Pus or watery
Pre-test 5 (14.3%)
21 (60%)
Post-test 0 (0%)
35 (100%)
P-
value < 0.001 < α = 0.05
knowledge
of the participants was 42% and after
the intervention, the knowledge increased to 64%
as evidenced by 54.3% participants replied
correct answer and after interventions, the
knowledge level increased up to 20%. There was
a significant increase in the know
study participants regarding the use of Digoxin
after the intervention. Before the intervention, the
6%
Khan et al.; AJRNH, 3(1): 33-41, 2020
; Article no.
36
Demographic profile of the population, (n=35)
Frequency
Percent
10 29%
11 33%
11 32%
2 6%
26 74%
4 11.40%
4 11.40%
1 1%
21
60%
14 40%
5 14.28%
9 25.71%
12
34.28%
9 25.71%
13 37.14%
10 28.57%
7 20%
5 14.28%
Fig. 1.
Table 2. Knowledge of participants regarding the detection of infection
Pus or watery discharge from the wound
Palpitation
21 (60%)
3 (8.6%)
35 (100%)
0 (0%)
value < 0.001 < α = 0.05
of the participants was 42% and after
the intervention, the knowledge increased to 64%
as evidenced by 54.3% participants replied
correct answer and after interventions, the
knowledge level increased up to 20%. There was
a significant increase in the know
ledge of the
study participants regarding the use of Digoxin
after the intervention. Before the intervention, the
knowledge of the participants was 43% and after
the intervention, the knowledge increased to
64%. Also, there was a significant increase in th
knowledge regarding checking PT, prophylactic
antibiotics, dysfunction of the valve and
regarding warning signs and needs immediate
medical attention.
29%
33%
32%
Age Distribution
18-28
29-39
40-50
50+
; Article no.
AJRNH.53445
Table 2. Knowledge of participants regarding the detection of infection
Don’t know
6(17%)
0 (0%)
knowledge of the participants was 43% and after
the intervention, the knowledge increased to
64%. Also, there was a significant increase in th
e
knowledge regarding checking PT, prophylactic
antibiotics, dysfunction of the valve and
regarding warning signs and needs immediate
Khan et al.; AJRNH, 3(1): 33-41, 2020; Article no.AJRNH.53445
37
Table 3. Knowledge of participants regarding the rest after surgery
Variable
6-8 months
3-6 months
1 month
Pre-Test 9 (25.7%) 25 (71.4%) 1 (2.9%)
Post-Test 5 (14.3%) 28 (80%) 2 (5.7%)
Chi-square test P-value = 0.520 > 0.05
4. DISCUSSION
Anti-coagulants therapy is the most important
post-operative mechanical valve replacement
therapy. Anti-coagulant therapy prevents the
formation of clots which can reduce severe
complication. Our study is the first to provide
valuable data on the effect of Health Education
regarding knowledge of Post-Operative care
among patients with post-operative mechanical
valve replacement. This study aimed to verify
Knowledge of the post-operative care rest
exercise, personal hygiene and medication with
the use of oral anticoagulation in patients with
mechanical valve replacement.
The significant increase found in the knowledge
regarding sleep after the intervention. Before the
intervention, the knowledge was (56%) which
increased to 94% after the intervention. The
results compare with the study found that 87% of
men and 75% of women said that they were able
to hear the closing sound of their mechanical
valve. Women were more disturbed by the valve
sound than men in their sleeping hours
[13].In
the study knowledge regarding exercise
increased up to 91% from 40% after the
intervention. Similarly, the knowledge of the
participants regarding infection after cardiac
valve replacement increased after the
intervention. The study showed that the
European Society of Cardiology recommends
that physical exercise like walking for people with
mechanical heart valve replacement should
consist of 150 minutes per week, while others
recommend three to four hours per week [14].
In this study knowledge of patients regarding
surgical wound care after bath significantly
improved to 91% (P-value < 0.001). Knowledge
of patients regarding the care of the wound after
surgery increased from 11% to 29% with
intervention. Although numerous improvements
in prevention and perioperative care, about deep
sternal wound infection DSWI is still a permanent
alarm in cardiac surgery patient because of its
significant rate and relevant impact on the length
of hospital stay, costs, and mortality [15].
Although the incidence of this complication is in
part due to the increased number of patients at
high-risk for infection because of advanced age
and rate of relevant comorbidities in the
population due to inadequate knowledge among
people undergoing cardiac surgery. Rigorous
attention to the details of preoperative,
intraoperative, and post-operative management
could contribute to keeping DSWIs at a minimal
rate. Current results suggest that health
education about wound infection can improve
patients knowledge before the intervention 20
(55%) replied that they could detect but after the
intervention 33 (100%) said that they can detect
the wound infection. After the intervention, the
knowledge level of the patients regarding the
correct answer increased up to 100%. P-value
also indicates that the test is significant. P-value
< 0.001 < α = 0.05.
The result showed how the patients will identify
the overdose of anticoagulant, almost 9% of the
patients answered correctly whereas after the
intervention 87% of the patients correctly
answered. The p-value < 0.001 < α = 0.05 shows
that our test was significant. About the score
obtained in the instrument by another study, the
majority (61.8%) presented regular knowledge,
followed by 40 (36.4%) patients who had good
knowledge and two (1.8%) who had poor
knowledge [16]. The results of another
study conducted in the nursing field in which
60% of patients answered correctly almost
the entire questionnaire addressing oral
anticoagulation knowledge except one question
addressing the influence of diet, were less
knowledge regarding overdose of oral
anticoagulant [17].
The most important feature in treatment success
is the periodical and careful follow-up of INR
levels and assurance that patients will adhere to
the treatment, which is a difficult task for clinical
practice without educational teaching intervention
[18]. Despite the practical relevance of teaching
patients regarding their therapy, the best strategy
to educate patients about anticoagulation has yet
to be determined our results showed pretest 5
(14.3%) and posttest significantly improved
patient knowledge 26 (74.3%) P-value < 0.067 <
α = 0.05.
Khan et al.; AJRNH, 3(1): 33-41, 2020; Article no.AJRNH.53445
38
When the participants were questioned about
identification of valve dysfunction, only 7(20%)
correctly answered the question but after the
intervention, their knowledge level increased up
to 33 (94.3 %) P-value also shows that there was
statistical difference in the knowledge level of the
participants before and after the intervention as
shown in Table 1. Thrombosis is the main cause
of prosthetic heart valve dysfunction. According
to various data, it occurs in 0.1 – 5.7% of patients
per year. Also, disorders of the prosthetic
functioning may occur due to the vegetation
growth, the development of ring abscess
formation [19,20].
5. CONCLUSION
Based on the findings of the study, post-test
knowledge level of patients about Post-operative
care with prosthetic valve replacement has been
increased. The primary outcome of this health
education teaching on knowledge regarding post-
operative care in patients with mechanical heart
valve replacement project was a health
education intervention did make a significant
difference in personal hygiene, food and oral
anticoagulation therapy knowledge in primary
care. Thus health education interventions help
in the improvement of the patient's
knowledge regarding postoperative care. The
cardiology department must arrange sessions for
the postoperative cardiac valve replacement
patients regarding postoperative care. Further
studies are recommended to identify reasons for
low knowledge among patients with prosthetic
valve replacement.in this study the author
developed a pamphlet for awareness regarding
post-operative care and knowledge among
patients with mechanical heart valve
replacement.
CONSENT AND ETHICAL APPROVAL
The study was reviewed and ethical clearance
was granted from the Ethics Review Committee
of the Khyber Medical University, Peshawar.
Also, permission was granted from LRH
administration. Informed consents were taken
from all the participants before filling the
questionnaires.
COMPETING INTERESTS
Authors have declared that no competing
interests exist.
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APPENDIX
HEALTH EDUCATION PAMPHLET FOR PATIENTS UNDERGONE MECHANICAL VALVE
REPLACEMENT
Mechanical valve replacement is a procedure for the patients who are having functional abnormality of
a diseased heart valve, moreover stenosis (narrowing of the orifice when the valve is open) or
regurgitation (incompetence when the valve is closed) a combination of the two. Here usually we are
using the following prosthetics/mechanical valves in patient with dysfunction of their valves.
1. Tilting disc valve-In this type of valves a disc is tilting to open and close the valve.
2. Caged-ball design -A cage attached to the sewing ring that houses a silastic ball.
DIET
You should include variety of foods and should eat proper balanced diet, like pulses, fresh
fruits plenty of liquids
Avoid fatty foods Red Meat(buffalo, cow ,cheese, butter, unsaturated Vanaspati, if you are
having increased body weight
White garlic and fishes especially Trout, Salman fishes should include in the diet
If the doctor says to restrict salt in diet, first try to avoid and take a less amount of salty foods
such as pickles, lemons, limes and any citrus fruits .Try to take less salt one fourth teaspoon
daily.
Include salad, and cabbages in constant amount daily.
Try to avoid green leafy vegetables like Spanish, Mustard and all others of dark green leaves
Vit k containing vegetables which make thicken the blood.
REST AND EXERCISE
Take rest for 3 to 6 months after the surgery. Period of rest will differ for each patient’s
according to their health condition.
Avoid lifting heavy weights for the first 3 months and binding down for anything which is force
of gravity and give pressure to your incisional area.
Khan et al.; AJRNH, 3(1): 33-41, 2020; Article no.AJRNH.53445
40
Avoid strenuous arm movement such as golf or tennis, swings. When getting out of chair and
of bed, use legs rather than pressure on arms. Arm should not bear weight and should be
used only for balance nor for weight..
Use alternative positions of 3 to 4 month to decrease stress on sternum; avoid side lying and
prone position.
Sleep at least for 6 to 8hrs inthe night. Take rest for some time in the afternoon after lunch.
Exercises that causes fatigue and Shortness of breath should be avoided.
Activities which are dangerous should be avoid.
Avoid intake of cafeen,opium and smoking
Walking is the best exercise after the surgery at least for 20-30 and approximately 150
minutes per week...
Daily walk should be in a particular distance and gradually increase the distance, and follow
physicians
Avoid swimming and climbing stairs for at 4 months.
Obey instruction for activity progression in your daily life for light routine works.
Daily activities can be done by self. You can return to work within 3 to 6 months after the
surgery according to doctor’s instructions.
Do not drive for at least 6 weeks after surgery (ways side in auto- car)
Resume sexual activity when you can climb two flights of stairs without stopping (with
physician’s recommendations)
PERSONAL HYGIENE AND CARE OF SURGICAL WOUND
Take bath daily with soap and water and wear clean cotton cloth Inspect and cleanse surgical
incisions daily with soap and water. Dry the wound with a clean white cloth. Keep the wound always
dry. Don't use any medicines without doctor’s order. Don't apply powder or oil over the wound that will
cause infection of the surgical wound.
Seek medical advice if any watery discharge or pus coming from the surgical wound or presence of
itching or reduces over the wound occurs.
Avoid scratching the wound with nail or any other object.
MEDICATIONS
1. Tab.Digoxin is given for increase the ability of hearts muscles to contract and arrange the
rhythm. Count the pulse rate for 1 minute taking the tablet.
2. Don't take the tab of the pulse rate is below 60/Mt.
3. Continue the medicine as per doctor’s order.
4. Tablets such as Lasix, Aldactone, etc. Are given for removing the unwanted water from all
over the body and improve the ability of the heart to pump. If the doctor advised to take tablet
daily, take tablet every day as the same time.
5. Seek medical advice if sudden weight gain of peripheral edema or decreased amount of urine
occurs
6. Tab.warfarin, Dindivan, Asithrom (CUEMADIN) (Anticoagulants) should take regularly as per
the doctors order and special instruction given by charge nurses regarding anticoagulants.
This is to prevent blood clotting. This should take life long and don't stop of decrease the dose
without doctors’ advice.
POINTS TO REMEMBER WHILE TAKING ANTICOAGULANTS
Should take the tablet every day in the evening 5 PM at the correct time.
The tablet should be taken 1 hr. before food and 1 hr. after food
Note down the date, time and amount of the tablet
Don't double the dose if one dose is forgotten
Prothrombin Time (PT) test should be done monthly and show the report to the doctor.
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41
Avoid getting injured. Take care while using sharp objects. Don't use tooth brush with hard
bristles.
Don't take medicines which contains steroids or aspirin. Tell the doctor about the
anticoagulant you are taking if you need to take any other medicines
Bring the needed dose of anticoagulant while you travel a long distance
HOW CAN YOU UNDERSTAND THE INCREASED DOSE OF THE ANTICOAGULANT?
Bleeding from the surgical wound
Bleeding from the nose while snuffing
Bleeding from the gum while brushing
Blood in the sputum
Presence blood in the urine or stool
Increased bleeding while menstruation
Mechanical valve are made entirely of synthetic materials. These valves offer the benefits of good
long term durability but pose a significant risk of thromboembolism and require long-term
anticoagulation. The regular and adequate anticoagulation and regular follow up, usually the patients
will have low grade fever, fatigue for the first few weeks. Seek medical advice if it persist for more
than 1 month. Thrombo embolic complications will occur, if the anticoagulant is not taking regularly. If
the thrombus occurs inside the prosthetic valve, the valve will become stuck.
SIGNS AND SYMPTOMS OCCURS DURING DYSFUNCTION OF THE VALVE
Appearance of signs and symptoms which was present before the surgery
(If the replaced valve is filling disc type) the sound that was heard during closure and opening
of the valve will become decrease or stop and sign will appear as like before.
The thrombus occurs in the valve and when dislodge and flow through the circulation. The
thrombus will block any vessel of the body and may cause stroke of unconsciousness of
blindness. Paraplegia or hemiplegia or pain over the extremities, etc.
If infection occurs at the site of the prosthetic valve due to some other causes, the symptoms
will be prolonged fever, chills and increase fatigue.
If any one of the above symptoms occur immediate medical attention is necessary
The most common site of infection in infective endocarditis after prosthetic valve replacement
is through dental or urologic infection. So taking prophylactic antibiotic is necessary before
dental or urologic procedures.
Information of anticoagulation therapy should be given to distinct before any procedures.
© 2020 Khan et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
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http://www.sdiarticle4.com/review-history/53445
