RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BENGALURU, KARNATAKA.

SYNOPSIS PROFORMA FOR REGISTRATION OF

SUBJECT FOR DISSERTATION

MR. FINNY PATHICKAL BENNY

MEDICAL- SURGICAL NURSING

I YEAR MSC NURSING

YEAR 2011-2012

SJB COLLEGE OF NURSING

BENGALURU-560060.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BENGALURU, KARNATAKA.

ANNEXURE-1

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT

FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / Mr FINNY PATHICKAL BENNY
1ST YEAR M.Sc. ( NURSING ),
SJB COLLEGE OF NURSING,
BGS HEALTH AND EDUCATION CITY
KENGERI,
BENGALURU – 500 060.
2. / NAME OF THE INSTITUTION / SJB COLLEGE OF NURSING,
BGS HEALTH AND EDUCATION CITY
KENGERI, BENGALURU-60.
3. / COURSE OF STUDY AND SUBJECT / 1ST YEAR M.Sc. NURSING
MEDICAL-SURGICAL NURSING
4. / DATE OF ADMISSION TO COURSE / 24-10- 2011
5. / TITLE OF TOPIC / “A STUDY TO EVALUATE THE EFFECTIVENESS OF SELF INSTRUTIONAL MODULE (SIM) ON KNOWLEDGE REGARDING THE LIFE STYLE MODIFICATIONS AMONG THE PATIENTS WITH VALVULAR DISORDERS WHO HAVE UNDERGONE VALVE REPLACEMENT SURGERY IN SELECTED CRADIAC HOSPITALS, BENGALURU.”

6. BRIEF RESUME OF INTENDED WORK

INTRODUCTION

“I believe every person has a heart, and if you can reach it,

you can make a difference”.

By UliDerickson

The normal heart valve performs an amazing mechanical function.Theactivity starts when the foetus is barely 6 to 8 weeks old and works last till the end of the life. Opening and closing with each beat of the heart, about 40 million times per year and for a lifetime that is over 2.5 billion times generally without a failure. Sometimes there may be a chance that heart valves may not work properly. 1

In today’s world, most deaths in the developing and developed countries are attributable to non-communicable diseases and just over half of these are the result of cardiovascular diseases. More than one third of deaths occur in middle aged adults. In India an estimated 2.27 million people died due to cardio vascular disease during 1990 and the projection of deaths due to increase of heart disease from 1.17 million to 1.59 million in 2000 and 2.30 million by 2010 .The prevalence of coronary valve disease is reported to be 2 to 3 times higher in urban population than in rural population and it is estimated as 96.7 percentage in 1000 adult population in urban and 27.1 percentage in rural population.2The American heart association reported a statistics in the basis of 2007 mortality rate which shows that, there was more than 2200 deaths occurring due to CVD in America in each day.3

In India, it has become a major health issue with deaths due to CVD expected to double during 1985 to 2015. Mortality estimates due to CVD vary widely by state, ranging from 10% in Meghalaya(49%) in Punjab (49%), Goa (42%) Tamil Nadu (36%) & Andrapradesh (31%) have the highest CVD related mortality estimates.4Some diseases, such as rheumatic fever, endocarditis, streptococcal infections, and calcification are capable of causing damage the valves that will eventually need to be repaired or replaced.5

Valvular heart disease ranks well below coronary heart disease in worldwide.Stroke, hypertension, obesity, and diabetes as major threats to the public health, nevertheless, it is the source of significant morbidity and mortality rates. Cardiac disease prevalence has been estimated to range from as low as 1 per 100,000 school-age children in Costa Rica to as high as 150 per 100,000 in China. Prevalence and mortality rates vary among communities even within the same country as a function of crowding, the availability of medical resources and population-wide programs for detection and treatment.5

When a valve is getting malfunction, four abnormalities may happen. The valve does not open at all, or there is narrowing of the pathway thereby restricting the forward flow of blood which is called as stenosis. Another type is that the valve does not close properly and allow the blood to flow backwards that is called as regurgitation or insufficiency. Next type is the abnormal protrusion or intrusion of valve,generally called as valve prolapse and finally the valve neither opens nor closes properly, causing a combination of above problems. Often clients with early or mild forms of valve disease live with a fairlynormal life without any treatment. But symptoms such as dizziness, fatigue, shortness of breath and chest painetc, become significant enough to affect the daily life before and after the surgery. Today valve surgery can correct these problems and restore the function of diseased valves .6 The support by the nurse with health education will restore the optimal health of clients who has undergone valve replacement surgery.7

6.1 NEED FOR THE STUDY

Cardio Vascular disease (CVD) has become a major killer of mankind. It accounts for over one million deaths each year, with a yearly death of more than 400,000 Americans.8

In India, CVD has become a major health issue and expected tobe double during 1985 to 2015. Mortality estimates due to CVD vary widely by state, ranging from 10% in Meghalaya (49%) in Punjab (49%), Goa (42%) Tamil Nadu (36%) & Andrapradesh (31%) have the highest CVD related mortality estimates.4

The WHO estimated that 60% of the World’s cardiac patient was Indian by 2010. Recent studies showed that Valvular heart disease is a leading cause of morbidity and mortality in India.9 Significant valvular heart disease has a national prevalence of 2.5% and affects 13% of patients with 75 years old.10

The nurse must be aware of cardio-vascular disease risk factors and be alert for opportunities to teach health promotions measures to the patients with valve replacement surgery and their families.Clinical nurse needs necessary knowledge to provide a health teaching to acquire client’s normal daily life activities which eventually will leads the heart to its normalfunction.

A comparative study was conducted from January 2003 to December 2008 by New Delhi Universityon a short term mortality and morbidity of mechanical and bio prosthetic heart valves in the Indian population.A total sample of 503patientswhohad undergone cardiac valve replacement surgery was retrospectively analysed.Clientswith bothmechanical and biological valves were selected.The study concluded that, patients with Mechanical valves (n=257) are associated with a significantly higher complication rate compared with patients having biologicalvalves (n=246). The study reveals that after the surgery secondary complications will be associated in both mechanical and biological valve replacement clients. The complications include secondary myocardial infraction, ischemia, and abnormal rhythm etc.11

A study was conductedon 2007 and published on Annals of thoracic surgery regarding the quality of life after the valve replacement surgery. Sample sizes of 184 patients with mitral valve prolapse or regurgitation were selected for control and experimental group with Nottingham Health Profile quality-of-life analysis. The average interval between surgery and administration of the Quality of Life techniques was approximately 7.5 years in both groups.The study reveals that the factors for death were preoperative unstable angina pectoris (relative risk ratio, 4.4; 95% confidence interval, 2.2 to 8.8), use of mitral prosthesis (relative risk ratio, 2.7; 95% confidence interval, 1.4 to 5.3), preoperative renal insufficiency (relative risk ratio, 1.0; 95% confidence interval, 1.0 to 1.007), and preoperative cerebrovascular disorder (relative risk ratio, 2.7; 95% confidence interval, 1.0 to 5.3). The study revealed that the quality of life after the surgery had altered and was thought to trigger the secondary cardiac disease. Subjects who had positive attitudes and activities in their lifestyles showed lesser cardiac risk factors.12

There are some noted essential lifestyle changes needed for the client after valve replacement surgery. For most clients, after surgery enhanced functional capacity leads to a greater ability to perform the activities of daily living. Older clients who undergo heart valve surgery have longer hospital stays and more complications. Turning back to the cardiac normal function after surgery in hospital and home care is also an opportunity to the health care personals to evaluate medical management and to educate clients about the safety of increasing physical activity, procedures outcome, reducing the risk factors and monitoring warning signs and symptoms .13

Nurses have the responsibility to bring back the client to a better quality of life by several methods such as health awareness program, health profile screening, and healtheducations. Proper teaching and guidance will leads the clients to a better competent life. Here the investigator felt the need of educate the client who has undergone surgery for valvular repair, which will improve the client daily activities and the heart functioning after the surgery.

6.2 REVIEW OF LITERATURE

Review of literature for the present study is explained under the following headings:

  1. LiteraturerelatedtoLifestylemodificationaftervalvereplacementsurgery.
  2. Literaturerelatedtotheeffectivenessof Self Instructional Module (SIM).

1. Literature relatedtoLifestylemodificationaftervalvereplacementsurgery.

A cross-sectional survey was conducted on Association of Trans fatty acids and clarified butter intake with higher risk of coronary artery disease in rural and urban populations with low fat consumption. The survey included a sample 1769 rural and 1806 urban randomly selected subjects between 25-64 years of age from Moradabad in North India. The survey revealed among urban and rural subjects consuming moderate to high fat diets and had a significantly higher prevalence of coronary artery disease. These prevalence was in people who are consuming clarified butter plus vegetable oils in both rural (9.8, 7.1 vs. 3.0%) and urban (16.2, 13.5 vs. 11.0%), men as well woman as in rural (9.2, 4.5 vs. 1.5%) and urban (10.7, 8.8 vs. 6.4%). The researcher concluded that it is possible that lower intake of total visible fat (20 g/day) by decreased intake of milk, increased physical activity and cessation of smoking may benefit some populations in the prevention and reduction of coronary artery disease.14

A study was conducted by doctors in Karolinska University Hospital, Sweden in order to assess the quality of life and the mortality rate after the heart surgery. The study included 4,086 cardiac surgery patients and identified 141patients who had a postoperative intensive care unit stay of more than 10 days with the Karnofsky performance scale and the Short Form-36 questionnairescale .The data regarding patient’s outcome were collected. The studyresults concludedthat early mortality was 33%. They found significantly lower physical (39.7 %) and mental (44.1 %) scores, especially in patients who required dialysis. However, long-term survival and functional status were encouraging according to the Quality of life.15

An experimental study was conducted at Department of Cardiothoracic Surgery, University Hospital, Sweden from 1998 to 2003. A sample size of 225clients who underwent primary heart valve surgery were selected, who required 8 days or more of treatment in an intensive care unit with Nottingham health profile and SF-36 scale were analyzed. A cohort group (n =154) matched for sex, age, type of procedure, and week of operation, with an uncomplicated postoperative course (ICU stay of 2 days or less) served as the control group. The study revealeda 5 year Survivor in the total ICU group was 68%,this group showed quality of life by lesser physical mobilityafter heart valve surgery compared with controls group and 80% patients experienced improvement after surgery in terms of quality of life.16

A study was conducted on lifestyle changes following acute myocardial infarction, patient’s perspectives for assessing the impact of life style changes in heart disease. The study found that the secondary cardiac warning signs taking responsibility for lifestyle changes. The study highlights the need for the development of supports to the patient’s through by providing information to families to reduce anxiety and fear regarding secondary cardiac diseases after the surgey.17

In 2007 the American college of Cardiology and American heart association grouped a guideline committee for administering guideline to the health professionals regarding the importance of life style modifications after the cardiac surgery on the basis of various studies and statistics. In the committee they include patients with heart valve surgical repair or replacement for prime aspects of consideration. The Writing Committee focused its attention on two general performance measurement sets: Referral of eligible patients to an outpatient Cardiac rehabilitation (CR) program, and delivery of appropriate CR services by CR programs. The committee recommends that the guideline should be implemented in the health care delivery system.18

Several articleswerepublished online regarding the need for the life style changes after the valve replacement surgery. It was evident that sedentary life style changes such as food, activities pattern19,reducing cigarette smoking, weight control, dietary recommendations, rest20 and Sexual activities adjustmentwhich improved the quality of life after the surgery. 21

2. Literature related to the effectiveness of Self Instructional Module (SIM).

A study was conducted on 2009 to assess the effectiveness of Self Instructional Module regarding quality of life among patients following CABG surgeries in the elderly .A total number of 63 patients with 65 years of age group,both males and females were selected by convenience sampling technique. A detailed questionnaire was used to collect data about quality of life and improvement in lifestyle after CABG surgery . The study result showed that a high proportion of the patients experienced improvement (that is 45 patients) in life style modifications, while a substantial number (that is 15 patients) had exacerbations in cognitive function, lack of confidence and dependence. The study concluded that an important step is needed to improve the quality of life, might be through the institution of a structured multidisciplinary rehabilitation program, also the life style modification with focus on emotional support.22

A study was conducted to assess the effectiveness ofSelf Instructional Module on patient knowledge and compliance of Quality of Life among 30 patients who had underwent valve replacement surgery and 18 patients who had had coronary artery bypass surgery were included in this study. Among them 25 patients were taught by masters-prepared clinical specialists and 23 by nurses with less than master’s preparation. Measurements of knowledge and compliance were obtained preoperatively. The study revealed that the patientswho are received teaching from masters-prepared nurses had significantly higher test scores at discharge than the teaching received by nurses with less than master’sdegree. So there is an effectiveness of teaching programme by the nurses with masters in degree regarding Quality of life after valve replacement surgery.23

6.3 STATEMENT OF THE PROBLEM

“A study to evaluate the effectiveness of Self Instructional Module (SIM) on knowledge regarding the life style modifications among the patientswith valvular disorders who have undergone valve replacement surgery in selected Cardiac hospitals, Bengaluru.”

6.4 OBJECTIVES

  1. Toassesstheknowledgeamongpatientswho have undergonevalvereplacementsurgeryregardinglifestylemodificationbypretestknowledgescore.
  2. ToevaluatetheeffectivenessofSelf Instructional Moduleonknowledgeregardinglifestylemodification for patients who have undergonevalvereplacementsurgerybycomparingpreandposttestknowledgescores.
  3. Tofindoutassociationofpretestknowledgescoreswithselecteddemographicvariables.

6.4.1HYPOTHESIS

H1:Therewillbeasignificantdifferencebetweenpre-testandpost-testknowledgescoresregardinglife style modification of patients who have undergone valvular replacement surgery.

H2:Therewillbesignificantassociationbetweenpretestknowledgescoresand selecteddemographicvariables.

6.4.2VARIABLES

  1. Independentvariable:Self Instructional Moduleonknowledgeregardinglifestylemodification for patient who have undergonevalvereplacementsurgery.
  2. Dependentvariable:knowledgeofpatients regardinglifestylemodification
  3. Demographicvariables:Age,sex,residing, family history, occupation, source of information,educationalbackgroundandworkingexperienceofthepatients.

6.5OPERATIONALDEFINITIONS

  1. Evaluate:Itreferstosystematicdeterminationofmerit,worthandsignificanceofsubject’sresponsetoSelf Instructional Module (SIM).
  2. Effectiveness:ItreferstotheextenttowhichtheSelf Instructional Module (SIM) hasachievedthedesiredeffectinimprovingtheknowledgeofpatients as evidencedfromgaininknowledgescores on life style modification.
  3. Self Instructional Module (SIM):Itreferstothesystematicallydevelopedinstructionalmethodandteachingaidsdesignedforpatients to provideinformationonlifestylemodifications.
  4. Knowledge:Itreferstocorrectresponsesofpatients to thequestionnaireonlifestylemodifications.
  5. Lifestyle modification:It refersthe change in habits of a client’s including alcohol Consumption, smoking, physical activity, food habits etc.which enhance optimal cardiac function after surgery.
  6. Valvereplacementsurgery:Itreferstothereplacementofimpairedheartvalve withtheprostheticvalve

6.6ASSUMPTION

  1. Patients,who have undergonethevalvereplacementsurgery,mayhavesomeknowledgeregardinglifestylemodifications.
  2. Self Instructional Modulemayimprovetheknowledgeofpatientswho have undergone valve replacement surgery regardinglifestyle modifications.

6.7 DELIMITATIONS

  1. Studyislimitedtopatientswhohaveundergonevalvereplacementsurgeryinselectedhospital,Bengaluru.
  2. Studyislimitedtopatientswhoarewillingtoparticipate.

7. MATERIALSANDMETHODS

7.1 Sources of data: patients who have undergone valve replacement surgery in selected hospital, Bengaluru.

7.1.1 Research Approach: Evaluative approach.

7.1.2 Research design: Pre-experimental one group pre-test and post-test design.

7.1.3 Setting: selectedCardiac hospitals in Bengaluru.

7.1.4 Sample size: 40 patients who has undergone valve replacement surgery at selected Cardiac hospitals in Bengaluru.

7.1.5 Inclusion criteria:

  • Patients, whohaveundergonevalvereplacementsurgery, presentatthetimeofdatacollection.
  • Patient who are able to read English and kannada

7.1.6 Exclusioncriteria:

  • Patientswhoarenotwillingtoparticipateinthestudy.
  • Patientswhoarecriticallyill, atthetimeofdatacollection.
  • Pediatric patient.

7.2. Methodofcollectionofdata

7.2.1 Samplingtechnique:Non-probabilitypurposivesamplingtechnique.

7.2.2 Tool of research: Self-administer structured questionnaire.

Structuredquestionnaireconsistoftwoparts:

PartI-Demographicdata

PartII-Knowledgebasedquestionnaireregardinglifestylemodification aftervalvereplacementsurgery

7.2.3 Collectionofdata

The investigatorhimselfcollectsthedatafrompatients from selected hospital,Bengaluru.

  • Investigatorhimselfcollectsthedatafrompatientsthroughstructuredquestionnaire.
  • Administers Self Instructional Module to the patients who have undergone valve replacement surgery.
  • Samestructuredquestionnaireisusedforpost-testtoevaluatetheeffectivenessofSelf Instructional Module.

7.2.4 Duration ofthedatacollection: 4weeks.

7.2.5Methodofdataanalysisandpresentation

  1. Theinvestigatorusesdescriptiveandinferentialstatisticstechniquesbyusingmean,median,frequency, reliability test,standarddeviation,pairedt-testandchi-squaretest for data analysis.
  2. Theanalyzeddatawillbepresentedintheformoftables,diagramsandgraphsbasedonfindings.

7.3 Doesthestudyrequireanyinvestigationtobeconductedonhumanbeingsor animal?Ifsodescribebriefly?

Yes[Structuredquestionnairetopatients]

7.4 Hasethicalclearancebeenobtainedfromyourinstitution?

  1. Yes,consentwillbeobtainedfromconcernedsubjectsandauthorityofinstitution.
  2. Privacy,confidentialityandanonymitywillbemaintained.
  3. Scientificobjectivityofthestudywillbemaintainedwithhonestyandimpartiality.

8. REFERENCE

  1. Willam and Wilkins. Pathophysiology 2 in one reference for nurses.1stedition. Pheladelphia: Lipincott Publication: 2005. p.143
  2. Park. K. Textbook of preventive and social medicine. 18thed. Jabalpur: M/s Banarsidas Bhanot Publishers; 1970. p.13-5, 29,287.
  3. Heart Disease and Stroke Statistics—2011 Update A Report from the American Heart Association. [Online] 2012 Feb8 [cited2012 Feb 6]. Available from: URL:
  4. Sharon .L.Lewis, Chintamani, Mrinalini.Mani. Et al. Medical and Surgical Nursing,7th ed Philadelphia: Mosby Elsiver Publications; 2011. p.745-928.
  5. Fauci AS, Braunwald E, Isselbacher KJ, Wilson JD, et al, editors. Harrison’s principles of internal medicine. 14th ed. New York: McGraw Hill, Health Professions Division; 1998.Vol 2 .p1949
  6. Heart Valve Disease. [Online] 2010 Jan16 [cited2011 Nov 10]. Available from: URL: Valve Disease/
  7. What are overweight and obesity? [online] Nov 01 2010 [cited 2012 Feb 11] URL;
  8. Katherin.M, Erika.S, Sivarajan.Froelicher. Cardiac nursing.4th ed. Lippincott Williams and Wilkins publishers: 1997. ch 29,31,35Heart disease on the rise in India. [online]. 2009 Apr 02 [cited2012 Feb 10]. Available from: URL:
  9. Suman Bhandari, K Subramanyam, N Trehan. Valvular Heart Disease: Diagnosis and Management. JAPI. 2007 Aug 6 ; 55:575-84. Available from: URL:
  10. Cases Studies in Valvular Heart Disease: An Evidence-Based, Real-Life Interactive Experience.[Online].2011Apr2 [cited2012 Jan10];Availablefrom:URL: diseases-2011r497-03
  11. Mandiye Shiv Sagar, Agarwa Saket, Pratap Himanshu, Kumar Singh Aditya, et al. Comparison over short term mortality and morbidity of mechanical and bio prosthetic heart valves in the Indian population. Indian Journals for Thoracic and Cardio vascular Surgery 2010 JUN 24; 26:139–43.
  12. Janne J. Jokinen, Mikko J. Hippelainen, Otto A. Pitkänen.Mitral Valve Replacement versus Repair: Propensity-Adjusted Survival and Quality-of-Life Analysis. Annals of thoracic surgery 2007 MAR; 84:451-8
  13. Questions about heart failure. [Online] 2006 Sep09 [cited2011 Nov 25]. Available from: URL:
  14. Singh RB, Niaz MA, Ghosh S, Beegom R, Rastogi V, Sharma JP, Dube GK. Association of Trans fatty acids and clarified butter intake with higher risk of coronary artery disease in rural and urban populations with low fat consumption. Int J Cardiol 1996 Oct 25; 56(3):289-98.
  15. Emma Lagercrantz, Dan Lindblom, Ulrik Sartipy. Survival and Quality of Life in Cardiac Surgery Patients With Prolonged Intensive Care: Annals of thoracic surgery 2010 Sep :89:490–6
  16. Laila Hellgren, Elisabeth Stahle, Quality of Life after Heart Valve Surgery with Prolonged Intensive Care.Annals of thoracic surgery 2004April :80:1693-98
  17. Parvathi .G. A study to assess the effectiveness of structured teaching programme on life style modifications of patients with Myocardial Infarction attending Cardiology outpatient department in selected hospitals of Bellary. Unpublished Master of nursing Dissertation. Rajiv Gandhi University of health science. Bangalore. 2008; p. 5-6
  18. Randal J. Thomas, Marjorie King, Karen Lui, Neil Oldridge, et al. AACVPR/ACC/AHA 2007 Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services. [Online] [Cited2011 Nov 29]. Available from: URL
  19. Edward .Winslow, Nancy. Bohannon, Stephen A. Lifestyle Modification: Weight Control, Exercise, and Smoking Cessation. American journal of medicine 1996 ; 25-35
  20. Heart Disease: Tips for Prevention [Online] 2009 Mar [cited2011 Dec 20]. Available from: URL:
  21. Resuming Activities and Exercise after Heart Surgery. [Online] [cited2011dec 25]. Available from: URL:
  22. Anastasios Merkouris. Quality of life after coronary artery bypass graft surgery in the elderly. European Journal of cardio vascular nursing 2009 Mar; 8(1): 74-81.
  23. Linde BJ, Janz NM. Effect of a teaching program on knowledge and compliance of cardiac patients. 1979 Sep; 28(5):282-6

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