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SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION SUBMITTED BY: Ms. ANUPA SUSAN ABRAHAM I M.Sc. NURSING MEDICAL SURGICAL NURSING (2011-2013 BATCH) FORTIS INSTITUTE OF NURSING #20/5, YELACHENAHALLI, KANAKAPURA ROAD BANGALORE-560078 SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION 1. NAME OF THE Ms. ANUPA SUSAN ABRAHAM, CANDIDATE AND 1ST YEAR M.Sc. NURSING, ADDRESS FORTIS INSTITUTE OF NURSING, #20/5, YELACHANAHALLI, KANAKAPURA ROAD, BANGALORE-560078. 2. 3. NAME OF THE FORTIS INSTITUTE OF NURSING, INSTITUTION BANGALORE. COURSE OF STUDY MASTERS DEGREE IN NURSING, AND SUBJECT MEDICAL AND SURGICAL NURSING. 4. DATE OF 31st MAY 2011 ADMISSION 5. TITLE OF THE A STUDY TO ASSESS THE TOPIC EFFECTIVENESS OF VIDEO ASSISSTED TEACHING PROGRAMME ON KNOWLEDGE OF STAFF NURSES REGARDING POST OPERATIVE MANAGEMENT OF PATIENTS WITH VALVE REPLACEMENT SURGERY AT SELECTED HOSPITALS, BANGALORE. 1 6.0 BRIEF RESUME OF THE INTENDED WORK INTRODUCTION: ''Cardio vascular nurses and their patients create a tapestry together and there are no neutral events in nursing.'' Cathie E. L. Babara D. The heart is a cone shaped organ, and is relatively small, roughly the same size as a closed fist-about 12cm (5 in) long, 9cm (3.5in) wide at its broadest point, and 6cm (2.5 in) thick. Its mass average 250g in adult females and 300g in adult males. The heart lies in the mediastinum, a mass of tissue that extends from the sternum to the vertebral Colum between the lungs.1 The valve of the heart control the flow of blood through the heart into the pulmonary artery and aorta by opening and closing in response to the blood pressure changes as the heart contracts and relaxes through the cardiac cycle.2 Valvular dysfunction occurs when the heart valves cannot fully open and fully close. A stenosed valve may impede the flow of blood from one chamber to the next; an insufficient (incompetent) valve may allow blood to regurgitate (flow backward).3 Valvular heart disease can be either stenotic or regurgitant diseased cardiac valve that restrict the forward flow of blood and unable to open fully are referred to be as stenotic cardiac valves that close incompetently and permit the backward flow of blood are referred to be as regurgitate or incompetent.4 Diseases of the heart valves include a diverse group of acquired and congenital lesions. Some of these occur in isolation and other occurs in association with other heart diseases. Deformed cardiac valves may 2 cause disease by two major mechanisms. First, they impose a major hemodynamic burden on the cardiac chambers by causing obstruction (stenosis) or regurgitation (incompetence) or sometimes a combination of two. Second, the abnormal valves are more susceptible to infection and thus predispose patients to infective endocarditic and its many complications with the possible exception of infective endocarditic and carcinoid heart disease, lesions of the tricuspid and pulmonic valves are much less common. Major causes of acquired heart valve disease include mitral valve stenosis mitral regurgitation, aortic stenosis or aortic regurgitation.5 In Asia, there are more than 12 million people are affected by rheumatic heart diseases and there are more than 40,000 deaths annually. This shows the increased burden of valvular heart disease in Asian countries.6 In India the prevalence of valvular heart disease varies from 1-5.4/1000. The major cause for this is rheumatic heart disease. A prevalence of 21/10,000 is the estimated statistical data. The incidence varies from 0.2 to 0.75 per 1000 per year.7 The incidence of mitral valvular disease is 50-60% of all cases, aortic valvular disease 10%, pulmonic valvular disease 1% and combined mitral and aortic valvular diseases are 20% of all cases.8 The total annual mortality due to valve disease in world is approximately 20,000 patients/year. This mortality is predominantly related to aortic valve disease i.e. 12,000/year with the remaining related to mitral valve disease.9 The patients who are undergoing valve replacement surgery require support from a specialist. Surgery can affect the long term outcome of the patients, but quality of life and benefits from the surgery is likely to be enhanced by effective patient education. Nurses are considered as the 3 heart of the health care institution. So they have a major role in the educating the patients about their condition. Nurse teaches all patients with valvular heart disease about the diagnosis, the progressive nature of valvular heart disease, and the treatment plan. The patient is taught that the infection agent, usually a bacterium, is able to adhere to the diseased heart valve more readily than to a normal valve. The nurse collaborates with the patient to develop a medication schedule and teaches about the name, action, side effects and any drug-drug or drug-food interactions of the prescribed medications for heart failure, dysrhythmias, angina pectoris, or other symptoms. The nurse teaches the patient about the procedures and anticipated recovery.13 6.1 NEED FOR THE STUDY: The heart contains two atrio-ventricular valves, the mitral and tricuspid, and two semilunar valves, the aortic and the pulmonic which are located in four strategic locations to control unidirectional blood flow. Types of valvular heart disease are defined according to the valve or valves affected and the two types of functional alteration, stenosis and regurgitation.10 Valvular heart disease mainly results from rheumatic fever. Rheumatic fever is a preventable disease, but the combination of a lack of resources, lack of infrastructure, political, social and economic instability, poverty, overcrowding, malnutrition and lack of political will contributes to the persistence of a high burden of rheumatic fever, rheumatic VHDs and infective endocarditic. 9 Significant valvular heart disease includes mitral or aortic stenosis severity, moderate or severe mitral regurgitation, moderate or severe aortic regurgitation and moderate or severe tricuspid regurgitation. Mitral 4 regurgitation and aortic regurgitation are the most frequent valve diseases. Valvular disease is higher in individuals; with mitral regurgitation and aortic regurgitation as the most frequent valve disease (49% and 28% respectively). The left ventricular (LV) dimensions Function and the presence and severity of heart valvular disease is evaluated by echocardiography. Aortic regurgitation (AR) is characterized by diastolic reflux of blood from the aorta into the left ventricle (LV). Acute AR typically causes severe pulmonary edema and hypotension and is a surgical emergency. Chronic severe AR causes combined LV volume and pressure overload. It is accompanied by systolic hypertension and wide pulse pressure, which account for peripheral physical findings, such as bounding pulses.9 More than 30,000 patients currently undergo surgery for acquired valvular heart disease in Germany each year, of whom nearly 17,000 have disease of a single valve, more than 3000 have disease of two or three valves, and roughly 12,000 undergo a valvular procedure in combination with an aortocoronary bypass operation. The aortic and mitral valves are the more commonly affected ones; the pulmonary valve, in contrast, is affected almost exclusively by congenital diseases, which will not be discussed in this article. Surgical procedures on the tricuspid valve are also rare, accounting for only 2.6% of the isolated, single-valve operations performed in 2007.10 When a prosthetic valve is implanted, close follow-up is required to assess the hemodynamic status, proper valve function and potential complication. Close monitoring of anticoagulant therapy is needed for mechanical valve cases.11 5 After the implantation of a prosthetic valve, the expected complications of chronic and uncorrected valve disease are exchanged for those associated with the prosthetic valve. Complications after valve replacement include thromboembolic bleeding, ventricular failure, pulmonic hypertension, sudden death, arrhythmias conduction abnormalities, mechanical complications, and infective endocarditis. Infections of prosthetic heart valve are a very serious complication (0-1 2.3% per patient year). If the implanted cardiac valve doesn't work well for whatever reason, the clinical situation is termed dysfunction (malfunction) of the implanted valve. Dysfunctions include mechanical dysfunctions of the implanted valve due to defects and wear of material or failure of valve mechanism. The mechanical dysfunction can occur due to extrinsic or intrinsic factors. So close monitoring of the hemodynamic status is essential during the post operative period.12 The health care nurse has a key role in teaching, assessing and caring for patients who are in the post- operative period she familiarizes. The client and family with the critical care environment and demonstrates them how to splint the chest incision, cough, deep breath and perform exercise.9 Nursing care continues as for most post- operative patients including incision care, the patient teaching including diet, activity medications and self care. The nurse educates the patient about long term anticoagulant therapy, explaining the need for frequent follow up appointments and blood laboratory studies and provides teaching about prescribed medications.13 6 It is felt that a structured teaching programme can be more useful to improve the knowledge of nurses regarding the post- operative management of patient with heart valve replacement surgery. A study was conducted by Massha Anees, about the management of heart valvular disease, and the total number of samples selected are 45 patients hospitalized at Punjab institute of cardiology, Lahore were studied during the month of June, 2010, results: About 37.85% of patients are diagnosed with VHD and accounts for 60% of total patient population. It reveals that most of the patients are diagnosed during the age of 21-40 years (37.8%), 28.90% of upto 20 years and 33.30% were diagnosed at age above 40 years and 60% of patients diagnosed are male. It depicts that in most of the valve replacement cases, Mechanical valve (91.1%) is used. The valve which is mostly at risk is mitral valve (46.7%) followed by DVR 28.9% aortic valve (22.22%) and tricuspid valve (2.22%) Around 40% of patients with Rheumatic heart disease suffer from VHD whereas infective endocarditis affects 11.1% of patients, MVP 4.4% and congenital cases admitted to hospital are 2.2%.9 Learning is better when more sense organs are utilized. Video is a versatile education vehicle which stimulates and reinforces ideas beliefs and tendencies through sight and sound together which makes the experience real, concrete and immediate.14 This implies the effectiveness of video assisted teaching in imparting the knowledge. So it is felt that video assisted teaching programme regarding the post- operative management of heart valve replacement surgery will improve their knowledge so that they can render high quality nursing care to the patient after heart valve replacement surgery. 7 Further during the clinical experience, the investigator observed that due to inadequate care, the patients after heart valve replacement surgery developed post -operative complications and had prolonged hospital stay. Hence the investigator felt the need to develop a video assisted teaching programme regarding the post operative management of patient with heart valve replacement surgery to improve the knowledge of staff nurses. 8 6.2 REVIEW OF LITERATURE A review of literature on the research topic makes the researcher familiar with the existing studies and provides information which helps to focus on a particular problem, lays a foundation upon which to base new knowledge. It creates accurate picture of the information found on the subject. 6.2.1 Review related to post operative management of heart valve replacement surgery. 6.2.2 6.2.1 Review related video assisted teaching. REVIEW RELATED TO POST OPERATIVE MANAGEMENT OF HEART VALVE REPLACEMENT SURGERY. A study conducted by Edward M B and Taylor K M on valve replacement surgery in the UK (1986 -1997) by UK heart valve Registry. The UKHVR is a computerized data based collecting prospective data on VR surgery in all UK cardiac units and all patients are tracked by natural agencies who registry all death of UK .Results showed that from January 1st to December 31st 1997,a total of 58,195 patients underwent first time valve replacement surgery and received 63.649 valves . Mean age at operation in 1986 was 58.7 years (range 18 – 87 years) and this rose to 64.7 years (range 18 - 94years) in 1997. Majority of patient received a mechanical valve within this group the number of bileaflet valve implants increase since 1986 and there is a reversal in the down ward trend in pericardial valves implanted in 1993.Follow up was 96.1% complete, with a total of 342.993 patients – years. Mortality (30 days) fell from 6.9% in 1995 but increase to 6.7% in the 2 years to 1997. Actuarial survival at 1, 5 and 10 years was 89.5%, 78.85% and 61.8% respectively, 9 confidence intervals of 0.5% reflects the enormity of the data base and quality of the data.20 A retrospective study was conducted on cardiothoracic surgeon regarding management of post operative cardiac critical care at John Hopkins hospital, from January 2007, to Feb 2009. The results were compared using a 2 sample't' test and 2-tiled fisher exact test. And the cardio thoracic surgeons provides postoperative critical care led to a mean (SD) decrease in hospital length of stay from 13.4 (0.9) to 11.2(0.04) days (P<0.0001). These improvements occurred without losing benefits in other quality measures. Cardio thoracic surgeons may be clinically qualified to provide post operative cardiac critical / care in a semi closed unit.21 A study conducted by department of surgery, university of Virginia health system USA regarding surgical care improvement –study used quality improvement measures. In 2006, the surgical care improvement project (SCIP) developed out of the STP project and its process measures. The result showed seven of the SCIP initiatives apply to the perioperative period and prophylactic antibiotics should be received within 1 hour prior to surgical incision , be selected for activity against the most probable antimicrobial contaminants and be discontinued within 24 h after the surgery end-time .Euglycemia should be maintained, with wellcontrolled morning blood glucose concentrations on the first two postoperative days especially in cardiac Surgery patients, hair at the surgical site should be removed with clippers or by depilatory methods, not with a blade ,urinary catheters are to be removed within the first two postoperative days and normothermia should be maintained peri -operatively. Study concluded there is strong evidence that implementation of protocols that standardize practices reduce the risk of surgical infection.22 10 Sheffers J M,Schuikers N conducted a study on ambulatory post operative care of patients following coronary artery bypass and valve replacement surgery on patients who are seen for medical follow-up after coronary artery bypass graft (CABG) / valve replacement surgery. This study as a summary of the comparison of the surgical post operative problems and potential significant complications. In addition, as an aid to simplify and direct outpatient post-operative care, they present an algorithm which addresses the expected clinical features of post-operative patients, recommended routine follow-up diagnostic tests, signs, symptoms and appropriate screening procedures for significant postoperative complications and recommendations for rehabilitation and risk factor management. This approach is designed to enable the practitioner to address these complex patients with confidence and to assist them with positive lifestyle adaptations and risk factor reduction and to predict and prevent significant post-operative complications.23 A study conducted on risk profile and outcomes of aortic valve replacement in 273 octogenarian that underwent aortic valve replacement by Sujatha Kesavan. The aim of the study to include the patient, relationship.The result showed logistic Euro score (LES) was collected to characterize the predicated operative risk. Two groups were defined LES ≥ 15(n-80) and Les < (n-193) in pts with LES ≥ 15, 30d mortality was (14%) (95% cl; 7%-23%) compared with 4% (95%cl: 2%-8%) In the LES < 15 group ( P< 0.007) despite the increase in number of operation from 1996 to 2008, the average LES did not change, only 5% of patients had prior bypass surgery the LES identified a Low risk qualities of patient with very low mortality ( 4%,n-8, p<0.007) at 36d. The overall surgical results for octogenarian were excellent. The low risk group had an excellent outcome and the high risk had a poor outcome after surgical 11 aortic valve replacement. It may be the treatment with transcatheter aortic valve implantation.24 6.2.3 REVIEW RELATED TO VIDEO –ASSISSTED TEACHING Kumar mahendra conducted a study on 60 staff nurses to assess the effectiveness of video assisted teaching on needle strick injury regarding knowledge and attitude of staff nurses working in selected hospital in Hassan on November 2002.The research design is quasi-experiment with pre test and post test. The result showed the overall post test mean percentage of knowledge and attitude was higher in experiment group than in control group and 't' value were knowledge (t=26.67at p<0.001) after administration of video assisted teaching the scores of knowledge (88%) and attitude (83.20%) increased significantly. There was no association between knowledge and attitude level with selected demographic variables. The Independent‘t’ value (knowledge= 26.67, attitude= 16.32) was greater than table value at p<0.001 level of significance. The finding signifies that the video assisted teaching was effective to enhance the knowledge and to mould attitude of staff nurses Overall mean knowledge scores (pre test=13.53, post test= 26.66) and mean attitude scores are (pre test= 43.39, post- test= 74.92). Knowledge (43.90%) and attitude (54.60%) scores of staff nurses were less before administration of video assisted teaching.25 6.3 STATEMENT OF THE PROBLEM A STUDY TO ASSESS THE EFFECTIVENESS OF VIDEO ASSISTED TEACHING PROGRAMME ON KNOWLEDGE OF STAFF NURSES REGARDING POST OPERATIVE MANAGEMENT OF PATIENTS WITH VALVE REPLACEMENT SURGERY AT SELECTED HOSPITALS, BANGLORE. 12 6.4 OBJECTIVES OF THE STUDY 1. To assess the demographic profile of staff nurses. 2. To assess the knowledge of staff nurses regarding post operative management of heart valve replacement surgery. 3. To find out the effectiveness of video assisted teaching programme on knowledge regarding post operative management of heart valve replacement surgery. 4. To associate the post test knowledge of score of staff nurses regarding post operative management of heart valve surgery. 6.5 OPERATIONAL DEFINITION 6.5.1 ASSESS: In the present study assess refers to,' measure the knowledge of the staff nurses regarding the post operative management of heart valve replacement surgery. 6.5.2 EFFECTIVENESS: In the present study effectiveness Refers to, 'again of knowledge of staff nurses regarding the post operative management of patients with heart valve replacement surgery as determined by significant difference in pre and post test knowledge score. 6.5.3 VIDEO ASSISTED TEACHING PROGRAMME: A system of recording and reproducing moving visual images using magnetic tape are used to communicate with and see each other to a group of people. In this study teaching with video shall be done upon post operative management of heart valve replacement surgery. 13 6.5.4 KNOWLEDGE: In the present study, 'the correct response from the staff nurses regarding the post operative management of patient with heart valve replacement surgery as observed from score based on closed ended questionnaire. 6.5.5 POST OPERATIVE MANAGEMENT: Defined as the nursing interventions provided by nurses to the patients after heart valve surgery which involves respiratory care, hemodynamic monitoring, maintaining fluid –electrolyte, care of chest drainage, administration of medications, wound care, nutrition, exercise, prevention of complications and patient education. 6.5.6 HEART VALVE REPLACEMENT SURGERY: It is defined as the surgical procedure in which the diseased heart valve (mitral valve, tricuspid valve, aortic valve or pulmonary valve) is replaced with a prosthetic valve. 6.5.7 STAFF NURSE: A person who has successfully completed either the diploma or Baccalaureate programme in nursing and working as a staff nurse. 6.6 HYPOTHESES: H0: There is no significant difference between pre and post- test knowledge score of staff nurses regarding post operative management of heart valve replacement surgery. H0.1: There is no significant association between the post test knowledge score of post operative management of heart. 14 H1.1: There is a significant difference between pre and post test knowledge score of post operative management of heart valve replacement surgery. H1.2: There is a significant association between post test knowledge score of post operative management of heart valve replacement surgery and selected demographic variables 6.7 VARIABLES IN THE STUDY: Independent variable: Video assisted teaching programme regarding the post operative management of patient with heart valve replacement surgery. Dependent variable: Knowledge of staff nurses regarding the post operative management of patient with heart valve replacement surgery. Demographic variables: Age, sex education qualification, income of staff nurses, Years of professional experience of staff nurses, area of residence, source of information. 7.0 MATERIALS AND METHODS 7.1.1 Source of data : Staff nurses in selected hospitals in Bangalore 7.1.2Research approach: An experimental research approach 7.1.3 Research design : A quasi-experimental design with one group pre test and post-test. 7.1.4 Research settings : Selected hospitals, Bangalore. 15 : Population of study includes staff 7.1.5 Population nurses. 7.1.6 Sampling technique : Purposive sampling technique : 60 7.1.7 Sample size 7.1.8 Sampling criteria 7.1.9Inclusioncriteria: Staff nurses who are willing to participate in this study. : Staff nurses who are available during the period of data collection : Staff nurses who completed in any one of the formal basic education in nursing. 7.2 Exclusion criteria: Staff nurses who are not available at the time. 7.2.1 TOOL FOR DATA COLLECTION: Data collection tool contain items on the following aspects. PART 1- contains the items of demographic characteristics of staff nurses comprising of age, sex, education qualification, and income of staff nurses, years of professional experience of staff nurses, area of residence, source of information. PART 2- Knowledge assessment questionnaire regarding post operative management heart valve replacement surgery 7.2.2 METHOD OF DATA COLLECTION The data will be collected personally using structured questionnaire on knowledge of staff nurses regarding post operative management of heart valve replacement surgery. 16 7.2.3 METHOD OF DATA ANALYSIS: The investigator will analyse the data obtained, by using descriptive and inferential statistics. The plan of data analysis as follows. DESCRIPTIVE STATISTICS: Mean, mean %, median and standard deviation will be used. INFERENTIAL STATISTICS: Student paired t-test will be used for measuring the significant mean difference between pre and post-test knowledge. Chi square (2) test for measuring association level of knowledge and selected demographic variables. 7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON OTHER HUMAN OR ANIMALS? Yes, the knowledge of staff nurses on post operative management of heart valve replacement will be assessed by using self administered questionnaire 7.3.1 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM THE INSTITUTION 1. The ethical clearance is obtained from the research committee of Fortis institute of nursing. 2. Written permission will be obtained from concerned authorities of selected hospitals. 3. Written permission will be obtained from the sample who is involved in the study before collecting the data. 17 7.3.2 LIST OF REFERENCESES: 1. Tortora, Grabowski. Principles of anatomy and physiology.10th ed.USA: Churchill Livingstone; 2003. P.660. 2. Basavanthappa B T. Medical surgical Nursing. 1st ed. New Delhi: Japee brother; 2003. P. 409-13. 3. Black Joyce M. Medical surgical nursing. 7th ed. vol 1. Elsevier; 2005. P.1231-2. 4. Levison G E .Medical surgical nursing.7th ed. Indian: Elsevier; 2011. P.747. 5. Khawaja tahir mahmood, Mashal anees, Ayesha asghar. Valvular heart disease.2011; 3(1): 315-21. Available at: URL:Jbsr.pharmainfo.in/document/vol 3issue/2011030163.pdf 6. Ronald .professional guide to heart diseases. 8th ed. Philadelphia: Lippincott publishers; p 640- 46. 7. WHO statistics (2011) 8. Luckmann J, Sorensen C K. Text book of medical surgical Nursing.5th ed. Philadelphian: Lippincott publishers; 2003 .p .412-16. 9. Donaldm, Lloyd jone. Heart disease and stroke statistic. Journal of the American Heart Association; 2011. 30-36 URL:Circ.ahajournals.org/content/ 123/4/e18.full.pdf 10.Revolts J M.Performance of the lonescu-shiley pericardial valve in the aortic position: 100 months clinical experience. The Journal of Thoracic and Cardiovascular surgery.2006. 247-51 11.Gerard. Valvular Heart Diseases. 1st ed. Jones and Barlett; 2005 p 137-41 12. Lord c. Patients with mechanical valve-role of nurse current perspective. American journal of nursing; 2006. P 64-68 18 13.Suzanne C S, Brenda G B. Text book of medical surgical nursing. 10th ed. Philadelphia: Lippincott Williams and Wilkins Company; 2004. P. 533- 48. 14.Neeraja K.P. Text book of nursing Education. 1st ed. New Delhi: jaypee publishers; 2005.p 196-198 15.Ankur kapoor. Heart valvular replacement. National Bureau of Health intelligence; 2007.p198-99 Available at: URL:www.heart-valve-surgery.com/surgeon.../surgeon 16.Denise F Polit, Nursing research principles and methods. 7th ed. Philadelphia: Lippincott; 2004. P 4 17.Berg.W.D. Knowledge of nurses regarding management of heart valve surgery patient. Journal of Cardio Vascular Nursing 138(3); 2006. 18.Sung.j, wong.K. Effect of a Teaching program on knowledge and compliance of cardiac patients, Heart and lungs, September/October-volume 28-issue 5; 2008. 67-71. 19.Edward M B, Taylor K M. valve replacement surgery in u.k. J Heart valve Dis, 1999 Nov; 8(6): 697-701. Available at: URL: www.ncbi.nih.gov/pubmed?term=PMID%3A%2010616250 20.Whitman GJ, Haddad M, Hirose H, Allen JG, Lusardi M, Murphy MA.Cardiothoracic surgeon management of postoperative cardiac critical care. Arch Surg. 2011 Nov; 146 (11):1253-60.available at: URL: www.ncbi.nih.gov/pubmed?term=PMID%3A%2022106316. 21.Rosenbergee L H, Politano A D, Sawyer R G. Surgical care improvement. Surg Infect (Larchme). 2001 June; 12(3): 163-8. Available at: 19 URL:www.ncbi.nlm.nih.gov/pubmed?term=PMID%3A%202 1767148%20%20 22.Sheffers J M,Schuikers N. Ambulatory post operative care of patients following coronary artery bypass and valve replacement surgery. Prog Cardiovasc Nurs. 1991 Jan-Mar; 6(1): 3-12. Available at: URL:www.ncbi.nlm.nih.gov/pubmed?term=PMID%3A%201 852755%20%20 23.Kesavan S, Khan Iqbal A, Hutter J, Pike K, Rogers C, Tumer M, etal,. Risk profile and outcomes of aortic valve replacement. World J Cardiol. 2011 Nov 26; 3(11):359-66. Available at URL: www.ncbi.nlm.nih.gov/pubmed?term. 24.Kumar Mahendra. Video assisted teaching on needle stick injury. International Journal of Nursing Education. 2010 July 1; 2(2): 25-7. Available at: URL: www.library.nhs.uk/booksandjournalls/details.aspx?t=staff+n urses&stfo=True&sc=bnj.ovi.bnia,bnj.ebs.cinahl,bnj.ovi.emez ,bnj.ebs.heh,bnj.ovi.hmie.pub. 20 9 SIGNATURE OF Ms. ANUPA SUSAN ABRAHAM THE CANDIDATE 10 REMARKS OF THE GUIDE Study is feasible; the design structured teaching program helps to improve the knowledge of staff nurses regarding management of patients undergoing valve replacement surgery. 11 NAME AND DESIGNATION OF 11.1 THE GUIDE 11.2 SIGNATURE Mr. PRABHUSWAMY A C. ASSOCIATE PROFESSOR Mr. PRABHUSWAMY A C. 11.3 CO-GUIDE Prof. SHRIDHAR K V. 11.4 SIGNATURE Prof. SHRIDHAR K V. 11.5 HEAD OF THE Prof. SHRIDHAR K V. DEPARTMENT 11.6 SIGNATURE REMARKS OF 12 THE PRINCIPAL Prof. SHRIDHAR K V. Study is feasible; the design structured teaching program helps to improve the knowledge of staff nurses regarding management of patients undergoing valve replacement surgery. 12.1 SIGNATURE Prof. SHRIDHAR K V. 21