A total of 130 patients who underwent cardiac valve replacement in our hospital from January 2019 to January 2020 were enrolled in our study. All enrolled patients were randomly divided into study group and control group with 65 cases each. The demographic characteristics of the patients in the study group are as follows：The age range is 28.63-74.38 years old, the average age is 53.83±3.21years old. The gender distribution was 39 males and 26 females. Mitral valve replacement was performed in 22 cases, aortic valve replacement in 23 cases, simultaneous aortic and mitral valve replacement in 20 cases. Concurrent surgeries included: 42 cases of mechanical valve replacement in, 22 cases of biological valve replacement, 7 cases of thromboclearance in the left atrium, 19 cases of tricuspid valve plasty, 5 cases of mitral valve plasty, 3 cases of mitral valve vegetations removal, 2 cases of coronary artery bypass grafting, 1 case of repair of superior mesenteric artery pseudoaneurysm, and 1 case of modified trunk stent implantation. The demographic characteristics of the patients in the study group are as follows：The age range is 28.59-75.72 years old, the average age is 53.61±3.42years old. The gender distribution was 38 males and 27 females. Mitral valve replacement was performed in 21 cases, aortic valve replacement in 23 cases, simultaneous aortic and mitral valve replacement in 21 cases. Concurrent surgeries included: 41 cases of mechanical valve replacement, 23 cases of biological valve replacement, 8 cases of thromboclearance in the left atrium, 18 cases of tricuspid valve plasty, 6 cases of mitral valve plasty, 6 cases of mitral valve vegetations removal, 2 cases of coronary artery bypass grafting, 1 case of repair of superior mesenteric artery pseudoaneurysm, and 1 case of modified trunk stent implantation. Baseline characteristics were comparable between the two groups（P>0.05）. The formulation of this research protocol complies with the relevant requirements of the Declaration of Helsinki of the World Medical Association.
Inclusion and Exclusion Criteria
Inclusion criteria: (1) with complete clinical data; (2) with normal spirit and good compliance; (3) willing to participate; (4) provided of informed consent.
Exclusion criteria: (1)combined with serious organic diseases; (2) accompanied by serious cardiovascular or cerebrovascular diseases; (3) inability to communicate properly.
The control group was given routine health education. The specific contents are as follows: (1) Informing the patients that they need to take the medication on time and in the amount, and recorded the medication. (2) Rechecking the international normalized ratio to determine if the dosage of anticoagulant was appropriate for the patients. (3) Paying attention to identify early clinical signs of bleeding or thrombosis due to excessive or insufficient use of anticoagulants. (4) Women of childbearing age were advised to use contraception and to consider pregnancy at least 2.5 years after surgery under the guidance of a doctor. (5) Preventing trauma as much as possible. (6) When receiving treatment or undergoing various traumatic examinations, it is necessary to inform the doctor to avoid bleeding events.
On the basis of the control group, the study group was given phased written health education combined with healthy diet. A phased written health education team was established, consisting of 1 assistant chief physician, 1 head nurse, 6 senior nurses, and 1 nutritionist. The staff must had worked in our hospital for more than 5 years. The team members had undergone a one-month training (December 2018), mainly studying the phased health education of heart valve replacement surgery. According to the characteristics of recovery after heart valve replacement, the nursing process was divided into 3 phases, namely the first-stage rehabilitation (from the day after the operation to the day of discharge), the second-stage rehabilitation (from the day of discharge to within 2 months after the operation) and third stage (recovery stage, from 2 months to 6 months postoperatively). According to the characteristics of the patients' recovery at different stages, a health education and healthy diet manual was formulated and distributed to the patients to ensure that each person had one copy. The senior nurses in the team established a WeChat group. The patients and their relatives, as well as the nurses participating in this research, were added to the chat group to facilitate the communication between patients and nursing staff. The nursing staff should answer the questions raised by the patients. At the same time, a WeChat public account was established, and at 8 o'clock in the morning every Monday and Wednesday, the content of the precautions after heart valve replacement was pushed on time to guide patients to learn relevant knowledge. Primary nurses gave health education to patients at 3 pm every Friday, about 45 minutes each time, once a week. During the intervention period, a total of 24 health education was conducted, and the content of health education was released through the WeChat public account. At the same time, patients were organized to communicate in the WeChat group twice a week, each time for 40-50 minutes. A week before each health education, the primary nurses needed to inform the patients and their relatives of the specific time for health education by phone or by WeChat, and reminded the patients to check the content of WeChat. Once the health education was released, the patients should be told to read it as soon as possible. After that, the primary nurses should organize the patients to communicate in the WeChat group. Team members needed to answer patients’ questions in detail. In addition, patients could communicate with each other and share their experience of rehabilitation.
The content of the phased health education are as follows:(i) First stage rehabilitation: Anticoagulant therapy was given within 24h after operation, and the anticoagulant drug warfarin was taken orally at dose. Meanwhile, the patients' thrombin time was measured regularly, and the warfarin dose was adjusted timely until the thrombin time reached the normal level. The patients and their relatives were informed of the dosage and method of the drug used in detail, and the relatives should participate in the whole process of taking medicine. Meanwhile, visual metaphors and repeated explanations was used to explain the methods of taking medicine (see Figure 1), so that patients could fully understand anticoagulant drugs and other related knowledge, possible complications and countermeasures. Informed the patients of the importance of regular testing, so that each patient can correctly grasp the time of drug use, dosage, possible complications and precautions, etc. Praised the behavior of taking medication actively to improve patients' enthusiasm and cooperation in taking medication. When the patients came around from the anaesthetic and the vital signs were stable, auscultated the patient's breath sounds, guided the patient to perform abdominal breathing and deep breathing, and assisted the patients in passive movement of the limbs. Patients could try bedside activities 1-3 days after surgery, such as standing alone by the bed or sitting on a chair. The primary nurses should actively communicate with the patients, grasped the patients' psychological characteristics, and conducted psychological counseling. The primary nurses should tell the patients and their relatives to eat easy-to-digest, bland foods, mainly low-salt, low-fat, and high-fiber foods. Patients should be advised to avoid eating foods like pig liver, spinach, carrots, etc. These foods are rich in vitamin K, which can antagonize anticoagulant drugs and shorten prothrombin time. (ii) Second stage rehabilitation: Instructed the patients to continue to take medication as prescribed, and reminded the patients to take medication daily through WeChat. The patients’ heart function (cardiopulmonary exercise test and 6-min walking test) was evaluated every week before participating in health education. The tests should be terminated, if the patients developed cyanosis, dizziness, blood pressure reduction, the patients actively requested to stop the tests, or electrocardiogram showed pathological Q waves during the tests. The patients' extreme exercise volume and the second-largest exercise volume were evaluated using the maximum extreme exercise state of cardiopulmonary exercise and the distance of 6-min walking test. The nursing staff guided patients to conduct self-care including guidance on life behaviors, and consulted relevant materials. After sorting out the materials that were helpful to the patients' recovery, sent them to the patients. Formulated exercise programs for patients such as physical resistance, Tai Chi, yoga, balance, etc. Reminded patients to pay attention to healthy diet, avoid drinking beverages and foods containing additives, carbonated beverages, quit smoking and alcohol, pay attention to body weight. Once the patients' weight exceeded the normal weight, they should control their diet to keep weight. (iii) Recovery stage：Instructed patients to live a healthy life and consolidate self-care behaviors. According to patients’ questions, nurses constantly supplement health education and dietary guidance.
The knowledge and compliance of anticoagulant drugs in the first and second stage of rehabilitation, and recovery stage of the two groups were compared. The healthy behavior ability and quality of life in each stage of both groups were observed.
Medication compliance: The medication compliance of all patients at all stages was evaluated by the Modified Morisky Scale (MMS). There are 4 questions in this scale, with 3 points for each question. The higher the score, the worse the compliance. Complete compliance: ≤ 4 points. Incomplete compliance: 5-8 points. Complete noncompliance: ≥ 9 points.
Degree of anticoagulant drugs knowledge: A questionnaire designed by our hospital was used to evaluate the degree of anticoagulant drugs knowledge in patients, a total of 8 items in 4 aspects, including risk factors and importance of anticoagulant drugs with anticoagulant knowledge. Mastery: Correctly answered more than 7 items. Partial mastery: Correctly answer 5 or 6 items. Failure to master: Correctly answered less than or equal to 4 items. Total mastery rate = partial mastery rate + mastery rate.
Healthy behavior ability: All patients were evaluated using the Healthy Behavior Ability Scale, which has 28 items from the 4 dimensions of psychological well-being, health responsibility, nutrition management, and exercise management, and uses Likert scale, the total score is 0-112 points. The higher the score, the higher the patients' healthy behavior ability.
Quality of life: The quality of life of all patients was assessed using the World Health Organization Quality of Life (WHOQOL-BREF). The scale has 5 areas including environment, social relations, independence, psychology and physical health. There are 26 items in total and the score is 1-5 points, the total score is 0-130 points. The higher the score, the higher the patient’s quality of life.
Data were statistically analyzed using statistical software SPSS21.0. Measurement data were expressed as mean ± standard deviation ( ± SD) and evaluated using a t-test. Count data were expressed as a percentage and compared using a Chi-square test. P<0.05 was considered statistically significant.