Choose from one (1) of the following patient groups: 

1. An elderly patient who has aortic valve stenosis who requires an aortic valve replacement
2. An adolescent who is scheduled to undergo an appendicectomy 
3. An adult patient with severe obesity who is scheduled to undergo bariatric surgery

Introduction:

Aortic valve stenosis is caused due to narrowing of the valve orifice that increases resistance to blood flow from the left ventricle to the aorta (Yurek, Jakub, & Menacho, 2015). Congenital valve malformations and acquired calcification of the tricuspid valve are the common causes of aortic valve stenosis (Yurek, et al., 2015).  Calcification of the aortic valve progresses from the base of the cusps to the leaflets and decreases the leaflet motion and effective valve area. The leaflets become more rigid with the progression of calcification and obstruct the left ventricular outflow and fusion of the commissures, which results in aortic stenosis.  Angina, syncope, and heart failure are common symptoms of Aortic stenosis (Patel, & Kirtane,2016). Nearly two-thirds of patients with advanced aortic stenosis experience angina, as observed in patients with coronary artery disease. Cardiac glycosides, diuretics and low sodium diet help to treat heart failure in patients with aortic valve stenosis (Paul, & Hice, 2014). When the valve becomes calcified, and patients are at risk of developing left-sided heart failure, the valve replacement or percutaneous balloon aortic valvuloplasty is performed in the patients. Aortic valve replacement is an open-heart procedure with a cardiopulmonary bypass which involves the replacement of the damaged valve with a mechanical or biological valve (Lachell, & Henry, 2015).  Mechanical valves are more durable but require lifetime anticoagulation therapy postoperatively to prevent clot formation (Oterhals, Fridlund, Nordrehaug., Haaverstad, & Norekvål, 2013). The present report discusses the perioperative nursing actions and discharges education for an elderly patient who requires an aortic valve replacement.

Preoperative Assessment:

Aortic valve replacement is most commonly performed in elderly patients who have aortic stenosis. Thorough preoperative assessment allows the health care professionals to plan the surgery on the aortic valve carefully (Russo, et al., 2015). Before performing aortic surgery, information about the aortic valve cusp morphology and function should be obtained (Russo, et al., 2015).  Echocardiography should be conducted to identify the progression of aortic regurgitation and determine the associated pathology. Coronary angiography should be performed in patients who are older than 40 years and those who have a risk of coronary artery disease (Russo, et al., 2015). Cardiac catheterisation helps to evaluate the degree of aortic regurgitation, left ventricular dilatation and left ventricular function.  Advanced aortic stenosis can be identified by symptoms of dizziness, syncope which indicates decreased blood flow to the brain (McGhee, 2015). Dyspnea and angina indicate decreased tissue perfusion to the central circulation. Auscultations help to identify systolic murmur, and palpitation reveals a thrill.  Chest pain, heart failure and syncope are the common symptoms of aortic stenosis. Based on the subjective and objective data obtained during the assessment, the nurse can diagnose whether the patient has excess fluid volume due to decreased cardiac output or secondary to valvular disease (Webb, & Wood, 2012). Further, diagnosis related to activity intolerance due to decreased oxygen supply, the risk of infection and the patient’s anxiety related to his or her condition can be identified in the preoperative assessment. A thorough evaluation of areas of infection such as dental status, respiratory and urinary system should be conducted in the patients who require aortic valve replacement. Other examinations include pulmonary function test, renal function test, and complete blood test (Jilaihawi, et al., 2012). Patients taking anticoagulation medications preoperatively should be advised to stop taking them 72 hours before the procedure. Any dental work, if needed, should be performed before the valve replacement to decrease the risk of infective endocarditis. The nurse and health care providers should ensure that the patient has signed informed consent and underwent necessary laboratory and blood typing test before the surgery (Osnabrugge, et al., 2013).

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