6 - Rajiv Gandhi University of Health Sciences



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE. KARNATAKA .

PRO FORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

|1. |NAME OF THE CANDIDATE AND ADDRESS |MS.SILPA CHAMARTHI |

| | |1ST YEAR M.S.C.NURSING |

| | |BANGALORE CITY COLLEGE |

| | |905/100,CHELIKERE MAIN ROAD,KALYAN NAGAR,BANASWADI |

| | |BANGALORE-560043 |

|2. |NAME OF THE INSTITUTION |BANGALORE CITY COLLEGE |

| | |905/100,CHELIKERE MAIN ROAD |

| | |KALYAN NAGAR POST |

| | |BANGALORE-560043. |

|3. |COURSE OF THE STUDY AND SUBJECT |1ST YEAR MSC NURSING, |

| | |PAEDIATRIC NURSING |

|4. |DATE OF ADMISSION OF THE COURSE |22/05/2012 |

| | | |

|5. |TITLE OF THE STUDY |“A study to Asses the knowledge and practices regarding post operative |

| | |Nursing care of children with congenital heart diseases in pediatric Intensive|

| | |care unit among staff nurses in selected cardiac hospitals,Bangalore in view |

| | |to use Self Instructional Module based on identified knowledge deficit.” |

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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE. KARNATAKA .

PRO FORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

| |NAME OF THE CANDIDATE AND ADDRESS |MS.SILPA CHAMARTHI |

|1 | |1ST YEAR M.S.C.NURSING |

| | |BANGALORE CITY COLLEGE |

| | |905/100,CHELIKERE MAIN ROAD,KALYAN NAGAR,BANASWADI |

| | |BANGALORE-560043 |

|2 |NAME OF THE INSTITUTION |BANGALORE CITY COLLEGE |

| | |905/100,CHELIKERE MAIN ROAD |

| | |KALYAN NAGAR POST |

| | |BANGALORE-560043. |

|3 |COURSE OF THE STUDY AND SUBJECT |1ST YEAR MSC NURSING, |

| | |PAEDIATRIC NURSING |

|4 |DATE OF ADMISSION OF THE COURSE |22/05/2012 |

|5 |TITLE OF THE STUDY |“A study to Asses the knowledge and practices regarding post operative Nursing |

| | |care of children with congenital heart diseases in pediatric Intensive care unit |

| | |among staff nurses in selected cardiac hospitals,Bangalore in view to use Self |

| | |Instructional Module based on identified knowledge deficit.” |

|6 |BRIEF RESUME OF THE WORK | |

| |6. Introduction | |

| |6.1. Need for the study |Enclosed |

| |6.2.Review of related literature |Enclosed |

| |6.2.1 Statement of the problem |Enclosed |

| |6.3.Objectives of the study |Enclosed |

| |6.4.Operational Definitions |Enclosed |

| |6.5. Assumptions |Enclosed |

| |6.6. Hypothesis |Enclosed |

| |6.7 Variables |Enclosed |

| |MATERIALS AND METHODS |

|7. |7.1 Sources 0f data : Data will be collected from the staf nurses in selected cardiac hospitals,Bangalore. |

| |7.2 Method of data collection : Structured -knowledge questionnaire |

| |7.3 Does the study require any investigations or interventions to be conducted on the patients or other humans or animals ? No |

| |7.4 Has ethical clearance been obtained from your institution? |

| |YES.Ethical clearance is enclosed. |

|8. |8.0 list of references : enclosed |

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6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

Every heart that beat strong and cheerfully.

Has left hopeful impulse behind it in the world.

And bettered the tradition of mankind.

- Robert Louis Stevenson.

India’s heath care sector is growing astoundingly fast. India has become a hot

medical destination for patients in the Middle East, Africa and even the West. And word is spreading that Indian hospitals can provide world class care at competitive rates. Many Indians today get good care, but many more, atleast seventy percent of the population still do not have access to the best. Even as we pat ourselves for all the achievements, let us not lose sight for this shocking reality. “The primary objectives should be to make top class medicare available to the common man.” 1

Individuals with congenital heart diseases are living longer than those born in past decades. Between 1979 & 1997 deaths from heart defects declined by 39.4%. 2

The increasing information regarding incidence rate and survival rate highlights that along with surgical treatment, comprehensive nursing care to these children with congenital heart diseases are essential. The specific nursing interventions are to assist in restoring optimal functioning of the cardio pulmonary, gastro intestinal, renal and central nervous system which help in easy and quick recovery of children with cardiac surgery. 3

Congenital heart defects, abnormalities in the structural development of the heart occur in approximately 1% of live births. With improved detection, diagnosis, medical management and surgical techniques the number of children surviving with congenital heart diseases is increasing. 4

When critically ill client’s vital functions are dangerously unstable, they need nursing skills turned to perfection: Observation that’s super sharp, alert to the tiniest change, attention to details, that’s totally precise and the ability to make irreversible decisions quickly and correctly. Such life saving competence always rests on a foundation of knowledge. 5

Monitoring of child requires skillful observation and careful monitoring by competent nurses which can prevent fatal complications in critically ill child. The nurse plays an important role in monitoring the client’s progress.

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She has to be competent and skillful in handling situations that will result in affecting the stability of the client. She has to make decisions, which are beneficial to the client’s life. By carefully monitoring the client, a competent nurse is able to recognize the early clues and manage problems before the escalate. When observation has been converted to direct, goal oriented therapeutic plans, the client should be able to experience more rapid positive outcomes. 5

The important nursing management for the client with altered level of consciousness include maintaining airway, fluid, nutrition , circulation, safety, oral care, activity, skin integrity , normal body temperature, elimination and supporting the family. 6

6.1 NEED FOR THE STUDY

The recent advances in cardiac surgery about 2/3rd of the patients suffering from congenital heart diseases have surgically correctable lesion with gratifying prognosis, provided that the surgical interventions are done in the very first year of life. 7

A study conducted that in general incidence of congenital heart diseases varies from 8 – 10 per 1000 alive new born population. There are eight common lesions which account for 85% of all cases. They are (i) Ventricular septal defect(VSD) (ii) Patent ductus arteriosus(PDA) (iii)Atrial septal defect (ASD) (iv) Pulmonary value stenosis (v) aortic valve stenosis (vi) coaortication of aorta (vii) tetralogy of fallot (viii)transposition of great arteries.The remaining 15% account for a variety of more rate and complex lesion. 8

Corrective surgery of congenital heart diseases in neonates the Prague experience, concluded that, due to complex improvement in perioperative, anesthetic, surgical and pot operative care, contemporary hospital mortality can be reduced to 1-3%. Palliative procedures still play an important role in the staged treatment of several complex heart disease in neonates. 9

Contemporary thinking for congenital heart diseases explain that the increasing information regarding the significance of incidence and survival rate high lights that along with surgical treatment, comprehensive nursing care to these children are essential. 10

A study conducted among the neonates with congenital heart diseases, interpreted that nursing care of the children with congenital heart diseases incorporates a knowledge base of the anatomy and physiology of congenital heart diseases, surgical repair, complications associated with congenital heart diseases, diagnostic testing, medical therapy and psycho social support. The pediatric nurse is a vital member of the cardiac team in providing accurate assessment, implementing medical therapies and supporting the family. 11

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Peri operative nursing care for congenital heart diseases concluded that continuity of nursing care between the pre operative and post operative phases of the patients with congenital heart diseases is the goal of the peri operative nurse. Good assessment and planning are essential to effective participation in the various stages of the operative courses from pre medication store transport of the child from ICU to the ward. 12

Cardiac surgery in a critically ill infants during the first three months of life concluded that in pediatric practice application of this technology is likely to have maximum impact in pediatric ICU and operating theatres. Children undergoing cardiac surgery are one group likely to benefit from continuous monitoring especially in the pre operative and immediate post operative periods. 13

The staff nurses working in PICU should have knowledgeable skill to provide excellent post operative nursing care to the children with congenital heart diseases and who have undergone cardiac surgery. Prompt and accurate assessment of the children’s condition is very much essential to provide effective nursing care to the children, which results in earlier mobilization, prevention of complications like arrhythmi, infections, respiratory insufficiency and decreased cardiac output.

As a health team member, the nurse must have adequate knowledge and she has to be highly competent to give care to those children who have undergone cardiac surgery. Then only the heath team will get the best results.

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6.2 REVIEW OF LITERATURE

Good research doesn’t exist in vacuum (Polit & Hungler). The chapter deals with the literature which is reviewed and relevant to the present study.

Review related to Congenital Heart Diseases

Congenital is a latin word derivative of ‘icon’ – together and ‘genitus’ – born.

The word implication is that Congenital Heart Disease present at birth.

A study estimates that Indians will comprise 60% of world cardiac patients by 2010. 14

A study conducted that no specific causes are found in most cases of congenital malformations of the heart. In a minority of cases clear cut single causes, either environmental or genetic are responsible.

A study describes that congenital defects cardiac structures may be classified in two groups:

1) A cyanotic heart disease, in which the infant has no cyanosis because there is no mixing of un oxygenated blood in the systemic circulations.

2) Cyanotic heart diseases in which the infant shows varying degrees of cyanosis because un oxygenated blood enters the systemic circulation. 3

A study conducted on Congenital Heart Disease explained that evolving concepts of diagnosis and management of patient with congenital heart disease precise diagnosis and meticuloiusly operative and peri operative care by the team or essential elements of success. Collaboration at the team of cardiologist, surgeons, radiologist, anesthesiologists and nurses has mage the many developments possible. 15

Review related to nursing management of children with Congenital Heart Disease

A study conducted on factors associated with early extubation after cardiac surgery in young children undergoing congenital heart surgery require mechanical ventilation we sought to identify pre and intra operative factors associated with successful extubation less than 24 hrs. Early extubation is possible in many very young children undergoing Congenital Heart surgery with a low rate of failed extubation. 16

A study conducted on nursing care for children with Congenital Heart Disease face unique challenges, especially when caring for neonates diagnosed with hypoplastic left heart syndrome. The treatment options for these neonates present difficult choices for the child’s decision makers and are not without significant life altering consequences.

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In order to assist in the decision making process, nurses as patient and family advocates should acknowledge the unique role they play in the informed consent process, while simultaneously identifying specific ethical principles that are components of this process. 17

A study conducted to find out the risk factors for long intensive care unit stay after cardio pulmonary bypass in Children and identified that, pre operative mechanical ventilation, neonatal status, medical problems, cardio pulmonary bypass time or ischemic time and circulatory arrest, post operative delayed sternal closure, sepsis, renal failure, pulmonary hypertension, arrhythmia. These post operative complication that are most strongly associated with increasing length of the study in the intensive care unit. 18

A study conducted on tran catheter closure of atrial septal defects mentioned that until recently surgical repair was the standard treatment for an atrial spetal defect (ASD) a common Congenital Heart defect. Closing ASD using a device inserted via a catheter now offerts another option for some patients. Equipments and procedures costs may be higher for trans catheter closure than for surgery but overall costs may be reduced through avoiding intensive care unit costs and through shorter hospital stays. 19

A study conducted on management of post operative low cardiac output syndrome interpreted that, the management of the infant with Congenital Heart Disease is a multi disciplinary collaborative effort that is individualized to each patient low cardiac output is frequently seen in the post operative infant death arrhythmia, preload, after load and contracting alterations it can be a significant complications after open heart surgery. The management of the younger patients, the higher acuity under high technology environment of the cardiac intensive care units requires acute assessment and manipulation of therepies to minimize deleterious effects in caring for these patients. 20

A study conducted on post operative management in patient with complex Congenital Heart Disease described by life threatening problems occur in children after cardiac surgery because of the inter play of diminished cardiac output, increased metabolic demand, inflammatory response to cardio pulmonary bypass and mal adoptive response to stress. Therefore the post operative management of patients with complex congenital heart defects is directed at optimization of oxygen delivery to maintain end organ function and promote wound healing. 21

A study conducted on outcome of cardio pulmonary resuscitation in a Pediatric Intensive Care Unit found that after cardio pulmonary resuscitation in the pediatric CICU the rate of success was 63% and the rate of survival was 42%. The availability of effective mechanical cardio pulmonary support and knowledge and skill in this area can improve the outcome of CPR. 22

A study conducted on management of congenital heat disease explained that management of CHD depends in this type, severity natural history of the specific

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malformation, age and the secondary effect on the defect.Management includes diagnostic, regular follow-up, preventive and therapeutic management. Preventive measures should be taken against infective endocardiac brain abscess, pulmonary vascular obstructive disesase (PVOD). Therapeutic measures include treatment for cardiac failure, infective endocaridists, common infections, atthythmia, cyanotic spells, cerebro vascular complications. Early surgical correction is indicated for CHD with large pulmonary blood flow to prevent the complications. 23

A study concluded that knowledge of the theoretic base that underlies hemodynamic monitoring will assist the clinicians in developing decision making skills to interpret, analyze trends and to formulate a nursing management plan appropriate for each individual patient. The author stated that the assessment of competence of care providers generated tremendous to meet current demands. It has to be dynamic, reflecting current expectations and linked to outcomes clinically. It is no longer enough to show that care provides are capable of safely carrying out procedures, unless we can demonstrate that when a procedure is carried out in a actual clinical setting the out comes reflect safely. 24

A study conducted in the conckpit of an airline and in the ICU. Repetitive tasks, boredom, fatigue, and the sudden need to act quickly to avoid disaster are common grounds for the critical care nurse and the airline pilot. There is need for backup systems, some of them redundant to some extent, and a variety of warning devices and monitoring systems. The nature of intensive care makes monitoring mandatory. It involves the knowledge and skills of highly trained nurses and physician. 25

A study conducted that assessment and monitoring of patients vital signs are routine components of everyday nursing practice. The methods used will of course vary from simple to complex in critical care areas. There is a wide variation in the quality of assessment, monitoring and documentation of these parameters due to a range of factors including intra and inter observer reliability, equipment malfunction and patient preparation, education of nurses and other health workers in the physiological and technical rationale underpinning the collection of vital signs data and significance of alterations in findings remain an important challenge. 26

A study conducted on enhancing safety in a pediatric unit in Australia. These descriptive studies demonstrate how a group of nurses in the clinical setting can identify and implement safe practice to enhance safety. The aim of the study was to determine a safer method of disposing used sharp items. Changes in practice were implemented following the finding of the study and resulted in enhanced safety in the pediatric unit. 27

A study conducted on pediatric cardiology emergencies explained that emergencies pediatric cardiology are heart failure, cyanosis and rhythm disturbances. The signs of heart failure are tachycardia, tachyon, and hepatomegaly.The therapy consists of oxygen, diuretics and digoxin. Occasionally intubation with mechanical ventilation and

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intravenous catrlamines are needed. 28

A study conducted on preventing pulmonary hypertensive crisis in the pediatric patient after cardiac surgery discussed that ,the critical care nurse can implement several interventions in the immediate post operative period to help to prevent the potentially lethal complications of pulmonary hypertensive crisis in a cardiac surgery patient .Respiratory interventions include hyperventilation ,maintaining an alkaline pH,supplemental oxygen and low positive end expiratory pressure.In addition ,the nurse must consider the serum potassium hematocrit and patient temperature and administer appropriate medicatons.’ 29

A study conducted states that hospitalization of a child is likely to lead to emotional ,social and environmental disturbances to the family and alter the parental role.It s essential for the health staff to build a caring relationship with the sick child as well as his parents.’ 30

A study conducted on staff behavior that parents found most helpful was that of being able to be near to their children and make sure that their children was getting best possible care when nurse used the nursing mutual participation model of care (a set of programme of support and information)parents felt significantly less amount of stress.’ 31

A study conducted on perioperative management of pulmonary circulation in the children with congential heart disease interpreted that in all the cardiac abnormalties critical care nurse play a key role in the control of pulmonary vascular resistance and blood flow by colabarative in therapies designated to increase, decrease or promote mixing to reduce mortality and morbidity in the these clients’32

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Statement of the problem

A study “To Asses The Knowledge and Practices Of Staff Nurses Regarding The Post Operative Nursing Care Of Children With Congenital Heart Disease In Pediatric Intensive Care Unit(PICU) Among Staff Nurses Selected Cardiac Hospitals ,Bangalore In view to use Self Instructional Module based on identified knowledge deficit.”

6.3. Objectives of the study

• to asses the knowledge of staff nurses regarding the post operative nursing care of children

• to asses the practices of staff nurses regarding the post operative nursing care of children

• to find out the association between the knowledge and practices regarding post operative nursing care of children with congenital heart diseases with selected demographic variables.

• To develop self instructional module.

6.4.Operational definitions

Knowledge: Knowledge means the awareness or information gained by educational qualification, experience and attendance of in service education programme about the post operative nursing care of children with congenial heart disease.

Practice: Practice refers to the observable action rendered by the staff nurses with their educational qualification, experience and attendance of in service education programme, in Pediatric Intensive Care Unit regarding post operative nursing care of children with congenital heart disease.

Staff nurse: Nursing personnel in Pediatric Intensive Care Unit with minimum experience of 6 months and above, who give direct patient care to children with congenital heart disease who had undergone cardiac surgery.

Children: Individual below 12 years of age diagnosed as congenital heart disease and who have undergone cardiac surgery.

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6.5. Assumptions

• Staff nurses working in PICU may have adequate knowledge and may be highly competent in their practices regarding post operative nursing care of children with congenital heart disease.

• Increase in Knowledge and increase in experience among nurses ensures quality care.

• Variables like educational qualification department of work ,experience,attendance of inservice education programme, have a positive influence on the level of practices among the nursing personal.

6.6. Hypothesis

There will be association between the knowledge of staff nurses regarding the postoperative nursing care of children with congenital heart disease with selected demographic variables(age,educational qualification,experience in PICU).

There will be association between the practices of staff nurses regarding the postoperative nursing care of children with congenital heart disease with selected demographic variables(age,educational qualification,experience in PICU).

6.7. Variables:

Dependent variable: Knowledge and practice of staff nurses in selected cardiac hospitals, Bangalore.

Independent variable: Age,education,experience in PICU, Self-instructional module.

7. MATERIALS AND METHODS

7.1 Source of data

Data will be collected from staff nurses working in pediatric ICU at selected cardiac hospitals in Bangalore.

7.2 Method of data collection

7.2.1.Research approach: Explorative approach.

7.2.2.Research design: Descriptive Research

7.2.3.Population: Staff nurses working in pediatric ICU at selected cardiac hospitals in

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Bangalore.

7.2.4.Setting: Selected cardiac hospitals in Bangalore.

7.2.5. Sample Size: 50

7.2.6.Sample technique: Convenient sampling

7.2.7.Sampling criteria:

(i) Inclusive criteria –staff nurses working in pediatric ICU at selected cardiac hospital, Bangalore.

(ii) Exclusive criteria –staff nurses working in other wards except PICU will not come under this study.

7.2.8. Sample: Staff nurses working in pediatric ICU at selected cardiac hospitals who fulfill the inclusion criteria at Bangalore.

7.2.9. Method of data collection: Structured-knowledge questionnaire.

7.2.10. Tools of data collection: Data will be collected by structured knowledge and attitude questionnaire by using non participatory observation check list.

7.2.11. Method of data analysis: The data obtained is analyzed by using descriptive and inferential statistics. Organizing the data in a master sheet. Computation of frequencies on percentage, mean and standard deviation. Karl Pearson correlation coefficient test and chi-square test at 0.01 level to find out the significance between knowledge and practice scores in relation to demographic variables.

7.3 Does the study require any investigations on interventions to be conducted on patient or other human being or animals?

- NO

7.4 Has ethical clearance been obtained from your institution?

- Yes. Ethical clearance report is enclosed.

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8. LIST OF REFERENCES

1. Cover story. The best and the rest exclusive 20 city survey of hospitals and Medical colleges. The week.April24.2005.p.23-23.

2. Binder RC,Bail JW, Pediatric nursing care for children. 3rd Ed. New Jersey: Pearson Education pvt ltd; 2003:p.478-94.

3. Marlow DR, Redding BA. Textbook of pediatric nursing. 6th ed. Philadelpia: W.B.Saunders company; 2002:p.460-90

4. Smith P. Primary care in children with congenital heart disease. J.Pediatr Nurse. 2001: 16(5).p.308-19.

5. Frank M, Burrel. Nurses versus Machine – Slaves or masters of technology? JUGNN.2000:28(4).p.433-40.

6. Martin JA. Management of the neonate after the arterial switch operation for Transposition of the great arteries and intact ventricular system. Prog Cardio Vascular nursing.1999;4(3).p.89-98.

7. Gupte S, Karunakara BP, Maiya PP. The short text book of pediatrics. 1oth ed. New Delhi: Jaypee brothers medical publishers(pvt)ltd;2004.

8. Parthasarathy.A. Menon.PSN.Joshi.et.al. IAP Text book of pediatrics. 2nd ed. New Delhi: Jaypee brothers medical publishers (pvt)ltd;2003.p.332-75.

9. Hucin B, Tlaskal T, Geboure R, corrective surgery of congenital heart disease in neonates. The Prague experience. Croat medical journal. 2002: 43(6).p.665-71.

10. Suddaby EC. Contemporary thinking for congenital heart disease. Pediatric Nursing Journal.2001:27(3).p.223-38.

11. Merle C. Nursing considerations of the neonates with congenital heart disease. Clinical perinatal.2001:28(1).p.223-8.

12. Foldy SM, Gorman JB. Peri operative nursing care for congenital heart defect. Crit care nurse clin. North America.1999:1(2).p.289-95

13. Hatheril M, Tibby SM, Durward A, Rajan. Continuous intra arterial bolld gas Monitoring in infants and children with cyanotic heart disease. British Journal Of Anaesthesia.1997:79(1).p.665-7.

14. Engle MA. Cyanotic congenital heart disease.A.M.J. Cardiol.1996

:37(2):283-308.

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15. Davis S, Worley S, Mee RB, Harrison AM. Factors associated with early extubation after cardiac surgery in young children. Pediatric critical care medicine. 2004:5(1).p.63-8.

16. Zeigler VL. Ethical principles and parental choice: treatment option for Neonates with hypo plastic left heart syndrome. Pediatric nurse.2003: 29(1).p.65-9

17. Penny DJ, Hoskote A, Goldman AP. Risk factors for long intensive care nit stay after cardio pulmonary bypass in children. Critical care medicine.2003:31(1).p.28-33

18. Hailey D. Trans catheter closure of atrial septal defects. Issues emerge health technol.2003:47(1),p.1-6.

19. Cuadrado AR .Management of post operative low cardiac out patient syndrome. Critical care nurse.2002:25(3):p.63-71.

20. Twodetell JS .Post operative management in patient with complex congenital heart disease: Seminar Thorasic cardio vascular surgical pediatric care.Surgical annual.2002:5(5)p.187-205.

21. Parra DA .outcome of cardio pulmonary Resuscitation in a paediatric cardiac intensive care unit. Critical care medicine.2000:28(9):p.3364-6.

22. Prasodo AM .Management of congenital heart disease.Pediatr Indones.1999:29(3-4):p.78-90

23. Thelan LA.Critical care nursing.Philadelphia:Mosby com[any :1999

24. Tobin JM.Principles and practice of intensive care monitoring .New York:Mc.grow Hill INC:1998.

25. Quinn T.Cardio vascular monitoring .Journal of advanced nursing.1998:27(3):666-7.

26. Barret M.Enhancing safety in a pediatric unit .The contempory nurse.2003:18(1).:p.265-9

27. Stocker F,wyler F.Pediatric cardiological emergencies .Ther Umsch 1999:51(9):P:601-6.

28. Medicus L,Thompson L.Preventing pulmonary hypertensive crisis in the pediatric patient after cardiac surgery.American jounal of critical care 1995:4(1):P 49-53.

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29. Farrel,Frost.The most importane needs iof parents of critically ill children Intensive and critical care nursing.1992:8(3):P 130-9

30. Miles,Carter.Perception of hospitalization:A stress inoculation programme for parents and children .Maternal child health journey.1995:11(1):P 87-94

31. Norris MK,Roland JM.Peri operative management of pulmonary circulation in children with congential heart defect.AACN .Clinical issues:Criticl care nurse.1994:5(3):P 255-62

32. Chang AC.Pediatric cardiac intensive care::Current state of art and beyond.The millennium.current opinion in pediatrics .2000:12:p 238-46

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|9. |Signature of the candidate | |

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|10. |Remarks of the Guide | |

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|11. |Name and Designation | |

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| |11.1 Guide | |

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| |11.2 Signature | |

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| |11.3 Head of the Department | |

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