PROGRAMME

CERTIFICATE IN PAEDIATRIC NURSING

COHORT

COHORT 16

BLOCK

BLOCK 1

FULL NAME

WAN KHADIJAH BINTI WAN YUSOFF

I/C NUMBER

NOOR AFIKA BINTI AZRI

850109-03-6260
920810-09-5198

MATRIX NUMBER
TITLE

PATENT DUCTUS ARTERIOSUS

PROGRAMME COORDINATOR

MADAM AMUDHA

CLINICAL PRECEPTOR
MARK OBTAINED

CONTENTS
No

Contents

1.

Learning Objective

Page Numbers
3

2.

Personal Data

3.

Patient history

6- 20

4.

Assessment and patient condition

21-28

5.

Disease Condition

29-48

6.

Management and treatment

49-56

7.

Nursing Care Plan

57-62

11.

Discharge plan

63-64

12.

Conclusion

65-66

13.

Reference

67-68

14.

Appendix

69

LEARNING OBJECTIVE
At the end of this case study I will able to:

1. Explain the patients biodata, family background including family medical history and
socioeconomic background.
2. Explain the chief complaint including present medical history, past medical and surgical
2

history also allergy history of the patient.

3. State the growth and development, milestones including physical measures, gross motor,
fine motor and socialization.
4. State the birth history and immunization history of the patient.
5. State the diet history including nutritional assessment (growth chart), feeding milestone
and 24-hour recall.
6. State the physical assessment and diagnostic evaluation with the treatment to the patient.
7. Explain the disease condition including definition, incidence, etiology, investigation,
management and complications.
8. Explain appropriate nursing care plan for patient with patern ductus atreosus.
9. Explain health education given to family members related to patern ductus atreosus

PERSONAL
DATA

PERSONAL DATA
Name: nur x

Gender: Female

Age: 1 6/12 years old

Religion: Muslim

Birthday: January 04, 2013

Birthplace: Hospital shah alam

Civil status: Single

Nationality: Malaysian

Fathers occupation

: Lorry driver

Mothers occupation: Factory worker

Attending physician: Dr. J.d.

Address: No 3, jln aman perdana

Admitting diagnosis: PDA

4b/ku5 shah alam, selangor

Date of admission: Feb 16, 2014

Date of discharged: Feb 19 2014

Chief complaint: lethargic and frequently

Allergy : Unknown

having cough and fever

Past medical history: NIL

Past surgical history: NIL

Initial v/s (9:00am)
Temperature: 37.3 c
Heart rate: 165

Patient history

FAMILY PEDIGREE

Madam. E (mother)
30 years old
Housewife

Mr. T (father)
33 years old
Businessman

Mohd k
5 years old

Nur X
1 and 6 months old

SOSIOECONOMIC BACKGROUND

Mr.T and Madam E was live in PPRT at Jalan Aman perdana, Shah Alam Selangor. Nur X
(patient) is the second child in the family. The mother of Mister J is working in chemical factory
meanwhile her father is a lorry driver. The father earns about RM 2500 while her mother earns
RM1000 per month.

HISTORY OF PRESENTING ILLNESS

The mother of the patient was said to be working in Chemical Factory in shah alam and for the
whole 9 months of her pregnancy to the patient, she was exposed to insecticides. The patient was
healthy when she was born until she was 2 month old when her mother noticed she is not so
active, her heart beat was faster than usual, Rapid breathing, inability and difficulty with feeding
in which she easily get tired with the feeding. Her breast feeding was not regular too plus she
doesnt like bottle feeding. She also loses weight. According to mother since birth nur x
frequently get cold and flu and difficult to recover. The mother then brought her to SA hospital
and she was admitted because suspected to have CHD. Lanoxin, Furosemide and Aldactone were
given for maintenance. Laboratory exams were done such as 2D echo, chest X-ray and ECG in
SA hospital.
On March 18, 2013, the patient was 2 months old and was diagnosed with CHD (PDA).
She was advised for operation but due to financial constraints, the operation was not done.
On October 2013, they were referred to Institude Jantung Negara (IJN). Patient went to IJN to
have her operation done. One day prior to admission to IJN; the patient was screened, had
checked-up, FBC was done and showed an elevated WBC. The chest X-ray shows an enlarged

heart and evidence of an excessive amount of blood flow to the lungs. An echocardiogram is
performed again to confirm the diagnosis. Echo result demonstrated the size of the ductus
arteriosus more than normal size and the heart chambers have become enlarged due to the extra
blood flow or ventricular hypertrophy.
Her operation was scheduled then and she was given propylaxsis of antibiotic. The
decision for surgery is because the child develop moderate CHD

PAST MEDICAL AND SURGICAL HISTORY

The patient was the second child of her mother. The first child was healthy because she
was not yet exposed to any chemicals during that time. The mother is said to be G2P2 and was
on her 36th week of gestation. and on January 4, 2013 a healthy 7.5 lbs baby girl was born. The
patient had regular pre-natal and after birth checkups and after being diagnosed with her disease,
she had her check-ups every 2 months.
The patient also experienced cough, colds and fever. She cannot able to stand or even sit alone.
When she was 3 months old, she took her 3 medications namely, lanoxin, aldactone and
furosemide
Nur x got no history of surgical procedure since birth till now also not having allergic
reaction to any foods or drugs or dust also fragrances noted.

FAMILY MEDICAL HISTORY

FATHER
Father of Nur X, Mr. T he is 33 years old and healthy man. Mr. T has no history of allergic to
dust, drugs or foods. His parental background also did not have any history of congenital illness.
His maternal background was well. There is no history of any congenital anomalies among his
sibling.
MOTHER
Nur X mother, Madam E also a healthy woman. She has no history of allergic to any drugs, food
or environment, congenital anomalies, inherited disorders and chronic illnesses.Her family
background also did not have any history of congenital illness noted.

ANTENATAL HISTORY
During pregnancy, the mother was healthy and she had proper nutrition intake. She did not take
any traditional medicine or any medication except prescribed by doctor. All the observation
especially blood pressure was in the normal side during follow up but according to mother she
was working in factory and expose to insectiside for whole 9 months she carries the baby.

POSTNATAL HISTORY
Nur x was delivered on January 04, 2013 through spontaneous vaginal delivery. She is full term
baby at 38 weeks gestation. Nur x was born with:
Birth weight

: 3.55 kg

Head circumference

: 33 cm

Birth length

: 48.5 cm

10

According to midwife, immediate after birth Nur X was born she appeared pink, active and
crying loudly. No congenital abnormality and sign of respiratory distress. Intramuscular Vitamin
K, Hepatitis B and Intradermal BCG were given.

IMMUNIZATION HISTORY
Immunization: the production of immunity by artificial means. Passive immunity may be
conferred by the injection of an antiserum, but the production of active immunity calls for the
use of a vaccine.
Vaccine: a special preparation of antigenic material that can be used to stimulate the
development of antibodies and thus confer active immunity against a specific disease or number
of diseases. It is usually given by injection but may be introduced into the skin through light
scratches; for some diseases (e.g. polio), oral vaccines are available. Many vaccines are produced
by culturing bacteria or viruses under conditions that lead to a loss of their virulence but not of
their antigenic nature. Other vaccines consist of specially treated toxins (toxoids) or of dead
bacteria that are still antigenic. (Elizabeth A. M., 2004).
Nur x had her immunization till her age completely. He had taken the immunization at
clinic T. According to her mother nur x took a compulsory immunization and she never miss for
her son immunization time.

11

AGE

VACCINE

DATE GIVEN

AT BIRTH

BCG

January 04, 2013

AT BIRTH

Hepatitis B

January 04, 2013

1 MONTHS

Hepatitis B (2nd dose)

Taken

2 MONTHS

DPT , OPV, HIB ( 1st dose )

Taken

3 MONTHS

DPT , OPV , HIB ( 2nd dose )

Taken

5 MONTHS

Hepatitis B, DPT, OPV,HIB

Taken

( 3rd dose )
12 MONTHS

MMR ,

Taken

Next immunization on 18 months old (DPT, OPV 4th dose).

Summary of Injection Site

Vaccine

Route of administration

Injection site

BCG
Hep B
DTP
OPV
Hib

Intradermal
Intramuscular
Intramuscular
Oral
Intramuscular

Upper left arm

Upper anterolateral side of the thigh
Upper anterolateralside of the thigh
Mouth
Upper anterolateralside of the thigh
(older children: upper arm)
Upper left arm
Upper left arm

MMR
Subcutaneous
TT/DT
Intramuscular
DIET HISTORY
According to mother, Nur X was breast feed since birth and given mix feeding (milk x +
breast feeding) after 6 months. Nur x also started with weaning diet at the age of 6 months. The
mother firstly introduced her with plain porridge that she cooked by herself. After that she added
and mix with other ingredients such as potato, carrot and an extra slowly weeks by weeks
according to doctors advises because she need to be fluid restricted. Nur x was tolerated well
12

with all the feeding but she need to maintain strict fluid intake as advise by doctor. Slowly by 1
year her mother also introduced him with adult food (such as rice with small vegetables also
chicken or fish). But his most favorite food is porridge (either chicken or fish).
DEVELOPMENT MILESTONES
Developmental milestones are a set of functional skills or age-specific tasks that most children
can do at a certain age range. Although each milestone has an age level, the actual age when a
normally developing child reaches that milestone can very quiet a bit.
HISTORY OF MILESTONES
Nur x

Book Picture

Weight
Birth

3.55 kg

2.7 3.5 kg

1 year 6kg

8.1 10.5 kg

Length
Birth

48.5 cm

50 cm

1 year 73 cm

75 cm

Head of circumference
Birth

- 33 cm

33 35 cm

1 year 45 cm

45 47 cm
GROSS MOTOR

Nur X
1-month old
According to mother, Nur X was

Book Picture
Can turn head from side to side when
prone. Lift head momentarily from bed.
13

unable to turn head from side to

Has marked head lag, especially when

side when prone position. She

pulled from lying to sitting position.

Assumes asymmetric tonic neck reflex

looks tired.
Back uniformly rounded when in
sitting position and absence of
head control.
2 months old
Nur X still having head lag when
pulled to sitting position.
unable to lift head when in prone
position.

position when supine.

In sitting position back is Uniformly
rounded, absence of head control.
Assumes less flexed position when
prone.
Less head lag when pulled to sitting
position.
Can lift head almost 45 degrees off
table.
Assumed asymmetric tonic neck reflex
position immediately.

Able to hold head more erect when

3 months old
Nur X unable to raise head and

sitting but still bobs forward.

Able to raise head and shoulders from

shoulders from position 45 90

degrees angle.

6 months old
According to mother, Nur X Able to
hold head more erect when sitting
but still bobs forward.
still unable to control her head while
pulling her to the sitting position.
Able to sit with support.
unable to turn prone to supine and

prone position to 45 90-degree angle.

When held in standing position, able to
bear slight fraction of weight on legs.
Can lift chest and upper abdomen off
table, bearing weight on hands.
Sits in high chair with back straight.
Rolls from back to abdomen.
When held in standing position, bears
almost all of weight.
Hand regard absent

14

reverse.
8 months
able to control her head while pulling
her to the sitting position.
able to lift head for 10 minute when

Can crawl like commando

Can stands holding on to support (upper
arm)

in prone position.
Unable to crawl
Still sit with support
Unable to stands holding on to
support (upper arm)

9 months
Still unable to crawls
Still unable to sit without supported

10 months
Unable to stand with support (hand)
Unable Clapping

11 months
Nur X unable to stand spontaneously.

crawls-hands and knees

sits unsupported for 10 minutes or more,
lean forward but cannot pivot
pull self to stand
stands with support (elbow)

She also cannot sit without

supported.
12 months
able to turn site to site
able to hold head but still sit with
supported
13 months
Unable to stand

stand with support (hand)

clapping

cruising on all fours pivoting

walks with 2 hands held
Sit without support at 11 months
gets from lying to sitting to crawling to
standing
walks alone/one hand held (12-24mths)
15

 Walked without support at 12 months

FINE MOTOR
Nur X
1-month old
Mother did not remember the exactly

Book Picture
Hands predominantly closed.
Grasp reflex strong
Hands clenches on contact with rattle.

what Nur x was able to do on this age.

Hand frequently opens.

Grasp reflex fading

2 months old
According to mother, got grasp reflex.
Mother did not remember the exactly

Actively hold rattle but will not reach

what Nur x was able to do on this age.

3 months old
According to mother, Nur X was Always

for it.
Grasp reflex absent.
Hands kept loosely, open.
Clutches own hand, pull at blankets

played with her clothes and hold a rattle

and clothes.

6 months old
According to mother nur x was unable to

hold her bottle feeding at this age.

Resecures a dropped object.

Drop 1 cube when another is given.
Grasp and manipulates small objects.
Holds bottle.
Grasps feet and pull to mouth

pincer grip developing (pincer grip 9 months

Nur X will take items or objects given

scissors grasp)

start with her index finger.

10 months
16

 Nur x try to push small item using her

repeatedly throws object onto floor

less likely to take all objects into

index finger and he already start to hold

items item using pincer grasp.
She also likely to put all object into mouth
SPEECH
Nur X

mouth

Book Picture
Cries to express displeasure.
Make small, throaty sounds.
Makes a comfort sound during

1-month old
According to mother, nur x was not
always cry. She only cry when hungry,

feeding.
Coos.
Vocalizes to familiar voice.

wet and discomfort.

2 months old
According to mother, Nur x was able to

recognized her voice.

3 months old
Nur x can be smiling when her mother
called her.

Squeal to show pleasure.

Coos, babbles, chuckles.
Vocalizes when smiling.
Less crying during periods of

wakefulness.
Babbling in single syllables

6 months old
Nur X babbling in single syllables such

one word with meaning

as dada.
11 months old
Nur x can correctly call correct person mama, papa, and she able to

imitating sounds from nursery rhymes.

12 months
Not able to have 2 -3 words with meaning

says 2-3 words with meaning

understand phrases, e.g. (where are
your shoes)

17

SOCIALIZATION
Miss N

Book Picture
Watches parents face intently as she

1-month old
According to mother, Nur x was quite if

or he talks to infant.

somebody talked to her.

2 months old
According to mother, Nur x was able to
Demonstrates social smile in

smile on this age

3 months old
Nur x not so interest in surrounding.

response to various stimuli.

Display considerable interest in
surroundings.

6 months old
According to mother, Nur x was able to

recognized her parent and scared to

Ceases crying when parent enters
strangers
room.
Can recognize familiar faces and
objects, such as feeding bottle.
Shows awareness of strange situation

12 months
drinks from a cup with help
knows and turns to name

Hold arms out to be picked.

Laughs when head is hidden in a
towel.
Frequent mood swings from crying
to laugh with little or no provocation.

18

PHYSICAL
ASSESSMENT
&
PATIENT CONDITION

19

PHYSICAL ASSESSMENT

1. During admission (July 16, 2014; 8:10 am), I do assess on Nur x when she admitted.
General appearance of Nur x she looked pale lethargic, coughing, mild tachypnea. So I
took the vital signs and do the physical assessment of patient and take some of history of
Nur x from her parent.
2. The parameter on admission as below:
Temperature

: 37.3 C

Heart rate

: 165 bpm

Respiration rate

: 64 bpm

Weight

: 6.6 kg

3. auscultation done and continuous ('machinery') murmur is audible at the left

infraclavicular area or upper left sternal border. this murmur sound is a noise caused by
the turbulence of blood flowing through the PDA.
4. Peripheral pulses are bounding as the run-off into the pulmonary circulation drops the
diastolic pressure and causes a wide pulse pressure. If the pulmonary circulation is
markedly overloaded there will be tachycardia, tachypnea and a wide pulse pressure.
5. Physical assessment done: the result as below.

20

Physical Assessment Head to Toe

SKIN
RESULT
Pale skin with 0/4 functional level (cannot move without assistance) poor weakness on
both extremities; poor weight gain chest circumference of 44 cm

INTERPRETATION & ANALYSIS

There is presence of pale skin due to poor peripheral circulation and cardiac output
HEAD

RESULT
Head is larger than the body; Head Circumference of 44.5cm absence of nodules; hair strands
are thin; color of the hair is black. Scalp is clean and not dry. The anterior fontanelle palpable
and Posterior fontanelle is fully closed.

EYES

21

RESULT
Pupils are Symmetry. Conjunctiva is pink and glossy. No strabismus. No eyes discharge. Can
fixate on small an object and reactive to light and accommodation (+).

EAR
RESULT
Pattern and symmetry. Pinna is in place and correct alignment. No abnormal opening of the ear
& skin tag. No ear discharge. Localizes sounds by turning head. Responds to own name.

NOSE
RESULT
Pattern & symmetry. In correct placement. Both nostrils equal in size. Septum in midline no
22

deviated of septum. No nasal discharge.

MOUTH
RESULT
Lips smooth, moist, looks pale
Gums firm, coral pink
Mucous membrane pale, smooth, moist, no oral trush.

NECK
RESULT
Symmetrical and palpations reveal no nodules and masses; (+) distended nodules and masses; (+)
distended neck vein
INTERPRETATION & ANALYSIS
Accumulation of blood in veins that are returning blood to the heart.
NAILS
RESULT
Poor capillary refill
INTERPRETATION & ANALYSIS
Inadequate systemic perfusion; poor capillary perfusion and cardiac output
ABDOMEN
RESULT
Skin is smooth, no scar. Abdomen is soft, in cylinder shape, prominent and bowel sound is
present. Umbilical is clean, no umbilical hernia and not tender while palpation
23

CHEST
RESULT
No chest pain, Symmetry. Chest movement symmetry. dyspnea and cough noted with machinery
murmur noted. Mild intercostal retraction.
INTERPRETATION & ANALYSIS
There is presence of murmur because of valves does not close tightly and blood leaks backward
turbulent blood flow through the heart valves

GENITALIA
RESULT
Clean, no redness of skin and no discharge.
ANUS
RESULT
Clean, no polyps & hemorrhoids

MUSCULOSKELETAL
RESULT

24

There is severe muscle weakness in both upper and lower extremities. No deformities and
swelling on the joints
INTERPRETATION & ANALYSIS
Poor cardiac output
Neurologic
RESULT
Awake and alert

Disease
Condition

25

CARDIOVASCULAR SYSTEM
The heart is a hollow muscular organ which beats over 100,000 times a day to pump
blood around the body's 60,000 miles of blood vessels. The right side of the heart receives blood
and sends it to the lungs to be oxygenated, while the left side receives oxygenated blood from the
lungs and sends it out to the tissues of the body.

The cardiovascular system is made up of the organs involved in receiving and pumping
blood out to the lung and spread to whole body circulation and consists of the: Endocardium; is
the inner layer of heart, Epicardium is the middle layer of heart, Myocardium is the outer layer of
heart and Pericardium which is the protective membrane surrounding it. The heart is protected by
the
The heart has four chambers, in the lower heart the right and left Ventricles, and in the
upper heart the right and left Atria. In a normal heart beat the atria contract while the ventricles
26

relax, then the ventricles contract while the atria relax. There are Valves through which blood
passes between ventricle and atrium, these close in such a way that blood does not backwash
during the pauses between ventricular contractions. The right and left ventricles are divided by a
thick wall which known as ventricular septum, babies born with "hole in the heart" have a small
gap here, which is a problem since oxygenated and deoxygenated can blood mix. The walls of
the left ventricle are thicker as it has to pump blood to all the tissues, compared to the right
ventricle which only pumps blood as far as the lungs.
FUNCTION OF ORGAN IN CARDIOVASCULAR SYSTEM
1. The heart chambers
There are four chambers in the heart. The two upper chambers are called the atria. They receive
blood from the veins. The two lower chambers are the ventricles. Blood is pumped from the
ventricles to the arteries and to the rest of the body.
2. The heart valves
There are two types of valves located in the heart: the atrioventricular valves and the semilunar
valves. The sound we associate with the heartbeat is actually the closing of heart valves. Lubdub is the sound often used to describe the sound of the heartbeat. The first sound, lub, is the
sound of atrioventricular valves closing. The second sound, dub, is the sound of your
semilunar valves. If any of your heart valves are not working correctly, then another sound might
be heard. This is referred to as a heart murmur.
3. Blood Vessels

27

There are three main types of blood vessels. Arteries, capillaries, and veins form a system of
tubes that carry blood to and from the heart. The blood vessels form an incredible network of
tubes throughout the body. An adult has as many of 100,000 miles of blood vessels in their body.
4. Arteries
These large blood vessels are made of a thick muscular layer to withstand higher blood pressure.
They carry blood from the heart to the capillaries.
5. Capillaries
Capillaries form a vast network of very small vessels that enable the exchange of materials
between blood and the tissue cells. The term capillary bed refers to a network of capillaries that
supply blood to an organ.
6. Veins
Veins return blood from the capillaries back to the heart. They are made up of a relatively thin
muscular layer and contain internal valves to keep the blood from ever flowing backwards.
About 60% of the blood volume is located in the veins at any given time.
7. Blood
When a baby is born it has about one cup of blood in its whole body The average adult has
anywhere from four to five quarts in their body. About 8% of human body weight is blood.
Blood is a specialized fluid in the body with several important roles:
It transports nutrients to the cells in your body (including oxygen,
28

glucose, amino acids, blood lipids)

It transports waste materials from cells to your elimination organs
such as the liver, kidneys, and lungs
It supports your immune system function by circulating white blood
cells and detecting pathogens with antibodies
It transports hormones

It regulates your core temperature

It regulates pH balance

It coagulates to help the body heal cuts and other wounds

Blood is made up of cells suspended in a liquid we call plasma. Plasma accounts for 54.3% of
blood volume. Cells that are suspended in plasma include:

Blood flow

Deoxygenated blood from the body flows from the superior and inferior vena cava veins to your
right atrium. This blood is pumped to the right ventricle and then proceeds to the pulmonary
trunk where it is oxygenated by the act of inhalation. This newly oxygenated blood then flows
through pulmonary veins to the left atrium and is pumped to the left ventricle to continue to the
aorta and the rest of the body. These are referred to as the pulmonary and systemic circuits.

Blood pressure
29

The circulation of blood throughout the body happens due to changes in blood pressure.
Blood naturally flows from areas of high pressure to areas of lower pressure. When the ventricles
contract the pressure necessary to push the blood into the arteries is created. As the blood
travels throughout the body the pressure continually decreases.
NORMAL FETAL CIRCULATION

30

31

The blood that flows through the fetus is actually more complicated than after the
baby is born (normal heart). This is because the mother (the placenta) is doing the work
that the babys lungs will do after birth.
The placenta accepts the bluest blood (blood without oxygen) from the fetus
through blood vessels that leave the fetus through the umbilical cord (umbilical arteries,
there are two of them). When blood goes through the placenta it picks up oxygen and
becomes red. The red blood then returns to the fetus via the third vessel in the umbilical
cord (umbilical vein). The red blood that enters the fetus passes through the fetal liver
and enters the right side of the heart.
The red blood goes through one of the two extra connections in the fetal heart that
will close after the baby is born. The hole between the top two heart chambers (right and
left atrium) is called a patent foramen ovale (PFO). This hole allows the reddest blood to
go from the right atrium to left atrium and then to the left ventricle and out the aorta. As a
result, the blood with the most oxygen gets to the brain. Blood coming back from the
fetuss body also enters the right atrium, but the fetus is able to send this blue blood from
the right atrium to the right ventricle (the chamber that normally pumps blood to the
lungs). Most of the blood that leaves the right ventricle in the fetus bypasses the lungs
through the second of the two extra fetal connections known as the ductus arteriosus.
The ductus arteriosus sends the bluer blood to the organs in the lower half of the
fetal body. This also allows for the bluest blood to leave the fetus through the umbilical
arteries and get back to the placenta to pick up oxygen. Since the patent foramen ovale
and ductus arteriosus are normal findings in the fetus, it is impossible to predict whether
32

or not these connections will close normally after birth in a normal fetal heart. These two
bypass pathways in the fetal circulation make it possible for most fetuses to survive
pregnancy even when there are complex heart problems and not be affected until after
birth when these pathways begin to close.
DEFINITION PATENT DUCTUS ARTERIOSUS (PDA)
Patent ductus arteriosus (PDA), in which there is a persistent communication
between the descending thoracic aorta and the pulmonary artery that results from failure
of normal physiologic closure of the fetal ductus is one of the more common congenital
heart defects.

33

Pathophysiology
The ductus arteriosus is normally patent during fetal life; it is an important structure in
fetal development as it contributes to the flow of blood to the rest of the fetal organs and
structure. From the 6th week of fetal life onwards, the ductus is responsible for most of the right
ventricular outflow, and it contributes to 60% of the total cardiac output throughout the fetal life.
Only about 5-10% of its outflow passes through the lungs. Thus, a patent ductus arteriosus
(PDA) produces a left-to-right shunt. In other words, it allows blood to go from the systemic
circulation to the pulmonary circulation. Therefore, pulmonary blood flow is excessive.
Pulmonary engorgement results with decreased pulmonary compliance. The reaction of the
pulmonary vasculature to the increased blood flow is unpredictable. Schematic diagram of a leftto-right shunt of blood flow from the descending aorta via the patent ductus arteriosus (PDA) to
the main pulmonary artery. The magnitude of the excess pulmonary blood flow depends on
relatively Few factors. The larger the internal diameter of the narrowest portion of the ductus
34

arteriosus, the larger the left-to-right shunt. If the ductus arteriosus is restrictive, then the length
of the narrowed area also affects the magnitude of the shunt. A longer ductus is associated with a
smaller shunt. Finally, the magnitude of the left-to-right shunt is partially controlled by the
relationship of the pulmonary vascular resistance (PVR) to the systemic vascular resistance
(SVR). If the SVR is high and/or the PVR is low, the flow through the ductus arteriosus is
potentially large. Beginning at the ductus arteriosus, the course of blood flow (through systole
and diastole) in a typical patent ductus arteriosus (PDA) with pulmonary over circulation is as
follows: patent ductus arteriosus (PDA), pulmonary arteries, pulmonary capillaries, pulmonary
veins, left atrium, left ventricle, aorta, patent ductus arteriosus (PDA). Therefore, a large left-toright shunt through a patent ductus arteriosus (PDA) results in left atrial and left ventricular
enlargement. The pulmonary veins and the ascending aorta can also be dilated with a sufficiently
large patent ductus arteriosus (PDA). In addition, if little or no restriction is present at the level
of the patent ductus arteriosus (PDA), pulmonary hypertension results.
Functional and anatomic closure in the fetus
The oxygen tension is relatively low, because the pulmonary system is nonfunctional.
Coupled with high levels of circulating prostaglandins, this acts to keep the ductus open. The
high levels of prostaglandins result from the little amount of pulmonary circulation and the high
levels of production in the placenta. At birth, the placenta is removed, eliminating a major source
of prostaglandin production, and the lungs expand, activating the organ in which most
prostaglandins are metabolized. In addition, with the onset of normal respiration, oxygen tension
in the blood markedly increases. Pulmonary vascular resistance decreases with this activity.
Normally, functional closure of the ductus arteriosus occurs by about 15 hours of life in healthy

35

infants born at term. This occurs by abrupt contraction of the muscular wall of the ductus
arteriosus, which is associated with increases in the partial pressure of oxygen (PO2) coincident
with the first breath. A preferential shift of blood flow occurs; the blood moves away from the
ductus and directly from the right ventricle into the lungs. Until functional closure is complete
and PVR is lower than SVR, some residual left-to-right flow occurs from the aorta through the
ductus and into the pulmonary arteries. This was first demonstrated by multiple experiments in
the 1940s and has been subsequently confirmed. Although the neonatal ductus appears to be
highly sensitive to changes in arterial oxygen tension, the actual reasons for closure or persistent
patency are complex and involve manipulation by the autonomic nervous system, chemical
mediators, and the ductal musculature. A balance of factors that cause relaxation and contraction
determine the vascular tone of the ductus. Major factors causing relaxation are the high
prostaglandin levels, hypoxemia, and nitric oxide production in the ductus. Factors resulting in
contraction include decreased prostaglandin levels, increased PO2, increased endothelin-1,
norepinephrine, acetylcholine, bradykinin, and decreased PGE receptors. Increased prostaglandin
sensitivity, in conjunction with pulmonary immaturity leading to hypoxia, contributes to the
increased frequency of patent ductus arteriosus (PDA) in premature neonates. Although
functional closure usually occurs in the first few hours of life, true anatomic closure, in which the
ductus loses the ability to reopen, may take several weeks. A second stage of closure related to
fibrous proliferation of the intima is complete in 2-3 weeks.
Cassels et al defined true persistence of the ductus arteriosus as a patent ductus arteriosus
(PDA) present in infants older than 3 months. Thus, patency after 3 months is considered
abnormal, and treatment should be considered at this juncture, although urgency is seldom
necessary. Some canine breeds, such as certain strains of poodle, have a large prevalence of
36

patent ductus arteriosus (PDA). Spontaneous closure after 5 months is rare in the full-term infant.
Left untreated, patients with a large patent ductus arteriosus (PDA) are at risk to develop
Eisenmenger Syndrome, in which the PVR can exceed SVR, and the usual left-to-right shunting
reverses to a right-to-left direction. At this stage, the PVR is irreversible, closure of the patent
ductus arteriosus (PDA) is contraindicated, and lung transplantation may be the only hope for
long-term survival. Failure of ductus arteriosus to contract Failure of ductus arteriosus
contraction in preterm neonates has been suggested to be due to poor prostaglandin metabolism
because of immature lungs. Furthermore, high reactivity to prostaglandin and reduced calcium
sensitivity to oxygen in vascular smooth muscle cells contribute to contraction of the ductus. The
absence of ductus arteriosus contraction in full-term neonates might be due to failed
prostaglandin metabolism most likely caused by hypoxemia, asphyxia, or increased pulmonary
blood flow, renal failure, and respiratory disorders. Cyclooxygenase (COX)-2 (an isoform of
COX-producing prostaglandins) induction and expression might also prevent ductal closure. The
activation of G protein-coupled receptors EP4 by PGE2, the primary prostaglandin regulating
ductal tone leads to ductal smooth muscle relaxation. During late gestation, the decrease in
prostaglandin levels results in constriction of the ductus arteriosus. Thus, the intimal cushions
come into contact and occlude the ductus lumen.

Volume-pressure relationships
Further progression of disease is dependent on volume and pressure relationships, as follows:
Volume = pressure/resistance
High volume yields increasing pulmonary artery pressures, eventually producing endothelial and
37

muscular changes in the vessel wall. These changes may eventually lead to pulmonary vascular
obstructive disease (PVOD), a condition of resistance to pulmonary blood flow that may be
irreversible and will preclude definitive repair.
Etiology
The exact cause of patent ductus arteriosus is unknown. In 95 percent of births, the ductus
arteriosus closes normally. Risk factors associated with the development of patent ductus
arteriosus include:

Rubella

Alcohol consumption during pregnancy

Expose to teratogenic during pregnancy

Maternal age greater than 40 y/old

Coxsackie virus

Maternal insulin dependent in diabetes mother

Genetics
Familial cases of patent ductus arteriosus (PDA) have been recorded, but a genetic cause has not
been determined. In infants born at term who have a persistent patent ductus arteriosus (PDA),
the recurrence rate among siblings is 5%.
Prematurity
Prematurity or immaturity of the infant at the time of delivery contributes to the patency of the
38

ductus. Several factors are involved, including immaturity of the smooth muscle within the
structure or the inability of the immature lungs to clear the circulating prostaglandins that remain
from gestation. These mechanisms are not fully understood. Conditions that contribute to low
oxygen tension in the blood, such as immature lungs, coexisting congenital heart defects, and
high altitude, are associated with persistent patency of the ductus
Epidemiology
The estimated incidence of patent ductus arteriosus (PDA) in US children born at term is
between 0.02% and 0.006% of live births. This incidence is increased in children who are born
prematurely (20% in premature infants > 32 weeks' gestation up to 60% in those < 28 weeks'
gestation), children with a history of perinatal asphyxia, and, possibly, children born at high
altitude. In addition, up to 30% of low birth weight infants (< 2500 g) develop a patent ductus
arteriosus (PDA). Siblings also have an increased incidence. Perinatal asphyxia usually only
delays the closure of the ductus, and, over time, the ductus typically closes without specific
therapy. As an isolated lesion, patent ductus arteriosus (PDA) represents 5-10% of all congenital
heart lesions. It occurs in approximately 0.008% of live premature births. No data support a race
predilection. However, there is a female preponderance (female-to-male ratio, 2:1) if the patent
ductus arteriosus (PDA) is not associated with other risk factors. In patients in whom the patent
ductus arteriosus (PDA) is associated with a specific teratogenic exposure, such as congenital
rubella, the incidence is equal between the sexes. Occasionally, an older child is referred with the
late discovery of a typical ductus arteriosus murmur (eg, machinery or continuous murmur).

39

40

Symptoms
Patent ductus arteriosus symptoms vary with the size of the defect and whether the baby
is full-term or premature. A small PDA might cause no signs or symptoms and go
undetected for some time, even until adulthood. A large PDA can cause signs of heart
failure soon after birth.
A large PDA found during infancy or childhood might cause:
-

Poor eating, which leads to poor growth and Isn't gaining weight

Sweating with crying or eating

Persistent fast breathing or breathlessness and rapid heart rate

41

Tires easily when eating or playing

Becomes breathless when eating or crying

Risk factors
Risk factors for having a patent ductus arteriosus include:
o Premature birth. Patent ductus arteriosus (PDA) occurs more commonly in babies
who are born too early than in babies who are born full term.
o Family history and other genetic conditions. A family history of heart defects and
other genetic conditions, such as Down syndrome, increase the risk of having a
PDA.
o Rubella infection during pregnancy. If you contract German measles (rubella)
during pregnancy, your baby's risk of heart defects increases. The rubella virus
crosses the placenta and spreads through the baby's circulatory system, damaging
blood vessels and organs, including the heart.
Investigation

Auscultation
continuous ('machinery') murmur is audible at the left infraclavicular area or
upper left sternal border. this murmur sound is a noise caused by the turbulence of
blood flowing through the PDA.

Check pulse (wide pulse pressure & bounding pulse.

42

Blood test (FBC, BUSE)

Blood test can show patients HB status, WBC show infection status and BUSE
can shows patient electrolyte balance.

CXR (cardiomegaly & pulmonary edema)

A diagnostic test that uses invisible X-ray beams to produce images of internal
tissues, bones, and organs onto film. With a PDA, the heart may be enlarged due
to larger amounts of blood flow recirculating through the lungs back to the heart.
Also, there may be changes that take place in the lungs due to extra blood flow
that can be seen on an X-ray.

ECG
is a simple, painless test that records the heart's electrical activity. For babies who
have PDA, an ECG can show whether the heart is enlarged. Specifically left
ventricle hypertrophy The test also can show other subtle changes that can suggest
the presence of a PDA.

ECHO
(echo) is a painless test that uses sound waves to create a moving picture of
babys heart. During echo, the sound waves bounce off the child's heart. A
computer converts the sound waves into pictures of the heart's structures. The test
allows the doctor to clearly see any problems with the way the heart is formed or
the way it's working. Echo is the most important test available to the baby's
43

cardiologist to both diagnose a heart problem and follow the problem over time.
In babies who have PDA, echo shows how big the PDA is and how well the heart
is responding to it. When medical treatments are used to try to close a PDA, echo
is used to see how well the treatments are working.

Cardiac catheterization.
A cardiac catheterization is an invasive procedure that gives very detailed
information about the structures inside the heart. Under sedation, a small, thin,
flexible tube (catheter) is inserted into a blood vessel in the groin, and guided to
the inside of the heart. Blood pressure and oxygen measurements are taken in the
four chambers of the heart, as well as the pulmonary artery and aorta. Contrast
dye is also injected to more clearly visualize the structures inside the heart. The
cardiac catheterization procedure may also be an option for treatment. During the
procedure, the child is sedated and a small, thin, flexible tube (catheter) is inserted
into a blood vessel in the groin and guided to the inside of the heart. Once the
catheter is in the heart, the cardiologist will pass a special device, either a coil or a
PDA occluder (depending on the size of the PDA). This device will close the PDA
and therefore stop the blood flow through the PDA.

Complications
A small patent ductus arteriosus might not cause complications. Larger, untreated defects
could cause:
High blood pressure in the lungs (pulmonary hypertension). Too much blood circulating

44

through the heart's main arteries through a patent ductus arteriosus can lead to
pulmonary hypertension, which can cause permanent lung damage. A large patent
ductus arteriosus can lead to Eisenmenger syndrome, an irreversible type of pulmonary
hypertension.
Heart failure. A patent ductus arteriosus can eventually cause the heart to enlarge and
weaken, leading to heart failure, a chronic condition in which the heart can't pump
effectively.
Heart infection (endocarditis). People who have structural heart problems, such as a
patent ductus arteriosus, are at a higher risk of an inflammation of the heart's inner
lining (infectious endocarditis) than are people who have healthy hearts.
Prevention
There's no sure way to prevent having a baby with a patent ductus arteriosus. However,
it's important to do everything possible to have a healthy pregnancy.
Seek early prenatal care

Quitting smoking, reducing stress, stopping birth control

Discuss medications you're taking

Eat a healthy diet. Include a vitamin supplement that contains folic acid. And Exercise
regularly.
Avoid risks. These include harmful substances such as chemical, alcohol,
45

cigarettes and illegal drugs.

Avoid infections. vaccinations during pregnancy.

Keep diabetes under control. If have diabetes, work with

doctor to manage the condition before and during pregnancy.
If have a family history of heart defects or other genetic
disorders, consider talking with a genetic counselor before becoming
pregnant.

MANAGEMENT AND TREATMENT

46

Treatment and management

A small patent ductus arteriosus may close spontaneously as your child grows. A PDA that
causes symptoms will require medical management, and possibly even surgical repair.
cardiologist will check periodically to see whether the PDA is closing on its own. If a PDA does
not close on its own, it will be repaired to prevent lung problems that will develop from longtime exposure to extra blood flow. Patent ductus arteriosus (PDA) is treated with medicines,
catheter-based procedures, and surgery. The goal of treatment is to close the PDA to prevent
complications and reverse the effects of increased blood volume. For full-term infants, treatment
is needed if the child's PDA is large or causing health problems. For premature infants, treatment
is needed if the PDA is causing breathing problems or heart problems.
Specific treatment for PDA will be determined by doctor based on:

child's age, overall health, and medical history

Extent of the disease

child's tolerance for specific medications, procedures, or therapies

Expectations for the course of the disease

Parent s opinion or preference

Treatment include:
1. Medications
Medication use in patent ductus arteriosus (PDA) is based upon the clinical status of the
patient. In the presence of symptoms of pulmonary over circulation or pulmonary hypertension
related to a patent ductus arteriosus (PDA), closing the lesion is usually most prudent
47

Prostaglandins are utilized to maintain the patency of the ductus arteriosus until surgical
ligation is performed. When surgical ligation is not indicated, prostaglandin inhibitors (eg,
nonsteroid antiinflammatory drugs (NSAIDs) are used to close the ductus arteriosus.
Intravenous (IV) indomethacin or IV ibuprofen is used to treat patent ductus arteriosus
(PDA) in the neonate and in premature infants. an intravenous (IV) medication called
indomethacin may help close a patent ductus arteriosus it related to aspirin and ibuprofen and
works by stimulating the muscles inside the PDA to constrict, thereby closing the
connection. The dose used for ibuprofen is 10 mg/kg bolus followed by 5 mg/kg/d for 2
additional days. Ibuprofen was initially thought to have less adverse effects, such as a decreased
incidence of oliguria, gastrointestinal (GI) toxicity, and cerebral hypoperfusion. But The use of
ibuprofen also has been shown to increase the incidence of pulmonary hypertension and chronic
lung disease. A Cochrane database review showed no statistically significant difference in
closure between ibuprofen and indomethacin. The effectiveness ibuprofen and indomethacin
clearly decreases with increasing postnatal age (Fanos V. et al., 2011)

1. Catheter-Based Procedures
Catheter-based procedures often are used to close PDAs in infants or children who are large
enough to have the procedure. trans catheter device closure is a procedure that uses a thin,
hollow tube placed into a blood vessel. The doctor passes a small metal coil or other blocking
device through the catheter to the site of the PDA. This blocks blood flow through the vessel.
These coils can help the baby avoid surgery. The Catheters are thin, flexible tubes used in a
procedure called cardiac catheterization. The procedure sometimes is done on small PDAs to
48

prevent the risk of infective endocarditis (IE), an infection of the lining of the heart, valves, or
arteries.
During the procedure, your child will be sedated or given medicine so that he or she will
sleep and not feel any discomfort. The doctor will place a catheter in a large blood vessel in the
upper thigh (groin) and guide it to your child's heart. A small metal coil or other blocking device
is then passed up through the catheter and placed in the PDA to block blood flow through the
vessel. So the ductus atreosus will be block and closed. Surgery may be needed if the catheter
procedure does not work or it cannot be used. Catheter-based procedures don't require the child's
chest to be opened. They also let the child recover quickly.
Closing a PDA using a catheter often is done on an outpatient basis. Complications from
catheter-based procedures are rare and short term. They can include bleeding, infection, and
movement of the blocking device from where it was placed.
Post Catheter-Based Procedures
When the procedure is complete, the catheter(s) will be withdrawn. Several gauze pads and a
large piece of medical tape will be placed on the site where the catheter was inserted to prevent
bleeding. In some cases, a small, flat weight or sandbag may be used to help keep pressure on the
catheterization site and decrease the chance of bleeding. If blood vessels in the leg were used,
pantient will be told to keep the leg straight for a few hours after the procedure to minimize the
chance of bleeding at the catheterization site. Patient will be taken to a unit in the hospital where
they will be monitored by nursing staff for several hours after the procedure. The length of time
it takes for patient to wake up after the procedure will depend on the type of medicine given to

49

for relaxation prior to the procedure, and also on child's reaction to the medication. After the
procedure, nurse will monitor the pulses and skin temperature in the leg or arm that was used for
the procedure. child may be able to go home after a specified period of time, providing child
does not need further treatment or monitoring. Parent will be given written instructions regarding
care of the catheterization site, bathing, activity restrictions, and any new medications the child
may need to take at home. antibiotics will be given to prevent bacterial endocarditis for a specific
time period after discharge from the hospital if the coil or occluder device was used.
2. Surgery
Surgery for PDA or PDA ligation may be done if:

A premature or full-term infant develops health problems from the PDA and is too small
to have a catheter-based procedure

A PDA isn't successfully closed by a catheter-based procedure

Surgery is planned for treatment of related congenital heart defects

Often, surgery isn't done until after 6 months of age in infants who don't have health
problems from their PDAs. Doctors sometime perform surgery on small PDAs to prevent
the risk of IE.
For the surgery, the patient will be given medicine so that he or she will sleep and not feel

any discomfort. The surgeon will make a small cut between your child's ribs to reach the
PDA. Doctor will then close the PDA with stitches or clips. This surgery
does not require opening the heart. The patient is under general anesthesia during the whole
50

procedure. a breathing tube or endotracheal tube is inserted down the throat and is connected
to a ventilator. The patient will be lie on his/her side with the right side down. The incision is
made near the left armpit on the left side of the chest. A small cut between the ribs to open
the chest cavity to reveal the PDA between the pulmonary artery and the aorta. This incision
is called Left Posterolateral Thoracotomy. Several nerves like the vagus, phrenic and
recurrent laryngeal nerves are close to the PDA shunt. The surgeon takes great care to
identify and avoid any damage to these nerves. The PDA is then tied with sutures or closed
with surgical clips. Tubes will be placed in the chest cavity to drain the blood and fluid
produced after surgery. Then the incision will be closed with sutures, cleaned and dressed. So
the child need to be NBM for at least 6 hours with iv therapy as order by Doctor. consent
should be taken from parents. Complications from surgery are rare and usually short term.
They can include hoarseness, a paralyzed diaphragm (the muscle below the lungs), infection,
bleeding, or fluid buildup around the lungs.

51

After Surgery
After surgery, the patient will be then transported to the Intensive Care Unit (ICU) or
Post-Surgical Care Unit. patients blood pressure, pulse, ECG etc., will be monitored
continuously. Once the child is able to breathe on its own, the ventilator will be slowly weaned
off. Chest tubes also will be removed when the drainage stops. Stay in the ICU is usually a day
or less if there are no complications. The patient will spend a few days in the hospital and will be
given medicines to reduce pain and anxiety. Most patient go home 2 days after surgery.
Premature infants usually have to stay in the hospital longer because of their other health issues.
Parent will be given knowledge after the surgery regarding:

Limits on activity for your child while he or she recovers

52

Follow-up appointments with your child's doctors

How to give your child medicines at home, for example pain medications, such as
acetaminophen or ibuprofen, may be recommended to keep your child comfortable.
When child goes home after surgery, parent can expect that the child will feel fairly

comfortable, although there may be some short-term pain. Child should begin to eat better and
gain weight quickly. Within a few weeks and should fully recover by able to take part in normal
activities. Long-term complications from surgery are rare. However, they can include narrowing
of the aorta, incomplete closure of the PDA, and reopening of the PDA.

53

NURSING CARE
PLAN

54

DIAGNOSIS

INTERVENTION

RATIONALE

Decreased cardiac output

Observe child behavior and

To plan early further treatment

related to cardiac

Monitor signs of CHF

and intervention.

malformations

(restlessness, tachycardia,
tachypnea, tightness, fatigue,
periorbital edema and oliguria).

GOAL: To Maintain

adequate cardiac output:

Assess of the quality and strength

As a base line data and

of heart rate, peripheral pulses,

planning further intervention

blood pressure, spo2, skin color

and warmth.

Monitor intake and output by

Urine output less indicate that

weighing the pampers and give the patient in early shock.

mother pen with paper to write
child intake.

Administer antidiuretics as order

by doctor eg. Lasix and aldacton

hypertension

Plan the nursing care for example

taking vital sign together with
given medication

DIAGNOSIS

To reduce pulmonary

INTERVENTION

55

To promote uninterrupted rest

period and save energy

RATIONALE

Activity intolerance related to

imbalance between oxygen

Assess level of activity that To plan for further intervention

the child tolerated

consumption by the body, and

Allow the child to rest

To promote child, engage with

the supply of oxygen to the

frequently, and avoid

the activity

cells.

disturbances during sleep.

GOAL :To Maintaining

adequate levels of activity

Encourage games

To preserve oxygen

and activities to do lightly.

consumption for the activity

Help the child to

choose activities appropriat

To promote child normal

development

e to the age, condition

and ability of the child.

Avoid the ambient

temperature is too hot or too

To make sure child comfort

during the activity

cold

Avoid the things that cause

fear / anxiety in children.

DIAGNOSIS

INTERVENTION

Altered Growth and

Development related to

Anxiety can cause child use

more oxygen during activity.

RATIONALE

Performed baseline developmental As a base line data and

assessment such as Denver
56

planning for further

inadequate supply of

developmental assessment.

intervention

oxygen and nutrients to the

Monitor development milestone

To ensure task is appropriate

tissues.

and provide appropriate

with the child development

developmental task.

milestone

Give the stimulation of growth

To encourage child interest

and development, play activities,

with the developmental

gaming, watching TV, puzzles,

activity

GOAL: Provide support for

the growth and
development

drawing, and others according to

the condition and age of the child.

Plan for play period with the rest.

To avoid child tired and

stress.

to keep providing stimulation

Involve the family in the

for developmental activity.

development activity

Involve speech, occupational and

physio therapist

To support developmental
milestone and prepare child
for future environment.

DIAGNOSIS

INTERVENTION

RATIONAL

Impaired gas exchange

Observe child behavior and

To plan early further treatment

skin color (restlessness,

and intervention.

related to pulmonary

57

congestion.

tachycardia, tachypnea,
tightness, fatigue).

rate and SPO2 every hourly.

GOAL: To Reduce the

increase in pulmonary

Monitor respiration rate, heart

Adjust the position of the child

As a base line data and planning

further intervention
To improve child airway pattern
and reduce abdomen pressure to

with Fowler position.

vascular resistance

the respiratory system

To prevent hypoxemia
Administer oxygen as order by
doctor

To minimize oxygen consumption

Plan the nursing care for

example taking vital sign
together with given medication

Provide optimal nutrition.

To improve child energy and

effective oxygen use.

DIAGNOSIS

INTERVENTION

Imbalanced Nutrition, Less

Provide a balanced diet,

Than Body Requirements r / t

high nutrients

fatigue at mealtime and

to achieve adequate growth.

increased caloric needs.

Monitor height and weight,

58

RATIONALE

To preserve energy

As baseline data to plan

documented in the form of

Goal: Maintaining growth in

graphs to identify trends in

weight and height appropriate

the growth of the child.

further intervention

Weight is indication of

Measure body weight each

changers in nutritional

day with the same weight

status

and the same time.

Record intake and output

correctly.

in nutritional status

Give food with small

portions but often to avoid

fatigue at meals.

To detect abnormalities

To prevent fatigue and

chest discomfort

Children who receive

diuretics are usually very
thirsty, therefore not
restricted fluid.

59

To prevent dehydration
and cardiac overload

DISCHARGE
PLAN

Family education
1. Medication as ordered by Doctor. Informed parents regarding medication indication side
effect and contraindication
2. Activity restrictios, no strenuous activity or contact sports for 6.8 weeks to prevent chest
3.
4.
5.
6.
7.
8.
9.

discomfort.
Care of the incision to prevent any infection, Wound gapping
Dietary recommendation
Bathing or showering guidelines
Any redness swelling or discharge from the incision
Report any poor appetite nausea vomiting
Explained regarding sign and symptom of breathing difficulty
Attend follow up as schedule to improve the illness

60

Home care
1.
2.
3.
4.

Arrange home visit review medication vital sign, and diet

Arrange for home medical equipment- oxygen feeding pump
Teach parent regarding CPR technique
Avoid activities with high risk of injury

19 February 2014@ 0900hours

Smooth first post-operative day and the patient discharged at home after 3 days. After two
weeks post-operative echocardiography study confirm the total closure with no residual
leak through the ductus. Nur x looked very active and good condition.

CONCLUSION

61

62

Conclusion
Patent Ductus Arteriosus is a cardiovascular disorder found in patients of all ages and
the sizes, from tiny premature infants to older adults. Clinical implications vary depending on
the anatomy of ductus arteriosus and the underlying cardiovascular status of the patient. In
most cases we can't do anything to prevent having a baby with a heart defect. However, it's
important to do everything possible to have a healthy pregnancy.

63

REFERRENCE

64

Book
Bryan,D, Tortora, GJ,(2010). Essentials of Anatomy and Physiology, 8th Edition, John Wiley &
Sons, Inc.
Hockenberry, M, J,Wilson, D (2008). Wongs Nursing Care of Infants and Children, Nine
Edition, Canada, Mosby Elsevier. (p. 1697).
Elizabeth A. M. (2004). Dictionary of Nursing, Immunization, Fajar Bakti Sdn. Bhd, pg. 240.
Elizabeth A. M. (2004). Dictionary of Nursing, Immunization, Fajar Bakti Sdn. Bhd, pg. 505.
Keong,M,T,Piau, W,C,Seah,L,W, (2008). Handbook of Hospital Paediatrics, 2nd Edition,
Unipress Medical & Healthcare.
Mims Malaysia, Dims,(2008). Malaysia Index of Medical Specialities, 112th edition, Malaysia,
Kementerian Kesihatan Malaysia.
Weller.F,Barlow,S,(2006). Nurses Aids Series Paediatric Nursing, 7th Edition, British
Article
Schneider DJ, Moore JW. Patent ductus arteriosus. Circulation. 2006; 114:18731882.
Fanos V, Pusceddu M, Dess` A, Marcialis MA. Should we definitively abandon prophylaxis for
patent ductus arteriosus in preterm new-borns? Clinics. 2011;66(12):2141-2149.

65

66

APPENDIXS

67