heart disease in children...b.sc. nursing & gnm syllabus

Heart disease in children

Rahul Dhaker

Asst. Professor,

Pal College of Nursing & Medical Sciences, Kathgodam, Uttarakhand

Introduction

• The most common heart disease in children

are congenital heart disease and rheumatic

fever with its consequences.

• Congestive cardiac failure is a common

pediatric emergency, with its different

etiology than that of adults. 2R Dh@ker, Lecturer, PCNMS

• Congenital heart defects are problems with

the heart's structure that are present at birth.

These defects can involve:-

• The interior walls of the heart

• The valves inside the heart

• The arteries and veins that carry blood to

the heart or the body

R Dh@ker, Lecturer, PCNMS 3

• There are many types of congenital heart

defects. They range from simple defects with

no symptoms to complex defects with severe,

life-threatening symptoms.

• They affect 8 out of every 1,000 newborns

Cont…introduction

• Other heart disease which may found in

infants and children are cardiomyopathy,

myocarditis, pericardial disease etc.

5R Dh@ker, Lecturer, PCNMS

Cont…

• Common clinical features of cardiac disease

include-

–Chest pain

–Tachycardia

–Bradycardia

–Dyspnea

–Cyanosis

Cont…

• Sweating during feeding

• Orthropnea

• Feeding difficult

• Clubbing

• Edema

• Chest deformity

• Engorgement of neck veins

• Hepatomegaly etc. 7R Dh@ker, Lecturer, PCNMS

Cont….

• History of illness ,

• Clinical examination, cardiac examination and

auscultation are very important aspect of

diagnostic evaluation before the planning of

investigations.

• The investigations to detect the cardiac problems

and to confirm the diagnosis include -

Cont…

• X-ray studies

• ECG

• Echocardiography

• MRI

• Radionuclide angiography

• Cardiac catheterization

• ABG analysis

• Complete hemogram

• Urinalysis etc.

circulation

Congenital Heart disease

• CHD is the structural malformation of the heart

or grater vessels, present at birth.

• It is the most common congenital malformation

• The exact number of prevalence is not known

Etiology • The exact cause of CHD is unknown in about 90%

of case.

• Heredity and consanguineous marriage are

important etiology factors.

• Genetic disorder and chromosomal aberrations (

trisomy – 21, Turner's syndrome) are also known

to predispose congenital heart disease. 14R Dh@ker, Lecturer, PCNMS

Cont…

• Other associated factors responsible for CHD

include fetal and maternal infections, drug intake,

alcohol intake by mother, maternal IDDM, fetal

hypoxia, birth asphyxia etc.

Classification of CHD

• CHD can be grouped into three categories-

• Acynotic CHD- there is increased pulmonary

blood flow due to left to right shunt. It includes:-

– Ventricular septal defect (VSD)

– Atrial septal defect (ASD)

– Patent ductus arteriosus (PDA)

– Atrio- Ventricular canal (AVC)

Cont…Classification of CHD

• Cyanotic CHD- there is diminished pulmonary

blood flow due to Right to Left shunt. It

includes:-

– Tetralogy of fallot (TOF)

– Tricuspid Atresia (TA)

– Transposition of grater arteries (TGA)

– Hypoplastic left heart syndrome

Cont…

• Obstructive lesions:-

–Coarctation of aorta

–Aortic Value stenosis

–Pulmonary value stenosis

–Congenital mitral stenosis

R Dh@ker, Lecturer, PCNMS19

Ventricular septal Defect (VSD)

• A ventricular septal defect is an opening in the

ventricular septum, or dividing wall between the

two lower chambers of the heart known as the

right and left ventricles.

• VSD is a congenital (present at birth) heart defect.

• As the fetus is growing, something occurs to affect

heart development during the first 8 weeks of

pregnancy, resulting in a VSD21R Dh@ker, Lecturer, PCNMS

• It is most common acyanotic congenital

heart disease.

• It is found approximately 25% of all CHD.

• The size of defect can be small & large.

Etiology

• In most children, the cause isn't known

• In some cases, the tendency to develop a VSD may

have a genetic basis.

• Risk factors

– Ventricular septal defect appears to run in families

and sometimes occurs with other genetic problems,

such as Down syndrome

Cont….etiology

• Having the following conditions during pregnancy

can increase risk of having a baby with a heart

defect.

–Rubella infection

– Poorly controlled diabetes

–Drug or alcohol use or exposure to certain

substances

Types of VSD

• Membranous VSD

• Muscular VSD

• Atrioventricular canal type VSD

• Conal septal VSD

Symptoms of VSD

• The size of the ventricular septal opening will

affect the type of symptoms noted, the severity of

symptoms, and the age at which they first occur.

• The following are the most common symptoms of

– fatigue

– sweating

– rapid breathing

– heavy breathing

Cont…Symptoms of VSD

– congested breathing

–disinterest in feeding, or tiring while feeding

–poor weight gain

Diagnosis • complete exam and look for signs of VSD, which

may include heart murmurs.

• Tests may perform include:

• chest x-ray

• electrocardiogram (ECG)

• echocardiogram (echo)

• cardiac catheterization

• cardiac magnetic resonance

imaging (MRI)29R Dh@ker, Lecturer, PCNMS

Treatment for ventricular septal

Defect

Specific treatment for VSD will be determined by child's

physician 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

•Opinion or preference

R Dh@ker, Lecturer, PCNMS

Cont…

• Medical management

• adequate nutrition

• infection control

• surgical repair

• interventional cardiac catheterization

• Postoperative care

Medical management• In small VSD usually no medical management is

required.

• Surgical repairer may be indicated in some cases.

• Prevention of complication is very essential

measure.

• Spontaneous closure of VSD occurs in 30 to 50%

cases with small defect.33R Dh@ker, Lecturer, PCNMS

Cont…

• In large VSD, initial management of associated

problem like CCF and endocarditis, should be

done with appropriate treatment.

• Surgical is done as one- stage or two-stage

operational.

• One stage operational with patch closure of VSD

by Open-heart method can be performed.

Cont…

• Two stage approach is done with first stage, to

band the pulmonary artery to restrict pulmonary

blood flow by closed- heart methods.

• Second stage operation is done to patch close the

VSD and remove the PA band.

Complication

• The common complication of VSD are CCF,

recurrent respiratory tract infection, infective

endocarditis, pulmonary stenosis, pulmonary

hypertension.

Patent Ducts

Arteriosus

Patent Ducts Arteriosus

• It is persistent vascular connection between the

pulmonary artery and the aorta.

• Functionally the closure of ductus arteriosus occurs

soon after birth.

• When ductus arteriosus remains patent and open after

birth, the blood flow in the ductus from the aorta to

the pulmonary artery due to higher pressure in the

aorta.

• PDA is common in preterm infants who weight

less than 1.5kg.

• It is the more common type in female baby and

occurs approximately 11% of all CHDs.

• A small PDA may cause no symptoms, but a large

one may cause poor eating, failure to thrive or

breathlessness.

• During the first 60 hours of life, spontaneous

closure of the ductus occurs in 55% of full-term

newborn infants.

• By 2-6 months of age, closure occurs in more

than 95% of healthy infants.

Clinical manifestations• Clinical presentation of PDA depend upon the size

of ductus and its patency.

• Symptomatic cases manifested with –

– Tachycardia

– Bounding pulse

– Dyspnea and frequency respiratory infection.

– Precordial pain,

– hoarseness voice

– Feeding difficulties

– Slow weight gain

– Growth failure 44R Dh@ker, Lecturer, PCNMS

Diagnosis evaluation • History of illness

• Physical examination

• Chest X-ray

• ECG

• Two- dimensional echocardiogram

• Doppler study

Management

• Medical Management

• Surgical Management

Medical Management

• In symptomatic patient with PDA,

– Indomethanic 0.1 to 0.25mg/kg/IV over 30 minutes

very slowly is administered every 12 to 24 hrs for 3

doses.

– Anti-prostaglandin agent

– Aspirin

• Supportive care is provided with rest, adequate

intake of calorie for weight gain and promotion of

growth and development.

Surgical management

• Transaction or ligation of patent ductus arteriosus

is performed via lateral thoracotomy, a closed

heart intervention.

• It is done preferably between 3 and 10 years of age

in asymptomatic patients and in symptomatic

patients.

• The result of surgery is excellent.

• pre- operative and postoperative care for

thoracic surgery to be provided with all

precaution.49R Dh@ker, Lecturer, PCNMS

Complication • CCF

• Infective endocarditis

• Pulmonary hypertension

• Rarely

– Thromboembolism

–Rheumatic heart disease

Atrial Septal Defect

Introduction

• A "hole" in the wall that separates the top two

chambers of the heart.

• This defect allows oxygen-rich blood to leak into

the oxygen-poor blood chambers in the heart.

• ASD is a defect in the septum between the heart's

two upper chambers (atria). The septum is a wall

that separates the heart's left and right sides.

• Atrial Septal defects occur in 6 percent to 8

percent of all children born with congenital heart

disease.

• For unknown reasons, girls have Atrial Septal

defects twice as often as boys.

Etiology

• The causes of heart defects such as atrial septal defect

among most babies are unknown.

• Some babies have heart defects because of changes in their

genes or chromosomes.

• Very small defects of (less than 5 millimeters or ¼ inch) are

less likely to cause problems. Smaller defects are often

discovered much later in life than larger ones.

• Risk factors- during pregnancy may increase risk

of having a baby with a heart defect, including:-

– Rubella infection

– Drug, tobacco or alcohol use, or exposure to certain

substances

– Diabetes

– Obesity

– Phenylketonuria (PKU)

Epidemiology

• The 3 major types of atrial septal defect (ASD)

account for 10% of all congenital heart disease

and as much as 20-40% of congenital heart

disease presenting in adulthood.

• The most common types of ASD include the

following:-

Cont… Epidemiology

– Ostium secundum: The most common type of ASD

accounting for 75% of all ASD cases, representing

approximately 7% of all congenital cardiac defects and 30-

40% of all congenital heart disease in patients older than 40

years.

– Ostium primum: The second most common type of ASD

accounts for 15-20% of all ASDs.

– Sinus venosus: The least common of the three, sinus

venosus (SV) ASD is seen in 5-10% of all ASDs.

• Ostium secundum atrial septal defect

• Ostium primum atrial septal defect

• Sinus venosus atrial septal defect.

• Coronary sinus atrial septal defect.

Clinical Manifestation

• Many babies born with atrial septal defects don't

have associated signs or symptoms.

• The size of an ASD and its location in the heart

will determine what kinds of symptoms a child

experiences.

Cont… clinical Manifestation

• Shortness of breath, especially when exercising

• Fatigue

• Swelling of legs, feet or abdomen

• Heart palpitations or skipped beats

• Frequent lung infections

• Stroke

• Heart murmur

Diagnostic Evaluation

• History of illness

• physical examination

• Chest X-ray

• Electrocardiogram (ECG)

• Echocardiogram (or “echo”)

Management • A physician decides the best course of treatment

for ASD based on:

– A child's age, overall health and medical history

– Severity of the disease

– A child's tolerance for specific medications, procedures

or therapies

– Expectations for the course of the disease

– Parents’ opinions or preferences

Medical Management

• Many children have no symptoms and require no

medications.

• Digoxin

• Diuretics

Surgical Management

• A health care provider may recommend surgery

for a child with a large atrial septal defect, even if

there are few symptoms, to prevent problems

later in life.

• Surgery may also be recommended for an adult

who has many or severe symptoms.

• Surgery involves fixing the hole and may be done

through cardiac catheterization or open-heart

surgery.

• Repair of the defect is done by suture closure or

pericardial patch repair by suture closure or

pericardial patch repair by Open Hearth Surgery.

Complication

• Right-sided heart failure

• Heart rhythm abnormalities (arrhythmias)

• Increased risk of a stroke

• Infective endocarditis

• Less common serious

– Pulmonary hypertension

Tetralogy

fallot

• Tetralogy of Fallot (TOF) is a congenital heart

defect which is classically understood to involve

four anatomical abnormalities of the heart

• It is the most common cyanotic heart defect, and

the most common cause of blue baby syndrome.

• TOF is usually a right-to-left shunt, in which

higher resistance to right ventricular outflow

results in more severe cyanosis symptoms.78R Dh@ker, Lecturer, PCNMS

• This condition is characterized by the combinations

of four defect.

– Pulmonary stenosis

– Ventricular defect

– Overriding of aorta

– Right ventricular hypertrophy

• Tetralogy of Fallot is a rare, complex heart defect

that occurs in about 5 out of every 10,000 babies.

• It affects boys and girls equally.79R Dh@ker, Lecturer, PCNMS

• Ventricular septal defect (VSD)

• Overriding aorta − the aortic valve is enlarged and appears to

arise from both the left and right ventricles instead of the left

ventricle as in normal hearts.

• Pulmonary stenosis − narrowing of the pulmonary valve and

outflow tract or area below the valve that creates an obstruction

(blockage) of blood flow from the right ventricle to the

pulmonary artery.

• Right ventricular hypertrophy − thickening of the muscular

walls of the right ventricle, which occurs because the right

ventricle is pumping at high pressure.

Causes Tetralogy of Fallot• Cause unknown

• Certain conditions or factors that occur during pregnancy may raise risk for having a child with tetralogy of Fallot. These conditions and factors include:

– German measles (rubella) and some other viral illnesses

– Poor nutrition

– Overuse of alcohol

– Age (being older than 40)

– Diabetes

• Heredity may play a role in causing tetralogy of Fallot.

Clinical manifestation • Clinical feature of TOF depend upon size of VSD

and degree of right ventricular outflow

obstruction.

• Blue baby or cyanosis of lips and nailbeds with

Dyspnea is found initially with crying and

exertion in neonates especially when the ductus

arteriosus beings to close.

• Hypercyanotic spells

• Irritability

• Dyspnea

• Cyanosis

• Tet spell

• Flacidity with or without unconsciousness.

• Slow weight gain

• By the age of 2year the child usually develop

clubbing.

• Metabolic acidosis

• Exercise intolerance may develop 84R Dh@ker, Lecturer, PCNMS

Diagnostic test • History of illness

• Physical examination

• Chest X-ray

• ECG

• Two dimensional ECHO

Management • The child with TOF should be managed for

cyanosis, hypoxia spells and other associative

complication.

• Oxygen therapy

• Correction of dehydration

• Anemia

• Antibiotic therapy

• Supportive nursing care and continuous

monitoring of child’s condition.

Cont…

• Hypoxic spells should be managed –

– Knee chest position

– Sedative

– Oral propranolol therapy

– IV fluid

– Treatment of acidosis

– Oxygen therapy

• Neonate –

– Prostaglandin E1.

Surgical Management

• Palliative surgery

• Definitive correction

• Complete Intracardiac Repair

Palliative surgery

• Palliative surgery is performed by different

techniques as –

–Modified BT shunt

– Potts operations

–Waterson’s operations

Definitive correction

• It is performed by direct vision open heart

surgery for patch closure of VSD and relief of

right ventricular obstruction.

Complication • Hypoxia spells

• Polychythemia

• CCF

• Post operative complication including-

– Death

– Arrhythmia

– Exercise disability

– Complete heart block

– Operative complication

Transposition

Grater Arteries

• Transposition of the great arteries (TGA) is a heart

condition that is present at birth, and often is called

a congenital heart defect.

• TGA occurs when the two main arteries going out

of the heart—the pulmonary artery and the

aorta—are switched in position, or “transposed”.

• It accounting 5 to 10% of all CHDs.

• It occurs predominantly in males. 97R Dh@ker, Lecturer, PCNMS

•video

Causes• The cause of TGA is unknown at this time.

• Scientific researchers have found that some diseases and behaviors might be associated with a higher risk for TGA. These include:-

– The mother having a viral illness during pregnancy

– The mother having poor nutrition during pregnancy

– The mother using an excessive amount of alcohol during pregnancy

– The mother being older than 40 years of age

– The mother having diabetes during pregnancy

– The baby having Down syndrome99R Dh@ker, Lecturer, PCNMS

Clinical Manifestation • Neonate with TGA is presented-

– Severe cyanosis

– Dyspnea

– Metabolic acidosis

– Severe hypoxia

– CCF

• The condition may complicated with-

– Multiorgan ischemia

– Cardiomegaly

– Growth failure

– Clubbing may develop in few months.

Diagnosis evaluation

• History of illness

• Physical examination- Auscultation of heart sound

• Chest X-ray

• ECG

• ECHO

• angiocardiography 101R Dh@ker, Lecturer, PCNMS

Management • Medical management of the condition is done with-

– IV prostaglandin E1

–Digoxin

–Diuretics

– Iron therapy

– Severe hypoxia can be treated with balloon atrial

septostomy.

Cont…

• Surgical management is planned depending upon

the associative defect.

• Atrial swith operaton

• Restelli’s operation

• Beffe’s operation

Rastelli operation:

Arterial switch procedure:

Complications:

• Congestive heart failure

• Arrhythmia

• Eisenmenger syndrome (irreversible and

progressive pulmonary vascular obstructive

disease)

Prognosis:• The overall survival rate following arterial switch

operation is 90%.

• The overall mortality rate following an atrial level

switch is low; however, long-term morbidity

associated with systemic (right) ventricular dilatation

and failure, systemic atrioventricular (tricuspid) valve

regurgitation, and atrial bradyarrhythmias and

tachyarrhythmias is significant.

•Video

Congestive

Cardiac

Failure

• Congestive cardiac failure (CCF) is a common

pediatric emergency.

• It is also termed as congestive heart failure.

• It indicates inadequate cardiac output.

• Heart failure (HF) results from structural or

functional cardiac disorders that impair the ability

of the ventricle(s) to fill with and/or eject blood.

• Heart Failure (HF) is the clinical condition in

which the heart fails to meet the metabolic and

circulatory demands of the body.

• It presents as the final common pathway of a

combination of structural, functional and biologic

mechanisms.

• Pulmonary and/or systemic congestion may

develop as a consequence of heart failure,

resulting in Congestive Heart Failure (CHF)

Definition

• CCF can be defined as “inability of the heart to

maintain an output at rest or during stress,

necessary for the metabolic needs of the body and

inability to receive blood into the ventricular

cavities at low pressure during diastole”.

Causes • Various forms of congenital heart disease such as

ventricular septal defect (VSD), patent ductus arteriosus (PDA) or common AV canal

• Heart valve disease caused by Rheumatic fever or other infections

• Infections of the heart valves and/or heart muscle (endocarditis)

• Cardiac arrhythmias (irregular heartbeats)

• Cardiomyopathy or another primary disease of the heart muscle

• Coronary artery disease

• Inflammation of heart muscle (myocarditis)

Clinical Manifestation• Decrease cardiac output leads to inadequate supply of

oxygen and nutrition to the tissue.

• Failure to gain weight in infancy.

• Shortness of breath or labored breathing

• Fatigue

• Needing to take frequent rest breaks while playing with friends

• Falling asleep when feeding or becoming too tired to eat during infancy

• Cough and congestion in the lungs

• Sweating 115R Dh@ker, Lecturer, PCNMS

• Weak peripheral pulse

• Cool extremities

• Pallor

• Pulmonary congestion is manifested-

– Tachycardia

– Cyanosis

– Chest retraction

– Nasal flaring

– Grunting

– Cough

– Pulmonary edema

Diagnosis evaluation • Detail history of illness

• Physical Examination-

– Palpation of weak peripheral pulse with cold extremities

– Auscultation of heart sound. Rhythm

– Auscultation of lungs

• Chest X-ray

• CBC

• ECG

• ECHO

• Cardiac catheterization (cath)117R Dh@ker, Lecturer, PCNMS

Management • Management of CCF is aimed at correction of

inadequate cardiac output.

• This can be achieved by reducing cardiac work,

improving cardiac performance by reducing heart

size and correction the cause of heart failure.

Cont…

• Sedative should be administered to managed

restlessness and to reduce anxiety.

• Diuretics – 0.5-1.5mg/kg.

• Digoxin

• Iron supplement

• Antibiotic

• Vasodilator

• ACE inhibitors

Cont…

• Diet should be planned with low salt for sodium restriction and to given in small amount frequently.

• Supportive nursing care should be emphasize-

– Skin care

– Other hygiene measures

– Prevention of infection

– Fluid electrolyte balance

– Diet

– Administration of medication

– Continuous monitoring of child’s condition

– Maintenance of intake output and other record.

Cont…

• Emotional support and health education with

necessary instruction should dietary and activity

restriction, drug intake, prevention of

complication, daily hygiene care and measures of

prevention of infection.

Prognosis • Prognosis in case of CCF depends upon the cause

and available of treatment.

• Early diagnosis and treatment promote better

prognosis.

• Long term suffering may lead to failure to thrive

and growth retardation.

Acute Rheumatic Fever

Introduction• Acute rheumatic fever is an autoimmune

collagen disease occurs as a hypersensitivity

reaction to group-A beta hemolytic

streptococcal infection.

• It is characterized by inflammatory lesion of

connective tissue and endothelial tissue.

• It affect-– Heart – Joint – Blood vessels – Other connective tissue. – Brian

• It is the most important acquired heart disease in

children and commonly found in 4 to 15 yr of age

with incidence rate 5.0/1000approximately.

• Rheumatic fever (RF), also known as acute

rheumatic fever (ARF)

Etiology • Predisposing factors of ARF are-

– genetic predisposition,

– temperate climate,

– winter season,

– unhygienic living condition,

– overcrowding in the family,

– poor dietary intake and

– increasing immunological response.

IN INDIA

• RHD is prevalent in range of 5-7/1000 in 5-15 age groups.

• About 1 million cases of RHD

• RHD constitutes 20-30% hospital admissions due to CVD.

• Streptococcal infections common in children living in under –privileged conditions and RF accounts for 1-

3% of the cases.

• Important cause of chronic disease and death in

developing world

• Underdiagnosed and undertreated

• Ages 5-15 yrs are most susceptible

• Rare <3 yrs

• Common in 3rd world countries

• Environmental factors-- over crowding, poor

sanitation, poverty, poor housing

• Incidence more during fall ,winter & early spring

AGENT FAC.

HOST FAC.ENVIRONMENTAL

Cont…Etiology

• The etiology of

rheumatic fever is

not clear, but there

is strong associative

with beta hemolytic

streptococcal

–Sore throat

Clinical manifestation

• The clinical feature of acute

rheumatic fever can be

grouped as major, minor and

essential manifestations.

• STREPTOCOCCUS SORE

THROAT

A culture positive case of streptococcal pharyngitis with

typical tonsillar in a 16-year-old.

Cont…

• Major Manifestation-

–Carditis

– Polyarthritis

–Chorea

• it is purposeless involuntary, rapid movement.

Usually associated with muscle weakness,

speech disturbance

– Subcutaneous nodules-

• It is found as firm painless nodule over the

extensor surface of certain joints( elbows, knees

and wrists).

Erythema

marginatum

Subcutaneous

nodules

Closer view of erythema marginatumErythema marginatum on the trunk, showing erythematous lesions with pale centers and rounded or serpiginous margins

Cont…

• Minor manifestation-

– Fever

– ECG changes with prolonged P-R interval

– Elevate ESR

• Essential Criteria

– Elevated ASO titer – indicate streptococcal

infection(normal 200 IU/ml)

– Positive throat swab culture- streptococcal infection

• Other manifestation-

– Pericardial pain

– Abdominal pain

– Headache

– General weakness

– Tachycardia

– Sweating

– Vomiting

– skin rash

– Anemia

– Pleuritis

– Weight loss

Cont…

Diagnosis evaluation • Doppler ECHO

• Endomycocardial biopsy

• Chest X-ray

• ECG

• Blood test

– ESR

– ASO- titer

– WBC count

Management • Bed rest

• Nutritious diet

– Provide of protein, vitamins,

– Salt restriction is not necessary unless CCF is present.

– Avoid rich spicy food

Cont… Management

• Antibiotic therapy- penicillin is administered after skin test

to eradicate streptococcal infection.

• Penicillin 4 lacks unite deep IM, twice a day is given for 10

to 14 days.

• Benzathine penicillin 1.2 mega units every 21 days or 0.6

mega units every 15 days to given.

• Oral penicillin 4 lacks units (250mg), every 4 to 6 hours for

10 to 14 days.

• Erythomycin can be used in penicillin sensitive patients.

• Aspirin is administered as suppressive therapy to

control pain and inflammation of joint

• Dose of Aspirin 90 to 120 mg/kg/day in 4 divided.

• It may be needed for 12 weeks

• Steroid( prednisolone) therapy is given as

suppressive therapy along with aspirin.

• the initial dose is 40 to 60 mg/day or 2 mg/kg/day in

divided 4 dose, 7 to 10 days.

Cont… Management

• Management of chorea can be done with diazepam

or phenobarbitone.

• Treatment of complication if present, symptomatic

care to be provided accordingly.

Cont… Management

heart disease in children...b.sc. nursing & gnm syllabus

Healthcare

contents - arunachal pradesh · upgradation of gnm school...

staff nurse under national urban health mission · of gnm /...

sainath school of nursing, gnm syllabus

post basic b.sc. nursing - geetanjali...

b.k.l. walawalkar hospital, - swamisamarth.com · nursing...

driems · for anm/lhv there is no age bar both boys and...

b.sc nursing

b.sc. nursing college in delhi

597.pdf · 2018-05-08 · mental health institute, s c b...

critical analysis for b.sc nursing

combined entrance examination – 2018 ( paramedical ... ·...

nursing education in india: anm, gnm, b.sc and pbb.sc

gnm (3 1/2 years course) admission batch,2009-10. college of...

admission open home tutors available home...

provisional allotment list b.sc nursing, mp state nursing

ap gnm nursing application form 2013

no. hpu(b.sc. nursing-admission)et/2019 himachal pradesh ......

3rd round seat allotment of gnm nursing course :...

ds-,e-lh- dkwfyt vkwq ufl±x - kmc-up's best private...

camscanner 08-01-2020...