Redalyc.Neonatal Nursing Care of the Infant with Congenital Heart Disease

Online Brazilian Journal of Nursing E-ISSN: 1676-4285 [email protected] Universidade Federal Fluminense Brasil

da Silveira Magalhães, Simone; Veraci Oliveira Queiroz, Maria; Camelo Chaves, Edna Maria Neonatal nursing care of the infant with congenital heart disease: an integrative review Online Brazilian Journal of Nursing, vol. 15, núm. 4, 2016, pp. 724-734 Universidade Federal Fluminense Rio de Janeiro, Brasil

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Neonatal nursing care of the infant with congenital heart disease: an integrative review

Simone da Silveira Magalhães1,2, Maria Veraci Oliveira Queiroz1, Edna Maria Camelo Chaves1

1 State University of Ceará 2 Walter Cantídio University Hospital

ABSTRACT Aim: To search for available evidence in the literature about nursing care for newborns with congenital heart disease in neonatal units. Method: An integrative review of the literature performed between July and August 2015, based on research in LILACS, PubMed and CINAHL databases. Result: Nine articles were identified according to established criteria. The information was analyzed and synthesized in three thematic categories: Detecting congenital heart disease; Providing care for the neonate in the intensive care unit; Family and the care measures to the newborn. Discussion: Neonatal screening for critical heart defects by pulse oximetry and nursing care at bedside surgeries were the main health care measures of nurses for infants with neonatal heart disease. Conclusion: There is a need for more professional involvement in the provision of care for these children in order to provide evidence-based clinical practice, and there are gaps in nurses’ knowledge production that demonstrate this reality.

Descriptors: Heart Defects, Congenital; Nursing Care; Neonatal Nursing; Infant, Newborn.

Magalhães SS, Queiroz MVO, Chaves EMC. Neonatal nursing care of the infant with congenital heart disease: an integrative 724 review. Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):724-734. Available from: http://www.objnursing. uff.br/index.php/nursing/article/view/5415 INTRODUCTION tion during clinical practice with children with congenital heart diseases, using an innovative Cardiac malformations are the most fre- methodology supported by scientific evidence. quent occurrence of all congenital malforma- Integrative review is one of the methods used tions. The prevalence of congenital cardiopa- in EBP that allows the incorporation of evidence thies in Brazil in 2009 was 675,495 children and into clinical practice. This study aimed to find the adolescents, in addition to 552,092 adults. In evidence available in the literature on nursing every 1000 infants, approximately one to two care for newborns with congenital heart disease, present a potentially fatal cardiac issue, usually in the neonatal unit, with a focus on providing because both systemic and pulmonary blood resources for clinical practice and directions for flow depend on a patent ductus arteriosus(1,2). further research. Congenital heart conditions account for 24% of infant deaths and approximately 4,800 children are born each year with one of the seven METHOD critical congenital heart diseases(3). However, infants with critical heart disease may remain An integrative review is a research method asymptomatic for the first few days of life and capable of synthesizing the results of previous be discharged from hospital, and their health research on a given phenomenon through a can deteriorate rapidly at home. Therefore, early systematic and summarized analysis of the lite- diagnosis in a timely manner is fundamental to rature. It enables the identification of knowled- improve prognosis and reduce morbidity and ge gaps in relation to the phenomenon under mortality rates in these cases(4,5). study and the need for future studies in the Considering that congenital heart diseases area(8). According to the method, the research are anomalies that determine the life and deve- followed these steps: Elaboration of the resear- lopment of the children, and also that nursing ch guiding question; Research in the literature is included in all stages of the process of health of primary studies based on the inclusion and care for babies with heart disease, even in non- exclusion criteria; Sorting of the pre-selected -specialized units such as the neonatal unit, there studies (extraction of data from primary studies); is a need to improve the clinical practice of these Critical analysis of the primary studies selected; professionals so that they can provide safe and Analysis and synthesis of the evaluated results; evidence-based care measures. Integration review(9). Studies show that evidence-based practice Considering the high prevalence of conge- (EBP) raises quality levels in the provision of care, nital cardiopathies in neonatal units, especially improves patient outcomes, reduces costs, and among preterm infants, and the fact that the brings greater satisfaction to nurses, although it is provision of care to these newborns presents not as yet a practice implemented in many health a challenge for nurses, the following question systems around the world(6). EBP is a movement was elaborated: “What evidence is available in that seeks to link theory to practice with the goal the literature about the nursing care provided of gathering, applying and evaluating the best to newborns with congenital heart defects in research results for safe clinical practice(7). neonatal units?” In order to carry out the rese- In order to fill nursing training gaps, it is arch in the articles published between July and expected that there will be continuing educa- August 2015, we used the following databases,

Magalhães SS, Queiroz MVO, Chaves EMC. Neonatal nursing care of the infant with congenital heart disease: an integrative review. Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):724-734. Available from: http://www.objnursing. 725 uff.br/index.php/nursing/article/view/5415 accessed through the Portal of Journals of the articles with no participation of nurses in the Coordination of Improvement of Higher Edu- research, and those published before February cation Personnel (CAPES): Latin American and 2004. Duplicated studies were also excluded in Caribbean Literature of Health Sciences (LILACS), the selection of articles. To make the selection, which comprises publications in the area of heal- we read the articles’ titles and abstracts, as well th in Latin America and the Caribbean; National as some complete texts, in order to determine Library of Medicine of the National Institutes of whether they covered the research question Health (PubMed), a digital archive produced by and met the inclusion or exclusion criteria. The the National Library of Medicine (USA) in the search resulted in 470 eligible studies. After the Biosciences field; Cumulative Index to Nursing first reading and application of the inclusion and Allied Health Literature (CINAHL), which and exclusion criteria, 25 studies were selected. contains the main scientific publications in the After the second reading, however, only nine nursing area. Keywords and descriptors were were selected as the final sample of the review. used according to the Health Sciences Descrip- Of the total search, 57 studies were not related tors (DeCS) and the Medical Subject Headings to the theme, three were editorials, nine were (MESH), used in different combinations with repeated in the databases, 341 had no complete the following Portuguese and English Boolean texts available, in three there was no participa- operators: recém-nascido, neonato, cardiopatias tion of nurses in the research, 31 were out of the congênitas, unidades de terapia intensiva neo- timeframe, five were letters to the editor, seven natal, unidade neonatal, neonatologia, cuidados were review studies, four were case studies, and de enfermagem, infant, newborn, neonate, one was published in Spanish. The first three congenital heart defects, heart abnormalities, steps of the review are summarized in Figure 1. malformation of heart, neonatal intensive care Data extraction and analysis were carried units, nursing care. out through an adapted instrument that ad- In the selection of the literature, we applied dressed the identification of the article and its the following inclusion criteria: articles with authors, year and country of publication, study complete texts available, published in Portu- institution, publication journal and methodologi- guese and English, addressing questions related cal characteristics of the study (type of research, to the topic or answering the research guiding its question or goal, sample, data treatment, question, and articles involving the participation interventions performed, results, analysis, impli- of nurses. It was important to include studies cations/conclusions, authors’ recommendations carried out after February 2004 due to the publi- and evidence level), and also method precision cation of Ministerial Order No. 198 of the Ministry evaluation. The information was analyzed and of Health, which established the National Policy synthesized in thematic categories through the of Permanent Education in Health as a strategy of approximation of similar themes addressed in the the Unified Public Health System for the training studies. The results were presented in tables with and development of workers for the Sector(10). titles, authors, journals and year of publications, The exclusion criteria were as follows: una- sources (databases), goals, sample and method- vailability of full texts, letter-response studies, ological details, results, conclusions, types of clini- editorials, review-method studies, narrative re- cal questions of the studies and their respective views, traditional literature reviews, case studies, levels of evidence, according to the classification primary studies that did not address the topic, proposed by Melnyk and Fineout-Overholt(6).

Magalhães SS, Queiroz MVO, Chaves EMC. Neonatal nursing care of the infant with congenital heart disease: an integrative 726 review. Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):724-734. Available from: http://www.objnursing. uff.br/index.php/nursing/article/view/5415 Figure 1 - Summary of the first three stages of the integrative review about care for infants with congenital heart defects in neonatal units. Fortaleza, 2015. Source: author’s research

“What evidence is available in the literature about nursing Guiding care provided to newborns with congenital heart defects in question neonatal units?”

Study research Systematic search - 470 studies and selection

LILACS - 50 PubMed - 250 CINAHL - 170 studies studies studies

Reading of Titles and abstracts, inclusion and exclusion criteria

Study data 25 studies extra ction 461 excluded: 57 - Not related to theme 3 - Editorials Full text reading 9 - Duplicated 341 - Full text not available 3 - No participation of nurses 31 - Before February 2004 5 - Letters to editor 7 - Review studies 4 - Case studies 1 - Published in Spanish

Nine studies

( nal sample)

RESULTS subjects of the studies, three spoke about intervention/treatment or diagnosis/diagnostic tests, Of the nine studies selected, we found one having different evidence levels (III, IV and VII). dissertation which, despite being considered Two addressed issues of meaning, both with gray literature, was relevant to the topic and not level IV of evidence. The remaining studies (four) determined as subject to the exclusion criterion. dealt with questions about prognosis/prediction As for the language of the publications, four were or etiology, all of which were classified as level in the English language and the remainder in IV evidence. Three studies specifically discussed Portuguese. Only one article was selected from congenital heart disease. The others presented the CINAHL database and two from PubMed. The care measures pertinent to neonates and their others were selected from LILACS. In addition to relatives, which also apply to babies with heart the dissertation, the studies in the final sample diseases, so they were considered in this review. were published in seven different journals, two Thus, the studies were arranged in three catego- of which were aimed at the medical public. The ries, as follows: A) Recognizing congenital heart years with the greatest number of publications disease, with two studies; B) Providing care to were 2012 and 2014. With regard to the clinical the neonate in the intensive care unit, with four

Figure 2 - Main characteristics of selected studies as final sample of the integrative review. Fortale- za, 2015. Source: author’s research

Methodologi- Category Aim Results cal Mapping -Definition of the sample and screening goals, technology To develop strategies (pulse oximetry) and criteria (algorithm); Diagnostic strategies for the implementa- (echocardiogram, chest x-ray) Qualitative-des- A(11) tion of safe, effective -Connection with home care / primary care criptive study and efficient scree- -The role of public health and the providers of family care and ning. education in the process -Coordination of the implementation of activities -The average age of the children was eight months, with 8.5% of the total being neonates To describe the clinical -53.7% of the children were admitted to surgery and 58.5% had characteristics of ter- Observational cyanogenic heart disease, mainly tetralogy of Fallot. ms found in nursing cross-sectional - The most frequent disease among children was ventricular A(12) records in the charts study (according septal defect of children with con- to the authors) -19.5% of the cases were associated with Down syndrome genital heart disease -The terms found in the medical records were: cyanotic, respi- ratory effort, tachypnea, pale, tachycardia and fatigue when suckling

Magalhães SS, Queiroz MVO, Chaves EMC. Neonatal nursing care of the infant with congenital heart disease: an integrative 728 review. Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):724-734. Available from: http://www.objnursing. uff.br/index.php/nursing/article/view/5415 To describe the interaction between nurse and neonate -Increased heart rate and decreased oxygen saturation during the practice -I-This Relationships characterized by the technical touch of the of providing care in Exploratory-des- nurses processes of orotra- criptive research, B(13) -I-You Relationships were not continuous attitudes cheal aspiration and qualitative ap- -Relations may suffer influences from the environment, emotio- collection of blood for proach (authors) nal and psychological state of the subjects of the relationship exams, with emphasis -The caring touch could not be achieved on the physiological and behavioral responses -All the nurses demonstrated knowledge about the skin characteristics of preterm infants, as well as sensitivity and professional To know the nursing experience care measures pro- Exploratory-des- - Care measures in the prevention of injury: use of hydrocolloids vided in the preven- criptive study, in bony prominences, daily hygiene, use of transparent film as B(14) tion of skin lesion in with qualitative protection, barrier to fix electrodes, removal of adhesives with neonates approach the use of mineral oil, skin evaluation, change of decubitus and small use of adhesives -Factors for prevention: monitoring, hygiene, change of decubitus and adequate perfusion To prove the effecti- -Weight at birth, gestational age and weight at the time of sur- veness of surgical in- gery were significantly different between the groups (p <0.05) Quasi-experi- tervention at bedside -Maternal status, postoperative day of surgery, discharge day ment with two B(15) in the ICU, preferable and number of pregnancies were not significantly different groups (> 1000g for premature babies -There were no surgery or hospital mortality and <1000g) with persistent ductus -The time for surgical indication is controversial, but the proce- arteriosus dure is effective - The mean prevalence of malformations was 3.0% To evaluate the preva- -The most relevant malformations were hydrocephalus, myelo- lence of neonates with Descriptive, meningocele, anencephaly, congenital crooked foot, polydac- congenital malforma- cross-sectional tyly, and upper and lower limb deformity tions in public institu- B(16) and quantitative - Congenital heart disease accounted for 10% of the sample tions and the nursing study (author) in - Therapy in the first 24 hours: oxygen therapy and maintenance care practice during three institutions of the airways, nutrition, drug therapy, installation of venous ac- the first 24 hours of cess, water balance, assistance in surgical procedures, dressings, infants’ life hygiene and comfort and orientation to parents - Central category of the study was “experiencing the hospitalization of the neonate in NICU” To know the experien- -Other categories: definition of the NICU; Reasons for hospi- ce of the relatives of talization; Information received; Reaction of family members; children hospitalized Exploratory-des- Meaning of having a child hospitalized in the NICU; Feelings in a neonatal intensive criptive study, generated; Assessment of care measures; Participation of family C(17) care unit (NICU) to qualitative rese- members in care practice; Involvement in care practice; Evalua- obtain subsidies to arch (authors) tion of the assistance received improve patient and -Family members show fear, but get engaged with the care family care practices practice and evaluate it positively -Family mostly remembers the doctor and social worker as the caregivers

was instituted as part of the Brazilian neonatal brings scientific evidence to support the care screening program. practice. The review selected a study that outlined The review also selected a study with charts strategies used to establish pulse oximetry as a of children, in which the nurses registered the screening program for critical congenital heart clinical characteristics of the babies with conge- diseases(11). Screening for pulse oximetry is an nital heart diseases. These are all important signs effective process that can increase the early for the recognition of the problem and a correct detection of the seven major cardiac defects evaluation and planning of the assistance pro- and is a painless and non-invasive technique vided. However, the characteristics related to to measure pre and post ductal oxygen satu- the emotional, social and/or spiritual aspects of ration in newborns. This screening may help to the family were not recorded and these charac- identify hypoxia not detected by the human teristics are also important in order to plan ap- eye, being a simple and economical tool that propriate care measures(12). This study presented complements the clinical evaluation(20). Curren- nursing records that demonstrated the signs and tly, nurses are directly involved in this type of symptoms of congenital heart disease, but were screening, and can develop it in health services. not specific for neonatal nursing, the focus of Hence, the importance of being aware of stu- the study. However, the research recommended dies that approach this activity as an important family-centered care, in addition to aspects that field of action of neonatal nursing. They need, transcend the biological, which is so important therefore, to have an understanding of the de- in the context of child health care. velopment of the activity and skills involved in The hospitalization of a child with con- its execution, as described in the study, which genital heart disease, especially for surgery,

Magalhães SS, Queiroz MVO, Chaves EMC. Neonatal nursing care of the infant with congenital heart disease: an integrative 730 review. Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):724-734. Available from: http://www.objnursing. uff.br/index.php/nursing/article/view/5415 represents a crisis for the family system, with a the newborn, including those with congenital mixture of feelings (fear of death, surgery, anes- heart diseases, emphasizing the qualification thesia, guilt, impotence) throughout the disease and sensitivity of the health care professionals, process, but it also represents a perspective acquired through experiences and continuing of healing and improvement in the quality of education in service(14). Prematurity often occurs life(21). Three of the four studies grouped in the with congenital heart disease. Premature ba- neonatal care category in the neonatal unit did bies have even more fragile skin than full-term not specifically address the provision of care to babies, which can be the gateway to infections. newborns with congenital heart disease, but For babies with heart disease infection is alre- were also included as evidence about the pro- ady a major risk, which is exacerbated in the vision of care for these children. The first study, case of preterm births and low birth weight. synthesized here, demonstrated the need to Thus, taking care of patients’ skin with the best work with the understanding of the “newborn possible evidence is an important measure for being”, which was based on the Humanistic this population. Theory, to evaluate the relationship of care The study that reported on the arterial ca- practices in neonatal intensive care, specifically nal ligation at the bedside, despite the publica- invasive procedures. It was concluded that it is tion in a medical journal, denoted the important possible to establish a true encounter, although presence of the nurse in the composition of the the researchers did not observe this relationship team that performs the procedure. Research has at the time of the care practice during monito- proven that the technique minimizes the risks ring in the field of research(13). This situation also to which babies may be exposed in the case highlights the need to expand nursing clinical of a surgical intervention outside the neonatal competence, which involves the ability and unit - transportation, hypothermia, handling, attitude to treat a specific population, such as among others(15). Early prophylactic surgery is newborns with congenital heart defects. This considered to reduce the fatal complications of involves a whole structure, including the family, prematurity, such as necrotizing enterocolitis in an intense way, and demands from the profes- and bronchopulmonary dysplasia(23). Thus, pro- sional an even closer approach to the patient, in viding assistance to babies submitted to arterial a humanized relationship. In this approach, it is canal ligation is also neonatal nursing care, even necessary to involve the family in the process of in a maternity ward, without specialized cardio- providing care to the child, which modifies the logy and/or surgery services. relationship of the professionals with the parents Like congenital heart disease, other malfor- and changes the quality of the service, changing mations are constant in the reality of neonatal the whole dynamics of work. The transformative units. The dissertation that was part of the sam- professional action begins by considering, a ple of this integrative review, which addressed priori, that the family is the owner of specific the care delivered to babies with congenital knowledge, and of a world view, constituted by malformations, also addressed babies with car- its praxis, in common sense, that must be valued, diac defects. The results of the study showed considered and respected(22). that most of the care measures for infants with The study that discussed the prevention congenital malformations during their first 24 of skin lesions on the baby emphasized the hours of life referred to exams and surgeries, importance of skin care for the integral care of which confirms the approach of the study cited

Magalhães SS, Queiroz MVO, Chaves EMC. Neonatal nursing care of the infant with congenital heart disease: an integrative review. Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):724-734. Available from: http://www.objnursing. 731 uff.br/index.php/nursing/article/view/5415 above. The author emphasized the need for Intervention Classification (NIC), classification scientific knowledge as an essential condition for a nursing diagnosis, of the North Ameri- for nurses to promote health care, as well as to can Nursing Diagnoses Association (NANDA stabilize their patients’ clinical condition, solve International), the study showed that nursing problems and improve the prognosis of these actions should seek to support mothers in the children in their future life(16). Essential nursing neonatal unit to establish a relationship of trust competencies should be determined based on and better development of the maternal role. It patient and family needs, reflecting a dynamic also demonstrated that the implementation of integration of knowledge, skills, experience and these actions does not require greater techno- attitudes to identify these needs and optimize logy, besides the professional and human ability the results(24). to provide care for women who make up the Nurses who work in neonatology need to mother-child binomial(18). be able to provide care to babies with conditions, Finally, the last study described the view- because extra-cardiac abnormalities, including point of the families with infants hospitalized those which are abdominal, are often associa- at the neonatal unit, about the nursing care ted with congenital heart diseases. Babies with performed. There was an understanding of the these abnormalities may present a higher risk of importance of such care measures and the re- morbidity and mortality(25). The dissertation on cognition of their humanization, but there was malformations also highlighted family-centered still a limitation to the comprehension of the care, an aspect that cannot be dissociated from breadth of the actions of these professionals by quality nursing care intended for infants with the families, basically restricting them to tech- malformations(16). As the search carried out nical, procedural measures(19). found studies that addressed this aspect of professional care, they were grouped in the category “The family and the provision of care to CONCLUSION the newborn”, demonstrating their importance. The first study analyzed in this category The search for evidence through the identi- reported the experience of families of children fication, gathering and synthesis of knowledge, hospitalized in a NICU. It did not specifically the objective of this study, showed that there is address infants hospitalized for congenital little evidence available in the literature dealing heart disease, but the feelings experienced can with the theme of nursing care measures to the be extended to families in this population. The baby with congenital heart disease, within the experience described was marked by feelings of scope of a neonatal unit. In many of the studies fear, uncertainty and tension that can affect the reviewed, the nurses dealt with postoperative family structure as a unit of care practices. Thus, care in specialized units, rather than in the ma- the study emphasized the need and importance ternity units where the babies often stayed until of involving the family in care and that the family, a specific intervention was performed. itself, should also be the object of nursing care(17). The review study demonstrated the need In the same context, another study addres- for greater involvement of nurses to improve sed the opinions of the mothers of the hos- the nursing care for children with congenital pitalized babies, about what they perceived heart defects. It also highlighted that there about nursing interventions. Using the Nursing are gaps in nurses’ knowledge production that

Magalhães SS, Queiroz MVO, Chaves EMC. Neonatal nursing care of the infant with congenital heart disease: an integrative 732 review. Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):724-734. Available from: http://www.objnursing. uff.br/index.php/nursing/article/view/5415 supported the need for improvement, in order [Cited 02 nov 2015]; 5(11). Disponível em: http:// to implement evidence-based clinical practice. www.gestaoesociedade.org/gestaoesociedade/ We consider that the path to the improvement article/viewFile/1220/906 10. Brasil. Ministério da Saúde. Portaria n. 198/GM, of care is always through science, with the de- de 13 de fevereiro de 2004. Institui a Política Na- velopment of studies that will strengthen this cional de Educação Permanente em Saúde como care, integrating theory and practice. estratégia do Sistema Único de Saúde para a formação e o desenvolvimento de trabalhadores para o setor e dá outras providências [Internet]. REFERENCES Diário Oficial da União 13 fev 2004 [cited 2015 jun 10]. Available from: http://bvsms.saude.gov.br/ 1. Mellander M. Diagnosis and management of bvs/saudelegis/gm/2014/prt0278_27_02_2014. life-threatening cardiac malformations in the html newborn. Seminars in Fetal & Neonatal Medicine. 11. Kemper AR, Mahle WT, Martin GR, Cooley WC, 2013; 18: 302-310. Kumar P, Morrow WR, Kelm K, Pearson GD, Gli- 2. Pinto Júnior VC, Castelo Branco KMP, Cavalcante dewell J, Grosse SD, Howell RR. Strategies for RC, Carvalho Júnior W, Lima JRC, Freitas SM, Fraga implementing screening for critical congenital MNO, Souza MNG. Epidemiologia das Cardiopa- heart disease. Pediatrics. 2011; 128(5). [incluída tias Congênitas no Brasil. Rer Bras Cir Cardiovasc. na revisão] São José do Rio Preto: 2015; 30(2): 219-224. 12. Silva VG, Guimarães TCF, Cavalcanti ACD, Pereira 3. Livolsi K, Bowman DS. Implementing a Screening JMV, Queluci GC, Santana RF. Terms of Nursing: Program for Congenital Cardiac Defects in New- human responses of children hospitalized with borns in a Community Hospital Setting. Journal heart disease – a cross-sectional study. Online of obstetric, gynecologic, and neonatal nursing. braz j nurs. [Internet]. 2014 [cited 2015 jul 21]; 2014; 43(S1). 13(2): 162-170. Available from: http://www. 4. Simpson E, Culp S. Do You Know Who’s at Risk? objnursing.uff.br/index.php/nursing/article/ Screening for Critical Congenital Heart Disease view/4315 [incluída na revisão] Using Pulse Oximetry. Journal of obstetric, gy- 13. Rolim KMC, Cardoso MVLML. A interação necologic, and neonatal nursing. 2013; 42(S1). enfermeira-recém-nascido durante a prática de 5. Loyot CA, Palmer CA. Fast Track Initiation of a aspiração orotraqueal e coleta de sangue. Rev Congenital Heart Disease Screening Program. Esc Enferm USP. 2006; 40(4): 515-523. [incluída Journal of obstetric, gynecologic, and neonatal na revisão] nursing. 2013; 42(S1). 14. Rolim KMC, Farias CPX, Marques LC, Magalhães FJ, 6. Melnyk BM, Fineout-Overholt E. Evidence-based Gurgel EPP, Caetano JA. A atuação da enfermeira practice in nursing & healthcare : a guide to best na prevenção de lesão de pele do recém-nascido. practice. 2nd ed. Philadelphia: Lippincott Willia- Rev enferm UERJ. Rio de Janeiro: 2009; 7(4): 544- ms & Wilkins; 2011. 549. [incluída na revisão] 7. Ercole FF, Melo LS, Alcoforado CLGC. Revisão 15. Metin K, Maltepe F, Kir M, Bilen Ç, Sökmen A, Oto integrativa versus revisão sistemática. [editorial] Ö, Ugurlu B. Ligation of patente ductus arteriosus Rev Min Enferm. 2014 jan-mar; 18(1): 12-14. in low birth weight premature infants: timing for 8. Crossetti, MGO. Revisão integrativa de pesquisa intervention and effectiveness of bed-side sur- na Enfermagem o rigor científico que lhe é exi- gery. J cardiothorac surg. 2012; 7(129). [incluída gido [editorial]. Rev Gaúcha Enferm. 2012 jun; na revisão] 33(2): 8-9. 16. Fontoura FC. Recém-nascidos com malformações 9. Botelho LLR, Cunha CCA, Macedo M. O método da congênitas: prevalência e cuidado de Enferma- revisão integrativa nos estudos organizacionais. gem na unidade neonatal. Dissertação (Mestrado Gestão e sociedade [Internet]. 2011 may-aug em Enfermagem) – Universidade Federal do Ceará; 2012. [incluída na revisão]

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Magalhães SS, Queiroz MVO, Chaves EMC. Neonatal nursing care of the infant with congenital heart disease: an integrative 734 review. Online braz j nurs [internet] 2016 Dec [cited year month day]; 15 (4):724-734. Available from: http://www.objnursing. uff.br/index.php/nursing/article/view/5415