A two-year-old patient is admitted into the ward with a diagnosis of Tetralogy of Fallot.
- Draw and label the position of heart defects in tetralogy of Fallot and direction of blood flow.
- List six clinical manifestations the patient presents.
- State five actual nursing diagnoses for this patient.
Tetralogy of Fallot consists of four associated defects:
- Ventricular septal defect; This involves the membranous septum and the anterior portion of the muscular septum , and right ventricular hypertrophy.
- Dextroposition of the aorta or overriding aorta; The aorta overrides the right ventricle and is in communication with the septal defect
- Narrowing of the pulmonary outﬂow channel; including pulmonic valve stenosis, a decrease in the size of the pulmonary trunk, or both
- Hypertrophy of the right ventricle; Due to the raised work required to pump blood through the obstructed pulmonary channels.
Signs and symptoms;
- Cyanosis due to right-to-left shunting at the ventricular septal defect. The degree of cyanosis is determined by the restriction of blood flow into the pulmonary bed. Right ventricular outﬂow obstruction causes deoxygenated blood from the right ventricle to shunt across the ventricular septal defect and be ejected into the systemic circulation.
- Hypercyanotic attacks (“tet spells”) which often occur the morning during crying, feeding, or defecating. These stressful activities often raise oxygen needs. Crying and defecating may additionally raise pulmonary vascular resistance.
- Acutely cyanotic, irritability & diaphoresis which often occur with the tet spells.
- Loss of conciousness; Later in the spell, the infant becomes limp and may lose consciousness.
- Harsh systolic ejection murmur on auscultation from turbulent ﬂow across the narrow right ventricular outﬂow track.
- Chest radiograph
- Electrocardiogram & echocardiogram. (echocardiogram PROVIDES the definitive diagnosis)
- Total surgical correction is required for all children with tetralogy of Fallot.
- Placing the infant in the knee-chest position increases systemic vascular resistance, which increases pulmonary blood ﬂow and decreases right-to-left shunting. During a hypercyanotic spell, toddlers and older children may spontaneously assume the squatting position, which functions like the knee-chest position to relieve the spell.
- Ineffective infant feeding pattern
- Imbalanced nutrition: less than body requirements
- Activity intolerance
- Ineffective peripheral tissue perfusion
- Acute Pain
- Decreased cardiac output
There are Three simple steps to writing a nursing care plan for you to use the nursing process in managing this client
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