Decreased Cardiac Output related to Tetralogy of Fallot

Tetralogy of Fallot (TOF) in Children

Tetralogy of Fallot / TOF is a cardiac anomaly that refers to a combination of four related heart defects that commonly occur together. The four defects are:

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

Children with tetralogy of Fallot:

might experience dizziness, fainting, or seizures
are at a higher risk of developing an infection of the inner layer of the heart called endocarditis
can have an irregular heartbeat, called an arrhythmia, which with TOF is caused by elevated pressure in the right side of the heart

The symptoms of tetralogy of Fallot include:
  • Blue or purple tint to lips, skin and nails (cyanosis)
  • Heart murmur - the heart sounds abnormal when a doctor listens with a stethoscope
  • In older children, abnormal shape of the fingertips ("clubbing")
  • Spells during which oxygen levels drop - lips and skin will become bluer, and the child will become fussy or irritable and then sleepy or unresponsive

Nursing Interventions for Tetralogy of Fallot

Nursing Diagnosis : Decreased Cardiac Output r / t ineffective circulation, secondary to the presence of cardiac malformations

Goal: Children can maintain adequate cardiac output

  • Vital signs are normal with age.
  • There is no dyspnea, rapid breathing and deep, cyanosis, anxiety / lethargy, tachycardia, murmurs.
  • Clients composmetis.
  • Akral warm.
  • Peripheral pulse strong and equal on both extremities.
  • Capillary refill time less than 3 seconds.
  • Urine output of 1-2 ml / kg / hour.

  1. Monitor vital signs, peripheral pulses, capillary refill by comparing measurements at both extremities while standing, sitting and lying down if possible.
  2. Assess and record the apical pulse for 1 full minute.
  3. Observation of cyanotic attacks.
  4. Give a knee-chest position in children.
  5. Observe for signs of decreased sensory: lethargy, confusion, and disorientation.
  6. Monitor intake and output adequately.
  7. Provide adequate rest time for children and accompany children during activity.
  8. Serve foods that are easily digestible and reduce the consumption of caffeine.
  9. Collaboration in the examination serial ECGs, chest radiographs, administration of anti dysrhythmias.
  10. Collaboration of oxygen.
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4 Nursing Diagnosis related to Alzheimer's Disease

Alzheimer's disease is named after Dr. Alois Alzheimer, a German doctor. In 1906, Dr. Alzheimer noticed changes in the brain tissue of a woman who had died of an unusual mental illness.

Alzheimer's disease is one of the most serious and progressive forms of mental deterioration known as dementia. Alzheimer’s disease (AD) affects almost 50% of those over the age of 85.

Dementia is a loss of thinking, remembering, and reasoning skills that interferes with a person’s daily life and activities. All people who develop Alzheimer's disease become unable to care for themselves once the condition reaches its final stages

Scientists do not yet fully understand what causes Alzheimer's disease. It is likely that the causes include some mix of genetic, environmental, and lifestyle factors. These factors affect each person differently. Research indicates that the disease is associated with plaques and tangles in the brain.

Memory problems are typically one of the first signs of Alzheimer's disease. Sometimes, other thinking problems, such as trouble finding the right words or poor judgment, are most prominent early on.

4 Nursing Diagnosis related to Alzheimer's Disease

1. Risk for Injury related to :
  • The inability to recognize / identify hazards in the environment
  • Disorientation, confusion, impaired decision making
  • Weakness, the muscles are not coordinated, the presence of seizure activity.
2. Disturbed Thought Processes - Scribd related to :
  • Irreversible neuronal degeneration
  • Memory Loss
  • Psychological Conflict
  • Sleep deprivation
3. Disturbed Sleep pattern related to :
  • Changes in sensory
  • Psychological pressure
  • Changes in activity patterns
4. Disturbed Sensory Perception related to :
  • Changes in perception, transmission and / or sensory integration
  • Limitations related to the social environment.
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Nursing Diagnosis for Acute Respiratory Distress Syndrome (ARDS)

Acute respiratory distress syndrome (ARDS) is a life-threatening lung condition that prevents enough oxygen from getting to the lungs and into the blood. Clinically, it is characterized by dyspnea, profound hypoxemia, decreased lung compliance, and diffuse bilateral infiltrates on chest radiography. Provision of supplemental oxygen, lung rest, and supportive care are the fundamentals of therapy.

ARDS usually develops in people who are already very ill with another disease or who have major injuries.

Common causes include:
  • Breathing vomit into the lungs (aspiration)
  • Inhaling chemicals
  • Lung transplant
  • Pneumonia
  • Septic shock (infection throughout the body)
  • Trauma

Risk factors
  • Smoke inhalation
  • Burns
  • Near drowning
  • Diabetic ketoacidosis
  • Pregnancy
  • Eclampsia
  • Amniotic fluid embolus
  • Drugs - paraquat, heroin, aspirin
  • Acute pancreatitis
  • Disseminated intravascular coagulation (DIC)
  • Head injury/raised intracranial pressure (ICP)
  • Fat emboli
  • Transfusions of blood products
  • Heart/lung bypass
  • Tumour lysis syndrome
  • Pulmonary contusion

  • Difficulty breathing
  • Low blood pressure and organ failure
  • Rapid breathing
  • Shortness of breath
Symptoms usually develop within 24 to 48 hours of the injury or illness. Often, people with ARDS are so sick they cannot complain of symptoms.

Nursing Diagnosis for Acute Respiratory Distress Syndrome (ARDS)
  1. Ineffective breathing pattern
  2. Impaired Gas Exchange
  3. Ineffective airway clearance
  4. Decreased Cardiac Output
  5. Risk for Injury
  6. Excess Fluid Volume
  7. Impaired Verbal Communication
  8. Impaired Physical Mobility
  9. Impaired Skin Integrity
  10. Sleep Pattern Disturbance
  11. Ineffective Coping
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Nursing Assessment of Pleural Effusion : Physical Examination

Provision of nursing care is a therapeutic process that involves cooperation relationships with clients, families or communities to achieve optimal health level (Canpernito, 2000.2).

Nurses need a scientific method in the therapeutic process is the nursing process. The nursing process is used to assist nurses in nursing practice systematically in troubleshooting existing nursing, where the four components influence each other, namely: assessment, planning, implementation and evaluation. (Budianna Keliat, 1994.2).

Pleural Effusion Physical Examination

1. General health status

The level of consciousness of patients needs to be studied, how the general appearance of the patient, the patient's facial expression during conducted diagnose, attitudes and behavior of patients towards the officer, how the mood of patients to determine the patient's level of anxiety and tension. There should also be height weight measurements of patients.

2. Respiratory System

Inspection in patients with pleural effusion; diseased hemithorax convex shape, horizontal ribs, widened space between the ribs, decreased respiratory movement. Encouragement of the mediastinum towards the contra lateral hemithorax known from the position of the trachea and ictus cordis. Respiration tends to increase and the patient is usually dyspnea.

Vocal fremitus decreased mainly for pleural effusion fluid amount is more than 250 cc. Besides, it is also found on palpation of the chest wall movement on the left chest pain.

Sensitive to percussion sound dim depending on the amount of fluid. If the liquid does not fill the pleural cavity, there will be an upper limit to the liquid in the form of a curved line above the lateral end to medical patients in a sitting position. This line is called Ellis-Damoiseau-line. The most obvious line at the front of the chest, in the back is less clear.

Auscultation of breath sounds decreased until it disappears. In a sitting position to a more fluid upper thinner, and behind it there is compression atelectasis of the lung parenchyma, may be found auscultation signs of compression atelectasis around the upper limit of the liquid. Coupled with a sign i - e does it mean when people are asked to say the words i will e nasal voice, called egophony (Alsagaf H, Ida Bagus, Widjaya Adjis, Abdol Mukty, 1994.79)

3. Cardiovascular system

On inspection to note the location of ictus cordis, normally located on ICS - 5 at the left midclavicular linea with a width of 1 cm. This examination aims to determine whether there is cardiac enlargement. Palpation to calculate heart rate and be aware of the depth and the absence of a regular heart rate, should also check for vibrations that thrill ictus cordis. Percussion to determine the limits of the heart where the heart area sounded dull. It aims to determine is there any heart or left ventricular enlargement. Auscultation to determine the first and second heart sound gallop and is there a single or a third heart sound that is a symptom of heart trouble and is there a murmur which showed an increase in blood flow turbulence.

4. Digestive System

On inspection note, if abdominal bulge or flat, protruding belly edge or not, prominent umbilicus or not, but it is also necessary in inspection presence or absence of nodules or masses.

Auscultation to listen to sound normal intestinal peristalsis where the value 5-35 times per minute. On palpation should also be noted, is there any abdominal tenderness, is there a mass (tumor, stool), abdominal skin turgor to determine the degree of hydration of the patient, whether palpable liver, the spleen is also palpable. Tympanik normal abdominal percussion, a mass of solid or liquid will cause a dull sound (liver, ascites, urinarta bladder, tumors).

5. Neurological System

On inspection of the level of awareness needs to be studied as well, GCS examination is required. Is there composmentis or somnolence or comma. Pathological reflexes, and how the physiological reflex. Additionally sensory functions also need to be assessed as hearing, sight, smell, touch and taste.

6. Musculoskeletal System

On inspection to note is there pretibial edema, palpation at both extremities to determine the level of peripheral perfusion as well as the examination capillary refil time. By inspection and palpation examination of muscle strength were compared between the left and right.

7. Integumentary System

Inspection of the general condition of skin hygiene, the presence or absence of color in the skin lesions, in patients with pleural effusion, usually will appear cyanosis due to failure of the O2 transport system. On palpation need to be checked on the warmth of the skin (cold, warm, fever). Then the skin texture (smooth-soft-rough) as well as skin turgor to determine the degree of hydration of a person.
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