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