NURSING CARE PLAN Tetralogy of Fallot

Cues Objective: -V/S: BP:80/50 mmHg PR: 124 bpm RR: 28 cpm Temp: 37.1 C -with O2 inhalation @ 2lpm via nasal cannula as ordered -circumoral cyanosis noted Need Activity and exercise pattern Nursing Diagnosis Impaired gas exchange related to altered oxygen supply as evidenced by dyspnea, tachypnea, tachycardia, and fatigue secondary to Congenital Heart Disease t/c Tetralogy of fallot. Congenital Heart Disease refers to a problem with the hearts structure and function due to abnormal heart development Before birth. It can disrupt the normal flow of blood to the different parts of the body thus affecting the exchange of gasses. Objective of care That within 8 hr span of care the patient will be able to demonstrate improving ventilation as evidenced by: a. Respiratory rate within normal limits b. Absence of cyanosis c. Clear breath sounds on both lung fields d. ABG test result within normal range Interventions and Rationale 1. Establish good trusting relationship with the patient and significant others To gain both trust and cooperation 2. Monitor respiratory rate/depth, use of accessory muscles, areas of cyanosis. Indicators of adequacy of respiratory function or degree of compromise and therapy needs/effectiveness. 3. Auscultate breath sounds, noting presence or absence and adventitious sounds. Development of atelectasis and stasis of secretion can impair gas exchange. 4. Monitor vital signs; note changes in cardiac rhythm. Compensatory. Compensatory changes in vital signs and development of dysrhythmias reflect effects of impaired gas exchange. 5. Help with breathing exercises. Pursed lip breathing. Helps improve oxygen inspiration of the lungs. 6. Elevate head of bed to moderate or high back rest. Helps the lung expand and aids in the relaxation of the muscles decreasing the oxygen demand of the body. Evaluation

Cues Objectives: -bluish discoloration on lips noted -clubbing of finger noted -nasal flaring -use of accessory muscle noted -with capillary refill time of 3 seconds -with O2 of 2 lpm via nasal cannula as ordered -body weakness noted(allways on bed)

Need Activity and exercise pattern

Nursing Diagnosis Ineffective tissue perfusion (cardiopulmonary) Related to decrease oxygen cellular exchange secondary to congenital heart disease t/c tetralogy of fallot

Objective of care That within 8hours span of care, the patient will be able to have adequate tissue perfusion as evidenced by: a) Absence or decrease bluish discoloration of lips; 1. Due to narrowing of b) Decrease respiratory the artery which rate within normal small amount of range; and oxygenated blood can c) Learn techniques to pass through the minimize or lessen systemic circulation the risk of decrease Which the patient tissue perfusion experience difficulty in breathing.

Interventions and Rationale 1. Monitored skin colour and temp. every 2hours. Assess for signs of skin breakdown. Cool, blanched, mottled skin and cyanosis may indicate tissue perfusion. 2. Monitored and documented patients vital signs every hour. Decrease heart rate and blood pressure may indicate increased arteriovenous exchange,which leads to decrease tissue perfusion. 3. Keep patient warm Warmth aids vasodilation, which improve tissue perfusion. 4. Elevate lower extremities. To increase arterial blood supply and improve tissue perfusion. 5. Change position regularly and inspect skin every shift. To avoid decrease in tissue perfusion and risk of skin breakdown.

Evaluation

ASSESSMENT

NURSING DIAGNOSES SCIENTIFIC ANALYSIS

PLANNING

NURSING INTERVENTION

RATIONALE

EVALUA-TION

Cyanosis dyspnea delay in growth and development blue anoxia attacks

Risk for Decreased cardiac output related to structural abnormalities of the heart.

Tetralogy fallot results in low oxygenation of blood due to mixing of oxygenated and de oxygenated blood in the left ventricle through the VSD and preferential low of both oxygenated and deoxgenated blood from the ventricles through the aorta because of obstruction to flow through the pulmonary valve.

After 4 hours of nursing intervention the pt, will have adequate cardiac output as evidenced by cardiac rate within normal range.

Assess and record the vital sign. Administer cardiac drugs as ordered. Assess dypsnea,exertion skin color during rest and when active. Avoid allowing the infant to cry for a long period of time,use soft nipple when feeding.

If the patient experience cardiac output he cardiac and respiratory rate will increase and bp will decrease. Cardiac drugs are given to increase the strength of cardiac contractions. Indicates hypoxia and increase oxygen need. Conserves energy,cross cut nipple requires less energy for infant to feed.