Nursing Diagnosis and Intervention for Tetralogy of Fallot
Tetralogy of Fallot (TF) is a cardiac disorder, with cyanosis disorder characterized by an abnormal combination of 4 things include; ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. The most important component in determining the degree of severity of the disease is pulmonary stenosis from very mild to severe. Pulmonary stenosis is progressive, more and more severe. Tetralogy of Fallot (TF) is a cyanotic heart disease is most commonly found, which ranks fourth tetralogy of Fallot congenital heart disease in children after ventricular septal defect, atrial septal defect and persistent ductus arteriosus, or approximately 10-15% of all heart disease congenital cyanotic congenital heart disease among Tetralogy of Fallot is 2/3. Tetralogy of Fallot is a congenital heart disease that is most often found are marked with central cyanosis due to right-to-left shunt.
Tetralogy of Fallot (TOF) is a type of cyanotic congenital heart disease. The disorder is a disorder that occurs where there is growth defect or hole from the infundibulum intraventricular septum (septum between the ventricular cavity) on the condition that the defect at least as big as the aortic orifice.
As a consequence, the presence of four anatomical abnormalities obtained as follows:
- Ventricular septal defect (VSD) is a hole in the septum between the two ventricles cavity.
- Pulmonary stenosis occurs due to narrowing of the blood vessels that exit valve from the right ventricle to the lungs, the muscle below the valve section also thicken and cause narrowing.
- Overriding aorta where the main blood vessel coming out of the left ventricular chamber astride the bulkhead, so it seems most of the aorta out of the right ventricle.
- Right ventricular hypertrophy or thickening of the muscle in the right ventricle due to increased pressure in the right ventricle due to pulmonary stenosis.
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.
- Collaboration IV fluid administration.