Nursing Care Plan for Tetralogy of Fallot

Wednesday, April 25, 2012 ·
Nursing Diagnosis Interventions Tetralogy of FallotTetralogy of Fallot

Definition

Tetralogy of Fallot is a congenital heart disease with cyanosis, a combination of the four main symptoms are:
  1. obstruction of the flow out of the right ventricle (pulmonary stenosis),
  2. ventricular septal defect,
  3. the position of the right of the aorta and
  4. right ventricular hypertrophy together form a tetralogy of Fallot.

Clinical manifestations
  1. cyanosis
  2. dyspnoea
  3. dyspnoea attacks paroksimal (blue anoxia attacks)
  4. delay in growth and development
  5. normal rate of blood vessels
  6. systolic murmur

Assessment - Nursing Care Plan for Tetralogy of Fallot

Data that is commonly found in patients with tetralogy of Fallot are:
  • thorough cyanosis of mucous membranes or lips, tongue, conjunctiva. Cyanosis also occur at the time of crying, eating, tight, soak in water, can be peripheral or central.
  • dyspnoea usually accompanies the activity of eating, crying or tension / stress.
  • weakness, commonly in the legs.
  • growth and development not in accordance with age.
  • digital clubbing
  • headache
  • epistaxis

Nursing Diagnosis for Tetralogy of Fallot
  1. Risk for Decreased cardiac output related to structural abnormalities of the heart.
  2. Activity Intolerance related to imbalance in the fulfillment of oxygen to the body's needs.
  3. Impaired growth and development related to inadequate oxygenation, tissue nutrisis needs, social isolation.
  4. Risk for infection related to the general conditions is inadequate.

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