- Decreased Cardiac Output related to lack of oxygenated blood and Mixed oxygenated and deoxygenated blood as evidenced by Cyanosis and Clubbing of fingers
- Compromised Family Coping related to situational family crisis and developmental crisis as evidenced by Overprotective behavior of the parents/family member and Ineffective coping mechanisms
- Impaired Gas Exchange related to poor production of oxygenated blood and
Insufficient oxygenated blood circulation due to Mixed oxygenated and deoxygenated blood as evidenced by difficulty breathing and alteration in the level of consciousness, Cyanosis
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Verbalizes inability to breath properly Objective data: -Cyanosis -Murmur upon auscultation -Tet spells -Clubbing of fingers -Squatting -Dyspnoea -Fatigue -Poor developmental growth | Decreased Cardiac Output related to lack of oxygenated blood and Mixed oxygenated and deoxygenated blood as evidenced by Cyanosis and Clubbing of fingers | Patient will demonstrate an oxygen saturation level within expected limits. Patient will be able to tolerate playing or exercise without dyspnea, fatigue, or fainting. | 1. Place the patient on their left side, knees to chest. Positioning the patient on the left side with knees to the chest reduces the blood flow through the septal hole from the right ventricle and improves blood circulation to the lungs. The increase in the aortic and left ventricular pressure increases oxygenated blood flow to the tissues. 2. Cautiously administer oxygen therapy as prescribed. When a child has Tetralogy of Fallot, breathing more oxygen minimizes their oxygen levels. Cautiously provide oxygen with only the prescribed amount via a face mask to improve blood oxygen levels. 3. Manage Tet spells. Morphine, propranolol (or metoprolol), or, in difficult situations, phenylephrine may be administered to the child. These medications lessen that spells’ incidence and severity. 4. Prepare for surgical management. Surgical management can include a palliative shunt or complete repair: Palliative shunt: The shunt directs blood flow from the left or right subclavian artery to the pulmonary arteries. It enables the infant to reach an appropriate size for a complete surgical repair. Complete repair: The right ventricular pulmonic stenosis is removed, and the opening in the ventricular septum (between the ventricles) is patched up. 5. Refer to a cardiologist. Cardiologists specialize in preventing, detecting, and treating congenital cardiac diseases such as TOF. The patient will need lifelong follow-ups with a cardiologist who will monitor and manage the condition. | Patient demonstrated an oxygen saturation level within expected limits. Patient tolerated playing or exercise without dyspnea, fatigue, or fainting. |
| Subjective data: Verbalized concern and fear about the condition Objective data: -Overprotective behavior of the parents/family member -Expression of inadequate knowledge -Anxiety -Withdrawal -Ineffective coping mechanisms | Compromised Family Coping related to situational family crisis and developmental crisis as evidenced by Overprotective behavior of the parents/family member and Ineffective coping mechanisms | Family will be able to use coping mechanisms towards the crisis effectively. Parents/family will be able to verbalize acceptance of the current situation. Parents/Family will be able to verbalize a positive outlook on the situation. | 1. Assist the family in identifying a suitable coping mechanism. Assist the family in developing and employing coping mechanisms to deal with the crisis and take control of the situation. 2. Encourage to maintain open communication. Encourage social communication and expression of feelings. Feelings of anxiety, exhaustion, and loneliness are expected and can be managed. 3. Instruct on the effects of overprotective behavior. Teach that being overprotective can impede a child’s growth and development during their early years. It can result in risk aversion, parental dependence, a higher chance of psychological problems, a deficiency in practical coping skills, and long-term anxiety. 4. Refer to a family counselor. Family therapy or counseling in a group setting can instruct on how the behaviors of all family members affect not only the relationships between family members but the family as a whole. Strategies can then be developed on effective teamwork and coping. | |
| Subjective data: Dyspnoea Diaphoresis (excessive sweating) Objective data: -Altered respiratory patterns -Restlessness -Lethargy -Cyanosis -Confusion -Irritability -Abnormal arterial blood gas values or blood pH -Decreased oxygen saturation | Impaired Gas Exchange related to poor production of oxygenated blood and Insufficient oxygenated blood circulation due to Mixed oxygenated and deoxygenated blood as evidenced by difficulty breathing and alteration in the level of consciousness, Cyanosis | Patient will maintain oxygen saturation within normal limits. Patient will present an alert, conscious, and coherent level of consciousness. Patient will be able to play or tolerate activities with no complaints of difficulty breathing. | 1. Assist patient in knee-chest position. Children may squat to increase pulmonary blood flow and relieve dyspnea and cyanosis. 2. Prepare the patient for surgery. Open heart surgery to repair the flaws or temporary shunts to enhance blood flow to the lungs are the surgical treatments for patients with tetralogy of Fallot. 3. Promote aerobic exercise. Moderate exercise training increases aerobic capacity and gas exchange in people with corrected TOF. 4. Administer oxygen therapy as ordered. A baby with severe cyanosis is given supplemental oxygen when initially diagnosed. In situations of lung compromise, the additional oxygen helps the infant’s oxygen levels. Oxygen therapy produces pulmonary vasodilation and systemic vasoconstriction. However, in children with Tetralogy of Fallot, consuming more oxygen has minimal impact on the child’s oxygen levels. 5. Administer prostaglandin therapy. Prostaglandin treatment may be necessary for neonates with severe right ventricular outflow blockage who exhibit extreme hypoxemia and cyanosis to preserve ductal patency and pulmonary flow before surgery. 6. Collaborate with RT. Respiratory therapists carry out prescribed breathing exercises and drug treatments. When choosing the best oxygen therapy for each patient, they are the specialist to consult. | Patient maintained oxygen saturation within normal limits. Patient presented an alert, conscious, and coherent level of consciousness. Patient able to play or tolerate activities with no complaints of difficulty breathing. |