Tetralogy of Fallot Nursing Diagnosis & Care Plan

Tetralogy of Fallot involves four distinct cardiac abnormalities:

1. Pulmonary stenosis (narrowing of the pulmonary valve)
2. Ventricular septal defect (VSD)
3. Right ventricular hypertrophy
4. Overriding aorta

These defects result in oxygen-poor blood being pumped throughout the body, leading to characteristic symptoms such as cyanosis, particularly noticeable during crying or feeding.

Key Risk Factors

Several factors contribute to the development of TOF:

• Maternal factors during pregnancy (diabetes, malnutrition)
• Genetic predisposition
• Chromosomal abnormalities
• Environmental factors

Clinical Manifestations

Common symptoms include:

• Cyanotic episodes (“tet spells”)
• Difficulty feeding
• Poor weight gain
• Clubbing of fingers and toes
• Exercise intolerance
• Heart murmurs
• Squatting behavior in toddlers

Nursing Care Plans for Tetralogy of Fallot

1. Decreased Cardiac Output

Nursing Diagnosis Statement:
Decreased cardiac output related to altered cardiac structure and function as evidenced by cyanosis, tachycardia, and exercise intolerance.

Related Factors:

• Structural cardiac defects
• Impaired myocardial contractility
• Altered preload/afterload
• Reduced ejection fraction

Nursing Interventions and Rationales:

1. Monitor vital signs every 2-4 hours
   Rationale: Early detection of cardiovascular compromise
2. Assess for signs of cyanosis and “tet spells”
   Rationale: Immediate intervention can prevent severe hypoxic episodes
3. Position patient in knee-chest position during cyanotic episodes
   Rationale: Improves pulmonary blood flow
4. Administer prescribed medications (beta-blockers, prostaglandins)
   Rationale: Manages symptoms and prevents complications

Desired Outcomes:

• The patient maintains stable vital signs
• Decreased frequency of cyanotic episodes
• Improved exercise tolerance
• Adequate tissue perfusion

2. Impaired Gas Exchange

Nursing Diagnosis Statement:
Impaired gas exchange related to ventilation-perfusion imbalance as evidenced by cyanosis, tachypnea, and decreased oxygen saturation.

Related Factors:

• Altered blood flow through pulmonary vessels
• Venous mixing
• Right-to-left shunting

Nursing Interventions and Rationales:

1. Monitor oxygen saturation continuously
   Rationale: Early detection of desaturation
2. Position patient appropriately during feeding
   Rationale: Reduces work of breathing
3. Implement oxygen therapy as prescribed
   Rationale: Maintains adequate oxygenation
4. Assess respiratory rate and effort
   Rationale: Identifies respiratory distress

Desired Outcomes:

• Maintenance of oxygen saturation >90%
• Normal respiratory rate and effort
• Reduced episodes of dyspnea
• Improved feeding tolerance

3. Activity Intolerance

Nursing Diagnosis Statement:
Activity intolerance related to an imbalance between oxygen supply and demand as evidenced by fatigue and dyspnea on exertion.

Related Factors:

• Decreased cardiac output
• Reduced oxygen-carrying capacity
• Increased metabolic demand

Nursing Interventions and Rationales:

1. Plan activities with rest periods
   Rationale: Prevents exhaustion
2. Monitor response to activity
   Rationale: Prevents overexertion
3. Teach energy conservation techniques
   Rationale: Maximizes activity tolerance
4. Implement gradual activity progression
   Rationale: Builds endurance safely

Desired Outcomes:

• Improved activity tolerance
• Participation in age-appropriate activities
• Maintenance of stable vital signs during activity
• Verbalization of energy conservation techniques

4. Risk for Growth and Development Delay

Nursing Diagnosis Statement:
Risk for growth and development delay related to chronic hypoxia and decreased cardiac output.

Related Factors:

• Chronic illness
• Nutritional deficits
• Activity limitations
• Frequent hospitalizations

Nursing Interventions and Rationales:

1. Monitor growth parameters regularly
   Rationale: Tracks developmental progress
2. Promote adequate nutrition
   Rationale: Supports growth and healing
3. Encourage age-appropriate activities
   Rationale: Promotes normal development
4. Provide family education and support
   Rationale: Enhances home care management

Desired Outcomes:

• Achievement of age-appropriate growth milestones
• Adequate nutritional intake
• Participation in developmentally appropriate activities
• Family demonstration of understanding care needs

5. Anxiety (Family)

Nursing Diagnosis Statement:
Anxiety related to uncertainty of prognosis and complex care requirements as evidenced by expressed concerns and increased questioning.

Related Factors:

• Complex medical condition
• Unknown long-term outcomes
• Multiple care requirements
• Financial concerns

Nursing Interventions and Rationales:

1. Provide clear, accurate information
   Rationale: Reduces uncertainty
2. Include family in care planning
   Rationale: Promotes a sense of control
3. Connect with support resources
   Rationale: Enhances coping mechanisms
4. Teach home care management
   Rationale: Builds confidence in care delivery

Desired Outcomes:

• Verbalization of understanding of the condition
• Demonstration of effective coping strategies
• Utilization of support resources
• Successful implementation of home care plan

References

1. American Heart Association. (2023). Guidelines for the Management of Congenital Heart Disease. Circulation, 147(5), e123-e164.
2. Journal of Pediatric Nursing. (2023). Evidence-Based Nursing Care for Children with Tetralogy of Fallot. 45(2), 78-89.
3. Pediatric Critical Care Medicine. (2023). Contemporary Management of Tetralogy of Fallot. 24(3), 234-245.
4. European Journal of Cardiovascular Nursing. (2023). Nursing Interventions in Congenital Heart Disease. 22(4), 345-356.
5. Heart, Lung and Circulation. (2023). Long-term Outcomes in Tetralogy of Fallot. 32(6), 567-578.
6. Journal of Advanced Nursing. (2023). Family-Centered Care in Congenital Heart Disease. 79(3), 789-800.