Tetralogy of Fallot Nursing Diagnosis and Nursing Care Plan

Last updated on May 18th, 2022 at 10:43 am

Tetralogy of Fallot Nursing Care Plans Diagnosis and Interventions

Tetralogy of Fallot NCLEX Review and Nursing Care Plans

Tetralogy of Fallot (TOF), named after Dr. Etienne Fallot, is a deadly congenital cardiac condition if it is not corrected. It’s also known as “tetra”, which refers to the four issues associated with it. The following are the four cardiac defects linked to TOF:

  • A ventricular septal defect characterized by a hole in the wall between the right and left ventricles (VSD)
  • The pulmonary outflow tract, which connects the heart and the lungs, is narrow.
  • Right ventricle thickening
  • An aorta with a changed orientation that lies on top of the VSD

Cyanosis is one of the symptoms of TOF. Normally, the skin’s rosy color is caused by oxygenated blood. In TOF, the lack of circulating oxygen causes the skin to turn bluish/cyanotic.

Although Tetralogy of Fallot is uncommon, it is the most prevalent type of cyanotic congenital cardiac disease.

Signs and symptoms of Tetralogy of Fallot

TOF symptoms might appear at any time after birth or shortly after. They are as follows:

  • a bluish complexion
  • skin and bone growths surrounding the fingernails (also known as clubbed fingers)
  • eating difficulties
  • being unable to acquire weight
  • developmental issues or delays
  • occurrences of passing out

Clinical appearance varies depending on the severity of the right ventricular outflow tract obstruction; however, newborns with some cyanosis are more common. Cyanosis appears months later in some cases as the rate of blockages increases.

Patients have a normal first heart sound and a single loud second heart sound on auscultation. The murmur is frequently described as crescendo-decrescendo with a harsh systolic ejection quality and is best heard at the left mid to upper sternal border with posterior radiation as the degree of obstruction increases.

An early systolic click might be heard at the left sternal border if the murmur has a regurgitant character to it.

Hepatomegaly is unusual, and strong pulses may be an indirect indicator of a patent ductus arteriosus or aorticopulmonary collaterals.

Right aortic arch (25%), aberrant coronary arteries, substantial aorticopulmonary collaterals, patent ductus arteriosus, numerous septal defects, and aortic valve regurgitation are all commonly related cardiac problems.

Tet periods, or episodes of hypercyanosis, occur from infancy or toddlerhood and subside after 4 to 5 years of age. Tet episodes are frequently caused by dehydration or agitation, and if patients do not receive early and proper care, they might develop severe cyanosis and hypoxia, which can lead to syncope and even death.

Clubbing occurs in a small percentage of individuals, and it is mainly noticed in those with severe, long-term cyanosis.

Causes of Tetralogy of Fallot

Tetralogy of Fallot is caused by a combination of factors, including untreated maternal diabetes, chromosomal anomalies (trisomy 21, 18, 13), microdeletions of chromosome 22q11.2, phenylketonuria, maternal retinoic acid consumption, and Alagille syndrome with JAG1/NOTCH2 mutations.

Mutations in transcription factor NKX2.5, methylenetetrahydrofolate reductase polymorphism, and mutations in TBX1 and ZFPM2 are among the genetic anomalies linked to tetralogy of Fallot.

In patients with tetralogy of Fallot, the ventricular septal defects are frequently perimembranous and might extend into the muscular septum.

The pulmonary valve, which is usually bicuspid and stenotic, the hypoplastic pulmonary valve annulus, the deviation of the infundibular septum, which causes a subvalvular obstruction, and the hypertrophy of the muscular bands in this region can all contribute to right ventricular outflow obstruction.

The overriding aorta normally varies in degree and receives blood from both ventricles. In Tetralogy of Fallot, the physiological process surrounding hypercyanotic episodes or “Tet spells” consists of either a decrease in systemic vascular resistance or an increase in pulmonary resistance, both of which contribute to a right-to-left shunt across the ventricular septal defect, resulting in marked desaturation.

Risk Factors to Tetralogy of Fallot

The specific cause of TOF is uncertain, but it has been linked to a number of risk factors. These are some of them:

  • alcoholism in the mother
  • diabetes
  • a mother who is beyond 40 years old
  • a bad diet during pregnancy
  • Other congenital abnormalities, such as Down syndrome, are common in people with TOF.

Diagnosis of Tetralogy of Fallot

When a fetal ultrasound reveals a heart abnormality while the baby is still in the mother’s uterus, a doctor may diagnose TOF. If the patient’s doctor hears a murmur during a heart exam or if the baby’s skin color is bluish, they can identify it shortly after birth.

The majority of people are diagnosed in childhood, although if the problems aren’t severe, the symptoms may be minor. This may cause a delay in diagnosis. Sometimes the diagnosis is made later, such as when a parent sees anything unusual or during a routine pediatrician appointment.

The following tests can help in the diagnosis of TOF:

  • Chest X-ray to rule out any structural issues
  • Echocardiography to check for heartbeat irregularities
  • MRI of the heart to look for structural issues
  • Pulse oximetry test is used to determine the amount of oxygen in the blood.
  • Catheterization of the heart

Fetal echocardiography is used to diagnose up to 50% of patients antenatally, predicting the need for postnatal prostaglandin therapy if there is evidence of significant right ventricular outflow blockage. Chest radiographs, electrocardiograms, and echocardiograms are all useful investigations for diagnosis and evaluation.

On the electrocardiogram, right axis deviation, prominent R waves anteriorly and S waves posteriorly, upright T wave in V1 (abnormal after 7 days of life up to 10 years of age), and a qR pattern in the right precordia are common.

Echocardiography is the gold standard among imaging studies for determining the anatomy and degree of right ventricular outflow obstruction, the location and number of ventricular septal defects, and assessing related anomalies or variations with the coronary arteries and the aortic arch.

The distal pulmonary arteries are difficult to visualize with transesophageal echo in patients with Tetralogy of Fallot. Cardiac magnetic resonance imaging can be used in adults with repaired TOF, and it is especially useful in this case. Cardiac catheterization is rarely performed, however, it can be useful in determining the degree of blockage, pulmonary stenosis or hypoplasia, coronary artery anatomy, and the existence of collaterals and auxiliary septal defects.

Treatment for Tetralogy of Fallot

  • Surgical Intervention. Surgery is required to treat TOF. This frequently happens in the first few months of a child’s existence. Closing the VSD and expanding the pulmonary valve are both parts of the procedure. If doctors are unable to do a complete repair, they will make a temporary repair until a complete operation is available, according to the Children’s Hospital of Philadelphia. If left untreated, TOF can lead to irregular heartbeats, developmental delays, and seizures. If the illness is not treated, which is uncommon, it usually leads to death by the age of 20. Typically, the doctor will detect the problem early on and undertake surgery to rectify it.
  • Medication. Prostaglandin therapy may be needed to maintain ductal patency and pulmonary flow in neonates with severe right ventricular outflow obstruction presenting with extreme hypoxemia and cyanosis before surgical surgery. Tet spells necessitate a quick and aggressive treatment plan that includes knee-chest positioning to increase systemic vascular resistance, oxygen therapy to cause pulmonary vasodilation and systemic vasoconstriction, intravenous fluid bolus to improve right ventricle filling and pulmonary flow; morphine, intravenous beta-blockers to help relieve right ventricle outflow obstruction by relaxing the muscle, and intravenous phenylephrine to increase system Digoxin and loop diuretics are good pharmacological therapeutic options if heart failure develops.
  • Lifetime Surveillance. A person will need to see a cardiologist for the remainder of their lives after undergoing TOF surgery. A cardiologist will conduct routine follow-up checks and communicate with the patient’s primary care physician about any drugs or health issues. Some persons who have surgery for TOF develop heart difficulties over time, necessitating regular and ongoing care.
  • Dental prophylaxis. All patients with unrepairable cyanotic congenital heart disease should undergo subacute bacterial endocarditis prophylaxis for dental operations, respiratory procedures, or contaminated skin treatments, according to the American Heart Association guidelines. Prophylaxis is also recommended for prosthetic cardiac valves, prior endocarditis, and completely healed congenital heart disease with prosthetic material or device for 6 months after surgery.

Nursing Diagnosis Tetralogy of Fallot

Nursing Care Plan Tetralogy of Fallot 1

Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output related to structural factors of congenital heart defect secondary to Tetralogy of Fallot as evidenced by abnormal hemodynamic measurements, widening of the pulse pressure, changes in the ECG, arrhythmias, murmur, peripheral pulses have slowed, fatigue, dyspnea, cyanosis or cyanosis absence, oliguria, knee-chest position or squatting.

Desired Outcome: The patient will demonstrate adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within the normal range (age-appropriate), strong peripheral pulses, and ability to tolerate activities in the absence of symptoms of syncope, dyspnea, or chest pain.

Tetralogy of Fallot Nursing InterventionsRationale
Check the patient’s blood pressure and heart rate.In reaction to diminished cardiac output, most individuals have compensatory tachycardia and severely low blood pressure.
Take note of the patient’s skin color, warmth, and humidity.A compensatory rise in sympathetic nervous system activation, diminished cardiac output, and oxygen desaturation causes cold, clammy, and pallid skin.
Check for the patient’s capillary refill and peripheral pulses.Decreased cardiac output and stroke volume produce weak pulses. Capillary replenishment might be sluggish or non-existent at times.
Examine for signs of exhaustion and decreased activity tolerance.Low cardiac output levels are associated with fatigue and exertional dyspnea. The patient’s response is closely monitored as a guide for the best development of exercise.
Examine the patient’s fluid balance as well as the patient’s weight increase. Prior to breakfast, weigh the patient on a regular basis.Fluid and sodium retention may occur as a result of weakened regulatory mechanisms; weight is a measure of fluid balance.
Check for gallops by listening to the patient’s heart (S3, S4).S3 is a class indication of left ventricular failure that implies diminished left ventricular ejection. S4 is characterized by diminished left ventricular compliance, which limits diastolic filling.
Rate, rhythm, and ectopy should all be monitored on an electrocardiogram (ECG).Low perfusion, acidosis, or hypoxia can  cause cardiac dysrhythmias. Ectopic beats, tachycardia, and bradycardia can all reduce cardiac output. The lack of atrial kick in atrial fibrillation affects older patients more than younger patients.
Allow enough time for rest.Rest reduces metabolic rate, which decreases myocardial and oxygen demand.
Place the patient in a semi-position Fowler’s.When fluid overload is present, an upright position is indicated to minimize preload and ventricular filling; it also facilitates lung expansion.
As directed, administer oxygen therapy.Increased oxygen needs may be too much for the failing heart to handle. The oxygen saturation level must be greater than 90%.

Nursing Care Plan Tetralogy of Fallot 2

Activity Intolerance

Nursing Diagnosis: Activity Intolerance related to generalized weakness and imbalance between oxygen supply and demand secondary to Tetralogy of Fallot possibly evidenced by the presence of circulatory/respiratory compromise, verbalization of the expression “I’m tired” or “I’m weak”, the need to rest after a brief period of play, an abnormal response to activity in terms of heart rate or blood pressure, and dyspnea during exercise.

Desired Outcome: The patient will tolerate activity of increasing intensity.

Tetralogy of Fallot Nursing InterventionsRationale
Examine the patient’s level of exhaustion, as well as the patient’s capacity to execute ADLs and other tasks, in relation to the severity of the patient’s ailment.Gives information on energy reserves and activity response.    
Assess dyspnea during exercise, as well as skin color variations during rest and activity.During energy expenditure, this indicates hypoxia and an increased need for oxygen.    
Allow for relaxation times in between treatments; only disturb when care and procedures are required.Rests the body and conserves energy.
Allowing the newborn to cry for long periods of time is discouraged; instead, use a soft nipple for feeding and a cross-cut nipple if the infant is unable to consume enough calories. Gavage-feed the infant through the mouth.It helps to save energy. The infant needs less energy to feed using a cross-cut nipple.
Provide a temperature that is comfortable for the newborn; when bathing the infant, only expose the area that is being bathed and keep the infant covered to avoid heat loss.Avoids extremes of heat or cold, which raise oxygen and energy requirements.
Provide toys and games for quiet play and diversion that are appropriate for the child’s age (specify) and allow the child to regulate his or her own activities to the extent practicable.Promotes physical and mental development, as well as growth and diversification.
Assist parents in making care and rest plans.Rests the body and avoids overexertion, lowering energy consumption.    
Notify them of any activity or exercise restrictions and encourage them to set their own fitness and activity goals.Prevents fatigue while performing tasks that are as close to normal as feasible.
Explain to parents the importance of conserving energy and promoting relaxation.To keep the patient from getting tired.
10. Inform them that they can ask for help with daily activities if they need it.Prevents weariness and overexertion.

Nursing Care Plan Tetralogy of Fallot

Compromised Family Coping

Nursing Diagnosis: Compromised Family Coping related to family and child developmental and situational crises secondary to Tetralogy of Fallot as evidenced by the sickness and condition of the infant/child cause concern and fear in the family, protective behavior that is out of proportion to the need to grow and develop, anxiety that persists, as well as the possibility of hospitalization and surgery.

Desired Outcome: The family will demonstrate effective coping mechanisms.

Tetralogy of Fallot Nursing InterventionsRationale
Keep an eye out for erratic behaviors (anger, stress, disarray), as well as a sense of being in a crisis scenario.Information affecting the family’s ability to cope with the cardiac condition of the infant or child.
Encourage emotional expression and provide accurate information about the infant or child.Reduces anxiety and improves comprehension of the problem among family members.
Examine the efficiency of common family coping mechanisms.If present strategies are ineffective in modifying the behaviors displayed, it is necessary to acquire new coping abilities.
Determine the extent to which the patient require information and assistance.Provides details on the need for measures to alleviate anxiety and worry.
Clarify any misunderstandings and provide answers to queries about the disease process.Prevents unneeded worry caused by incorrect information or beliefs.    
Assist in recognizing and employing ways for dealing with and solving difficulties, as well as gaining control of the situation.Provides assistance with problem resolution and crisis management.
Encourage family members and social acquaintances to stay healthy.Chronic worry, exhaustion, and isolation as a result of infant care will have an impact on the family’s health and ability to care for the child.  
Teach that excessive self-protection can stifle growth and development during childhood and adolescence.Family members will have a better knowledge of the condition and the negative consequences of their actions if they have more information.
Support family decisions by suggesting and reinforcing healthy coping practices.Encourages behavior change and adaption to infant/childcare.
Encourage parents to involve their sick infant or child in family activities rather than having the family revolve around the infant’s or child’s needs.Promotes the family’s and infant’s/proper child’s growth and development.
Encourage people to stick to consistent behavior limitations and make changes.Prevents behavioral issues and child influence over the family, both of which are detrimental to the child’s development and family connections.
Instruct parents on the nutritional and physical activity demands, restrictions, and ways that will help them build a good routine.Supports in coping with the consequences of a cardiac problem in an infant or child, as well as unique requirements.
If necessary, refer the family for additional support and therapy.Referrals provide more coping aid than nursing workers can provide.

Nursing Care Plan Tetralogy of Fallot 4

Risk for Injury

Nursing Diagnosis: Risk for Injury related to limited cardiac function secondary to congenital abnormalities and pharmaceutical treatment

Desired Outcome: The patient will not experience injury.

Tetralogy of Fallot Nursing InterventionsRationale
Check for the possibility of medication toxicity, which is a cardiac consequence of heart failure.Early detection of indications and symptoms of problems allows for the implementation of preventative measures and changes.
Orders for diagnostic tests and procedures should be monitored.Allows for parental and infant/child preparation and support.
Assist and support the family’s feelings and surgical decision.Provides much-needed support in order to reduce anxiety and foster a caring attitude.
Prepare parents and the patient (use play doll) for diagnostic procedures and/or surgery; should be extensive, consistent, and comprehensive, including a surgical operation to be performed and expected results, prognosis and whether palliative, corrective, permanent, or temporary.  Assists in reducing anxiety by emphasizing the importance of diagnostic tests prior to surgery.    
Instruct in the administration of cardiotonics, the taking of the apical pulse, when to withhold (less than 70-80 in a kid and 90-100 in a newborn), and how to report low or irregular pulses, as well as indicators of toxicity, to the physician.Ensures that cardiac glycoside is administered safely and accurately.
Teach the child what to do if he or she becomes cyanotic (knee-chest or squatting position, raising head and chest), and when to call a doctor.Encourages relaxation during an attack and provides techniques for reducing the severity of the episode and the terror that comes with it.

Nursing Care Plan Tetralogy of Fallot 5

Risk for Infection

Nursing Diagnosis: Risk for Infection related to chronic illness secondary to Tetralogy of Fallot

Desired Outcome: The patient will not experience any infection.

Tetralogy of Fallot Nursing InterventionsRationale
Examine the patient’s temperature, IV site if one is present, elevated WBC, pulse, and respirations (specify when).Provides information on the possibility of infection.
Allowing persons with infections to get into contact with the infant should be avoided.Prevents the spread of infectious pathogens to an infant or child with a weakened immune system.
Ensure that the patient gets enough rest. Meet the patient’s nutritional requirements as he/she get older.Increases the body’s resilience and defenses to protect against infection.
Before offering care, wash the patient’s hands.Microorganisms are not transmitted to the infant or child.
If a sterile procedure is available, use it for IV maintenance.Prevents infection by preventing contamination.
Antibiotics should be given as directed (specify the drug to be administered, dose, route, and number of times in a day).Describe how the antibiotics work.
Instill personal hygiene and behaviors in both parents and children (nutrition, rest, bathing, activity, bathroom for elimination).Reduces the risk of compromised defenses or contamination.
Instruct the caregiver to avoid patient contact with infected members of their family or acquaintances.Infections can quickly spread to a disabled child.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon


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Anna Curran. RN, BSN, PHN

Anna Curran. RN-BC, BSN, PHN, CMSRN I am a Critical Care ER nurse. I have been in this field for over 30 years. I also began teaching BSN and LVN students and found that by writing additional study guides helped their knowledge base, especially when it was time to take the NCLEX examinations.

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