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NURSING CARE PLAN

Tetralogy of Fallot

ASSESSMENT NURSING SCIENTIFIC PLANNING RATIONALE IMPLEMENTATION EVALUA-TION


DIAGNOSES ANALYSIS
Cyanosis Risk for Tetralogy fallot After 4 hours of nursing If the patient experience cardiac Assessed and record the vital sign. Objective evaluation:
dyspnea Decreased cardiac results in low intervention the pt, will output he cardiac and respiratory rate Administered cardiac drugs as Baby's condition was
delay in growth output related to oxygenation of have adequate cardiac will increase and bp will decrease. ordered. improved
and development structural blood due to output as evidenced by Cardiac drugs are given to increase Assessed dypsnea,exertion skin
blue anoxia abnormalities of mixing of cardiac rate within the strength of cardiac contractions. color during rest and when active.
attacks the heart. oxygenated and normal range. Indicates hypoxia and increase Avoided allowing the infant to cry
de oxygenated Assess and record the oxygen need. for a long period of time, use soft
blood in the left vital sign. Conserves energy,cross cut nipple nipple when feeding.
ventricle Administer cardiac requires less energy for infant to
through the drugs as ordered. feed.
VSD and Assess
preferential low dypsnea,exertion skin
of both color during rest and
oxygenated and when active.
deoxgenated Avoid allowing the
blood from the infant to cry for a long
ventricles period of time,use soft
through the nipple when feeding
aorta because of
obstruction to
flow through
the pulmonary
valve.
ASSESSMENT NURSING SCIENTIFIC PLANNING RATIONALE IMPLEMENTATION EVALUA-TION
DIAGNOSES ANALYSIS
Objective: Impaired gas Congenital 1. Establish good To gain both trust and Established good trusting Objective evaluation:
exchange related Heart Disease trusting relationship cooperation relationship with the patient the baby condition
-V/S: to altered oxygen refers to a with the patient and was improved
and significant others
supply as
BP:80/50 mmHg evidenced by problem with significant others Monitored respiratory
Indicators of adequacy of
dyspnea, the hearts 2. Monitor respiratory rate/depth, use of accessory
respiratory function or degree of
PR: 124 bpm tachypnea, structure and rate/depth, use of muscles, areas of cyanosis.
compromise and therapy
RR: 28 cpm
tachycardia, and function due to accessory muscles, needs/effectiveness Auscultated breath sounds,
fatigue secondary abnormal heart areas of cyanosis. noting presence or absence
Temp: 37.1 C to Congenital development 3. Auscultate breath Development of atelectasis and and adventitious sounds.
Heart Disease t/c sounds, noting stasis of secretion can impair gas
-with O2 Tetralogy of fallot Before birth. It exchange
can disrupt the
presence or absence Monitored vital signs; note
inhalation @ and adventitious
normal flow of changes in cardiac rhythm.
2lpm via nasal sounds.
blood to the Compensatory changes in vital Compensatory.
cannula as different parts signs and development of Helped with breathing
ordered of the body thus 4. Monitor vital signs; dysrhythmias reflect effects of exercises. Pursed lip
affecting the note changes in impaired gas exchange
-circumoral breathing.
exchange of cardiac rhythm.
cyanosis noted gasses Helps improve oxygen inspiration Elevated head of bed to
Compensatory.
of the lungs moderate or high back rest.
5. Help with breathing
exercises. Pursed lip Helps the lung expand and aids in
breathing. the relaxation of the muscles
6. Elevate head of bed decreasing the oxygen demand of
to moderate or high the body
back rest.
ASSESSMENT NURSING SCIENTIFIC PLANNING RATIONALE IMPLEMENTATION EVALUA-TION
DIAGNOSES ANALYSIS
Objectives: Ineffective tissue Due to 1. Monitor skin colour Cool, blanched, mottled skin Monitored skin colour and Objective evaluation:
perfusion narrowing of and temp. every and cyanosis may indicate temp. every 2hours. the baby condition
-bluish the artery which tissue perfusion was improved
2hours. Assess for Assessed for signs of skin
discoloration on (cardiopulmonary small amount of signs of skin Decrease heart rate and
oxygenated breakdown.
lips noted ) blood pressure may
blood can pass breakdown.
indicateincreased Monitored and documented
-clubbing of Related to through the 2. Monitor and arteriovenousexchange,whic patients vital signs every
finger noted decrease oxygen systemic documented patients h leads to decrease tissue hour..
cellular exchange circulation vital signs every perfusion Kept patient warm
-nasal flaring secondary to
Which the hour.. Warmth aids Elevated lower extremities.
patient 3. Keep patient warm vasodilation,which improve
-use of accessory congenital heart experience Changed position regularly
4. Elevate lower tissue perfusion
disease t/c and inspect skin every shift.
muscle noted difficulty in
extremities. To increase arterial blood
tetralogy of fallot breathing supply and improve tissue
-with capillary 5. Change position
perfusion.
refill time of 3 regularly and inspect To avoid decrease in tissue
seconds skin every shift. perfusion and risk of skin
breakdown.
-with O2 of 2 lpm
via nasal cannula
as ordered

-body weakness
noted(allways on
bed)