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 results in low intervention the pt, will output he cardiac and respiratory rate  Administered cardiac drugs as Baby's condition was
delay in growth cardiac output oxygenation of have adequate cardiac will increase and bp will decrease. ordered. improved
and development related to blood due to output as evidenced by  Cardiac drugs are given to increase  Assessed dypsnea,exertion skin
blue anoxia structural mixing of cardiac rate within the strength of cardiac contractions. color during rest and when active.
attacks abnormalities of oxygenated and normal range.  Indicates hypoxia and increase  Avoided allowing the infant to cry
the heart. 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 problem with significant others  Monitored respiratory
evidenced by Indicators of adequacy of
mmHg dyspnea, the hearts 2. Monitor respiratory rate/depth, use of accessory
respiratory function or degree of
tachypnea, structure and rate/depth, use of compromise and therapy muscles, areas of cyanosis.
PR: 124 bpm tachycardia, and function due to accessory muscles, needs/effectiveness  Auscultated breath sounds,
fatigue secondary abnormal heart areas of cyanosis. noting presence or absence
RR: 28 cpm to Congenital Development of atelectasis and
development 3. Auscultate breath and adventitious sounds.
Heart Disease t/c sounds, noting stasis of secretion can impair gas
Temp: 37.1 C
Tetralogy of Before birth. It exchange
presence or absence  Monitored vital signs; note
-with O2 fallot can disrupt the
normal flow of and adventitious changes in cardiac rhythm.
inhalation @ sounds.
blood to the Compensatory changes in vital  Compensatory.
2lpm via nasal different parts signs and development of  Helped with breathing
cannula as of the body thus 4. Monitor vital signs; dysrhythmias reflect effects of exercises. Pursed lip
ordered affecting the note changes in impaired gas exchange
exchange of breathing.
cardiac rhythm.
-circumoral gasses Helps improve oxygen inspiration  Elevated head of bed to
Compensatory.
cyanosis noted 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 2hours. Assess for tissue perfusion was improved
 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.  Monitored and documented
indicateincreased
-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 Which the hour..  Warmth aids
secondary to  Elevated lower extremities.
patient 3. Keep patient warm vasodilation,which improve
-use of accessory congenital heart experience tissue perfusion
 Changed position regularly
disease t/c 4. Elevate lower and inspect skin every shift.
muscle noted difficulty in  To increase arterial blood
tetralogy of fallot breathing extremities.
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)