General Santos Doctors’ Medical School Foundation Inc.

Bulaong Subdivision, Barangay West, General Santos City 9500

Tel No.: (083) 302-3507, Telefax No.: (083) 552-9793

Tetralogy of Fallot

A Case Presentation

Presented to the Faculty of Nursing Program

In Partial Fulfillment of the Requirement

for NCM122-n

In partial fulfillment of the Requirements

For NCM 122-n

Presented to:

Lyndon A. Aque Jr., RN

Presented by:

Anthony Jude A. Tarnate, SN

, SN
 Acknowledgment

The student nurses would like to express their profound appreciation and sincere

gratitude to these people for their expertise, assistance, guidance, and patience while writing

this case study. Without their persistent help, this case study would not have been possible.

We want to acknowledge General Santos Doctors’ Medical School Foundation

Incorporated for providing the student nurses a quality education supporting our career goals

by actively providing us with the best experiences and education they could offer.

Dr. Grace Joy Gerada-Nietes, RN, College Dean, for opening the doors of

opportunities to the student nurses to bring only the best from the students;

Ms. Maria Irene Dayon-Chomi, RN, MAN, the program head, for ensuring students are

on track in developing the student's skills and knowledge,

Ms. Nancy A. Sarmiento, RN, MAN, the clinical coordinator, has provided extensive

personal and professional guidance in pursuing our goals.

The student nurses’ Clinical Instructor Mr. Lyndon A. Aque, Jr., RN, for helping,

guiding, and sharing their knowledge with us in completing the case study.

The student nurses' families have always been there and have not forgotten to express

their unending love, moral, and financial support in helping finish the case study.

Above all, to the Almighty Father, for the guidance and for answering the prayers of the

student nurses.
 CASE DESCRIPTION

On January 13, 2024, a Female, 38 years old patient Ms. C was admitted to General

Santos Doctor’s Hospital at 9:45am due to dizziness. Her Initial Diagnosis is To consider

chemical pneumonitis secondary to organophosphate inhalation (Mithion).

INTRODUCTION

Chemical pneumonitis secondary to organophosphate inhalation (Mathion) is a serious

medical condition characterized by inflammation of the lung tissue resulting from exposure to

organophosphate compounds through inhalation. Organophosphates are a class of chemicals

commonly used as insecticides, herbicides, and fungicides, as well as in certain industrial

processes. When these substances are inhaled, they can lead to a range of respiratory

complications, including chemical pneumonitis. Organophosphates exert their effort by inhibiting

acetylcholinesterase, an enzyme essential for the breakdown of Acetylcholine, a

neurotransmitter. In the context of organophosphate exposure, the accumulation of

acetylcholine leads to overstimulation of the nervous system, affecting not only neuromuscular

junctions but also contributing to respiratory distress and lung inflammation. (Brunner and

Subddarth’s, Medical-Surgical nursing 2022, 5th edition) and (Physical and Chemical Injury to

the Lungs, 2020).

 PATHOPHYSIOLOGY

Predisposing
Factors Precipitating
Improper placement Factors
of genes on specific
chromosomes Maternal
Microdeletions of exposure to
genes on specific alcohol,
chromosomes hydantoin,
Trisomies 13, 18, 21

Unclear interactions between

genetic associations and
environmental risk factors

Deviation of conal septum in

antero-cephalad direction

Tetralogy of Fallot

Ventricular Right
Septal Defect Overriding Pulmonary Ventricular
Aortic Root Stenosis
 RISK FACTORS

● Occupational Exposure:

Individuals working in agriculture, pest control, or industries where organophosphate -

containing pesticides or chemicals are used are at an increased risk.

● Improper handling and Application:

Failure to follow safety guidelines and protocols increase the likelihood of inhalation.

● Inadequate Personal Protective Equipment (PPE):

Insufficient use of appropriate PPE.

● Poor Ventilation:

Inadequate ventilation increases the concentration of organophosphate fumes, making

it more likely for individuals to inhale toxic levels.

● Accident exposure:

Accidental exposure, such as spills, leaks, or improper storage of substance.

● Duration and Intensity of the Exposure:

Prolonged or high level exposure increases the likelihood of adverse respiratory effects.

● Individual Sensitivity:

Susceptible to the toxic effects due to pre-existing respiratory conditions, age, or

compromised immune functions.

 ● Lack of Training and Awareness:

Inadequate training and awareness about the risk associated with organophosphate

exposure, as well as the proper use of protective measurements, can contribute to an

increased risk of chemical pneumonitis.

SIGNS AND SYMPTOMS

• Cyanosis

• Shortness of Breath (Dyspnea)

• Clubbing of Fingers and Toes

•Poor Growth

•Tiring Easily

• Episodes of Tet Spells (Tetralogy Spells)

• Squatting Position

DIAGNOSTIC TEST/PROCEDURE
1. Physical Examination: A thorough physical examination by a healthcare provider may

reveal characteristic signs, such as cyanosis, heart murmurs, and clubbing of fingers

and toes.

2. Electrocardiogram (ECG or EKG): An ECG measures the electrical activity of the

heart. It can help identify abnormal heart rhythms and patterns associated with TOF.

3. Chest X-ray: A chest X-ray can provide images of the heart and lungs, revealing

structural abnormalities, such as an enlarged heart or changes in the pulmonary blood

vessels.

4. Echocardiogram: This is a key imaging test for diagnosing TOF. It uses sound waves

to create detailed images of the heart's structure and function. An echocardiogram can

reveal the presence and severity of the four abnormalities associated with TOF.

5. Cardiac Catheterization: In some cases, a cardiac catheterization may be performed.

This involves inserting a thin, flexible tube (catheter) into the blood vessels to measure

pressure, oxygen levels, and obtain more detailed information about the heart's

anatomy.

6. Magnetic Resonance Imaging (MRI): Cardiac MRI can provide detailed images of the

heart, allowing for a comprehensive assessment of the heart's structure and function.

7. Pulse Oximetry: This non-invasive test measures the oxygen saturation levels in the

blood. It can be useful in detecting and monitoring cyanosis associated with TOF.

8. Genetic Testing: Genetic testing may be recommended, especially if there is a family

history of congenital heart defects or if there are other features suggestive of a genetic

syndrome associated with TOF.

MEDICAL MANAGEMENT
 ● Monitoring and Follow-up: Regular follow-up appointments with a pediatric cardiologist

or a congenital heart specialist are essential for monitoring the patient's condition. This

may involve routine physical exams, electrocardiograms (ECGs), echocardiograms, and

other diagnostic tests to assess the heart's function.

● Oxygen Therapy: In cases of severe cyanosis, oxygen therapy may be provided to

improve oxygen levels in the blood and alleviate symptoms. However, it's important to

note that oxygen therapy does not address the underlying structural abnormalities and is

primarily used for symptom relief.

● Medications: Some medications may be prescribed to manage symptoms associated

with TOF. Common medications include diuretics to reduce fluid retention and ease the

workload on the heart, and medications to manage arrhythmias if they occur.

● Prophylactic Antibiotics: People with TOF may be at an increased risk of infective

endocarditis, a serious infection of the heart lining. Prophylactic antibiotics may be

recommended before certain dental or surgical procedures to reduce this risk.

● Nutritional Support: Infants with TOF who have difficulty feeding or poor weight gain

may require nutritional support, including high-calorie formulas or, in severe cases, a

temporary feeding tube.

SURGICAL MANAGEMENT

Timing of Surgery:

1. Neonatal Repair: In many cases, surgical repair is performed during the first few

months of life, often within the first year. Early intervention is crucial to prevent

long-term complications and improve the child's overall health.

 2. Palliative Procedures: In some situations, especially if the baby is premature or

has other health issues, a temporary palliative procedure may be performed

initially to improve blood flow. This is followed by complete repair at a later stage.

Intracardiac Repair (Total Correction):

The primary surgical goal is to correct the four abnormalities associated with

TOF:

3. Closure of Ventricular Septal Defect (VSD): The hole between the heart's

lower chambers (ventricles) is closed using a patch.

4. Relieving Pulmonary Stenosis: The narrowing or obstruction in the pulmonary

valve or pulmonary artery is relieved to allow better blood flow to the lungs.

5. Reconstruction of the Right Ventricular Outflow Tract (RVOT): The surgeon

may enlarge the pulmonary valve or replace it with a conduit to improve blood

flow from the right ventricle to the pulmonary artery.

6. Overriding Aorta Correction: Repositioning the aorta to its normal position over

the left ventricle.

NURSING INTERVENTIONS

● Monitor Vital signs - Monitoring the vital signs of the patient allows us to identify the

baseline status

● Administer prescribed pain medications and assess pain levels regularly.

● Encourage and assist with deep breathing exercises - as pain and discomfort may limit

the depth of breathing.

● Provide comprehensive education to the parents or caregivers about TOF, the upcoming

surgical procedure, and what to expect during the hospital stay.

 ● Collaborate with a dietitian to assess and address nutritional needs, especially if the

child has difficulty feeding or poor weight gain.

● Monitor respiratory status closely. Administer oxygen as prescribed and assist with

respiratory treatments, such as incentive spirometry.

● Assess and care for the incision site, ensuring cleanliness and proper dressing changes.

- for the mother's recovery and overall well-being.

● Administer pain medications as prescribed and assess pain levels regularly. Use non-

pharmacological interventions, such as positioning and comfort measures..

● Provide clear instructions on postoperative care, including restrictions on activities, signs

of infection, and when to seek medical attention.

● Monitor urinary output and assist with bladder emptying if necessary- prevent

complications such as urinary retention and urinary tract infections.

● Educate the family on any prescribed medications and monitor for potential side effects.

Emphasize the importance of medication adherence.

● Educate the family about the importance of regular follow-up appointments with a

cardiologist to monitor heart function, identify any potential issues, and adjust the care

plan as needed.

PROGNOSIS

The prognosis for individuals with Tetralogy of Fallot (TOF) has significantly improved

over the years, especially with advancements in medical and surgical interventions. With

appropriate treatment, most individuals with TOF can lead relatively normal lives. However, the

prognosis can vary based on several factors, including the severity of the condition, the

presence of associated anomalies, and the timing and success of surgical repair. It's important

to note that the prognosis for TOF has improved significantly with advances in medical and

surgical care. Early diagnosis, timely intervention, and ongoing medical management contribute
to positive outcomes. Each individual's prognosis is unique, and healthcare providers work

closely with patients and their families to tailor the care plan to their specific needs and

circumstances. Regular follow-up care, adherence to medical recommendations, and a healthy

lifestyle contribute to long-term well-being for individuals with Tetralogy of Fallot.

 REFERENCES:

● Hinkle, J. l., Cheever, K. H., & Overbaugh, K. J. (2022). Brunner & Suddarth’s \

Textbook of Medical - Surgical Nursing (15th ed., Vol. 2). wolters Kluwer.

● Gatzoulis MA, Balaji S, Webber SA, Siu SC, Hokanson JS, Poile C, Rosenthal M,

Nakazawa M, Moller JH, Gillette PC, Webb GD, Redington AN. Risk factors for of

tetralogy of Fallot: a multicentre study. Lancet. 2000; 356: 975–981.

● American Heart Association. (2018, January 19). Tetralogy of Fallot.

www.heart.org.

https://www.heart.org/en/health-topics/congenital-heart-defects/about-congenital-

heart-defects/tetralogy-of-fallot

● Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide:

Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.

● Mayo Clinic. (2021). Tetralogy of Fallot – Symptoms and causes.

https://www.mayoclinic.org/diseases-conditions/tetralogy-of-fallot/symptoms-

causes/syc-20353477