Question

Cindy is a 6-month-old female born at 38 weeks gestation. At birth she was mildly cyanotic

with a systolic murmur and diagnosed with Tetralogy of Fallot. Tetralogy of Fallot is the most

common cyanotic congenital heart defect. Cyanosis has increased over the past 6 months.

Parents state that she has been irritable and having feeding problems. Specifically, she has Tet

spells while crying and after feedings. She has failure to gain weight. Cindy is admitted to the

pediatric cardiac unit for evaluation of her congenital heart defect.

Initial assessment findings:

Skin: cyanotic

Lung sounds: crackles

T. 98.8 F

HR: 160 beats per minute

RR: 60 breaths per minute

SPO2: 80%

Weight 12.1 lbs. (5.5 kg)

Length: 20 inches (7.86cm)

Part 1: Discuss the initial assessment findings in this case study. How would you interpret

them?

Part 2: What are important nursing assessments for an infant with Tetralogy of Fallot and

potential heart failure? Why are they important? Discuss at least 6 nursing assessments.

Answer 1

Part - 1.intial assessment finding in tetralogy of fallot is cyanosis is main and important factors, which decrease oxygen saturation, bluish skin, nail especially when baby crying, feeding is also called as blue spell or tet spell.

Crackel sound are important finding in tetralogy of fallot, due to obstruction in outflow in right ventricle, or inflow in lungs,

Heart rate is more, tachycardia due to decrease cardiac output so Increse heart rate.

Rapid respiration also due to fulfill requirements of oxygen

Spo2 is 80,due to cyanosis or disease conditions, heart unable to suplly pure oxygenated blood.

Weight and height is slow growing due to disease condition or poor oxygen saturation.

PART - 2 important nursing assessments -

Firstly asses the vital signs blood pressure, temperature, pulse, respiration O2 saturation. Treat the abnormalities according to priority.

Cynosis is a most common symptom, squatting technique is beneficial for Increase blood flow, knee chest position also best for compensation. Providing O2 therapy according to prescribed by the physician.

Monitor temperature hyperthermia for infection.

Elevate the head of the child in semifowler position.

Seizure, loss of consciousness is important clinical menifestaion, preventing the child from injury, asses the respiration and Airways.

Stunted growth or poor weight gain symptoms also found in this disease so we should proper follow up with physicians, take medication regularly, which improves health status and subside symptoms.

Monitor for facial edema, peripheral edema, auscult breath sound, report abnormal findings indicate that collection of fluid.

Provide proper rest, which improves health and provides small frequent feeding which fullfill all need and improve oxygen saturation.