CLINICAL

PRESENTATION
ON
TETRALOGY OF
FALLOT

SUBMITTED TO: Mrs. Mohanambal M.sc (Nursing) Vice Principal

SUBMITTED BY: Mrs.Kayalvizhi M.sc (Nursing) Year

SUBMITTED ON:13/04//2017
General objectives:

At the end of class students will able to understand and gain

knowledge regarding Tetralogy of Fallot and implementing the patient in
clinical area.

Specific objectives:

Students will able to

To introduce the Tetralogy of Fallot

To define the definition of Tetralogy of Fallot

To enumerate the etiological and risk factors, classification/ types
of
Tetralogy of Fallot

To explain the pathophysiology of Tetralogy of Fallot

To know the diagnostic evaluation of Tetralogy of Fallot

To list out the clinical manifestation of Tetralogy of

Fallot

To describe the medical management of Tetralogy of

Fallot

To discuss the nursing management of Tetralogy of

Fallot
 INTRODUCTION

I am Kayalvizhi, studying 1 st year M.Sc (N) in Indira College of Nursing Dept of

child health Nursing. I am going to speciality practicals in ........................ Hospital,
there I am posted in CICU there I find one case i.e; Tetralogy of Fallot. So as felt to this
s my case presentation

Mr M.Harish, 3 years, male from k.k nagar admitted in ........................Hospital

in CICU on ..at 4:30pm with the complains of poor maternal nutrition, viral

illness.
 IDENTIFICATION

1. Personal Data
Name: Master.Harish
Age: 3y/o
Sex: Female
Address:

Occupation: N/A

Education: nil

Marital status: single

Religion: Hindu
Date and Time of admission:

Admitting Physician:

Diagnosis: tetrology of fallot

HISTORY COLLECTION

Chief complains:

My patient Mr. M.Harish,3years, male admitted in R,K Hospital

complains poor maternal nutrition, viral illness..

Present medical history:

he admitted in CICU due to poor maternal nutrition, viral illness with
complain of lethargic, viral illness, difficulty in breathing

Past medical history:

he was admitted in hospital due to poor maternal nutrition, viral illness

Present surgical history:

Not significant of surgical history

Family history:
There is no any evidence of hereditary and communicable disease in
his family

Family profile:

Slink Name of the family age sex relation occupation remar

members ship k

1. M.Samba murthy 29y M Father Employ

2. S.Mala 26y F Mother House wife

3. S.Pushpa 4yr F Sister -

FAMILY TREE
 Mr. samba murthy Mrs. Mala
29 yrs/male 26yrs/female

Baby pushpa Master Harish

4 yrs/female 3 yrs/male

Male Female Patient

BIRTH HISTORY

1.Antinatal History

The child mothers arranged marriage. Mother had taken 2 doses of TT injection 5 th
and 7th month of gestation. The child mother had attended the regular antenatal check up. But
the mother doesnt taken Iron and Folic acid tablet during pregnancy period. The mother
does not exposed to radiation/toxic drugs and any illness/complications during pregnancy.

2.Natal History

The mother Mrs. Mala delivered baby at 35 weeks and 1.8 kg. Vaginal delivery in
Govt. Hospital Trichy on 02/12/2013 at 11.30am. The delivery was contacted by trained
health team members from hospital. Baby cried late 10 minutes after delivery. Birth weight
was 1.800kg. The child have any birth injuries. Thus child is the 2nd child of Mrs. Mala .
3.Post Natal History

The child does not have any history of cyanosis, and no history of eye discharge. The
breast feeding was initiated within 2 hours. The baby was passed meconium but does not
pass urine within 48 hours. The baby have low birth weight 1.800kg also APGAR SCORE
was 6/10. The child met various kinds of care and intensive care support.

IMMUNIZATION SCHEDULE

S.No Age Group Type of Dose Route Given/Not

Vaccine given
1. At birth BCG 0.1ml IM Given
Hepatitis-B 0.5ml IM Given

At birth OPV 2 drops Oral Given

At 6 weeks OPV-1 2 drops Oral

DPT-1 0.5ml IM Given
Hep-B-1 0.5ml IM

2. At 10 weeks OPV-2 2 drops Oral

DPT-2 0.5ml IM Given
Hep-2 0.5ml IM

3. At 14 weeks OPV-3 2drops Oral

DPT-3 0.5ml IM Given
Hep-B-3 0.5ml IM

4 9 months Measles 0.5ml SC Given

Vitamin A 1ml Oral

5. 16-24 months DPT booster 0.5ml IM

Measles2nd 0.5ml Subcutaneau Given
dose 2 Drops oral
OPV Booster
.
 Nutritional history:

No Time Diet Amount Calorie Protein carbohydrate Fat

1 8am Milk 150 ml 110 kcal 3 4 3.8

2 9am Idly 2 2 no's 372 kcal 6.9 58.9 0.2

3 12.30pm Rice with 200 gms 690 kcal 6.9 74.5 5.2
curry

4 4pm Tea 150 ml 150 kcal 3 4 3.8

5 8.30pm Rice with 150 gms 20.8 58.9 0.2

curry

DEGREE OF MALNUTRITION
Actual Weight
100
Expected Weight

Expected Weight =?

1-6 years=age in years2+8

=32+8

Expected Weight =14 kgs

Actual Weight
100
Expected Weight

10
100=71.4
14

The baby was undergone 1st degree malnourishment.

 GROWTH AND DEVELOPMENT

Book Picture Childs Picture Remark

1)Physical Examination:-

Biological Development:-

Vital signs:-
Temperature: the child the child had

36.5 C Temp: 36 C decreased
Pulse : 90-130 b/m Pulse: 92 b/m Respiration
Respiration:26-28 Res: 18 b/m
b/m Blood pressure:
Blood Pressure: 100/60 mm of Hg
99/6426/24 mm of Hg

Height:- Height 96cm the child had

Age in years6+77 Normal Height
3years - 95cm

Weight:- Weight 10kg the child had

Age in years2+8kg malnourished
3years 14kg weight

2)Gross motor skills:- the child can able to

stand alone one foot
2-3 years:- because
Stands on one foot
alone the child can able to
walks on tip toe for
few steps
the child had
Walks on tip toe for I asked childs mother Normal Gross
few steps if the child can jumps motor skills
from step/low chair
the mother says that
Jumps from step low sheuse to jump from
chair step (or) low chair

the child can able to

rides a walker/pedal
car
 Book Picture Childs Picture Remark
Rides a walker / the child can able to
pedal car picks up objects from
floor without losing
balances

Picks up objects I gave a ball to the

from floor without child. The child can
losing balances able to throw ball over
4-5 feet
can through large
ball over hand 4 to 5 the child mother says
feet that she able to jump
from place with both
feet on floor
Jumps well in place
with both feet off
floor

I gave the cubes to

3)Fine motor skills:- the child she can able
to make tower using
2-3years:- those cubes
Builds tower of eight
cubes I gave the crayons to the child had good
the child the child fine motor skills
Able to initiative draws a vertical
vertical/circular strokes
strokes
the child had good
finger co-ordination
Has good hand,
finger co-ordination
the child can able to
Holds crayon with hold the buttons
finger

Buttons one large

front button I gave the mixture to
Unbuttons large front the child and the child
buttons able to eat without
spilling
Self feeding with
occasional
 Book Picture Childs Picture Remark

4)Self care:- I gave the feeding cup

to the child she able to
Hold cup with both hold the cup with both
hands hands

Puts spoon into

mouth and with Yes. The child enjoys The child had
spilling finger feeding she good self care
dont prefer spoon activities.
feeding.
Enjoy finger feeding
the mother says that if
she feels the urgency
Removes simple of urination she let her
garments know to assist her to
Using toilet skills toilet

The child comb her

May attain self care hair and wear dress
with help with hermothers help.

5)Sensory development:- I asked the child to

touch the ice and
Determine the asked how she feels the child had
distance from crib Normal sensory
high chair to floor development
Normal hearing

Prefer food as the

child likes may the child feels that
respond to cooling sensation
unpleasant orders
Develop sensation of
touch and pain

6)Psychosocial
development:-

Sense of Autonomy Vs The child can not able

 Book Picture Childs Picture Remark
doubt & shame:- to be without her
Tolerates mother. the child had
Separation appropriate
loss fearful of She is sacred of others psychosocial
strangers development
according to her
Hugs & kisses the child use to kiss age
parents her parents

Begins to
passiveness she imitate her parents

Beings to imitate
parents she able to identify her
girl and boy friends
Awareness of gender
identity the child had jealously
with her brother
Increase autonomous
behavior
focuses on own
wishes

Decrease thumb
sucking
Imitates sex role
behavior of adults
the child mother says
7)Psychosexual that she calls her
development:- during the toileting
the child had attain
Anal stage:- appropriate
Obtains pleasure psychosexual
from the feeling of development
distended bladder according to her
from the masses of age
focus in the rectum
and from the release
of content from those
organs

Conscious sense of
self and learning to
tolerate frustration

8)Spiritual development:- the childs mother

 Book Picture Childs Picture Remark
goes to the temple
Intuitive Vs projective weekly once with his
faith:- family

Imitates religious the child had attain

behavior such as appropriate
bowing the head in spiritual
prayer but does not development
understand the according to her
meaning age

9)Intellectual
development/cognitive
development:-
the child tells past
Sensory motor stage 15- events for eg she can
24 months able to remember what
she ate 2 days before
Pre-operational stage:
(24-30 months ) the child had
Beginning of mental the child can able to attained
representation of carry the past events appropriate
events and in the mind. intellectual
differentiates past development
and present except.
Short attention span child cant able to Cant differentiate
differentiate self from self from objects
Beginning of traces others
of memory begins
sense of time and
anticipation of
events
Beginning to think,
begin casual
thinking
thinks some
solution to problem
can differentiate self
from objects the child can able to
follow mothers orders
10)Moral development:-

Pre conventional morality:-

 Book Picture Childs Picture Remark
follows to rules strictly the child speaks 850
words
Accept changes in the child had good
the rules moral
development
11)language/speech
development:-

3 years : 900 words the child had attain

Normal speech
the child use to play development
with her group of
friends

12)Play:- like fond of dramatic

play with her friends
co-operation play:-
children begin to
exchange and gradually to
interact with them in play calories:1200kcal/day
activities like paintings, Protein: 2kg/day
play telephone, co- Fat:2kg/day
operative, fond of dramatic Iron: 8mg/day
play, Interest in stores Calcium: 450mg/day
Fluids:90m/kg/day
13)Nutrition:- Vitamin A: 4000 IV/day

Calories:1300-1500 the child had not

kcal/day attain Normal
Protein:3-4 gm/kg/day Nutrition pattern
Fat: 4-5 gm/kg/day due to loss of
Iron:10mg/day the child had itchy red appetite
Calcium: 500mg/day skin
Fluids:90-100ml/kg/day
Vitamin A: 5000 IV/day

14)Problems:-

Health problems:-
Dental carries the child had itchy
Nutritional skinrashes
deficiency the child does not problem
Warm infestation haveany
developmental
15)Developmental problems
problem:-
 Book Picture Childs Picture Remark

Selfishness
Hurting others
Destructiveness the child does not
Ensuesis have any
Encorpresis developmental
Bad languages problems
Masturbation
Sibling rivalry

16)Needs of Toddler:-

Love and security

Independence
Managing the bed
time problem
Discipline leading to
self-control meeting
the Nutritional needs
Accident prevention the child not met all
respect individuality the Needs
of children

Help to expand then

skill in develop their
potential mastery of
self control
the child not met
Provide a sense of all the Needs
initiation set limits to
childrens
behavior/security

Toileting, napping,
healthy practices and
play indoor and out
door games, dental
hygiene optional
valines

IMPRESSION:-

The child had a problem itchy dry skin, incomplete intellectual development, the child had
poor Nutritional pattern due to loss of appetite.
 HEALTH ASSESSMENT

Personal history:

Diet: patient diet includes vegetarian a. he takes food in per day 3

times.

Rest & sleep: disturbed sleep pattern

Elimination: abnormal bowel & bladder (bowel - constipation & urination is

frequently & small amount of urine is passing)

Socio economic history:

Environmental history:-Housing: building and own house

Ventilation: adequate ventilation

Electricity: present

Water supply: municipality tap

Physical examination:

vitals signs patient value normal value remarks

Temperature 98.60F98.60F 98.60F98.60F normal
Normal

Pulse 92b/min
92b/min 72b/min
72b/min abnormal
Abnormal
Respiration 22b/min 16-18b/min abnormal
22b/min 16-18b/min Abnormal
Blood pressure 120/60mmhg 120/80mmhg abnormal
120/60mmhg 120/80mmhg Abnormal
Spo2 93% 93% 100% 100% normal
normal

General appearance:
Consciousness: conscious
Orientation: oriented time, place, and date

Nourishment: moderate nourished

Health: un healthy

Body build: moderate

Activity: dull

Look: anxious

Hygiene: moderately hygiene

Speech: clear

REVIEW OF SYSTEMS

Skin/ integumentary system:

Colour: black

Texture: wrinkles skin/dry skin

Skin turgor: present

 Hydration: well hydrated

Discolouration: no discolouration of skin

Subjective symptoms: dry skin is present

Nails:
Nail beds: pale in colour
Nail plates: flat, absnce of clubbing

Cyanosis: no central and peripheral cyanosis Colour: black

Texture: dry

Eyes:

eye brows: symmetric

Eyelashes: equally distributed

Papillary reflex: abnormal

Conjunctiva: abnormal

Vision: abnormal vision (blurred vision)

Ears:

Pinna: normally placed

Cerumen: no defect
Otarrhea: no discharges from ear

Hearing: no defect in hearing process

Nose:

Nasal septum: no deviation of nasal septum

Nasal pathway: clear nasal pathway

Smell: no defect

Mouth & pharynx:

Lips: absence of cracks and pale in colour Tongue:
coated tongue

Bleeding : no history of bleeding

Tooth decay: history of tooth decay

Dental care: no history of dental caries

Neck:

ROM: not possible

Lymph nodes: not palpable

Trachea: present in midline

Thyroid gland: not enlarged

Jugular vein: not distended.

SYSTEMIC EXAMINATION

Heart:
Cardiovascular system:
H/O hypertension: hypertensive
Varicose veins: no H/o varicose veins

Dysponea: present

Orthopnea: not evident

Chest pain: evident

Palpitation: present

Heart sounds: present S1 S2 sounds

Pluse:92b/min
Heart beat: abnormal rate and rhythm

Inspection: on inspection the thoracic cavity is normal and clear, no lesions

detected, sutured mark presented

Palpation: no palpable masses detected

Percussion: no percussion performed

Auscultation: on auscultation at 5 areas , pulmonic, aortic, erbs point, mitral, apical area.
S1 S2 sounds are clear and gallop sounds present
 INVESTIGATIONS

No Name of the Patient value Normal value Remarks

investigation
1. Hb% 11.1gms 12-14gms abnormal

2. TWBC 8300cells/cumm 1,500000cells/cumm abnormal

3. DC
P 86% 4,5000c/cumm abnormal

L 11%

E 0.3%

4. platelet count 1.7 laks/cumm

5. bil.urea 47mg/dl 10-40mg/dl abnormal

6. sr. creatine 1.0 0.5-1.4mg/dl normal

7. ECG Extreme Normal abnormal

tachycardia
lt.ant. hemi
block
invented T
wave
ST-T
Abnormality
excessive
overload of lt.
atrium, lt.
ventricular
hypertrophy

8. Xray abnormal normal abnormal

 Tetralogy of fallot

Introduction:

Tetralogy of Fallot (TOF) is one of the most common congenital heart disorders
(CHDs). This condition is classified as a cyanotic heart disorder, because tetralogy of
Fallot results in an inadequate flow of blood to the lungs for oxygenation (right-to-left
shunt) (see the following image). Patients with tetralogy of Fallot initially present with
cyanosis shortly after birth, thereby attracting early medical attention.

Louis Arthur Fallot, after whom the name tetralogy of Fallot is derived, was not
the first person to recognize the condition. Stensen first described it in 1672; however, it
was Fallot who first accurately described the clinical and complete pathologic features
of the defects.

ANATOMY AND PHYSIOLOGY:

ANATOMY OF HEART:

The heart is a hallow muscular organ located in the center of the thorax
where it occupies the space between the lungs (mediastinum) and rests on the
diaphragm.
It weights approximately 3oogrms (10.6oz) the weights and size of the
 heart are influenced by age, gender, body weight, extent of physical
exercises and conditioning and heart disease.
The hart pumps to the blood to the tissues, supplying them with oxygen
and other nutrients.

The heart composed of 3 layers

The inner layer or endocardium consists of endothelial tissue and lines the
inside of the heart valves.
The middle layer or myocardium is made up of muscles fibbers and is
responsible for the pumping action.

The exterior layer of the heart is called the epicardium.

The heart is encased in a thin fibrous sac called the pericardium, which is
composed of to layers.

Adhering to the epicardium is the visceral pericardium

Enveloping the visceral pericardium is the parietal pericardium, tough
fibrous tissues that attaches to the great vessels, diaphragm, sternum and
vertebral column and supports the heart in the mediastinum.
The space between 2 layers (pericardial space) is normally filled with about
20ml of fluid which lubricates the surface of the heart and reduce friction
during systole.

FUNCTIONS OF THE HEART:

Electophysiogic properties:

The cardiac electrophysiologic properties of cardiac muscle regulates the heart

rate and rhythm.

The properties of cardiac include:

Exacitability
Automaticity
Contractility
 Refractoriness
Conductivity

Exacitability: the ability of cardiac muscle cells to depolarize in response to

stimuli/responses to electrical impulses

Automaticity: ability to initiate an electrical impulse. Ability of cardiac

pacemaker cells to initiate an impulse spontaneously and repetitively without external
neuro hormonal control.

Contractility: the heart muscle is composed of long narrow cells or fibres. The action of
potential initiates the muscles contraction by releasing calcium through the tubules of
the cell membrane.

Refractoriness: refractoriness is the heart inability to response to a new stimulus

while still in a state of depolarization from an earlier stimulus.

Conductivity: ability to transmit an electrical impulses from one cell to

another.

DEFINITION:
Heart failure is a significant cardiac functional disorder that can results in reduced
oxygen delivery to the bodys organs tissues.

The in ability of heart to supply blood circulation for the body needs.

Heart failure is an abnormal clinical condition involving impaired cardiac pumping.

It results in the characteristics pathophysiologic changes of vasoconstriction and fluid
retention. Heart failure formerly called as congestive heart failure. Heart failure I not a
disease.

INCIDENCE:

Heart failure is association with high rest of morbidity, mortality and

economic costs. In hospital mortality for these patients is 4% with a men length
of hospital stay of 6.5 days. Hospital re-admission for 20 to 30 days 50%at 6 to
12 months mortality rate increases.

Heart failure can affect both women and men alough the mortality is higher
among women

Heart failure affects about 5million people in U.S with 5000,000 new cases
diagnosed each year

It is mainly affected in aging people age below 75 years of age. In India

mainly affected 33% of people in the year diagnosed as chronic heart failure.

ETIOLOGY AND RISK FACTORS:

The performance of heart depends on 4 essential components:

1) Contractility of the muscle

2) Preload (amount of blood in the ventricles at the end of diastole)

3) After load (the pressure against which the left ventricles ejects)

4) Heart rate

The causes of heart failure can be divided into 3 subgroups

Abnormal loading conditions

Abnormal muscle function
Conditions or disease that limit ventricular filling

Abnormal loading condition:

conditions that increases preload conditions that increases after loa

Regurgitation of mitral or Hypertension

tricuspid valve Pulmonary or systemic aortic or
Hyper volemia plumonic stenosis
Congenital defect (left-right High peripheral vascular
shunts) resistance
Ventricular septal defect
Atrial septal defect
Patent ductus arteriosus
Abnormal muscle function:

Myocardial infraction

Myocarditis

Cardiomyopathy

Ventricular aneurysm

Long term alcohol consumption

Coronary heart disease

Metabolic heart disease

Endocrine heart rate

Limited ventricular filling:

Mitral or tricuspid stenosis

Cardiac tamponade

Constrictive pericarditis

Hypertrophic obstructive cardiomyopathy

CAUSES OF HEART FAILURE:

Chronic heart failure Acute heart failure

Coronary heart disease Acute myocardial infraction
Hypertension Dysrhythmias
Rheumatic heart disease Pulmonary mboli
Congenital heart disease Thyrotoxicosis
Corpulmonale Hypertensive crises
Cardiomyopathy Rupture of papillary muscle
Anemia Ventricle septal defect
Bacterial endocarditis Myocarditis.
Val uvular disorder
RISK FACTORS:

Primary risk factor CAD and advancing age

Hypertension
Diabetes mellitus
Cigarette smoking
Obesity
High serum cholesterol level.

PATHOPHYSIOLOGY:
The cause(s) of most congenital heart diseases (CHDs) are unknown,
although genetic studies suggest a multifactorial etiology. A study from
Portugal reported that methylene tetrahydrofolate reductase (MTHFR) gene
polymorphism can be considered a susceptibility gene for tetralogy of Fallot.
Prenatal factors associated with a higher incidence of tetralogy of Fallot
(TOF) include maternal rubella (or other viral illnesses) during pregnancy, poor
prenatal nutrition, maternal alcohol use, maternal age older than 40 years,
maternal phenylketonuria (PKU) birth defects, and diabetes. Children with
Down syndrome also have a higher incidence of tetralogy of Fallot, as do
infants with fetal hydantoin syndrome or fetal carbamazepine syndrome.
As one of the conotruncal malformations, tetralogy of Fallot can be associated
with a spectrum of lesions known as CATCH 22 (cardiac defects, abnormal facies,
thymic hypoplasia, cleft palate, hypocalcemia). Cytogenetic analysis may demonstrate
deletions of a segment of chromosome band 22q11 (DiGeorge critical region). Ablation
of cells of the neural crest has been shown to reproduce conotruncal malformations.
These abnormalities are associated with the DiGeorge syndrome and branchial
arch abnormalities.
The hemodynamics of tetralogy of Fallot depend on the degree of right
ventricular (RV) outflow tract obstruction (RVOTO). The ventricular septal
defect (VSD) is usually nonrestrictive, and the RV and left ventricular (LV)
pressures are equalized. If the obstruction is severe, the intracardiac shunt is from right
to left, and pulmonary blood flow may be markedly diminished. In this instance, blood
flow may depend on the patent ductus arteriosus (PDA) or bronchial collaterals.
 BOOK PICTURE PATIENT PICTURE

CLINICAL MANIFESTATION: CLINICAL MANIFESTATION:

The manifestations of heart failure Breathlessness
depends on the specific ventricular cough
involved the precipitating cause of failure, fever
the degree of impaired, the rate of oedema in lower extremities
progression the duration of the failure and tachycardia
the clients underlying conditions. increased pulse and respiration rate
oliguria
The signs and symptoms of heart failure insomnia
can be related to which ventricles are
affected. Left sided heart failure causes
different manifestations then right sided
heart failure. In chronic heart failure.
Patient may have right and left ventricular
failure.

left side heart failure:

Pulmonary congestion includes:-

dysnea, cough, pulmonary crackles
low oxygen saturation levels
heart sounds s3 or ventricular gallop
detected on auscultation, orthopnea,
paraxymal nocturnal dysnea,
adventitious breath sounds heard in
various areas of lungs, oliguria
insomnia, tachycardia, palpitations

right side heart failure:

Congestion in peripheral tissues and

the viscra predominates

Increased jugular venous distension

Systemic clinical manifestation: Assessing for heart failure:
oedema of lower extremities general:
hepatomegaly as cites fatigue
anorexia and nausea, weakness and decreased activity tolerance
weight gain due to retention of fluid dependent edema
Assessing for heart failure: general:
fatigue cardiovascular:
decreased activity tolerance apical impulses enlarged with left
dependent edema lateral displacement
jugular venous distension(JVD)
weight gain
cardiovascular: respiratory:
third heart sound s3
apical impulses enlarged with dysnea on exertion
leftlateral displacement pulmonary crackles that dont
pallor and cyanosis clear with cough
jugular venous distension(JVD) paroxysmal nocturnal dysnea
respiratory: (PND)
dysnea on exertion cerbro vascular:
pulmonary crackles that dont un explained confusion or altered
clear with cough mental status
orthopnea light headedness
paroxysmal nocturnal dysnea renal:oliguia and
(PND) decreased frequency
cerbro vascular: during the day
un explained confusion or altered
mental status gastro intestinal:
light headedness renal:
oliguia and decreased frequency no significance
during the day
nocturia
gastro intestinal:
anorexia and nausea
enlarged liver
ascites
hepato jugular reflux
DIAGNOSTIC EVALUATIONS
DIAGNOSTIC EVALUATIONS
history collection and physical
history collection and physical examination
examination Hemoglobin
assessment of ventricular function Total White Blood Count
serum chemistries, cardiac Direct count -P;L;E
enzymes, BNP levels, liver function Platelet count
tests, serum electrolytes, Bilirubin urea
 BUN,CBC. Serum creatinine
Chest x-ray ECG
12 lead ECG Chest x- ray
Echocardiography Routine urinalysis
Exercise stress testing
Nuclear imagaing studies MEDICAL MANAGEMENT
Hemodynamic monitoring
Cardiac catherization Inj. Dytor 20- 1gm, IV,BD
Routine uninalysis Inj. Taxim 1grm, IV 8th hrly
Inj. PNZ 40mg, IV, OD
MEDICAL MANAGEMENT*/ T. IVAS10mg oral, BD
T. Metoprolo 25mg, oral, OD
The goal of management of heart Continuous O2 inhalation
failure to relieve patient Floret
symptoms,
to improve functional status and Nitrofix nebulisation
quality of life and to extend survival. duolin
medical management based on type
, severity and cause of heart failure
specific objectives of medical
management includes the following
eliminates or reduce any etiologic
contributory factors such as
controlled hypertension or aterial
fibrillation with a rapid ventricular
response
optimize pharmacologic and other
therapeutic regimens
reduce the work load on the heart
by reducing preload and after load
promote a life style conducive to
cardiac health
prevent episodes of acute
decompensate heart failure.
managing the patient with heart
failure includes providing
comprehensive education and
counselling to the patient and
family
it is important that patient and
family understand the nature of
heart failure and the importance of
their participation in the treatment
regimen
life style recommendations
include restriction of dietary
sodium, avoidance of excessive fluid
 intake, alcohol and smoking weight
reduction when indicates and regular
exercises
pharmacologic therapy
angiotensin I- converting enzyme
inhibitors
angiotensin II receptor blockers
hydralazine and isosorbid dinitrate
betablockers and calcium channel
blockers
diuretics
digitalis
intravenous infusion
- nesiritide
- milrinome
- dobutamine
medications for diastolic
dysfunction
other medications for heart failure:
anticoagulants
non steroidal inflammatory drugs

Nutritional therapy:
a low sodium (2-3g/day) diet and
avoidance of drinking excessive Nutritional therapy:
amount of fluid are usually
recommended Provided a low sodium (2-3g/day)
diet and avoidance of drinking
dietary restriction of sodium excessive amount of fluid are
reduces fluid retention and the usually recommended
symptoms of peripheral and dietary restriction of sodium
pulmonary congestion reduces fluid retention and the
diet needs to be made with symptoms of peripheral and
consideration of good nutirion as pulmonary congestion
well s the patients likes and dislikes diet needs to be made with
and cultural food patterns consideration of good nutirion as
well s the patients likes and dislikes and
Additional therapy: cultural food patterns
supplemented oxygen Additional therapy:
other interventions
coronary artery revascularization supplemented oxygen
with PTCA; CABG surgery may be
considered
ventricular function may improve
in some patients when coronary
flow is increased.
Cardiac resynchronization therapy
 Cardiac transplantation
Mechanical circulation assistance
with an implanted ventricular
assist device
ultra filtration

COLLABORATIVE THERAPY:
treatment for underlying cause
o2 therapy at 2-6l/min by
nasalcannula
rest activity period
COLLABORATIVE THERAPY:
drug therapy
daily weights treatment for underlying cause
sodium restricted diet o2 therapy at 2-6l/min by nasal
circulatory assisted devices cannula
cardiac resynchronization therapy rest activity period
with internal cardio ventricular drug therapy
defibrillator daily weights
cardiac transplantation sodium restricted diet

Complication:

based on assessment data, potential Complication:

complication that may develop
including the following :
not significant
hypotension, poor perfusion and
cardiogenic shock
dysrhythmias
thrombo embolism
pericardial effusion and cardiac
tamponade.
NURSING MANAGEMENT:
NURSING MANAGEMENT:
Assessment:
Assessment:
Subjective data: Subjective data:
importance health information
importance health information Past health
1.Past health history: CAD,HTN,
cardiomyopathy, congenital heart history: CAD,HTN, rapid or irregular heart
disease or valvular, DM, thyroid or
lung disease rapid or irregular heart rate
rate.
2.medications: use of an compliance
with any cardiac medications, use of
diuretics, estrogens, corticosteroids,
non steroidal inflammatory drugs, over
the counter drug, herbal supplements.
Functional health pattern:
medications: use of an compliance
with any cardiac medications, use of
diuretics, corticosteroids, non steroidal
inflammatory drugs, over the counter
drug
Functional health pattern:

Health perception Health perception -

-healthmanagement:- healthmanagement:- fatigue, anxiety,
fatigue, anxiety, depression. depression.
Nutritional metabolic- Nutritional metabolic-
usual sodium intake, Usual sodium intake, ankle swelling
nausea, vomiting, Elimination:
anorexia, stomach bloating, decreased day time
weight gain, ankle swelling urinary output, constipation
Activity exercises:
Elimination:
dysnea, cough, palpitations,
nocturia, decreased day time
dizziness, fainting
urinary output,
Sleep and rest:
constipation
dysnea,insomnia.
Activity exercises:
Cognitive perceptual:
dysnea, orthopne, cough,
chest pain or heaviness, abdominal
palpitations, dizziness, fainting
discomfort; behavioural changes; visual
Sleep and rest: changes.
number of pillows
used for sleeping, paroxysmal
nocturnal, dysnea, insomnia.
Cognitive perceptual: chest pain
or heaviness, abdominal
discomfort; behavioural changes;
visual changes.
objective data:
Integumentary: cool, peripheral
oedema.
Respiration: tachypnea, wheezes,
tinged sputum.
objective data:
Cardiovascular: tachycardia, s3
Integumentary: cool, diaphoretic
&s4 murmurs, pulses
skin, cyanosis or pallor, peripheral
alterations,
oedema.
increased jugular vein pressure
Respiration: tachypnea, crackles,
Gastro intestinal: abdominal
rhonchi, wheezes, frothy, blood
distension
tinged sputum.
Neurologic: restlessness,confusion,
Cardiovascular: tachycardia, s3 &s4
decreased alteration or memory.
murmurs, pulses alterations,PMI
 displaced inferiorly and posterior
jugular vein distension
Gastro intestinal: abdominal
distension, hepatosplenomegaly,
ascites.
Neurologic: restlessness,confusion,
decreased alteration or memory.
NURSING DIAGNOSIS:
1. Risk for Decreased cardiac output related to structural abnormalities of
the heart.
2. Activity Intolerance related to imbalance in the fulfilment of oxygen to
the body's needs.
3. Impaired growth and development related to inadequate oxygenation,
tissue nitrifies needs, social isolation.
4. Risk for infection related to the general conditions is inadequate.

Theory application
Roys adaptation model Introduction:

Sister callista Roy began her nursing career in 1963. After receiving B.Sc(N)
from moult saint marry college.

1960receives Msc in nursing

1977 her doctorate in sociology

Roys model is characterised as a system theory with a strong analogies of

intervention.

General system:

Due to set of organized components released to form a whole employee feedback

cycle of input, through put, output.

INPUT: Input includes tensions adaption level (the range of stimuli to which
persons adaptation early)

THROUGH PUT: through put makes use of a person processes and effect
ions. Process refers to control mechanism that a person uses as a adaptive system.
Effectors refers to the physiologic function, self concept and role function
involved in adaptation.
OUTPUT: output is the outcome of the system when system is a person.
Output refers to persons behaviour.
Metaparadigm and RAM:

Human being:
Person is a bio psychological being in constant interaction with changing environment and
recipient the nursing care as living system
Environment:
Environment and surrounding and effect the development
and behaviour of the persons group. The internal and external are the part of
the persons environment.
For ex: elderly person admitted to hospital all the conditions of influence on
him/her.

Health:
heath is a process whereby individual are striving to achieve their
maximum potential. It can be seen in healthy people, exercises regularly, not
smoking pay attention dietary pattern. It is a process to relieve acute and
chronic illness and terminal stages of diseases & to control the sign and
symptoms, to promote health of the persons by promoting adaptive
responses.
Nurses:
the nurses to reduce the ineffective responses as output behaviour of the person. The
nurse
promotes the health in all life processes. The nurses suggested by the model include
approaches
aimed at maintaining adaptive responses that support the persons effort to creativity use
his or
her coping
 Nurses Notes

Name of the patient: M. Harish

Ward: CICU
Diagnosis: tetralogy of fallot
Age: 1year
Sex: male
Dr. Name: Dr.
E.p no: 794143
Bed. no: 1

TIME DIET MEDICATION NURSING CARE PLAN

730 Idly with observation:
chutney Inj. Dytor 20 Patient is very thin & less
activity and weakness;
830 water 50ml 1gm IV BD Inj. cough; fever;
breathlessness. Monitored
coconut water 0
800 Taxim 1gm IV 8th vital signs Temp:98.6 F
100ml Pluse:92b/min
rice porage Resp:22b/min
1030 hrly Inj. PNZ
Blood
1 cup pressure:120/60mm
40mg IV OD hg
T.Ivas 10mg SpO2: 93%
oral BD Provide position
 changing
T. Metoprolo frequently
25mg Oral Provide complete
bed rest
OD Provide calm
environment
floret} Administer
medication as
nitrofix} perphysician
nebulisation prescribed

duolin}

o2 inhalation

Administered O2
Provide nebulisation
History collection
and performed
physical
examination
Provide
psychological
support

Provided health
education about

Diet
Exercises
Personal hygiene
Relaxation therapy.
HEALTH EDUCATION

1.Medication :

instructed to:

take medications as prescribed by the physician

ensure the right oute in taking medications
take the medications on time and without lapse.

2.2.Exercise :

instructed to:

Do exercise within limits

Avoid the strenuous ones
Squatting
Active range of motion exercise

3.Treatment :

instructed to:

follow the prescribed treatment regimen

comply with the laboratory examinations
follow surgical treatment as per the physician

4.Hygiene :

encouraged to bath daily

instructed to do proper hand washing prior to and after handling patient

5.Outpatient orders:

Encouraged to have frequent medical visits

Taught to report any unusualities such as difficulty of breathing and decrease level of
consciousness
Provided with oral and written information regarding this discharge plan.

6.Diet :

instructed to:

Monitor the fluid intake and output accurately

 Abide by the limited intake as prescribed
Distribute the fluid intake over 24 hours as appropriate.
Consume high fibre diet in order to prevent constipation.
Limit salt intake to prevent further edema and cardiac overload
Avoid processing foods
Read labels of seasoning agent for sodium and pottasium content.
Bibliography:

Brunner &Suddarths text book of Medical Surgical Nursing, 12 th edition;

volume:1; page no:825-838 & 685-690

Lewis text book of Medical Surgical Nursing, Elsevier publication; page

no:820-837

Joyce. M. Black text book of Medical Surgical Nursing, 7th edition;

volume:2; page no:1649-1669 & 1548-559

Ross & Willison anatomy & physiology 2nd edition,2001; pageno:678-682.

Mosby doug consult for nurses, 2006, mosby publication