Tetralogy of Fallot: A Nursing Perspective

Tetralogy of Fallot

There are many congenital defects of the heart. Tetralogy of Fallot actually involves four major heart defects. When caring for a pediatric patient who is diagnosed with Tetralogy of Fallot or for a pediatric patient who is suspected to have Tetralogy of Fallot the nurse must take all four of these defects into consideration when assessing and intervening. The end goal for a child who is being treated for Tetralogy of Fallot is to obtain cardiopulmonary function that is adequate involving but not limited to adequate perfusion, output, and heart rhythm.

By obtaining the aforementioned goals the pediatric patient will be able to attain a more optimal nutritional status, increased activity tolerance, improved growth and development as well as improved respiratory function from correcting defects that would otherwise prevent adequate cardiopulmonary function.

Pathophysiology

Tetralogy of Fallot encompasses the subsequent four heart defects: Ventricular septal defect, pulmonary stenosis, an overriding aorta as well as a right ventricular hypertrophy. Pulmonary stenosis is the narrowing below or at the pulmonary valve, this narrowing’s outcome is from the impediment of blood that flows from the right ventricle to the pulmonary artery.

Ventricular septal defect permits blood to move across from the left ventricle to the right ventricle. The overriding aorta involves the position shift of the aorta toward the direction of the right side of the heart. Right ventricular hypertrophy occurs when the walls of the right ventricle enlarge which is caused by increased stress on the area that results from pulmonary stenosis.

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Signs and symptoms

There are many signs and symptoms that occur when a pediatric patient is suspected to have Tetralogy of Fallot and the nurse should look for the following: murmur, cyanosis, hypoxemia, dyspnea, sleepiness, decreased oxygen saturation, agitation, adventitious lung sounds and postures such as bending at knees or fetal position. An echocardiography may divulge right ventricular hypertrophy, reduction in size of the pulmonary artery and decrease in pulmonary blood flow. Electrocardiogram may point out right ventricular hypertrophy. Once a cardiac catheterization is performed it will expose the degree of structural defects. The term “TET spell” is cyanosis that is caused by activity intolerance such as feeding, crying or playing.

Medical treatment

Tetralogy of Fallot is medically managed by prescribing propranolol for infants who are hypercyanotic. In cases of severe Tetralogy of Fallot prostaglandin E1 is used to sustain patency of the ductus arteriosus while waiting for the pediatric patient to undergo surgery. Once the patient is able to undergo corrective surgery the surgeon will close the ventricular septal defect with a patch and the pulmonary stenosis will be eradicated by resection. Enlargement of pulmonary outflow tract is also achieved by use of a patch. Cardiopulmonary bypass is used during corrective surgery to maintain circulation of blood and oxygen to the body. It is preferable for the patient to undergo surgery to correct the defects prior to 6 months of age, however, if the patient has severe pulmonary stenosis or atresia the Blalock-Taussig procedure is usually performed and a full correction is done at a later date. The Blalock-Taussig procedure divides the left subclavian artery and connects to the left pulmonary artery which allows blood flow to the lungs to uptake oxygen.

Nursing interventions and care

Assessment of vital signs including blood pressure measurements conducted on both upper and lower extremities, continuous pulse oximetry and cardiac monitoring. An in depth cardiovascular assessment is essential and should include evaluating the following: heart rate and rhythm, murmurs, clicks, gallops, peripheral pulses, skin and nail bed color, capillary refill rate, pulse pressure, jugular vein distention, edema, thrills, point of maximum impulse, heaves and lifts. The nurse should also take note of retractions, crackles, rales, rhonchi and the work of breathing while conducting a respiratory assessment. It is pertinent to assess the daily weights as well as intake and output of the patient in order ensure fluid volume status is appropriate. Administering appropriate respiratory support is probable. Monitoring and reporting of lab values is especially crucial as electrolytes can quickly influence the conductivity of the heart. It is likely that the infant with Tetralogy of Fallot will be provided with a formula of higher caloric value with use of a higher flow nipple and also obtain nourishment via nasogastric tube or gastrostomy tube in order to promote growth. If a patient is having a “TET spell” the nurse can calm the patient, apply oxygen and put the patient in a knee-to-chest position and the nurse may also need to administer medication to increase systemic vascular resistance.

Discharge teaching

The nurse must assess if the caregivers have any special considerations prior to beginning discharge teaching such as language barriers, deafness, or illiteracy and choose the best method of teaching to meet those needs. The nurse must also encourage and answer any questions the patient’s family may have prior to discharge. Discharge teaching should include signs and symptoms that need to be reported to the physician immediately such as signs of cyanosis. Discharge paperwork should include contact information for the treating physician in case any problems occur. Return demonstration a highly effective way to determine to confirm that the caregivers understand how to care for the pediatric patient with Tetralogy of Fallot. Stressing the importance of attending follow-up appointments while providing written dates and times should be part of discharge teaching if possible.

Conclusion

Tetralogy of Fallot is a serious medical condition that needs lifetime observation. An in depth nursing assessment is essential throughout all points of care whether it be preoperatively, intraoperatively, or postoperatively. Nursing interventions must be carried out based upon having a thorough understanding of the correlation between the pathophysiology of Tetralogy of Fallot and the manifestations that present in the individual patient. The nursing staff must provide the caregivers with teachings that emphasize the importance of going to follow-up appointments as well as assessing if the caregivers understand the education provided from other members of the clinical team. In regards to nursing care for the patient with Tetralogy of Fallot, all nursing interventions, no matter how minor will vastly support achieving desired outcomes.

References

1. Buonocore AM, Oji O, Pravikoff D. (2018). Tetralogy of Fallot. CINAHL Nursing Guide.
2. Ricci, S.S., Kyle, T., Carman, S. (2017). Maternity and Pediatric Nursing. Philadelphia, PA: Wolters Kluwer
3. Schub E, Oji O, Pravikoff D. (2019). Tetralogy of Fallot: Caring for the Pediatric Patient with CINAHL Nursing Guide.
4. Verklan, M. T., Walden, M., Association of Women’s Health, Obstetric, and Neonatal Nurses, American Association of Critical-Care Nurses & National Association of Neonatal Nurses. (2015). Core curriculum for neonatal intensive care nursing.