Patient identification data:

Name:-Rosika khatun
Father’s name:-Nabu Molla
Age:7 yr.
Sex:Female.
Ward:SNM
Registration No.:81488
Religion:-Muslim
Date of admission:3.10.12
Unit:B1
Under:Dr.K.L Barik
Diagnosis:Tetralogy of fallot
Address:Vill.-Bajejoypur
Po.-Jaypur
Dist.-Burdwan
P.s-Mongal Court
Name of the informant & relation with the child:Jashmina Khatun ,mother
Chief complaints:
On the first day of admission(3.10.2012)-Patient admitted with
Respiratory distress and weakness but no evidence of fever.
On the 2nd day of admission:-Respiratory distress slightly reduced but weak ness still present.

Present medical history:Patient admitted to the hospital due to respiratory distress for 1 month along with weakness
.Abnormal lung sound wheeze and creps is present.patient body weight is 15 k.g.
Past medical history:patient treated for respiratory distress for tetralogy of fallot after birth.September 2007 for this
condition she treated at Sri sathya sai institute of higher medical sciences ,Bangalor .In that time surgery was decided
but can not be offered due to long waiting list. So only symptomatic treatment is continued. She has no history of any
malaria,tuberculosis, epilepsy and allergic reaction .But she has past history of jaundice and bronchopneumonia .
Surgical history:Not applicabl
Family history:

Types of family:-Nuclear family

Total family member:5

Monthly income: Rs5000/

 Name Age Relation Education Occupation Health status
With patient

Sk.Hasan 65 yrs. Grandfather Not literate Farmer Asthma

present

Nabu molla 40 yrs. Father Class X Farmer Good

Jasmina Khatun 35 yrs. Mother Class V Housewife Good

Ajmira Khatun 12yrs. Elder sister Class VI Student Good

Pedigree:

Index-

Male

Female

Dead
male

Patient
Social history:

Environment :Rural area

Type of house:Kancha and it contains 3 rooms.

Ventilation:Cross ventilation present.

Sanitation:Sanitary latrin

Live stock:They have a cow

Availability of electricity:Present

Play facilities-Present

Communication-By phone and transport system

Immunization History:-Complited according to age

Physical examination:

General appearance:

Gait\Posture:Normal
Body build:Thin
Health:Weak
Mental status
Conciousness:Councious
Height\Length:115 cm.
Weight :14 kg
Vital Signs
Temperature:97.2 ̊ F
Pulse rate :110 beats\min.
Respiratiory rate:30 breath\min
Skin Condition
Colour :pallor but no present of jaundice or cyanosis.
Oedema :Not present
Turger :No presence of dehydration.
Head and face:Head is proportionate to the body.Head circumference is 41 cm.
Scalp :Clean and hair is fine,no presence of dandruff and pediculosis.
Anterior frontanelle:closed
Eyes :No presence of any discharge.
Eye brows :Normal
Eye lashes:Adequate
Eye lids :Oedematous
Conjunctiva:Pale ,anaemia present
Sclera :.No present of jaundice.
Pupils:Reactive to light.
Ears :Top of the pina cross the imaginary line draws at the lateral aspect of eyes.
External ear :Shape of the both ears are normal and no present of any discharge.
Nose :Shape of the nose is normal and no present of any discharge and deviated nasal septum.
Mouth and pharynx
Lips :Pale, no present of cleft lip
Teeth :No presence of dental caries and discolouration.
Palate :No presence of cleft palate.
Tongue :Clean,no presence of any coat.
Neck :Short neck
Lymph node :Lymph node is not enlarged and palpable.
Thyroid gland :Not palpable
Chest :Chest circumference is 40 cm.
Heart sound :Audible
Breath sound :No presence of abnormal lung sound.
Breast :No presence of any mass.

Abdomen :
Inspection :Abdomen is ronded in shape,no present of any skin rashes,scars,distention.
Palpation :Spleen and liver is not palpable.
 Percussion :No presence of gas,fluid.
Auscultation : Bowel sound present.
Extremities :Extremities are symmetry, range of motion is present.
Clubbing of finger: present .
Ankle Oedema:Not present .
Reflexes:All reflexes are present.
Spine & back:No presence of congenital defects, swelling or tenderness.
Genitals and rectum:No presence of haemorrhoids,vaginal discharge and inguinal node is not enlarged.

GROWTH AND DEVELOPMENT : PHYSICAL DEVELOPMENT

The following are signs of expected physical development in a toddler:

GROSS MOTOR SKILLS (use of large muscles in the legs and arms)

 Stands alone well by 12 months

 Walks well by 12 - 15 months (if the child is not walking by 18 months, he or she should be evaluated by a health
care provider)

 Learns to walk backwards and up steps with help at about 16 - 18 months

 Throws a ball overhand and kicks a ball forward at about 18 - 24 months

 Jumps in place by about 24 months

 Rides a tricycle and stands briefly on one foot by about 36 months

FINE MOTOR SKILLS (use of small muscles in hands and fingers)

 Makes tower of three cubes by around 15 months

 Scribbles by 15 - 18 months

 Can use spoon and drink from a cup by 24 months

 Can copy a circle by 36 months

LANGUAGE DEVELOPMENT

 Uses 2 - 3 words (other than Mama or Dada) at 12 - 15 months

 Understands and follows simple commands ("bring to Mommy") at 14 - 16 months

 Names pictures of items and animals at 18 - 24 months

 Points to named body parts at 18 - 24 months

 Begins to say his or her own name at 22 - 24 months

 Combines 2 words at 16 to 24 months -- there is a range of ages at which children are first able to combine words
into sentences; if a toddler cannot do so by 24 months, parents should consult their health care provider

 Knows gender and age by 36 months

SOCIAL DEVELOPMENT

 Indicates some needs by pointing at 12 - 15 months

 Looks for help when in trouble by 18 months

 Helps to undress and put things away by 18 - 24 months

  Listens to stories when shown pictures and can tell about immediate experiences by 24 months

 Can engage in pretend play and simple games by 24 - 36 months

Investigation:

1.Complete haemogram(8.10.2012)

Hb-11.3gm%
Total count-8.5 × 109 \L
Neutrophil-58%
Eosinophil-4%
Platelet-Adequate ×109\L
- 240×109\L
E.S.R-04\mm
2. 2-D,M,Mode Echocardiography (5.10.2012)
 Situs solitus,levocardia
 AV-VA concordance
 Normal great vessel relationship
 Large VSD(12mm)
 Overriding of aorta
 Right ventricular hypertrophy
 IAS-Intact
 Valves pericardium other chamber normal
 Aorto –mitral contimeatry maintained
Disease Condition:
Definition:- is a congenital heart defect which is classically understood to involve four anatomical abnormalities
(although only three of them are always present). It is the most common cyanotic heart defect, and the most common
cause of blue baby syndrome.

Incidence: 4:10.000 live births

Tetralogy of Fallot represents 15% of all the congenital heart disease, and is the most common of the cyanotic congenital
malformations1 , representing 55-70%. In a recent study by Boudjemline et al., in a series of 337 cases of conotruncal
heart disease, tetralogy of Fallot made up 56% of these cases, vascular malposition 16%, coarctation with or without
interruption of the aortic arch 14%, truncus arteriosus 9% and agenesis of the pulmonary valves 5%7 .

Related Anatomy and Physiology

It is a hollow muscular organ .It consist of four chambers called the right atrium,left atrium,right ventricle and left
ventricle.It lies in the middle mediastinum,within a pericardial sac and rests on the superior surface of the
diaphragm.The great vessel of the heart look upwards,diaphragmatic surface downwards and apex will be directed
downwards, forwards and to the left.Heart is divided vertically by the septam.

The main function of heart is blood circulation to whole body by pumping activity.

Pathophysiology:

In tetralogy of fallot,blood normally returns from the systemic circulation to the right atrium and right
ventricle.The outflow of blood from the right ventricle is resisted by the pulmonary stenosis so that the blood
flows through the ventricular septal defect into the aorta.This is right to left shunt.Hypertrophy of the right
ventricle occurs as a result of the pressure exerted against the pulmonary stenosis.Because the blood from the
right ventricle is unoxygenated,cyanosis results.With the decrease in the flow of blood to the lungs,the amount
of unoxygenated blood reaching the systemic circulation is increased.Polycythemia develops because the body
attempts to compensate for the unoxygenated blood.the resulting increased viscosity of the blood causes
slowing of the circulation and possibly thrombophlebitis,emboli,and cerebrovascular disease.
Clinical feature:Patient with tetralogy of fallot become symptomatic any time after birth.Neonates as well as infants
may develop anoxic spells(paroxysmal attacks of dyspnea)cyanosis may be present from birth or make its appearance
some years after birth.The commonest symptoms are dyspnea on exertion and exercise intolerance.Paroxysmal dyspnic
attacks may occur during the first 24 months of life and last for few minutes to hours.Short episode may be followed by
sleep but prolonged episode may lead to unconsciousness,convulsions,hemiparesis or death.These children do not grow
and develop normally.Their nutritional status is poor .Mental slowness may result from chronic hypoxia of the brain.On
auscultation a loud,harsh systolic murmur may be heard at the left middle to lower sternal border.
Diagnosis:History and physical examination is more important to detect the disease.
Chest X-ray-chest x-ray was the definitive method of diagnosis. The abnormal "coeur-en-sabot" (boot-like) appearance
of a heart with tetralogy of Fallot is classically visible via chest x-ray, although most infants with tetralogy may not show
this finding.Absence of interstitial lung markings are another classic finding in tetralogy.

Echocardiography:- echocardiography shows evidence of the aortic override,thick anterior right ventricular wall,and
large aorta.
Complication:Patients with tetralogy of fallot are subject to many difficulties .the dyspnea and increasing exercise
intolerance limit the patients considerably .If anaemia is along with tetralogy of fallot then oxygen carring capacity of
blood reduces the exercise tolerance.It can also result in cardiac enlargement ,congestive cardiac failure.Patients are
prone to infective endocarditis.Neurological complications occur frequently Anoxic infarction in the central nervous
system may occur during an anoxic spell and result in hemiplegia.Venous thrombosis due to sluggish circulation from
polycythemia can also result in hemiplegia.Any cyanotic patient present with headache,convulsions vomiting with or
without fever and neurological deficit

Manage ment:

Medical management:

Prior to corrective surgery, children with tetralogy of Fallot may be prone to consequential acute hypoxia (tet spells),
characterized by sudden cyanosis and syncope. These may be treated by both pharmacologocal and non pharmacological
way.

Non Pharmacological :

 Knee chest position

 Humidified oxygen.
 Pharmacological:

Tab Inderal

Correct anaemia by syp.Tonoferon.

Multivitamin to increase the body defence by syp.A-Z

Drug study

Name of Generic Mode of Dose Indication Contraindication Side Nurses

the drug name action effect responsibility

Tab Propranolol Propranolol 10 Hypertensi Sinus bradycardia, Insomni- -6 rights should

Inderal competivel mg- on,Portal cardiogenic a, be maintained.
y blocks β1 tds hypertensio shock,Pulmonary Cold -Bowel pattern
and β2 n, oedema,cardiac extremitie is assesed,
receptors to Anxiety, failure,Raynaud’s -s,fatigue, -weight is
decrease d essential disease,hypoglycae Dizzienes measured.
heart rate tremor, mia,severe , -Breathing
myocardial hyperthyroi haemorrhage, lassitude, pattern is
contractilit di-sm metabolic vomiting, assesed,
y. acidosis,2nd or 3rd nausea, -Carefully side
degree heart Anorexia, effect is
block,pregnancy. Constipati observed.
-on, -Never stop the
Wheezing medicine
,mood without doctors
alteration order.
-Get out from
bed slowly.

Surgical management:The operative treatment is two varieties palliative and definitive.The palliative treatment consist
of anastomosing a systematic a systematic artery with the pulmonary artery .the palliative operations prolong life and
increase the exercise tolerance.The three main systemic pulmonary anastomoses are :

i.Blalock-taussing shunt-Which consist of subclavian artery with pulmonary artery anastomosis .It is preferred on the side
opposite to aortic arch.

ii.Pott’s Shunt-The descending aorta is anastomosed to the pulmonary artery.

iii.Waterston’s Shunt-Ascending aorta and right pulmonary artery anastomosis.

The definitive operation or corrective surgery is

modified blalock-taussing shunt-It consist of closing the ventricular septal defect and resecting the infundibular
obstruction.

Nursing management-given through nursing care plan.

Nursing management-(8.10.2012 -10.10.2012)(8.10.2012-10.10.2012)

Assessment Diagnosis Goal Planning Intervention Evaluation

Subjective Ineffective To give  Respiratory  Respiratory Patient’s
data:- breathing relief from rate, rate, rhythm breathing
Difficulty in pattern related breathing rhythm,breath breath sound is difficulty is
brething. to related to difficulty. sound will be assesed. reduced .
bidirectional
Objective assesed.
shunting as Before
data:-  Knee chest
evidenced by intervention
Facial dyspnea.  Knee chest position is respiratory rate
expression, position will given. is 30
Increase be given. breath\min and
respiratory  Moist oxygen after
rate,restless  Moist oxygen is intervention
will be administered. respiratory rate
administered. is 26
 Vital signs are breath\min.
 Vital signs will checked and
be checked and recorded.
recorded.
 Patient is
 Patient will be encouraged to
encouraged to take deep
take slow deep breathing and
To maintain breathing and coughing. Patient takes
Subjective Altered coughing. food
nutritional
data:- nutrition less cooperatively
status.
Patient’s than body
complain requirement
related to  Personal liking
Objective  Personal liking
respiratory and disliking is
data:- and disliking
distress as will be assesed. assesed.
Weakness evidenced by  Small and
 Small and
patient’s frequent food frequent food
complain. will be given. is given.

 Before meals  Before meals

oral care is oral care is
provided. provided.

 Intake output  Intake output

chart will be chart is
maintained. maintained.

 Family  Family
members will be members are
instructed to instructed to
give low
give low
costly,protein
containing food. costly,protein
containing
food.
Assessment Diagnosis Goal Planning Intervention Evaluation
Subjective Activity To maitain  Activity level  Activity level Patient feel
data:- intolerance related adequate will be is assesed. comfort
Unable to do to respiratory activity level. assesed.
any work. distress as  Patient is
evidenced by  Patient will assisted to do
Objective fatigue. be assisted to range of
data:- do range of motion
Fatigue motion exercise.
exercise.
 Patient is
 Patient will instructed to
be instructed take rest in
to take rest in between
between activity.
activity.

 Personal
 Personal hygiene is
hygiene will maintained
be
maintained.

 Systemic Chances of
 Systemic and infection is
Subjective
Risk for To reduce the and localized reduced.
data:- infection related chances of localized signs and
Not to reduce body infection. signs and symptoms
applicable. defence. symptoms of infection
Objective of infection are
data:- will be monitored.
Reduce body monitored.  Hand
defence.  Hand washing is
washing will done before
be done and after
before and any
after any procedure.
procedure.
 Vital signs
 Vital signs checked and
will be recorded.
checked and
recorded.
 Family
 Family members are
members taught about
will be the signs
taught about and
the signs symptoms
 and of infection
symptoms
of infection.  Proper
nutritious
 Proper food is
nutritious given.
food will be
give

Assessment Diagnosis Goal Planning Intervention Evaluation

Subjective Parental .To  Understanding  Understanding
data:- anxiety related reduce level will be level is assesed. Anxiety
Feel fear to frequent the assesed. level is
about the hospitalization anxiety  All procedures is slight
disease. as evidenced by level.  All procedures explained before reduced.
verbalization. will be done.
Objective explained before
done.  Information is
data:-
given about
Verbalization, disease,treatment
 Information will
Facial and prognosis.
be given about
expression. disease,treatmen
t and prognosis.

Health teaching:

Education is given about

i.the knee chest position to reduce respiratory distress.

ii.rest between activity.

iii.to take easily available,cheap ,nutritious food to matain the nutritious level.

iv.to take food in small amount and frequent time.

v.Sign and symptom of infection.

Day to day progress:-

On 8.10.2012

 Patient is fully concious.

 She slept not well at last night.
  She passed urine but not passed stool.
 Mild respiratory distress is present
 She did not take breakfast.
 Body weight is 14kg.
 Weakness is present.
 Todays vital sign are-
T- 96.4̊F
P-120b/m
R-30b/m

On 9.10.2012


She is fully concious.

She slept well at last night.

She passed urine and stool.

She take breakfast.

No presence of respiratory distress

Weakness is present.

Todays vital sign are-
T-96.2̊F
P-110b/m
R-24b/m
On 10.10.2012

 She is fully concious.

 She slept well at last night
 She passed urine and stool.
 She take breakfast.
 Todays vital sign are
T-96.4̊F
P-100b/m
R-22b/m
Discharge advice:-
 Rest between activity.
 Take cheap ,iron containing nutritious food.
 Take small food in frequent time.
 Maintain personal hygiene.

Prognosis:

Untreated, Tetralogy of Fallot rapidly results in progressive right ventricular hypertrophy due to the increased
resistance on the right ventricle. This progresses to heart failure (dilated cardiomyopathy) which begins in the
right heart and often leads to left heart failure. Actuarial survival for untreated Tetralogy of Fallot is
approximately 75% after the first year of life, 60% by four years, 30% by ten years, and 5% by forty years.

Patients who have undergone total surgical repair of Tetralogy of Fallot have improved hemodynamics and
often have good to excellent cardiac function after the operation with some to no exercise intolerance (New
York Heart Association Class I-II). Surgical success and long-term outcome greatly depend on the particular
anatomy of the patient and the surgeon's skill and experience with this type of repair.
Ninety percent of patients with total repair as infants develop a progressively leaky pulmonary valve later in
adulthood. They require, therefore, follow up in specialized Adult Congenital Heart Disease cent

Conclusion:-Tetralogy of fallot is a congenital cyanotic heart disease .The common cause of cyanotic
congenotal heart disease is a communication between the pulmonary and systemic circulations through which
venous blood enters the systemic circulatory system .cyanosis may be sees at birth or may not be apparent until
later,commonly during the first year of life.It tends to increase as the child grows older.

Now a days various type of congenital heart defect are found.Tetralogy of fallot is four associated
anomalies. So to present this case I gain variors knowledge about the disease and its management and I my
group also get some idea about the disease and its management.

Bibliography:

i.Ghai O.P,Gupta piyush,Paul V.k.Essential paediatrics.New Delhi:6th edition.Cbs.407-409.

ii.Hockenberry Marilyn J, Wilson David.Essentials of pediatric nursing.Noida:8 th edition.Elsevier.2009.870-872.

ii.Marlow Dorothy R,Redding Barbara A.Text book of paediatric nursing.Noida:6 th edition.Elsevier.2009.479-481

iv.www.google.com
 Case Presentation
On
Tetralogy OF Fallot

Submitted to Submitted by
Madam aparna Nandi Munmun Roy

Govt.College Of Nursing, M.sc Nursing 1st year

Burdwan Govt.College of Nursing,

Burdwan