LESSON PLAN

O
TETRALOGY
N OF FALLOT
SUBJECT: CHILD HEALTH NURSING

SUBMITTED BY:
Miss PUSHPLATA
GENERAL OBJECTIVE

On completion of the class the students will be able to understand the disease condition Tetralogy of Fallot so as to
apply this knowledge in their future practice with a positive attitude.

SPECIFIC OBJECTIVE:

On completion of the class the students will be able to;

1. Introduction of the Tetralogy of Fallot

2. Definition of Introduction of the Tetralogy of Fallot
3. Symptoms of Introduction of the Tetralogy of Fallot
4. Causes for Tetralogy of Fallot
5. Risk factors for Tetralogy of Fallot
6. Complications for Tetralogy of Fallot

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S.no Time Objectives Content Teachers A.v.aid Evaluation
/ students s
activity
To give an INTRODUCTION
1 2min Introduction Lecture Black What do you
Tetralogy of Fallot (teh-tral-uh-je
about Tetralogy and board know about
of Fallot ov fuh-LOE) is a rare condition caused by a discussio Tetralogy of
combination of four heart defects that are n method Fallot ?
present at birth. These defects, which affect
the structure of the heart, cause oxygen-
poor blood to flow out of the heart and into
the rest of the body. Infants and children
with tetralogy of Fallot usually have blue-
tinged skin because their blood doesn't
carry enough oxygen.
Tetralogy of Fallot is often
diagnosed during infancy or soon after.
However, tetralogy of Fallot may not be
detected until later in life, depending on the
severity of the defects and symptoms. With
early diagnosis followed by appropriate
treatment, most children with tetralogy of
Fallot live relatively normal lives, though
they'll need regular medical care and may

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 have restrictions on exercise.

2 2min To know about DEFINITION Lecture Flash What are

the definition of method cards definitions
Tetralogy of Fallot (TOF) is
Tetralogy of of Tetralogy
Fallot ? a congenital heart defect which is classically of Fallot ?
understood to involve four anatomical
abnormalities of the heart (although only three
of them are always present). It is the most
common cyanotic heart defect, and the most
common cause ofblue baby syndrome.
It was described in 1672 by Niels
Stensen, in 1773 by Edward Sandifort, and in
1888 by the French physician Étienne-Louis
Arthur Fallot, after whom it is named.

Lecture Flip List out the

3 2min To list out the SYMPTOMS method chart Symptoms
Symptoms of Tetralogy of Fallot symptoms vary, of Tetralogy
Tetralogy of of Fallot ?
depending on the extent of obstruction of
Fallot
blood flow out of the right ventricle and
into the lungs. Signs and symptoms may
include:
 A bluish coloration of the skin caused by

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 blood low in oxygen (cyanosis)
 Shortness of breath and rapid
breathing, especially during feeding
 Loss of consciousness (fainting)
 Clubbing of fingers and toes — an
abnormal, rounded shape of the nail bed
 Poor weight gain
 Tiring easily during play
 Irritability
 Prolonged crying
 A heart murmur

Tet spells
Sometimes, babies with tetralogy of
Fallot will suddenly develop deep blue
skin, nails and lips after crying, feeding,
having a bowel movement, or kicking his or
her legs upon awakening. These episodes
are called Tet spells and are caused by a
rapid drop in the amount of oxygen in the
blood. Toddlers or older children may
instinctively squat when they are short of
breath. Squatting increases blood flow to
the lungs. Tet spells are more common in

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 young infants, around 2 to 4 months old.
When to see a doctor
Seek medical help if you notice that your
baby has the following symptoms:
 Difficulty breathing
 Bluish discoloration of the skin
 Passing out or seizures
 Weakness
 Unusual irritability

CAUSES Lecture pamphl What are the

4 2min To know about method ets causes of
the causes of Tetralogy of Fallot occurs during fetal Fallot?
Tetralogy of growth, when the baby's heart is
Fallot? developing. While factors such as poor
maternal nutrition, viral illness or genetic
disorders may increase the risk of this
condition, in most cases the cause of
tetralogy of Fallot is unknown.
The four abnormalities that make up
the tetralogy of Fallot include:
 Pulmonary valve stenosis. This is a
narrowing of the pulmonary valve, the flap
that separates the right ventricle of the

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 heart from the pulmonary artery, the main
blood vessel leading to the lungs.
Constriction of the pulmonary valve
reduces blood flow to the lungs. The
narrowing may also affect the muscle
beneath the pulmonary valve.
 Ventricular septal defect. This is a hole
in the wall that separates the two lower
chambers (ventricles) of the heart. The
hole allows deoxygenated blood in the
right ventricle — blood that has circulated
through the body and is en route to the
lungs to replenish its oxygen supply — to
flow into the left ventricle and mix with
oxygenated blood fresh from the lungs.
Blood from the left ventricle also flows
back to the right ventricle in an inefficient
manner. This ability for blood to flow
through the ventricular septal defect dilutes
the supply of oxygenated blood to the body
and eventually can weaken the heart.
 Overriding aorta. Normally the aorta,
the main artery leading out to the body,
branches off the left ventricle. In tetralogy

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 of Fallot, the aorta is shifted slightly to the
right and lies directly above the ventricular
septal defect. In this position the aorta
receives blood from both the right and left
ventricles, mixing the oxygen-poor blood
from the right ventricle with the oxygen-
rich blood from the left ventricle.
 Right ventricular hypertrophy. When
the heart's pumping action is overworked,
it causes the muscular wall of the right
ventricle to enlarge and thicken. Over time
this may cause the heart to stiffen, become
weak and eventually fail.
Rarely, some babies who have tetralogy of
Fallot will have a hole between their
heart's upper chambers (atrial septal
defect), as well. When this occurs, the
condition is known as pentalogy of Fallot.

Lecture Flash What is the

5 3min To know about PATHOPHYSIOLOGY method chard pathophysiol
the  The initial defect in TOF is a narrowing of ogy for
pathophysiology the right ventricular outflow tract into the Tetralogy of
of Tetralogy of pulmonary artery. This prevents Fallot ?

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Fallot ? deoxygenated blood from entering the
pulmonary circuit.
 In response to this outflow obstruction, the
myocardium of the right ventricle
hypertrophies in order to contract
forcefully enough to push blood past the
stenosis.
 Additionally, patients have a large
ventricular septal defect which allows
shunting of blood between the ventricles.
In a patient with an isolated VSD, the
blood flow is shunted initially from left‐to‐
right.
 However, in TOF, the right ventricular
outflow obstruction may impede the
normal blood flow so significantly that the
left side of the heart becomes the path of
least resistance.
 Blood from the right ventricle is then
forced into the left ventricle, creating a
right‐to‐left shunt and subsequent cyanosis.
 Finally, the aorta overrides the ventricular
septal defect, straddling the VSD. This
allows deoxygenated blood shunted from
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 the right ventricle to immediately exit the
heart mixed with blood from the left
ventricle.
Lecture chart What are the
RISK FACTORS method risk factors
6 2min To know about While the exact cause of tetralogy of Fallot of Tetralogy
the riskfactors of is unknown, several factors may increase of Fallot ?
Tetralogy of the risk of a baby being born with this
Fallot ?
condition. These include:
 A viral illness in the mother, such as
rubella (German measles), during
pregnancy
 Maternal alcoholism
 Poor nutrition
 A mother older than 40
 A parent with tetralogy of Fallot
 Babies who are also born with Down
syndrome or DiGeorge syndrome

7 Lecture Flash What are the

COMPLICATIONS
3min To know the method cards complication
complications of All babies with tetralogy of Fallot need s of tetology
Tetralogy of corrective surgery. Without treatment, your of fallot?
Fallot ? baby may not grow and develop properly.

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 He or she is also at increased risk of serious
complications, such as infective
endocarditis, an inflammation of the inner
lining of the heart caused by a bacterial
infection.
Untreated cases of tetralogy of Fallot
usually develop severe complications over
time, which may result in death or disability
by early adulthood.

8 Lecture Chain How can

3min To know the test TEST AND DIAGNOSIS method chart you diagnose
and diagnosis of After your baby is born, your baby's doctor Tetralogy of
Tetralogy of Fallot ?
may suspect tetralogy of Fallot if the baby
Fallot ?
has blue-tinged skin or if a heart murmur —
an abnormal whooshing sound caused by
turbulent blood flow — is heard in your
child's chest. By using several tests, your
doctor can confirm the diagnosis.
 Chest X-ray. A typical sign of tetralogy
of Fallot on an X-ray is a "boot-shaped"
heart, because the right ventricle is
enlarged.
 Blood test. Your child will need a test that

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 measures the number of each type of cell
in the blood, called a complete blood
count. In tetralogy of Fallot, the number
of red blood cells may be abnormally high
(erythrocytosis) as the body attempts to
increase the oxygen level in the blood.
 Oxygen level measurement (pulse
oximetry). This test uses a small sensor
that can be placed on a finger or toe to
measure the amount of oxygen in the
blood.
 Echocardiography. Echocardiograms use
high-pitched sound waves, inaudible to
the human ear, to produce an image of the
heart. Sound waves bounce off your
baby's heart and produce moving images
that can be viewed on a video screen. This
test helps diagnose tetralogy of Fallot
because it allows the doctor to see
whether there is a ventricular septal
defect, if the structure of the pulmonary
valve is normal, if the right ventricle is
functioning properly, and if the aorta is
positioned properly.

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 Electrocardiogram. An
electrocardiogram records the electrical
activity in the heart each time it contracts.
During this procedure, patches with wires
(electrodes) are placed on your baby's
chest, wrists and ankles. The electrodes
measure electrical activity, which is
recorded on paper. This test helps
determine if your baby's right ventricle is
enlarged (ventricular hypertrophy) and if
the heart rhythm is regular.
 Cardiac catheterization. During this
procedure, your doctor inserts a thin
flexible tube (catheter) into an artery or
vein in your baby's groin and threads it up
to his or her heart. A dye is injected
through the catheter to make your baby's
heart structures visible on X-ray pictures.
The catheter also measures pressure and
oxygen levels in the chambers of the heart
and in the blood vessels.

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9 4min To know about Lecture chart How can
TREATMENT
the treatment and method you treat
drugs for Surgery is the only effective treatment for Tetralogy of
Tetralogy of tetralogy of Fallot. There are two types of Fallot ?
Fallot ? surgery that may be performed, including
intracardiac repair or a temporary
procedure that uses a shunt. Most babies
and children will have intracardiac repair.
Intracardiac repair
Tetralogy of Fallot treatment for most
babies involves a type of open-heart
surgery called intracardiac repair. This
surgery is typically performed during the
first year of life. During this procedure, the
surgeon places a patch over the ventricular
septal defect to close the hole between the
ventricles. He or she also repairs the
narrowed pulmonary valve and widens the
pulmonary arteries to increase blood flow
to the lungs. After intracardiac repair, the
oxygen level in the blood increases and
your baby's symptoms will lessen.

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Temporary surgery
Occasionally babies need to undergo a
temporary surgery before having
intracardiac repair. If your baby was born
prematurely or has pulmonary arteries that
are underdeveloped (hypoplastic), doctors
will create a bypass (shunt) between the
aorta and pulmonary artery. This bypass
increases blood flow to the lungs. When
your baby is ready for intracardiac repair,
the shunt is removed.

After the surgery

While most babies do well after
intracardiac repair, complications are
possible. Possible complications are
chronic pulmonary regurgitation, in which
blood leaks through the pulmonary valve,
and an irregular heartbeat (arrhythmia).
Sometimes blood flow to the lungs is still
restricted after intracardiac repair. Infants
and children with these complications may
require another surgery, and in some cases,
their pulmonary valves may be replaced by

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artificial valves. Pulmonary valve
replacement sometimes isn't necessary until
decades after the original surgery. In
addition, as with any surgery, there's a risk
of infection, unexpected bleeding or blood
clots. Arrhythmias are usually treated with
medication, but some people may need a
pacemaker or implantable defibrillator later
in life. Complications can continue
throughout childhood, adolescence and
adulthood. Your child will need lifelong
medical follow-up to monitor for and treat
any complications.

Ongoing care
After surgery your baby will require
continuing care. Your doctor will schedule
routine checkups with your child to make
sure that the procedure was successful and
to monitor for any new problems.
Your doctor may also recommend that your
child limit physical activity. However, if
surgery was completely successful and
there's no pulmonary valve leakage or

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 obstruction, your child may not have any
activity restrictions.
Sometimes, doctors recommend that your
child take antibiotics during dental
procedures to prevent infections that may
cause endocarditis, an inflammation of the
lining of the heart. Although, in cases
where the heart was completely repaired,
your child may not need preventive
antibiotics. Preventive antibiotics are,
however, recommended specifically for
those who have artificial valves or who've
had repair with prosthetic material. Ask
your cardiologist what's right for your
child.

10 4min To know about POSTOPERATIVE CARE FOR YOUR Lecture flipchart Explain
the postoperative method about the
CHILD:
care for your postoperativ
children Children will spend time in the intensive
e care for
care unit (ICU) after tetralogy of Fallot repair.
your child
During the first several hours after surgery,
your child will be very drowsy from the
anesthesia that was used during the operation,
and from medications given to relax him/her

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and to help with pain. As time goes by, your
child will become more alert.
While your child is in the ICU, special
equipment will be used to help him/her
recover, and may include the following:
 Ventilator - a machine that helps your child
breathe while he/she is under anesthesia
during the operation. A small, plastic tube
is guided into the windpipe and attached to
the ventilator, which breathes for your
child while he/she is too sleepy to breathe
effectively on his/her own. After a truncus
repair, children will benefit from remaining
on the ventilator overnight or even longer
so they can rest.
 Intravenous (IV) catheters - small, plastic
tubes inserted through the skin into blood
vessels to provide IV fluids and important
medicines that help your child recover
from the operation.
 arterial line - a specialized IV placed in the
wrist or other area of the body where a
pulse can be felt, that measures blood
pressure continuously during surgery and

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 while your child is in the ICU.
 Nasogastric (NG) tube - a small, flexible
tube that keeps the stomach drained of acid
and gas bubbles that may build up during
surgery.
 urinary catheter - a small, flexible tube
that allows urine to drain out of the bladder
and accurately measures how much urine
the body makes, which helps determine
how well the heart is functioning. After
surgery, the heart will be a little weaker
than it was before, and, therefore, the body
may start to hold onto fluid, causing
swelling and puffiness. Diuretics may be
given to help the kidneys to remove excess
fluid from the body.
 Chest tube - a drainage tube may be
inserted to keep the chest free of blood that
would otherwise accumulate after the
incision is closed. Bleeding may occur for
several hours, or even a few days after
surgery.
 Heart monitor - a machine that constantly
displays a picture of your child's heart

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 rhythm, and monitors heart rate, arterial
blood pressure, and other values.

11 1min To conclude the Lecture Black Discuss the

SUMMARY AND CONCLUSION
tetralogy of fallot method board summary
 Definitive surgical correction of tetralogy and
of Fallot by the open technic has not been conclusion
Accompanied by a higher operative mortality
than that associated with the shunt operations.
 As a result of the surgical technics being
directed at the correction of the defects,
greater improvement approximating
normal is attained.

 Fifty patients with tetralogy of Fallot have

had surgical correction of their complex
defects made possible by the open technic
during the past 5 years. The overall 5-year
operative mortality was 18 per cent.

 This was reduced to 15 per cent during the

past 2 years in 20 patients. Forty-one of the
patients are alive, asymptomatic, and have
normal physical activity. Fifteen patients
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 have had cardiac evaluation studies
including cardiac catheterization from 11/2
to 3 years postoperatively.

 Thirteen patients had normal cardiac

hemodynamics. In only two patients was
there evidence of incomplete hemodynamic
improvement even though marked clinical
improvement was gained.

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 BIBLIOGRAPHY
BOOK REFERENCE
1. A Textbook of Child Health Nursing, Manoj Yadav, PV Publications, 1st Edition,
2. Textbook of pediatric Nursing, Dorothy R Marlow, Elsevier Publication,6th Editions,
3. Essentials of Pediatric Nursing, wongs , Elsevier Publication,7th Editions,
4. Textbook of of pediatric Nursing, Beevi, Elsevier Publication,1st Edition,
5. Essentials of Pediatric Nursing, Piyush Gupta, CBS Publication, 2nd edition,

JOURNAL REFERENCE

 http://www.ncbi.nlm.nih.gov/pubmed/21957416

WEB REFERENCE

 http://en.wikipedia.org/wiki/Tetralogy_of_Fallot
 http://www.childrenshospital.org/az/Site515/mainpageS515P0.html
 http://www.mayoclinic.com/health/tetralogy-of-fallot/DS00615

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 http://emedicine.medscape.com/article/2035949-overview

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