Nursing Interventions for Tetralogy of Fallot

Nursing Diagnosis : Decreased Cardiac Output r / t ineffective circulation, secondary to the presence of cardiac malformations

Goal: Children can maintain adequate cardiac output


  • Vital signs are normal with age.
  • There is no dyspnea, rapid breathing and deep, cyanosis, anxiety / lethargy, tachycardia, murmurs.
  • Clients composmetis.
  • Akral warm.
  • Peripheral pulse strong and equal on both extremities.
  • Capillary refill time less than 3 seconds.
  • Urine output of 1-2 ml / kg / hour.

  1. Monitor vital signs, peripheral pulses, capillary refill by comparing measurements at both extremities while standing, sitting and lying down if possible.
  2. Assess and record the apical pulse for 1 full minute.
  3. Observation of cyanotic attacks.
  4. Give a knee-chest position in children.
  5. Observe for signs of decreased sensory: lethargy, confusion, and disorientation.
  6. Monitor intake and output adequately.
  7. Provide adequate rest time for children and accompany children during activity.
  8. Serve foods that are easily digestible and reduce the consumption of caffeine.
  9. Collaboration in the examination serial ECGs, chest radiographs, administration of anti dysrhythmias.
  10. Collaboration of oxygen.
  11. Collaboration IV fluid administration.
Source :