Risk for Decreased Cardiac Output related to Tetralogy of Fallot

Nursing Diagnosis: Risk for Decreased Cardiac Output related to structural abnormalities of the heart

Goal:

• no decline in cardiac output

Expected outcomes are:

• vital signs within normal limits,
• free of symptoms of heart failure,
• reported a decrease in episodes of dyspnoea,
• participate in activities that reduce the heart's workload,
• adequate urine output: 0.5 to 2 ml / kg body weight.

Nursing Interventions - Risk for Decreased Cardiac Output related to Tetralogy of Fallot:

1. Assess the pulse rate, respiration, blood pressure regularly every 4 hours.
R :/ Monitoring the change of heart circulation as early as possible.

2. Record the heart sounds.
R :/ Know of any changes in heart rhythm.

3. Assess changes in skin color of the cyanosis and pallor.
R :/ Pale showed a decrease in peripheral perfusion to inadequate cardiac output. Cyanosis occurs as a result of obstruction of blood flow to the ventricles.

4. Limit your activities adequately.
R :/ adequate rest is needed to improve the efficiency of cardiac contraction and oxygen consumption and reduce redundant work.

5. Monitor intake and output every 24 hours.
R :/ kidneys respond to decrease cardiac output by withholding the production of fluid and sodium.

6. Provide a quiet environment of psychological conditions.
R :/ emotional stress produces vasoconstriction which increases blood pressure and increased heart work.