S.no Time Objectives Content Teachers/ students activity

A.v.aids

Evaluation

1 2minTo give an Introduction about Tetralogy of Fallot

INTRODUCTION

Tetralogy of Fallot (teh-tral-uh-je ov fuh-LOE) is a rare condition caused by a combination of four heart defects that are 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

Lecture and discussion method

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What do you know about Tetralogy of Fallot ?

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To know about the definition of Tetralogy of Fallot ?

To list out the Symptoms of Tetralogy of Fallot

have restrictions on exercise.

DEFINITION

Tetralogy of Fallot (TOF) is a congenital heart defect which is classically 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.

SYMPTOMS

Tetralogy of Fallot symptoms vary, depending on the extent of obstruction of blood flow out of the right ventricle and into the lungs. Signs and symptoms may include:

A bluish coloration of the skin caused by

Lecture method

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Flash cards

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What are definitions of Tetralogy of Fallot ?

List out the Symptoms of Tetralogy of Fallot ?

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

4 2min To know about the causes of Tetralogy of Fallot?

young infants, around 2 to 4 months old.When to see a doctorSeek 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

Tetralogy of Fallot occurs during fetal growth, when the baby's heart is 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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What are the causes of Fallot?

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

5 3min To know about the pathophysiologyof Tetralogy of

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.

PATHOPHYSIOLOGY The initial defect in TOF is a narrowing of

the right ventricular outflow tract into the pulmonary artery. This prevents

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Flash chard

What is the pathophysiology for Tetralogy of Fallot ?

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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To know about the riskfactors of Tetralogy of Fallot ?

To know the complications of Tetralogy of Fallot ?

the right ventricle to immediately exit the heart mixed with blood from the left ventricle.

RISK FACTORSWhile the exact cause of tetralogy of Fallot is unknown, several factors may increase the risk of a baby being born with this 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

COMPLICATIONS

All babies with tetralogy of Fallot need corrective surgery. Without treatment, your baby may not grow and develop properly.

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chart

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What are the risk factors of Tetralogy of Fallot ?

What are the complications of tetology of fallot?

83min To know the test

and diagnosis of Tetralogy of Fallot ?

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.

TEST AND DIAGNOSIS

After your baby is born, your baby's doctor may suspect tetralogy of Fallot if the baby 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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Chain chart

How can you diagnose Tetralogy of Fallot ?

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.

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.

9 4min To know about the treatment and drugs for Tetralogy of Fallot ?

TREATMENT

Surgery is the only effective treatment for tetralogy of Fallot. There are two types of 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 repairTetralogy 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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chart How can you treat Tetralogy of Fallot ?

Temporary surgeryOccasionally 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 surgeryWhile 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

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 careAfter 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

10 4min To know about the postoperative care for your children

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.

POSTOPERATIVE CARE FOR YOUR CHILD: Children will spend time in the intensive care unit (ICU) after tetralogy of Fallot repair. 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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flipchart Explain about the postoperative care for your child

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

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

11 1min To conclude the tetralogy of fallot

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

SUMMARY AND CONCLUSION Definitive surgical correction of tetralogyof Fallot by the open technic has not beenAccompanied 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 have had cardiac evaluation studies including cardiac catheterization from 11/2 to 3 years postoperatively.

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Discuss the summary and conclusion

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

Manisha College of nursing

Lesson plan on

Tetralogy of Fallot

Submitted to Submitted by

Mrs. C.R. Shamsheer begum madam Mrs. Nimisha Rajan

M.Sc. (N) Principal M.Sc.(N), 2nd year

Dept. of child health nursing Dept. of child health nursing

Manisha college of nursing Manisha college of nursing

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

7. Test and diagnosis for Tetralogy of Fallot

8. Treatment for Tetralogy of Fallot

9. Summary and conclusion

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

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

LOW-DOSE SEQUENTIAL COMBINED-SPINAL EPIDURAL ANESTHESIA FOR CESAREAN SECTION IN PATIENT WITH UNCORRECTEDTETROLOGY OF FALLOT

Solanki SL, Jain A, Singh A, Sharma A.

Source

Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education & Research, Chandigarh,

India.

Abstract

Tetrology of Fallot (TOF) is the most commonly encountered congenital cardiac lesion in pregnancy. Although there

are controversies regarding safe anesthetic technique for parturient with TOF, we use low-dose sequential combined-spinal

epidural anesthesia in such a case posted for Cesarean section and found that low dose (0.5 ml of 0.5%) intrathecal

bupivacaine and fentanyl with sequential epidural bupivacaine supplementation was adequate for the performance of an

uncomplicated Cesarean section with minimal side effects and good fetal outcome. Thus, though the choice of anesthesia

can vary in such patients, low-dose sequential combined-spinal epidural can be a safe alternate to achieve good anesthesia

with impressive cardiovascular stability.

Name of the course : M.SC (nursing)

Year of the study : 2nd year

Clinical specialty : child health nursing

Topic : tetralogy of fallot

Name of the unit :unit IV

Method of teaching : lecture cum discussion

A.V.aids : handouts, flipchart, suspensory chart, flash cards, roller board, flash cards.

Venue : class room

Date of the presentation:

Duration : 30min

Size of the group : 30no’s

Previous knowledge of the group: students may have previous knowledge regarding tetralogy of fallot.