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학습 자료 둘러보기 →| Concept | Description | Nursing Implication |
|---|---|---|
| Tetralogy of Fallot (TOF) | Congenital cyanotic heart defect with 4 components: VSD, Pulmonary Stenosis, Overriding Aorta, RV Hypertrophy. | Monitor for chronic cyanosis, clubbing, and acute hypercyanotic spells. |
| Hypercyanotic Spell ("Tet Spell") | Acute, life-threatening episode of profound cyanosis and hypoxemia due to increased right-to-left shunt. | Immediate intervention required: Knee-chest position, O2, calm the child, medications (morphine, propranolol, fluids). |
| Chronic vs. Acute Findings | Clubbing and baseline low SpO2 are chronic. Loss of consciousness is an acute, emergent change. | Prioritize assessment and intervention for acute changes over stable, chronic conditions. |
| Nursing Prioritization (ABCs) | Airway, Breathing, Circulation. A change in consciousness directly threatens Airway and Breathing. | Any finding involving altered mental status or respiratory distress is typically the highest priority. |
| Finding in TOF | Acute vs. Chronic | Priority Level & Rationale |
|---|---|---|
| Severe Cyanosis + LOC | Acute Emergency (Tet spell) | Highest Priority. Threatens ABCs, requires immediate action to prevent brain damage/death. |
| Mild Clubbing | Chronic (Develops over time) | Low Priority. Document and monitor, but not an immediate concern. |
| HR 140 bpm | Can be Normal (for age/activity) or a sign of distress | Moderate Priority. Requires assessment of context (is the child calm or agitated?). Not definitive for a spell. |
| SpO2 85% on RA | Chronic Baseline for uncorrected TOF | Moderate Priority. Requires planning for long-term care/surgery, but not an immediate intervention. |
학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.