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학습 자료 둘러보기 →| Concept | Description | Nursing Implication |
|---|---|---|
| Tetralogy of Fallot (TOF) | Cyanotic heart defect with 4 components: VSD, Pulmonary Stenosis, Overriding Aorta, Right Ventricular Hypertrophy. | Monitor for cyanosis, clubbing, spells. Educate parents on spell management. |
| Hypercyanotic Spell ("Tet Spell") | Acute episode of increased right-to-left shunting causing severe cyanosis, dyspnea, and agitation. Often triggered by crying, feeding, defecation. | Immediate recognition is critical. Implement K-O-M-E protocol. |
| Knee-Chest Position | Compensatory maneuver that increases systemic vascular resistance (SVR), reducing right-to-left shunt. | Support and maintain this position. Do not force the infant out of it. |
| Spell Management (K-O-M-E) | Standardized emergency response: Knee-chest, Oxygen, Morphine, Evaluation/meds (Propranolol, IV fluids). | Know the sequence. Positioning and calming are first-line nursing actions. |
| Condition | Trigger for Deterioration | Compensatory Position/Behavior | Key Nursing Intervention |
|---|---|---|---|
| Tetralogy of Fallot (Hypercyanotic Spell) | Decreased SVR (e.g., crying, fever), Increased PVR | Knee-Chest Position (Squatting in older children) | Allow position, Calm, O2, Prepare meds (Morphine, Propranolol) |
| Heart Failure (Acute Pulmonary Edema) | Fluid overload, Increased cardiac workload | High Fowler's / Tripod Position | High Fowler's, O2, Diuretics, Morphine (for anxiety & preload reduction) |
| Severe Asthma Attack | Bronchospasm, Inflammation | Tripod Position (Leaning forward, arms braced) | High Fowler's, O2, Bronchodilators, Steroids |
학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.