Nursing Field Notes / Cardio · Congenital Heart Defects III · NUR 235 Peds

🫀 HEART DEFECTS SET NG-151 ASD·VSD·PDA·AVSD NG-118 Tetralogy of Fallot NG-183 Stenosis & Coarctation NG-201 Surgery & Chest Tubes

Tetralogy of Fallot 💜

TOF — four defects, one blue baby · the CYANOTIC classic

NG-118 CARDIO · PEDS ADHD-friendly visual edition

Tetra = 4. Four defects that all push the same direction: blood is blocked on the way to the lungs, so it takes the hole instead and goes RIGHT → LEFT, straight out to the body without ever picking up oxygen. That is cyanosis. When it happens all at once it is a “TET SPELL” — and the first thing you do is knees to chest.

📄 Simple Nursing original — opens in Drive →

4️⃣ P·R·O·VPulmonary stenosis · RV hypertrophy · Overriding aorta · VSD. Tetra = 4.

💜 RIGHT → LEFTCYANOTIC, with ↓ decreased pulmonary blood flow. Blue skin, O₂ sat 65–85%.

🚨 TET SPELL → KNEES TO CHESTInfant: knee-to-chest. Older child: squatting. Position FIRST, then oxygen.

🩸 Report Hgb over 22 g/dLPolycythemia = thick blood = clot risk. Keep them hydrated.

🫀

THE BASE HEART

STEP 0 · SAME PICTURE AS EVERY PAGE

Same drawing as the ASD/VSD/PDA page and the stenosis page. Learn the normal, then add the four changes.

🫀 The normal heart — the drawing all four pages share

right heart · O₂-poor left heart · O₂-rich L → R shunt R → L shunt obstruction (bow-tie)

🧠 “Blue in on the left of the page, red out on the right.” Right heart (blue) is drawn on your left, left heart (red) on your right — an anatomic view, facing the patient.

🔁 BASE NORMAL CIRCULATION — identical on every page in this set

Say this out loud before every defect:

Body ➡ SVC + IVC ➡ RIGHT ATRIUM

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tricuspid valve ➡ RIGHT VENTRICLE

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pulmonic valve ➡ PULMONARY ARTERY ➡ LUNGS (pick up O₂)

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pulmonary veins ➡ LEFT ATRIUM

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mitral valve ➡ LEFT VENTRICLE

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aortic valve ➡ AORTA ➡ body

The LEFT side is a high-pressure pump; the RIGHT side is a low-pressure pump. That one fact predicts every shunt on every page: if there is a hole, blood takes the easy road and goes LEFT → RIGHT — back into the lungs — until something blocks the right side or raises right-sided pressure. Only then does it reverse and go RIGHT → LEFT, which is when the baby turns blue.

🧠 “Lefty is stronger, so lefty pushes.” Left → Right = pink (blood still gets to the lungs). Right → Left = blue (blood skips the lungs). Blue blood in a pink baby's body = cyanosis.

⭐ THE classification you are tested on — Tetralogy lives in the CYANOTIC row

Group	Shunt direction	Pulmonary blood flow	Blue?	Defects
💛 ACYANOTIC	LEFT → RIGHT	↑ INCREASED — too much blood to the lungs	No (pink at first)	ASD · VSD · PDA · AVSD
🧡 OBSTRUCTIVE	none — the road is narrowed	normal or ↓, depending on where the narrowing is	Usually no	Pulmonic stenosis · Aortic stenosis · Coarctation of the aorta
💜 CYANOTIC	RIGHT → LEFT	↓ DECREASED — blood skips the lungs	YES	Tetralogy of Fallot · Tricuspid atresia
🩵 MIXED	both ways — red and blue blood mix	varies	Yes	Transposition of the great arteries · Truncus arteriosus · TAPVR · hypoplastic left heart

🧠 “Pink holes, blue Ts, orange gates.” Holes (ASD/VSD/PDA/AVSD) leave the baby pink · the big Ts (Tetralogy, Tricuspid atresia, Transposition) turn the baby blue · the gates (stenosis, coarctation) are orange bow-ties — nothing is leaking, something is blocked.

🧭 How to read every diagram in this series

Blue chambers = right heart, O₂-poor blood.
Red chambers = left heart, O₂-rich blood.
Topaz arrow = a LEFT → RIGHT shunt (acyanotic).
Amethyst arrow = a RIGHT → LEFT shunt (cyanotic) — the TOF arrow.
Citrine bow-tie ▶◀ = an obstruction — TOF has one, at the pulmonary valve.
Lavender = heart muscle. A thick lavender wall = hypertrophy.

🧠 Read the drawing right. It is an anatomic view, so the patient's RIGHT heart is on YOUR LEFT. That is why a “left-to-right” shunt arrow points ← to your left on every diagram in this series. Same picture, four pages.

⭐ Why TOF turns a baby blue — one sentence

Answer first: the pulmonary valve is narrowed, so the right ventricle cannot push blood forward into the lungs. Pressure in the right ventricle climbs until it is higher than the left.

Now the hole (the VSD) runs backwards: blue blood crosses RIGHT → LEFT and is picked up by the overriding aorta, which sits directly over the hole. Blue blood is pumped out to the body.

Less blood reaches the lungs → decreased pulmonary blood flow → hypoxemia and cyanosis.

🧠 “Blocked in front, hole in the middle, aorta on top.” Blocked exit + a hole + an aorta sitting over that hole = blue blood out the front door.

4️⃣

THE FOUR DEFECTS

STEP 1 · TETRA = 4 · P·R·O·V

All four drawn on the same base heart, in one picture — because they only make sense together.

💜 All FOUR components on one drawing — P · R · O · V

🧠 “PROVe it's Tetralogy.” Pulmonary stenosis · Right ventricular hypertrophy · Overriding aorta · VSD. Say PROV out loud four times — it is worth an easy point.

1️⃣ P — PULMONARY STENOSIS THE DRIVER

What: the outflow from the right ventricle to the lungs is narrowed (the citrine bow-tie ▶◀).

Why it matters: this is the engine of the whole disease. The tighter the stenosis, the higher the RV pressure, the bigger the right-to-left shunt, the bluer the child.

Sound: a systolic ejection murmur at the left upper sternal border — the murmur is from the stenosis, not from the VSD.

🧠 Pinch the straw, the drink backs up. Pinch the pulmonary artery and the right ventricle backs up into the hole.

2️⃣ R — RIGHT VENTRICULAR HYPERTROPHY

What: the RV muscle thickens (the fat lavender wall) because it is pushing against a narrowed valve every single beat.

Why it matters: hypertrophy is a result, not a cause — and it is what makes RV pressure exceed LV pressure, which is what reverses the shunt.

X-ray classic: a “boot-shaped heart” — the uplifted apex of a thick right ventricle.

🧠 “Lift weights, grow muscle.” The RV lifts against a closed door all day, so it bulks up. A boot-shaped heart kicks the door.

3️⃣ O — OVERRIDING AORTA

What: the aorta is shifted over the septum, so its opening sits directly on top of the hole — it collects blood from BOTH ventricles. That is why the funnel in the drawing is blue on the left and red on the right.

Why it matters: it is the delivery route. Without it, blue blood would just cross into the LV; with it, blue blood is aimed straight at the body.

🧠 “The aorta sits on the hole like a chimney on a crack.” Whatever comes up the crack goes straight out the chimney.

4️⃣ V — VSD (ventricular septal defect)

What: a hole between the ventricles — the same hole you learned on the ASD/VSD/PDA page.

Why it matters: in an isolated VSD the shunt runs LEFT → RIGHT and the baby stays pink. In Tetralogy the pulmonary stenosis flips the pressures, so the very same hole now runs RIGHT → LEFT and the baby turns blue.

EXAM TIP The hole did not change — the pressure did. That single idea is the difference between the acyanotic group and the cyanotic group.

🧠 “Same hole, opposite direction.” Direction is decided by pressure, never by the hole.

⭐ TOF vs a plain VSD — the comparison that gets tested

	Isolated VSD (NG-151)	VSD inside Tetralogy of Fallot
Group	ACYANOTIC	CYANOTIC
Shunt direction	LEFT → RIGHT	RIGHT → LEFT
Pulmonary blood flow	↑ increased — lungs flooded	↓ decreased — lungs starved
Color	Pink	Blue · O₂ sat 65–85%
Why	Left-sided pressure is higher — normal	Pulmonary stenosis raises RIGHT-sided pressure above the left
Main risk	Heart failure, pulmonary hypertension	Tet spells, hypoxia, polycythemia & clots

🧠 “Add a pinch, flip the flow.” A VSD plus a pinched pulmonary artery = Tetralogy, and the arrow turns around.

💜 The rest of the cyanotic & mixed family — know the one-liners

Defect	One-line definition	Treatment
Tetralogy of Fallot	4 defects: P·R·O·V — right-to-left shunt, decreased pulmonary blood flow	Surgical repair (VSD patch + relieve the outflow obstruction)
Tricuspid atresia	Closure of the tricuspid valve — no door from RA to RV — so an ASD (and usually a VSD/PDA) is what keeps the child alive	Surgical repair, in staged operations
Transposition of the great arteries (TGA)	Reversal of the 2 main arteries leaving the heart — the pulmonary artery and the aorta are swapped, creating two separate circles that never meet	Surgical repair (arterial switch); prostaglandin + balloon atrial septostomy to allow mixing until then
Truncus arteriosus	One single great vessel leaves the heart instead of two — a connection between the aorta & pulmonary artery — sitting over a VSD	Surgical repair

SOURCE FIX The original sheet grouped TGA and truncus arteriosus under “right-to-left blood flow.” In the classification you will be tested on they are MIXED blood flow defects — red and blue blood mix rather than shunting one direction. They are still cyanotic, so the color clue is the same.

🧠 “The blue Ts” — Tetralogy · Tricuspid atresia · Transposition · Truncus. Four T's, all blue, all end in surgical repair.

💜

TET SPELLS & CLUES

STEP 2 · MOST TESTED

A hypercyanotic episode. Answer first: knees to chest. Then oxygen, then calm, then call.

🚨 During an episode — the IMMEDIATE action is the POSITION

🦵 POSITION FIRST — knee-to-chest (infant) or squatting (older child). It is the fastest, cheapest intervention and it works in seconds.

💨 Give oxygen — blow-by or mask, whatever the child will tolerate without fighting.

🤫 Calm and comfort — a quiet, dim room. Crying makes the spell worse, so soothing IS treatment.

📞 Notify the provider · anticipate IV fluids and morphine as ordered, and continuous monitoring.

Never leave the child, and never force a struggling child into a mask — agitation deepens the spell.

🧠 “Knees, O₂, quiet, call.” Four steps in order. If the question offers “place the infant in a knee-chest position”, that is the answer — every time.

🔎 What a spell looks like & what sets one off

During the spell:

💙 Sudden deep cyanosis — much bluer than the child's baseline.
😤 Deep, rapid breathing (hyperpnea).
😡 Irritability & inconsolable crying, then limpness / lethargy.
🔇 The murmur gets QUIETER — less blood is crossing the narrowed pulmonary valve. NCLEX TRAP
😵 Severe spells: syncope, seizure, and they can be fatal.

Classic triggers:

🌅 Waking up in the morning — the most classic time of all.
😭 Crying, a tantrum, pain, or a procedure.
🍼 Feeding and straining with a bowel movement.
🛁 A warm bath and fever (both drop systemic resistance).
💧 Dehydration.

🧠 A quieter murmur in a bluer child is WORSE, not better. If nothing is getting through the valve there is nothing left to make noise.

✅ PREVENTION — the 5 source tips, and why each one works

😴 DO NOT interrupt sleep, and give a calm, quiet environment upon waking — waking is the peak spell time.

🍼 Offer a pacifier during crying — sucking soothes and stops the crying that triggers spells.

🥄 Small & frequent feedings — a big feed is too much work for a hypoxic infant.

🤱 Swaddle or hold the infant during procedures — containment lowers distress.

💧 Prevent dehydration and treat fever/constipation — dehydration thickens already-thick blood and invites spells and clots.

🧠 “Let them sleep, let them suck, feed them small, hold them close, keep them wet.” Every prevention tip is one thing: keep the child calm and hydrated.

🩸 The three chronic hypoxia signs — cyanosis, clubbing, polycythemia

Answer first: polycythemia in a cyanotic child is a CLOT problem, not a “good compensation.” Thick blood plus dehydration is how these children stroke.

So the nursing priorities are: keep fluids up, treat fever early, avoid long NPO windows without IV fluids, and report a hemoglobin over 22 g/dL.

🧠 “Blue → thick → sticky → stroke.” Four words, the whole chain. Break it with water.

🚨 The 5 heart-failure signs to REPORT — HF = HEAVY FLUID

⚖️Weight GAINwater gain

👀Puffiness around the eyesperiorbital edema

🥶Pale, coolextremities

🧷Reduced number of wet diapersless urine out

🍼Decreased feedingtires out fast

🧠 “HF = HEAVY FLUID.” Heavy on the scale · heavy eyes · heavy breathing · light diaper. Five signs, one phrase.

🩺

CARE & DISCHARGE

STEP 3 · FIX IT, THEN TEACH IT

Treatment is surgical. Everything else is keeping the child calm, hydrated and out of a spell until then.

🔪 TREATMENT: surgical repair

Complete repair — usually in the first year of life: the surgeon patches the VSD and relieves the right ventricular outflow obstruction (the pulmonary stenosis). Once the VSD is closed and the outflow is open, the shunt has nowhere to go and the child pinks up.

Palliative shunt — if the infant is too small or too unstable for full repair, a systemic-to-pulmonary shunt (the modified Blalock–Taussig shunt) is placed to send more blood to the lungs until repair is possible.

Before surgery, nursing keeps the child out of spells:

😴 protect sleep · calm environment on waking
🍼 small frequent feeds · pacifier for crying
💧 hydration — the single best clot-prevention measure
🌡️ treat fever promptly; avoid constipation and straining
📈 know the child's baseline O₂ sat so you can recognize a spell

🧠 “Patch the hole, open the road.” Two surgical moves fix all four defects, because the hypertrophy and the overriding aorta were only consequences.

🚨 DISCHARGE TEACHING — what parents must call about

Report immediately:

💙 A spell — any sudden deepening of cyanosis, especially with limpness or fainting.
⚖️ The 5 heart-failure signs — weight gain, puffy eyes, pale cool skin, fewer wet diapers, decreased feeding.
🩸 Hemoglobin over 22 g/dL at a clinic draw.
🌡️ Fever, vomiting, diarrhea — anything that dehydrates.
🧠 Neuro changes: extreme irritability, seizure, weakness on one side (stroke from thick blood).

Teach the position at home:

🦵 Every caregiver must be able to demonstrate the knee-to-chest position before discharge — teach-back, not just a handout.
🤫 Keep the environment calm; do not startle the child awake.
💧 Push fluids on hot days, during illness, and before/after any NPO period.
🦷 Endocarditis prophylaxis (amoxicillin is first-line) before dental work — required for unrepaired cyanotic defects and for repairs with prosthetic material in the first 6 months. Excellent daily oral care regardless.
💉 Keep immunizations current.

🧠 “If they turn blue — bend the knees, then call.” Parents should never be waiting for instructions during a spell.

❌ The traps that cost points

Never treat a quieter murmur as improvement in a bluer child — it means less blood is crossing the stenosis.
Never let a TOF child go long without fluids — dehydration triggers spells and clots.
Never expect a normal O₂ sat. Baseline in TOF is 65–85%; treat the child, not the number.
❌ Don't reach for oxygen before positioning — knees to chest is step one.
❌ Don't force a screaming child into a mask; agitation deepens the spell.

🧠 “Position, then oxygen.” If both are options on the exam, the position wins.

🧪 Labs & monitoring you will actually see

🧪 Hemoglobin & hematocrit — both high from polycythemia. Report Hgb > 22 g/dL.
📉 Iron studies — a “normal” Hgb in a cyanotic child can actually mean relative anemia, which makes hypoxia worse. Iron deficiency is a real spell risk.
💨 Continuous pulse oximetry with the child's documented baseline at the bedside.
🫁 ABG during a spell: low PaO₂, and metabolic acidosis if it is prolonged.
📷 Chest x-ray: the classic boot-shaped heart. Echocardiogram confirms all four defects.

🧠 “High H&H is not good news here.” It is the body screaming for oxygen.

⚡

QUICK RECALL

SAY IT OUT LOUD

4️⃣ PROVPulmonary stenosis · RVH · Overriding aorta · VSD

💜 RIGHT → LEFTCYANOTIC · decreased pulmonary blood flow · sat 65–85%

🦵 KNEES TO CHESTThe first action in a tet spell. Older child squats.

🩸 Hgb > 22 g/dL → reportPolycythemia = clot risk. Hydrate. Treatment = surgical repair.

⭐ One last time — where Tetralogy sits

Group	Shunt direction	Pulmonary blood flow	Blue?	Defects
💛 ACYANOTIC	LEFT → RIGHT	↑ INCREASED — too much blood to the lungs	No (pink at first)	ASD · VSD · PDA · AVSD
🧡 OBSTRUCTIVE	none — the road is narrowed	normal or ↓, depending on where the narrowing is	Usually no	Pulmonic stenosis · Aortic stenosis · Coarctation of the aorta
💜 CYANOTIC	RIGHT → LEFT	↓ DECREASED — blood skips the lungs	YES	Tetralogy of Fallot · Tricuspid atresia
🩵 MIXED	both ways — red and blue blood mix	varies	Yes	Transposition of the great arteries · Truncus arteriosus · TAPVR · hypoplastic left heart

🎯 Cover & check — 6 rapid-fire questions

Q1: Name the four defects of Tetralogy of Fallot.

PROV — Pulmonary stenosis, Right ventricular hypertrophy, Overriding aorta, VSD. Tetra = 4.

Q2: A 6-month-old with TOF suddenly turns deeply blue and is breathing hard after waking. What is your FIRST action?

Place the infant in the knee-to-chest position immediately. Then give oxygen, keep the child calm and quiet, and notify the provider. An older child would be told to squat.

Q3: Why does knee-to-chest / squatting work?

Folding the legs increases systemic vascular resistance. That makes it harder for blood to shunt right-to-left through the VSD, so more blood is pushed forward through the pulmonary stenosis and into the lungs.

Q4: The murmur of a TOF child gets softer during an episode. Good or bad?

BAD. The murmur comes from blood crossing the narrowed pulmonary outflow. A softer murmur means less blood is getting through — the spell is worsening.

Q5: Which lab value do you report, and why does it matter?

Hemoglobin over 22 g/dL. Chronic hypoxia drives polycythemia; the thick, sludgy blood raises the risk of clots and stroke. Keep the child hydrated and treat fever early.

Q6: Which prevention teaching points did the source list?

Do not interrupt sleep and provide a calm quiet environment on waking; offer a pacifier during crying; small and frequent feedings; swaddle or hold the infant during procedures. Add: prevent dehydration and treat fever.