✳️ 1.
Tetralogy of Fallot (TOF)
Assessment: Cyanosis, fatigue, clubbing, squatting, murmur
Nursing Diagnoses:
Decreased cardiac output related to structural heart defects as evidenced by
cyanosis and fatigue.
Activity intolerance related to imbalanced oxygen supply as evidenced by dyspnea
and squatting during play.
Impaired gas exchange related to right-to-left shunting of blood as evidenced by
low O₂ saturation and cyanosis.
Delayed growth and development related to chronic hypoxia as evidenced by growth
retardation.
Risk for infection related to invasive cardiac procedures or surgery.
✳️ 2. Ventricular Septal Defect (VSD)
Assessment: Harsh murmur, failure to thrive, frequent respiratory infections
Nursing Diagnoses:
Ineffective tissue perfusion (cardiac) related to mixing of oxygenated and
deoxygenated blood as evidenced by fatigue and delayed growth.
Risk for impaired growth and development related to increased metabolic demand and
inadequate caloric intake.
Risk for infection related to frequent respiratory tract infections.
Imbalanced nutrition: less than body requirements related to fatigue during
feeding.
✳️ 3. Cleft Lip and Palate
Assessment: Feeding difficulty, risk for aspiration, anxiety
Nursing Diagnoses:
Ineffective infant feeding pattern related to oral structural defect as evidenced
by regurgitation and poor latch.
Risk for aspiration related to communication between oral and nasal cavity.
Risk for infection related to surgical incision or nasal regurgitation.
Parental anxiety related to altered appearance and feeding concerns.
Impaired verbal communication (long-term) related to cleft palate affecting speech
development.
✳️ 4. Hydrocephalus
Assessment: Bulging fontanels, irritability, sunsetting eyes, vomiting
Nursing Diagnoses:
Excess fluid volume related to impaired CSF drainage as evidenced by increased head
circumference.
Risk for injury related to increased intracranial pressure and surgical
interventions (shunt).
Impaired physical mobility related to increased head size and neurological
deficits.
Risk for delayed development related to neurologic impairment.
Risk for infection related to presence of ventriculoperitoneal shunt.
✳️ 5. Spina Bifida (Myelomeningocele)
Assessment: Protruding sac, flaccid paralysis, bowel/bladder issues
Nursing Diagnoses:
Risk for infection related to exposed neural tissue.
Impaired physical mobility related to neuromuscular impairment.
Impaired urinary elimination related to neurogenic bladder.
Bowel incontinence related to loss of sphincter control.
Body image disturbance (older child) related to visible defect and physical
limitations.
✳️ 6. Down Syndrome
Assessment: Hypotonia, developmental delays, feeding issues, congenital heart
defect
Nursing Diagnoses:
Delayed growth and development related to chromosomal abnormality.
Imbalanced nutrition: less than body requirements related to poor muscle tone
affecting feeding.
Risk for infection related to decreased immune response.
Risk for injury related to poor muscle tone and delayed reflexes.
Ineffective family coping related to having a child with a long-term developmental
condition.
✳️ 7. Pyloric Stenosis
Assessment: Projectile vomiting, olive-shaped mass, dehydration
Nursing Diagnoses:
Imbalanced nutrition: less than body requirements related to vomiting.
Deficient fluid volume related to excessive fluid loss from vomiting.
Risk for electrolyte imbalance related to persistent vomiting.
Acute pain related to gastric distention.
✳️ 8. Hirschsprung Disease
Assessment: Failure to pass meconium, abdominal distention, ribbon-like stools
Nursing Diagnoses:
Constipation related to absence of ganglion cells as evidenced by failure to pass
stool.
Imbalanced nutrition: less than body requirements related to decreased appetite and
absorption.
Disturbed body image (post-colostomy) related to stoma presence.
Risk for impaired skin integrity related to colostomy leakage.
✳️ 9. Imperforate Anus
Assessment: No anal opening, no stool, abdominal distention
Nursing Diagnoses:
Bowel incontinence related to anatomical malformation.
Risk for impaired skin integrity related to presence of colostomy.
Acute pain related to surgical incision.
✳️ 10. Tricuspid Atresia
Assessment: Cyanosis, hypoxia, failure to thrive
Nursing Diagnoses:
Ineffective tissue perfusion related to right heart obstruction.
Impaired gas exchange related to unoxygenated blood mixing with oxygenated blood.
Activity intolerance related to hypoxemia.
Risk for infection related to cardiac surgery.
