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cleft palate-Tabitha New Born - Coggle Diagram
cleft palate-Tabitha New Born
Nursing diagnosis #1: Ineffective airway clearance r/t trauma of oral surgery aeb respiratory rate changes
short term: make sure airway if patent and clear to allow for maximum oxygenation
long term: infant is healed, and airway remains clear
evaluation: airway is patent and maintains clear
Nursing intervention #1: assess infants' respiratory rate/depth
rationale: aspirations of secretions may cause tachypnea
Nursing intervention #2: place infant in seat 30–45-degree angle
rationale: prevents infants' tongue from obstructing the airway
Nursing intervention #4: position the infant upright during feeding and after
rationale: prevents aspiration of milk
Nursing intervention #3: provide oral/nasal suctioning as needed
rationale: provide a patent airway
Nursing diagnosis #2: anxiety r/t situational crisis of defect of infant aeb response to imperfect infant
Nursing intervention #4: Inform parents usual age for cleft lip repair
rationale: provides information to reduce fear and anxiety
Nursing intervention #2: emphasize the infant positive features when providing information
rationale: promotes positive feelings for the infant
Nursing intervention #1: allow parents to stay with infant and encourage to assist as appropriate
rationale: reduces anxiety
Nursing intervention #3: suggest visits with parents who have a child with similar defect
rationale: provides support to reduce anxiety
Labs: None
Medication: Tylenol 15 mg/kg q 4 hrs for pain
short term: parent feels reduced feelings of anxiety
long term: parent is aware of procedure and how it can be fixed
long term: parents come to acceptance with defect and procedure
evaluation: parents are less anxious because they have sufficient knowledge about the defect and procedure
Nursing diagnosis #3: deficient knowledge r/t lack of information of procedure aeb request for information
Nursing intervention #1: assess parents abilities to feed the infant
rationale: provides info about defect before surgery
short term: parents are aware of procedure needed and when it is to be performed
long term: parents are aware of how to care for infant after surgery
evaluation: parents can teach back about procedure and explain what it is and how it is done
Nursing intervention #4: teach to hold infant in upright position while feeding
rationale: helps prevent aspiration of milk and secretions
Nursing intervention #2: inform parents of general timing of repair
rationale: child must be 10 weeks old, over 10 lbs, fever free, hemoglobin over 10
Nursing diagnosis #4: risk for injury r/t surgery
Nursing intervention #4: monitor lip protective device taped on operative site
rationale: relaxes the site and prevents tension on sutures
Nursing intervention #2: assess for respiratory distress following palate surgery
rationale: monitors breathing through a smaller airway
Nursing intervention #3: provide air humidification
rationale: decreases dry mouth and mucous membranes
Nursing intervention #1: assess suture line for drainage, cleanliness, swelling, etc
rationale: provides info that may indicate infection
Short term: infant is not at risk for injury following the procedure
long term: infant healed after surgery injury free
evalutaion: there is no evidence of infection or injury to infant