ASSESSMENT NURSING Scientific Basis Objective of care Implementation Rationale

I. Physiologic deficitRisk for imbalanced Cleft palate usually After 1 month of 1.surgery 1.repair cleft lip and
nutrition; less than makes holistic ng. care, -Cleft lip repair- bet. palate
CUES: body requirements breastfeeding the child will be Birth and 3 months
Objective r/t feeding problems difficult because the able to: -cleft palate repair-
caused by cleft lip infant has difficulty 1. Acquire adequate by 1 yr of age
-a small notch in the and palate. sucking properly. nutrition. -follow up surgery-
lip and extend from The palate prevents bet. Age of 2 and
the lip through the food and liquid from late ten yrs.
upper gum and palate. going up the nose 2.wear prosthetic 2.to aid proper
when swallowing. palate called eating
-baby is not able to “An opening in the obrerator
suck the nipple of palate makes it 3.when feeding,
her mother impossible for the hold infant in 3.to help keep the
baby to seal off his upright position food from coming
-change in nose mouth and make 4.Provide special out of the nose
shape the suction typically nipples or feeding 4.to suck
used to keep the devices (eg, soft adequately in
breast (or bottle) in pliable bottle with standard nipples
place and pull the soft nipple with (nursingcrib.com)
nipple to the back of enlarged opening) for
his mouth.” a child unable
5.speech 5.to provide an
therapy(first 6 overview of the
months) treatment and
suggest specific
language and
speech stimulation
gains to play with
the baby
6.dental care 6.help align the
teeth
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective Data: Problem Identified: Short-term After 1 month of 1.surgery 1.repair cleft lip and
Cleft lip palate objectives: After 8 holistic ng. care, -Cleft lip repair- bet. palate
“Nahubag man ang hours of nursing the child will be Birth and 3 months
ngabil sa ako baby Nursing Diagnosis intervention the able to: -cleft palate repair-
gikan sap ag admit Statement: significant other of 1. Acquire adequate by 1 yr of age
dirir sa ospital” as Risk for infection the patient will: nutrition. -follow up surgery-
verbalized by the related to - bet. Age of 2 and
mother of the late ten yrs.
hospitalization.
patient. Long-term 2.wear prosthetic 2.to aid proper
objectives: After palate called eating
Cause
Objective Data: hospitalization, the obrerator
Analysis:Cleft
patient will: 3.when feeding,
palate usually
Vital Signs - have adequate hold infant in 3.to help keep the
makes
Temperature: 37.8 breastfeeding nutrients provided upright position food from coming
(Celsius) difficult because the by the mother 4.Provide special out of the nose
RR: 15 cpm infant has difficulty - the s nipples or feeding 4.to suck
O2 Sat: 90% sucking properly. devices (eg, soft adequately in
The palate prevents pliable bottle with standard nipples
-a small swelling food and liquid from soft nipple with (nursingcrib.com)
notch in the lip and going up the nose enlarged opening) for
extend from the lip when swallowing. a child unable
through the upper “An opening in the 5.speech 5.to provide an
gum and palate. palate makes it therapy(first 6 overview of the
impossible for the months) treatment and
-baby is not able to baby to seal off his suggest specific
suck the nipple of mouth and make language and
her mother the suction typically speech stimulation
used to keep the gains to play with
-change in nose breast (or bottle) in the baby
shape place and pull the 6.dental care 6.help align the
nipple to the back of teeth
his mouth.”