NAME: LYCA M.

PIAMONTE DATE: FEBRUARY 5, 2021

YEAR AND SECTION: BSN 2 SUBMITTED TO: MS. SHEILA MUTIA, RN

1. MAKE NURSING CARE PLANS FOR PREOPERATIVE CLEFT LIP/ CLEFT PALATE PATIENTS.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Parent’s poor coping Ineffective family coping After 8 hours of nursing Independent: After 8 hours of nursing
mechanism about infant’s related to birth of child intervention: Help parents to hold intervention parents hold,
situation. with structural defect.  Parents will began infant and facilitate comfort and show
bonding process feeding process concern for infant.
with the infant. Contact is essential for “goal met”
bonding.
Point our positive
attributes of infants (hair,
eyes, alertness)
Helps parents see child as
a whole, rather than
concentrating on the
defect.
Explain surgical procedure
and expected outcome.
Show pictures of other
children’s cleft lip repair.
Eliminating unknown
factors helps to decrease
anxiety.
Support open visitation
Allow parents to begin the
bonding process.
Encourage parents to
participate in caretaking
 activities (holding,
diapering, feeding)
Participation in infant care
decreases anxiety and
provides parents with
sense of purpose
Refer to a parent support
group.
Support groups allow
parents to express their
feelings and concerns to
find people with concerns
similar to their own and
seek additional
information.

2. WHAT ARE THE NURSING ACTIONS AND RATIONALE NEEDED BY THE CLIENT?
 Help parents to hold infant and facilitate feeding process
Contact is essential for bonding.
 Point our positive attributes of infants (hair, eyes, alertness)
Helps parents see child as a whole, rather than concentrating on the defect.
 Explain surgical procedure and expected outcome. Show pictures of other children’s cleft lip repair.
Eliminating unknown factors helps to decrease anxiety.
 Support open visitation
Allow parents to begin the bonding process.
 Encourage parents to participate in caretaking activities (holding, diapering, feeding)
Participation in infant care decreases anxiety and provides parents with sense of purpose
 Refer to a parent support group.
Support groups allow parents to express their feelings and concerns to find people with concerns similar to their own and seek
additional information.
3. WHAT IS YOUR NURSING RESPONSIBILITIES IN ASSESSING/FEEDING WITH CLEFT LIP/ CLEFT PALATE PATIENTS?
ASSESSMENT
  Inspection. Diagnosis of cleft palate is made at birth with the close inspection of the newborn’s palate; to be certain that a cleft
palate is not missed, the examiner must insert a gloved finger into the newborn’s mouth to feel the palate to determine that it is
intact.
 Observation. Cleft lip can be diagnosed through observation of the physical appearance of the newborn.
 Interview. In interviewing the family and collecting data, the nurse must include exploration of the family’s acceptance of the
newborn; conduct a thorough interview with the caregiver that includes a question about the methods they found to be most
effective in feeding the infant.
 Physical exam. Physical examination of the infant includes temperature, apical pulse, and respirations; listen to breath sounds,
observe skin turgor and color, infant’s neurologic status, noting alertness and responsiveness.

FEEDING

 Teach and observe parents to hold infant while feeding with the head in an upright position, use a nipple or feeding device,
allow feeder to control the flow or the infant to express the formula, apply gentle, steady pressure on the bottom of the bottle
and avoid removing the nipple frequently; instruct in feeding method that will be used postoperatively.
 Teach and observe to feed slowly and in small amounts, burping frequently, and extend nipple or feeding device well back into
the mouth.
 Inform parents that feeding should not last any longer than 20 to 30 minutes.