590NURSING CARE PLAN The Infant with a Cleft Lip and/or …

590 CHAPTER 17. The Infant with a Cleft Lip NURSING care plan . and/or Palate GOAL INTERVENTION RATIONALE EXPECTED OUTCOME. Preoperative care 1. Risk for Aspiration (Breast Milk, Formula, or Mucus) related to anatomic defect NIC Priority Intervention: Aspiration NOC Suggested Outcome: Airway Precautions: Prevention or Maintenance: Toleration of enteral minimization of risk factors in the feedings without aspiration. patient at risk of aspiration. The Infant will have no episodes of Assess respiratory status and Allows for early identification of The Infant exhibits no signs of gagging or aspiration. monitor vital signs at least every problems. respiratory distress. 2 hours. Position on side after feedings. Prevents aspiration of feedings. Feed slowly and use adaptive Facilitates intake while minimizing equipment as needed. risk of aspiration. Burp frequently (after every Helps to prevent regurgitation and 15 30 mL of fluid). aspiration. Position upright for feedings.

590 CHAPTER 17 Allows for early identification of problems. Prevents aspiration of feedings. Facilitates intake while minimizing risk of aspiration. Helps to prevent regurgitation and aspiration. Minimizes passage of feedings through cleft. Suctioning may be necessary to remove milk or mucus. Contact is essential for bonding. Helps parents see the child as a

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