590NURSING CARE PLAN The Infant with a Cleft …

1 590 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.

2 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. Minimizes passage of feedings through Cleft . Keep suction equipment and bulb Suctioning may be necessary to syringe at bedside. remove milk or mucus.

3 2. Ineffective Family Coping related to situational crisis of birth of a child with a defect NIC Priority Intervention: Family NOC Suggested Outcome: Positive Involvement: Facilitating family Coping: Extent of coping participation in the emotional and mechanisms and ability to perform physical care of the child. child's physical and emotional care . Parents will begin bonding process Help parents to hold the Infant and Contact is essential for bonding. Parents hold, comfort, and show with the Infant . facilitate feeding process.

4 Concern for the Infant . Point out positive attributes of Helps parents see the child as a Infant (hair, eyes, alertness, etc). whole, rather than concentrating on the defect. Explain surgical procedure and Eliminating unknown factors helps expected outcome. Show pictures to decrease anxiety. of other children's Cleft lip repair. The family's coping ability will be Assess parents knowledge of the Helps to determine the appropriate The family demonstrates improved maximized. Parents will verbalize the defect, their degree of anxiety and timing and amount of information coping ability before discharge.

5 Nature and sequelae of the defect. level of discomfort, and the to be given regarding the child's interpersonal relationships among defect. family members. Explore the reactions of extended Extended family is an important Parents receive necessary support to family members. source of support for most parents care for their Infant . of a newborn. Family members can often help promote acceptance and compliance with the treatment plan . Support open visitation. Allows parents to continue the bonding process. Encourage parents to participate in Participation in Infant care caretaking activities (holding, decreases anxiety and provides diapering, feeding).

6 Parents with a sense of purpose. Alterations in Gastrointestinal Function 591. The Infant with a Cleft Lip NURSING care plan . and/or Palate (continued). GOAL INTERVENTION RATIONALE EXPECTED OUTCOME. 2. Ineffective Family Coping related to situational crisis of birth of a child with a defect (continued). Provide information about the Concrete information allows etiology of Cleft lip and palate parents time to understand the defects and the special needs of defect and reduces guilt. these infants. Encourage questions.

7 Refer to parent support groups. Support groups allow parents to express their feelings and concerns, to find people with concerns similar to their own, and to seek additional information. 3. Altered Nutrition: Less Than Body Requirements related to the Infant 's inability to ingest nutrients NIC Priority Intervention: Nutrition NOC Suggested Outcome: Nutrition Management: Provision of a balanced Status: Amount of food and fluid dietary intake of foods and fluids. taken into the body over a 24-hour period. The Infant will gain weight steadily.

8 Assess fluid and calorie intake daily. Provides an objective measurement The Infant maintains adequate Assess weight daily (same scale, of whether the Infant is receiving nutritional intake and gains weight same time, with Infant completely sufficient caloric intake to promote appropriately. undressed). growth. Using the same scale and procedure when weighing the Infant provides for comparability between daily weights. Observe for any respiratory Any symptoms of respiratory impairment. compromise will interfere with the Infant 's ability to suck.

9 Feedings should be initiated only if there are no signs of respiratory distress. Provide 100 150 cal/kg/day and Provides optimal calories and fluids 100 130 mL/kg/day of feedings for growth and hydration. and fluid. If the Infant needs an increased number of calories to grow, referral to a nutritionist should be made. Formulas with higher calorie concentrations per ounce are available without increasing total fluids. Facilitate breastfeeding. Breast milk is recommended as the Successful breastfeeding is achieved if best food for an Infant .

10 The process desired. of breastfeeding helps to promote bonding between mother and Infant . Hold the Infant in a semisitting Makes swallowing easier and position. reduces the amount of fluid return from the nose. Give the mother information on Information and specific breastfeeding the Infant with a Cleft suggestions may encourage the lip and/or palate such as plugging mother to persist with the Cleft lip and eliciting a let-down breastfeeding. reflex before nursing. Contact the LaLeche League for the The LaLeche League promotes name of a support person.