Sr.M.Prema A.N.M
Incharge - Nursing
The nurse provides and directs nursing care that enhances the care delivery setting to protect client, family / significant others and health care personnal.
Assess / triage client – (s) to priorities the order of care delivery.
Perform procedures necessary for admitting transferring or discharging a client.
Educate client and family about clients rights and responsibilities.
Participate in performance improvement / quality assurance process.
Make appropriate referrals to community resources.
Collaboration with health care.
Maintain continuity of care.
Maintain client confidentiality / privacy.
Ensure that client has given informed. Consent for treatment participate in educating staff.
Nursing Interventions Pre – op Cleft lip repair
Feed in upright position to decrease chance of aspiration and decrease amount of air swallowed.
Burp frequently. Increased swallowed air caused abdominal distension and discomfort.
If infant unable to suck, use a rubber tipped syringe and dry formula into side of mouth, finish feeding with water to wash away formula in palate area.
Provide small, frequent feedings provide emotional support parents / family.
Demonstrate benefits of surgery by showing before and after picture.
Reinforce that disorder is not their fault and that it will not affect child’s life span or mental ability.
Post Operative Cleft-Lip repair
Maintain patient airway (child may appear to have respiratory distress because of closure of previously open space adaptation occurs quickly) Assess (Colour monitor amount of swallowing to deleit hemorrhage.
Do not place in prone position or with pressure on cheeks avoid only pressure or tension on suture line by anticipating child’s needs.
- Prevent crying
- Keep child (Comfortable and content)
Use elbow restraints or pin sleeves of shirts to diaper to keep child’s hands away from sutureline.
Resume feedings as ordered. Keep suture line clean after each feeding with saline or water to remove crusts and prevent scarring.
Provide pain control / relief.
Nursing interventions pre – op cleft palate repair
- Prepare parents to care for child after surgery.
- Instruct concerning feeding methods and positioning.
Nursing interventions Post-op Cleft palate repair
- Position on side for drainage of blood / mucus.
- Have suction available but only in emergency.
- Prevent injury or trauma to suture line.
- Use cups only for liquids no bottles.
- Avoid straws, utensils popside sticks, chewing gum.
- Provide soft toys.
- Use elbow restraints.
- Provide liquid diet initially, then progress to soft diet before returning to normal.
- Give water after each feeding to cleanse suture line.
- Hold and cuddle these babies to help distract them.
SPINE
Safety
Physical
Interpersonal
Nutrition
Environmental
The word spine will help you to remember these issues.