Strompolis Week 3 November 17 CPs

Strompolis Week 3 November 17 CPs - Strompolis Katie Week 3...

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Strompolis, Katie Week 3: November 17 th NICU plan of Care Patient Problems with identified Nursing Diagnoses and goals: 1. Patient Problem: Cleft Palate. Nursing Diagnosis : Risk for Aspiration related to anatomic defect Subjective Data (that supports this nursing diagnosis) : Objective Data (that supports this nursing diagnosis) : Cleft palate Patient’s Goal : Patient will not have a gagging or aspiration issues Patient’s Outcome(s) (must be measureable and include time frames): Patient will not gag or aspirate formula by 2000 17 November Patient will not gag or aspirate on regurgitation by 2000 17 November Patient will not gag or aspirate on mucus by 2000 17 November Nursing Actions – Indicate needed Nursing Interventions/Assessment/Monitoring Activities. Include Scientific Rationales with Reference Source in Italics (utilize at least 2 NURSING articles) : 1. Nurse will Assess respiratory status such as rate, depth, and effort dyspnea, cyanosis, nasal flaring, chest retractions, breath sounds, skin color, capillary refill and monitor vital signs at least every 2 hours Assessment provides data about respiratory status and function. Aspirating secretions or milk can cause tachypnea, abnormal breath sounds, bluish skin, or delayed capillary filling from decreased oxygenation, frequent monitoring allows for earlier interventions in the case of a problem (Hockenberry&Wilson, 2013). 2. Nurse will position child in an upright position to feed her the upright position will minimize feedings going through the cleft (Williams, 2012) 3. Nurse will administer feedings slowly and use adaptive equipment such as special needs feeder, the pigeon bottle or the Mead-Johnson Cleft palate nurser, as needed. The physiological changes of the cleft palate inhibit effective sucking. Using adaptive equipment compensates for the ineffective sucking which facilitates intake while minimizing risk of aspiration (Williams, 2012). 4. Nurse will stop feeding to burp infant after every 15-30mL Infants with clefts swallow excessive air during feedings, frequent burping is important to minimize regurgitation and risk of aspiration 5. Nurse will position child laterally after feedings Lateral position will help prevent aspiration of any regurgitation from the feeding (Santos, 2014) 6. Nurse will keep suction equipment and bulb syringe at the crib-side. Cautionary measures in the case of aspiration of milk or mucus (Hockenberry&Wilson, 2013).
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