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Cleft L ip and Cleft Palate
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I. PERSONAL DATA
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I. PERSONAL DATA
Name: C , Baby Boy S.J.Age: 3 days old
Sex: Male
Religion: Roman Catholic
Citizenship: Filipino
Date of Birth: July 3, 2010Place of Birth: SJDEFI Hospital, Roxas Blvd. Pasay City
Nationality: Filipino
Address: 257 Catalina St. Velasquez Tondo, Manila
Name of the nearest relative: Rosalyn Cruz
Relation: Mother
Address: 257 Catalina St. Velasquez Tondo, Manila
Unit/ward: NSU
Time of admission: 12:59
Physician: Dr. Abad Santos
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II. HISTORY
OFPRESENT ILLNESS
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II. HISTORY OF PRESENT ILLNESS
Prior to admission, the baby was born on a28 year old mother with GRAVIDA 1 PARA 0
through vacuum extraction.
Baby boy was admitted to NSU directed from
OR, full term gestation (38weeks) and was
diagnose to have unilateral cleft palate and cleft
lip. The vital sign were normal having
temperature: 36.8 C; respiratory rate: 45cpm;heart rate: 150bpm; weight: 3050grams and
with normal reflexes. No distress noted.
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III. MEDICAL HISTORY
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III. MEDICAL HISTORY
This is the case of Baby Boy Cruz, 11 days
old, male. Born on July 03, 2010 thru vacuum
extraction and admitted in Potentially Septic
Section of Nursery. With weight of 3050 g. or 6.2lbs, length of 58 cm and with head circumference
of 32 cm. He was diagnosed to have cleft lip and
palate.
Immunization:
Anti- Hepatitis B
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IV. FAMILY HISTORY
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IV. FAMILY HISTORY
Paternal Side
Christian Ellson
(-) Deformities of the lip and palate.
Maternal Side
Rosalyn Cruz
(-) Deformities of the lip and palate.
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V. ACTIVITIES
OFDAILY LIVING
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V. ACTIVITIES OF DAILY LIVINGActivities During Hospitalization Analysis
Fluids and Nutrition He received his feeding through
bottle feeding 30 cc every 3 hours
and has a hard time in consuming it.
He has difficulty in sucking
because roof of the mouth is not
formed completely.
Elimination
Bladder and Bowel
Usually have urine and stool every
change of diaper.
The present condition doesnt
affect the way of excreting theurine and stool.
Rest and Sleep He acquires a good rest and sleep but
there are times that he was
experiencing difficulty of breathing.
The patient experienced
difficulty of breathing because
of the cleft lip and palate that
altered his sleeping pattern.
Hygiene The nurse on duty provided his oralevery time the patients has dirt and
personal hygiene like full bath every
4:00 in the morning and cord care
for every diaper change.
Nurses gives priority in
maintaining good body odor
and try to cope up in the present
problem by using other method
of oral and personal hygiene.
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VI. PHYSICAL ASSESSMENT
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PHYSICAL ASSESSMENTA. General Condition
Body Part Technique Used Normal Findings Actual Findings Analysis
Skin Inspection Ruddy Pink in color
Presence of lanugo in the
shoulders, back and arms
Ruddy Pink in color
Presence of lanugos in the
shoulders, back and arms
Normal
Hair Inspection Silky, resilient hair
Evenly distributed
Silky, resilient hair
Slight thick hair
Evenly distributed
Normal
Head Inspection
Palpation
Anterior fontanelle is soft
No caput succedaneum
Appears disproportionately
large
Forehead is large and
prominent
Anterior fontanelle is soft
No caput succedaneum
Appears
disproportionately large
Forehead is large and
prominent
Normal
Eyes Inspection Slight grey pupil
Round Cornea
Eyes are symmetrically
aligned
Pupils are equal in size(+) Blink reflex
Slight grey pupil
Round Cornea
Eyes are symmetrically
aligned
Pupils are equal in size(+) Blink reflex
Normal
Weight: 3050 grams Temperature: 36.6 C
Length: 50 cm HR: 133 bpm
Head Circumference: 32 cm RR: 46 cpm
B d P t T h i U d N l Fi di A t l Fi di A l i
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Body Part Technique Used Normal Findings Actual Findings Analysis
Ears Inspection
Palpation
Pinna recoils after folded
Outer canthus of the eye is
higher than the top most
part of the ear.
Formed and firm and
instant recoil
Normal
Nose Inspection Appears large for the face
Presence of milia
Has nasal septum
Presence of milia
Has no nasal septum
Has gap in the right nostril
up to the lip (Cleft lip)
Because of the gap, air
leaks into the nasal
cavity resulting in a
hypernasal voice
resonance and nasal
emissions.
Mouth Inspection Open evenly when crying
Tongue appears large &prominent in the mouth.
The palate should be intact.
(+) Rooting Reflex
(+) Sucking Reflex
(+)Swallowing Reflex
(+) Extrusion Reflex
Has a hole in the hard
palate connecting to thenasal cavity (Cleft lip and
palate)
No tooth
(+) Rooting Reflex
(-) Sucking Reflex
(+)Swallowing Reflex
Cleft may cause
problems withfeeding(due to lack of
suction), ear disease,
and speech. The
upright sitting
position allows gravity
to help the baby
swallow the milk more
easily.
Chin Inspection Appears to be receding &
quivers easily when crying
Usually has milia
Appears to be receding &
quivers easily when crying
Usually has milia
Normal
Neck Inspection Short and chubby with
creased skin folds
Short and chubby with
creased skin folds
Normal
Body Part Technique Used Normal Findings Actual Findings Analysis
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Body Part Technique Used Normal Findings Actual Findings Analysis
Chest Inspection Have buds (nipples)
Appear symmetric
Without chest retraction
Clavicles are straight
The chest is as wide in theanteroposterior diameter
as it is across
With chest retraction
Have buds (nipples)
Appear symmetric
Clavicles are straight
Patient with chest
retraction may have
breathing difficulties
as a result of fatigue.
Thus, always usegentle handling.
Abdomen Inspection Contour is slightly
protuberant
Dome-shaped
Contour is slightly
protuberant
Dome-shaped
Normal
Genital Inspection Ruggated, darkened
Penis appears small
Ruggated, darkened
Penis appears small
Normal
Back Inspection
Palpation
No dimpling and pinpoint
opening in the skin
(+) Trunk Incurvation
No dimpling and pinpoint
opening in the skin
(+) Trunk Incurvation
Normal
Extremities Inspection
Palpation
Arms and legs appear short
(+) Moro Reflex
(+) Palmar Grasp Reflex
(+)Babinski Reflex
Arms and legs appear short
(+) Moro Reflex
(+) Palmar Grasp Reflex
(+)Babinski Reflex
Normal
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Birth History:
Baby boy Cruz delivered through vacuumextraction, blood type O, Rh (+) and with an AOGof 38 weeks. APGAR scoring done 1 min. afterbirth and 5 min. after shows normal.
Physical examination:
Baby boy Cruz has good cry, well flexedactivities and pinkish all over when examined. He
weighed 3050 g ( 6 lbs 12 oz), length is 50 cm andhead circumference is 32 cm. .Examination alsoshowed a normal perineum, back extremities andsucking reflex. Baby boy Cruz also has (+) cleftpalate and (+) cleft lip
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VII. DISEASE ENTITY
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DEFINITION
Cleft Lip and Cleft Palate an opening
in the lip and palate may occur
separately or in combination.Cleft lip and palate are twice as
common in males as in females;
isolated cleft palate is more commonin females.
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Cleft lip (Cheiloschisis)
Cleft lip is a congenital anomaly that occurs at
a rate of 1 in 800 births. If the cleft does not affect the palate structure of the
mouth it is referred to as cleft lip.Cleft lip is formed in the top of the lip as either a small
gap or an indentation in the lip (partial or incomplete
cleft) or it continues into the nose (complete cleft)
Cleft lip can be unilateral or bilateral.
It is due to the failure of fusion of the maxillary and
medial nasal processes (formation of the primary
palate).
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Cleft Palate (Palatoschisis)
Cleft palate is a congenital anomaly thatoccurs in approximately 1 of every 2000births, and it is more common in boys thangirls.It is a condition in which the two plates of the
skull that form the hard palate (roof of themouth) are not completely joined.
It ranges in severity from soft palate involvement
alone to a defect including the hard palate andportions of the maxilla.Cleft palate may or may not be associated with
cleft lip.
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Children with these structural disorders may have
associated:
dental malformations speech problems
frequent otitis media, the latter resulting from
improper functioning of the Eustachian tubes.
Babies with cleft lip do not usually have feeding
problems or speech impairments. Infants with cleft
palate, with or without cleft lip, often have difficultyfeeding and impaired speech. The baby may feed too
slowly, take in too much air while eating, or bring
milk up through the nose.
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Variation in Cleft Deformity
Incomplete
Cleft Palate
Unilateral
complete lip
and palate
Bilateral
complete lip
and palate
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NORMAL ANATOMY & PHYSIOLOGY
Lips are a visible body partat the mouth of humans and
many animals. Lips are soft,
movable, and serve as the
opening for food intake and
in the articulation of sound
and speech
Palate is the roof of
the mouth in humans and
othermammals. It separates
the oral cavityfrom the nasal
cavity.
The palate is divided into
two parts, the anterior
bony hard palate, and the
posterior fleshy soft
palate or velum.
Cupids bow is central to the upper lip with
http://en.wikipedia.org/wiki/Mouthhttp://en.wikipedia.org/wiki/Mammalhttp://en.wikipedia.org/wiki/Oral_cavityhttp://en.wikipedia.org/wiki/Nasal_cavityhttp://en.wikipedia.org/wiki/Nasal_cavityhttp://en.wikipedia.org/wiki/Hard_palatehttp://en.wikipedia.org/wiki/Soft_palatehttp://en.wikipedia.org/wiki/Soft_palatehttp://en.wikipedia.org/wiki/Soft_palatehttp://en.wikipedia.org/wiki/Soft_palatehttp://en.wikipedia.org/wiki/Soft_palatehttp://en.wikipedia.org/wiki/Hard_palatehttp://en.wikipedia.org/wiki/Hard_palatehttp://en.wikipedia.org/wiki/Hard_palatehttp://en.wikipedia.org/wiki/Nasal_cavityhttp://en.wikipedia.org/wiki/Nasal_cavityhttp://en.wikipedia.org/wiki/Nasal_cavityhttp://en.wikipedia.org/wiki/Oral_cavityhttp://en.wikipedia.org/wiki/Oral_cavityhttp://en.wikipedia.org/wiki/Oral_cavityhttp://en.wikipedia.org/wiki/Mammalhttp://en.wikipedia.org/wiki/Mouth7/28/2019 Case Study Cleft Lip
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Cupids bow is central to the upper lip, withits peaks delineating the philtrum between the
philtral columns.The demarcation between mucosa and skin
of the lip is called the vermilion border. Themucosa or vermilion of the lip is further dividedinto dry and wet sections. The protuberantvermilion in the midline is referred to as the
tubercle. The two nostrils (nares) are separatedby the columnella externally and the septuminternally.
Below the surface, the orbicularis oris
muscle encircles the oral aperture, creating asphincter. The fibers decussate in the midlinecreating the philtrum. In the cleft lip, theorbicularis muscle inserts into the nasal alar base.
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The presence of the palate makes it possible tobreathe and chew at the same time. When food is
swallowed, the soft palate rises up and blocks off
the entrance to the rear nasal passage. When
food is not being swallowed, this passage is open,
making it possible to breathe through the mouth
and through the nose. As well, prior to
swallowing food is pressed up against the palateand pushed to the back of the throat using the
tongue.
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The palate also functions in speaking and
singing. When sound emerges from the
chest, the sound waves that have beenproduced by the vocal cords bounce off
the hard palate and out the mouth. The
hard palate directs and resonates. Formation of the palate occurs
during development of the fetus.
Improper formation of the hard palateoccurs in one of every 500-1000 babies.
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This condition, called cleft palate, is correctable by
surgery. Its cause is still unresolved.
A combination of inherited traits and some
environmental factors in the mother's womb aresuspected of causing the abnormality.
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PATHOPHYSIOLOGY
During embryonic development thelateral and medial tissues forming the
upper lip palates fuse between weeks 7
and 8 of gestation; the palatal tissuesforming the hard and soft palates fuse
between weeks 7 and 12 gestation.
Cleft lip and cleft palate result when
these tissues fail to fuse.
Predisposing Factors: Precipi tating F actors:
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Predisposing Factors:
Infants
Both genders than
higher in male
Etiology: incomplete fusion
of the nasomedial or
intermaxi l lary process
duri ng the 2ndmonth of
embryonic development
Precipi tating F actors:
Viral inf ection
Folic acid
deficiency
The cleft causes structur es of
the face and mouth to develop
without the normal restraints
of encir cling lip muscles
External nose Nasal septum Al veolar processes Nasal cart i lages
Usuall y just beneath
the center of one nostr i l
The more complete the
cleft l ip, the greater the
chance that teeth in the
li ne of the cleft wi ll be
missing or malformed
Bilaterally
Symmetric
Asymmetric
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Signs and Symptoms
What are the signs and symptoms of the condition?
Symptoms of cleft lip and cleft palate vary from person toperson, depending on the extent of the defect.
Cleft lip may show up only as a small notch in the border ofthe upper lip. It may also involve a complete split of the lip
that extends into the floor of the nose. Cleft lip may involve one or both sides of the upper lip.
Often, the bone that supports the upper teeth is involved tosome degree. Extra, missing, or deformed teeth may also bepart of cleft lip. Frequently, the outside of the nostril issomewhat flattened, too.
Cleft palate may involve only the uvula, or it may involve theentire roof of the mouth. The uvula is the soft, fleshy massthat hangs down from the roof of the back of the mouth.
Wh t th li ti f l ft ?
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What are the complications of clefts?
Breathing: When the palate and jaw are malformed, breathing
becomes difficult. Treatments include surgery and oralappliances.
Feeding: Problems with feeding are more common in cleft
children. A nutritionist and speech therapist that specializes in
swallowing may be helpful. Special feeding devices are alsoavailable.
Ear infections and hearing loss: Any malformation of the
upper airway can affect the function of the Eustachian tube and
increase the possibility of persistent fluid in the middle ear, whichis a primary cause of repeat ear infections. Hearing loss can be a
consequence of repeat ear infections and persistent middle ear
fluid. Tubes can be inserted in the ear by an otolaryngologist to
alleviate fluid build-up and restore hearing.
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What are the complications of clefts?
Speech and language delays: Normal development ofthe lips and palate are essential for a child to properly
form sounds and speak clearly. Cleft surgery repairs
these structures; speech therapy helps with language
development.Dental problems: Sometimes a cleft involves the gums
and jaw, affecting the proper growth of teeth and
alignment of the jaw. A paediatrics dentist or
orthodontist can assist with this problem.
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MANAGEMENT Assess for problems with feeding, breathing parental
bonding, and speech. Ensure adequate nutrition and prevent aspiration.
a. Provide special nipples or feeding devices (eg,soft pliable bottle with soft nipple with enlarged
opening) for a child unable to suck adequately onstandard nipples.
b. Hold the child in a semi upright position; directthe formula away from the cleft and toward the sideand back of the mouth to prevent aspiration.
c. Feed the infant slowly and burp frequently toprevent excessive swallowing of air and regurgitation.
d. Stimulate sucking by gently rubbing the nippleagainst the lower lip.
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Support the infants and parents
emotional and social adjustment.
a. Help facilitate the familys acceptance
of the infant by encouraging the parents to
express their feelings and concerns and byconveying an attitude of acceptance toward
the infant.
b. Emphasize the infants positive aspectsand express optimism regarding surgical
correction.
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Provide preoperative care.
a. Depending in the defect and the childs general
condition, surgical correction of the cleft lipusually occurs at 1
to 3 months of age; repair of the cleft palate is usually
performed between 6 and 18 months of age. Repair of the cleft
palate may require several stages of surgery as the child
grows.
b. Early correction of cleft lip enables more normalsucking patterns and facilitates bonding. Early correction
of cleft palate enables development of more normal speech
patterns.
c. Delayed closure or large defects may require the use oforthodontic appliances.
d. The responsibilities of the nurse are to: 1. Reinforce thephysicians explanation of surgical procedures.
2. Provide mouth care to prevent infection.
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Provide child and family teaching.
Demonstrate surgical wound care.
Show proper feeding techniques and positions.
Explain that temperature of feeding formulas should be
monitored closely because new palate has no nerve endings;
therefore; the child can suffer a burn to the palate easily and
without knowing it.
Explain handling of prosthesis if indicated.
Stress the importance of long-term follow up, including speech
therapy, and preventing or correcting dental abnormalities.
Discuss the need for, at least, annual hearing evaluations
because of the increased susceptibility to recurrent otitis. The
child may require myringotomy and surgical placement of
drainage tubes.
Teach infection control measures.
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TREATMENT
Surgical correction, timing varies:
Cleft Lip:
Within the first few days of life to makefeeding easier.
Delay lip repairs for 2 to 8 months to
minimize surgical and anesthesia risks, ruleout associated congenital anomalies, and
allow time for parental bonding.
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Cleft Palate- performed only after the
infant is gaining weight and infection free:
Usually completed by age 12 to 18
months
Two steps : soft palate between ages 6
and 18 months; hard palate as late as
age 5 years.
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Speech Therapy:
Palate essential to speech formation;structural changes, even in a repaired
cleft, can permanently affect speech
patterns Hearing difficulties common in children
with cleft palate because of middle ear
damage or infections.
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VIII. LABORATORY
EXAMINATIONS
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A .) HEMATOLOGY
DATE: July 4, 2010 PID: 20859-62
Requesting Doctor: Dr. MontalbanTEST RESULT UNIT REFERENCE
Leukocyte 19.36 10^q/L 5.0-10.0
Erythrocyte 6.82 10^q/L M:4.6-6.2F:4.2-5.4
Hemoglobin 19.67 g/dL M:12.0-17.0
F:11.0-15.0
Hematocrit 59.08 % M:40.0-54.00
F:37.0-47.0
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TEST RESULT UNIT REERENCE
ThrombocyteNeutropil
Lympocyte
Monocyte
EosinophilBasophil
33359.3
25.9
8.5
1.44.9
10^q/L%
%
%
%%
150-45050.0- 70.0
20.0-40.0
0.0-7.0
0.00-5.0000.000-1.000
Normal Findings Result Analysis
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Leukocytes H 19.67 Elevated WBC counts indicates
the presence of infection.
Erythrocytes 6.2 Normal
Hemoglobin H- 19.67 Elevated hemoglobin, is the
increased red blood cellproduction as a compensatory
mechanism when blood oxygen
carrying capacity is compromised
to meet the demand of tissue
Normal Findings Result Analysis
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Hematocrit H- 59.08 Elevated hemoglobin may due
because of dehydration
Thrombocytes N - 333 Normal
Neutropils 59.3 Normal
Monocytes H- 8.5 Monocyte may increase in
response to stress. It also
indicates that the patient has
infection because of his
condition
Lymphocytes 25.9 Shows a normal range that
fights the microorganism.
Normal Findings Result Analysis
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Shows a normal range that fights themicroorganism.Shows a normal range that fights themicroorganism.
Eosiphil N- 1.4 Normal
Basophil H- 4.9 The result was high which
indicates that theres
infection.
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iX. Drug study
DRUG CLASSIFICATION MECHANISM OF
ACTION
INDICATION CONTRA-
INDICATION
SIDE EFFECTS NURSING
CONSIDERATION
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Name:
ampicillin
Dose:
150 mg
Frequency
:
q12
Route:
IV
-Penicillin
- Antibiotic
Bactericidal.
Interferes
with cell wall
synthesis of
susceptible
organisms,
preventing
bacterial
multiplication, renders
cell wall
osmotically
unstable and
burst due to
osmotic
pressure.
Treatmen
t of
infectious
cause bysusceptibl
e strain of
bacteria.
Hypersensi
tivity to
penicillins,
cephalospo
rins or
imipenem
Rashes,
Fever,
Abdominal
pain,nause
a, vomiting,
diarrhea
Check doctors
order.
Report pain ordiscomfort at
sites, unusual
bleeding or
bruising,
mouth sores,
rashes, severediarrhea,
difficulty in
breathing.
Should be
taken on an
emptystomach.
(Take on an
empty
stomach 1 hr
before or 2 hr
after meals.)
DRUG CLASSIFICATION MECHANISM OFACTION
INDICATION CONTRA-INDICATION
SIDE EFFECTS NURSINGCONSIDERATION
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Name:
Amikacin
Dose:
45 mg
Frequency:
OD
Route:
IV
Amino
glycosides
Interferes
with protein
synthesis in
bacterial cell
by binding to
ribosomal
subunit,
causing
misreading
of genetic
code which
leads to
inaccurate
peptidesequence
and
bacterial
death.
Treatment
of infections
caused by
susceptible
strains of
microorgani
sms,
especially
gram
negative
bacteria
Hypersensit
ivity to
aminoglycos
ides
Nausea,
vomiting,
diarrhea,
Headache,
Fever,
Check
doctors
order.
Assess
patient for
signs and
symptoms of
infection.
Monitor
intake and
output.
Increase fluid
intake, ifindicated.
Document
DRUG CLASSIFICATION MECHANISMOF ACTION
INDICATION CONTRA-INDICATION
SIDE EFFECTS NURSINGCONSIDERATION
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Name:
Calmoseptine
(Topical)
Emollients &
Skin
Protectives
Calmosep
tine ointm
ent
promotes
woundgranulati
on and re-
epithiliali
zation.
Protects, soothes &
helps promote
healing in those w/
impaired skin
integrity related to:
Feeding tube site
leakage; wound
drainage; urinary &
fecal incontinence,
bedsores; ileoanal
reservoirs, ileostomy,
urostomy; moistureeg
perspiration, acne &
scrapes; fungal
infections, eczema &
impetigo;
diaper rash; insect
bites; burns due to
flame, radiation or
chemicals; fistula,
fissures, excoriation;
colonoscopy,
external
hemorrhoids;
chafing, chapping of
skin; vag & rectalitchiness;pricklyheat
Do not use
this
medicatio
n if you are
allergic tozinc,
dimethico
ne, lanolin,
cod liver
oil,
petroleum
jelly,parabens,
mineral
oil, or wax.
signs of an
allergic
reaction:
hives;
difficultybreathing;
swelling of
your face,
lips,
tongue, or
throat. Stop
using zincoxide rectal
suppositori
es if you
have rectal
bleeding or
continued
pain.
Check
doctors
order.
Call your
doctor if you
have any
signs of
infection such
as redness
and warmthor oozing skin
lesions..
Avoid getting
this
medication in
your mouth
or eye
Document.
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x. Nursing care plan
Assessment/
Cues
Nursing
Diagnosis
Etiology Planning Nursing
Intervention
Rationale Evaluation
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Cues Diagnosis Intervention
Objective:
The patient
has difficulty
suckingeffectively and
prone in nasal
regurgitation
and aspiration
because air
leaks into the
mouth from
the cleft.
Difficulty of
feeding and
nasal
regurgitationrelated to
failure of
maxillary
prominence on
the affected side
and medial
nasal
prominences tomerge.
Cleft lip
(Cheiloschisis)
and cleft palate
(Palatoschisis),which can also
occur together
as cleft lip and
palate, are
variations of a
type of clef ting
congenital
deformitycaused by
abnormal facial
development
during gestation.
A cleft is a
fissure or
openinga gap.
It is the non-
fusion of the
body's natural
structures that
form before
birth.
After 8
hours of
nursing
interventio
n the
patient will
have
greater
success of
feeding in a
more
upright
position.
Maintain
adequate
nutrition to
ensure normal
growth and
development.
Teach the
parents how to
breast feed the
infant.
Experiment with
feeding devices.
A baby with a
cleft palate has
an excellent
appetite but
often has trouble
feeding because
of air leaks
around the cleft
and nasal
regurgitation.
Advise them to
hold the infant in
a near-sitting
position, with the
flow directed to
the side or back
of the baby's
tongue. Tell them
to burp the baby
frequently
because he tends
to swallow a lot
of air
After 8 hours of
nursing
intervention,
the patient hadgreater success
of feeding in a
more upright
position.
Cues BackgroundKnowledge
NursingDiagnosis
Goal/Objectives
NursingInterventions
Rationale Evaluation
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Subjective:
Objective:
Inability to
inititiate/
sustain an
effective suck
Inability to
coordinate
sucking,
swallowing,
and
breathing.
Impaired
ability of an
infant to
suck or
coordinate
the suck/
swallow
responses
resulting in
inadequate
oral
nutrition for
metabolic
needs. Thiswas affected
by the
anatomical
abnormality
of the
patient as he
has a cleft
lip and
palate
deformities.
Ineffective
infant
feeding
pattern
related to
anatomical
abnormality
After 2
days of
nursing
intervent
ion the
client
will be
able to be
free from
aspiratio
n and
display
adequate
output asmeasure
by
sufficient
number
of wet
diapers
daily.
Independent:
Using the
same scale,
weight
infants at
same time
each day.
Continuous
ly assess
infants
sucking
pattern
Assess
parentsknowledge
of feeding
techniques
Assess
patients
level of
anxiety
with
regards to
infants
feeding
difficulty
To ensure early
recognition of
excessive
weight loss.
To monitor for
ineffective
pattern
To help identify
and clear up
misconceptions
Anxiety may
interfere with
parents; ability
to learn new
techniques.
Goal was fully
met. The
patient is
now free
from
aspiration
and
displayed
adequate
output as
measured
by
sufficient
number ofwet
diapers
daily.
Cues BackgroundKnowledge
NursingDiagnosis
Goal/Objectives
NursingInterventions
Rationale Evaluation
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g g j
Remain
with
parents
and infant
during
feeding
Teach
parents to
place infant
in upright
position
during
feeding,
To identify
problem areas
and direct
intervention.
To prevent
aspiration.
Cues Nursing Diagnosis Goal/ Objectives NursingInterventions
Rationale Evaluation
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OBJECTIVE:
Difficult in
feeding
Malformation
of lips and roof
of the mouth
Risk for
Aspiration
(Breast Milk,
formula or
mucus) as
related toanatomic
effect.
After 1hour of
nursing
intervention the
patient will be able
to experience no
aspiration asevidenced by
noiseless
respirations, clear
breath sounds, and
clear odorless
secretions.
Independent
Position the
infant in a
football hold
to maintain
properbreathing.
Monitor and
record vital
signs
Stop feeding
immediately if
you suspect
aspiration,
Apply suction
as needed,
Elevate the
head of
patients bed
during and
after feedingsunless
contraindicate
d,
To prevent
from possible
of episode of
choking or
aspiration
To detectaspiration or
impaired gas
exchange.
To avoid
further
aspiration.
To help
prevent
aspirations.
After 1 hour of
nursing
intervention
the patient
doesnt
experience noaspiration as
evidenced by
noiseless
respirations,
clear breath
sounds, and
clear odorless
secretions.
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