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Newborn Nursing Notes for Cleft Lip

This document contains a nursing note for a baby named Ivy born with a cleft lip and palate. The note details the baby's condition including defects from failed embryonic development and difficulties breathing and feeding. The nurse administered oxygen, IV fluids, monitored vitals and took measures to clear the airway and support feeding. After 8 hours of these interventions the baby was breathing normally with stable vitals and was no longer irritable.

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Marielle Chua
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291 views2 pages

Newborn Nursing Notes for Cleft Lip

This document contains a nursing note for a baby named Ivy born with a cleft lip and palate. The note details the baby's condition including defects from failed embryonic development and difficulties breathing and feeding. The nurse administered oxygen, IV fluids, monitored vitals and took measures to clear the airway and support feeding. After 8 hours of these interventions the baby was breathing normally with stable vitals and was no longer irritable.

Uploaded by

Marielle Chua
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Republic of the Philippines

Department of Health
COTABATO REGIONAL AND MEDICAL CENTER

LAST NAME FIRST NAME SUFFIIX,IF ANY MIDDLE NAME HEALTH RECORD

BABY IVY
AGE/ SEX DATE OF BIRTH(mm/dd/yy) WARD ROOM
PEDIA WARD

NURSES NOTES
DATE FOCUS DATA/ACTION/RESPONSE
TIME/SHIFT

03/22/2021 Ineffective Airway Clearance Data


9AM - Born at 9 months gestation spontaneously thru cephalic
presentation.
- The infant had a defect that occur on the left side
embryonic developmental failure of abnormal opening in
the lip and palate.
- The patient had a cleft lip which involve the alveolar ridge
and dental anomalies (absent teeth) and also the presence of
cleft palate which there is nasal distortion, soft and hard
palate through the roof of mouth.
- The patient cried a lot when she was out in the tummy of
her mother. The first intervention modifies on feeding
techniques as needed for adequate growth. She was
delivered very weak with flaring of the nostrils, retraction
of the chest and difficulty breathing noted.
9:30AM- Action
2:30PM - Administer oxygen inhalation via facial mask at
6Lpm/min.
- Hook D50.3 NSS 500 cc as venoclysis and place soluset
0f 50 cc IVF at KVO rate
- Monitor and record vital signs.
- Assess the infant’s respiratory rate, depth, and effort.
- Assess skin color and capillary refill.
- Place the infant in an infant seat at a 30° to 45°.
- Position the infant in an upright position during feeding
and elevate the head of the crib 30° after.
- Provide mouth and throat suctioning for secretions.
- Feed the infant slowly and burp frequently.
- Provide special nipples or feeding devices such as pigeon
feeder with a one-way valve.
3PM Response
After 8 hours of nursing intervention, the patient was able
to breath normally as evidenced by maintained airway
patency, normal breathing pattern, vital signs are in normal
range, and no longer irritable.

Chua, Marielle P./Margallo,V.


NDU BSN 2 NDU CI
03/22/2021 12: 15PM

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