Assessment S: N/A O: -pain of 8 in a scale of 1 to 10 -tantrums -crying -irritability -swelling of the area

Nursing Diagnosis P: Risk for infection E: Related to surgical procedure S: swelling of the area, pain of 8 in a scale of 1 to 10, crying, tantrums, irritability

Scientific background Cleft lip surgery, the child will have general anesthesia. The surgeon will trim the tissue and sew the lip together. The stitches will be very small so that the scar is as small as possible. Most of the stitches will absorbs into the tissue as the scare heals so they will not have to be removed later. Due to the scar there is a risk for infection. Source: www.nlm.nih.gov/medlineplus/ cleftlipandpalate

Goals Nov. 25, 2013 11:30 AM Short term: After the operation, nursing interventions will be rendered q2h resulting that the infants mucosal tissue will heal without infection.

Planning 1. Assess V/S q30min until stable. 2. Assess oral cavity q2h or as needed or tenderness, reddened 3. 4. Use careful handwashing and sterile technique when working with suture line. 5. Apply

Rationale 1. Elevated temp may indicate infection (warmth.) 2. Aids in identifying infection. 3. Helps decrease the presence of bacteria. 4. Prevents the spread of microorganisms from other sources. 5. Counteracts the growth of bacteria.

Evaluation November 25, 2013 1:30 AM After nursing interventions were rendered after 22h, the goal was met AEB: infant remains free of infection in oral cavity, tissue remain intact and firm and healing process progresses without adverse events.