Abstract
To identify the main nursing diagnoses and interventions in children in the immediate postoperative period of palatoplasty. Documentary and retrospective study, developed in a Brazilian public and tertiary hospital, between August and September 2020. Children who underwent only palatoplasty, between January and December 2019, aged between 10 and 24 months, were included. Those with medical syndromes and/or comorbidities were excluded. The Theoretical Framework of Basic Human Needs and the NANDA International and Nursing Interventions Classification Taxonomies were used. Data underwent descriptive statistical analysis. The sample consisted of 126 children. Psychobiological needs such as oxygenation, hydration, nutrition, elimination, cutaneous-mucosal and physical integrity, pain and environmental perception predominated. Based on them, nine nursing diagnoses, with four focusing on the problem and five on risk, as well as 17 interventions, were identified. The use of standardized languages to identify affected human needs and, based on them, diagnoses and interventions, favored clinical reasoning for the construction and organization of clinical nursing practice.
Highlights
Cleft lip and/or palate are prevalent among the malformations affecting the face, being defined as openings or interruptions in the lip and/or oral cavity structures, the location and extension of which are variable
Aiming to make the findings more reliable, besides eliminating possible biases, we sought to assess the percentage of agreement among the findings described in the m edical record and those evidenced by the researchers regarding nursing diagnoses and interventions
Nursing diagnoses INTEGRITY OF THE IMPAIRED ORAL MUCOUS MEMBRANE (00045) Defining characteristics Oral discomfort Oral edema Related factor Surgical procedure Related factor Edema ACUTE PAIN (00132) Defining characteristics Change in appetite Expressive behavior Related factor Harmful physical agent INEFFECTIVE RESPIRATORY PATTERN (00032) Defining characteristics Nasal flaring Abnormal breathing pattern Breath with pursed lips Use of accessory muscles to breathe Related factor Edema INEFFECTIVE INFANT FEEDING PATTERN (00107) Defining characteristics Inability to initiate effective suction Associated condition Oral hypersensitivity n
Summary
Cleft lip and/or palate are prevalent among the malformations affecting the face, being defined as openings or interruptions in the lip and/or oral cavity structures, the location and extension of which are variable. In Brazil, the incidence is 1:650 live births The etiology involves both genetic and environmental factors, that is, it is multifactorial[1,2]. They result from failures in the fusion of facial processes that take place between the 4th and 12th gestational week and can be classified according to the anatomical location in cleft lip, palate, and lip and palate. As for the extension, they can be complete or incomplete, uni- or bilateral[1,2,3]. Patients with this malformation may present aesthetic, functional, and psychosocial problems. When the palate is affected, the surgery is called palatoplasty, which can be performed using different surgical techniques, depending on the classification of the cleft, anatomical amplitude, repair time (1 or 2 times), experience of the surgeon, and child’s general health status[1,4]
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