S.G. returns to your unit 6 months later for her cleft palate repair (palatoplasty).Which of these nursing interventions are appropriate as you plan her care? Select all that
apply, and explain why or why not.
a. Position patient side-lying or on abdomen postoperatively.
b. Use elbow restraints as needed.
c. Clear fluids; advance as tolerated. Patient may use a straw.
d. Administer pain medications as ordered.
e. Oral suction with a Yankauer catheter as needed.
f. Maintain strict intake and output.
a, b, d, f
a. Appropriate: This position facilitates drainage of oral secretions. Head of bed (HOB) can be
elevated 30 degrees.
b. Appropriate: Splints might be required to prevent the patient from putting hands in the mouth.
Swaddling or "cuddling" by parents may prevent interruption of the operative site.
c. Inappropriate: Clear fluids will be introduced, but the diet is advanced to pureed or soft, and
straws and other blunt objects are avoided to prevent trauma to the site.
d. Appropriate: Round-the-clock pain control is necessary initially to facilitate comfort and feeding.
Nonpharmacologic techniques can be used as well.
e. Inappropriate: Plastic oral suction catheters and tongue blades should be avoided. If there are
secretions, the surgeon might advise a soft suction tube to be used carefully away from the
surgical site. Always check first with the surgeon.
f. Appropriate: Careful assessment of hydration status in the infant after surgery is essential. IV
hydration should be maintained until the patient is taking sufficient fluids by mouth.
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