Running Head: CONCEPT MAP PRIORITY
Concept Map Priority Pathway
Dominika Barcicki
Course: NURS 252
March 16, 2015
Humber College
Professor: Eva Hearn
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Introduction
Cleft lip (CL) is a congenital anomaly that consists of one or more clefts (unilateral and
bilateral) in the upper lip as a result of failure in the embryo of maxillary and median nasal
processes to fuse correctly. (Mosby, pp. 377). The fusing of the maxillary and the pre-maxillary
processes occur during the third and twelfth week of embryonic development. (Perry, pp. 1421).
The “maxillofacial clefts are the most common congenital deformities of the head and neck. The
incidence varies widely among ethno-cultural groups, with higher frequency among Aboriginal
people than among people of European descent.” (Jarvis, pp. 396t). In Canada alone, the
abnormal malformations of the face and neck affect about 400 and 500 newborns every year.
There is a higher incidence of males than females born with maxillary defects of approximately
60 % to 80% of newborns that are affected. Cleft lip (CL) varies from a small notch to a
complete cleft extending into the base of the nose which is very noticeable at birth. Unilateral
clefts are 9 times more common than bilateral clefts occurring more so to the left side of the face.
The etiology of CL may be caused by exposure of teratogens (alcohol, anticonvulsants, steroids,
and retinoids) during pregnancy. Also mothers who smoke during pregnancy are 2 times at risks
of their newborns to have this birth defect. (Perry, pp. 1421). CL treatment is a surgical repair
occurring during 6 to 12 weeks of age, involves long term interventions and management
focusing on prevention of complications and normal development of the child. (Perry, pp. 1422).
In the case study of a 3 month old male with a left upper cleft lip repair relevant data
pertaining to priority pathway are as follow: client 8hrs post-op, left upper lip repair, IV Ns
@12mls/hr, incision edges approximated, incision swollen with moderate serosanguinous
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drainage, client fussy alert reflexes normal, vital signs on admission from PACU (Postanesthesia Care Unit) at T 39.0C, R 22, P 48, Bp 112/64, SpO2 96% RA.
Chosen pathophysiological priority
The priority chosen clinical pathway from the case study is the risk for ineffective
breathing related to surgical correction of the lip. The 3 month old client with the upper left
cleft lip repair 8 hours post –op has swelling to the incision perhaps between the base of the nose
and the upper lip anterior border of the oral cavity. This can cause breathing compromise to the
nasal cavity and oral cavity to some extent depending on the severity of the surgical procedure
involving the cleft lip repair. (Jarvis, pp. 368). The major focus here is the respiratory system
involving the transfer of oxygen and carbon dioxide between the atmosphere and the circulatory
system. Inadequate exchange of oxygen and carbon dioxide may result in acute respiratory
failure or compromise. (Lewis, pp. 1990). Based on the client’s actual vital signs from PACU
(case study) : with respirations of 22 beats per min, pulse 48 bpm, blood pressure of 112/64,
SpO2 96% RA results are: respirations and pulse are below normal range with blood pressure
above normal values for a 3 month old infant. (Normal values of vital signs for an infant are:
respirations 30-40, pulse 70-190, Bp 80/40) These current values below and above normal are
possibly a result of the surgical procedure involving general anesthesia. General anesthesia
during and after surgery affects the entire central nervous system which in turn affects
neurological state (LOC), airway, breathing, circulation, input/output, and other body systems.
As a result the whole body system slows down for a period of time and returns to
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normal once the anesthetic wears off. Therefore, during the 24 hrs period post-op or longer, it is
crucial to monitor client’s vital signs to ensure there are no complications of respiratory /
cardiovascular compromise resulting from general anesthesia such as hypercapnic respiratory
failure; were respirations are slowed down by the drug effect therefore insufficient CO2 is
excreted from the body result increase in PaCO2. (Lewis, pp. 1990).
Clinical Manifestations/Complications
The clinical manifestations of post –op complications resulting from cleft lip repair such
as dyspnea, low O2 saturation, restlessness, and mental status changes are some of the early
signs of respiratory compromise. Further complications may arise such as aspiration pneumonia,
pulmonary edema, pulmonary emboli and ventilation-induced lung injury are a cause of acute
respiratory failure. These complications interfere with oxygen transfer into the circulatory
system. Respiratory compromise or hypoxemic respiratory failure is closely related to low
cardiac output which in-turn causes congestive heart failure or shock. (Lewis, pp. 1990). For
example pulmonary edema involves fluid overload were the heart is unable to pump blood
efficiently and blood/ fluid backs up in the veins causing excess fluid build-up in the lungs.
Aspiration pneumonia is another complication which can result from decreased consciousness
from general anesthesia that depresses the cough and epiglottal reflexes which can allow
aspiration of oral-pharyngeal contents into the lungs causing fluid build- up and infection.
(Lewis, pp. 660).
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Nursing Interventions/ Prevention and Treatment
The primary focus during postoperative period is preventing complications while the
client is healing. Priority assessments include airway breathing circulation status, neurological
orientation such as level of consciousness and sensory/ motor reflexes, gastrointestinal and
genitourinary status by recording/assessing intake (actual IV NS @ 12mls/hr) and output,
examining surgical site dressing and drainage. (Lewis, pp. 457-458). By monitoring vital signs
every 1-2 hrs or as needed (prn) especially within 24hrs post-op ensures that client is not
undergoing any early systemic distress that can result in severe complications listed previously in
the essay. Auscultating client’s lungs helps to ensure there is no fluid build-up such as crackles
in the lower lobes of the lung fields. Actual SpO2 in the case study is 96% on RA which is
within normal range of 95%-100% on average; however incase vital signs rapidly change
cardiorespiratory monitor is needed during this time to detect early signs of respiratory
compromise by measuring infant’s respiration rate, heart rate and oxygen level. Repositioning
client every 2 hrs or prn ensures expansion of all lung fields, this prevents fluid build-up in the
lungs after surgery. Assessment of the surgical incision and dressing of CL site is essential in
preventing infection and further inflammation of the incision. By monitoring client’s temperature
for hyperthermia (actual T 39.0 C) which can be a clinical manifestation of possible infection to
the surgical site is vital. In addition, elbow restrains are used to prevent infant from rubbing the
incision preventing the disruption to the site. Elbow restrains need to be taken off every 2hrs to
exercise the infant’s arms and promote comfort. Administering pain medication around the clock
as ordered by MD prevents infant from crying and also prevents disruption of the surgical
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incision. Upright infant seat may be needed if post-operative secretions is an issue, therefore
keeping the airway clear. (Perry, pp. 1423).
Conclusion
In conclusion, surgical repair management post-op of the cleft lip (CL) involves many
steps of nursing interventions and considerations. By focusing on the priority post-operative
airway management of the cleft lip repair prevents many post-operative complications such as
respiratory distress involving the surgical incision of CL. It takes very close nursing monitoring
of client’s vital signs, proper care of the incision, and promoting client’s comfort for example by
the use of pain medications during this period. Therefore, nursing interventions and treatments
ensures positive client outcomes in the long-term and effective nursing care overall.
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References
Jarvis, C. (2014). In Browne, A., MacDonlad-Jenkins, J., & Lucktkar-Flude, M. Eds.), Physical
Examination and Health Assessment: Canadian Edition (2nd ed). Toronto: Elsevier.
Lewis, S., Heitkemper, M., Dirksen, S., and O’Brien, P. (2014). Medical-Surgical Nursing in
Canada. Assessment and Management of Clinical Promlems (3rd Canadian ed). Toronto:
Elsevier.
Mosby. (2013). Mosby’s Dictionary of Medicine, Nursing, and Health Professions. Toronto:
Elsvier.
Perry, S. E., Lowdermilk, D. L., and Hockenberry, M.J. (2013). Maternal Child Nursing Care in
Canada (1st ed.). Toronto: Mosby Elsevier.
*Please note, I was not able to use peer review journals to support my priority pathway/
not enough information available pertaining to airway management/cleft lip*