Seguimiento de preescolar mediante el programa de paciente fisurado: proceso de enfermería

Abstract

The Nursing Care Process according to the Human Needs Model of Inés Astorquiza[1] was applied to a girl with special needs who used specialized secondary care in the South of Chile, due to malformations of the oronasal cavity and genetic conditions. Medical diagnoses: Cleft palate hard and soft palate, Robin Syndrome and Ankyloglossia. Surgical history of palatorrhaphy in 2019. She attends the first check-up in the polyclinic at the end of 2022, she is admitted to the Cleft Program recently implemented in the Hospital of her city, before she had to travel to another region who were in charge of her for 4 years. Through nursing assessment, the following clinical findings were identified: nasal tone of voice, mouth breathing, sleep apnea, mandibular retrognathia and presence of cavities. The state of priority need was “breathing” with the label Ineffective Breathing Pattern (00032). The interventions (NIC) were 7310-Nursing care upon admission and 5240-Counseling: presenting the Cleft program to the parents of the preschool. As a result, she is admitted to the Cleft Program, hours are assigned to her, and she receives advice on controls with specialists for the management of the ineffective respiratory pattern: ENT, audiometry, speech therapy, orthodontics, and dental care. The relevance of an efficient nursing management to grant continuous, timely services and with high quality standards is evident. The application of the PAE through the discipline model presented favored the investigation of needs and allowed a holistic approach.

[1] Inés Astorquiza's Model of Human Needs: a local authored nursing disciplinary model.