help with my nursing care plan!

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its my first time to make nursing care plan so im a bit confused with it...my patient has congenital cleft palate which was recently repaired. now he developed oro-nasal reflux of fluid. so the doctors advised him to undergo pharyngeal flap surgery . i have to make nursing plan for post operative case. HELP! i need it badly:bugeyes:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

hello, 34-20, and welcome to allnurses! :welcome:

there is nothing i can do to help you based on the information you have provided. a care plan is about solving the patient's problems. the problems are determined from the symptoms that they have. symptoms are objective observations or subjective perceptions of the patient. you've given no indication as to what those symptoms are except he has oro-nasal reflux. that's not enough to make a care plan. surely, there is more to what is going on with this patient than that. i would expect this patient to be having symptoms of breathing and swallowing difficulties, eating and nutrition issues, other symptoms involving the inside of their mouth, possibly pain, skin concerns, problems with oral communication, developmental delays in their growth cycle and they are at a risk for infection. where's all this information that you should have obtained? it is needed to develop a plan of care. provide that and i will be able to help you.

please read this post: https://allnurses.com/forums/f205/help-nursing-care-plans-277791.html and the information on how to write care plans on these threads:

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