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Cleft Lip and Cleft Palate Nursing Case Study w/ NCP

Monday, 16 June 2014

Cleft lip and cleft palate are abnormalities in closure of the lip or palatine shelf that may occur separately or in combination. Cleft lip deformities can occur unilaterally, bilaterally or rarely, in the midline. Only the lip may be involved, or the defect may extend into the upper jaw or nasal cavity. Incidence is highest in children with a family history of cleft defects, those exposed to teratogens during fetal development, or those with various chromosomal abnormality syndromes.

During the fifth to eighth weeks of pregnancy, the fusion of the maxillary and nasal processes occurs. Various causes may lead to lack of or only partial fusion of the lip, with or without nasal septal deviation or unfused nasal floors, and malpositioning or absence of upper teeth and gingiva. From the ninth to twelfth weeks of fetal growth, the palatine shelf, which forms the hard (bony) and soft (muscular) palates, closes as well. Improper fusion can affect one or both palates, the bones of the maxilla, and the gum line on one or both sides of the premaxilla as well as the uvula, and may include the mucosal layers, or occur under the submucosa. A double cleft runs from the soft palate forward to either side of the nose, and separates the maxilla and premaxilla into freely moving segments.

■ Congenital syndromes
■ Impaired sucking ability and decreased nutrition
■ Parental psychological distress at disfigurement and impairment

Postsurgical repair:
■ Respiratory distress from aspiration
■ Surgical wound infection
■ Recurrent ear infections with possible hearing loss
■ Speech and language development impairments
■ Dental abnormalities and malocclusions

Health perception and management
■ Maternal exposure to radiation or infection
■ Family member or relative with cleft lip or cleft palate

Nutrition and metabolism
■ Poor feeding
■ Difficulty sucking

Physical findings
General appearance and nutrition
■ Visible unilateral or bilateral cleft lip
■ Underweight

Eyes, ears, nose, and throat
■ Nasal distortion

■ Visible cleft palate involving soft or hard palate with opening between the mouth and the nasal cavity
■ Impaired sucking (with cleft lip and cleft palate)

Nursing care plan
Nursing diagnosis
Nursing priorities

Imbalanced nutrition: Less than body requirements related to inability to ingest food because of difficulty sucking
     Observe feeding and intervene to optimize nutrient intake.

Ineffective airway clearance related to possible aspiration of secretions or milk as a result of defect
     Monitor for aspiration and take steps to minimize this complication.

Impaired oral mucous membrane related to defect and retention of formula in oral cavity
     Monitor for, prevent, and treat any breakdown.

Ineffective coping (family) related to anxiety, guilt, or emotional conflict as a result of neonate's defect
     Provide support and educate the family.

Deficient knowledge (parental) related to feeding of the neonate and surgical procedure to correct defect
     Educate the parents about feeding and surgical repair.

Other potential nursing diagnoses: Impaired home maintenance related to care of neonate with defect ■ Complicated grieving (parental) related to loss of the perfect child ■ Ineffective infant feeding pattern related to physical defect ■ Risk for impaired parenting related to crisis of having neonate with defect or interruption in parental bonding process ■ Risk for infection related to trauma to oral mucosa as result of improper feeding technique

Imbalanced nutrition: Less than body requirements related to inability to ingest food because of difficulty sucking
Expected outcome
The neonate will exhibit adequate nutritional status to maintain growth and healing.
Suggested NOC Outcomes
Breastfeeding establishment: Infant; Nutritional status; Swallowing status: Oral phase
Nursing interventions
Intervention type
Assess nutritional status and needs, including:
     sucking or swallowing ability

     daily caloric and fluid intake
     daily weight gain or loss.

The infant's appetite isn't affected by the defect, but the ability to suck properly is impaired, so intake may be reduced.
The infant may be unable to form an adequate seal for sucking. Documented daily intake helps determine whether the infant is meeting nutritional needs or whether the feeding method needs to be changed, possibly to gastric gavage. Monitoring weight daily evaluates the success of the feeding pattern and reveals the optimal weight gain desired or the need for a change in feeding method to minimize weight loss.
Based on assessment, calculate the minimum number of calories per kilogram per day and the number of milliliters per kilogram per day of feeding needed.
This indicates the infant's nutritional requirements.

To help the breast-feeding mother, teach her to:
     massage her breasts and nipples before nursing.
     apply pressure to the areola with her fingers, guide the nipple to side of the infant's mouth, and hold it there during feeding.
     allow extra feeding time.
     burp the infant frequently during feeding.
     hold the infant in an upright or a sitting position while feeding.
An alternative is for the mother to pump her breasts and feed the infant with a bottle.
An infant with a cleft palate may not be able to breast‑feed. An infant with a cleft lip may be able to breast‑feed if the cleft doesn't affect sucking.
     Massaging breasts and nipples brings milk near the surface for ease in sucking and hardens breasts, helping the infant to hold the nipple in his mouth.
     Holding the nipple in the infant's mouth allows the infant to nurse with its gums rather than by sucking, if sucking is difficult.
     Feeding may take up to 1½ hours.
     The infant swallows more air during feedings.
     Holding the infant in an upright or a sitting position enhances swallowing and prevents milk from coming through the defect and out of the nose, thus decreasing the risk of aspiration.
     Pumping breast milk satisfies the mother's desire to breast‑feed and provides an excellent source of nourishment.
To help the bottle-feeding mother, teach her to:

     hold the infant in an upright or a near‑sitting position during feeding.
     select an appropriate nipple.
     place the nipple at the side or back of the infant's tongue.
     thicken milk with small amount of cereal.
     feed the infant small amounts slowly, and burp the infant after each 10 to 15 ml of milk.
     refrain from removing the nipple from the infant's mouth unless necessary.
     give the infant some water after feeding.
     gently wipe milk away from the infant's face and nose with a damp cloth and pat dry.
Safe bottle‑feeding maintains the infant's nutritional status.
     Holding the infant in an upright or a near‑sitting position reduces the risk of aspiration and of swallowing air.
     The mother may have to experiment to find the nipple or device that's most suitable for the infant, depending on the defect.
     Placing the nipple at the side or back of the infant's tongue avoids the cleft and enhances swallowing.
     Thicker milk allows for easier swallowing because of increased gravity flow.
     Feeding slowly and burping regularly prevent regurgitation or vomiting by expelling the air the infant swallows during feeding.
     Removing the nipple may cause the infant to cry, making feeding more difficult.
     Water rinses milk away from the mouth and defect.
     Wiping removes milk that may have entered and drained from the nose.

[Additional individualized interventions]

Suggested NIC Interventions
Bottle feeding; Breastfeeding assistance; Nutritional monitoring
Ineffective airway clearance related to possible aspiration of secretions or milk as a result of defect
Expected outcome
The infant will maintain a clear airway.
Suggested NOC Outcomes
Aspiration prevention; Respiratory status: Airway patency
Nursing interventions
Intervention type
Assess the infant's respiratory status, noting:
     rate, depth, and effort
     dyspnea and cyanosis
     nasal flaring and chest retractions
     breath sounds
     skin color
     capillary refill.
Assessment provides data about respiratory status and function. Aspirating secretions or milk can cause tachypnea, abnormal breath sounds, bluish skin, or delayed capillary filling from decreased oxygenation.

Observe for abdominal distention.
Distention, resulting from swallowed air, compromises respirations.
Carefully suction the oropharynx and nasopharynx when needed.
Suctioning removes excess liquids and secretions in the pharynx.
Position the infant in an infant seat at a 30- to 45-degree angle.
Such positioning prevents the infant's tongue from falling back and obstructing the airway.
Feed the infant in an upright position, and elevate the head of the crib 30 degrees after feedings.
This position prevents aspiration of milk.

[Additional individualized interventions]

Suggested NIC Interventions
Aspiration precautions; Respiratory monitoring
Impaired oral mucous membrane related to defect and retention of formula in oral cavity
Expected outcome
The infant will maintain good tissue integrity and intact oral mucous membranes.
Suggested NOC Outcomes
Tissue integrity: Skin & mucous membranes
Nursing interventions
Intervention type
Assess for impairment by observing:
     reddened, tender areas on the lip or palate
     formula in the oral cavity or crust formation.
Impairment may cause irritation or inflammation of mucous membrane.

Give the neonate with a cleft palate a small amount of water after each feeding.
Water will help rinse residual breast milk or formula out of the oral cavity
Clean cleft lip with a little water or half-normal saline solution and hydrogen peroxide after each feeding.
Cleaning rinses away milk after feeding. Hydrogen peroxide solution has bactericidal cleaning action.
Apply a small amount of cream or baby oil to the infant's lips.
Cream or oil prevents drying and cracking.
Report persistent irritation for further treatment.
Persistent irritation may lead to infection if the mucosa breaks down.

[Additional individualized interventions]

Suggested NIC Interventions
Oral health maintenance; Skin surveillance
Ineffective coping (family) related to anxiety, guilt, or emotional conflict as a result of neonate's defect
Expected outcome
The parents will develop a trusting relationship with the caregivers and begin the adaptation process by verbalizing their understanding of the neonate's defect.
Suggested NOC Outcomes
Anxiety level; Family participation in professional care; Knowledge: Disease process; Parent-infant attachment
Nursing interventions
Intervention type
Encourage and allow parental expression of feelings and fears about caring for the neonate, what others might say, or loss of the "perfect child."
Society places great importance on physical appearance; impairment causes parental shock, guilt, and disappointment.
Allow the parents to see and hold the neonate as soon after birth as possible, after the obstetrician has informed them of the defect.
Delay in seeing the neonate may heighten the parents' anxiety and sadness.
Allow the parents to grieve the loss of the "perfect child."
Grieving may help the parents accept the child with a defect.
If appropriate, reinforce that the neonate is in other ways normal and healthy.
Reinforcement helps reduce the parents' sadness and anger and helps them begin adapting to the crisis.
Handle the neonate in a caring manner, and encourage the parents to hold and cuddle their child.
Such handling promotes bonding and the neonate's normal social and emotional development.
Allow for open visitation with the neonate when desired, encouraging the parents' active role in giving care.
Visits promote a flexible, secure environment for development of the parent‑child relationship.
Assess the parents' understanding of cleft lip and cleft palate.

Assessment reveals how much and what kind of information the parents need and what misinformation they may have.
Assure the parents in a calm, positive way that the defect can be repaired functionally and cosmetically with surgery.
This reassures the parents that the defect can be corrected and helps them in the grieving process.
Provide information about:

     the neonate's condition, its causes and prevalence, and the nature of the defect

     the neonate's short‑term needs, such as feeding

     the neonate's long‑term problems, such as impaired speech, dental problems, upper respiratory tract and ear infections, and probable need for surgery.

Information increases the parents' understanding of the defect.

Explaining the neonate's condition helps ameliorate the parents' guilt feelings.

This reduces anxiety about the most difficult problem in caring for the neonate.

This prepares the parents for long‑term health needs. The palate is essential to speech formation, and changes in structure—even after surgery—may permanently affect speech. Mouth breathing may cause changes in the shape of the mouth and dental problems, with the need to straighten teeth and correct the shape of jaw. Middle ear infections from failure of the eustachian tube to drain may contribute to hearing loss. Upper respiratory tract infections are common. Depending on the deformity, the child may need subsequent surgeries for further correction.
Allow the parents to ask as many questions as they want.
The more questions the parents ask, the better able they'll be to adapt.
Encourage participation in a support group for parents of neonates with congenital defects.
Such groups offer support, information, and a positive view of the treatment outcome.

[Additional individualized interventions]

Suggested NIC Interventions
Coping enhancement; Family mobilization; Parenting promotion; Teaching: Disease process
Deficient knowledge (parental) related to feeding of the neonate and surgical procedure to correct defect
Expected outcome
The parents will receive appropriate information about feeding and defect repair, demonstrate correct feeding techniques, and verbalize their understanding of the information provided.
Suggested NOC Outcomes
Knowledge: Illness care; Knowledge: Treatment procedure(s)
Nursing interventions
Intervention type
Inform the parents of the general timing of surgical repair and what to expect from the neonate. Show them photographs of infants before and after surgical repair.

If the infant's weight is optimal and he has no other neonatal anomalies, he may undergo surgery to repair a cleft lip shortly after birth; this can minimize the parents' shame or embarrassment. Surgery may also take place in 2 to 3 months or as late as 8 months to allow for bonding and to rule out other congenital anomalies. Cleft palate may be repaired in two steps by 12 to 16 months; or repair of the soft palate may proceed in 6 to 18 months and repair of the hard palate, as late as age 5. Timing of the procedures is related to normal growth changes, and repair usually takes place before speech development.
Instruct the parents in breast‑feeding or bottle‑feeding techniques, as appropriate.
Proper feeding technique helps maintain the infant's nutritional status without complications.
Before surgery, teach the parents what care techniques they'll need to use, including:

     feeding the infant without a nipple unless specifically ordered to use a nipple by the plastic surgeon

     using a Logan bar over the lip incision to prevent tension on the sutures, and elbow splints or a special jacket to hold the neonate's arms straight and away from his mouth until the suture line heals.

     positioning the neonate on his back using an infant seat or on his side so that the infant can be closely observed for excessive secretions.
Introducing new care techniques a few days before surgery helps the infant adapt to restrictions.

Teaching the parents how to
feed the infant by nonnipple devices prevents injury to the surgical site.

Restrictive positioning prevents disturbance of the suture line, preventing proper healing with minimal scarring.

The semi-seated back position is the position of choice to maintain respiratory function after surgery.
Instruct the parents in postoperative care measures, including:

     incision care

     dietary modifications

     trying to prevent the infant from sucking and blowing

     not inserting silverware or straws into the infant's mouth

     rinsing the oral cavity with sterile water after feeding.

Providing information helps dispel the parents' anxiety and promotes compliance.
Cleaning the incision helps the suture line heal.

Dietary modifications help meet the infant's nutritional needs while maintaining integrity of the suture line.

Sucking and blowing put stress on the suture line.

Inserting objects into the mouth could traumatize the suture line.

Rinsing the oral cavity removes residual food or fluids, which are possible sources of irritation and infection.
Refer the parents to community and home health care resources.

Referrals help the parents and family with continued physical and emotional support outside the hospital.
Use pamphlets to illustrate the procedure, suture lines, scar, proper positioning and monitoring for complications.
Illustrations show what to expect and possible outcomes while reinforcing written and aural learning.

[Additional individualized interventions]

Suggested NIC Interventions
Referral; Teaching: Procedure/treatment

Teaching checklist
■ Causes of cleft lip and cleft palate
■ Feeding and nutrition
■ Surgical repair
■ Preoperative and postoperative care
■ Complications, such as ear infections, speech abnormalities, dental concerns
■ Risk to future pregnancies, importance of prenatal vitamin with folic acid
■ Community, school-based (beginning at age 3), and web-based resources for support, information, and services
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