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Nursing Care Plan | NCP Cleft Palate, Cleft Lip

Cleft lip and cleft palate are facial malformations of the upper lip or palate that are the fourth most common congenital abnormality in the United States. They may appear separately or, more commonly, together. The malformation is a result of a failure of the maxillary and median nasal processes to fuse during the second month of embryonic development. Cleft lip may vary from a small notch to a complete cleft that extends into the base of the nose. When cleft palate occurs alone, it is midline, but when it occurs with cleft lip, it may extend into either side of the soft palate. Related complications of cleft lip/cleft palate include dental malformations, frequent otitis media leading to hearing impairment, speech difficulties, and social isolation due to poor self-image and speech impairments.

A genetic cause for cleft lip/cleft palate is likely; however, environmental exposure to teratogens during critical embryonic development cannot be ruled out. Cleft lip with or without cleft palate is etiologically and genetically distinct from isolated cleft palate. Isolated cleft palate has a greater incidence of associated anomalies. There is a twofold increase in the occurrence of clefts with maternal smoking in early pregnancy.
Nursing care plan
Nursing care plan physical assessment and examination
A family history of cleft lip or cleft palate may or may not exist. Identical twins are more likely to share the disorder than are fraternal twins. Inquire about teratogen exposure during the first trimester of pregnancy.

The cleft lip may vary from a small notch to a widespread open cleft and may be unilateral or bilateral. The cleft palate also varies in the extent of the malformation: it can involve only the uvula, extend into the soft and hard palate, or be unilateral, bilateral, or midline.

Parents’ and families’ adjustments to an infant with cleft lip or cleft palate may be difficult. The deformity is usually readily observable at birth and often totally unexpected. Support for the family is essential and includes explanations of the surgical procedures and long-term prognosis.

Nursing care plan primary nursing diagnosis: Altered nutrition: Less than body requirements related to inadequate intake.

Nursing care plan intervention and physical treatment
CL and CP are treated with a combination of surgery, speech therapy, and orthodontic work. Surgical repair of a CL is performed within the first month after birth. The repair improves the child’s ability to suck. The optimal time to surgically correct a CP is controversial. Times range from 28 days of life to 18 months. Most surgeons prefer to perform the surgery at an early age, before faulty speech habits develop. The more extensive the surgery required, the later the surgery may occur. Surgical repair of CL (cheiloplasty) is usually uncomplicated with no long-term intervention, other than possible scar revision. Surgical repair of CP (palatoplasty) is more extensive and may require more than one surgery. If the infant has horseshoe defect, surgery may be impossible. A contoured speech bulb attached to the back of a denture appliance to occlude the nasopharynx may help the child speak.

Because of the long-term, multidisciplinary nature of services needed for the child, assist the parents in accessing appropriate support within the health care system. Support the parents before and during the surgical procedure by identifying the positive features of the newborn. Call the infant by name. Current surgical practices provide excellent repairs with minimal scarring. Encourage parents to discuss their feelings about the child’s appearance. Sharing pictures of children with successful CL repairs may help the parents cope with their fears and anxieties.

Depending on the severity of the cleft, children with CL/CP will have problems sucking. Work with the parents and experiment with devices that will improve nutrition, such as different kinds of nipples. The infant may feed better if the parents use a nipple with a flange that occludes the cleft or a large, soft nipple with large holes. Try holding the infant at different positions during feeding (e.g., at a 60- to 80-degree angle). Breastfeeding can be successfully carried out as long as the mother can maintain a seal during nursing. In some nursing pairs, the breast tissue may help form the seal. Otherwise, the mother can use the hand not holding the infant or she can use a molded nipple.

Parents should be allowed to verbalize fears and anxiety about the deformity. The first time parents see their baby, they may experience shock, disappointment, or guilt. If you help them see the baby’s assets, you encourage bonding and acceptance. Allow ample time for the parents to hold the infant to promote bonding. Explain the surgical procedure and postoperative care to parents.

The postoperative management of an infant with a CL focuses on protection of the operative site. Arm restraints prevent the child from rubbing the site and from self-injury. Hang baby toys within reach of the baby’s restrained hands. Many infants are more comfortable in an infant seat rather than lying in a crib. In order to avoid facial contact with the sheets, do not place infants on their stomachs for sleep. Pacifiers are contraindicated, and feeding methods should be designed to reduce any tension on the suture line. Use a cotton-tipped applicator and a cleansing solution to clean the suture line. An antibiotic ointment may be prescribed. Pain should be controlled with analgesic medication and nonpharmacologic strategies such as holding and rocking.

The postoperative management of an infant with a CP centers on prevention of injury to the operative site. Do not place sharp or potentially injurious objects in the child’s mouth (spoons, forks, straws, etc.). Feeding may be done from the side, but self-feeding is prohibited. After feeding, make sure to cleanse the child’s mouth with water or a cleansing solution.

Nursing care plan discharge and home health care guidelines
Teach the parents feeding techniques, how to observe for aspiration, and to bubble the infant frequently. After surgery, teach the parents to avoid putting objects into the infant’s mouth.

Teach the parents to care for the incision and to assess the incision for infection. Explain the importance of keeping the infant’s hands away from the face. Tell the parents that it is important to hold the infant and remove the restraints from time to time.

Teach the parents the signs of pain in an infant, and explore with them nonpharmacologic methods to relieve pain. Review with the parents the analgesic medication dosage, time, and route.

Instruct parents that the child may have more recurrent middle ear infections than other children. The child may also need orthodontic or speech therapy at some time because of the deformity of the mouth and palate.
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