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Outline
Pathophysiology
Cleft lip is characterized by a slit or opening that goes through the lip and into the nose on one or both sides of the lip. Cleft palate is an opening in the roof of the mouth, called the palate. Cleft lip and cleft palate may occur together or individually.
Etiology
During the early part of pregnancy, around week 7 or week 8, the tissues of the mouth and lips begin to form and join. Genetic and environmental factors are believed to be the cause of these tissues not joining correctly which leaves an opening in the lip or palate. Studies have shown that pregnant women who use certain medications to treat epilepsy and those who have diabetes or smoke are at increased risk of having a baby with orofacial clefts.
Desired Outcome
Patient will have normal breathing pattern; patient will have adequate nutrition; patient will have optimal hearing and speech
Cleft Lip / Cleft Palate Nursing Care Plan
Subjective Data:
- Difficulty feeding
- Hearing loss
Objective Data:
- Cleft / opening in lip or palate
- Aspiration of food/secretions
- Frequent ear infections
- Speech difficulty
Nursing Interventions and Rationales
| Nursing Intervention (ADPIE) | Rationale |
| Assess infants skin color/capillary refill | decreased oxygenation is typically an issue with the defect due to possible aspiration. Assess for cyanosis/decreased tissue perfusion |
| Assess abdominal distention | difficulty feeding in infants can result in large amounts of air causing abdominal distention |
| Assess respiratory status | clefts can often lead to aspiration of milk or secretions due to the incomplete closure of the lip or palate. Infants can develop pneumonia/respiratory distress |
| Assess infants sucking ability | provide infant with special nipples/feeding tools that have a way valve. This helps reduce risk of aspiration and air intake |
| Suction nasal/oral passages as needed | helps to remove any excess fluid or secretions from the infant’s airway |
| Monitor infant’s weight/caloric intake | helps determine if infant is feeding properly or if other interventions are needed. |
| Prepare infant/family for surgery | infant will likely need surgery to repair the defect. Educate and support family for this process |
| Give referral info for dental, speech, and auditory consults | infant may have frequent ear infections as a result of Eustachian tube blockages that result in hearing loss. Consult audiology. Difficulty hearing can lead to speech delays. Consult speech. Dental issues may arise from the defect lip/palate. Consult dentist |
| provide education and resources for families/caregivers | Proper way of feeding infant with assistive devices
Post-surgical care of the incision site When to call the doctor for any complications that may arise |
References
- https://www.mayoclinic.org/diseases-conditions/cleft-palate/symptoms-causes/syc-20370985
- https://www.cdc.gov/ncbddd/birthdefects/cleftlip.html
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