Nursing Care Plan (NCP) for Cleft Lip / Cleft Palate

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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 

Writing a Nursing Care Plan (NCP) for Cleft Lip / Cleft Palate

A Nursing Care Plan (NCP) for Cleft Lip / Cleft Palate starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

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Transcript

Hey everyone, today, we’re going to be creating a nursing care plan for cleft lip and palate. So, let’s get started. First, we’re going to be going over the pathophysiology. So cleft lip is characterized by a slitter 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. Some nursing considerations: we want to assess skin color, respiratory status, abdominal distention, sucking ability, infant weight, caloric intake, provide families and caregivers with education on surgery and consult the dentist and auditory and speech therapists. Desired outcomes: the patient will have normal breathing, adequate nutrition, and optimal hearing and speech. 

So, here’s an example to show you; this is the cleft lip. You’re going to see it’s unilateral, on one side right here. And that’s that opening that you see right here? This here is the cleft palate, and you’re going to notice this one has that opening right here on the roof of the mouth. That’s the palate. So that’s the palate. And then this one was the lip, and this can be bilateral wanted to note that it could be both sides too. This happens to be unilateral. 

So, we’re going to go ahead and get started on the care plan. We’re going to be writing out some of that subjective data and objective data. So what are we going to see with these patients? So, some subjective data are difficult to feed and some possible hearing loss. Objective is you’re going to have that opening. So, in the lip or the palate and possible speech difficulty. So, we have some difficulty feeding, hearing loss, possible aspiration on food, secretions, and frequent ear infections. 

So, we’re going to move on to the interventions. One of the first things that we want to do, we want to assess the infant skin color and capillary refill. So, we’re going to do an assessment. Decreased oxygenation is typically an issue with the defect due to possible aspiration. So, we want to assess this and decreased tissue perfusion. We also want to make sure we’re assessing for abdominal distension. Unfortunately, there’s difficulty feeding in these infants that result in large amounts of air that causes abdominal distension. You want to make sure we’re assessing respiratory status as these can often lead to aspiration of milk or secretions due to the incomplete closure of the lip or palate. Infants can develop pneumonia and respiratory distress. We want to assess infants’ sucking ability. We want to make sure that we’re providing infants with special nipples or feeding tools that have a one-way valve to them. This helps reduce the risk of aspiration and any excess air intake. We want to make sure that we’re suctioning the nasal and oral passages as needed. So, you want to make sure that we’re suctioning. This is going to help remove any excess fluid or secretions from the infant’s airway. We’re going to monitor the infant’s weight and caloric intake. This is going to help determine if the infant is feeding properly, or if there’s any other interventions that are going to be needed. And we want to make sure that we’re going to get a referral for dental, speech, and auditory consults. So, an infant may have frequent ear infections as a result of those eustachian tube blockages that result in hearing loss. So, we’re going to want to make sure we’re consulting audiology. There may be difficulty hearing leading to speech delays. So, we’re going to want to consult speech. And there may be dental issues that may arise from the defect of the upper palate. So that is why we’re going to want to make sure we have the dentist. 

So, we’re going to move on to some key points. So cleft lip, cleft palate, it’s going to be that opening or slit through the lip nose or the roof of the mouth that didn’t fully close properly during development. It’s a genetic environmental factor that’s believed to be the cause of not joining properly. Some subjective and objective data. You’ll see difficulty feeding, possible hearing loss, cleft opening in the lip. And you’re going to see that possible aspiration on food, they’re going to have frequent ear infections, and speech difficulty. We’re going to make sure we’re doing a thorough assessment. So, assessing skin color, cap refill, their respiratory status, abdominal distension, and their sucking ability. We can also monitor their weight and caloric intake, as well as obtain surgery and consults. We’re going to prepare families for surgery, and we’re going to refer the families to the dentist, the audiologist, and speech therapist. And we’re going to educate on when to consult the physician for any complications. Alright. And that is the end of that care plan. 

You guys did wonderful. We love you guys. Go out, be the best self today and as always happy nursing.

 

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