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Nursing Care Plan for Cleft Lip / Cleft Palate

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Orofacial clefts, individually known as cleft lip and cleft palate, are the most common birth defects. These defects happen early in pregnancy when the lips and palate do not form properly. 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.


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

  • Assess infant’s respiratory status, including rate, depth and effort before and after surgery


Clefts can often cause aspiration of milk or secretions due to incomplete closure of palate or lip. This can cause infants to develop pneumonia and respiratory distress.


  • Assess infant for skin color and capillary refill


Decreased oxygenation is often an issue with the defect due to possible aspiration. Assess for cyanosis and decreased tissue perfusion.


  • Assess abdomen for distention


Difficulty feeding in infants can result in the ingestion of large amounts of air, causing abdominal distention.


  • Assess infant’s sucking ability; Provide special nipples and feeding devices with one-way valve


Depending on severity and location of cleft, infant may have difficulty sucking from a bottle.

Special devices can help infant feed on formula or expressed breast milk with a reduced risk of aspiration and air intake


  • Perform oral and nasal suction as necessary


To remove excess fluid or secretions and clear airway


  • Monitor infant’s caloric intake and weight


Determine if feeding method is adequate or if other interventions should be initiated. Make sure patient is receiving adequate nutrition


  • Prepare patient and family for surgery


Patient will likely need surgery to correct the defect. Prepare patient per facility protocol and help provide support for patient’s family


  • Provide referral information for dental, speech and audiology consults


Patient may have frequent ear infections as a result of eustachian tube blockages that result in hearing loss, consult audiology.

Difficulty with hearing can lead to speech delays, consult speech therapy.

Dental issues are likely to arise from defect of palate and lip, consult dentist.


  • Provide education and resource information for parents and caregivers


Provide demonstrations for cleaning suture site following surgery.

Provide assistance with proper feeding, especially if using assistive feeding devices.

Educate family regarding diet as child matures according to limitations



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