Cleft lip and cleft palate is a defect caused by the failure of the soft and bony tissue to fuse in utero. These may occur singly or together and often occur with other congenital anomalies such as spina bifida, hydrocephalus, or cardiac defects. Cleft lip deformities can occur unilaterally, bilaterally or rarely, in the midline. Treatment consists of surgical repair, usually of the lip first between 6 to 10 weeks of age, followed by the palate between 12 to 18 months of age. The surgical procedures are dependent on the condition of the child and physician preference. Management involves a multidisciplinary approach that includes the surgeon, pediatrician, nurse, orthodontist, prosthodontist, otolaryngologist, and speech therapist.
Nursing Care Plans
Nursing goals for clients with cleft lip and cleft palate include maintaining adequate nutrition, increasing family coping, reducing the parents’ anxiety and guilt regarding the newborn‘s physical defects, and preparing parents for the future repair of the cleft lip and palate.
Here are six (6) nursing care plans (NCP) for cleft lip and cleft palate:
- Ineffective Airway Clearance
- Imbalanced Nutrition: Less than Body Requirements
- Deficient Knowledge
- Compromised Family Coping
- Risk for Injury
Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
May be related to
Possibly evidenced by
- Abnormal breath sounds
- Postoperative edema
- Productive/non-productive cough
- Respiratory rate and depth changes
- Infant will maintain a clear airway as evidenced by clear breath sounds, respiratory rate of 20 to 30 breaths per minute, absence of cyanosis, and respiratory distress.
|Assess the infant’s respiratory rate, depth, and effort.||Aspiration of secretions or milk may cause tachypnea.|
|Assess skin color and capillary refill.||Bluish discoloration of the skin or prolonged capillary filling happens because of the decreased oxygenation produced by the defect.|
|Assess for abdominal distention.||The infant may swallow excess air during bottle feeding causing abdominal distention that may result in upward pressure on the diaphragm and lungs hence compromising respiration.|
|Place the infant in an infant seat at a 30° to 45°.||This position prevents the infant’s tongue from falling back and obstructing the airway.|
|Position the infant in an upright position during feeding and elevate the head of the crib 30° after.||Such position prevents aspiration of milk.|
|Provide oral and nasal suctioning as needed.||The purpose of suctioning is to maintain a patent airway and improve oxygenation by removing excess fluids and secretions in the oral and nasal cavity.|
|Feed the infant slowly and burp frequently.||Burping frequently during a feeding will reduce spitting up and prevent excessive swallowing of air.|
|Provide special nipples or feeding devices such as pigeon feeder with a one-way valve.||Feeding may work better using special bottles or nipples with a wider base.|
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Maternal and Newborn Care Plans
Nursing care plans related to the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:
- Abruptio Placenta| 3 Care Plan
- Cesarean Birth | 10 Care Plans
- Cleft Palate and Cleft Lip | 6 Care Plans
- Dysfunctional Labor (Dystocia) | 4 Care Plans
- Elective Termination | 6 Care Plans
- Gestational Diabetes Mellitus | 4 Care Plans
- Hyperbilirubinemia | 4 Care Plans
- Labor Stages, Induced and Augmented Labor | 36 Care Plans
- Neonatal Sepsis | 5 Care Plans
- Perinatal Loss | 5 Care Plans
- Placenta Previa | 3 Care Plans
- Postpartum Hemorrhage | 8 Care Plans
- Postpartum Thrombophlebitis | 4 Care Plans
- Prenatal Hemorrhage | 7 Care Plans
- Prenatal Substance Dependence/Abuse | 6 Care Plans
- Precipitous Labor | 3 Care Plans
- Pregnancy Induced Hypertension | 6 Care Plans
- Premature Dilation of the Cervix | 3 Care Plans
- Prenatal Infection | 3 Care Plans
- Preterm Labor | 6 Care Plans
- Puerperal Infection | 4 Care Plans
Recommended books and resources:
- Nursing Care Plans: Diagnoses, Interventions, and Outcomes
- Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
- Nursing Diagnoses 2015-17: Definitions and Classification
- Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR)
- Manual of Psychiatric Nursing Care Planning
- Maternal Newborn Nursing Care Plans
- Delmar's Maternal-Infant Nursing Care Plans, 2nd Edition
- Maternal Newborn Nursing Care Plans