Nursing Care Plan (NCP) for Cleft Lip / Cleft Palate
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Study Tools For Nursing Care Plan (NCP) for Cleft Lip / Cleft Palate
Cleft Lip or Palate Interventions (Picmonic)
Cleft Lip & Palate Management (Cheatsheet)
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Outline
Lesson Objective for Cleft Lip / Cleft Palate Nursing Care Plan
- Understanding Cleft Lip/Palate Anatomy:
- Define the anatomy and structural components involved in cleft lip and cleft palate conditions.
- Recognize the impact of these congenital anomalies on facial and oral structures.
- Comprehensive Assessment Skills:
- Develop comprehensive assessment skills specific to infants with cleft lip/palate, including facial features and oral structures.
- Understand the potential complications associated with cleft lip/palate, such as feeding difficulties and speech delays.
- Effective Communication Techniques:
- Learn communication techniques tailored to infants with cleft lip/palate to establish a trusting relationship with the child and their family.
- Understand the importance of clear communication regarding care plans and procedures with parents or caregivers.
- Collaborative Multidisciplinary Care:
- Appreciate the multidisciplinary nature of care for individuals with cleft lip/palate, involving surgeons, speech therapists, nutritionists, and other healthcare professionals.
- Foster collaboration among team members to ensure comprehensive and coordinated care.
- Supporting Families:
- Provide emotional support and education to families regarding the challenges and interventions associated with cleft lip/palate.
- Empower families with the knowledge and skills needed to care for their child at home and navigate the healthcare system.
Pathophysiology of Cleft Lip / Cleft Palate
- Embryonic Developmental Defect:
- Cleft lip and cleft palate result from incomplete fusion of the embryonic facial structures during early development, typically between the 6th and 12th weeks of gestation.
- Genetic and Environmental Factors:
- Genetic factors play a role in the development of cleft lip/palate, with a combination of genetic mutations contributing to the risk.
- Environmental factors, such as maternal smoking, certain medications, and nutritional deficiencies, can increase the likelihood of these congenital anomalies.
- Formation of Cleft Lip:
- Cleft lip occurs when there is incomplete fusion of the upper lip structures, leading to an opening or gap in the upper lip.
- The severity of cleft lip can vary, ranging from a small notch to a more extensive opening that extends into the nose.
- Formation of Cleft Palate:
- Cleft palate involves incomplete fusion of the palatal structures, leading to an opening or gap in the roof of the mouth.
- The cleft may involve the hard palate, soft palate, or both, affecting speech, feeding, and facial development.
Etiology of Cleft Lip / Cleft Palate
- Genetic Factors:
- Genetic predisposition plays a significant role, with a family history of cleft lip/palate increasing the likelihood of occurrence.
- Environmental Factors:
- Exposure to certain environmental factors during pregnancy, such as tobacco smoke, alcohol, medications, and nutritional deficiencies, can contribute to the development of cleft lip/palate.
- Multifactorial Causes:
- Cleft lip/palate often results from a combination of genetic and environmental factors, making it a multifactorial condition.
- Folic Acid Deficiency:
- Inadequate maternal intake of folic acid during early pregnancy has been associated with an increased risk of cleft lip/palate.
- Medical Conditions:
- Some medical conditions, such as diabetes and certain syndromes (e.g., Pierre Robin sequence), may be associated with an increased risk of cleft lip/palate.
Desired Outcome for Cleft Lip / Cleft Palate Nursing Care Plan
- Optimal Facial and Oral Structure:
- Promote and support interventions that facilitate the optimal development of facial and oral structures, aiming for corrective surgical procedures to achieve normal appearance.
- Effective Feeding:
- Ensure the infant’s ability to feed effectively, either through breast or bottle, by providing appropriate feeding techniques and support to meet nutritional needs.
- Speech Development:
- Support interventions to promote normal speech development, addressing any speech impediments associated with cleft lip/palate through early interventions, speech therapy, and corrective surgeries.
- Psychosocial Well-being:
- Foster a supportive environment for the child and family, addressing emotional and psychosocial needs related to the condition and associated treatments.
- Prevention of Complications:
- Monitor and manage potential complications, such as ear infections, dental issues, and speech delays, to prevent long-term adverse effects on the child’s health and well-being.
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 Assessment for Cleft Lip / Cleft Palate
- Prenatal History:
- Obtain detailed information about the mother’s prenatal care, exposure to risk factors, and any complications during pregnancy.
- Family History:
- Assess the family history for a potential genetic predisposition to cleft lip/palate and gather information on previous occurrences within the family.
- Maternal Health and Lifestyle:
- Evaluate the mother’s overall health, nutritional status, and lifestyle factors such as smoking and alcohol consumption during pregnancy.
- Physical Examination of the Infant:
- Perform a thorough examination of the newborn, focusing on the presence and extent of the cleft, associated anomalies, and overall health.
- Feeding Difficulties:
- Assess the infant’s ability to feed, as cleft lip/palate may impact breastfeeding or bottle-feeding. Monitor weight gain and nutritional intake.
- Speech Development:
- Anticipate potential speech difficulties related to the cleft and observe the child’s oral motor skills as they grow.
- Psychosocial Assessment:
- Evaluate the emotional well-being of the family, providing support and counseling as needed to address concerns related to the child’s condition.
- Referral to Specialists:
- Collaborate with specialists such as pediatric surgeons, speech therapists, and genetic counselors to ensure comprehensive care and management for the child and family.
Implementation for Cleft Lip / Cleft Palate
- Feeding Support:
- Collaborate with a lactation consultant or provide guidance on proper feeding techniques to address challenges associated with cleft lip/palate. This may involve specialized bottles or nipples.
- Surgical Consultation and Intervention:
- Facilitate early consultation with a pediatric surgeon for corrective surgery. Educate parents on the surgical procedure, potential risks, and postoperative care.
- Speech Therapy:
- Initiate early intervention with a speech therapist to address speech and language development. Regular sessions can help overcome speech difficulties associated with the cleft.
- Dental Care:
- Coordinate with a pediatric dentist for regular dental check-ups and early intervention to address dental issues related to cleft lip/palate.
- Psychosocial Support:
- Offer emotional support and connect the family with support groups or counseling services to cope with the psychological and social aspects of raising a child with cleft lip/palate.
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 |
Evaluation for Cleft Lip / Cleft Palate
- Feeding Progress:
- Assess the infant’s feeding progress, considering weight gain and nutritional intake. Evaluate if feeding interventions have been effective.
- Surgical Outcomes:
- Monitor the outcomes of corrective surgery, assessing for complications, healing, and improvement in the physical appearance of the cleft lip/palate.
- Speech Development:
- Evaluate the child’s speech development over time, considering clarity, articulation, and language skills. Collaborate with the speech therapist to track progress.
- Dental Health:
- Assess the child’s dental health through regular check-ups. Monitor for any dental issues related to the cleft and ensure appropriate interventions are in place.
- Psychosocial Well-being:
- Evaluate the emotional well-being of the child and family. Consider their adaptation to the challenges, involvement in support groups, and overall psychosocial adjustment.
- Orthodontic Assessment:
- Monitor the child’s orthodontic needs and progress, including the alignment of teeth and jaw. Collaborate with the orthodontic team to address any issues related to dental occlusion and alignment.
- Facial Growth and Development:
- Evaluate the child’s facial growth and development as they age. Monitor for any changes in the symmetry of facial features and collaborate with specialists if additional interventions or adjustments are required.
- Educational Progress:
- Assess the child’s educational progress, considering any challenges related to speech or communication. Collaborate with educators and specialists to ensure appropriate support and accommodations are in place to facilitate optimal learning.
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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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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Nursing Care Plan (NCP) for Osteoarthritis (OA), Degenerative Joint Disease
Nursing Care Plan (NCP) for Osteoporosis
Nursing Care Plan (NCP) for Otitis Media / Acute Otitis Media (AOM)
Nursing Care Plan (NCP) for Paranoid Disorders
Nursing Care Plan (NCP) for Parkinson’s Disease
Nursing Care Plan (NCP) for Pediculosis Capitis / Head Lice
Nursing Care Plan (NCP) for Pericarditis
Nursing Care Plan (NCP) for Personality Disorders
Nursing Care Plan (NCP) for Pertussis / Whooping Cough
Nursing Care Plan (NCP) for Phenylketonuria (PKU)
Nursing Care Plan (NCP) for Pneumonia
Nursing Care Plan (NCP) for Pneumothorax/Hemothorax
Nursing Care Plan (NCP) for Polycystic Ovarian Syndrome (PCOS)
Nursing Care Plan (NCP) for Post-Traumatic Stress Disorder (PTSD)
Nursing Care Plan (NCP) for Postpartum Hemorrhage (PPH)
Nursing Care Plan (NCP) for Preterm Labor / Premature Labor
Nursing Care Plan (NCP) for Psoriasis
Nursing Care Plan (NCP) for Pulmonary Embolism
Nursing Care Plan (NCP) for Respiratory Failure
Nursing Care Plan (NCP) for Restrictive Lung Diseases
Nursing Care Plan (NCP) for Reye’s Syndrome
Nursing Care Plan (NCP) for Rhabdomyolysis
Nursing Care Plan (NCP) for Rheumatic Fever
Nursing Care Plan (NCP) for Rheumatoid Arthritis (RA)
Nursing Care Plan (NCP) for Risk for Fall
Nursing Care Plan (NCP) for Schizophrenia
Nursing Care Plan (NCP) for Scoliosis
Nursing Care Plan (NCP) for Seizures
Nursing Care Plan (NCP) for Sepsis
Nursing Care Plan (NCP) for Sickle Cell Anemia
Nursing Care Plan (NCP) for Skin cancer – Melanoma, Basal Cell Carcinoma, Squamous Cell Carcinoma
Nursing Care Plan (NCP) for Skull Fractures
Nursing Care Plan (NCP) for Somatic Symptom Disorder (SSD)
Nursing Care Plan (NCP) for Spinal Cord Injury
Nursing Care Plan (NCP) for Stomach Cancer (Gastric Cancer)
Nursing Care Plan (NCP) for Stroke (CVA)
Nursing Care Plan (NCP) for Suicidal Behavior Disorder
Nursing Care Plan (NCP) for Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Nursing Care Plan (NCP) for Systemic Lupus Erythematosus (SLE)
Nursing Care Plan (NCP) for Tonsillitis
Nursing Care Plan (NCP) for Transient Tachypnea of Newborn
Nursing Care Plan (NCP) for Tuberculosis
Nursing Care Plan (NCP) for Urinary Tract Infection (UTI)
Nursing Care Plan for (NCP) Autism Spectrum Disorder
Nursing Care Plan for (NCP) Fetal Alcohol Syndrome (FAS)
Nursing Care Plan for Amputation
Nursing Care Plan for Cirrhosis (Liver)
Nursing Care Plan for Endometriosis
Nursing Care Plan for Fibromyalgia
Nursing Care Plan for Macular Degeneration
Nursing Care Plan for Newborn Reflexes
Nursing Care Plan for Scleroderma
Nursing Case Study for (PTSD) Post Traumatic Stress Disorder
Nursing Case Study for Breast Cancer
Overview of Childhood Growth & Development
Overview of Developmental Theories
Palliative Care for Progressive Care Certified Nurse (PCCN)
Patient and Healthcare Team Safety (Disasters, Environmental Hazards) for Certified Perioperative Nurse (CNOR)
Patient Communication Techniques for Certified Perioperative Nurse (CNOR)
Patient Safety for Certified Emergency Nursing (CEN)
Patients with Communication Difficulties
Pediatric Oncology Basics
Phases of Nurse-Client Relationship
Phenylketonuria
Piaget’s Theory of Cognitive Development
Pituitary Adenoma
Planning Community Health Interventions Nursing Mnemonic (PRECEDE-PROCEED)
Post-Traumatic Stress Disorder (PTSD)
PPE Precautions (Personal Protective Equipment) for Certified Perioperative Nurse (CNOR)
Practice Settings
Preoperative (Preop)Assessment
Product Evaluation and Selection for Certified Perioperative Nurse (CNOR)
Program Planning
Response to Diversity for Progressive Care Certified Nurse (PCCN)
RN to MSN
Schizophrenia Case Study (45 min)
Septic Shock (Sepsis) Case Study (45 min)
Social Effects on Health, Illness, and Disability
Stress and Crisis
Surgical Attire Guideline Adherence (Surgical, Perioperative Zones) for Certified Perioperative Nurse (CNOR)
Transportation and Storage (Single Use Items) for Certified Perioperative Nurse (CNOR)
Trauma Surgery – Medical History Nursing Mnemonic (AMPLE)
Absolute Reticulocyte Count (ARC) Lab Values
Access to Care
Adult Vital Signs (VS)
Advance Directives
Brief CPR (Cardiopulmonary Resuscitation) Overview
Community Aggregates
Continuity of Care
Day in the Life of a Community Health Nurse
Developmental Considerations for the Hospitalized Individual
Erikson’s Theory of Psychosocial Development
Family Structure and Impact on Development
Famotidine (Pepcid) Nursing Considerations
Growth & Development – Early Adulthood
Growth & Development – Late Adulthood
Growth & Development – Middle Adulthood
Growth & Development -Transitioning to Adult Care
Head to Toe Nursing Assessment (Physical Exam)
Human Trafficking for Certified Emergency Nursing (CEN)
Kohlberg’s Theory of Moral Development
Macro and Micronutrients
Nursing Care and Pathophysiology for Chlamydia (STI)
Nursing Care and Pathophysiology for Gonorrhea (STI)
Nursing Care and Pathophysiology for Human Papilloma Virus (HPV STI)
Nursing Care and Pathophysiology for Influenza (Flu)
Nursing Care Delivery Models
Nursing Care Plan (NCP) for Anxiety
Nursing Care Plan (NCP) for Aortic Aneurysm
Nursing Care Plan (NCP) for Appendicitis
Nursing Care Plan (NCP) for Asthma
Nursing Care Plan (NCP) for Asthma / Childhood Asthma
Nursing Care Plan (NCP) for Bowel Obstruction
Nursing Care Plan (NCP) for Burn Injury (First, Second, Third degree)
Nursing Care Plan (NCP) for Dehydration & Fever
Nursing Care Plan (NCP) for Epiglottitis
Nursing Care Plan (NCP) for Gastroesophageal Reflux Disease (GERD)
Nursing Care Plan (NCP) for Herpes Zoster – Shingles
Nursing Care Plan (NCP) for Hydrocephalus
Nursing Care Plan (NCP) for Lymphoma (Hodgkin’s, Non-Hodgkin’s)
Nursing Care Plan (NCP) for Mood Disorders (Major Depressive Disorder, Bipolar Disorder)
Nursing Care Plan (NCP) for Nephrotic Syndrome
Nursing Care Plan (NCP) for Newborns
Nursing Care Plan (NCP) for Nutrition Imbalance
Nursing Care Plan (NCP) for Osteoporosis
Nursing Care Plan (NCP) for Otitis Media / Acute Otitis Media (AOM)
Nursing Care Plan (NCP) for Pediculosis Capitis / Head Lice
Nursing Care Plan (NCP) for Personality Disorders
Nursing Care Plan (NCP) for Pertussis / Whooping Cough
Nursing Care Plan (NCP) for Pneumonia
Nursing Care Plan (NCP) for Reye’s Syndrome
Nursing Care Plan (NCP) for Risk for Fall
Nursing Care Plan (NCP) for Scoliosis
Nursing Care Plan (NCP) for Urinary Tract Infection (UTI)
Nursing Care Plan for Macular Degeneration
Nutritional Requirements
Patient Education
Piaget’s Theory of Cognitive Development
Pituitary Gland