6 Cleft Lip and Cleft Palate Nursing Care Plans
Ineffective Airway ClearanceNursing Diagnosis
- 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.|
Imbalanced Nutrition: Less than Body RequirementsNursing Diagnosis
- Imbalanced Nutrition: Less Than Body Requirements
- Inability to ingest food
- Presence of cleft lip/palate
- Difficulty sucking
- Inflammed buccal cavity
- Poor feeding
- Weakness of the swallowing muscles
- The neonate will exhibit adequate nutritional status to maintain growth and healing.
|Assess infant sucking and swallowing ability.||The infant with a cleft lip or palate may find it challenging to establish breast and bottle feeding due to the impaired sucking ability hence compromising nutrition.|
|Monitor daily caloric and fluid intake.||Recording daily intake will determine whether the infant is meeting nutritional needs or whether the feeding method needs to be adjusted (gastric gavage will be necessary).|
|Record daily weight of the infant.||Documenting daily weight evaluates the whether the feeding pattern is successful or needs to be adjusted.|
|Educate the mother on how to massage her breasts and nipples before nursing the infant.Cleft Lip and Cleft Palate Nursing Care Plans.||Breast and nipple massage will cause milk to flow freely near the surface for a comfortable suck and will harden breasts, allowing the infant to hold the nipple in his/her mouth.|
|Instruct the mother to apply pressure to the areola using her fingers, guide the nipple to the side of the infant’s mouth, and hold it there during feeding.||Holding the nipple in the infant’s mouth allows the infant to nurse with its gums rather than by sucking if sucking is difficult.|
|Encourage frequent burping after feeding.||When an infant drink from a bottle, they can swallow some air, which goes down into their stomach along with the milk or formula so burping will help to prevent it from happening.|
|Hold the infant in an upright or a sitting position while feeding.||An upright or a sitting position improves swallowing and prevents milk from coming through the defect and out of the nasal cavity, therefore reducing the risk of aspiration.|
|An alternative is for the mother to pump her breasts and feed the infant with a bottle.||Pumping breast milk satisfies the mother’s desire to breastfeed and provides an excellent source of nourishment.|
|Instruct mother who bottle feed to use some cereal to thicken the milk.||Thicker milk will make swallowing easier due to the increased gravity flow brought about it.|
|Refrain from removing the bottle nipple from the infant’s mouth unless necessary.||Removing the nipple may cause the infant to cry, making feeding more challenging.|
- Situational crisis of congenital defect of the infant.
- Response to the imperfect infant (shock, denial, and grief).
- Severe reaction to the appearance of an infant with a facial defect.
- Expression of guilt, blame, and helplessness.
- Feelings of inadequacy and uncertainty
- Worried and anxious about impending surgery.
- Family will report decreased anxiety levels concerning infant’s condition.
|Assess level of anxiety and need for information. Ask parents to rank feelings of anxiety as none, mild, moderate, severe, or feelings of panic.||Provides information to allay anxiety manifested by the infant’s appearance at birth with level increased with the location and extent of the defect.|
|Encourage expression of concerns and questions about the condition, to discuss feelings about the appearance of the infant.||Provides an environment conducive to venting of feelings to facilitate the adjustment to the infant’s defect.|
|Provide an accepting environment and attitude and handle the infant in a gentle, caring, way.||Promotes trust and conveys to parents that infant is a valuable human baby deserving of love and caring.Cleft Lip and Cleft Palate Nursing Care Plans.|
|Communicate with parents in a calm, honest, way, discuss the surgical procedures for correction of the defects using pictures and models, and allow to view pictures of children with successful defect repair.||Promotes a calm and supportive environment to reduce anxiety and instill hope.|
|Allow parents to stay with the infant and encourage to assist in care as appropriate.||Reduces anxiety and promotes bonding that may be blocked by infant’s appearance.|
|Emphasize the infant positive features when providing information.||Promotes positive feelings for the infant.|
|Suggest visits with parents who have a child with a similar defect.||Provides support and information to reduce anxiety.|
|Inform parents of usual ages for cleft lip repair and/or cleft palate, stages of surgery and type of procedure performed.||Provides information to reduce fear and anxiety and to know what to expect.|
Cleft Lip and Cleft Palate Nursing Care Plans|Deficient KnowledgeNursing Diagnosis
- Lack of information about preoperative care
- Lack of information on feeding and surgical procedure to correct defect
- Request for information about cause of defects, feeding techniques, prevention of complications caused by defects preoperatively
- Family will obtain an increased knowledge about the infant preoperative care.
|Assess parent’s ability to feed the infant with a defect and acceptance of methods used, knowledge, cause, and type of defects, pre operative needs and care, ability of the infant to swallow.||Provides information about a defect that may be inherited or congenital, partial or complete, unilateral or bilateral cleft of the lip and/or palate, adequate nutritional status and freedom from infection before surgery is done.|
|Inform the parents of the general timing of surgical repair and what to expect from the neonate. Show them photographs of infants before and after surgical repair.||If the infant’s weight is optimal and he has no other neonatal anomalies, he may undergo surgery to repair a cleft lip shortly after birth; this can minimize the parents’ shame or embarrassment. Surgery may also take place in 2 to 3 months or as late as 8 months to allow for bonding and to rule out other congenital anomalies. Cleft palate may be repaired in two steps by 12 to 16 months; or repair of the soft palate may proceed in 6 to 18 months and repair of the hard palate, as late as age 5. The timing of the procedures is related to normal growth changes, and repair usually takes place before speech development.|
|Teach and observe parents to hold infant while feeding with the head in an upright position, use a nipple or feeding device, allow feeder to control the flow or the infant to express the formula, apply gentle, steady pressure on the bottom of the bottle and avoid removing the nipple frequently; instruct in feeding method that will be used postoperatively.||Holding head upright reduces the possibility of aspiration, a pressure at the base of the bottle prevents choking or coughing, special nipples or devices are used because the cleft interferes with the ability to suck and liquid often flows into the nose when taken into the mouth, use of a nipple encourages the development of sucking muscles.|
|Teach and observe to feed slowly and in small amounts, burping frequently, and extend nipple or feeding device well back into the mouth.||Prevents choking, abdominal distention, a possible flow of liquid into the nose or aspirated into the lungs causing pneumonia or otitis media or upper respiratory infections.|
|Inform parents that feeding should not last any longer than 20 to 30 minutes.||Prolonged feedings may deplete an infant’s energy and cause fatigue.|
|(Instruct in use and care of pre operative orthodontic device [plastic palate mold] for an infant with cleft palate including removing and cleaning daily, replacing, preventing the infant from removing palate).||Promotes the alignment of the maxilla and more normal speech sounds and prevents food from entering the nasal cavity.|
|Instruct parents to cleanse lip, oral cavity, and nose with water before and after feeding.||Prevents infection or skin breakdown with cleft lip or palate.|
|Teach parents to avoid prone position and place child on back or side (use arm restraints, use a cup for feeding if palate repair to be done, feed upright if lip repair is to be done for the period preoperatively).||Prepares the child to treatments that will be done postoperatively.Cleft Lip and Cleft Palate Nursing Care Plans.|
|Inform parents of procedure for correction of defects, medications, and procedures done to prepare the infant for surgery, what to expect postoperatively.||Prepares parents for surgical correction of defects and what to expect during convalescence|
Compromised Family CopingNursing Diagnosis
- Compromised Family Coping
- Inadequate information and temporary family disorganization caused by defects and future correction.
- Expression of concern about defects
- long-term care required for a successful outcome
- Confirmation of worry about normal growth and development
- Limited family support and assistance
- Family will increase coping ability concerning infant’s condition and care needs.
|Assess family coping methods used and their effectiveness; family ability to cope with a child that needs long-term care and guidance; stress on family relationships; developmental level of a family; perception of a crisis situation by family, response of siblings.||Provides information identifying coping methods that work and need to develop new coping skills, family attitudes directly affect child’s feeling of self-worth, a child with special needs may strengthen or strain family relationships.|
|Encourage family members to express problem areas and explore solutions together.||Reduces anxiety and enhances understanding; provides an opportunity to identify problems and problem-solving strategies.|
|Assist family members to identify 3 healthy coping mechanisms they can use.||Empowers the family to find the solution appropriate for them.|
|Assist family to establish short and long-term goals for child and importance of integrating the child into family activities.||Promotes involvement and control over situations and maintains parental role.|
|Encourage to follow home routines and meet child’s needs with the participation of family members.||Increases child’s sense of security and sense of belonging.|
|Give positive feedback to family and praise family efforts in the development of coping and problem-solving techniques in caring for the child.||Encourage family to continue involvement in long-term care.|
|Teach family that overprotective behavior may hinder growth and development and to treat the child as normally as it is possible.||Enhances family understanding of the importance of making child one of the family and adverse effects of overprotection of child.|
Risk for InjuryNursing Diagnosis
- [not applicable]
- Infant will not experience injury to incision.
- Infant will be free of trauma, accumulation of substances, infection.
|Assess suture line for cleanliness, redness, swelling, or drainage frequency.||Provides information indicating possible infection and need for cleansing away formula or drainage.|
|Assess for respiratory distress following palate surgery.||Monitors breathing through a smaller airway caused by edema and breathing through the nose.|
|Clean suture site of lip repair with gauze or cotton tipped applicator with saline, apply ointment after cleansing as prescribed; rinse mouth with water before and after each feeding.||Removes material to prevent inflammation or sloughing and final cosmetic result expected.|
|Provide air humidification or place in mist tent for a short time following surgery, as ordered.||Decreases dry mouth and nose mucous membranes.|
|Monitor lip protective device taped on operative site.||Relaxes the site and prevents tension on sutures caused by facial movement or crying.|
|Provide ordered analgesics for pain, hold, cuddle, or rock child, anticipate needs to prevent crying.||Promotes comfort and prevents crying caused by pain which creates tension on the suture line.|
|Apply soft elbow restraints and remove periodically to perform ROM on arms and allow for some movement and holding; a child may need a jacket restraint to prevent rolling over.||Prevents the child from touching or injuring the operative site.|
|Remove sharp objects or toys, avoid the use of forks, straws or other pointed objects.||Prevents trauma to mouth and suture line.|
|Feed with a cup or spoon if palate repair was done; avoid placing a spoon in mouth.||Prevents damage to the suture line.|
|Accompany child when playing or ambulating.||Prevents trauma caused by accidental falls.|
|Teach parents about cleansing suture site and to apply antibiotic ointment.||Prevents infection and enhances comfort and healing.|
|Teach parents in feeding method of infant and allow to practice appropriate technique using a syringe soft tube in mouth away from any suture line or using a cup for an older child.||Promotes nutrition following surgery without sucking on a nipple.|
|Instruct parents in soft diet inclusions and avoidance of toast, hard cookies, or foods, as ordered.||Provides nutritional needs until incisions heal completely.|
|Explain to parents and child to keep hands and objects away from the mouth or to maintain use of restraints with removal until the incision is healed.||Prevents trauma to the suture line.|
|Advise parents not to allow the child to play with small toys or those that are sharp or require sucking or blowing; suggest soft, stuffed toys for an infant.||Removes the possibility of placing a toy in mouth or damage incision.|
|Explain to parents that usual feeding patterns may be resumed in 2 weeks for lip repair or in 4 to 6 weeks for palate repair.||Provides estimated time based on suture removal and healing to resume regular bottle feeding or return to baseline dietary status.|
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- 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