Cleft Lip and Cleft Palate

I. PERSONAL DATA

I. PERSONAL DATA
Name: C , Baby Boy S.J. Age: 3 days old Sex: Male Religion: Roman Catholic Citizenship: Filipino Date of Birth: July 3, 2010 Place of Birth: SJDEFI Hospital, Roxas Blvd. Pasay City Nationality: Filipino Address: 257 Catalina St. Velasquez Tondo, Manila Name of the nearest relative: Rosalyn Cruz Relation: Mother Address: 257 Catalina St. Velasquez Tondo, Manila Unit/ward: NSU Time of admission: 12:59 Physician: Dr. Abad Santos

II. HISTORY OF PRESENT ILLNESS

II. HISTORY OF PRESENT ILLNESS

Prior to admission, the baby was born on a 28 year old mother with GRAVIDA 1 PARA 0 through vacuum extraction. Baby boy was admitted to NSU directed from OR, full term gestation (38weeks) and was diagnose to have unilateral cleft palate and cleft lip. The vital sign were normal having temperature: 36.8 C; respiratory rate: 45cpm; heart rate: 150bpm; weight: 3050grams and with normal reflexes. No distress noted.

III. MEDICAL HISTORY

III. MEDICAL HISTORY

This is the case of Baby Boy Cruz, 11 days old, male. Born on July 03, 2010 thru vacuum extraction and admitted in Potentially Septic Section of Nursery. With weight of 3050 g. or 6.2 lbs, length of 58 cm and with head circumference of 32 cm. He was diagnosed to have cleft lip and palate. Immunization: Anti- Hepatitis B

IV. FAMILY HISTORY

IV. FAMILY HISTORY

Paternal Side Christian Ellson (-) Deformities of the lip and palate. Maternal Side Rosalyn Cruz (-) Deformities of the lip and palate.

V. ACTIVITIES OF DAILY LIVING

V. ACTIVITIES OF DAILY LIVING

Activities
Fluids and Nutrition

During Hospitalization

Analysis

He received his feeding through He has difficulty in sucking bottle feeding 30 cc every 3 hours because roof of the mouth is not and has a hard time in consuming it. formed completely. Usually have urine and stool every change of diaper. The present condition doesnt affect the way of excreting the urine and stool.

Elimination Bladder and Bowel Rest and Sleep

He acquires a good rest and sleep but The patient experienced there are times that he was difficulty of breathing because experiencing difficulty of breathing. of the cleft lip and palate that altered his sleeping pattern.

Hygiene

The nurse on duty provided his oral every time the patients has dirt and personal hygiene like full bath every 4:00 in the morning and cord care for every diaper change.

Nurses gives priority in maintaining good body odor and try to cope up in the present problem by using other method of oral and personal hygiene.

VI. PHYSICAL ASSESSMENT

A. General Condition

PHYSICAL ASSESSMENT
Weight: 3050 grams Length: 50 cm Head Circumference: 32 cm
Body Part Skin Technique Used Inspection

Temperature: 36.6 C HR: 133 bpm RR: 46 cpm

Normal Findings Ruddy Pink in color Presence of lanugo in the shoulders, back and arms Actual Findings Ruddy Pink in color Presence of lanugos in the shoulders, back and arms Analysis Normal

Hair

Inspection

Silky, resilient hair Evenly distributed Anterior fontanelle is soft No caput succedaneum Appears disproportionately large Forehead is large and prominent

Silky, resilient hair Slight thick hair Evenly distributed Anterior fontanelle is soft No caput succedaneum Appears disproportionately large Forehead is large and prominent

Normal

Head

Inspection Palpation

Normal

Eyes

Inspection

Slight grey pupil Round Cornea Eyes are symmetrically aligned Pupils are equal in size (+) Blink reflex

Slight grey pupil Round Cornea Eyes are symmetrically aligned Pupils are equal in size (+) Blink reflex

Normal

Body Part Ears

Technique Used Inspection Palpation

Normal Findings Pinna recoils after folded Outer canthus of the eye is higher than the top most part of the ear. Appears large for the face Presence of milia Has nasal septum

Actual Findings Formed and firm and instant recoil

Analysis

Normal

Nose

Inspection

Presence of milia Has no nasal septum Has gap in the right nostril up to the lip (Cleft lip)

Mouth

Inspection

Open evenly when crying Tongue appears large & prominent in the mouth. The palate should be intact. (+) Rooting Reflex (+) Sucking Reflex (+)Swallowing Reflex (+) Extrusion Reflex

Has a hole in the hard palate connecting to the nasal cavity (Cleft lip and palate) No tooth (+) Rooting Reflex (-) Sucking Reflex (+)Swallowing Reflex

Because of the gap, air leaks into the nasal cavity resulting in a hypernasal voice resonance and nasal emissions. Cleft may cause problems with feeding(due to lack of suction), ear disease, and speech. The upright sitting position allows gravity to help the baby swallow the milk more easily. Normal

Chin

Inspection

Appears to be receding & quivers easily when crying Usually has milia Short and chubby with creased skin folds

Appears to be receding & quivers easily when crying Usually has milia Short and chubby with creased skin folds

Neck

Inspection

Normal

Body Part Chest

Technique Used Inspection

Normal Findings Have buds (nipples) Appear symmetric Without chest retraction Clavicles are straight The chest is as wide in the anteroposterior diameter as it is across Contour is slightly protuberant Dome-shaped Ruggated, darkened Penis appears small No dimpling and pinpoint opening in the skin (+) Trunk Incurvation

Actual Findings With chest retraction Have buds (nipples) Appear symmetric Clavicles are straight

Analysis Patient with chest retraction may have breathing difficulties as a result of fatigue. Thus, always use gentle handling. Normal

Abdomen

Inspection

Contour is slightly protuberant Dome-shaped Ruggated, darkened Penis appears small No dimpling and pinpoint opening in the skin (+) Trunk Incurvation

Genital

Inspection

Normal

Back

Inspection Palpation

Normal

Extremities

Inspection Palpation

Arms and legs appear short Arms and legs appear short (+) Moro Reflex (+) Moro Reflex (+) Palmar Grasp Reflex (+) Palmar Grasp Reflex (+)Babinski Reflex (+)Babinski Reflex

Normal

Birth History:
Baby boy Cruz delivered through vacuum extraction, blood type O, Rh (+) and with an AOG of 38 weeks. APGAR scoring done 1 min. after birth and 5 min. after shows normal. Physical examination: Baby boy Cruz has good cry, well flexed activities and pinkish all over when examined. He weighed 3050 g ( 6 lbs 12 oz), length is 50 cm and head circumference is 32 cm. .Examination also showed a normal perineum, back extremities and sucking reflex. Baby boy Cruz also has (+) cleft palate and (+) cleft lip

VII. DISEASE ENTITY

DEFINITION
Cleft Lip and Cleft Palate an opening in the lip and palate may occur separately or in combination. Cleft lip and palate are twice as common in males as in females; isolated cleft palate is more common in females.

Cleft lip (Cheiloschisis)

Cleft lip is a congenital anomaly that occurs at a rate of 1 in 800 births.
If

the cleft does not affect the palate structure of the mouth it is referred to as cleft lip. Cleft lip is formed in the top of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft) or it continues into the nose (complete cleft) Cleft lip can be unilateral or bilateral. It is due to the failure of fusion of the maxillary and medial nasal processes (formation of the primary palate).

Cleft Palate (Palatoschisis)

Cleft

palate is a congenital anomaly that occurs in approximately 1 of every 2000 births, and it is more common in boys than girls.
It

is a condition in which the two plates of the skull that form the hard palate (roof of the mouth) are not completely joined. It ranges in severity from soft palate involvement alone to a defect including the hard palate and portions of the maxilla. Cleft palate may or may not be associated with cleft lip.

Children with these structural disorders may have associated:

dental malformations speech problems frequent otitis media, the latter resulting from improper functioning of the Eustachian tubes.

Babies with cleft lip do not usually have feeding problems or speech impairments. Infants with cleft palate, with or without cleft lip, often have difficulty feeding and impaired speech. The baby may feed too slowly, take in too much air while eating, or bring milk up through the nose.

Variation in Cleft Deformity

Incomplete Cleft Palate

Unilateral complete lip and palate

Bilateral complete lip and palate

NORMAL ANATOMY & PHYSIOLOGY

Lips are a visible body part at the mouth of humans and many animals. Lips are soft, movable, and serve as the opening for food intake and in the articulation of sound and speech Palate is the roof of the mouth in humans and other mammals. It separates the oral cavity from the nasal cavity. The palate is divided into two parts, the anterior bony hard palate, and the posterior fleshy soft palate or velum.

Cupids bow is central to the upper lip, with its peaks delineating the philtrum between the philtral columns. The demarcation between mucosa and skin of the lip is called the vermilion border. The mucosa or vermilion of the lip is further divided into dry and wet sections. The protuberant vermilion in the midline is referred to as the tubercle. The two nostrils (nares) are separated by the columnella externally and the septum internally. Below the surface, the orbicularis oris muscle encircles the oral aperture, creating a sphincter. The fibers decussate in the midline creating the philtrum. In the cleft lip, the orbicularis muscle inserts into the nasal alar base.

The presence of the palate makes it possible to breathe and chew at the same time. When food is swallowed, the soft palate rises up and blocks off the entrance to the rear nasal passage. When food is not being swallowed, this passage is open, making it possible to breathe through the mouth and through the nose. As well, prior to swallowing food is pressed up against the palate and pushed to the back of the throat using the tongue.

The palate also functions in speaking and singing. When sound emerges from the chest, the sound waves that have been produced by the vocal cords bounce off the hard palate and out the mouth. The hard palate directs and resonates. Formation of the palate occurs during development of the fetus. Improper formation of the hard palate occurs in one of every 500-1000 babies.

This condition, called cleft palate, is correctable by surgery. Its cause is still unresolved. A combination of inherited traits and some environmental factors in the mother's womb are suspected of causing the abnormality.

PATHOPHYSIOLOGY
During embryonic development the lateral and medial tissues forming the upper lip palates fuse between weeks 7 and 8 of gestation; the palatal tissues forming the hard and soft palates fuse between weeks 7 and 12 gestation. Cleft lip and cleft palate result when these tissues fail to fuse.

Predisposing Factors: Infants Both genders than higher in male

Etiology: incomplete fusion of the nasomedial or intermaxillary process during the 2nd month of embryonic development
The cleft causes structures of the face and mouth to develop without the normal restraints of encircling lip muscles

Precipitating Factors: Viral infection Folic acid deficiency

External nose

Nasal septum

Alveolar processes Bilaterally

Nasal cartilages

Usually just beneath the center of one nostril

Symmetric
The more complete the cleft lip, the greater the chance that teeth in the line of the cleft will be missing or malformed

Asymmetric

Signs and Symptoms

What are the signs and symptoms of the condition? Symptoms of cleft lip and cleft palate vary from person to person, depending on the extent of the defect. Cleft lip may show up only as a small notch in the border of the upper lip. It may also involve a complete split of the lip that extends into the floor of the nose. Cleft lip may involve one or both sides of the upper lip. Often, the bone that supports the upper teeth is involved to some degree. Extra, missing, or deformed teeth may also be part of cleft lip. Frequently, the outside of the nostril is somewhat flattened, too. Cleft palate may involve only the uvula, or it may involve the entire roof of the mouth. The uvula is the soft, fleshy mass that hangs down from the roof of the back of the mouth.

What are the complications of clefts?

Breathing: When the palate and jaw are malformed, breathing becomes difficult. Treatments include surgery and oral appliances. Feeding: Problems with feeding are more common in cleft children. A nutritionist and speech therapist that specializes in swallowing may be helpful. Special feeding devices are also available. Ear infections and hearing loss: Any malformation of the upper airway can affect the function of the Eustachian tube and increase the possibility of persistent fluid in the middle ear, which is a primary cause of repeat ear infections. Hearing loss can be a consequence of repeat ear infections and persistent middle ear fluid. Tubes can be inserted in the ear by an otolaryngologist to alleviate fluid build-up and restore hearing.

What are the complications of clefts?

Speech and language delays: Normal development of the lips and palate are essential for a child to properly form sounds and speak clearly. Cleft surgery repairs these structures; speech therapy helps with language development. Dental problems: Sometimes a cleft involves the gums and jaw, affecting the proper growth of teeth and alignment of the jaw. A paediatrics dentist or orthodontist can assist with this problem.

MANAGEMENT

Assess for problems with feeding, breathing parental bonding, and speech. Ensure adequate nutrition and prevent aspiration. a. Provide special nipples or feeding devices (eg, soft pliable bottle with soft nipple with enlarged opening) for a child unable to suck adequately on standard nipples. b. Hold the child in a semi upright position; direct the formula away from the cleft and toward the side and back of the mouth to prevent aspiration. c. Feed the infant slowly and burp frequently to prevent excessive swallowing of air and regurgitation. d. Stimulate sucking by gently rubbing the nipple against the lower lip.

Support the infants and parents emotional and social adjustment.

a. Help facilitate the familys acceptance of the infant by encouraging the parents to express their feelings and concerns and by conveying an attitude of acceptance toward the infant. b. Emphasize the infants positive aspects and express optimism regarding surgical correction.

Provide preoperative care.

a. Depending in the defect and the childs general condition, surgical correction of the cleft lipusually occurs at 1 to 3 months of age; repair of the cleft palate is usually performed between 6 and 18 months of age. Repair of the cleft palate may require several stages of surgery as the child grows. b. Early correction of cleft lip enables more normal sucking patterns and facilitates bonding. Early correction of cleft palate enables development of more normal speech patterns. c. Delayed closure or large defects may require the use of orthodontic appliances. d. The responsibilities of the nurse are to:

1. Reinforce the physicians explanation of surgical procedures. 2. Provide mouth care to prevent infection.

Provide child and family teaching.

Demonstrate surgical wound care. Show proper feeding techniques and positions. Explain that temperature of feeding formulas should be monitored closely because new palate has no nerve endings; therefore; the child can suffer a burn to the palate easily and without knowing it. Explain handling of prosthesis if indicated. Stress the importance of long-term follow up, including speech therapy, and preventing or correcting dental abnormalities. Discuss the need for, at least, annual hearing evaluations because of the increased susceptibility to recurrent otitis. The child may require myringotomy and surgical placement of drainage tubes. Teach infection control measures.

TREATMENT
Surgical correction, timing varies: Cleft Lip:

Within the first few days of life to make feeding easier. Delay lip repairs for 2 to 8 months to minimize surgical and anesthesia risks, rule out associated congenital anomalies, and allow time for parental bonding.

Cleft Palate- performed only after the infant is gaining weight and infection free: Usually completed by age 12 to 18 months Two steps : soft palate between ages 6 and 18 months; hard palate as late as age 5 years.

Speech Therapy: Palate essential to speech formation; structural changes, even in a repaired cleft, can permanently affect speech patterns Hearing difficulties common in children with cleft palate because of middle ear damage or infections.

VIII. LABORATORY EXAMINATIONS

A.) HEMATOLOGY DATE: July 4, 2010 PID: 20859-62 Requesting Doctor: Dr. Montalban
TEST RESULT UNIT REFERENCE

Leukocyte Erythrocyte Hemoglobin

19.36 6.82 19.67

10^q/L 10^q/L g/dL

5.0-10.0 M:4.6-6.2 F:4.2-5.4 M:12.0-17.0 F:11.0-15.0 M:40.0-54.00 F:37.0-47.0

Hematocrit

59.08

TEST

RESULT

UNIT

REERENCE

Thrombocyte Neutropil Lympocyte Monocyte Eosinophil Basophil

333 59.3 25.9 8.5 1.4 4.9

10^q/L % % % % %

150-450 50.0- 70.0 20.0-40.0 0.0-7.0 0.00-5.000 0.000-1.000

Normal Findings

Result

Analysis

Leukocytes

H 19.67

Elevated WBC counts indicates the presence of infection.

Erythrocytes

6.2

Normal

Hemoglobin

H- 19.67

Elevated hemoglobin, is the increased red blood cell production as a compensatory mechanism when blood oxygen carrying capacity is compromised to meet the demand of tissue

Normal Findings Hematocrit

Result H- 59.08

Analysis Elevated hemoglobin may due because of dehydration

Thrombocytes

N - 333

Normal

Neutropils Monocytes

59.3 H- 8.5

Normal Monocyte may increase in response to stress. It also indicates that the patient has infection because of his condition

Lymphocytes

25.9

Shows a normal range that fights the microorganism.

Normal Findings

Result

Analysis

Eosiphil

N- 1.4

Normal

Basophil

Shows a normal range that fights the microorganism. H- 4.9 The result was high which indicates that theres infection.

iX. Drug study

DRUG

CLASSIFICATION

MECHANISM OF ACTION

INDICATION

CONTRAINDICATION

SIDE EFFECTS

NURSING CONSIDERATION

-Penicillin Name: ampicillin - Antibiotic Dose: 150 mg Frequency : q12 Route: IV

Bactericidal. Interferes with cell wall synthesis of susceptible organisms, preventing bacterial multiplicatio n, renders cell wall osmotically unstable and burst due to osmotic pressure.

Treatmen t of infectious cause by susceptibl e strain of bacteria.

Hypersensi tivity to penicillins, cephalospo rins or imipenem

Rashes, Fever, Abdominal pain,nause a, vomiting, diarrhea

Check doctors order. Report pain or discomfort at sites, unusual bleeding or bruising, mouth sores, rashes, severe diarrhea, difficulty in breathing.

Should be taken on an empty stomach. (Take on an empty stomach 1 hr before or 2 hr after meals.)

DRUG

CLASSIFICATION

MECHANISM OF ACTION

INDICATION

CONTRAINDICATION

SIDE EFFECTS

NURSING CONSIDERATION

Name: Amikacin
Dose: 45 mg Frequency: OD Route: IV

Amino glycosides

Interferes with protein synthesis in bacterial cell by binding to ribosomal subunit, causing misreading of genetic code which leads to inaccurate peptide sequence and bacterial death.

Treatment of infections caused by susceptible strains of microorgani sms, especially gram negative bacteria

Hypersensit ivity to aminoglycos ides

Nausea, vomiting, diarrhea, Headache, Fever,

Check doctors order.

Assess patient for signs and symptoms of infection. Monitor intake and output. Increase fluid intake, if indicated.

Document

DRUG

CLASSIFICATION

MECHANISM OF ACTION

INDICATION

CONTRAINDICATION

SIDE EFFECTS

NURSING CONSIDERATION

Name: Calmoseptine (Topical)

Emollients & Skin Protectives

Calmosep tine ointm ent promotes wound granulati on and reepithiliali zation.

Protects, soothes & helps promote healing in those w/ impaired skin integrity related to: Feeding tube site leakage; wound drainage; urinary & fecal incontinence, bedsores; ileoanal reservoirs, ileostomy, urostomy; moisture eg perspiration, acne & scrapes; fungal infections, eczema & impetigo; diaper rash; insect bites; burns due to flame, radiation or chemicals; fistula, fissures, excoriation; colonoscopy, external hemorrhoids; chafing, chapping of skin; vag & rectal itchiness;pricklyheat

Do not use this medicatio n if you are allergic to zinc, dimethico ne, lanolin, cod liver oil, petroleum jelly, parabens, mineral oil, or wax.

signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Stop using zinc oxide rectal suppositori es if you have rectal bleeding or continued pain.

Check doctors order. Call your doctor if you have any signs of infection such as redness and warmth or oozing skin lesions.. Avoid getting this medication in your mouth or eye Document.

x. Nursing care plan

Assessment/ Cues
Objective: The patient has difficulty sucking effectively and prone in nasal regurgitation and aspiration because air leaks into the mouth from the cleft.

Nursing Diagnosis
Difficulty of feeding and nasal regurgitation related to failure of maxillary prominence on the affected side and medial nasal prominences to merge.

Etiology

Planning

Nursing Intervention

Rationale

Evaluation

Cleft lip (Cheiloschisis) and cleft palate (Palatoschisis), which can also occur together as cleft lip and palate, are variations of a type of clef ting congenital deformity caused by abnormal facial development during gestation. A cleft is a fissure or openinga gap. It is the nonfusion of the body's natural structures that form before birth.

After 8 hours of nursing interventio n the patient will have greater success of feeding in a more upright position.

Maintain adequate nutrition to ensure normal growth and development.

Experiment with feeding devices. A baby with a cleft palate has an excellent appetite but often has trouble feeding because of air leaks around the cleft and nasal regurgitation.

After 8 hours of nursing intervention, the patient had greater success of feeding in a more upright position.

Teach the parents how to breast feed the infant.

Advise them to hold the infant in a near-sitting position, with the flow directed to the side or back of the baby's tongue. Tell them to burp the baby frequently because he tends to swallow a lot of air

Cues Subjective: Objective: Inability to inititiate/ sustain an effective suck Inability to coordinate sucking, swallowing, and breathing.

Background Knowledge Impaired ability of an infant to suck or coordinate the suck/ swallow responses resulting in inadequate oral nutrition for metabolic needs. This was affected by the anatomical abnormality of the patient as he has a cleft lip and palate deformities.

Nursing Diagnosis Ineffective infant feeding pattern related to anatomical abnormality

Goal/ Objectives After 2 days of nursing intervent ion the client will be able to be free from aspiratio n and display adequate output as measure by sufficient number of wet diapers daily.

Nursing Interventions Independent: Using the same scale, weight infants at same time each day. Continuous ly assess infants sucking pattern Assess parents knowledge of feeding techniques Assess patients level of anxiety with regards to infants feeding difficulty

Rationale

Evaluation Goal was fully met. The patient is now free from aspiration and displayed adequate output as measured by sufficient number of wet diapers daily.

To ensure early recognition of excessive weight loss. To monitor for ineffective pattern

To help identify and clear up misconceptions

Anxiety may interfere with parents; ability to learn new techniques.

Cues

Background Knowledge

Nursing Diagnosis

Goal/ Objectives

Nursing Interventions
Remain with parents and infant during feeding Teach parents to place infant in upright position during feeding,

Rationale
To identify problem areas and direct intervention.

Evaluation

To prevent aspiration.

Cues OBJECTIVE: Difficult in feeding Malformation of lips and roof of the mouth

Nursing Diagnosis Risk for Aspiration (Breast Milk, formula or mucus) as related to anatomic effect.

Goal/ Objectives After 1hour of nursing intervention the patient will be able to experience no aspiration as evidenced by noiseless respirations, clear breath sounds, and clear odorless secretions.

Nursing Interventions Independent Position the infant in a football hold to maintain proper breathing. Monitor and record vital signs Stop feeding immediately if you suspect aspiration, Apply suction as needed, Elevate the head of patients bed during and after feedings unless contraindicate d,

Rationale To prevent from possible of episode of choking or aspiration To detect aspiration or impaired gas exchange. To avoid further aspiration. To help prevent aspirations.

Evaluation After 1 hour of nursing intervention the patient doesnt experience no aspiration as evidenced by noiseless respirations, clear breath sounds, and clear odorless secretions.