A Six Month Old Baby Returns From Surgery With Elbow Restraints in Place. What Nursing Care
The virtually common facial malformations, cleft lip and cleft palate, occur either solitary or in combination.
What is Scissure Lip and Cleft Palate?
Although a crevice lip and a cleft palate often appear together, either defect may appear lone.
- Cleft lip and cleft palate are openings or splits in the upper lip, the roof of the oral cavity (palate) or both.
Pathophysiology
In embryonic development, the palate closes later than the lip, and the failure to close occurs for dissimilar reasons.
- The cleft lip and palate defects result from failure of the maxillary and premaxillary processes to fuse during the 5th to eighth week of intrauterine life.
- The crevice may be a simple notch in the vermilion line, or it may extend upwardly into the floor of the nose.
- The child born with a cleft palate simply with an intact lip does not have the external disfigurement that may be and so distressing to the new parent; however, the problems are more than serious.
- In an 8-week old embryo, there is yet no roof to the oral fissure; the tissues that are to become the palate are ii shelves running from the front to the dorsum of the mouth and projecting vertically downward on either side of the tongue.
- The shelves move from a vertical position to a horizontal position; their costless edges encounter and fuse in the midline.
- Afterwards, bone forms within this tissue to grade the difficult palate.
- Commonly the palate is intact past the 10th week of fetal life.
- Exactly what happens to preclude this closure is not known for sure, leading to a cleft lip and fissure palate.
Statistics and Incidences
Parents and family are naturally eager to see and hold their newborn and must exist prepared for the daze of seeing the facial disfigurement.
- Fissure lip occurs in virtually i in one,000 live births and is more than common in males.
- Cleft palate occurs in ane newborn in 2, 500, more ofttimes in females.
- Cleft palate occurs with a cleft lip about 50% of the time, most ofttimes with bilateral cleft lip.
Causes
The incidence of crevice palate is higher in the shut relatives of people with the defect than it is in the full general population, and some evidence indicates that ecology and hereditary factors play a office in this defect.
- Hereditary. The female parent or the begetter tin can pass on genes that crusade clefting, either alone or equally function of a genetic syndrome that includes a cleft lip or cleft palate as one of its signs.
- Ecology. In some cases, babies inherit a gene that makes them more likely to develop a scissure, and then an environmental trigger actually causes the scissure to occur.
Clinical Manifestations
Normally, a split (crevice) in the lip or palate is immediately identifiable at birth.
- Fissure. A split in the lip and roof of the oral cavity (palate) that can affect 1 or both sides of the confront; a split in the lip that can appear as merely a small notch in the lip or can extend from the lip through the upper glue and palate into the lesser of the olfactory organ; a split in the roof of the mouth that doesn't affect the appearance of the face.
- Difficulty with feedings. The newborn easily becomes choked on liquids.
- Difficulty swallowing. The newborn has a hard time in swallowing, with potential for liquids or foods to come up out the nose.
- Nasal speaking voice. Due to the split in the palate, the newborn has a nasal speaking voice.
Assessment and Diagnostic Findings
The physical appearance of the newborn confirms the diagnosis of cleft lip; diagnosis of fissure palate is made at nascence.
- Inspection. Diagnosis of crevice palate is fabricated at nativity with the close inspection of the newborn's palate; to exist certain that a fissure palate is not missed, the examiner must insert a gloved finger into the newborn's rima oris to feel the palate to determine that information technology is intact.
- Observation. Cleft lip tin be diagnosed through ascertainment of the physical appearance of the newborn.
Medical Direction
Treatment for a newborn with crack lip and palate includes:
- Surgery. Cleft lip repair, commonly performed by a plastic surgeon, is a major role of the treatment of a newborn with cleft lip, palate, or both; some surgeons favor early on repair, before the newborn is discharged from the infirmary; other surgeons prefer to wait until the newborn is one to ii months old, weighs about x lbs, and is gaining weight steadily.
- Dental speech appliance. If surgery must be delayed beyond the 3rd year, a dental speech appliance may help aid the child develop intelligible speech.
Nursing Management
A complete and thorough procedure of care should be undergone by the newborn with fissure lip and cleft palate.
Nursing Cess
I primary concern in the nursing care of the newborn with a scissure lip and cleft palate is the emotional care of the newborn'due south family.
- Interview. In interviewing the family and collecting data, the nurse must include exploration of the family unit'south acceptance of the newborn; comport a thorough interview with the caregiver that includes a question well-nigh the methods they constitute to be most effective in feeding the infant.
- Physical exam. Concrete examination of the baby includes temperature, apical pulse, and respirations; listen to breath sounds, detect peel turgor and colour, infant'south neurologic condition, noting alacrity and responsiveness.
Nursing Diagnoses
Based on the assessment data, the major nursing diagnoses are:
- Compromised family coping related to visible physical defect.
- Anxiety of family caregivers related to child's condition and surgical result.
- Deficient knowledge of family caregivers related to intendance of child before surgery and the surgical procedure.
- Risk for aspiration related to a reduced level of consciousness later surgery.
- Ineffective breathing pattern related to anatomical changes.
- Risk for deficient fluid volume related to NPO status after surgery.
- Astute pain related to surgical procedure.
- Risk of injury to the operative site related to newborn'southward desire to suck thumb or fingers and anatomical changes.
Nursing Care Planning and Goals
Goal setting and planning must be modified to adapt to the surgical plans; the major goals include:
- Maintaining adequate nutrition.
- Increasing family coping.
- Reducing the parents' anxiety and guilt regarding the newborn's physical defects, and preparing parents for the time to come repair of the cleft lip and palate.
Nursing Interventions
Nursing interventions for the patient with crevice lip and palate are:
- Maintain adequate nutrition. Breastfeeding may be successful because the chest tissue may mold to close the gap; if the newborn cannot exist breastfeed, the mother's breast milk may be expressed and used instead of formula; a soft nipple with a cross-cut fabricated to promote easy flow of milk may piece of work well.
- Positioning. If the cleft lip is unilateral, the nipple should be aimed at the unaffected side; the infant should be kept in an upright position during feeding.
- Tools for feeding. Lamb's nipples (actress long nipples) and special cleft palate nipples molded to fit into the open palate surface area to close the gap may exist used; one of the simplest and about effective methods may be the use of an eyedropper or an Asepto syringe with a short piece of rubber tubing on the tip (Breck feeder).
- Promote family coping. Encourage the family to enunciate their feelings regarding the defect and their thwarting; serve as a model for the family unit caregiver'southward attitudes toward the child.
- Reduce family anxiety. Give the family data about cleft repairs; encourage them to ask questions and reassure them that any question is valid.
- Provide family unit educational activity. Explain the usual routine of preoperative, intraoperative, and post operative care; written data is helpful, simply be certain the parents understand the information.
Evaluation
Major goals for the care of the infant with fissure lip and cleft palate include:
- Maintained adequate diet.
- Increased family coping.
- Reduced parents' anxiety and guilt regarding the newborn'southward concrete defects.
Documentation Guidelines
Documentation for a patient with cleft lip and palate include the post-obit:
- Assessment findings, including current and the past coping behaviors, emotional response to situation and stressors, back up systems available.
- Level of anxiety and precipitating/aggravating factors.
- Description of feelings.
- Awareness and ability to recognize and express feelings.
- Customer'due south clarification of response to pain, specifics of pain inventory, adequate level of pain.
- Plan of care.
- Educational activity plan.
- Responses of family members/client to interventions, teaching, and deportment performed.
- Attainment or progress toward desired outcomes.
- Modification to plan of intendance.
- Long term plan and who is responsible for actions.
- Specific referrals made.
Practice Quiz: Cleft Lip and Cleft Palate
Here are some practice questions for this study guide. Please visit our nursing test bank folio for more than NCLEX do questions.
1. When assessing a child with a cleft palate, the nurse is enlightened that the child is at risk for more frequent episodes of otitis media due to which of the post-obit?
A. Lowered resistance from malnutrition.
B. Ineffective functioning of the Eustachian tubes.
C. Plugging of the Eustachian tubes with nutrient particles.
D. Associated congenital defects of the heart ear.
1. Respond: B. Ineffective functioning of the Eustachian tubes.
- B: Considering of the structural defect, children with cleft palate may have ineffective functioning of their Eustachian tubes creating frequent bouts of otitis media.
- A: About children with cleft palate remain well-nourished and maintain adequate nutrition through the use of proper feeding techniques.
- C: Food particles do not pass through the cleft and into the Eustachian tubes.
- D: At that place is no clan between crevice palate and built ear deformities.
2. While assessing a newborn with crack lip, the nurse would exist alert that which of the post-obit will about likely be compromised?
A. Sucking ability.
B. Respiratory condition.
C. Locomotion.
D. GI function.
2. Answer: A. Sucking ability.
- A: Because of the defect, the kid will be unable to from the mouth adequately around the nipple, thereby requiring special devices to permit for feeding and sucking gratification.
- B: Respiratory status may be compromised if the child is fed improperly or during the postoperative period.
- C: Locomotion would exist a problem for the older infant because of the use of restraints.
- D: GI functioning is not compromised in the child with a cleft lip.
3. When providing postoperative care for the child with a cleft palate, the nurse should position the child in which of the following positions?
A. Supine.
B. Prone.
C. In an infant seat.
D. On the side.
three. Answer: B. Prone.
- B: Postoperatively children with crack palate should be placed on their abdomens to facilitate drainage.
- A: If the child is placed in the supine position, he or she may aspirate.
- C: Using an baby seat does non facilitate drainage.
- D: Side-lying does not facilitate drainage as well equally the prone position.
four. An 18-calendar month-former is scheduled for a scissure palate repair. The usual type of restraints for the child with a fissure palate repair are:
A. Elbow restraints.
B. Full arm restraints.
C. Wrist restraints.
D. Mummy restraints.
4. Answer: A. Elbow restraints.
- A: The to the lowest degree restrictive restraint for the baby with cleft lip and cleft palate repair is elbow restraints.
- B, C, D: Answers B, C, and D are more restrictive and unnecessary; therefore, they are wrong.
5. A home care nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement if fabricated by the mother indicates a need for farther instructions?
A. "I will utilize a nipple with a pocket-sized hole to prevent choking."
B. "I will stimulate sucking by rubbing the nipple on the lower lip."
C. "I will allow the infant fourth dimension to consume."
D. "I will allow the infant to residue ofttimes to provide time for swallowing what has been placed in the oral fissure."
5. Answer: B. "I will stimulate sucking by rubbing the nipple on the lower lip."
- B: An infant with cleft palate would have difficulty in feeding despite stimulation for sucking.
- A, C, D: All these options are right for an babe with cleft palate.
Run across Also
Related topics to this study guide:
- Pediatric Nursing Study Guides
- Nursing Notes: Study Guides for Various Topics
- Pediatric Nursing NCLEX Exercise Questions
Farther Reading
Recommended resources and books for pediatric nursing:
- PedsNotes: Nurse's Clinical Pocket Guide (Nurse'south Clinical Pocket Guides)
- Pediatric Nursing Made Incredibly Easy
- Wong's Essentials of Pediatric Nursing
- Pediatric Nursing: The Disquisitional Components of Nursing Intendance
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Source: https://nurseslabs.com/cleft-lip-cleft-palate/
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