Cleft Lip and Palate Nursing Care Plan: Nursing Diagnosis and Guide

Cleft lip and palate are congenital conditions that occur when the soft and bony tissues of the lip or palate do not fuse properly during fetal development. These defects can occur individually or together and are sometimes associated with other congenital anomalies like spina bifida, hydrocephalus, or cardiac defects. For newborns diagnosed with cleft lip and palate, nursing care is crucial. This comprehensive guide provides a detailed nursing care plan, including nursing diagnoses, interventions, and goals to support infants and their families through this challenging condition.

Nursing Care Plans and Management

Nursing care for infants with cleft lip and palate is multifaceted, aiming to address the immediate physical needs of the newborn while also supporting the family’s emotional and educational requirements. Key nursing goals include ensuring adequate nutrition, enhancing family coping mechanisms, alleviating parental anxiety and guilt related to the infant’s condition, and preparing parents for the surgical interventions required to repair the cleft lip and palate.

Nursing Problem Priorities

The primary nursing priorities for infants with cleft lip and palate are:

Maintaining a clear airway and preventing aspiration.
Ensuring adequate nutritional intake and appropriate feeding techniques.
Reducing parental anxiety and promoting effective coping.
Preventing injury and infection, especially post-surgery.
Providing comprehensive patient and family education for long-term management.

Nursing Assessment

A thorough assessment is critical to identify the specific needs of the infant with cleft lip and palate and to tailor the nursing care plan accordingly. The nursing assessment should include both subjective and objective data.

Subjective Data: (Primarily obtained from parents or caregivers)

Parental concerns and anxieties about the infant’s condition and appearance.
Family history of cleft lip, cleft palate, or other congenital anomalies.
Feeding history and any difficulties encountered.
Parental understanding of cleft lip and palate and planned treatments.
Social support systems available to the family.

Objective Data: (Directly observed and measured by the nurse)

Respiratory Status:
- Respiratory rate, depth, and effort.
- Presence of retractions, nasal flaring, or other signs of respiratory distress.
- Auscultation of breath sounds for clarity and presence of adventitious sounds.
- Skin color, noting any cyanosis (especially circumoral or central).
- Capillary refill time.
Oral Cavity Examination:
- Visual inspection of the lip and palate to determine the type and extent of the cleft (unilateral, bilateral, complete, incomplete).
- Assess the size and location of the cleft lip and/or palate.
- Note any associated facial deformities.
Feeding Assessment:
- Infant’s sucking and swallowing reflexes.
- Coordination of suck-swallow-breathe.
- Ability to latch onto a nipple (breast or bottle).
- Presence of nasal regurgitation during feeding.
- Length of feeding times and intake amounts.
- Weight, length, and head circumference measurements, plotted on growth charts.
- Signs of dehydration or malnutrition.
Post-Operative Assessment (if applicable):
- Surgical site assessment for redness, swelling, drainage, and approximation of wound edges.
- Pain level and effectiveness of pain management.
- Presence of elbow restraints and their proper application.
- Signs of infection (fever, increased heart rate, wound drainage).
- Tolerance of oral feedings post-surgery.
Parent-Infant Interaction:
- Observe parental holding, comforting, and interaction with the infant.
- Assess parental emotional responses to the infant’s condition.
- Identify parental coping mechanisms and support needs.

Nursing Diagnosis

Based on the comprehensive assessment, several nursing diagnoses may be relevant for an infant with cleft lip and palate. These diagnoses guide the development of individualized nursing interventions. Common nursing diagnoses include:

Risk for Aspiration related to cleft palate and ineffective sucking and swallowing.
Imbalanced Nutrition: Less Than Body Requirements related to feeding difficulties associated with cleft lip and/or palate.
Risk for Infection related to surgical incision and altered oral anatomy.
Risk for Injury related to post-surgical site disruption and improper feeding techniques.
Anxiety (Parental) related to infant’s congenital anomaly, surgical procedures, and long-term care needs.
Disturbed Body Image (Parental) related to infant’s facial defect.
Deficient Knowledge (Parents) related to cleft lip and palate, feeding techniques, surgical procedures, and follow-up care.
Ineffective Infant Feeding Pattern related to cleft lip/palate and impaired oral suction.
Impaired Parenting related to stress of infant’s condition and perceived burden of care.

Nursing Goals

The goals of nursing care are designed to address the identified nursing diagnoses and promote positive outcomes for the infant and family. These goals should be specific, measurable, achievable, relevant, and time-bound (SMART).

Airway and Aspiration:
- Maintain a clear airway at all times, evidenced by clear breath sounds and absence of respiratory distress.
- Exhibit effective breathing patterns with a respiratory rate within normal limits and no signs of aspiration during or after feeding.
Nutrition:
- Achieve and maintain adequate nutritional intake to support growth and development, as evidenced by consistent weight gain and appropriate developmental milestones.
- Demonstrate effective feeding techniques that minimize nasal regurgitation and maximize oral intake.
Infection and Injury Prevention:
- Remain free from infection at the surgical site and in the oral cavity, evidenced by absence of redness, swelling, purulent drainage, and fever.
- Experience no injury to the surgical site, demonstrated by intact sutures and proper wound healing.
Parental Anxiety and Coping:
- Parents will report a decrease in anxiety levels related to the infant’s condition and care.
- Parents will demonstrate effective coping mechanisms and actively participate in the infant’s care.
- Parents will verbalize understanding of the infant’s condition, treatment plan, and prognosis.
Knowledge and Education:
- Parents will verbalize understanding of cleft lip and palate, feeding techniques, surgical repair, and necessary follow-up care.
- Parents will demonstrate proper feeding techniques and post-operative care procedures.
- Parents will identify potential complications and know when to seek medical attention.

Nursing Interventions and Actions

Nursing interventions for infants with cleft lip and palate are tailored to address the specific nursing diagnoses and achieve the established goals. These interventions are categorized by the primary nursing priorities.

1. Maintaining Airway Clearance and Preventing Aspiration

Infants with cleft palate are at high risk for aspiration due to the abnormal anatomy and difficulty coordinating sucking, swallowing, and breathing. Post-surgical edema can further compromise the airway.

Assess Respiratory Status Regularly:
- Monitor respiratory rate, depth, and effort every 1-2 hours and PRN. Document findings.
  - Rationale: Early detection of respiratory distress is crucial for timely intervention. Tachypnea, retractions, and increased effort can indicate aspiration or airway obstruction.
- Auscultate breath sounds before and after feedings and PRN.
  - Rationale: Adventitious breath sounds (wheezing, crackles) may indicate aspiration of secretions or formula.
- Observe for signs of cyanosis, especially during and after feedings.
  - Rationale: Cyanosis is a late sign of respiratory distress and hypoxia.
Positioning for Optimal Airway:
- Elevate the infant’s head and chest to a 30-45 degree angle during and after feedings. Use an infant seat or prop the crib mattress.
  - Rationale: Upright positioning helps prevent the tongue from obstructing the airway and reduces reflux and aspiration risk. Gravity assists with drainage of secretions and formula.
- Position infant on their back or side after feeding, avoiding the prone position, especially post-lip repair.
  - Rationale: Back or side positioning prevents pressure on the lip suture line and promotes drainage. Prone position increases aspiration risk.
Suctioning as Needed:
- Have suction equipment readily available at the bedside.
  - Rationale: Immediate suctioning is necessary to clear the airway in case of aspiration or increased secretions.
- Perform gentle oral and nasal suctioning as needed, especially before feedings and if signs of respiratory distress are present. Use a soft, flexible catheter.
  - Rationale: Suctioning removes excess secretions, mucus, or formula from the oral and nasal cavities, maintaining a patent airway. Gentle suctioning minimizes trauma, especially to the surgical site.
- Avoid deep or aggressive suctioning, particularly near the suture line post-surgery.
  - Rationale: Aggressive suctioning can damage delicate tissues and disrupt suture lines, increasing infection risk.
Feeding Techniques to Minimize Aspiration:
- Feed the infant slowly and in small amounts, allowing frequent pauses for swallowing and breathing.
  - Rationale: Slow feeding reduces the volume of liquid in the mouth at one time, decreasing aspiration risk. Pauses allow the infant to coordinate suck-swallow-breathe and prevent overwhelming the swallowing mechanism.
- Burp the infant frequently during and after feedings.
  - Rationale: Frequent burping removes swallowed air, reducing gastric distention and reflux, which can contribute to aspiration.
- Use specialized feeding nipples or devices as recommended by the healthcare team (e.g., Pigeon nipple, Haberman feeder).
  - Rationale: Special nipples are designed to deliver formula effectively to infants with cleft lip/palate, reducing air intake and nasal regurgitation. They often have features like one-way valves and compressible bottles.
- Ensure the nipple is placed correctly in the infant’s mouth to facilitate swallowing and minimize air intake.
  - Rationale: Proper nipple placement directs formula towards the side of the mouth and tongue, promoting swallowing and reducing flow into the cleft area.

2. Improving Nutritional Status and Teaching Feeding Methods

Infants with cleft lip and palate often struggle with feeding, leading to inadequate nutritional intake and potential growth delays.

Assess Sucking and Swallowing Ability:
- Evaluate the infant’s suck strength and coordination by observing feeding attempts and intraoral examination.
  - Rationale: Assessing sucking and swallowing helps determine the severity of feeding difficulties and guides the selection of appropriate feeding methods and devices.
- Note the presence of nasal regurgitation, coughing, choking, or excessive air intake during feeding.
  - Rationale: These signs indicate ineffective feeding and increased aspiration risk, requiring adjustments to feeding techniques or devices.
Monitor Nutritional Intake and Growth:
- Record daily caloric and fluid intake accurately.
  - Rationale: Precise intake monitoring helps determine if the infant is meeting nutritional needs and if adjustments to feeding plans are necessary.
- Weigh the infant daily and plot weight, length, and head circumference on growth charts regularly.
  - Rationale: Daily weights and growth measurements track the infant’s nutritional status and growth progress. Failure to thrive indicates inadequate nutrition.
- Monitor hydration status, including urine output, mucous membrane moisture, and skin turgor.
  - Rationale: Dehydration can occur if fluid intake is insufficient, especially with feeding difficulties and potential fluid loss through nasal regurgitation.
Educate and Support Breastfeeding Mothers (if desired):
- Encourage mothers who wish to breastfeed and provide support and guidance.
  - Rationale: Breast milk provides optimal nutrition and immunological benefits. While challenging, breastfeeding may be possible for some infants with cleft lip, especially with proper positioning and support.
- Teach techniques to improve latch and seal, such as using fingers to support the lip and guide the nipple.
  - Rationale: Supporting the lip and guiding the nipple can help create a better seal and facilitate breastfeeding for infants with cleft lip.
- Advise mothers to pump breast milk and supplement with bottle feeding if direct breastfeeding is not fully successful.
  - Rationale: Pumping ensures the infant receives breast milk’s benefits, and bottle feeding allows for controlled intake and use of specialized nipples.
Teach Bottle Feeding Techniques:
- Demonstrate and educate parents on proper positioning (upright or semi-upright).
- Instruct on using specialized nipples and bottles (e.g., Pigeon, Mead Johnson, Haberman).
  - Rationale: These devices are designed to assist infants with cleft lip and palate in feeding effectively.
- Teach paced feeding techniques, allowing frequent breaks and burping.
  - Rationale: Paced feeding mimics breastfeeding, prevents overfeeding, and allows the infant to control the pace of feeding.
- Advise thickening formula with cereal only if recommended by a pediatrician or feeding specialist.
  - Rationale: Thickening formula may reduce regurgitation but should be done cautiously and only under professional guidance due to potential risks.
Oral Feeding Readiness and Transition to Solids:
- Assess infant’s readiness for oral feeding post-surgery, typically around 4 hours post-op for lip repair and after initial recovery for palate repair.
  - Rationale: Gradual introduction to oral feeding post-surgery minimizes vomiting risk and allows for assessment of tolerance.
- Introduce clear liquids first, followed by formula or breast milk, in small amounts.
  - Rationale: Starting with clear liquids and gradually progressing reduces the risk of vomiting and aspiration.
- Educate parents about introducing soft solid foods at the appropriate developmental age (around 6 months), ensuring soft textures and avoiding coarse foods that could enter the nasopharynx.
  - Rationale: Soft foods minimize aspiration risk and are easier to manage orally for infants with cleft palate, especially post-surgery.

3. Reducing Anxiety and Enhancing Coping

The diagnosis of cleft lip and palate can evoke significant anxiety, guilt, and emotional distress in parents. Nursing interventions focus on providing emotional support, education, and resources to enhance parental coping.

Assess Parental Emotional State and Coping Mechanisms:
- Assess parents’ emotional responses to the infant’s diagnosis, including anxiety, guilt, sadness, and shock.
  - Rationale: Understanding parental emotions is crucial for providing tailored support and interventions.
- Explore existing coping mechanisms and identify support systems available to the family.
  - Rationale: Identifying existing coping strategies and support networks helps build upon strengths and address areas of need.
- Observe parent-infant interactions and identify any signs of difficulty bonding or accepting the infant.
  - Rationale: Early identification of bonding difficulties allows for timely interventions to promote positive parent-infant relationships.
Provide Emotional Support and Therapeutic Communication:
- Create a safe and accepting environment for parents to express their feelings and concerns without judgment.
  - Rationale: Open communication and a non-judgmental approach build trust and encourage parents to share their emotions.
- Listen actively and empathetically to parental concerns and validate their feelings.
  - Rationale: Active listening and validation acknowledge parental distress and promote emotional processing.
- Offer reassurance and hope, emphasizing the positive outcomes of surgical repair and long-term management.
  - Rationale: Providing realistic hope and highlighting positive outcomes can alleviate anxiety and instill optimism.
- Emphasize the infant’s positive attributes and strengths, focusing on abilities rather than limitations.
  - Rationale: Focusing on the infant’s positive qualities promotes parental bonding and a positive self-image for the child.
Provide Accurate and Honest Information:
- Explain cleft lip and palate in clear, understandable terms, using visual aids and models if available.
  - Rationale: Clear and accurate information reduces anxiety associated with the unknown and empowers parents to understand the condition.
- Discuss the treatment plan in detail, including surgical procedures, timelines, and expected outcomes.
  - Rationale: Providing a clear treatment plan reduces uncertainty and allows parents to prepare for upcoming procedures.
- Address parental questions and concerns honestly and directly, correcting any misconceptions.
  - Rationale: Addressing concerns and correcting misinformation builds trust and ensures informed decision-making.
Facilitate Support Systems and Resources:
- Connect parents with other families who have children with cleft lip and palate through support groups or online forums.
  - Rationale: Peer support provides emotional validation, practical advice, and a sense of community.
- Provide information about cleft lip and palate organizations and resources, such as the Cleft Palate Foundation and the American Cleft Palate-Craniofacial Association.
  - Rationale: Connecting families with relevant organizations provides access to comprehensive resources, education, and support networks.
- Refer parents to genetic counseling to discuss recurrence risks and family planning.
  - Rationale: Genetic counseling provides information about inheritance patterns and recurrence risks, aiding informed family planning decisions.
- Collaborate with social workers and other healthcare professionals to address psychosocial needs and access community resources.
  - Rationale: Interdisciplinary collaboration ensures holistic support for the family, addressing emotional, social, and financial needs.

4. Preventing Injury and Infections

Infants with cleft lip and palate, especially post-surgery, are vulnerable to injury and infection. Nursing interventions aim to minimize these risks and promote healing.

Surgical Site Care and Infection Prevention:
- Assess the surgical site regularly for signs of infection: redness, swelling, increased warmth, drainage, and odor.
  - Rationale: Early detection of infection allows for prompt intervention and prevents complications.
- Cleanse the suture line gently after each feeding and PRN with sterile saline or as prescribed, using cotton-tipped applicators.
  - Rationale: Gentle cleansing removes formula residue and secretions, preventing crust formation and bacterial growth.
- Apply topical antibiotic ointment to the suture line as prescribed.
  - Rationale: Antibiotic ointment helps prevent bacterial infection and promotes wound healing.
- Avoid rubbing or pulling on the suture line during cleaning or care. Use a gentle rolling motion.
  - Rationale: Rough handling can disrupt sutures, delay healing, and increase infection risk.
Pain Management:
- Assess infant’s pain level using age-appropriate pain scales (e.g., NIPS, FLACC) regularly and PRN.
  - Rationale: Accurate pain assessment guides effective pain management.
- Administer prescribed analgesics (e.g., acetaminophen, ibuprofen) as ordered, around the clock or PRN for pain.
  - Rationale: Adequate pain relief minimizes crying and discomfort, which can put tension on the suture line.
- Utilize non-pharmacological pain management techniques: swaddling, rocking, pacifier (if appropriate), gentle holding, and quiet environment.
  - Rationale: Non-pharmacological methods complement analgesics and provide comfort and distraction.
- Anticipate infant’s needs and provide comfort measures to prevent crying and agitation, especially post-operatively.
  - Rationale: Preventing crying reduces tension on the suture line and promotes healing.
Preventing Accidental Injury to Surgical Site:
- Apply elbow restraints to prevent the infant from touching or rubbing the surgical site. Ensure proper fit and padding.
  - Rationale: Elbow restraints prevent accidental disruption of the suture line by the infant’s hands.
- Remove restraints periodically (every 2-4 hours) to assess skin integrity, provide range of motion exercises, and allow for parental holding and interaction.
  - Rationale: Periodic removal prevents skin breakdown and promotes circulation and development.
- Position the infant to avoid pressure on the suture line, especially after lip repair. Avoid prone position.
  - Rationale: Proper positioning minimizes pressure and tension on the surgical site.
- Keep sharp objects and small toys away from the infant. Avoid pacifiers, straws, and spoons in the mouth post-palate repair until sutures are healed.
  - Rationale: Sharp objects and oral devices can injure the suture line and disrupt healing.
Preventing Ear Infections (Otitis Media):
- Feed the infant in an upright position (greater than 60 degrees) and avoid bottle propping.
  - Rationale: Upright feeding reduces milk reflux into the Eustachian tube, minimizing ear infection risk.
- Educate parents about the increased risk of ear infections in infants with cleft palate and signs and symptoms to watch for (fever, ear pulling, irritability, drainage).
  - Rationale: Early recognition of ear infection symptoms allows for prompt medical attention and treatment.
- Encourage routine follow-up appointments with an otolaryngologist (ENT) or audiologist for hearing screenings and ear evaluations.
  - Rationale: Regular ear evaluations and hearing screenings are crucial due to the increased risk of otitis media and potential hearing loss.

5. Initiating Patient Education and Health Teachings

Comprehensive education is essential to empower parents to care for their infant at home and manage the long-term needs associated with cleft lip and palate.

Pre-Discharge Education:
- Review feeding techniques, including positioning, specialized devices, paced feeding, and burping. Provide hands-on demonstration and return demonstration.
  - Rationale: Ensures parents are confident and competent in feeding their infant safely and effectively at home.
- Educate on suture line care, cleaning procedures, and signs of infection. Provide written instructions and demonstration.
  - Rationale: Proper suture care is crucial for preventing infection and promoting healing. Written instructions serve as a reference at home.
- Teach pain management strategies, including medication administration and non-pharmacological comfort measures.
  - Rationale: Equips parents to manage infant pain effectively at home.
- Explain the importance of elbow restraints and demonstrate proper application and removal.
  - Rationale: Ensures parents understand the purpose and correct use of restraints to protect the surgical site.
- Discuss signs and symptoms of potential complications that require immediate medical attention: respiratory distress, infection, feeding difficulties, excessive bleeding.
  - Rationale: Empowers parents to recognize and respond promptly to potential problems.
- Provide information on long-term follow-up care, including appointments with surgeons, pediatricians, dentists, speech therapists, audiologists, and other specialists.
  - Rationale: Ensures parents understand the importance of ongoing multidisciplinary care for optimal outcomes.
Home Care and Community Resources:
- Provide a list of community resources and support organizations, including cleft palate foundations, support groups, and early intervention programs.
  - Rationale: Connects families with valuable support networks and resources for ongoing assistance.
- Offer contact information for the healthcare team and instructions on how to reach them with questions or concerns after discharge.
  - Rationale: Provides reassurance and access to professional support after discharge.
- Discuss the importance of creating a normal, nurturing home environment and treating the child as any other child, focusing on abilities and promoting development.
  - Rationale: Encourages positive parenting and promotes the child’s healthy development and self-esteem.
- Schedule follow-up appointments as needed, including home health visits if appropriate, to assess infant progress and provide ongoing support.
  - Rationale: Ensures continuity of care and addresses any challenges encountered at home.

Recommended Resources

For further information and support, consider these resources:

Cleft Palate Foundation: https://cleftline.org/
American Cleft Palate-Craniofacial Association (ACPA): https://acpa-cpf.org/
March of Dimes: https://www.marchofdimes.org/
Local hospitals and clinics with craniofacial teams.
Nursing Diagnosis Handbooks and Care Plan Resources.

References and Sources

Burca, N. D. L., Gephart, S. M., Miller, C., & Zukowsky, K. (2016, October). Promoting Breast Milk Nutrition in Infants With Cleft Lip and/or Palate. Advances in Neonatal Care, 16(5), 337-344.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span (8th ed.). F.A. Davis Company.
Kenner, C., Altimier, L., & Boykova, M. V. (Eds.). (2019). Comprehensive Neonatal Nursing Care. Springer Publishing Company.
Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing. Elsevier.
Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Wolters Kluwer.
Tolarova, M. M., & Elluru, R. G. (2022, March 10). Pediatric Cleft Lip and Palate Clinical Presentation: Physical Examination. Medscape Reference. Retrieved July 18, 2022.

Disclaimer: This nursing care plan is for informational purposes only and should not be considered medical advice. Always consult with a qualified healthcare professional for diagnosis and treatment of medical conditions.

Alt Text: Infant with unilateral cleft lip prior to surgical repair, showing the visible separation of the upper lip.

Alt Text: Infant post-cleft lip repair surgery, demonstrating the improved lip appearance and successful surgical outcome.

Alt Text: Pigeon nipple specialized feeding bottle designed for infants with cleft lip and palate to facilitate effective feeding and reduce air intake.

Alt Text: Nurse demonstrating proper feeding technique for an infant with cleft lip and palate using a specialized bottle in a semi-upright position.