case study cleft lip2 finale

Cleft Lip and Cleft PalateCleft Lip and Cleft Palate

I. PERSONAL DATAI. PERSONAL DATA

I. PERSONAL DATAName: 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 II. HISTORY OF OF PRESENT ILLNESSPRESENT ILLNESS

II. HISTORY OF PRESENT ILLNESSII. 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

IV. FAMILY HISTORY

IV. FAMILY HISTORY

Paternal SideChristian 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 LIVINGV. ACTIVITIES OF DAILY LIVINGActivities During Hospitalization Analysis

Fluids and Nutrition He received his feeding through bottle feeding – 30 cc every 3 hours and has a hard time in consuming it.

He has difficulty in sucking because roof of the mouth is not formed completely.

Elimination Bladder and Bowel

Usually have urine and stool every change of diaper.

The present condition doesn’t affect the way of excreting the urine and stool.

Rest and Sleep He acquires a good rest and sleep but there are times that he was experiencing difficulty of breathing.

The patient experienced difficulty of breathing because 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 ASSESSMENTVI. PHYSICAL ASSESSMENT

PHYSICAL ASSESSMENTA. General Condition

Body Part Technique Used Normal Findings Actual Findings Analysis

Skin Inspection Ruddy Pink in colorPresence of lanugo in the shoulders, back and arms

Ruddy Pink in colorPresence of lanugos in the shoulders, back and arms

Normal

Hair Inspection Silky, resilient hairEvenly distributed

Silky, resilient hairSlight thick hair

Evenly distributed

Normal

Head InspectionPalpation

Anterior fontanelle is softNo caput succedaneum

Appears disproportionately large

Forehead is large and prominent

Anterior fontanelle is softNo caput succedaneum

Appears disproportionately large

Forehead is large and prominent

Normal

Eyes Inspection Slight grey pupilRound Cornea

Eyes are symmetrically aligned

Pupils are equal in size (+) Blink reflex

Slight grey pupilRound Cornea

Eyes are symmetrically aligned

Pupils are equal in size (+) Blink reflex

Normal

Weight: 3050 grams Temperature: 36.6 C Length: 50 cm HR: 133 bpm Head Circumference: 32 cm RR: 46 cpm


Ears InspectionPalpation

Pinna recoils after foldedOuter canthus of the eye is higher than the top most part of the ear.

Formed and firm and instant recoil

Normal

Nose Inspection Appears large for the facePresence of miliaHas nasal septum

Presence of miliaHas no nasal septumHas gap in the right nostril up to the lip (Cleft lip)

Because of the gap, air leaks into the nasal cavity resulting in a hypernasal voice resonance and nasal emissions.

Mouth Inspection Open evenly when cryingTongue 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

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.

Chin Inspection Appears to be receding & quivers easily when cryingUsually has milia

Appears to be receding & quivers easily when cryingUsually has milia

Normal

Neck Inspection Short and chubby with creased skin folds

Short and chubby with creased skin folds

Normal


Chest Inspection Have buds (nipples)Appear symmetric

Without chest retractionClavicles are straight

The chest is as wide in the anteroposterior diameter

as it is across

With chest retractionHave buds (nipples)Appear symmetric

Clavicles are straight

Patient with chest retraction may have breathing difficulties as a result of fatigue.

Thus, always use gentle handling.

Abdomen Inspection Contour is slightly protuberant

Dome-shaped

Contour is slightly protuberant

Dome-shaped

Normal

Genital Inspection Ruggated, darkenedPenis appears small

Ruggated, darkenedPenis appears small

Normal

Back InspectionPalpation

No dimpling and pinpoint opening in the skin

(+) Trunk Incurvation

No dimpling and pinpoint opening in the skin

(+) Trunk Incurvation

Normal

Extremities InspectionPalpation

Arms and legs appear short (+) Moro Reflex

(+) Palmar Grasp Reflex(+)Babinski Reflex

Arms and legs appear short

(+) Moro Reflex(+) Palmar Grasp Reflex

(+)Babinski Reflex

Normal

Birth History:Birth History:

Baby boy Cruz delivered through vacuum Baby boy Cruz delivered through vacuum extraction, blood type O, Rh (+) and with an AOG extraction, blood type O, Rh (+) and with an AOG of 38 weeks. APGAR scoring done 1 min. after of 38 weeks. APGAR scoring done 1 min. after birth and 5 min. after shows normal. birth and 5 min. after shows normal.

Physical examination:Physical examination: Baby boy Cruz has good cry, well flexed Baby boy Cruz has good cry, well flexed

activities and pinkish all over when examined. He activities and pinkish all over when examined. He weighed 3050 g ( 6 lbs 12 oz), length is 50 cm and weighed 3050 g ( 6 lbs 12 oz), length is 50 cm and head circumference is 32 cm. .Examination also head circumference is 32 cm. .Examination also showed a normal perineum, back extremities and showed a normal perineum, back extremities and sucking reflex. Baby boy Cruz also has (+) cleft sucking reflex. Baby boy Cruz also has (+) cleft palate and (+) cleft lippalate 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 & PHYSIOLOGYNORMAL 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.

Cupid’s 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 Below the surface, the orbicularis oris muscle encircles the oral aperture, creating a muscle encircles the oral aperture, creating a sphincter. The fibers decussate in the midline sphincter. The fibers decussate in the midline creating the philtrum. In the cleft lip, the creating the philtrum. In the cleft lip, the orbicularis muscle inserts into the nasal alar base.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

Precipitating Factors:• Viral infection• Folic acid deficiency

The cleft causes structures of the face and mouth to develop without the normal restraints of encircling lip muscles

External nose Nasal septum Alveolar processes Nasal cartilages

Usually just beneath the center of one nostril

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

Bilaterally

Symmetric

Asymmetric

Signs and SymptomsWhat 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 infant’s and parents’ emotional and social adjustment.

a. Help facilitate the family’s 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 infant’s positive aspects and express optimism regarding surgical correction.

Provide preoperative care.a. Depending in the defect and the child’s 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 physician’s 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.) HEMATOLOGYDATE: July 4, 2010 PID: 20859-62Requesting Doctor: Dr. Montalban

TEST RESULT UNIT REFERENCE

Leukocyte 19.36 10^q/L 5.0-10.0

Erythrocyte 6.82 10^q/L M:4.6-6.2F:4.2-5.4

Hemoglobin 19.67 g/dL M:12.0-17.0F:11.0-15.0

Hematocrit 59.08 % M:40.0-54.00F:37.0-47.0

TEST RESULT UNIT REERENCE

ThrombocyteNeutropil

LympocyteMonocyteEosinophilBasophil

33359.325.98.51.44.9

10^q/L%%%%%

150-45050.0- 70.020.0-40.0

0.0-7.00.00-5.000

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


Hematocrit H- 59.08 Elevated hemoglobin may due because of dehydration

Thrombocytes N - 333 Normal

Neutropils 59.3 Normal

Monocytes H- 8.5 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.

Shows a normal range that fights the microorganism.Shows a normal range that fights the microorganism.


Eosiphil N- 1.4 Normal

Basophil H- 4.9 The result was high which indicates that there’s

infection.

iX. Drug study

DRUG CLASSIFICATION MECHANISM OF ACTION

INDICATION CONTRA-INDICATION

SIDE EFFECTS NURSING CONSIDERATION

Name:ampicillin

Dose:150 mg

Frequency:q12°

Route:IV

-Penicillin- Antibiotic

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

Treatment of infectious cause by susceptible strain of bacteria.

Hypersensitivity to penicillins, cephalosporins or imipenem

Rashes, Fever, Abdominal pain,nausea, vomiting, diarrhea

Check doctor’s 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.)

Document.




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 microorganisms, especially gram negative bacteria

Hypersensitivity to aminoglycosides

Nausea, vomiting, diarrhea, Headache,Fever,


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

Document




Name:Calmoseptine (Topical)

Emollients & Skin Protectives

Calmoseptine ointment promotes wound granulation and re-epithilialization.

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 medication if you are allergic to zinc, dimethicone, 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 suppositories if you have rectal bleeding or continued pain.


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

Nursing Diagnosis

Etiology Planning Nursing Intervention

Rationale Evaluation

Objective: The patient has difficultysucking effectively and prone in nasal regurgitation and aspiration because air leaks into the mouth fromthe cleft.

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

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 opening—a gap. It is the non-fusion of the body's natural structures that form before birth.

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

•Maintain adequate nutrition to ensure normal growth and development.

•Teach the parents how to breast feed the infant.

•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.

•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

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

Cues Background Knowledge

Nursing Diagnosis

Goal/ Objectives

Nursing Interventions


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

• 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.

• Ineffective infant feeding pattern related to anatomical abnormality

• After 2 days of nursing intervention the client will be able to be free from aspiration and display adequate output as measure by sufficient number of wet diapers daily.

Independent:•Using the same scale, weight infants at same time each day.•Continuously assess infant’s sucking pattern•Assess parents’ knowledge of feeding techniques•Assess patients’ level of anxiety with regards to infant’s feeding difficulty

•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.

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

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,

•To identify problem areas and direct intervention.

•To prevent aspiration.

Cues Nursing Diagnosis Goal/ Objectives Nursing Interventions


OBJECTIVE:Difficult in feedingMalformation of lips and roof of the mouth

Risk for Aspiration

(Breast Milk, formula or mucus) as related to anatomic effect.

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.

IndependentPosition 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 contraindicated,

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.

After 1 hour of nursing intervention the patient doesn’t experience no aspiration as evidenced by noiseless respirations, clear breath sounds, and clear odorless secretions.

case study cleft lip2 finale

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