Cleft lip and palate are congenital malformations that occur when facial structures don’t fuse properly during fetal development. This nursing diagnosis focuses on identifying and addressing the various challenges these conditions present, including feeding difficulties, potential developmental delays, and psychosocial concerns for patients and families.
Causes (Related to)
Cleft lip and palate can occur due to various factors affecting early fetal development:
- Genetic factors and family history
- Environmental factors during pregnancy:
- Smoking
- Alcohol consumption
- Certain medications
- Nutritional deficiencies (especially folic acid)
- Maternal health conditions during pregnancy
- Syndromes and chromosomal abnormalities
- Combination of genetic and environmental factors
Signs and Symptoms (As evidenced by)
The presentation of cleft lip and palate varies depending on the type and severity of the malformation.
Subjective: (Parent/Patient reports)
- Feeding difficulties
- Speech challenges
- Hearing problems
- Social concerns
- Self-image issues
- Family stress and anxiety
- Dental concerns
Objective: (Nurse assesses)
- Visible gap in lip and/or palate
- Nasal regurgitation during feeding
- Poor weight gain
- Otitis media
- Speech articulation problems
- Dental misalignment
- Facial asymmetry
- Compromised oral hygiene
Expected Outcomes
Successful management of cleft lip and palate includes:
- Adequate nutrition and weight gain
- Successful surgical repair
- Normal speech development
- Proper dental alignment
- Positive self-image
- Family adaptation and coping
- Prevention of complications
- Achievement of developmental milestones
Nursing Assessment
1. Physical Assessment
- Evaluate the type and extent of the cleft
- Monitor growth and development
- Assess feeding patterns
- Check vital signs
- Evaluate respiratory status
- Monitor hydration status
2. Nutritional Assessment
- Track weight gain
- Monitor feeding techniques
- Document intake and output
- Assess for signs of aspiration
- Evaluate specialized feeding equipment needs
3. Developmental Assessment
- Monitor speech development
- Track developmental milestones
- Assess hearing status
- Evaluate social interaction
- Document behavioral responses
4. Family Assessment
- Evaluate family coping mechanisms
- Assess support systems
- Document financial resources
- Monitor parent-child bonding
- Evaluate educational needs
Nursing Care Plans
Nursing Care Plan 1: Impaired Oral Mucous Membrane
Nursing Diagnosis Statement:
Impaired Oral Mucous Membrane related to an anatomical defect of cleft lip/palate as evidenced by disruption of oral tissues and difficulty maintaining oral hygiene.
Related Factors:
- Congenital malformation
- Surgical intervention
- Compromised oral hygiene
- Feeding difficulties
Nursing Interventions and Rationales:
- Assess oral cavity regularly
Rationale: Enables early detection of complications - Implement specialized oral care
Rationale: Prevents infection and promotes healing - Teach parents proper oral hygiene techniques
Rationale: Ensures continued care at home
Desired Outcomes:
- Maintain intact oral mucosa
- Demonstrate proper oral hygiene
- Show no signs of infection
- Achieve successful wound healing post-surgery
Nursing Care Plan 2: Ineffective Breathing Pattern
Nursing Diagnosis Statement:
Ineffective Breathing Pattern related to anatomical defect as evidenced by irregular breathing patterns and potential for aspiration.
Related Factors:
- Upper airway anomaly
- Feeding difficulties
- Post-surgical swelling
- Compromised airway clearance
Nursing Interventions and Rationales:
- Monitor respiratory status
Rationale: Ensures early detection of respiratory distress - Position properly during feeding
Rationale: Reduces risk of aspiration - Teach specialized feeding techniques
Rationale: Promotes safe feeding practices
Desired Outcomes:
- Maintain normal respiratory pattern
- Demonstrate effective feeding without aspiration
- Show normal oxygen saturation levels
Nursing Care Plan 3: Imbalanced Nutrition: Less Than Body Requirements
Nursing Diagnosis Statement:
Imbalanced Nutrition: Less Than Body Requirements related to feeding difficulties as evidenced by inadequate weight gain and feeding challenges.
Related Factors:
- Inability to create proper suction
- Nasal regurgitation
- Increased energy expenditure
- Feeding fatigue
Nursing Interventions and Rationales:
- Implement specialized feeding techniques
Rationale: Ensures adequate nutrition intake - Monitor weight gain
Rationale: Tracks nutritional status - Teach parents proper feeding methods
Rationale: Promotes successful feeding at home
Desired Outcomes:
- Achieve appropriate weight gain
- Demonstrate effective feeding techniques
- Maintain adequate hydration
- Show normal growth patterns
Nursing Care Plan 4: Risk for Delayed Development
Nursing Diagnosis Statement:
Risk for Delayed Development related to physical and social challenges as evidenced by potential speech delays and social interaction difficulties.
Related Factors:
- Speech impairment
- Hearing problems
- Social stigma
- Multiple surgical interventions
Nursing Interventions and Rationales:
- Monitor developmental milestones
Rationale: Enables early intervention - Facilitate early intervention services
Rationale: Promotes optimal development - Support family coping strategies
Rationale: Enhances family adaptation
Desired Outcomes:
- Achieve age-appropriate milestones
- Develop effective communication skills
- Demonstrate social engagement
- Show positive self-image development
Nursing Care Plan 5: Interrupted Family Processes
Nursing Diagnosis Statement:
Interrupted Family Processes related to chronic health condition as evidenced by expressed anxiety and stress regarding care management.
Related Factors:
- Complex care requirements
- Financial burden
- Emotional stress
- Social concerns
Nursing Interventions and Rationales:
- Provide family education
Rationale: Increases confidence in care delivery - Connect with support resources
Rationale: Enhances coping mechanisms - Facilitate care coordination
Rationale: Ensures comprehensive care management
Desired Outcomes:
- Demonstrate effective coping strategies
- Access appropriate support resources
- Show positive family adaptation
- Maintain family unity and support
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Parameters For Evaluation and Treatment of Patients With Cleft Lip/Palate or Other Craniofacial Differences. Cleft Palate Craniofac J. 2018 Jan;55(1):137-156. doi: 10.1177/1055665617739564. PMID: 34162066.
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- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
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