Case Study Cleft Lip

7/28/2019 Case Study Cleft Lip

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Cleft L ip and Cleft Palate


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I. PERSONAL DATA


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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, 2010Place 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


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II. HISTORY

OFPRESENT ILLNESS


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II. HISTORY OF PRESENT ILLNESS

Prior to admission, the baby was born on a28 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.


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III. MEDICAL HISTORY


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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 6.2lbs, length of 58 cm and with head circumference

of 32 cm. He was diagnosed to have cleft lip and

palate.

Immunization:

Anti- Hepatitis B


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IV. FAMILY HISTORY


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IV. FAMILY HISTORY

Paternal Side

Christian Ellson

(-) Deformities of the lip and palate.

Maternal Side

Rosalyn Cruz

(-) Deformities of the lip and palate.


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V. ACTIVITIES

OFDAILY LIVING


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V. 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 doesnt

affect the way of excreting theurine 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 oralevery 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.


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VI. PHYSICAL ASSESSMENT


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PHYSICAL ASSESSMENTA. General Condition

Body Part Technique Used Normal Findings Actual Findings Analysis

Skin Inspection Ruddy Pink in color

Presence of lanugo in the

shoulders, back and arms

Ruddy Pink in color

Presence of lanugos in the

shoulders, back and arms

Normal

Hair Inspection Silky, resilient hair

Evenly distributed

Silky, resilient hair

Slight thick hair

Evenly distributed

Normal

Head Inspection

Palpation

Anterior fontanelle is soft

No caput succedaneum

Appears disproportionately

large

Forehead is large and

prominent

Anterior fontanelle is soft

No caput succedaneum

Appears

disproportionately large

Forehead is large and

prominent

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

Weight: 3050 grams Temperature: 36.6 C

Length: 50 cm HR: 133 bpm

Head Circumference: 32 cm RR: 46 cpm

B d P t T h i U d N l Fi di A t l Fi di A l i


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Ears Inspection

Palpation

Pinna recoils after folded

Outer 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 face

Presence of milia

Has nasal septum

Presence of milia

Has no nasal septum

Has 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 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 thenasal cavity (Cleft lip and

palate)

No tooth

(+) Rooting Reflex

(-) Sucking Reflex

(+)Swallowing Reflex

Cleft may cause

problems withfeeding(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 crying

Usually has milia

Appears to be receding &

quivers easily when crying

Usually has milia

Normal

Neck Inspection Short and chubby with

creased skin folds

Short and chubby with

creased skin folds

Normal



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Chest Inspection Have buds (nipples)

Appear symmetric

Without chest retraction

Clavicles are straight

The chest is as wide in theanteroposterior diameter

as it is across

With chest retraction

Have buds (nipples)

Appear symmetric

Clavicles are straight

Patient with chest

retraction may have

breathing difficulties

as a result of fatigue.

Thus, always usegentle handling.

Abdomen Inspection Contour is slightly

protuberant

Dome-shaped

Contour is slightly

protuberant

Dome-shaped

Normal

Genital Inspection Ruggated, darkened

Penis appears small

Ruggated, darkened

Penis appears small

Normal

Back Inspection

Palpation

No dimpling and pinpoint

opening in the skin

(+) Trunk Incurvation

No dimpling and pinpoint

opening in the skin

(+) Trunk Incurvation

Normal

Extremities Inspection

Palpation

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


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Birth History:

Baby boy Cruz delivered through vacuumextraction, blood type O, Rh (+) and with an AOGof 38 weeks. APGAR scoring done 1 min. afterbirth and 5 min. after shows normal.

Physical examination:

Baby boy Cruz has good cry, well flexedactivities and pinkish all over when examined. He

weighed 3050 g ( 6 lbs 12 oz), length is 50 cm andhead circumference is 32 cm. .Examination alsoshowed a normal perineum, back extremities andsucking reflex. Baby boy Cruz also has (+) cleftpalate and (+) cleft lip


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VII. DISEASE ENTITY


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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 commonin females.


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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).


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Cleft Palate (Palatoschisis)

Cleft palate is a congenital anomaly thatoccurs in approximately 1 of every 2000births, and it is more common in boys thangirls.It is a condition in which the two plates of the

skull that form the hard palate (roof of themouth) are not completely joined.

It ranges in severity from soft palate involvement

alone to a defect including the hard palate andportions of the maxilla.Cleft palate may or may not be associated with

cleft lip.


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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 difficultyfeeding and impaired speech. The baby may feed too

slowly, take in too much air while eating, or bring

milk up through the nose.


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Variation in Cleft Deformity

Incomplete

Cleft Palate

Unilateral

complete lip

and palate

Bilateral

complete lip

and palate


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NORMAL ANATOMY & PHYSIOLOGY

Lips are a visible body partat 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

othermammals. It separates

the oral cavityfrom 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
http://en.wikipedia.org/wiki/Mouthhttp://en.wikipedia.org/wiki/Mammalhttp://en.wikipedia.org/wiki/Oral_cavityhttp://en.wikipedia.org/wiki/Nasal_cavityhttp://en.wikipedia.org/wiki/Nasal_cavityhttp://en.wikipedia.org/wiki/Hard_palatehttp://en.wikipedia.org/wiki/Soft_palatehttp://en.wikipedia.org/wiki/Soft_palatehttp://en.wikipedia.org/wiki/Soft_palatehttp://en.wikipedia.org/wiki/Soft_palatehttp://en.wikipedia.org/wiki/Soft_palatehttp://en.wikipedia.org/wiki/Hard_palatehttp://en.wikipedia.org/wiki/Hard_palatehttp://en.wikipedia.org/wiki/Hard_palatehttp://en.wikipedia.org/wiki/Nasal_cavityhttp://en.wikipedia.org/wiki/Nasal_cavityhttp://en.wikipedia.org/wiki/Nasal_cavityhttp://en.wikipedia.org/wiki/Oral_cavityhttp://en.wikipedia.org/wiki/Oral_cavityhttp://en.wikipedia.org/wiki/Oral_cavityhttp://en.wikipedia.org/wiki/Mammalhttp://en.wikipedia.org/wiki/Mouth


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Cupids bow is central to the upper lip, withits peaks delineating the philtrum between the

philtral columns.The demarcation between mucosa and skin

of the lip is called the vermilion border. Themucosa or vermilion of the lip is further dividedinto dry and wet sections. The protuberantvermilion in the midline is referred to as the

tubercle. The two nostrils (nares) are separatedby the columnella externally and the septuminternally.

Below the surface, the orbicularis oris

muscle encircles the oral aperture, creating asphincter. The fibers decussate in the midlinecreating the philtrum. In the cleft lip, theorbicularis muscle inserts into the nasal alar base.


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The presence of the palate makes it possible tobreathe 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 palateand pushed to the back of the throat using the

tongue.


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The palate also functions in speaking and

singing. When sound emerges from the

chest, the sound waves that have beenproduced 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 palateoccurs in one of every 500-1000 babies.


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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 aresuspected of causing the abnormality.


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PATHOPHYSIOLOGY

During embryonic development thelateral and medial tissues forming the

upper lip palates fuse between weeks 7

and 8 of gestation; the palatal tissuesforming 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: Precipi tating F actors:


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Predisposing Factors:

Infants

Both genders than

higher in male

Etiology: incomplete fusion

of the nasomedial or

intermaxi l lary process

duri ng the 2ndmonth of

embryonic development

Precipi tating F actors:

Viral inf ection

Folic acid

deficiency

The cleft causes structur es of

the face and mouth to develop

without the normal restraints

of encir cling lip muscles

External nose Nasal septum Al veolar processes Nasal cart i lages

Usuall y just beneath

the center of one nostr i l

The more complete the

cleft l ip, the greater the

chance that teeth in the

li ne of the cleft wi ll be

missing or malformed

Bilaterally

Symmetric

Asymmetric


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Signs and Symptoms

What are the signs and symptoms of the condition?

Symptoms of cleft lip and cleft palate vary from person toperson, depending on the extent of the defect.

Cleft lip may show up only as a small notch in the border ofthe 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 tosome degree. Extra, missing, or deformed teeth may also bepart of cleft lip. Frequently, the outside of the nostril issomewhat flattened, too.

Cleft palate may involve only the uvula, or it may involve theentire roof of the mouth. The uvula is the soft, fleshy massthat hangs down from the roof of the back of the mouth.

Wh t th li ti f l ft ?


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What are the complications of clefts?

Breathing: When the palate and jaw are malformed, breathing

becomes difficult. Treatments include surgery and oralappliances.

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 alsoavailable.

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, whichis 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.


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What are the complications of clefts?

Speech and language delays: Normal development ofthe 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.


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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 onstandard nipples.

b. Hold the child in a semi upright position; directthe formula away from the cleft and toward the sideand back of the mouth to prevent aspiration.

c. Feed the infant slowly and burp frequently toprevent excessive swallowing of air and regurgitation.

d. Stimulate sucking by gently rubbing the nippleagainst the lower lip.


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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 byconveying an attitude of acceptance toward

the infant.

b. Emphasize the infants positive aspectsand express optimism regarding surgical

correction.


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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 normalsucking 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 oforthodontic appliances.

d. The responsibilities of the nurse are to: 1. Reinforce thephysicians explanation of surgical procedures.

2. Provide mouth care to prevent infection.


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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.


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TREATMENT

Surgical correction, timing varies:

Cleft Lip:

Within the first few days of life to makefeeding easier.

Delay lip repairs for 2 to 8 months to

minimize surgical and anesthesia risks, ruleout associated congenital anomalies, and

allow time for parental bonding.


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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.


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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.


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VIII. LABORATORY

EXAMINATIONS


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A .) HEMATOLOGY

DATE: July 4, 2010 PID: 20859-62

Requesting Doctor: Dr. MontalbanTEST 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:12.0-17.0

F:11.0-15.0

Hematocrit 59.08 % M:40.0-54.00

F:37.0-47.0


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TEST RESULT UNIT REERENCE

ThrombocyteNeutropil

Lympocyte

Monocyte

EosinophilBasophil

33359.3

25.9

8.5

1.44.9

10^q/L%

%

%

%%

150-45050.0- 70.0

20.0-40.0

0.0-7.0

0.00-5.0000.000-1.000

Normal Findings Result Analysis


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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 cellproduction as a compensatory

mechanism when blood oxygen

carrying capacity is compromised

to meet the demand of tissue



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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.



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Shows a normal range that fights themicroorganism.Shows a normal range that fights themicroorganism.

Eosiphil N- 1.4 Normal

Basophil H- 4.9 The result was high which

indicates that theres

infection.


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iX. Drug study

DRUG CLASSIFICATION MECHANISM OF

ACTION

INDICATION CONTRA-

INDICATION

SIDE EFFECTS NURSING

CONSIDERATION


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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.

Treatmen

t of

infectious

cause bysusceptibl

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 ordiscomfort at

sites, unusual

bleeding or

bruising,

mouth sores,

rashes, severediarrhea,

difficulty in

breathing.

Should be

taken on an

emptystomach.

(Take on an

empty

stomach 1 hr

before or 2 hr

after meals.)

DRUG CLASSIFICATION MECHANISM OFACTION

INDICATION CONTRA-INDICATION

SIDE EFFECTS NURSINGCONSIDERATION


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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

peptidesequence

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, ifindicated.

Document

DRUG CLASSIFICATION MECHANISMOF ACTION

INDICATION CONTRA-INDICATION

SIDE EFFECTS NURSINGCONSIDERATION


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Name:

Calmoseptine

(Topical)

Emollients &

Skin

Protectives

Calmosep

tine ointm

ent

promotes

woundgranulati

on and re-

epithiliali

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; moistureeg

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 & rectalitchiness;pricklyheat

Do not use

this

medicatio

n if you are

allergic tozinc,

dimethico

ne, lanolin,

cod liver

oil,

petroleum

jelly,parabens,

mineral

oil, or wax.

signs of an

allergic

reaction:

hives;

difficultybreathing;

swelling of

your face,

lips,

tongue, or

throat. Stop

using zincoxide 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 warmthor oozing skin

lesions..

Avoid getting

this

medication in

your mouth

or eye

Document.


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x. Nursing care plan

Assessment/

Cues

Nursing

Diagnosis

Etiology Planning Nursing

Intervention

Rationale Evaluation


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Cues Diagnosis Intervention

Objective:

The patient

has difficulty

suckingeffectively and

prone in nasal

regurgitation

and aspiration

because air

leaks into the

mouth from

the cleft.

Difficulty of

feeding and

nasal

regurgitationrelated to

failure of

maxillary

prominence on

the affected side

and medial

nasal

prominences tomerge.

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

deformitycaused by

abnormal facial

development

during gestation.

A cleft is a

fissure or

openinga gap.

It is the non-

fusion 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.

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 hadgreater success

of feeding in a

more upright

position.

Cues BackgroundKnowledge

NursingDiagnosis

Goal/Objectives

NursingInterventions



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Subjective:

Objective:

Inability to

inititiate/

sustain an

effective suck

Inability 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. Thiswas 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

intervent

ion the

client

will be

able to be

free from

aspiratio

n and

display

adequate

output asmeasure

by

sufficient

number

of wet

diapers

daily.

Independent:

Using the

same scale,

weight

infants at

same time

each day.

Continuous

ly assess

infants

sucking

pattern

Assess

parentsknowledge

of feeding

techniques

Assess

patients

level of

anxiety

with

regards to

infants

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 ofwet

diapers

daily.

Cues BackgroundKnowledge

NursingDiagnosis

Goal/Objectives

NursingInterventions



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g g j

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 NursingInterventions



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OBJECTIVE:

Difficult in

feeding

Malformation

of lips and roof

of the mouth

Risk for

Aspiration

(Breast Milk,

formula or

mucus) as

related toanatomic

effect.

After 1hour of

nursing

intervention the

patient will be able

to experience no

aspiration asevidenced by

noiseless

respirations, clear

breath sounds, and

clear odorless

secretions.

Independent

Position the

infant in a

football hold

to maintain

properbreathing.

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 feedingsunless

contraindicate

d,

To prevent

from possible

of episode of

choking or

aspiration

To detectaspiration or

impaired gas

exchange.

To avoid

further

aspiration.

To help

prevent

aspirations.

After 1 hour of

nursing

intervention

the patient

doesnt

experience noaspiration as

evidenced by

noiseless

respirations,

clear breath

sounds, and

clear odorless

secretions.


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Documents

Case Study Cleft Lip