Which nursing intervention would the nurse provide for an infant with an unrepaired cleft lip

A cleft lip and palate is a defect caused by the failure of the soft and bony tissue to fuse in utero. These may occur singly or together and often occur with other congenital anomalies such as spina bifida, hydrocephalus, or cardiac defects.

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1. Ineffective Airway Clearance
Ineffective Airway Clearance
1. Ineffective Airway Clearance
Recommended Resources
References and Sources
Which nursing intervention is indicated for an infant born with a cleft lip?
Which feeding practices should be used for the infant with a cleft lip or palate quizlet?
How you will take care of an infant following a cleft lip repair?
What is the priority nursing goal of care for a neonate with cleft lip and palate?

In infants diagnosed with cleft lip, the fusion fails to occur in varying degrees, causing this disorder to range from a small notch in the upper lip to total separation of the lip and facial structures up into the floor of the nose, with even the upper teeth and gingiva absent. Cleft lip deformities can occur unilaterally, bilaterally, or rarely in the midline.

A cleft palate is an opening of the palate and occurs when the palatal process does not close as usual at approximately weeks 9 to 12 of intrauterine life. The incomplete closure is usually on the midline and may involve the anterior hard palate, the posterior soft palate, or both. It may occur as a separate anomaly or in conjunction with a cleft lip.

Treatment consists of surgical repair, usually of the lip between 6 to 10 weeks of age, followed by the palate between 12 to 18 months of age. The surgical procedures depend on the child’s condition and physician preference. Management involves a multidisciplinary approach that includes the surgeon, pediatrician, nurse, orthodontist, prosthodontist, otolaryngologist, and speech therapist.

Nursing goals for clients diagnosed with cleft lip and palate include maintaining adequate nutrition, increasing family coping, reducing the parents’ anxiety and guilt regarding the newborn‘s physical defects, and preparing parents for the future repair of the cleft lip and palate.

Here are seven (7) nursing diagnoses and nursing care plans (NCP) for cleft lip and cleft palate:

Ineffective Airway Clearance
Imbalanced Nutrition: Less than Body Requirements
Anxiety
Deficient Knowledge
Compromised Family Coping
Risk for Injury
Risk for (Ear) Infection

1. Ineffective Airway Clearance

Ineffective Airway Clearance

Infants diagnosed with a cleft palate cannot suck effectively either because pressing their tongue or a nipple against the roof of their mouth forces milk into their pharynx, possibly leading to aspiration. Additionally, because of the local edema that occurs after a cleft lip or palate surgery, it’s important to observe children closely in the immediate postoperative period for respiratory distress. After surgery, the infant has to learn to breathe through the nose, possibly adding to the respiratory difficulty.

Nursing Diagnosis

Ineffective Airway Clearance

Tracheobronchial aspiration of feedings
The trauma of oral surgery

Possibly evidenced by

Abnormal breath sounds
Cyanosis
Dyspnea
Postoperative edema
Productive/non-productive cough
Respiratory rate and depth changes
Tachypnea

Desired Outcomes

The infant will maintain a clear airway as evidenced by clear breath sounds and the absence of cyanosis.
The infant will display a respiratory rate of 20 to 30 breaths per minute, absence of retractions, and respiratory distress.

Nursing Assessment and Rationales

1. Assess the newborn’s respiratory rate, depth, and effort.
Aspiration of secretions or milk may cause tachypnea. Newborns are obligate nose breathers and show signs of distress if their nostrils become obstructed. The newborn’s respiratory rate can be observed most easily by watching the newborn’s abdomen because breathing primarily involves using the diaphragm and abdominal muscles.

2. Assess skin color and capillary refill.
Bluish discoloration of the skin or prolonged capillary filling happens because of the decreased oxygenation produced by the defect. The nurse should note, however, that the peripheral circulation of a newborn remains sluggish for at least the first 24 hours, which can cause cyanosis in the infant’s feet and hands (acrocyanosis).

3. Assess for abdominal distention.
The infant may swallow excess air during bottle feeding, causing abdominal distention that may result in upward pressure on the diaphragm and lungs, compromising respiration. To facilitate palpation (if not contraindicated), the knees and legs should be flexed toward the hips, which allows the abdominal muscles to relax.

Nursing Interventions and Rationales

1. Place the infant in an infant seat at 30° to 45°.
This position prevents the infant’s tongue from falling back and obstructing the airway. If possible, the infant can be placed in an infant bouncy seat. The semi-upright position facilitates burping, limits regurgitation of fluids, and prevents milk from entering the Eustachian tube and middle ear space, thus minimizing ear infections (Burca et al., 2016).

2. Position the infant in an upright position greater than 60° during feeding and elevate the head of the crib to 30° after.
General recommendations for body mechanics in infants with cleft lip or palate while feeding include the following: head support for neutral alignment of head and neck; arms forward, trunk midline, hips flexed; and lip, cheek, and jaw stabilization to provide a platform for sucking movements. Infants with cleft palate are fed in an upright position greater than 60° to allow gravity to facilitate fluid transfer and decrease the tendency for nasopharyngeal reflux (Burca et al., 2016).

3. Allow the infant time to swallow during feedings and provide oral care as appropriate.
Placing a small amount of breast milk or formula into the infant’s mouth and allowing time for swallowing will prevent aspiration. Offering small amounts of sterile water will cleanse the mouth after feeding. Formula or drainage is gently cleaned from the suture line with saline solution.

4. Provide oral and nasal suctioning as needed.
The purpose of suctioning is to maintain a patent airway and improve oxygenation by removing excess fluids and secretions in the oral and nasal cavities. Following either cleft lip or cleft palate surgery, infants may need their mouth suctioned to remove mucus, blood, and unswallowed saliva. When doing this, be exceedingly gentle, so you don’t touch the suture line with the catheter. Place the infant on their side to allow mouth secretions to drain forward.

5. Feed the infant slowly and burp frequently.
Burping frequently during feeding will reduce spitting up and prevent excessive swallowing of air. Holding the infant during feedings, burping frequently, and placing the infant in an infant seat after feeding or on the right side propped with a rolled blanket will aid in a positive outcome for this infant.

6. Position the infant appropriately after surgery.
Following a cleft lip repair, be sure the infant does not turn onto their abdomen because this could put pressure on the suture line, possibly tearing it. Careful positioning ensures the prevention of injury to the operative site.

7. Provide special nipples or feeding devices such as pigeon feeders with a one-way valve.
Feeding may work better using special bottles or nipples with a wider base. A syringe with a rubber tip, a long nipple with a large hole attached to a squeeze bottle, or a medicine dropper can be used to feed the infant formula or breast milk before and after surgery because sucking motions must be avoided to keep from applying tension on the suture line.

8. Coordinate with other health care teams for the holistic care and management of the infant.
Treatment of the infant diagnosed with cleft lip and palate requires multidisciplinary teamwork with a surgeon, pediatrician, pediatric dentist, orthodontist, nurse, psychologist, speech therapist, and social worker. The public health nurse should be responsible for coordinating parental counseling and referral as needed.

1. Ineffective Airway Clearance

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

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.

Reviewed and updated by M. Belleza, R.N.

Which nursing intervention is indicated for an infant born with a cleft lip?

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.

Which feeding practices should be used for the infant with a cleft lip or palate quizlet?

Most babies born with a cleft lip (and no cleft palate) feed well without any special equipment. They usually can breastfeed or use a regular bottle-feeding system. The only change needed might be positioning the nipple so the baby can latch.

How you will take care of an infant following a cleft lip repair?

For a short while after surgery, your child may not eat as well as before surgery..

Give soft, pureed or mashed foods for 3 weeks. ... .

Do not give foods that have chunks, lumps or pieces, such as seeds, grains, pulp or skin..

Do not give hard, crunchy foods such as cold cereal, cookies, crackers or chips..

What is the priority nursing goal of care for a neonate with cleft lip and palate?

Nursing goals for clients diagnosed with cleft lip and palate include maintaining adequate nutrition, increasing family coping, reducing the parents' anxiety and guilt regarding the newborn's physical defects, and preparing parents for the future repair of the cleft lip and palate.