The most common facial malformations, cleft lip and cleft palate, occur either alone or in combination. Show
What is Cleft Lip and Cleft Palate?Although a cleft lip and a cleft palate often appear together, either defect may appear alone.
PathophysiologyIn embryonic development, the palate closes later than the lip, and the failure to close occurs for different reasons.
Statistics and IncidencesParents and family are naturally eager to see and hold their newborn and must be prepared for the shock of seeing the facial disfigurement.
CausesThe incidence of cleft palate is higher in the close relatives of people with the defect than it is in the general population, and some evidence indicates that environmental and hereditary factors play a part in this defect.
Clinical ManifestationsUsually, a split (cleft) in the lip or palate is immediately identifiable at birth. Child with cleft lip and palate. Image via: Wikipedia.com
Assessment and Diagnostic FindingsThe physical appearance of the newborn confirms the diagnosis of cleft lip; diagnosis of cleft palate is made at birth.
Medical ManagementTreatment for a newborn with cleft lip and palate includes: Cleft lip repair
Nursing ManagementA complete and thorough process of care should be undergone by the newborn with cleft lip and cleft palate. Nursing AssessmentOne primary concern in the nursing care of the newborn with a cleft lip and cleft palate is the emotional care of the newborn’s family.
Nursing DiagnosesBased on the assessment data, the major nursing diagnoses are:
Nursing Care Planning and GoalsGoal setting and planning must be modified to adapt to the surgical plans; the major goals include:
Nursing InterventionsNursing interventions for the patient with cleft lip and palate are:
EvaluationMajor goals for the care of the infant with cleft lip and cleft palate include:
Documentation GuidelinesDocumentation for a patient with cleft lip and palate include the following:
Practice Quiz: Cleft Lip and Cleft PalateHere are some practice questions for this study guide. Please visit our nursing test bank page for more NCLEX practice questions. 1. When assessing a child with a cleft palate, the nurse is aware that the child is at risk for more frequent episodes of otitis media due to which of the following? A. Lowered resistance from malnutrition. 1. Answer: B. Ineffective functioning of the Eustachian tubes.
2. While assessing a newborn with cleft lip, the nurse would be alert that which of the following will most likely be compromised? A. Sucking ability. 2. Answer: A. Sucking ability.
3. When providing postoperative care for the child with a cleft palate, the nurse should position the child in which of the following positions? A. Supine. 3. Answer: B. Prone.
4. An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child with a cleft palate repair are: A. Elbow restraints. 4. Answer: A. Elbow restraints.
5. A home care nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement if made by the mother indicates a need for further instructions? A. “I will use a nipple with a small hole to prevent choking.” 5. Answer: B. “I will stimulate sucking by rubbing the nipple on the lower lip.”
For which amount of time would the nurse advise a parent to keep pumped breastmilk in the refrigerator?After 4 days of refrigeration, your breast milk should be used or thrown away. Breast milk has properties that slow the growth of bad bacteria. These properties begin to decline after a few days of refrigeration. If you think you won't use breast milk within a few days, the sooner you freeze it, the better.
Which instructions should the nurse include when teaching a mother about the storage of breast milk quizlet?Which nursing information is appropriate to include when discussing the storage of breast milk with a client? "Discard unused milk after a feeding within 2 hours."
What is the time limit for breast milk?Freshly expressed or pumped milk can be stored: At room temperature (77°F or colder) for up to 4 hours. In the refrigerator for up to 4 days. In the freezer for about 6 months is best; up to 12 months is acceptable.
Which instructions should the nurse include when teaching a mother about the storage of breast milk?Which instructions should the nurse include when teaching a mother about the storage of breast milk? 1. Store milk in 8 to 12 oz containers. 2.. Eat seaweed soup and rice.. Give both expressed milk and infant formula.. Restrict breastfeeding for some time after birth.. Rub a piece of soft date on the newborn's palate.. |