NARAYAN NURSING COLLEGE
JAMUHAR, ROHTAS
CASE PRESENTATION
ON
CLEFT LIP AND CLEFT PALATE
Submitted To: Submitted By:
DR. (PROF.) SAPNA SINGH PUJA KUMARI
HOD, CHN M.SC NURSING 2NDYEAR
NNC, GNSU, JAMUHAR NNC, GNSU, JAMUHAR
Section -1
1. IDENTIFICATION DATA
NAME : BABY NIYATI
AGE : 3 MONTHS
SEX : FEMALE
BIRTH WEIGHT : 2.2 KG
DATE OF BIRTH : 20 / 7 / 2021
DEVELOPMENTAL STAGE : INFANT
DATE OF ADMISSION : 21 /4 / 21
FATHERS NAME : Mr. SATPAL SINGH
MOTHERS NAME : Mrs. SUNITA
ADDRESS : BAHADURGARH, GURGAON
NAME OF DR. INCHARGE : DR. D. S. RAO
DIAGNOSIS :
a. SURGICAL DIAGNOSIS : CHEILOPLASTY
b. MEDICAL DIAGNOSIS : CLEFT LIP AND CLEFT PALATE
2. CHIEF COMPLAINTS
Child admitted to Dental department of SGT hospital, Gurgaon on
21 /11 / 16 with complaints of :-
defect in upper lip [ since birth ]
reverse coming of food [ since birth ]
3. PRESENT MEDICAL HISTORY
The child is admitted to PICU department of SGT hospital on 21st of
November 2016 for the surgical repairing cleft lip [cheiloplasty].
At birth the child was diagnosed with malformation of lip and palate. They
went to several hospitals for treatment and then some known person advised them
about SGT hospital. So they got admitted here and undergone with cheiloplasty.
Now the child is on antibiotic and anti-pyretic course.
4. PRESENT SURGICAL HISTORY
Presently, the child is 3 month old and has undergone with the
surgery called CHEILOPLASTY done for lip repair. When the child become 1 ½ yr
old, the doctors has decided to conduct palatoplasty, a corrective surgery for palate.
5. PAST MEDICAL HISTORY
Parents found this complaint of cleft lip and cleft palate from birth itself
At 10th day of life of child, they visited Maharaja Agrasen Hospital in Delhi.
Then they were referred to SGT Hospital by some known person.
6. PAST SURGICAL HISTORY
No significant past surgical history.
7. FAMILY HISTORY
SL.NO NAME AGE SEX EDUCATION OCCUPATION RELATION HEALTH
WITH STATUS
PATIENT
1. Mr. SATPAL 35 yr M Master degree PROFESSOR FATHER HEALTHY
2. Mrs. SAVITA 25 yr F Mas.in maths LECTURES MOTHER HEALTHY
3. Baby Navita 3mon F ----------- --------- SELF PATIENT
TYPE OF FAMILY
They belong to a nuclear family.
ILLNESS HISTORY
No specific illness seen in the family
FAMILY TREE
KEY:
(GRAND- (GRAND-
FATHER) MOTHER)
: MALE
: FEMALE
UNCLE AUNTY AUNTY FATHER MOTHER AUNTY
: AFFECTED CHILD
PATIENT
8. PERSONAL HEALTH HISTORY
Diet pattern: The child takes small and frequent feed with katori and spoon as she
cannot suck the breast feed.
Sleep pattern: The child sleeps about 5hr continuously during the night time and 2- 3 times
during the day time.
Elimination pattern: The normally passes urine 6-7 times a day and stool 1-2 times a day.
9. NUTRITIONAL HISTORY
Diet / feeding pattern : The child takes small and frequent spoon feed as she cannot suck
the breast feed.
Duration /time : Every 2nd hourly she takes the feed .
Cooking method : Expressed breast milk is given to child.
10. BIRTH HISTORY
Antenatal history : Childs mother had abdominal pain during pregnancy, so doctor
advised her to take aspirin [ NSAID ] to maintain the blood supply to the fetus.
Intranatal history : It was a full term normal home delivery with no complication.
APGAR score : Not known
Postnatal new born history : The birth weight of the child was 2.2 kg and she had cleft
lip and cleft palate from the birth.
11. IMMUNIZATION:
SL.NO NAME OF VACCINE AGE OF CHILD REMARK
1. BCG At birth Mark present
2. OPV till 14 weeks Taken
3. Hep- B till 14 weeks Taken
4. DPT till 14 weeks Taken
12. SOCIO-ECONOMIC STATUS:
The child belongs to a upper-middle class family. Where her father and mother both are
on private job.
13. ENVIRONMENTAL HISTORY
She lives in a village area where hygiene is not so maintained. Nearby area is agricultural
field, so water stagnation takes place. But her mother keep the house neat and tidy.
Section -2
PHYSICAL ASSESSMENT
Anthropometric measurements:
In book In child
1. Weight 2.5- 6 kg 4.5 kg
2. Height 60 -70 cm 65 cm
3. Head circumference 43 -45cm 45 cm
4. Chest circumference 42 -45 cm 43 cm
5. Abdominal 41 - 50 cm 41 cm
circumference
6. MAC 13 -15 cm 13.5 cm
Vital signs :
In book In child
1. Respiration 30- 60/min 46 / min
2. Temperature 97 -98’F 98.2’F
3. Heart rate 90- 160 /min 144 /min
4. Blood pressure 95/ 70mmHg 110 /46mmHg
Head to toe physical assessment:
General appearance
Skin : Normal skin texture.
Color : Pink, fair complexion with no pigmentation
Hair distribution : Regular hair distribution over the body.
Skin turgidity : Normal turgor [ no dehydration ]
Head
Head circumference : 45 cm
Shape : normal symmetry [ no hydrocephalus ]
Fontanelles : Anterior fontanelle is not closed but posterior is closed.
Hair texture and distribution : Normal hair distribution.
Condition of scalp : No dandruff.
Mouth and throat
Color of lips : Pink lips
Conditions of tongue : Normal symmetry tongue
Oral thrush : No oral thrush or coating
Any drooling of saliva : no drooling of saliva
Teeth : No teeth present
Palate : cleft palate present
Gums : Affected due to cleft palate
lip : Cleft lip present
Eyes
Movements of eye balls : Normal eye movement
Any squint : no squint
Reaction to light : normal pupillary reflex
Color of sclera : sclera is white
Eyelid swelling : mild eye swelling present
Eyelashes : Normal hair distribution
Eyebrows : normal symmetry and hair distribution
Ears
Position : No low lying ears
Auricles : both auricle are parallel and have no visible problems
Pinna : cartilaginous pinna
Any discharge : no discharge from the ears
Any lesions : no lesions present
Nose
Patency : nostrils are patent and have good air entry via it
Nasal discharge : no specific discharge from nose
Nasal septum : normal symmetry and have no DNS
Nasal flaring : no nasal flaring is present
Sneezing reflex : normal
Neck
Range of motion : normal range of motion are possible
Lymph nodes : not enlarged
Skin folds : normal skin folds as fatty deposition is less
Any rigidity : No rigidity and no webbed neck
Chest
Heart rate : 144 beats/ min
Symmetry of nipples : normal symmetry and are pink in color
Expansion of chest : normal expansion during breathing
Any retraction / grunting : no retraction
Any murmur : no murmur or crackle sound
Abdomen
Shape : normal shape and size
Any distension : no specific distension is noticed
Liver : no hepatomegaly
Spleen : no splenomegaly
Bowel sound : normal bowel sound
Extremities
Upper extremities :
o Range of motion : all range of motion activity can be performed
o Polydactyl : absent
o Syndactyl : absent
o Muscle tone : good muscle tone
Lower extremities
o Range of motion : all range of motion activity are present
o Polydactyl :absent
o Syndactyl : absent
o Club foot : absent
o Creases of sole : crease are present
Back and spine
Spinal curvature : no lordosis, kyphosis or scoliosis
Mongolian spot : absent
Any absent vertebre : no
Genitalia
Labia majora : normal
Labia minora : normal skin folding
Urethral opening : normal opening and no sign of abnormality
Any discharge : no abnormal discharge .
Neurological assessment
All reflexes are :
Glabellar reflex present
Doll’s eye reflex present
Rooting reflex present
Sucking reflex absent
Swallowing reflex present
Babinski reflex present
Moro’s reflex present
14. DEVELOPMENTAL MILESTONES
MILESTONES IN BOOK IN PATIENT
Lies in flexed position
Holds hand in tight fists
Objects are carried to mouth
Attentive to speech of others
Eyes follows moving person nearby
Smiles briefly
Completely depends on caregivers
CLEFT LIP AND CLEFT PALATE
INTRODUCTION:
Having a baby born with a cleft can be upsetting, but cleft lip and cleft palate can be
corrected. In most babies, a series of surgeries can restore normal function and achieve a
more normal appearance with minimal scarring.
DEFINITION:
Cleft lip and cleft palate are openings or splits in the upper lip, the roof of the mouth (palate)
or both. Cleft lip and cleft palate result when facial structures that are developing in an
unborn baby don't close completely.
ETIOLOGY / CAUSES:
IN BOOK IN CHILD
Genetics Not known
Maternal factors like Maternal factor ( suspected )
Drug abuse Aspirin ( NSAID )
Illness
Malnutrition
Viral Infections
Anemia
Hypoproteinemia
Exposure to X- ray
PATHOPHYSIOLOGY:
In facial morphogenesis, neural crest cells migrate into the facial region, where they form the
skeletal and connective tissue and all dental tissues except the enamel. Vascular endothelium
and muscle are of mesodermal origin. [4]
The upper lip is derived from medial nasal and maxillary processes. Failure of merging
between the medial nasal and maxillary processes at 5 weeks' gestation, on one or both sides,
results in cleft lip. CL usually occurs at the junction between the central and lateral parts of
the upper lip on either side. The cleft may affect only the upper lip, or it may extend more
deeply into the maxilla and the primary palate. (Cleft of the primary palate includes CL and
cleft of the alveolus.) If the fusion of palatal shelves is impaired also, the CL is accompanied
by CP, forming the CLP abnormality.
CP is a partial or total lack of fusion of palatal shelves. It can occur in numerous ways:
Defective growth of palatal shelves
Failure of the shelves to attain a horizontal position
Lack of contact between shelves
Rupture after fusion of shelves
The secondary palate develops from the right and left palatal processes. Fusion of palatal
shelves begins at 8 weeks' gestation and continues usually until 12 weeks' gestation. One
hypothesis is that a threshold is noted beyond which delayed movement of palatal shelves
does not allow closure to take place, and this results in a CP.
CLINICAL MANIFESTATION
IN BOOK IN CHILD
A split in the lip and roof of the
mouth (palate) that can affect
one or both sides of the face
A split in the lip that can appear A split in the lip that can appear
as only a small notch in the lip or as only a small notch in the lip or
can extend from the lip through can extend from the lip through
the upper gum and palate into the the upper gum and palate into the
bottom of the nose bottom of the nose
A split in the roof of the mouth
that doesn't affect the appearance
of the face
Difficulty with feedings Difficulty with feedings
Difficulty swallowing, with Difficulty swallowing, with
potential for liquids or foods to potential for liquids or foods to
come out the nose come out the nose
Nasal speaking voice
Chronic ear infections
INVESTIGATIONS
SL.NO INVESTIGATIONS CHILD NORMAL REMARK
VALUE VALUE
1. CBC
-Hb 9.5 gm% 12-16gm%
-TLC 10,000 4000-11,000
-PLT 5. 38 1.5 -4 high
- PCV 28. 3 36 -50 Low
2. BT 2.05 1 –3
3. CT 6.05 5 -10
4. PT 13.7 11 -16
5. HBsAg Negative Negative
6. LFT
Total protein 5.7 6- 8.3 g/ dl Low
Sr. globulin 1.7 2.5- 3.5 g/ dl Low
7.
KFT
Urea 23 mg/dl 15- 45 mg/ dl
Creatinine 0.43 mg/ dl 0.6- 1.2 mg/dl Low
MEDICATION
SL.NO MEDICATION DOSE ROUTE FREQUENCY ACTION
1. INJ. Augmentin 150mg IV TDS Aminopenicillins
2. INJ. PCM 7 ml IV TDS Anti-pyretic
3. IVF. ISO. P 115ml / IV QID
6 hourly
MEDICAL AND SURGICAL MANAGEMENT
Medical management :
Assessed the general condition
Given medical treatment
Provided complete bed rest
Surgical management :
CHEILOPLASTY
NURSING MANAGEMENT
1. Ineffective Breathing Pattern related to surgical correction of defect
2. Impaired Tissue Integrity related to mechanical factors
3. Altered Nutrition: Less Than Body Requirements related to inability to ingest
nutrients
4. Risk for Infection related to location of surgical procedure.
5. Risk for Aspiration (Breast Milk, Formula, or Mucus) related to anatomic defect
6. Ineffective Family Coping related to situational crisis of birth of a child with a
defect
7. Knowledge Deficit (Parent) related to lack of exposure and unfamiliarity with
resources.
S ASSE NSG. PLAN OF IMPLEMENTATION SCINTIFIC EVALUA
L SSM DIAGN OBJECT ACTION RATIONALE TION
N ENT OSIS IVES
O
7 OBJEC Fluid To -to maintain - intake and It provides Fluid
TIVE volume correct intake and output output chart was baseline data status is
DATA- deficit watery chart strictly maintained. maintaine
Loose related diarrhea - to observe the -any signs of d
stool to baby for any signs dehydration was -It helps to
restricte of dehydration assessed maintain
d diet. - to adminster iv -iv fluid was normal fluid
fluid administered status
-to assess random -random blood -it helps to
blood sugar sugar was detect
-to restrict oral assessed hypoglycaemia
fluids -Oral fluid was -It helps to
8. Anxiety -to adminster restricted reduce
SUBJE of -to antibiotics -Antibiotics was intestinal
CTIVE mother reduce adminstered infections
DATA related anxiety Mother’s
– -mother’s
to the of -to assess anxiety is
‘I am
hospitali mother mother’s knowledge level reduced
worrie
zation of knowledge was assessed -it provides
d
about baby -to provide detail -detail baseline data
my information information -It helps to
baby’s about baby’s regarding baby improve
discha condition was explained to mother’s
rge’ -to encourage to mother knowledge
OBJEC ask question -mother was and reduce
TIVE encouraged to anxiety
DATA- ask question.
anxiou -It clarifies the
s look
mother’s
doubt
S ASSE NSG. PLAN OF IMPLEMENTATION SCINTIFIC EVALUA
L SSM DIAGNO OBJEC ACTION RATIONALE TION
N ENT SIS TIVES
O
5. Loss Imbalance To -measure the -Weight was It provides Nutritional
of d nutrition maintai weight of baby measured. baseline data status is
weigh less than n -provide maintaine
t body nutritio frequent -Frequent breast -it maintains d.
feeding was
requireme nal breast feeding nutritional
provided if the baby
nt related status or expresses demand
demands.
to breast milk
inadequat -provide naso- -Naso-gastric tube -it reduces
e gastric feeding was provided abdominal
Feeding, -provide -Additional vitamin distension
respirator additional and mineral
y distress. vitamin and supplements were
6. mineral provided.
supplements Fear is
crying To -It reduces fear of reduced
- Mother was
Fear reduce -allow the unfamiliar envt.
allowed during
related to fear mother during It improves the
performing any
painful any procedure procedure
bonding
procedure -provide skin -skin to skin contact
, to skin contact was provided as -it makes the
unfamiliar -provide much as possible baby comfortable
envirnmen soothing voice -baby was handled
t and handle the with extra care
baby with
extra care
HEALTH TALKING
Cleft lip and cleft palate are congenital disease.
It can treated in the early childhood.
It would not affect speech of the child.
Educated the parents regarding the feeding practices.
RECENT RESEARCH ON CLEFT LIP AND CLEFT PALATE
Review Article Open Access
Cleft Lip and Palate: Etiology, Epidemiology, Preventive and Intervention Strategies
Eman Allam1,2* and Cynthia Stone3
1
Department of Oral Biology, Indiana University School of Dentistry, Indianapolis, IN, USA
2
Oral and Dental Research Division, National Research Centre, Cairo, Egypt
3
Department of Health Policy and Management, School of Public Health at IUPUI,
Indianapolis, IN, USA
Abstract
Cleft lip and palate represent a major public health problem due to the possible associated
life-long morbidity, complex etiology, and the extensive multidisciplinary commitment
required for intervention. It affects about 1.5 per 1000 live births (250,000 new cases per
year) worldwide, with tremendous variations across geographic areas and ethnic groups. It is
considered a debilitating condition that is associated with significant feeding, hearing, speech,
and psychological impairments. The wide surgical, dental, speech, social, and medical
involvement emphasize the importance of understanding the underlying determinants of these
defects to allow optimizing the treatment options and predicting the long-term course of the
affected individuals development. Optimal and early surgical intervention is necessary and
folic acid supplementation proved to be a highly efficient preventive strategy. However, there
are still many challenges to be addressed for cleft care especially in the developing parts of
the world.
