Cleft Palate Repair

 Definiton

Cleft palate repair – is surgical repair of congentinal defects in the palate

Causes of defects

1. Lack of embryonic development elements of the prepalate (face, lips, premaxilla and incisors)
2. Palate (hard or soft palate, uvula and additional maxillary teeth

• Nursing or feeding defects
• Speech defects
• Respiratory defects

Time of surgery preferred:

• Before the 2 years old

Procedure

• General anesthesia induction.
• Insertion of endotracheal tube
• Local anesthesia with epinephrine is injected to prevent homeostasis
• Repair of a complete unilateral (prepalatal and palatal) defect incisions are made of the soft palate
• Development of layers of oral mucosa, muscle and nasal mucosa
• Suture replacement are placed on the hard palate
• Optimal bone grafts are done
• Two layers are sutured muscle layers and oral mucosa

Nursing Considerations in preparing the patient

• The patient must be restrained properly since the table may be in reverse Trendelenburg position
• Keep the patient’s temperature well regulated since the patient’s body surface area is small
• Assist the surgeon in extending the head of the bed during the procedure
• Always observe aseptic technique during the surgery
• Minimize skin exposure as much as possible during the surgery

Nursing Considerations after the procedure

• Place comfortably the patient on his or her sides
• Use restraints on elbow level to prevent ample movement of the child
• Hydrate the child using cups instead of bottles, as well as to clean suture lines
• Support proper positioning by holding the child while feeding sessions to prevent aspiration.

 

Nursing Care Plan

Assessment Health perception and management Maternal exposure to radiation or infection Family member or relative with cleft lip or cleft palate Nutrition and metabolism Poor feeding Difficulty sucking Physical findings General appearance and nutrition  Visible unilateral or bilateral cleft lip Underweight Eyes, ears, nose, and throat Nasal distortion Gastrointestinal Visible cleft palate involving soft or hard palate with opening between the mouth and the nasal cavity Impaired sucking (with cleft lip and cleft palate)

Nursing Diagnosis

Imbalanced nutrition: Less than body requirements related to inability to ingest food because of difficulty sucking

Expected outcome

• The neonate will exhibit adequate nutritional status to maintain growth and healing.

Suggested NOC Outcomes

• Breastfeeding establishment: Infant; Nutritional status; Swallowing status: Oral phase

Nursing interventions

Independent

• Assess nutritional status and needs, including: sucking or swallowing ability, daily caloric and fluid intake, daily weight gain or loss.
  • Rationale:  The infant’s appetite isn’t affected by the defect, but the ability to suck properly is impaired, so intake may be reduced. The infant may be unable to form an adequate seal for sucking. Documented daily intake helps determine whether the infant is meeting nutritional needs or whether the feeding method needs to be changed, possibly to gastric gavage. Monitoring weight daily evaluates the success of the feeding pattern and reveals the optimal weight gain desired or the need for a change in feeding method to minimize weight loss.
• Based on assessment, calculate the minimum number of calories per kilogram per day and the number of milliliters per kilogram per day of feeding needed.
  • Rationale: This indicates the infant’s nutritional requirements.

To help the breast-feeding mother, teach her to: (An infant with a cleft palate may not be able to breast‑feed. An infant with a cleft lip may be able to breast‑feed if the cleft doesn’t affect sucking.)

• massage her breasts and nipples before nursing.
  • Rationale: Massaging breasts and nipples brings milk near the surface for ease in sucking and hardens breasts, helping the infant to hold the nipple in his mouth.
• apply pressure to the areola with her fingers, guide the nipple to side of the infant’s mouth, and hold it there during feeding.
  • Rationale: Holding the nipple in the infant’s mouth allows the infant to nurse with its gums rather than by sucking, if sucking is difficult.
• allow extra feeding time.
  • Rationale :  Feeding may take up to 1½ hours.
• burp the infant frequently during feeding.
  • Rationale: The infant swallows more air during feedings.
• hold the infant in an upright or a sitting position while feeding.
  • Rationale: Holding the infant in an upright or a sitting position enhances swallowing and prevents milk from coming through the defect and out of the nose, thus decreasing the risk of aspiration.
• An alternative is for the mother to pump her breasts and feed the infant with a bottle.
  • Rationale: Pumping breast milk satisfies the mother’s desire to breast‑feed and provides an excellent source of nourishment.

To help the bottle-feeding mother, teach her to: ( Safe bottle‑feeding maintains the infant’s nutritional status.)

• hold the infant in an upright or a near‑sitting position during feeding.
  • Rationale: Holding the infant in an upright or a near‑sitting position reduces the risk of aspiration and of swallowing air.
• select an appropriate nipple.
  • Rationale: The mother may have to experiment to find the nipple or device that’s most suitable for the infant, depending on the defect.
• place the nipple at the side or back of the infant’s tongue.
  • Rationale: Placing the nipple at the side or back of the infant’s tongue avoids the cleft and enhances swallowing.
• thicken milk with small amount of cereal.
  • Rationale: Thicker milk allows for easier swallowing because of increased gravity flow.
• feed the infant small amounts slowly, and burp the infant after each 10 to 15 ml of milk.
  • Rationale: Feeding slowly and burping regularly prevent regurgitation or vomiting by expelling the air the infant swallows during feeding.
• refrain from removing the nipple from the infant’s mouth unless necessary.
  • Rationale: Removing the nipple may cause the infant to cry, making feeding more difficult.
• give the infant some water after feeding.
  • Rationale: Water rinses milk away from the mouth and defect.
• gently wipe milk away from the infant’s face and nose with a damp cloth and pat dry.
  • Rationale: Wiping removes milk that may have entered and drained from the nose.