CASE STUDY

ON
CLEFT LIP

Submitted To Submitted By
Madam Papiya Saha Sudipta Halder
Faculty M.Sc. Nursing(Part-I)
CON, NRS Medical College & Hospital CON, NRS Medical College &Hospital
Identification :
Name of the baby : Master Yakub Sk
Sex : male
Age : 2 month
Religion : muslim
Address : doluipur, kaligaj, sapjola nadia
Ward : CB building 6th floor
unit : III
Registration no. : Rg11086701
Ratient serial no. : pa110007265
Hospital : N.R.S medical college and hospital, kolkata
Date of admission : 10th february, 2023
Time of admission : 16.19 hrs.
Provisional diagnosis : cleft lip and cleft palate
Uder doctor : Prof. D. Ghosh
Name of operation : Chelioplasty
Date of operation : 12th february 2023

Present Complaints :
Complaints during admission : Baby is admitted with cleft lip and cleft palate for surgery.

History of present illness :

Child is admitted N.R.S medical college and hospital, kolkata for operation
History of Past illness :
Child do not have any other medical problems in the past.
Congenital Problems : Child is born with cleft lip

Diagnosis :
Provisional : Cleft lip
Confirm : Cleft lip
Antenatal history
1st trimester
 Maternal age:- 25 years
 Years since marriage:- 2 years
  IFA taken or not :- taken
 Total No of ANC:- 3 times
 1st trimester USG:- USG done on 25/11/2022 Report:- single Live fetus , gestational age :-
13 weeks
 Hyperemesis:- vomiting occur only morning
 Any fever or rash:- nil
 H/o drug intake:- nil
 Blood group:- B+ve

2nd trimester
 TT doses:- taken
 When was quickening felt:- 5 months
 HTN/ GDM :- nil
3rd trimester
 APH:- nil
 Any drug intake:- nil
 Weight gain during pregnancy:- 12kg, pre pregnant weight :- 49, last trimester weight :- 6kg
 Foetal movement:- present
Family history
 Any hereditary or major illness:- nil
 Recurrent blood transfusion:- nil
 Developmental problem:- nil

Dietary Pattern :
Child was on breast feeding, but child could not suck properly that is why supplementary feeding
was given by spoon and katori
Immunization Status :
Name of vaccine Taken time Baby status
BCG , OPV,Hep-B at birth taken
Pentavalent,rota1,PCV1, at 6 weeks taken
IPV1, OPV1
Penta2, OPV2,Rota2 at 10 weeks taken
OPV3,Penta3,Rota3, At 14 weeks due
IPV2,PCV2

Play habits : Baby is sometimes playing with mobile object and sometimes with his own.
Sleep pattern : Baby sleeps 10 hours at night time and 8 hours at day time.
Socio Economic Status of the family :
Occupation of the father : Farmer
Occupation of the mother : House wife
Monthly income : 3000/-
Number of family members : 6
Total number of children : 2
Type of house : Kachha
Ventilation : Adequate
Light : Kerosine with Hurricane
Water supply : Tube well

Physical Examination
Gross motor – Weak
Fine motor – Not developed
Psychosocial : Not developed
Speech and Language – Not developed

Vital signs
 Temperature : 98.60F
 Pulse : 118 beats/mt
 Respiration : 38 beats/mt
 Blood pressure : 90/60 mm. of Hg

Nervous system :
Level of consciousness : Alert
Head size : 38 cm
Head shape : Normal
Neck : No gland is enlarged
Sensation : Is present
Knee reflex : Normal
Plantar reflex : Normal
Blinking reflex : Normal

Range of motion :
Flexion : Normal
Extension : Normal
Rotation : Normal
Abduction : Normal
Any limitation in movement : No

Integumentary System :
Colour of thee skin : Pink
Texture : Good & Normal
Skin temperature : 9.60 F
Any lesion : No
Edema : Not present
Colour of hair : Black and healthy
Any infection of : No
the skin
Nail : No cynosis is present
Icteric sclera : No
Scalp : Normal
Nose : Bifurcates nose

Cardiovascular System :
Heart sound :
S1 : Normal
S2 : Normal
Heart rate : 116 beats/mt

Respiratory System :
Respiratory rate : 38 beaths/mt
Respiratory Pattern : Normal
Bilateral airflow : Present
Breath sound : Normal
Any abnormal sound : Normal

Musculo-skeletal system :
Body posture : Normal
Body built : Normal
Height : 50 cm
Weight : 4.2 kg

Gastro –intestinal System :

Lip : cleft lip
Teeth : Not erupted
Palate : normal
Gum : Upper gum cleft, lower jaw normal.
Tongue : Normal, clean.
Bowel sound : Normal
Liver and Spleen : Not palpable

Genitourinary System :
Voiding : voids freely
Epispadius : No
Hypaspadias : No

Excretory System :
Bowel habit : Normal
Bladder : Normal
Urine color : Normal

Reflexes :
Sucking reflex : Weak
Moros reflex : Normal
Rooting reflex : Present
Babinski reflex : Present
Glabellar reflex : Weak
Grasping reflex : Weak
Dancing reflex : Absent
Grasping reflex :
- Palmer : Present
- Planter : Absent

Growth and devolopment assessment

Book picture Patient picture

Physical devolopment
-Posterior frontanel closes at 6-8 weeks
-Tears start appear Tears seen when crying
Motor devolopment Can hold a rattle
-Holds a rattle when placed in hand
-Less fixed prone position

Language Can laugh looking at her mother

-Laughs and squale
-Different cry in different situation

Social devolopment
-Smiles to mother/caregiver
-Knows that cry will bring attention

Sensory devolopment
-Turns head side when sound is made Can turn head to one side
-Visual acquity is hyperoptic
Cleft lip : A cleft lip results from failure of fusion of maxillary process with nose elevation on frontal
prominence.The extent of defect varies from a notch in the lip to a large clet reaching the floor of
nose .Cleft lip can occur on oneside or may be on both side .

Related anatomy and physiology:

The mouth or oral cavity is bounded by muscles and bones :
 Anteriorly : By the lips
 Posterorly : It is continuous with the oropharynx
 Laterally : By the muscles of chells.
 Superiorly : By the bony hard palate and muscular
soft palate.
 Inferiorly : By the muscular tongue and the soft tissues
of the floor of the mouth.

The oral cavity is lined throughout with mucous membrane, consisting of stratified
squamous epithelium which is containing small mucus – secreting glands.
The part of the mouth between the gums and the cheeks is the mouth proper. The mucous
membrane living of the cheeks and the lips is reflected on the gums.
The palate forms the roof of the mouth and is divided into the anterior hard palate and
posterior soft palate. The bones forming the hard palate are the maxilla ad the palatine bones.
The uvula is a curved fold of muscle’s covered with mucous membrane, having down from
the midline of the free border of the soft palate.
Pathophysiology :
Cleft deformities represent a genetic defect in cell migration that results in a failure of the
maxillary and premaxillary processes to come together between the third and twelve week of
embryonic development. Although often appearing together, cleft lip and cleft palate are distinct
malformations embryologically, occurring at different times during the developmental process.
Merging of the upper lip at the midline is completed between the 7 th and 11th weeks of gestation.
Fusion of the secondary palate (hard and soft palate) takes place later, between the seventh and
twelve weeks of gestation. In the process of migrating to a horizontal position, the palates are
separated by the tongue for a short time. If there is delay in this movement, or if the tongue fails to
descend soon, enough, the remainder of development proceeds but the palate never fuses.
Etiology :
The incidence of cleft lip or palate is 1.5 in 1,000 births. The incidence is highest in Asians,
followed by conscious and is lowest in Africans and Americans. Cleft of lip and with or without
palate is common in male and however the clefts of palate is most common in female.

According to Book According to My Patient

The cause of cleft lip and cleft palate may be Partially genetically as one of the person
genetic or due to unfavourable maternal from the patient’s fraternal side was having
factors. Maternal may be viral infectious congenital anomaly but now she is no use.
during 5th to 12th weeks of gestation, intake of
excessive alcohol, drug exposure to
phenytoin (dilanties) or diazepam (valium)
and dietary factors such as folic acid and
vitamins.
1. Genetic : It has been estimated that
the chances of a child having a cleft
palate is two percent when one of the
parents has a cleft plate. Child's mother had a history of hyperpyrexia
2. Unfavourable Maternal Factors : (PUO) associated with vomiting and loose
The include illness, especially viral motion. And which subdivided without any
infectious, during 5th week of medications.
gestation. Also exposure of x-rays,
anemia and hypooprotenemia.

Types of Cleft Lip & Cleft Palate :

Several classification are present. The Indian classification depicts the following types :
 Group – I (Prealveolar) : It includes only cleft lip in right or left side or bilateral and rarely
in midline. It can have subtypes i.e. group – I – A, which indicates cleft lip and alveolus and
group O – B – indicating sule surface cleft visible with smiling.
 Group – II ( Postalveolar) – It includes only cleft palate. Sub mucous cleft may found as
fistula or liquid uvula.
 Group – III (Combined) : It is includes both cleft lip and palate in midline or may be
unilateral or bilateral.
 Combined types are found more frequently (50%) then the isolated cleft lip (25%) and cleft
palate (25%).

Clinical Manifestation :
According to the Book According to the Patient
1. Physical appearance of cleft lip Both cleft lip and cleft palate is present in left
apparent at birth with incomplete side, along with mild extension towards the
formation of lip. nostril.
2. Cleft palate is found as an opening in
roof of the mouth during neonateal
examination.
3. Cleft lip can occur as either unilateral
(only on one side) or bilateral (Both
sides) and can vary from a slight
notch in the red portion of the lip to a
complete separation extending into
the nostril. Cleft plate can occur in
the hand bony plate or is the soft
palate, with or without a cleft lip
being present.

Diagnostic Evaluation :
According to the Book According to the Patient
Cleft lip with or without cleft palate is Hematology (27.01.2022)
apparent at birth. Even a small cleft of a - Bleeding time – 1 min 40 sec
palate can be detected by visual inspection - Clotting time – 6 min 10 sec
and palpation. When cleft palate is not
diagnosed at birth formula coming out of the Serology (27.01.2022)
nose, may be the first identification. Both HIV I – Non Reactive
defects can be diagnosed is utero by HIV II Non Reactive
ultrasound, if present. Hematology (27.01.2022)
Hb – 13.5 gm.dl
At lines CT Scan of the Brain WBC – 26,100%cum
 According to the Book According to the Patient
DC – Neutrophil – 64%
Esonophil – 02%
Basophil – 00%
Lymphocyte – 32%
Monocytes – 02%
ESR – 45 mm 1st hr reading
RBC – Normocytic and Normo-morpholoty
choromonic.
WBC – Shows toxic leucocytosis with toxic
granules present in neutrophils.
Platelets – Adequate
BIOCHEMISTRY (27.01.2022)
Sugar (R ) - 70 mg/dl
Urea - 51 mg/dl
Creatinine – 0.5 mg/dl
RADIOLOGY (27.01.2022)
Skull – Bulging outline of skull in Lt. parietal
area with bone deficit congenital anomaly of
cleft lip & palate seen.
CT SCAN ([ARANASAL SINUS)
(30.01.2022)
IMPESSION :
C T features are suggestive of mid cleft lip
and palate suggestive clinical correlation
there is mide cleft lip and palate, DNS to left
noted. The lower jaw is normal.

Treatment :
The treatment of cleft lip ad palate is complex and it involves many specialties, including a
plastic surgeon, nurse, opech pathologist and audiologist. Reconstruction begins in infancy and can
continue till adulthood. …….. of lip is usually performed when the infant is approximately 3
months of age.
 Cleft of hard palate are surgically closed at approximately 1 years of age to assist feeding
and to promote speech and language development.

Management :
The management consists of three spheres –
1. Medical Management
2. Surgical Management
3. Nursing Management

1. Medical Management
According to the Book According to My Patient
There is as such no medical management Feeding technique was advised to modify.
prior to surgery. However;
a) Reassurance to parents. Baby fed by spoon and kattori.
b) Feeding : Mother should be
encouraged to breast feed their babies
ad wherever there are feeding
problem expensed breast ilk can be
given.
c) Infections : Infections specially of
the middle can are common us these
children and is left untreated may lead
to deafness.

Complications :
According to the Book According to my patient
Immediate Problems :  No such complication has occurred fill
1. Feeding problem due to ineffective now.
seeking resulting is under nutrition.
2. Aspiration of feeds resulting
respiratory infection.
3. Parental anxiety due to defective
 According to the Book According to my patient
appearance of the infant.

Long-term Problems :
1. Recurrent infections especially in
otitis media.
2. Disturbed parent-child relationship
and maladjustment with won
acceptance to the infant.
3. Impairment of speech.
4. Malplacement of teeth.
5. Hearing problem due to oral
malformation specially in cleft palate.
6. Impaired body image due to image
due to altered shape of face and oral
cavity.

Prognosis :
Residual speech defect may result even after successful repair of palate which require help
from speech therapist. Cosmetic problem of scar as the lip may need cosmetic surgery and
counseling.

2. Surgical Management :
In Cleft Lip : Surgical repair of the defect of the lip is done, pureferably at 2-3 months of age,
when the infant is having good health (At 10 weeks age). The operation is termed as chelioplasty.
In My Patient surgery is still not performed

Pre Operative Care :

a) Training : The consensus of opinion among the plastic surgeons of India with regard to the
living of operation. They follow the “RULE OF TEN”
1. 10 weeks
2. Weight – 10 Ib In case of cleft lip
3. Haemoglobin – 10% gms
Post Operative Care :
Immediate care after surgical repair of the defect should include close observation and
monitoring of the vital signs, bleeding from site of operation, oral secretions, monitoring and
crying.
Special care to be given to prevent injury of the suture live. For repair of lip and he sine or
band aid to be paced on the suture line to prevent labial lesion on the repaired lip. Cogan blow was
used previously. Mummy nestaint and hand nestraine to be given.
a) Patient to be placed on back in repair in cleft lip and on abdomen in prove position.
b) Oral feeding to be allowed slowly with precautious, starting with clean liquids to full
liquid and then to soft food (according to age). Nutrition and hydration to be
maintained.
c) Nasogastric tube feeding may be necessary in some children.
d) Cleaning of suture line after each feed with normal saline orH 2 O2 or sterile mates or
antiseptic month wash to be done.
e) Antibiotic ointment can be applied on suture line in case of lip repair.
f) Do not allow finger or straw inside mouth.
g) Avoid sucking or talking loudly in repair of palate.
h) Play and diversion therapy to be allowed.

Nursing Management :
Nursing management include achievement of short term goals. Immediates goal –
1. Assisting the parents in their adjustment to the malformation.
2. Provision of adequate nutrition and prevention of aspiration
3. Prevention of infection
4. Parent education.

1. Parental Adjustment :
The most important way in which the nurse can help is through complete
acceptance of the infant and the deformity. The nurse’s attitude toward their infant
encourages parent to accept the child. These pictures may believe parents some
 of their anxiety about the eventual appearance of their own child. The
surgeon’s early discussion with the patients concerning therapy can also help them in their
adjustment.
2. Provision of adequate nutrition and prevention of aspiration :
 Feeding is given with long handle spoon or with dropper or with soft large hole
nipple.
 Allow small quality feed slowly.
 Avoid chaking and place the baby in upright position
 Burp the body in between feed.

3. Parent Education :
 If the infant rubs or otherwise irritates the tissue around the cleft lip or palate, the arms
can be gently restrained
 The fissure area are kept dean and water may be given with feeding to rinse the mouth.
 Explain the parent about the time of surgical correction. Head about the home care an
diet. Cleanness, immunize and follow up.
FEEDING TECHNIQUE : ESSR technique is enlarge, stimulate, swallow and rest feeding
techniques also works well with these infants the steps in ESSR are -
i) Enlarge the nipple
j) Stimulate the suck reflex
k) Swallow fluid appropriately
l) Rest when the infant signals with faced expression.

4. Post operative Care :

 Close observation and monitoring for vital signs, bleeding from site of operation and
secretions. Vomiting and crying
 The infant should be placed within the mummy restraint or hand restraint to prevent
injury of the suture time.
 The child should be placed on back in repair of cleft lip and on abdomen in prone
position for repair of cleft palate.
 Oral feeding to be allowed slowly with precautions. Starting with clear liquid to full
liquid and then to soft food.
 Nutrition and hydration to be maintained.
  Mouth care and cleaning of suture line after each feed with normal saline or H 2O2 or
sterile water or antiseptic mouth wash to be given.
 Antibiotics, and gases and other peroxide medication are to be given with precaution
 Do not allow finger, straw inside the mouth
 Avoid sucking and talking loudly in repair of palate.
ASSESS NURSING PLANNING IMPLEMEN EVALUATION
MENT DIAGNOSIS TATION
 Imbalanced -Patient’s nutrition -Body weight was Baby took katori
Subjective nutrition less than level to be checked spoon feeding
Data body assessed. -Skin turgor is
checked
Mother said, requirements -Patient’s skin
“my baby is related to feeding turgur to be
lethargetic difficulties as checked.
-Intake out chart
evidenced by -Intake and output Is maintained
decreased body chart to be
weight, and signs assessed.
of dehydration. -Health Education
to be given Upright position
given
regarding,
-Position of
holding the baby
while
Objective
breastfeeding.
data
Loose skin -Clearing the -Encougaged for
turgor katori spoon
mouth of the baby
feeding
after feeding.
-Mother to be
encouraged to
continue breast
feeding in proper
technique.
ASSESS NURSING GOAL PLANNING IMPLEMEN EVALUATI
MENT DIAGNOSIS TATION ON
Subjective Parents were To aliviate -Patient and relatives -Existing Their anxious
data anxious Parent’s to all made knowledge was Was reduced
Mothre related to the anxiety knowledgeable. assessed
said ,
malformation -Information to
be - They wew
“ we are
informed about
tenced of lips and provided regarding
Disease,risk
about our
palate and in the cause of the factor
child”
the bonding disease, follow up
process as care ad the line of
evidenced by treatment of the baby.
the child is - Involvement of the
deprived child with the family
from breast member to be
feeding. increased.
-Knowledge to be
provided regarding
Objective
the prognosis of the
data
Tenced disease.
face
-Parent’s should be
made aware of the
surgical management
and the overall
development of the
child.
-Patient’s to be
involved in handling
the child and feeding
the child.
ASSESS NURSING GOAL PLANNING IMPLEMENTATION EVALUA
MENT DIAGNOSIS TION
Risk for To -Patent is to the -Assessment is done Mouth is well
acquainted
injury and minimize assessed regarding his range of
knowledge
infection to risk of regarding motion. about possible
complications.
the surgical injury his/her range of -Mummy restrains
site related to motion. and hand restraint
surgical -Mummy was applied.
procedure. restraint/hand -Mother is explained
restraint to be the need of checked
provided. the surgical site.
-Checking of -Parent’s are made
the surgical site aware about the risk
to be done after surgery and how
-Provides to the to handle the child
made alone after surgery.
about the risks -Close observation of
after surgery the child's safety is
and how to done.
handle their -Patient’s or family
child often member should are
surgery. always kept.
-Close -Bed rails are
observation of provided on both side
the child's of the cot.
safety to be
done.
ASSESS NURSING GOAL PLANNING IMPLEMENTATIO EVALUA
MENT DIAGNOSIS N TION
Potential pain To -The pain level -Assessed the pain Mother gained
Minimize to be ensured . level. knowledge
after surgery
Perceived - regarding post
related to pain Pain scale to be -Assessment done by surgical basic
sued while the help of pain scale. management.
surgical
assessing the
procedure level of pain. -Comfortable position
- shall be provided.
Comfortable
position to be -Analgesics shall be
provided. provided.
-
Prescribed
analgesics to be -Mother is assisted in
provided and handling the baby's
maintained the care.
correct
calculation of -Baby should be kept
dose. in supine position on
his baby after surgery.
-Mother to be
engaged his
handling the
baby.

-Baby to be
kept in supine
position to
reduce injury to
lips and palate.
ASSESS NURSING GOAL PLANNING IMPLEMENTA EVALUA
MENT DIAGNOSIS TION TION
Knowledge To gain -Knowledge -The knowledge Mouth fells or
deficit related knowledge level of the level of mother and source of well
to the mother and the the relatives was …. And is well
condition of relatives to be assessed. assumed.
child, assessed.
treatment, -Explanation was
long term care -Explanation of given regarding the
and feeding the procedures to line of treatment.
technique. be done.
-Explanation was
given regarding the
-Fixed time to be feeding technique,
engaged every cause of disease,
day regarding cause of treatment
the teaching and follow up care
purpose. and management of
the disease.
-Patient relative
to be involved -Fixed lines was
during teaching. fixed engaged every
day for the teaching
purpose.
Patient relatives
were told to
participate in
teaching class.
ASSESS NURSING GOAL PLANNING IMPLEMENTA EVALUA
MENT DIAGNOSIS TION TION
Potential for To -Hand washing -Hand washing was Mother washed
infection and the minimize to be done before done before and her hand before
care related to the risk of and after each after each feeding and after
diseased process. infection procedure. procedure. cleaning the
baby.
- -Myself and mother
Mouth to be cleaned the mouth
made clean each each time
time after
feeding. -Ear was cleaned for
pus.
-Ear to be
checked in case -Bed making was
of any done with carbolic
supplication or lotion and clean
pus. linen.

-Bed making to -Vital sings was

be done with checked and
carbolic lotion recorded
and cleanliness
to be provided.

-Vital signs to be
checked and
recorded.
Health Education :
1. Celt lip or cleft palate occurs by the 35 th day after conception which is often before a
women knows she is pregnant.
2. the mother needs reassurance that she did nothing wrong dewing the pregnancy.
3. Many caregivers feel guilty about having a child with this disorder. Counsel
caregivers appropriately.
4. Noting is missing from the child’s face the pieces just need to be pt together.
5. family teaching also includes information about feeding techniques and care of the
operative sites.
6. Nurses should instruct caregiver or family member to clean the suture life after
feeding and as necessary with cotton lipped applicators dipped in diluted hydrogen.
Peroxide small amount of water should be offered after feeding to rinse away any
milk residue that could lead to bacterial growth.
7. If the infant had a cleft lip repair, a side or back lying only position should be used.
8. Nurse should discuss the possibility of additional surgeries on the lip, nose and palate
as the child grows and matures.

Preparation for home care :

Parents were demonstrated about the followings :
1. Baby bath.
2. Skin care.
3. feeding technique.
4. Clothing according to the season.
5. Immunization : due scheduled.
6. Follow up visit.
7. Speech therapy if needed in near future.
Bibliography :
1. Black. J. M., Medical Surgical Nursing. 8 th ed. New Delhi : Elsevier publication;
2009. P 816 – 818.

2. Nelson, Text Book of Pediatrics. 17th ed. New York : Elsevier Publication; 2004. P
417-419.

3. Datta. P, Pediatric Nursing. 2nd ed. Kolkata : Jaypee publication; 2009. P 316-317.