Cebu Normal University COLLEGE OF NURSING Cebu City

A CASE STUDY ON A PATIENT WITH TOTAL ISOLATE CLEFT PALATE

Submitted by: BSN-3A, RLE-4 Ampil, Sherry Mae M. Bacayo, Paul Guiler B. Caparas, Nicole E. Cortez, Irish M. Dayanan, Eloisa Claire P. Digal, Jollibee Sophie G. Entrolizo, Merry Cris S. Goc-ong, April Joyce H. Pitogo, Emmanuel L. Remedios, Ria Jane A. Remo, Cristine Rose M.

Submitted to: Mr. Domino B. Puson, R.N.

Background and Rationale of the Study Picture this: you are sitting on a bench next to a young mother as she looks at her beautiful 3-year-old baby girl walking towards her. The little girl had such big, beautiful, light-brown eyes and such perfectly shaped lips. But when she came near, she opened her mouth and spoke with a nasal tone and her speech was barely understandable. You realize, the beautiful baby girl has a cleft palate. Cleft palate is an oral malformation that occurs very early in pregnancy while the baby is developing inside the mother. It is a split or opening in the roof of the mouth and may involve the hard palate (the bony front portion of the roof of the mouth), and/or the soft palate (the soft back portion of the roof of the mouth). Clefts occur more often in children of Asian, Latino, or Native American descent. Compared with girls, twice as many boys have a cleft lip, both with and without a cleft palate. However, compared with boys, twice as many girls have cleft palate without a cleft lip. In most cases, the cause of cleft palate is unknown. This condition cannot be prevented. Most scientists believe clefts are due to a combination of genetic and environmental factors. There appears to be a greater chance of clefting in a newborn if a sibling, parent, or relative has had the problem. Another potential cause may be related to a medication a mother may have taken during her pregnancy. It may also occur as a result of exposure to viruses or chemicals while the fetus is developing in the womb. The purpose of this study is to identify the predisposing and precipitating factors involved in the case of one particular patient in which this disorder has been witnessed. Objectives of the Study This study aims to: y Study the history of the disease/disorder for this particular patient y Study the organs involved in this disorder y Trace the pathophysiology and find out the causes of the disease/disorder y Identify the nursing problems that may arise due to this disease/disorder Situational Appraisal: a. Patients Profile A case of R.K.C., 3 years old, female, single, a Roman Catholic living in Sabellano St., Pardo, Cebu City, admitted for the first time at Cebu City Medical Center last Jan. 24, 2012, 2:15 pm with a diagnosis of Cleft palate and has undergone cleft palate surgery. Medical Diagnosis Cleft palate, Total (Pre-operative) Cleft palate, Total Isolate (Post-operative) b. History of Patients Illness Patient was born to a G6P6 mother via NSVC at Local Health Center. Patient was noted to have cleft rd palate since birth. The mother has a history of UTI on the 3 month of pregnancy and took antibiotics at that time but failed to follow-up after completion of medication regimen. Few months after birth, patient was brought to a doctor for elevation of her CP. She was advised for operation but due to financial constraints was delayed until such time that patient was enrolled for a certain organization cleft lip and palate, thus this admission. c. Assessment Findings Upon assessment, the following data were obtained: Weight: 12.5 kg; Height: 97 cm; Head Circumference: 48cm; Chest Circumference: 53 cm; Abdominal Circumference: 50.5 cm; Arm circumference: 16 cm. With vital signs taken as follow: Temperature: 35.6C; Pulse Rate: 118 bpm; Respiratory Tate: 30cpm. Patient appeared neat and clean with kept and combed hair with noted body weakness; with ongoing IVF of D5MN @ 42-43 cc/hr with remaining level of 840ml. Her tongue was sutured; bilateral arm splints were placed on both upper extremities. Patient was awake and non-dyspneic. She is shy to strangers and wants her mother to always stay beside her. Patients pupils are equally round and reactive to light and accommodation; ears are the same color as facial skin and are symmetrical, mouth and tongue are pink and no swelling was noted on the surgical site; drooling and hypersalivation noted. Upon auscultation, the patient had soft, low pitched breath sounds; no adventitious breath sounds noted. Had equal chest expansion; regular and easily notable pulse; no neck vein distention noted. Audible bowel sounds at 30 gurgles/min; abdomen is flat and non-tender; urinates for an average of 2-3 times a day and defecates for an average of 1-2 times daily.

Reflexes which are present: blinking, sneezing, coughing, yawning; (cannot assess swallowing and gag reflex); motor functioning is congruent to the development of the child. d. Anatomy and Physiology of the Organ/s Involved

The hard and soft palate separates the oral cavity from the nasal cavity. The presence of the palate makes it possible to breathe and chew at the same time. When food is swallowed, the soft palate rises up and blocks off the entrance to the rear nasal passage. When food is not being swallowed, this passage is open, making it possible to breathe through the mouth and through the nose. Prior to swallowing, food is pressed up against the palate and pushed to the back of the throat using the tongue. The palate also functions in speaking and singing. When sound emerges from the chest, the sound waves that have been produced by the vocal cords bounce off the hard palate and out the mouth. The hard palate directs and resonates. e. Pathophysiology Genetics, environmental factors, and maternal diseases cause the fetus to have malfusion of bones and tissues, leading to malformation of the palate. This causes the child to have a cleft palate (palatoschisis). This is manifested by an opening in the roof of the mouth with can be palpated, escaping of milk or formula through the nose, abdominal distention due to swallowing air, slow weight gain, and altered verbal communication. Schematic Diagram of the Pathophysiological Process Environmental factors Genetics Maternal Diseases

Malfusion of bones and tissues

Malformation of Palate

Cleft Palate (palatoschisis)

Opening in roof of the mouth can be palpated With cleft palate, milk or formula escapes through the nose Abdominal distention due to swallowing air Slow weight gain Altered verbal communication

Summary of Medical and Surgical Management

a. Diagnostic Studies COMPONENT *CBC WBC RBC Hgb Hct Platelet *Differential count Eosinophils * Urinalysis Color Transparency Specific Gravity pH Urobilinogen RBC WBC *Fecalysis Color Consistency RBC WBC *Chest Radiography b. Pharmacologic Therapy * Azithromycin (zithromax) *Paracetamol *Ranitidine c. Intravenous Therapy Jan. 25, 2012- D1- D5IMB 500cc @ 42-43cc/hour D2- D5IMB 500cc @ 42-43cc/hour Jan. 26, 2012- D3- D5NM 1L @14-43cc/hour d. Surgical Procedure Performed
Cleft palate repair - a surgery to fix a cleft, or hole, in the palate, or the roof of the mouth Problem Analysis a. Summary of Nursing Diagnosis (prioritized) y Acute pain related to tissue injury secondary to cleft palate. y Activity intolerance related to post operative status. y Impaired verbal communication related to surgical operation secondary to cleft palate. y Risk for aspiration related to impaired swallowing as evidence by drooling of saliva. y Risk for infection to moist environment around surgical site. Conclusion From the data and history taken by the researchers, we suspect that the occurrences in this case are due to the history of the mothers medication intake during the first trimester of her pregnancy and lack in follow-up check-up. However, further studies will be needed to confirm this. Recommendation We recommend that further studies be conducted for this case and that proper education of pregnant mothers be done in order to prevent or minimize the occurrence of this disorder.

RESULT 12.9 4.52 125 0.37 447 6.5 Yellow Clear 1.010 8 <2 1-3 3-5 Brown Soft None None Clear lung fields

Date Taken Jan. 9. 2012 Jan. 9. 2012 Jan. 9. 2012 Jan. 9. 2012 Jan. 9. 2012 Jan. 9. 2012 Jan.11, 2012 Jan.11, 2012 Jan.11, 2012 Jan.11,2012 Jan.11, 2012 Jan.11, 2012 Jan.11, 2012 Jan.11, 2012 Jan.11, 2012 Jan.11, 2012 Jan.11, 2012 Jan. 9, 2012

REFERENCE 4.00-12.00 4.00-5.30 115-145 0.33-0.43 150-450 0.0-6.0 1.003-1.035 5-8 0.1-1.8 0-2 0-5

UNIT X109 /L X10/L g/L X10/L % mg/dl /hpf /hpf

INTERPRETATION elevated normal normal normal normal elevated normal normal normal normal normal normal normal normal normal normal normal normal

250/5 3:2L x 4 days OD PO 250mg q 4 hours RTC IVTT 13mg q 8 hours IVTT

for prophylaxis for pain and T > 38.5 for pain