The document provides demographic and clinical information about a 9-year-old female patient named Harshitha who presented with difficulty speaking due to a secondary cleft palate. It includes her medical history, family history, physical exam findings, assessment, treatment plan, and nursing responsibilities. The patient underwent secondary cleft palate repair surgery and received follow-up care including antibiotics and antipyretics. Her development was assessed as appropriate for her age based on standard parameters.

1. sd
CASE STUDY ON SECONDARY
CLEFT PALATE
SUBMITTED TO: MRS .NISHA MANE ,
ASSISSTANTPROFESSOR,D.Y.P.C.O.N
Submitted by :
MS.JAYSGEORGE
7/10/17
1ST YEAR MSC (N),
D.Y.P.C.O.N

2. TYPEPERSONALNAME
INTRODUCTION
As a part my clinical posting , I was posted in pediatric surgery unit. I took a 9 year old
child (ms.Harshitha) with the diagnosisof secondary cleft palate repair for my casestudy.
I collected history of the patient ,I had done a thorough physical assessment and find out
the needs of the child, I had dealt with disease condition and given five days care and
health education to the parent as well as to th child. Recording and reporting done.

3. TYPEPERSONALNAME
DEMOGRAPHIC DATA
Name: Harshitha janaskar
Age : 9 years
Sex : female
Age group: schooler
Address: nerul
Religion: Hindu
Mrd.no : 1603245
Admission unit: pediatric unit
Date of admission : 9/1/17
Informant: mother
Diagnosis: secondary cleft palate
CHIEF COMPLAINTS: Harshidha janaskar brought to the Dr. d .y patil hospital on 9/1/17 with the
chief complaints of difficulty in speaking as a result of cleft palate.
FAMILY HISTORY
Sr.
No
Name of the
family members
Age Sex Relation with
patient
occupation Health
status
1. Dashratha
janaskar
47 M Father House keeping Healthy
2. Darshana 35 F Mother House wife Healthy
pedie3. Sudharshan 15 M Son 10th
std Healthy
4. Harshidha 9 F Daughter Nil Cleft palate

4. TYPEPERSONALNAME
FAMILY TREE :
Keywords
male
SOCIOECONOMIC AND CULTURAL HISTORY :
Patient belongs to a middle-class family. Patient is from rathnagiri, patient lives in nerul. she belongs to
a nuclear family, they live in rented house with all the facilities like municipality water supply,
electricity and attached bathroom facilities. Proper hygiene maintained around surroundings, father is
the breadwinner of the family. They are following Indian culture and tradition.
BIRTH HISTORY
1) Antenatal history
Patient mother is a registered antenatal case during her pregnancy period. She has taken folic
acid and iron tablets and two dose of TT injection during pregnancy period 3-4
ultrasonography was done in the antenatal period. Mother has no infections like TORCH and
diseases like HTN, diabetes mellites, AIDS etc.
2) Intranatal history
Type of delivery is normal full term delivery. There were no complaints during the
delivery period. Baby cried after birth, at birth vaccines are given to the child. Birth
weight of the baby is 2.5kg.
3) Postnatal history
After the delivery, the child was had congenital anomaly like cleft palate. Mother
has breast fed the baby till 1 year but the patient had difficulty in breast feeding after
6 months along with the breast milk complimentary food also been given into the
child.
4) Newborn history
Birth weight: 2.5 kg
m
fe
m

5. TYPEPERSONALNAME
Breast feeding: breast feeding till 1 year
Meconium passage: the child had passage meconium within 48 hours of birth.
Urine passage: the child had passed urine within 24 hours of birth.
Color of the baby: color of the baby is slightly dark
IMMUNIZATION HISTORY
vaccine Time Dose Route Remark
Bcg
Opv 0
Hep -B
At birth 0.1ml
2 drops
0.5ml
Intradermal
Oral
IM
Given
DPT 1
Hep -B 1
Opv 1
6 weeks 0.5ml
0.5ml
IM
IM
Given
DPT 2
Hep -B2
Opv 2
10 weeks 0.5ml
2 drops
IM
Oral
Given
DPT 3
Hep-B3
Opv 3
14 weeks 0.5ml
2 drops
IM
Oral
Given
Measles 9 months 0.5ml Subcutaneous Given
DPT booster 5- 6 years 0.5ml IM Given
PRESENT MEDICAL/ SURGICAL HISTORY : when I took this patient for my case study.
patient had complaints of cold, difficulty in speaking and bifida uvula.
Patient underwent secondary cleft palate repair.

6. TYPEPERSONALNAME
PAST MEDICAL HISTORY: patient has no past medical history of diseases like jaundice , malaria ,
typhoid ,etc. patient has a history of common cold.
PAST SURGICAL HISTORY : patient had a history of cleft palate repair at the age of 4 years in Nair
hospital.
PHYSICAL EXAMINATION
GENERAL APPEARANCE: the appearance of the child is abnormal. the patient is having cleft
palate, so there is an opening between the roof of the mouth and nose.
Posture: normal posture
Gait: the gait of the child is balanced
Nourishment: the child is nourished
Activity: the child is dull in her activity
VITAL SIGNS
Temperature: 98.6 f
Pulse rate: 98 bts/min
Respiration :26 brths/min
Blood pressure :110/70mmhg
ANTHROPOMETRIC MEASUREMENTS:
Height: 120 cm
Weight: 28 kg
Head circumference: 54 cm
Chest circumference: 56 cm
Skin and mucus membrane:
Color: color of the child is brown.
Edema: there is no edema present on the skin.
Moisture: the temperature of the skin is normal.
Texture: the texture is normal and slightly dry.

7. TYPEPERSONALNAME
HEAD:
Skull/cranium size: the skull size is 54 cm. there is no enlargement in the shape of the skull. Normal range
of motion.
Fontanelles : both the fontanelles are closed.
Sutures: all the sutures are intact .
FACE:
Appearance: the appearance of the face is normal
Color: the color of the face is brown
Symmetry: the face is symmetric at both sides.
EYES:
Expression: the coordination of the eyes is similar in both sides.
Eyelids: the eyelids are not edematous and no infection.
Eyebrows: eyebrows equally distributed and no infection.
Conjunctiva: there is no conjunctivitis
Sclera: the sclera is white in color
Pupils: the pupil get constricted when exposed to light.
EARS:
Appearance: both the ears lie in the straight line of outer canthus of eye to the pinna of the ear.
Discharge: there is no discharge from the ear
Abnormalities: no abnormalities seen in ear.
Hearing activity is normal.
NOSE:
Appearance: the nose is short and the nasal deviation present .
Discharge: there is no discharge from the nose.

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MOUTH AND THROAT:
Lips: the lips are normal, complaints of cleft palate
Tongue: the tongue is light pink in color, the patient is having difficulty in speaking.
Teeth’s: normal number of teeth’s according to age are present there is no dental carrier or other infections.
NECK :
Appearance: the neck is short
There is enlargement of lymph nodes and thyroid gland
Movements: Normal range of motion.
CHEST AND RESPIRATORY SYSTEM:
Inspection: on inspecting the chest is expanding and relaxing, bilaterally symmetrical in shape.
Palpation: the movements of the chest is normal.
Percussion: there is no abnormal fluid collection.
Auscultation: on auscultating no abnormal sounds heard.
CARDIOVASCULAR SYSTEM :
Inspection: on inspecting the cardiovascular system no abnormalities are there.
Palpation: there is no abnormal enlargement
Percussion: there is no abnormal fluid collection
Auscultation: on auscultation there is no cardiac murmers . s1 and s2 heard.
ABDOMEN:
Inspection: on inspecting the counter of abdomen is cylindrical
Palpation: the liver is palpable, no tenderness observed, no hepatomegaly or splenomegaly.
Auscultation: bowel sounds is normal.
Percussion: there is no fluid or gas.

9. TYPEPERSONALNAME
BACK:
Spine; intact normal
Curvature: there is no abnormalities like scoliosis, kyphosis, lordosis.
Genito urinary system: child does not have urinary tract infection. Child is not having congenital
anomalies like hypospadias is and epispadiasis.
EXTREMITIES:
Deformities: there is no deformities .
Swelling / edema: not present
Muscles : muscle tone is normal, reflexes normal.
Fingers and toes : no polydactyly and syndactyly.
CENTRAL NERVOUS SYSTEM:
Birth injuries : no history of birth injuries.
Seizures : no history of seizures
Speech : delay in speech
DRUG STUDY
NAME OF DRUG DOSE/ROUTE MECHANISM OF ACTION SIDE
EFFECT
NURSES
RESPONSIBILITY
Inj.ceftrixone(1g
m)BD
1gm(100mg/kg
/day)2600mg/d
ay1vial+500m
g+15cc NS IV
Antibiotics
,Semisynthetic Third
generation
cephalosporin
Hypersentiv
ity
Nausea
Vomiting
Rash
Monitor patient
carefully during
the first dose of
the infusion for
signs of
hypersensitivity.
Inj . pan 20 1 vial+10CC
NS
5.5CC+10CC
NS IV OD
Proton pump inhibitor Diarrhea
Abdominal
pain
Flatulence
Nausea
Dry mouth
Prior to drug
administration
check lab tests
Monitor for
immediate report
of signs and
symptoms

10. TYPEPERSONALNAME
Vomiting
Syp.crocin ds 4ml sos if
temperature
>100℉
Antipyrectic Sleeping or
irritable
Rash
Cough
convulsion
Check for the
expiry date of the
medication before
administration.
SCHOOLER ASSESSMENT
SL.NO PARAMETER BOOK
PICTURE
PATIENT
BOOK
REMARK
Anthropometric measurement
✓ Height
✓ Weight
106-162cm
16-58kg
128cm
24 kg
Moderately
built
2. Vital signs
✓ Temperature
✓ Pulse
✓ Respiration
✓ Blood pressure
98.6o
f
80-100b/min
20-30b/min
120/80mmhg
98℉
84bts/min
28br/min
120/80mm
Of hg
Normal
range
3. Physical and motor development
✓ Central mandibular incisor
erupt
✓ Active age, constant activity
6years
6yrs
6yrs
6yrs
Appropriate
to age

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✓ Finger feeding
✓ More aware of hand as tool for
drawing and painting
✓ Maxillary central incision and
mandibular incision erupt.
✓ More cautions in approach to
new performances.
✓ Repeat performance to master
them
✓ Lateral incisors erupt
✓ Always on the go, jumps,
chases ,skips.
✓ Increased speed in fine motor
control.
✓ Use cursive writing
✓ Dresses self completely
6yrs
6yrs
6yrs
7yrs
7yrs
8-9yrs
8-9yrs
8-9yrs
8-9yrs
8-9yrs
6yrs
6yrs
6yrs
6yrs
5yrs
7yrs
7yrs
8yrs
7yrs
7yrs
Appropriate
To age
4. Mental development
✓ Develops concept of numbers,
Can count 13 pennies
✓ Knows whether it is morning or
afternoon
✓ Defines common objects such
as spoon and chair in terms of
their use
✓ Obeys 3 commands in
succession.
6yrs
6yrs
6yrs
6yrs
6yrs
6yrs
6yrs
6yrs
Appropriate
to age
Appropriate
to age

12. TYPEPERSONALNAME
✓ Knows right and left hand
✓ Notices that certain items are
missing from pictures
✓ Can copy a diamond
✓ Repeats 3 number backward
✓ Develop concept of time; reads
ordinary clock
✓ Give similarities and
differences between two things
from memory
✓ Counts backward from 20-1
✓ Repeats days of week and
months in order
✓ Describes common objects in
details
✓ Reads classic books also enjoy
comics
✓ More aware of time, can be
relied on to get to school on
time.
✓ Produces simple painting or
drawing
✓ Write brief stories
✓ Write occasional short letters to
friends or relatives
✓ Rises telephone for practical
purposes
6yrs
7yrs
7yrs
7yrs
7yrs
8-9yrs
8-9yrs
8-9yrs
8-9yrs
8-9yrs
8-9yrs
8-9yrs
10-12yrs
10-12yrs
10- 12yrs
6yrs
7yrs
7yrs
7yrs
7yrs
8yrs
8yrs
8yrs
8yrs
8yrs
-
8yrs
-
-
-
Appropriate
to age
Appropriate
to age

13. TYPEPERSONALNAME
✓ Responds to magazines, radio
✓ Reads for practical information
or own enjoyment, stories or
library book of adventure or
romance.
10-12yrs
10-12yrs
-
-
5. Adaptive development
✓ Uses knife to spread butter or
jam on bread
✓ Cuts, folds, pastes, paper, sews
crudely if needle is threaded
✓ Takes bath without supervision
✓ Performs bedtime activities
alone
✓ Likes table games, checkers
simple card games
✓ Sometimes steals money or
attractive items
✓ Uses table knife for cutting
meat; may need help with
tough or difficult pieces.
✓ Brushes and combs hair
acceptably without help
✓ Make use of common tools
such as hammer, saw, screw
driver
✓ Helps with routine household
task such as dusting, sweeping.
✓ Assumes responsibility of
sharing.
✓ Likes schools, wants to answer
all the questions
✓ Is ashamed of bad grades
✓ Make useful tools or does easy
repair works
6yrs
6yrs
6yrs
6yrs
6yrs
6yrs
6yrs
7yrs
7yrs
8-9yrs
8-9yrs
8-9yrs
10-12yrs
-
6yrs
6yrs
6yrs
6yrs
6yrs
6yrs
7yrs
8yrs
8yrs
-
Appropriate
to age
Appropriate
to age
Appropriate
to age

14. TYPEPERSONALNAME
✓ Raises pet
✓ Cooks or sews in small way.
✓ Washes and dries own hairs
✓ May stay alone at home for an
hour or more.
✓ Is successful in looking after
own need or take care of
another child
10-12yrs
10-12yrs
10-12yrs
10-12yrs
10-12yrs
-
-
-
6. Psychosexual theory
✓ Stage of latency
✓ Child masters the skills which
is learnt previously by them.
✓ Spend their time in play and
gain knowledge.
6-12yrs Developed Appropriate
to age
7. Psychosocial theory
Industry /inferiority
✓ They want to work and want
achievement. the aim is to
develop a feeling of
competence rather than
inability
6-12yrs Developed Appropriate
to age
8.
Pleasure motives;
Concrete on pleasure motive
Level 2: conventional morality
Stage 3(7-9yr)
6yrs
7-9yrs
Concrete
on pleasure
activity like
play
Developed
Appropriate
to age

15. TYPEPERSONALNAME
✓ Becomes socially sensitive,
justice means equality between
individuals they believe.
Stages 4
✓ Maintain social order and
perform or carryout fixed rule
and authority
10-12yrs
-
Appropriate
to age
-
9. Spiritual development
Stage 2- mythical / literal
✓ Child develop strong believe on
god. They feel thinking good
behavior is acquired by god.
6-12yrs
Child has
developed
belief on
god and
thinks god
is good.
Appropriate
to age
10. 6-12yrs Has
develop
some level
of
imagination
Appropriate
to age
11. Play;
✓ Imaginative play
✓ Associative play
✓ Formal play
✓ Competitive play
✓ Quiet play
6-12yrs
Associative
play
Formal
play
Quite play
Appropriate
to age
12. Accident
✓ Motor vehicle accident
✓ Drowning
✓ Burns
✓ Poisoning
✓ Sports injury
6-12yrs
Injury from
fall
Appropriate
to age

16. TYPEPERSONALNAME
ANATOMY AND PHYSIOLOGY

17. TYPEPERSONALNAME
ORAL CAVITY
Extends from the lips to the oropharyngeal isthmus. The oropharyngeal isthmus Is the junction of mouth
and pharynx.
Is bounded Above by the soft palate and the palatoglossal folds Below by the dorsum of the tongue
Subdivided into Vestibule & Oral cavity proper
VESTIBULE
Slit like space between the cheeks and the gums Communicates with the exterior through the oral fissure
When the jaws are closed, communicates with the oral cavity proper behind the 3rd molar tooth on each
side Superiorly and inferiorly limited by the reflection of mucous membrane from lips and cheek onto
the gums. The lateral wall of the vestibule is formed by the cheek
The cheek is composed of Buccinator muscle, covered laterally by the skin & medially by the mucous
membrane
A small papilla on the mucosa opposite the upper 2nd molar tooth marks the opening of the duct of the
parotid gland.
It is the cavity within the alveolar margins of the maxillae and the mandible
Its Roof is formed by the hard palate anteriorly and the soft palate posteriorly
Its Floor is formed by the mylohyoid muscle. The anterior 2/3rd of the tongue lies on the floor.
FLOOR OF THE MOUTH
Covered with mucous membrane in the midline, a mucosal fold, the frenulum, connects the tongue to the
floor of the mouth on each side of frenulum a small papilla has the opening of the duct of the

18. TYPEPERSONALNAME
submandibular gland a rounded ridge extending backward & laterally from the papilla is produced by
the sublingual gland
TONGUE
Mass of striated muscles covered with the mucous membrane divided into right and left halves by a
median septum.
Three parts:
Oral (anterior ⅔)
Pharyngeal (posterior ⅓)
Root (base)
Two surfaces:
Dorsal
Ventral

19. TYPEPERSONALNAME
DISEASE CONDITION
DEFINITION
It results from failure of masses of lateral palatine processes to meet and fuse together. It may be
unilateral or bilateral or may occur in isolation or with cleft lip. Cleft palate in isolation may found in the
midline involving only uvula or reaches the incisive foramen through soft palate.cleft palate is found as
an opening or elongated opening or fissure in the roof of the mouth which should be detected during
routine neonatal examination.
Causes
• Genetic or due to unfavourable maternal factors.
• Viral infections during 5th
to 12th
weeks of gestation.
• Ingestion of drugs.
• Exposure to x-ray.
• Anemia and hypoproteinemia.
Types of cleft lip and cleft palate
➢ Group 1(prealveolar)
➢ Group 2(postalveolar)
➢ Group 3(combined)
Complication
1. Feeding problems due to ineffective sucking resulting in undernutrition.
2. Aspiration of feeds resulting respiratory infections.
3. Parental anxiety due to defective appearance of the infant.
Long term problems
1. Recurrent infections especially otitis media.
2. Disturbed parent child relationship and maladjustment with nonacceptance of the infant.
3. Impairement of speech.

20. TYPEPERSONALNAME
4. Malocclusion and malplacement of teeth.
5. Hearing problems due to oral malformation especially in cleft palate.
6. Impaired body image.
Surgical management
Palatoplasty, the surgical reconstruction of the palate is done with repair of the cleft, at about age of 1 to
2 years of age. It should be done before the child develops defective speech.
Nursing management
✓ Demonstration to be given to the mother and family members regarding feeding of the baby to
prevent aspiration.
✓ Cleft palate baby may require palatal obturator which can make feeding easier.
✓ Precautions to be taken to prevent chocking.
✓ The infant to be placed in upright position during feeding.
✓ Burping to be done in between feeds.
✓ Monitoring of vital signs , bleeding from site of oeration, oral secretions, vomiting and crying.
✓ The infant should be kept dry , well fed and comfortable to prevent crying.
✓ Care of suture line to prevent infection is very important.
✓ mouth care and cleaning of suture line after each feed with normal saline or antiseptic mouth
wash.
✓ Antibiotics ,analgesics and other prescribed medications to be administered with specific
precautions.
Nursing diagnosis
1. Risk for aspiration related to anatomic correction.
2. Altered nutrition less than body requirement related to the surgical management.
3. Disturbed body Image related to anatomical defect of palate.
4. Impaired verbal communication related to congenital defect.
5. Parental anxiety related to post operative period of child .
6. Disturbed family coping pattern related to hospitalization of the child
7. Impaired skin intergirity related to surgical management
8. Risk for infection related to hospitaliztion
9. Knowledge deficit related to post operative period .
10. .Altered play related to hospitalization

21. TYPEPERSONALNAME
HEALTH EDUCATION
MEDICINES :
Antibiotics is given to fight an infection caused by bacteria. Give your child this medicines as
exactly ordered by pediatrician.Tell him /her if the child is allergic to any medicines.
FEEDING TECHNIQUES:
Feeding your child can be difficult. Try to be calm the patient. this will help your child relax as she
eats. Provide colourful and attractive foods. Parents should give attention to childrens likes and
dislikes.
SPEECH AND NUTRITION THERAPY:
I adviced parents about childs need of speech therapy and you may also need to meet with dietician
to know the best foods for your child.
PERSONAL HYGIENE:
I educated the parents and the child about importance of personal as well as the dental hygiene.
Because of inadequate dental hygiene child can cause inflammation in palate region. I encouraged
the child to maintain person hygiene such daiy bath and changing the dress and doing daily
brushing the teeths it will reduce the chances of infecton.
FOLLOW UP :
Child may need to return to check this stitches and to measure weight. Immediately take the
child to hospital if the child is not taking food well, reducing weight, sunken eyes, bleeding or
gap in the repaired site.

22. TYPEPERSONALNAME
RESEARCH STUDY : A study to Incidence of cleft Lip and palate in the state of
Andhra Pradesh, South India.
Srinivas Gosla Reddy, Rajgopal R. Reddy, Ewald M. Bronkhorst,1 Rajendra Prasad,2
Anke M. Ettema,3 Hermann F. Sailer,4 and Stefaan J. Bergé3
ABSTRACT
Objective:
To assess the incidence of cleft lip and palate defects in the state of Andhra Pradesh, India.
Design Setting:
The study was conducted in 2001 in the state of Andhra Pradesh, India. The state has a population of 76
million. Three districts, Cuddapah, Medak and Krishna, were identified for this study owing to their
diversity. They were urban, semi-urban and rural, respectively. Literacy rates and consanguinity of the
parents was elicited and was compared to national averages to find correlations to cleft births. Type and
side of cleft were recorded to compare with other studies around the world and other parts of India.
Results:
The birth rate of clefts was found to be 1.09 for every 1000 live births. This study found that 65% of the
children born with clefts were males. The distribution of the type of cleft showed 33% had CL, 64% had
CLP, 2% had CP and 1% had rare craniofacial clefts. Unilateral cleft lips were found in 79% of the
patients. Of the unilateral cleft lips 64% were left sided. There was a significant correlation of children
with clefts being born to parents who shared a consanguineous relationship and those who were illiterate
with the odds ratio between 5.25 and 7.21 for consanguinity and between 1.55 and 5.85 for
illiteracy, respectively.
Conclusion:
The birth rate of clefts was found to be comparable with other Asian studies, but lower than found
in other studies in Caucasian populations and higher than in African populations. The incidence
was found to be similar to other studies done in other parts of India. The distribution over the various
types of cleft was comparable to that found in other studies.

23. TYPEPERSONALNAME
CONCLUSION :
I had taken this case for casestudy and given 5 days care to the child.
Ihave dealt with history collection ,physical examination,investigation ,drug study ,
assessment and nursing careplan and application of theory. I have given care for 5 daysto
the child and given health education to the child as well as to the parents. The child and
his parents were very cooperative during care.

24. TYPEPERSONALNAME
BIBLIOGRAPHY
• Parul data,text book of pediatric nursing , 3rd
edition, jaypee brothers publication,
page ;no: 420-422.
• Wongs , essentials of pediatric nursing , 1st
south asia edition, Hockenberry Wilson
and judie, elseviers publications , page no: 687-690.
• Gulanic / myes nursing care plan , nursing diagnosis and intervention 5 th edition ,
mosby publications , page no :761-762.
• Ghai paul bagga , essential pediatrics , 7 th edition , cbs publications , page
no:152,337
• www.Google.com

25. TYPEPERSONALNAME