INTRODUCTION Spina bifida comes from the latin word “divided spine”, is a group of neural tubedefects that involves the brain and the spinal cord and/or meninges. It occurs when theneural tube does not close during the baby’s development. There are three major types ofspina bifida: spina bifida occulta, meningocele, and myelomeningocele. Meningocele is arare form of neural tube defect in which the spinal cord develops normal but the meningesprotrude from a spinal opening. Symptoms vary; while some people will have few or nosymptoms (emedTV.com). It has been reported that in 1000 live births 1-2 babies have thiskind of condition worldwide, in the Philippines it has been said that out of 86,241,691² ofthe population 5,174 were reported to have spina bifida in the year 2004(curereaserch.com). Our patient belongs to the category of spina bifida cystica with meningocele, a mildand rare form of neural tube defect where the spinal cord is not involved in the herniation.He was admitted in the neuro female ward with a chief complain of headache and increasein the head circumference. We chose this case because this is a rare condition in which it isnot commonly seen in the ward. It is an interesting case because not all have knowledgeabout this condition; we want to broaden our knowledge about this case so that we may beable to help prevent the occurrence of this condition in the community.
OBJECTIVESGeneral Objective: After two months of exposure at Davao Regional Hospital specifically at Ortho / NeuroWard, this case study aims to enhance our knowledge and understanding regarding thediagnosis of our client so as to develop new skills in dealing with this kind of illness and toimprove our learning regarding Spina Bifida that would be helpful in our future nursingprofession.Specific Objectives:After this case study, we will be able to:• Establish good interpersonal relationship with the client and his family to gain theircooperation during the process of gathering data;• Determine the client health status through analyzing the nature of Spina Bifida and itsdeviation from the normal physiologic process;• Trace the health history of the client and his family by taking the past and present healthhistory to know the predisposing and precipitating factors of client’s condition;• Define and discuss thoroughly the complete diagnosis of the client;• Present a through physical assessment on the client’s condition which serves as a baselinedata;• Discuss the anatomy and physiology of the involved system in the disease;• Trace the pathophysiology of the disease process by presenting the etiology, predisposing andprecipitating factors, its signs and symptoms present in the patient;• Interpret the results of congregated diagnostic procedures and laboratory examinations andits clinical significance;• Identify and discuss the different drugs used in the management of the client’s condition;• Formulate nursing care plan to provide adequate nursing interventions;• Make a detailed discharge planning necessary for the wellness of the client using the acronymMETHOD;• Interpret the general prognosis of the client base on a criteria; and• Appreciate the experience we had upon accomplishing the said case study as well as retainingthe supplemental knowledge that we were able to acquire throughout our 2 months exposureon the ward
PERSONAL DATAName: Patient SAge: 4 years oldGender: MaleDate of Birth: November 24, 2007Address: Southern Davao, PC, Davao Del NorteReligion: Roman CatholicNationality: FilipinoMother’s Name: SheilaFather’s Name: ArjieSiblings: Mayumi, ArsheilOrdinal Position: Second among the three siblings CLINICAL DATAWard: Neuro WardDate & Time Admitted: January 26, 2012 @ 3:30pmAdmitting Physician: Dr. Lucio Tems JrChief Complain: Increasing head circumferenceAddmitting Diagnosis: Spina Bifida with Non – Communicating HydrocephalusFinal Diagnosis: Meningocoele T4 – T6 with Syringomyelia T4 – T9, Obstructive Hydrocephalus Secondary to Chiari II Malformation
HISTORY OF PATIENTPast Medical History During the pregnancy our patient’s mother always complies on the pre –natal check up,she had her immunizations such as tetanus toxoid. She never took any medications that areharmful to her pregnancy and eats foods that are good to her and to the baby. At the firstmonth of her pregnancy she was noted to have frequent emesis gravidarum and UTI.Sometimes she was also expose to stress due to her work, which is a ”labandera”, and the lackof taking supplementary vitamins. After giving birth to our patient they noticed that there is a mass growing at the upperback. They seek medical attention and they were advised to have a surgical intervention butdue to financial problems they refused and went home so that they could save some money forthe operation. Patient S had completed his immunizations. He has no known allergy to foodsand drugs and has only caught minor diseases such as colds, fever, and cough. At the age of 2years old he had a convulsion; he was rushed to the hospital and was treated. But at the age of3 years old, they noticed a slight change in patient S’s behaviour. They noticed that he has ashort temper and often cries or having a temper tantrums; they also started to notice that hisright eye and right area of his jaw cannot move, tolerable headaches and a slight increase in thehead circumference.History of Present Illness Three months before admission, patient S was having his check-up because of coughand colds. As days pass, patient S was complaining of headaches, pain at the back, and theynoticed that his head is larger than any other child his age. It was then they decided to haveShann admitted. They went to Davao Regional Hospital to seek for medical intervention andthey were advised to admit their patient for VP shunting and he was diagnosed Spina Bifidawith Non – Communicating Hydrocephalus.Family Health Hisotry According to our source; patient S came from the Lazarito and Arguilles Clan. On thePaternal side not much was known in the names of his Grand Father and Mother and also theirhereditary diseases. But they had two siblings namely: Arjie Arguilles and Arnel Arguilles. Arjiewas the eldest among the two and was known to have hypertension, and Arnel was theyoungest, he passed away at an early age due to a congenital condition known as the Atrio-Septal Defect. In the Maternal side: Mario Lazarito and Norma Lazarito where Shann’s Grand Parents;Norma was said to have Diabetes Mellitus. They had four siblings namely: Sheila, Sheryll,
“Lolong”, and they youngest which was not identified by our source. Shiela was the eldestamong the four and has no known hereditary condition. Sheryll on the other hand was thesecond among the four and was known to have Diabetes, “Lolong” was the third and has noknown hereditary disease, and the youngest also has no known condition. Arjie and Shiela met and got married. They were blessed with three children. Mayumiwas the eldest; she has no known hereditary condition. S, our patient, which was the second,was known to have spina bifida, and the youngest was Arsheil who has Atrio – Septal Defect.
PHYSICAL ASSESSMENTGeneral Survey Our assessment took place on February 3, 2012 at 8 am; the patient was lying flat onbed with one pillow to elevate the head. He has a mesomorphic body built. He is slightlykyphotic and the right shoulder is lower than the left. He was on diet as tolerated withaspiration precaution. He has an IVF of D5.03 Nacl 500cc @ 60cc/hr, infusing well at leftmetacarpal vein.Vital SignsTemperature: 36.8°CHeart Rate: 108 bpmPulse Rate: 100 bpmRespiratory Rate: 25 cpmBlood Pressure: 90/60 mmHgSkin Our patient has a fair complexion of his skin. His skin is warm and dry to touch withgood skin turgor and with a capillary refill time of less than 3 seconds.Head Hair is black, shaved and evenly distributed, no infestations of lice noted uponinspection. Head is slightly larger than normal with 52 cm in diameter. With Ventriculo –Peritoneal Shunt at right side of the occipital area, with pinkish scar noted at the left side of theoccipital area.Eyes Eyes are symmetrical and are aligned at the upper pinnea of the ear. Iris is color brownand pupils are equally round and is reactive to light accommodation with a diameter of 2 mm.Our patient still cannot fully move the right eyelids, though can fully move the eyeballs fromside-to-side and up and down. Sunken eyeballs noted upon inspection.Ears Ears are symmetrical and are aligned at the outer canthus of the eye. Eardrums areintact with cerumen noted upon inspection. No lesions, discharges noted.Nose Nose is symmetrically aligned at the center of the head. No discharges noted uponinspectionNeck and Throat Patient was able to swallow. Upon palpation there was no mass noted.
Mouth Lips and the oral mucosa are pinkish in color with no lesion noted. The right side of thejaw is slightly slanted.Chest Chest is normal in shape, with AP diameter of 2:1. Right shoulder is lower than the leftshoulder. At the upper back, suture lines noted.Abdomen The abdomen is flat and is light brown in color with a bowel sound of 5. No lesionsnoted upon inspection.Genio – Urinary At his age, patient is able to hold his bladder for a long time.Upper Extremities Upper extremities are symmetrical in shape and size, and able to move both extremitieswithout difficulty. No lesions noted upon inspection.Lower Extremities Lower extremities are symmetrical in shape and size, with small scars noted at the shinpart of the leg.
COURSE IN THE WARDDate and Time Doctor’s Order Nurse’s Care1/26/12 -Please admit patient under -VS checked and recorded3: 30 pm neurosurgery ward -Secured consent to careTemp. 36 -Secure consent to care - DAT / NPO post midnight re-BP: 90/60 -I & O q shift instructedPR: 129 bpm -vs q 4 -I & O q shift recordedRR: 24 - DAT / NPO post midnight -Followed up lab exams - For VP shunting once with pedia requested clearance - Senior informed - Meds: Ranitidine 15mg IVTT q8 once on NPO IVF D5.3 Nacl 500cc @ 50-55 cc/hr - Laboratory examinations: CBC with BT, PT / APTT, Na, K, Ca, Creatinine, CXR APL1/27/12 -Followed – up all labs -Labs followed up7:00 am -Followed – up official reading of CXR -Informed Radiologic Dept. - For pedia clearance once with Official reading CXR complete lab work – up - May have DAT -DAT1/28/12 -Will do ECG 12 leads with long lead -ECG 12 leads taken8:15 am II -D/C Ranitidine as ordered -D/C Ranitidine1/29/12 -D/C IVF once comsumed -IVF consumed and8:00 am -Refer to Pedia tomorrow once with terminated complete labs -For referral to Pedia once with with complete labs, followed up labs1/30/12 -Follwed up Official Reading of CXR -Informed Official reading7:00 am CXR, to retrieve X ray film7:00 pm -For cranial CT Scan ( Plain ) -Instructed S.O for cranial CT Scan1/31/12 -Refer to Pediatrics for CP clearance -Informed Pediatrics for CP
9:00 am Clearance5:15 pm -Secure 1 unit of PRBC of Pt’s blood -Informed S.O. to secure type properly screened & blood for OR use, blood crossmatched for OR use request and crossmatching given2/1/12 -NPO post midnight -Instructed watcher that9:51 am -Schedule for VP shunting, Repair of patient should be on NPO Meningocele tomorrow 1st table starting midnight - Secure consent and procdure - Secured consent of the -Inform OR/Anesthesia procedure -Start Cefuroxime 350mg IVTT ANST - Scheduled elective VP 1 hr prior shunting and repair of meningocele tomorrow - OR/AROD aware - Skin testing done with result of negative; cefuroxime started IVTTT2:40 pm - Provided with CP clearance. Pls -Informed Dr. Daya and Dr. informed Dr. Daya / Dr. Bravo Bravo3 pm Pre op orders -Followed up availability of - For elective VP shunt and repair of meds meningocele under GETA - NPO -Meds: 1. Ranitidine 15mg IVTT PTOR 2. Metoclopromide 5mg IVTT PTOR5:45 pm - Insert IV D5.3NaCl 500cc x 60cc/hr - IVF started D5.3NaCl 500cc @ 60cc/hr at midnight - Instructed to wear gown - Removed any metallic objects - Pre op meds given IVTT prior to OR
2/2/12 Post Op orders: -Maintain NPO as ordered4:00 pm -S/P VP shunting & Repair of -Hooked to O2 inhalation via Meningocele under GETA face mask @ 6 liters per -To PACU minute -NPO Temporarily -VS checked and monitored -O2 @ 6 liter per minute via face -IVF D5.3 Nacl 400cc @ 60cc/ mask hr, regulated well -VS q15 minutes x 3 takings then q15 -Due meds given as ordered minutes -I & O monitored -Maintain flat on bed for 24 hours -IVF D5.3 Nacl 400 @ 60 cc/hr -Meds: Cefuroxime 300 mg IVTT q8h Ranitidine 20 mg IVTT q8h Tramadol 30 mg IVTT q8h Paracetamol 300 mg IVTT q6h RTC for pain -Monitor I & O q hourly - Repeat CBC post op -Keep pt. warm -Refer7 pm - To ward - Transferred out to ward per - NPO temporarily stretcher, endorsed to NOD - continue IVTT meds - Still on NPO - please follow up laboratory request - Due meds given2/3/12 -May have DAT with SAP - Resumed Diet as tolerated -Still flat on bed -instructed to maintain flat on -IVF D5.3 Nacl @ 60 cc/hr bed -Continue all meds -IVF regulated @ prescribed rate -Due meds available given as ordered2/4/12 -May elevate head with 1 pillow -Elevated head with 1 pillow6:00 am -refer2/5/12 -For dressing tomorrow - Dressing c/o ROD, followed8:00 am -Continue IVF up availability of materials -IVF regulated well at prescribed rate
2/6/128:00 am -Decrease IVF to 50 cc/hr -IVF decreased to 50 cc/hr, -D/C Tramadol & Ranitidine regulated well - Change dressing -D/C Tramadol & Ranitidine IVTT2/7/12 -May now remove IVF - IVF consumed and6:50 pm -Shift IV Meds to P.O discontinued Cefixime 100mg/5ml, 7ml BID -Shifted to PO meds Paracetamol 250mg/5ml, 5ml q4 - PO meds started PRN for fever2/8/12 -May Go Home -Carried out MGH ordered10:00 am -Home Meds as ordered x 7 days -Discharged plan made Cefixime 100mg/5ml, 7ml BID - Bills forwarded Paracetamol 250mg/5ml, 5ml q4 -Instructed take home meds PRN for fever -health teachings imparted -Neuro Surgery OPD check up on -Discharged ambulatory Feb.16, 2012 8-10 am
Anatomy and PhysiologyBrain - The brain is the center of the nervous system. The function of the brain is to providecoherent control over the actions of an animal. A centralized brain allows groups of muscles tobe co-activated in complex patterns; it also allows stimuli impinging on one part of the body toevoke responses in other parts, and it can prevent different parts of the body from acting atcross-purposes to each other. To generate purposeful and unified action, the brain first bringsinformation from sense organs together at a central location. It then processes this raw data toextract information about the structure of the environment. Next it combines the processedsensory information with information about the current needs of an animal and with memoryof past circumstances. Finally, on the basis of the results, it generates motor response patternsthat are suited to maximize the welfare of the animal. These signal-processing tasks requireintricate interplay between a variety of functional subsystemsThe brain is one of the largest and most complex organs in the human body.It is made up of more than 100 billion nerves that communicate in trillions of connections calledsynapses.The brain is made up of many specialized areas that work together:• The cortex is the outermost layer of brain cells. Thinking and voluntary movements begin inthe cortex.• The brain stem is between the spinal cord and the rest of the brain. Basic functions likebreathing and sleep are controlled here.• The basal ganglia are a cluster of structures in the center of the brain. The basal gangliacoordinate messages between multiple other brain areas.• The cerebellum is at the base and the back of the brain. The cerebellum is responsible forcoordination and balance.The brain is also divided into several lobes:• The frontal lobes are responsible for problem solving and judgment and motor function.• The parietal lobes manage sensation, handwriting, and body position.• The temporal lobes are involved with memory and hearing.• The occipital lobes contain the brains visual processing system.The brain is surrounded by a layer of tissue called the meninges. The skull (cranium) helpsprotect the brain from injury.Brain stem - The brain stem is similarly structured as the spinal cord: it consists of grey mattersurrounded by white matter fibre tracts. Its major regions are the midbrain, pons and medullaoblongata. The midbrain, which surrounds the cerebral aqueduct, provides fibre pathwaysbetween higher and lower brain centres, contains visual and auditory reflex and subcorticalmotor centres. The pons is mainly a conduction region, but its nuclei also contribute to theregulation of respiration and cranial nerves. The medulla oblongata takes an important role asan autonomic reflex centre involved in maintaining body homeostasis. In particular, nuclei inthe medulla regulate respiratory rhythm, heart rate, blood pressure and several cranial nerves.
Moreover, it provides conduction pathways between the inferior spinal cord and higher braincentres.Cerebellum - The cerebellum, which is located dorsal to the pons and medulla, accounts forabout 11% of total brain mass. Like the cerebrum, it has a thin outer cortex of grey matter,internal white matter, and small, deeply situated, paired masses (nuclei) of grey matter. Thecerebellum processes impulses received from the cerebral motor cortex, various brain stemnuclei and sensory receptors in order to appropriately control skeletal muscle contraction, thusgiving smooth, coordinated movements.Cerebral hemispheres - The cerebral hemispheres, located on the most superior part of thebrain, are separated by the longitudinal fissure. They make up approximately 83% of total brainmass, and are collectively referred to as the cerebrum. The cerebral cortex constitutes a 2-4mm thick grey matter surface layer and, because of its many convolutions, accounts for about40% of total brain mass. It is responsible for conscious behaviour and contains three differentfunctional areas: the motor areas, sensory areas and association areas. Located internally arethe white matter, responsible for communication between cerebral areas and between thecerebral cortex and lower regions of the CNS, as well as the basal nuclei (or basal ganglia),involved in controlling muscular movement.Cerebrospinal fluid - Cerebrospinal fluid (CSF) is a watery liquid similar in composition to bloodplasma. It is formed in the choroid plexuses and circulates through the ventricles into thesubarachnoidspace, where it is returned to the dural venous sinuses by the arachnoid villi. The primepurpose of the CSF is to support and cushion the brain and help nourish it.CSF serves four primary purposes:1.Buoyancy: The actual mass of the human brain is about 1400 grams; however, the net weightof the brain suspended in the CSF is equivalent to a mass of 25 grams. The brain thereforeexists in neutral buoyancy, which allows the brain to maintain its density without beingimpaired by its own weight, which would cut off blood supply and kill neurons in the lowersections without CSF.2.Protection: CSF protects the brain tissue from injury when jolted or hit. In certain situationssuch as auto accidents or sports injuries, the CSF cannot protect the brain from forced contactwith the skull case, causing hemorrhaging, brain damage, and sometimes death.3.Chemical stability: CSF flows throughout the inner ventricular system in the brain and isabsorbed back into the bloodstream, rinsing the metabolic waste from the central nervoussystem through the blood-brain barrier. This allows for homeostatic regulation of thedistribution ofneuroendocrine factors, to which slight changes can cause problems or damageto the nervous system. For example, high glycine concentration disrupts temperature and bloodpressure control, and high CSF pH causes dizziness and syncope.4.Prevention of brain ischemia: The prevention of brain ischemia is made by decreasing theamount of CSF in the limited space inside the skull. This decreases total intracranial pressureand facilitates blood perfusion.
Dermatomes and Myotome - Each spinal nerve pair services specific areas of the body withsensory and motor neurons. The sensory nerve fibers and the areas of the skin they receivestimulus from are called dermatomes. The motor nerve fibers and the specific muscles whichthey effect are called myotomes.Diencephalon - The diencephalon is located centrally within the forebrain. It consists of thethalamus,hypothalamus and epithalamus, which together enclose the third ventricle. The thalamus actsas a grouping and relay station for sensory inputs ascending to the sensory cortex andassociation areas. It also mediates motor activities, cortical arousal and memories. Thehypothalamus, by controlling the autonomic (involuntary) nervous system, is responsible formaintaining the body’s homeostatic balance. Moreover it forms a part of the limbic system, the‘emotional’ brain. The epithalamus consists of the pineal gland and the CSF producing choroidplexus.Meninges - The meninges are three connective tissue membranes enclosing the brain and thespinal cord. Their functions are to protect the CNS and blood vessels, enclose the venoussinuses, retain the cerebrospinal fluid, and form partitions within the skull. The outermostmeninx is the dura mater, which encloses the arachnoid mater and the innermost pia mater.Spinal Cord - The spinal cord is a long, thin, tubular bundle of nervous tissue and support cellsthat extends from the brain (the medulla oblongata specifically). The spinal cord begins at theoccipital bone and extends down to the space between the first and second lumbar vertebrae;it does not extend the entire length of the vertebral column. It is around 45 cm (18 in) in menand around 43 cm (17 in) long in women. Also, the spinal cord has a varying width, ranging from1/2 inch thick in the cervical and lumbar regions to 1/4 inch thick in the thoracic area. Theenclosing bony vertebral column protects the relatively shorter spinal cord. The spinal cordfunctions primarily in the transmission of neural signals between the brain and the rest of thebody but also contains neural circuits that can independently control numerous reflexes andcentral pattern generators. The spinal cord has three major functions: as a conduit for motorinformation, which travels down the spinal cord, as a conduit for sensory information in thereverse direction, and finally as a center for coordinating certain reflexes.
ETIOLOGY PREDISPOSING FACTORS Rationale Age ♦ Infants and children are more likely to have this condition because it is a birth defect. Heredity Couples who have spina bifida are more likely to have a child with spina bifida. Individuals who have had spina bifida are at risk of having a child with the same condition. Unknown Until now the cause of spina bifida is still unknown. Experts still some theory as to what is the cause of this condition. PRECIPITATING FACTORS Rationale Nutrition ♦ women who do not take folic acid or lack of folic acid prior to pregnancy and/or during early pregnancy have a higher risk of having spina bifida than women who take folic acid. Anti convulsants Valproic acid and carbamazepine belong to a group of drugs called folic acid antagonist. This group interferes with the body’s use of folic acid. Socio-economic factors ♦ Socio-economic status of the person would also affect the risk of having spina bifida because of the decrease compliance of nutrition and supplements of the mother during pregnancy. Diabetes Women who have diabetes before they become pregnant are at higher risk of having a child with spina bifida and other types of birth defects.Increase body temperature Studies suggest that if a woman’s body temperature goes up to 101 - 102°F (38.33 – 38.88°C) during early pregnancy, it would double the risk of having a child with spina bifida.
PATHOPHYSIOLOGY During the first month of pregnancy the upper part of the spinal cord and the brain isformed, followed by the formation of the lower spinal cord at 5 – 6 weeks during pregnancy. Aninterruption in the formation would result to failure in closure of the spinal cord leaving adefect in the spine. Factors affecting failure of closure would include the inadequate folic acidintake which is used by the body for cell production and development; anticonvulsant which isa folic acid antagonist blocks the absorption of folic acid. Having a history of diabetes before orduring pregnancy with high levels of glucose in the body would also affect the closure of thespine as well as having a high body temperature during pregnancy. In the first month of pregnancy, the central nervous system of the baby starts todevelop. Any slight interruption of the development will lead to a congenital defect. If it willoccur, there will be a defect in the spinal cord in which the neural tube will fails to close thuscreating an opening and forms a protrusion of the meninges through the spinal space and whatis now called the “Meningocele”. If treated through surgical repair of meningocele it would leadto a good prognosis. But if not, the protrusion will create an obstruction. Due to theobstruction, there will be an indirect flow of cerebro-spinal fluid in and out of the spinal cordand it will accumulate in the brain creating now a hydrocephalus. Hydrocephalus if treated withVP shunt would either lead to a good prognosis or would create a shunt complication includingshunt malfunction, clogged VP shunt or infection. If not treated, the CSF will still continue toaccumulate in the brain and in the long term the person would develop learning disabilities andwould further complicate to mental retardation. Meanwhile if there is a continuousaccumulation of the CSF, it cannot circulate properly and would force its way below the spinalcord. If that happens there would be a displacement of the foramen magnum and creates aherniation of the cerebellum, this condition is called Chiari II malformation in which the personwould experience headache, nausea and vomiting, dizziness, increased intra cranial pressure. Ifnot treated there would be a compression of the spinal cord making the person feel chokingsensation, arm stiffness, difficulty in feeding, swallowing and breathing and eventually woulddie.
Predisposing factors: Precipitating factors:- Age - Nutrition- Heredity - Medications- Unknown - Socio-economic factors -Diabetes - Increased body temp 1st month of Central Nervous System begins to form Defect in the spinal Defect in the closure of the neural tube Protruding sac through the defect- containing meninges Dx: - Meningocele Translumination - CT scan - MRI If treated: If not - Surgical repair of No direct flow of CSF to menigocele the spinal cord Good Obstruction of prognosis fluid in the brain CSF unable to circulate
Accumulation of CSF s/sx: Hydrocephal in the brain - increased us ICP - increase Fluid may head possibly forced circumferenc Displacement of foramen If treated: If not magnum treated: Chiari II - VP Fluid still malformation accumulated in the s/sx: Good Shunt - headache - muscleprognosis complication Learning weakness disabilities - nausea - increased ICP - dizziness s/sx: Mental - headache retardation If not treated: - nausea & vomiting - fever Compression of the spinal cord s/sx: - choking, - arm stiffness - difficulty in feeding, swallowing, and
IDEAL SURGICAL MANAGEMENT OF THE CONDITIONDiagnostic Exams in Detecting Spina BifidaDuring Pregnancy:1. Amniocentesis – a test that involves taking a sample of the mother’s amniotic fluid through a needle inserted into a womb of a mother. Elevated levels of AFP, a gamma 1 globulin, indicates the presence of neural tube defects.2. UltrasoundAfter Pregnancy:1. Translumination – a test where a light a shined through the sac to determine the structure of the sac. If the light is translucent it is meningocele, if not translucent would indicate that it is meningomyelocele.2. CT Scan3. MRISurgical Intervention of Spina Bifida:1. Repair of meningocele2. AV shunt
DIAGNOSTIC EXAMINATION HEMATOLOGY Date Taken: January 26, 2012 CBC, Blood Typing Examination Result Normal Value Significance Blood Component B+ Hemoglobin 126 g/L 134 - 170 Decreased. Indicates anemia or blood loss White Blood Cells 7.4 10^g/L 5.0 – 10.0 Normal Neutrophils .31 0.55 – 0.65 Decreased. Due to bone marrow damage Lymphocytes .60 0.25 – 0.35 Increased. Signifies that there is an infection Eosinophils .09 0.02 – 0.04 Increased. High Eosinophil count may indicate an allergic reactions, parasitic infections, autoimmune diseases. Hematocrit .35 0.40 – 0.50 Decreased. Indicates anemia or acute blood loss Protrombine time 14.0 11 - 17 Normal APTT 34.5 secs 21 – 35 secs Normal CT SCAN Date Taken: January 31, 2012 Cranium CT Scan Findings Impression Normal Findings Impression- Contiguous axial - Non communicatingimages of the brain hydrocephaluswere obtained. No - No evident acuteintravenous contrast intracerebralwas given hemorrhage- There is a moderatedegree of dilation ofboth lateral and 3rdventricles. The 4thventricle is normal insize. The gray-whitematter interface ismaintained. There isno evidence of acuteintracerebralhemorrhage. There is
no midline shift- The cortical sulcicisterns, sella and CPangles are normal forpatients stated age.- The visualizedparanasal sinuses andmastoid air cells arepneumatised.- The visualizedcranium is intact. HEMATOLOGY Date Taken: February 2, 2012 CBC EXAMINATION RESULT NORMAL SIGNIFICANCE VALUE Hemoglobin 103 g/L 134 - 170 Decreased when there is anemia, or blood loss due to surgery, or active bleeding WBC 13.6 ^g/L 5.0 – 10.0 Increased. May be increased with infection or inflammation. Neutrophils 0.69 0.55 – 0.65 Increased. May be due to infection, inflammation or stress Lymphocytes 0.27 0.25 – 0.35 Normal Hematocrit 0.29 0.40 – 0.50 Decreased, when there is anemia or blood loss due to surgery. CLINICAL CHEMISTRY Date Taken: February 2, 2012 FBS EXAMINATION RESULT NORMAL VALUE SIGNIFICANCE Fasting Blood Sugar 3.48 mmol/L Adults: 4.11- 5.58 mmol/L Normal 60 -90 yrs.: 4.56 – 6.38 mmol > 90 yrs.: 4.16- 6.72 mmol/L Children: 3.33 – 5.55 mmol/ L
CSF ANALYSIS Date Taken: February 2, 2012 EXAMINATION RESULT NORMAL VALUE SIGNIFICANCE Color Colorless Colorless Normal Transparency Cloudy Clear and Colorless Cloudy CSF indicates an infection or an increase in the WBCDifferential Count Lymphocytes 92 60 – 70 % Increased. Indicates infection CULTURE AND SENSITIVITY Date taken: February 5, 2012 Specimen: CSF EXAMINATION RESULT NORMAL VALUE SIGNIFICANCE Final No growth after 72 hours of incubating
DRUG STUDY RANITIDINEGeneric Name: Ranitidine hydrochlorideBrand Name: ZantacClassification: H2 Histamine Receptor AntagonistOrdered Dose: 1/26/12 15mg IVTT q 8hrs once on NPO 2/1/12 15mg IVTT prior to OR 2/2/12 20mg IVTT q 8hrsMode of Action: Competitively inhibits action of H2 at receptor sites of parietal cells, decreasing gastric acid secretion which relieves GI discomfortIndication:Pre operative: to relieve GI discomfort from NPO patientsPost operative: to counter the effects of NSAIDS, this causes an increase in gastricsecretionsContraindications: • Use cautiously in elderly patients. • Use cautiously in patients with hepatic dysfunction.Drug Interaction: • Antacids may interfere with ranitidine absorption • Deceases diazepam absorption • Smoking may increase gastric acid secretion and worsen disease • It may interfere with warfarin clearance, monitor patient closely for bleedingSide Effects:CNS: headache, dizzinessOphtha: blurred visionGI: constipation, nausea, vomiting, diarrhea, hepatotoxicityGU: gynecomastiaSystemic: Anaphylaxis, AngioedemaNursing Responsibilities:1. Observe the 5 basic rights of drug administration before giving the drug.2. Explain the purpose of the drug given to the patient.3. Explain to the patient for any side effects of the drug.3. Instruct the patient not to have activities which requires high alertness such as running,walking.4. Encourage the patient to eat high fiber foods and increase oral fluid intake becauseconstipation might occur as side effect.5. Instruct the patient to report any signs of hepatotoxicity such as: dark colored urine,clay-colored stool, yellow skin or sclera, itching.
MectoclopromideGeneric Name: Metoclopramide hydrochlorideBrand Name: Apo-MetoclopClassification: AntiemeticOrdered Dose: 2/1/12 5mg IVTT prior to ORMode of Action: Stimulates motility of upper GI tract by increasing lower esophageal sphincter tone. Blocks chemoreceptor trigger zone which prevents or minimizes nausea and vomiting. Also reduces gag reflex, improves gastric emptying and reduces gastric reflux.Indication: To prevent or reduce postoperative nausea and vomiting.Contraindication: • Use cautiously in patients with a history of depression, Parkinson’s disease, hypertension or renal impairment. Also contraindicated in patients taking drugs that are likely to cause extrapyramidal reactions and those with seizure disorders.Drug Interaction: • Alcohol use may cause additive CNS depression. Discourage using together. • Anticholinergics may antagonize GI motility effects of metoclopramide. • Acetaminophen, aspirin, cyclosporine, diazepam, and levodopa may increase the absorption of these drugs. Watch closely for adverse effects.Adverse Reaction:CNS: sedation, fatigue, headacheGI: dry mouth, constipation, nausea and vomiting, diarrheaGU: decrease libidoCV: hypotension, bradycardiaSystemic: rashesNursing responsibilities:1. Observe the 5 basic rights in drug administration before giving the drug to the patient.2. Explain the purpose of the drug to the patient.3. Explain for any side effects that might occur after giving the drug.4. Instruct the patient or significant other that sedation might occur as side effect and becareful when doing something to prevent further injuries.5. Instruct patient to increase oral fluid intake.6. Instruct the patient or significant other not to rise on bed immediately to preventorthostatic hypotension.7. Encourage patient to eat foods rich in fiber.
CEFIXIMEGeneric Name: CefiximeBrand Name: SupraxClassification: Third- Generation Cephalosporin; AntibioticOrdered Dose: 2/7/12 100mg/5ml 7ml BID POMode of Action: Inhibits cell wall synthesis, preventing osmotic instability; usually bactericidal which hinders or kills bacteria, including H. influenza, M. catarrhalis, S. pyogenes, S. pneumonia, E. coli, and P. mirabilis.Indication: To prevent infection especially for post operative patientsContraindication: • Contraindicated in patients hypersensitive to drug, other cephalosporins and penicillins.Drug Interaction: • Aluminum antacids and magnesium may reduce cefditoren absorption. Avoid using together. If used together, separate doses.Adverse Reaction:CNS: headache, dizzinessGI: nausea and vomiting, diarrhea, abdominal painGU: nephrotoxicityInteg: rash, urticariaRespi: dyspneaSystemic: anaphylaxisNursing responsibilities:1. Observe the 5 basic rights of drug administration before giving the drug to the patient.2. Check for any allergies of the drug.3. Explain the purpose of the drug to the patient.4. Explain for any side effects that might occur after giving the drug.5. Advice patient to have light to moderate meal before giving this drug.6. Instruct patient to report signs of allergic reactions to the drug such as: rashes, urticaria,dyspnea,7. Instruct patient to report for signs of nephrotoxicity. CEFUROXIME
Generic Name: Cefuroxime sodiumBrand Name: ZinacefClassification: Second - Generation Cephalosphorin; AntibioticOrdered Dose: 2/2/12 300mg IVTT q 8hrs ANSTMode of Action: Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal which hinders or kills susceptible bacteria, including many gram-positive organisms and enteric gram-negative bacilli.Indication: Post - operative prophylaxis for infectionContraindication: • Contraindicated in patients hypersensitive to drug and other drug cephalosporins.Drug interaction: • Diuretics may increase risk of adverse renal function • Probenicid may inhibit excretion and increase level of cefuroxime. Sometimes used for this effect. • Any food may increase drug absorption and bioavailability of suspension. Give suspension with food. Tablets may be given without regard to food.Adverse Reaction:CNS: dizziness, headacheGI: diarrhea, nausea and vomiting, abdominal crampsGU: nephrotoxicitySystemic: anaphylaxisNursing responsibilities:1. Observe the 5 basic rights of drug administraiton before giving the drug to the patient.2. Check for any allergies of this drug by doing skin testing.3. Explain the purpose of the drug to the patient.4. Explain possible side effects that might occur after giving the drug.5. Advice the patient to have light to moderate meal before giving the drug.6. Instruct the patient for signs of allergic reaction such as: rashes, urticaria, dyspnea,edema, itching, swelling PARACETAMOL
Generic Name: AcetaminophenBrand Name: Paracetamol, TylenolClassification: Antipyretic, Analgesic, Anti inflammatoryOrdered dose: 2/2/12 300mg IVTT q 6hrs RTC for pain 2/7/12 250mg/5ml 5ml q 4hrs PRN for feverMode of Action: Block pain impulses peripherally that occur in response to inhibition of prostaglandin synthesis; anti pyretic action results from inhibition of prostaglandin in the CNSIndication: to relieve mild pain, to relieve or prevent feverContraindication: contraindicated to patients hypersensitive to the drug, patients with problems in the liverSide Effects:CNS: drowsinessGI: nausea and vomiting, diarrhea, hepatotoxicityInteg: rash, urticariaNursing Responsibilities:1. Observe the 5 basic rights in drug administration before giving the drug to the patient.2. Explain the purpose of giving the drug.3. Explain to the patient the possible side effects of the drug.4. Instruct the patient not to overdose as it is harmful to the liver.5. Instruct patient to report signs of hepatotoxicity such as: dark colored urine, jaundice,icteric sclera, itching. TRAMADOL
Generic Name: Tramadol HydrochlorideBrand Name: Toradol, Tramal, OltramClassification: Opioid analgesicOrdered Dose: 2/2/12 30mg IVTT q 8hrsMode of Action: Not completely known, binds to opioid receptors, inhibits reuptake of norepinehrineIndication: to relieve painContraindication: contraindicated to patients with decrease in blood pressureSide Effects:CNS: dizziness, headache, anxietyGI: nausea and vomiting, GI bleeding, constipationCV: orthostatic hypotension, decrease blood pressureNursing Responsibilities:1. Observe the 5 basic rights of drug administration before giving to the patient.2. Explain the patient the purpose of the drug.3. Explain the possible side effects of the drug.4. Obtain BP first before giving the drug.5. Instruct the patient that orthostatic hypotension might occur and never to rise out of bedimmediately after lying down.6. Instruct the patient to have light meals before giving the drug.7. Encourage the patient to increase oral fluid intake.
Date/ Cues Nee Nursing Diagnosis Objective of Care Nursing Intervention EvaluationTime d F Subjective: N Impaired skin That within our 3 1. Establish rapport to FEBRUARY 6, 2012 E As verbalized by U integrity r/t tissue days span of care, the watcher and to the B the watcher T injury s/t surgical our patient will be patient @ R “wala na ang iya R intervention able to show signs ® to have a trusting U bukol sa likod, I of wound healing relationship, 3pm A wala pa na ayo T ®Surgery involves as evidenced by dry especially to toddlers R ang iya samad sa I cutting of skin and intact wound: who still has stranger GOAL MET! Y likod,” O surface and skin anxiety. N layers causing a. absence of signs After our 3 days span 3 Objective: A injury or trauma to of infection such as: 2. Assess the location of care, our patient was - with post L the skin. Because purulent of the wound, integrity, able to show signs of 2 operative wound - of the injury to the discharges, foul color wound healing as 0 at the upper M skin, there is smelling ; evidenced by dry and 1 back E vasodilation 3. Monitor vital signs intact wound: 2 T causing redness b. absence of ® to provide baseline - with suture line A surrounding the redness and data a. absence of signs of @ at the back B tissue of the injury itchiness; infection such as: O site. 4. Inspect the incision purulent discharges,7am - complains of L c. decrease pain felt every shift using foul smelling; pain at the I in the surgical site. REEDA (Redness, surgical site C Edema, Ecchymosis, b. absence of redness Discharge, and itchiness; P Approximation) A ® frequent c. decreased pain felt in T assessment can the surgical site. T detect early signs E and symptoms of R infection. N 4. Keep the area dry and clean
® moisture harborsbacteria andpathogens6. Carefully dresswounds® to preventinfection7. Limit/avoid use ofplastic materials suchas rubber sheet orplastic linens. Removewrinkled linens® moisturepotentiates skinbreakdown8. AdministerCefuroxime 300mgIVTT every 8 hrs asordered® to inhibit synthesisof bacterial cell wallcausing, cell death9. Administeranalgesics, GiveTramadol 30mg IVTT,as ordered10. Encourage to haveincrease protein intake
® to promote woundhealing11. Encourage watcherto provide patient withappropriate vitaminsespecially vitamin c® to provide positivenitrogen balance toaid in skin/tissuehealing
Date Cues Nee Nursing Objectives of Care Nursing Interventions Evaluation/Ti d Diagnosisme F Subjective: C Acute Pain r/t That within our 3 1. Establish rapport to FEBRUARY 3, 2012 E “sakit kaayo O tissue injury s/t hour span of care, the patient as well as the B akong likod” G surgical our patient will be significant others. @ R (referring to the N intervention able to decrease U surgical site at I level of pain to 2. Note location of 3pm A the back) T ® all cellular acceptable level as surgical procedures R I damage caused evidenced by: ® as this can influence GOAL PARTIALLY Y Objective: V by thermal, the amount of MET! - Grimmace face E mechanical, or a. Decrease pain postoperative pain 3 noted - chemical stimuli scale from 3 to 1; experienced. After our 3 hour span P results in the of care, our patient was 2 - Cries when E release of b. Absence or lessen 3. Monitor vital signs of able to decrease level 0 pain is felt R excitatory indicators of pain the patient of pain to acceptable 1 C neurotransmitte such as: grimaced ® changes in level as evidenced by: 2 - with Wong – E rs. Pain – face, crying, autonomic responses Baker FACES P sensitizing irritability; may indicate increase a. Decreased pain scale @ pain scale T substances in pain before the child from 3 to 1; rating of 3 out 5 U surround the c. Vital signs within verbalizes.12 where : A pain fibers in acceptable range. b. Lessen indicatorspm 0 – no pain L the extracellular 4. Observe non-verbal such as crying and 1 – 2 – mild fluid, creating cues (ex. facial irritability, although pain P the spread of the expressions, guarding patient still exhibit 3 – moderate A pain message position, irritability, grimaced face; pain T and causing restlessness) 4 – 5 – severe T inflammatory ® observations may or c. Vital signs of pain E response. may not be congruent Temp – 36.7°C R with verbal reports BP – 90/60 mmHg - Irritability and N indicating need for PR – 100 bpm restlessness further evaluation. RR – 28 cpm noted
5. Provide a calm and- with vital quiet environment.signs of:Temp – 36.3°C 6. Provide distractionsBP – 100/60 or divertionalmmHG techniques when painPR – 117 bpm occurs such as: toys,RR – 30 cpm music, reading stories ® distraction may help the child divert his/her attention to pain and focus on another object. 7. Give Tramadol 30mg IVTT, as ordered ® to maintain “acceptable” level of pain. 8. Encourage significant others to have the patient adequate rest periods. ® to prevent fatigue.
Date Cues Nee Nursing Objectives of Care Nursing Interventions Evaluation/Ti d Diagnosis me F Subjective: A Impaired Physical Within our span of 1. Establish rapport to FEBRUARY 8, 2012 E “Luya pa man C Mobility related care patient will the patient as well as the B iyang lawas, T to Decrease maintain position of significant others. @ R sige lang siya I muscle strenght function and skin U katulog, dili pa V secondary to Post integrity as 2. Monitor vital signs of 3pm A pud siya kaayo I Operative evidenced by: the patient R mag lihoklihok”, T Procedure - as baseline data GOAL MET! Y as verbalized by Y 1.Absence of grandmother - contractures 3. Determine diagnosis Within our span of 3 R 2.Absence of that contributes to care our patient was Objective: E footdrop, and immobility discharged with 2 - Post operative S 3.Absence of - this will help to maintained position of 0 patient T decubitus identify the causative function and skin 1 - Slowed or contributing factors. integrity as evidenced 2 movement P by: noted A 4. Observe movement @ - Irritability T when client is unaware a. Absence of noted T of observation contractures12 - Flat on bed E - to note any b. Absence ofpm - Always asleep R incongruencies with footdrop, and N reports of abilities. c. Absence of - with vital decubitus. signs of: 5. Support affected body parts using pillows/rolls - to maintain position of function and reduce risk of pressure ulcer 6. Assist in doing range of motion
- to maintain enoughoxygen circulation inthe extremities.7. Provide a calm andquiet environment.8. Encourage significantothers to have thepatient adequate restperiods.® to prevent fatigue.
Date Cues Nee Nursing Diagnosis Objectives of Care Nursing Interventions Evaluation/Ti dme F Subjective: N Risk for aspiration That within our 1. Note the level of FEBRUARY 3, 2012 E As verbalized by U r/t prescribed span of care, our consciousness of the B the watcher: T position patient will be able patient @ R “kung paka-onon R to experience no U nako siya, nag I aspiration as 2. Assess the ability of 3 pm A higha gihapon T evidenced by: the child to swallow R kay mao man gi I ® provides GOAL MET! Y ingon sa doctor” O a. clear breath information about N sounds, absence of potential for choking After our span of 3 Objective: A secretions in the or aspiration care, our patient was - Patient flat on L mouth noiseless able to experience no 2 bed as ordered - respirations; 3. Auscultate lung aspiration as 0 M sounds before and evidenced by: 1 - on Diet as E b. have proper after feeding 2 tolerated with T feeding; ® to determine a. clear breath strict aspiration A presence of sounds, absence of @ precaution B c. watcher will secretions secretions in the O identify risk factors mouth noiseless7am - restlessness L of aspiration. 4. Instruct watcher to respirations; noted I give semi-solid foods C ® to aid swallowing b. had proper - irritability noted efforts feeding; P A 5. Instruct watcher to c. watcher has T feed patient slowly identified risk factors T of aspiration. E 6. Instruct watcher to R give food when patient N is not restless, not talking or crying
® to decrease risk ofaspiration7. Provide tolerablewarm or cold liquids® activatestemperaturereceptors in themouth that help tostimulate swallowing8. Provide informationon the watcher aboutthe effects ofaspiration® to increaseawareness of thewatcher whenfeeding the patient9. Instruct watcher toavoid/limit activitiesthat increase intra-abdominal pressuresuch as: straining,coughing, crying,constrictive clothing® may slowdigestion, increasesthe risk forregurgitation
Date Cues Nee Nursing Objectives of Care Nursing Interventions Evaluation/Ti d Diagnosis me F Subjective: S Disturbed Sleep Within our span of 1. Establish rapport to FEBRUARY 8, 2012 E “Inig makatulog L Pattern related to care patient will the patient as well as the B na ang bata E Interruptions for appeared to have significant others. @ R madisturbo E therapeutics and enough sleep/rest - To decrease level of U napud pag naay P monitoring as evidenced by: anxiety. 7am A tambal ihatag - R ug pag magkuha R d. Decrease 2. Monitor vital signs of GOAL MET! Y na pud ug BP”, E yawning the patient as verbalized by S episodes, - To have baseline Within our span of care 2 grandmother T restlessness data. our patient appeared to and have enough sleep/rest 2 Objective: P irritability, 3. Identify presence of as evidenced by: 0 - Irritability A and factors that contributes 1 noted T e. Increase to sleep pattern 2 - Interrupted T energy level disturbance. 4.Decreased sleep E and feeling - To have a guideline yawning episodes, @ - Restlessness R rested. for proper restlessness and noted N interventions. irritability, and11 - Frequent 5.Increased energypm yawning 4. Observe and/or obtain level and feeling - Body malaise feedback from rested. patient/SOs regarding usual bedtime, routines, number of hours of sleep, time of arising and environmental needs. - To determine usual sleep pattern and provide comparative.
5. Identify circumstancesthat interrupt sleep andfrequency.- To determine theneeds of adjustment.6. Explain the necessityof disturbances formonitoring vital signsand/or other care whenclient is hospitalized7. Arrange care toprovide foruninterrupted periodsfor rest, especiallyallowing for longerperiods of sleep at nightwhen possible. Do asmuch care as possiblewithout waking clients.8. Provide quiet andcomfortableenvironment.- This will allowpatient to have longer/enough rest period.
PROGNOSIS Factors Poor Fair Good Justification1. Duration of Illness * The duration of illness, we rated it fair because from the birth our patient already has the condition. though he had undergone surgical intervention at an early age.2. Onset of Illness * The condition of the patient started after birth, they noticed a mass bulging at the back. At first they didn’t know what to do and were afraid what might happen to it. They sought medical attention and refused treatment at first because of the lack of financial resources3. Precipitating Factors * Since the cause of the disease is unknown, and sometimes triggered during pregnancy. As stated above, the mother during pregnancy was noted avoid taking vitamins and supplements during pregnancy.4. Willingness to take * Despite the age of the patient. Commonlythe medication complaining of taking medications, still complied with the aid of significant others to do so as ordered by the physician.5. Age * This condition is congenital and pediatric patients are prone to this condition.6. Environment * The environment is conducive to live. Free from harm and pollutants.7. Family Support * The grandmother of the patient is always there to watch and support him, though his mother is away from work they manage communicate with the use of cellphone. His father also comes to see him even though he is working hard to support his son’s hospitalization.
Computation: Rating Scale:POOR –1 x 3 = 3 0 – 1.5 = PoorFAIR – 2 x 2 = 4 1.6 – 2.0 = FairGOOD – 3 x 2 = 6 2.1 – 2.5 = GoodTotal: 13 / 7 = 1.8 = FAIRCONCLUSION: We tallied and computed for the prognosis of the patient. Our patient has a fairprognosis because they were able to seek medical and surgical attention at an early age and didnot wait for the condition to get worse. They are able and willing to comply the treatmentregimen given by the doctors. And the family is always there to support the patient. Also theyenvironment around the patient is good because he can play and interact with other peoplewithout getting any disease or problems in the ward.
DISCHARGE PLANMedicationInstructed to:- Take the medications religiously- Take the antibiotics with meals- Take the medications on time without any lapses- Educate the significant others about the drugs as well as its effect, indication, adverse effectsand what to do when it occurs -Take home meds: 1. Cefixime 100mg/5ml 7 ml BID2. Paracetamol 250mg/5ml 5ml q 4 hrs PRN for feverExercise- Encourage to resume normal daily activities- Encourage to exercise lower extremities by walking-Encourage ambulation for faster recovery of damaged tissues- Encourage passive range of motion exercises to strengthen musclesTreatment-Encouraged to follow the treatment regimen prescribed by the doctor- Explain the significant others the importance of drug compliance- Explain to the significant others, in their level of understanding, about the condition of thepatientHygieneEncouraged to:- Have daily hygiene- Clean the surgical site and always keep it dry and clean- Wash hands before and after eating and/or in contact with dirty objectsOut Patient Visit- Instruct to return for follow up check up the OPD- Instruct to monitor or watch closely for any unusuailties such as infections, bowel problems,cough and colds, and report to their physicianDiet- Instructed to continue to the usual diet- Encouraged to eat foods rich in protein to aid in the healing of the wounds- Encouraged to eat nutritious foods such as fruits and vegetables for faster growth anddevelopment of the child
RECOMENDATION This case is interesting to us learners because the cause of this condition is stillconsidered unknown and still needs to be studied. We recommend having further research and study of this case because there is more tolearn from this condition especially to us young nurses who still needs more knowledge andexperience. By exerting more effort and dedication we can help ourselves in this unendingquest for knowledge.