CP of Spina Bifida


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CP of Spina Bifida

  1. 1. By: Mark Kevin Felisilda, RNJun Rey Carlo Fundales,RN Jonathan Gonzales, RN Julberry Juan, RN
  2. 2. Spina bifida comes from the latin word “divided spine”. is a rarecongenital condition where there is failure of closure of the spinal cord due tosome factors that causes the spinal cord to create a sac-like cyst at the back ofthe person. The most common type of this condition is spina bifida occulta. It hasbeen reported that in 1000 live births 1-2 babies have this kind of conditionworldwide, in the Philippines it has been said that out of 86,241,691² of thepopulation 5,174 were reported to have spina bifida in the year 2004(curereaserch.com). Our patient belongs to the category of spina bifida cystica withmeningocele, a mild and rare form of neural tube defect where the spinal cord isnot involved in the herniation. He was admitted in the neuro female ward with achief complain of headache and increase in the head circumference. We chosethis case because this is a rare condition in which it is not commonly seen in theward. It is an interesting case because not all have knowledge about thiscondition; 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.
  3. 3. After two months of exposure at Davao Regional Hospital specificallyat Ortho / Neuro Ward, this case study aims to enhance our knowledge andunderstanding regarding the diagnosis of our client so as to develop new skillsin dealing with this kind of illness and to improve our learning regarding SpinaBifida that would be helpful in our future nursing profession.After this case study, we will be able to:• Establish good interpersonal relationship with the client and his family to gaintheir cooperation during the process of gathering data;• Determine the client health status through analyzing the nature of Spina Bifidaand its deviation from the normal physiologic process;• Trace the health history of the client and his family by taking the past andpresent health history to know the predisposing and precipitating factors ofclient’s condition;• Define and discuss thoroughly the complete diagnosis of the client;
  4. 4. • Present a through physical assessment on the client’s condition which serves asa baseline data;• Discuss the anatomy and physiology of the involved system in the disease;• Trace the pathophysiology of the disease process by presenting the etiology,predisposing and precipitating factors, its signs and symptoms present in thepatient;• Interpret the results of congregated diagnostic procedures and laboratoryexaminations and its clinical significance;• Identify and discuss the different drugs used in the management of the client’scondition;• Formulate nursing care plan to provide adequate nursing interventions;• Make a detailed discharge planning necessary for the wellness of the clientusing the acronym METHOD;• Interpret the general prognosis of the client base on a criteria; and• Appreciate the experience we had upon accomplishing the said case study aswell as retaining the supplemental knowledge that we were able to acquirethroughout our 2 months exposure on the ward
  5. 5. Name: Patient SAge: 4 years oldGender: MaleDate of Birth: November 24, 2007Address: Purok 4, Southern Davao, Panabo City, Davao Del NorteReligion: Roman CatholicNationality: FilipinoMother’s Name: SheilaFather’s Name: ArjieSiblings: Mayumi, ArsheilOrdinal Position: Second among the three siblingsWard: Neuro WardDate & Time Admitted: January 26, 2012 @ 3:30pmAdmitting Physician: Dr. Lucio Temonio JrChief Complain: Increasing head circumferenceAddmitting Diagnosis: Spina Bifida with Non – Communicating HydrocephalusFinal Diagnosis: Meningocoele T4 – T6 with Syringomyelia T4 – T9, ObstructiveHydrocephalus Secondary to Chiari II Malformation
  6. 6. Mother:- Visits pre natal check-up- Complete immunzations- ( -) medications during pregnancy- Experienced emesis gravidarum and UTI- Avoids taking vitamns and supplements- Sometimes stressed out from workPatient:-Cyst growing at the back of the patient- Advised surgical treatment but refused d/t lack of financial support- Complete immunizations, no known allergies on food and drugs- Age 2: experienced convulsion- Change in behavior: short temper- Right eye and jaw cannot completely move- Experience head ache and increase head circumference-Increasing head circumference and head ache
  7. 7. Father’s Side Mother’s Side Unknown Unknown Mario NormaArjie Arnel † Sheila “Lolong” Unknown Sheryll Legend: Patient S Arsheil - MaleMayumi ← - Female † - Deceased - Atrio – Septal defect - Hypertension - Diabetes ← - Patient
  8. 8. - Mesomorphic body built.- Slightly kyphotic and the right shoulder is lower than the left.-On DAT with SAP-IVF of D5.03 Nacl 500cc @ 60cc/hr, infusing well at left metacarpal vein.Temperature: 36.8°CHeart Rate: 108 bpmPulse Rate: 100 bpmRespiratory Rate: 25 cpmBlood Pressure: 90/60 mmHg
  9. 9. 1/26/12 The doctor ordered to admit in neuro ward Insert IVF For VP shunting1/27/12 For official reading of CXR For pedia clearance1/28/12 Ordered ECG 12 leads1/29/12 Discontinue IVF1/30/12 For Cranial CT scan1/31/12 To secure 1 unit PRBC for OR use
  10. 10. 2/1/12 Pre op orders made For insertion of IVF Provided with pedia clearance2/2/12 Post Op orders Ordered CBC post operative2/3/12 May have DAT with SAP Still flat on bed2/4/12 May elevate head with 1 pillow
  11. 11. 2/5/12 For dressing tomorrow 2/6/12 Decrease IVF to 50 cc/hr D/C Tramadol & Ranitidine2/7/12 May now remove IVF Shift IV Meds to P.O2/8/12 MGH as ordered
  12. 12. Predisposing Precipitating factors: factors: - Nutrition - Age - Medications - Heredity - Socio-economic factors - Unknown -Diabetes - Increased body temp 1st month of pregnancy Central Nervous System begins to form Defect in the spinal cordFailure of spine to join Defect in the closure the lumbosacral area of the neural tube Dx: Spina bifida - X ray occulta - CT scan Protruding sac through Protrusion with some - MRI the defect- containing parts of the spinal meninges cord
  13. 13. s/sx:- dimple formation of Meningocele Myelomeningocelethe affected area- tuft of hair in theaffected area Dx: -Translumination - CT scan - MRI If Treated If Not - Surgical repair of menigocele No diret flow of csf and myelomeningocele to the spinal cord Good Prognosis Obstruction of fluid in the brain CSF unable to circulate s/sx: - increased ICP Hydrocephalus - increase head Accumulation of CSF circumference in the brain - sunken eyeballs - vomiting
  14. 14. Fluid may If Treated If Not possibly force their way out -VP shunt Fluid continues to accumulate in Displacement of the brain the foramen magnum Good Prognosis Shunt Learning Complication Chiari malformation disabilities s/sx: Mental s/sx: - headache retardation - headache - muscle weakness - nausea & vomiting - nausea - increased ICP - fever - dizziness If not treated Myelomeningocele Compression of the spinal cordFlaccid paralysis Loss of bowel Loss of sensation s/sx: of the lower control and bladder choking, arm limb control stiffness, difficulty in feeding, swallowing, andImpaired mobility breathing Impaired urinary Impaired bowel elimination elimination Muscle atrophy
  15. 15. Hematology Jan 26, 2012 – CBC, Blood typing Creatinine,Electrolytes Jan 26, 2012Blood component B+ Creatinine 56.9mmol/L NormalHemoglobin 126g/L Decreased Sodium 145.8 mmol/L NormalWBC 7.4 10^g/L Normal Potassium 3.73 mmol/L NormalNeutrophils .31 Decreased Calcium 1.19 mmol/L NormalLymphocytes .60 IncreasedEosinophils .09 IncreasedHematocrit .35 DecreasedProtrombine time 14.0 Normal APTT 34.5 secs Normal Cranial CTS Jan 31, 2012 Urinalysis Jan 26, 2012 - Non communicating hydrocephalus - No evident acute intracerebral hemorrhageColor Light yellow NormalLeukocytes Negative NormalAlbumin Negative NormalpH 6.0 NormalSugar Negative NormalSp. Gravity 1.005 DecreasedBlood Negative NormalPus cells 0-2 Normal
  16. 16. Hematology Feb 2, 2012 –CBC Feb 5, 2012 Culture and SensitivityHemoglobin 126g/L Decreased No growth after 72 hours of incubatingWBC 7.4 10^g/L IncreasedNeutrophils .31 IncreasedLymphocytes .60 NormalHematocrit .35 Decreased FBS Feb 2, 2012 2.48 mmol/L Normal CSF analysis Feb 2, 2012 Color Colorles Normal s Transpar Cloudy Indicates increase in WBC ency or infection Lymphoc 92 Increased ytes
  17. 17. Brand name: ZantacClassification: H2 Histamine Receptor AntagonistMode of Action: Inhibits action of H2 receptor sites, decreases gastirc acid secretionIndication: Relieve GI discomfortsSide Effects:CNS: headache, dizzinessOphtha: blurred visionGI: constipation, nausea, vomiting, diarrhea,hepatotoxicityGU: gynecomastiaSystemic: Anaphylaxis, Angioedema
  18. 18. Brand name: Apo-metoclopClassification: AntiemticMode of Action: Bocks chemoreceptor trigger zone which prevents or minimize nausea and vomitingIndication: Prevent or reduce vomiting during and after operationSide Effects:CNS: sedation, fatigue, headacheGI: dry mouth, constipation, nausea and vomiting,diarrheaGU: decrease libidoCV: hypotension, bradycardiaSystemic: rashes
  19. 19. Brand name: SupraxClassification: 3rd Generation CephalosphorinMode of Action: Inhibits cell wall synthesisIndication: Prophylaxis for post op patientsSide Effects:CNS: headache, dizzinessGI: nausea and vomiting, diarrhea, abdominal painGU: nephrotoxicityInteg: rash, urticariaRespi: dyspneaSystemic: anaphylaxis
  20. 20. Brand name: ZinacefClassification: 2nd Generation CephalosphorinMode of Action: Inhibits cell wall synthesisIndication: Prophylaxis for post op patientsSide Effects:CNS: dizziness, headacheGI: diarrhea, nausea and vomiting, abdominalcrampsGU: nephrotoxicitySystemic: anaphylaxis
  21. 21. Brand name: Paracetamol, Acetaminophen, TylenolClassification: Antipyretic, AnalgesicMode 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 CNSSide Effects:CNS: drowsinessGI: nausea and vomiting, diarrhea, hepatotoxicity Integ: rash, urticaria
  22. 22. Brand Name: Toradol, Tramal, OltramClassification: Opioid analgesicMode of Action: Not completely known, binds to opioid receptors, inhibits reuptake of norepinehrineIndication: to relieve painSide Effects:CNS: dizziness, headache, anxietyGI: nausea and vomiting, GI bleeding, constipationCV: orthostatic hypotension, decrease blood pressure
  23. 23. Computation: Rating Scale: POOR –1 x 2 = 2 0 – 1.5 = Poor FAIR – 2 x 2 = 4 1.5 – 2.0 = Fair GOOD – 3 x 3 = 9 2.0 – 2.5 = Good Total: 15 / 7 = 2 = GOODCONCLUSION: