Watch More! Unlock the full videos with a FREE trial
Add to Study plan
Master
Included In This Lesson
Study Tools
Example Care Plan_Neural Tube Defect, Spina Bifida (Cheat Sheet)
Blank Nursing Care Plan_CS (Cheat Sheet)
Spinal Bifida (Image)
Types of Spina Bifida (Image)
Spina Bifida Assessment (Picmonic)
Access More! View the full outline and transcript with a FREE trial
Transcript
Hey everyone, today, we're going to be putting together a nursing care plan for a neural tube defect, spina bifida. So, let's get started first. We're going to go over the pathophysiology. So, a neural tube defect is a birth defect of the brain spine and spinal cord is spina bifida. The spinal vertebrae do not fully form and close to protect the spinal cord, leaving an opening along the spinal column. Nursing considerations: we want to do a newborn assessment, vital signs, dressing changes, administer medications, pre and post-surgical care. Desired outcomes: the patient will have optimal motor function. The patient will be free from infection, and the patient will be free from injury. And so here is an example of what spina bifida is. You'll notice how that sac is on the outside of the body. So, you're going to have the dura mater here. That's the spinal cord right here and the spinal fluid. That's on the inside here and it's just going to be exposed to the outside.
Alright, we're going to get into the care plan. We're going to find some subjective data and some objective data that we're going to write here. So, when a patient with spina bifida, what are you going to see in these patients? They're going to have some muscle weakness. One of the classics for spina bifida, you're going to have an abnormal hair or dimple on the back. That is classic. You're going to have that protrusion of the sac. So, you're going to have that lack of sensation, that protrusion of the sac of the opening of that spinal column you saw in that picture, lack of movement in the lower extremities, and you're going to have urinary or fecal incontinence later in the life, or a lack of control.
So, interventions, we want to make sure we're going to perform a newborn assessment and do vital signs. So, you want to do a proper assessment and vital signs. We're going to be looking for temperature, going to make sure that we're doing that Apgar score and a physical examination. We're going to be observing for the presence of abnormalities or physical defects. We want to note the spinal column, any abnormal toughs of hair or dimples on the infant's back that indicate a neural tube defect or spinal bifida. You want to gather baseline information you want to monitor for changes and signs of any sort of complications. Elevated temperature can be a sign of infection. So, you want to assess for any sort of irritation, redness, swelling, or drainage that may be around that sac; exposure of fluid sac or spinal cord through that opening and the skin increases the risk of bacterial infection. Another intervention we want to do is we want to make sure that we're applying moist, sterile dressing over that sac. We want to make sure we're providing dressing care as needed or per the facility protocol. Those moist dressings are going to help prevent drying of that sack that can cause rupture and or risk of infection. Another intervention we want to do, we make sure that we are performing careful handling during nursing care. Any change in the process of care activities as appropriate. We want to just make sure we're careful to avoid any sort of trauma to that sac and able to prevent any further damage to the spinal cord. Another intervention we are going to do, we want to provide any range of motion exercises, range of motion exercises or assistive devices. So, we want to promote strengthening and preventing contractures and atrophy of those muscles. Some patients may require some splints, braces, wheelchair, or any other devices that they may need as they grow. Another intervention is administering medications as needed, and that could be antibiotics for preventing infection, to antispasmodics or anticholinergics to help with bladder incontinence. We want to make sure we're providing pre and post-surgical care. So, the surgical site care should be done using sterile technique to prevent any sort of infection.
Alright, we're going to go over the key points. So, spina bifida, is a birth defect of the brain, spine, and spinal cord. The spinal vertebrae do not fully form and close to protect the spinal cord, leaving it open. Causes include genetics, lifestyle factors, or improper nutrients. Some subjective and objective data that you'll see with these patients. They'll have some muscle weakness, lack of sensation, that tough of hair or dimple on the back, lack of movement in the lower extremities, urinary or fecal incontinence, protrusion of that sac. These ones are classic here. We want to make sure we're doing that newborn assessment, check vital signs, and provide the appropriate dressing changes. Post-surgery we want to do those range of motion exercises, mobility devices, making sure that they have access to those and administering medications. Alright. And that's the end of that care plan, guys. You did amazing.
We love you guys. Go out, be your best self today, and as all ways, happy nursing.
Alright, we're going to get into the care plan. We're going to find some subjective data and some objective data that we're going to write here. So, when a patient with spina bifida, what are you going to see in these patients? They're going to have some muscle weakness. One of the classics for spina bifida, you're going to have an abnormal hair or dimple on the back. That is classic. You're going to have that protrusion of the sac. So, you're going to have that lack of sensation, that protrusion of the sac of the opening of that spinal column you saw in that picture, lack of movement in the lower extremities, and you're going to have urinary or fecal incontinence later in the life, or a lack of control.
So, interventions, we want to make sure we're going to perform a newborn assessment and do vital signs. So, you want to do a proper assessment and vital signs. We're going to be looking for temperature, going to make sure that we're doing that Apgar score and a physical examination. We're going to be observing for the presence of abnormalities or physical defects. We want to note the spinal column, any abnormal toughs of hair or dimples on the infant's back that indicate a neural tube defect or spinal bifida. You want to gather baseline information you want to monitor for changes and signs of any sort of complications. Elevated temperature can be a sign of infection. So, you want to assess for any sort of irritation, redness, swelling, or drainage that may be around that sac; exposure of fluid sac or spinal cord through that opening and the skin increases the risk of bacterial infection. Another intervention we want to do is we want to make sure that we're applying moist, sterile dressing over that sac. We want to make sure we're providing dressing care as needed or per the facility protocol. Those moist dressings are going to help prevent drying of that sack that can cause rupture and or risk of infection. Another intervention we want to do, we make sure that we are performing careful handling during nursing care. Any change in the process of care activities as appropriate. We want to just make sure we're careful to avoid any sort of trauma to that sac and able to prevent any further damage to the spinal cord. Another intervention we are going to do, we want to provide any range of motion exercises, range of motion exercises or assistive devices. So, we want to promote strengthening and preventing contractures and atrophy of those muscles. Some patients may require some splints, braces, wheelchair, or any other devices that they may need as they grow. Another intervention is administering medications as needed, and that could be antibiotics for preventing infection, to antispasmodics or anticholinergics to help with bladder incontinence. We want to make sure we're providing pre and post-surgical care. So, the surgical site care should be done using sterile technique to prevent any sort of infection.
Alright, we're going to go over the key points. So, spina bifida, is a birth defect of the brain, spine, and spinal cord. The spinal vertebrae do not fully form and close to protect the spinal cord, leaving it open. Causes include genetics, lifestyle factors, or improper nutrients. Some subjective and objective data that you'll see with these patients. They'll have some muscle weakness, lack of sensation, that tough of hair or dimple on the back, lack of movement in the lower extremities, urinary or fecal incontinence, protrusion of that sac. These ones are classic here. We want to make sure we're doing that newborn assessment, check vital signs, and provide the appropriate dressing changes. Post-surgery we want to do those range of motion exercises, mobility devices, making sure that they have access to those and administering medications. Alright. And that's the end of that care plan, guys. You did amazing.
We love you guys. Go out, be your best self today, and as all ways, happy nursing.
View the FULL Transcript
When you start a FREE trial you gain access to the full outline as well as:
- SIMCLEX (NCLEX Simulator)
- 6,500+ Practice NCLEX Questions
- 2,000+ HD Videos
- 300+ Nursing Cheatsheets
“Would suggest to all nursing students . . . Guaranteed to ease the stress!”
