Nursing Care Plan (NCP) for Neural Tube Defect, Spina Bifida

By the end of this lesson, nursing students will be able to develop a comprehensive Nursing Care Plan (NCP) for a pediatric patient diagnosed with Spina Bifida

Understanding Spina Bifida:
- Gain knowledge about the pathophysiology and classification of Spina Bifida.
- Identify the different types of Spina Bifida, including open (myelomeningocele) and closed (meningocele) defects.
Assessment and Risk Identification:
- Learn how to conduct a thorough assessment to identify the physical and neurological challenges associated with Spina Bifida.
- Recognize risk factors that may contribute to complications, such as hydrocephalus or tethered cord.
Interventions for Daily Care:
- Explore interventions for daily care, including skin and bowel management, mobility assistance, and positioning.
- Understand the importance of interdisciplinary collaboration in providing optimal care.
Prevention of Complications:
- Learn strategies to prevent complications like infections, neurogenic bladder, and musculoskeletal issues.
- Understand the role of preventive measures, such as folic acid supplementation during pregnancy.
Psychosocial Support and Family Education:
- Recognize the impact of Spina Bifida on the child and family.
- Gain insights into providing psychosocial support to both the child and their caregivers.
- Understand the importance of family education in promoting independence and quality of life for the child.

Pathophysiology for Neural Tube Defect, Spina Bifida

Altered Cerebrospinal Fluid Dynamics:
- The malformation in neural tube closure can disrupt the normal flow and absorption of cerebrospinal fluid (CSF), leading to the accumulation of fluid in the brain’s ventricles, and contributing to the development of hydrocephalus.
Chiari II Malformation:
- The structural abnormalities associated with Spina Bifida can result in the downward displacement of the cerebellum and brainstem through the foramen magnum, known as Chiari II malformation. This can further exacerbate neurological symptoms and complications.
Tethered Cord Syndrome:
- In Spina Bifida, the spinal cord may become tethered or abnormally attached to surrounding tissues, limiting its movement. Tethered cord syndrome can cause progressive neurological deficits and may require surgical intervention to prevent further complications.
Neural Tube Development Failure:
- Incomplete closure of the neural tube during fetal development, leading to exposure of neural tissue.
Meningocele:
- Protrusion of the meninges through the spinal defect without the spinal cord being exposed.
Myelomeningocele:
- Most severe form, involving the protrusion of both meninges and spinal cord through the spinal defect.
Neurological Implications:
- Disruption of normal nerve function below the level of the spinal defect, leading to paralysis, sensory deficits, and other neurological issues.
Associated Complications:
- Increased risk of hydrocephalus, Chiari malformation, tethered cord syndrome, and neurogenic bladder.

Etiology for Neural Tube Defect, Spina Bifida

Medication and Teratogenic Exposures:
- Certain medications, such as antiepileptic drugs and some antiretroviral medications, as well as exposure to teratogenic substances, can increase the risk of neural tube defects.
Maternal Obesity:
- Obesity in the mother before conception and during early pregnancy has been identified as a potential risk factor for neural tube defects, including Spina Bifida.
Hyperthermia during Pregnancy:
- Prolonged exposure to high temperatures, such as fever or the use of hot tubs during the early stages of pregnancy, may contribute to an elevated risk of neural tube defects, including the development of Spina Bifida in the fetus.
Genetic Factors:
- Inherited predisposition or genetic mutations play a role.
Environmental Factors:
- Exposure to certain environmental factors during pregnancy, such as inadequate folic acid intake.
Nutritional Factors:
- Insufficient folic acid during early pregnancy is a significant risk factor.
Multifactorial Influence:
- Interplay of genetic and environmental factors.
Increased Risk Groups:
- Women with a previous child with Spina Bifida, certain ethnic groups, and those with pre-existing diabetes.

Desired Outcome for Neural Tube Defect, Spina Bifida

Optimal Neurological Functioning:
- Promote the highest possible level of neurological functioning for the child.
Prevention of Complications:
- Minimize the risk of complications such as infections, tethered cord, and musculoskeletal issues.
Enhanced Mobility and Independence:
- Facilitate interventions that support mobility and independence in daily activities.
Effective Bowel and Bladder Management:
- Implement strategies for effective bowel and bladder management.
Psychosocial Well-being:
- Support the child and family emotionally, providing resources for coping and adaptation to the challenges of Spina Bifida.

Nursing Care Plan for Neural Tube Defect, Spina Bifida

Subjective Data:

Muscle weakness
Lack of sensation

Objective Data:

Abnormal tuft of hair or dimple on back
Protrusion of a sac from an opening in the spinal column
Lack of movement in lower extremities
Urinary or fecal incontinence later in life (lack of control)

Nursing Assessment for Neural Tube Defect, Spina Bifida

Neurological Assessment:
- Evaluate motor and sensory function below the level of the spinal defect.
- Assess reflexes and muscle strength.
Skin Integrity:
- Monitor for skin breakdown over the spinal defect area.
- Implement measures to prevent pressure ulcers.
Bowel and Bladder Function:
- Assess bowel and bladder function regularly.
- Implement a bowel and bladder management plan.
Mobility Assessment:
- Evaluate the child’s current level of mobility.
- Identify aids or assistive devices needed for optimal mobility.
Hydrocephalus Monitoring:
- Monitor for signs and symptoms of hydrocephalus.
- Collaborate with the healthcare team for appropriate interventions.
Orthopedic Assessment:
- Assess for orthopedic issues such as scoliosis or joint contractures.
- Collaborate with orthopedic specialists for management.
Psychosocial Assessment:
- Evaluate the child’s and family’s emotional well-being.
- Identify coping mechanisms and support systems.
Educational Assessment:
- Assess the child’s developmental and educational needs.
- Collaborate with educators to provide appropriate educational support.

Implementation for Neural Tube Defect, Spina Bifida

Neurological Monitoring:
- Implement a regular schedule for neurological assessments.
- Collaborate with neurology specialists for comprehensive monitoring.
Wound Care and Skin Protection:
- Provide meticulous wound care for open defects.
- Educate caregivers on the importance of skin protection and positioning.
Bowel and Bladder Management:
- Develop an individualized bowel and bladder management plan.
- Educate caregivers on techniques and routines.
Mobility Support:
- Collaborate with physical therapists to develop a mobility plan.
- Ensure accessibility and adapt the environment to promote independent mobility.
Psychosocial Support:
- Facilitate access to counseling services for the child and family.
- Encourage participation in support groups for families dealing with Spina Bifida.

Nursing Interventions and Rationales for Neural Tube Defect, Spina Bifida

Nursing Intervention (ADPIE)	Rationale
Perform newborn assessment, APGAR score and physical examination	Observe for presence of abnormalities or physical defects. Note spinal column, abnormal tufts of hair or dimples on infant’s back that indicate a closed neural tube defect or spina bifida occulta.
Assess and monitor vital signs	Gather baseline information, monitor for changes or signs of complications. Autonomic instability is possible with spinal cord involvement.
Apply moist, sterile dressing over sac. Provide dressing care as needed and per facility protocol	Moist dressings prevent drying of the sac that can cause rupture and risk infection.
Assess temperature and signs of infection. Assess for irritation, redness, swelling or drainage around the sac.	Exposure of a fluid sac or spinal cord through opening in the skin increases risk of bacterial infection
Perform careful handling during nursing care. Change process of care activities as appropriate	Be careful to avoid trauma to the sac to prevent further damage to the spinal cord
Provide pre- and post- surgical care	Surgical site care should be done using sterile technique following surgery to prevent infection.
Administer medications appropriately	Antibiotics may be given empirically to prevent infections. Antispasmodics and anticholinergics may be given to help bladder incontinence.
Assess bowel and bladder function	Note the presence of neurogenic bladder and amount of incontinent care required. Insert urinary catheter, provide catheter care, monitor urine output.
Provide incontinence care as required	Perform intermittent catheterization as required. Can educate older patients to self-catheterize Assist with bladder emptying as necessary (Crede’s maneuver). Provide bowel and skin care to prevent skin breakdown
Provide range of motion exercises	Promote strengthening and prevent contractures and atrophy of muscles
Provide assistance with assistive devices for mobility	Patient may require splints, braces, wheelchair or other devices as he/she grows according to level of disability.
Provide resources and education for parents / caregivers	Resources Home care Relieve anxiety Provide emotional support for care of patient. Relieve some stress by providing education and access to resources.

Evaluation for Neural Tube Defect, Spina Bifida

Neurological Functioning:
- Assess improvements or changes in motor and sensory function.
- Modify interventions based on neurological progress.
Complication Prevention:
- Evaluate the effectiveness of preventive measures.
- Adjust interventions as needed to prevent complications.
Mobility and Independence:
- Assess improvements in mobility and independence.
- Modify plans to support ongoing progress.
Bowel and Bladder Management:
- Monitor the success of the bowel and bladder management plan.
- Adjust strategies based on effectiveness.
Psychosocial Well-being:
- Assess the emotional well-being of the child and family.
- Modify support services as needed for continued psychosocial well-being.

References

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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.