The purpose of this study is to examine spina bifida and nursing care interventions. Spina bifida is a birth defect in central nervous system occurring due to neural tube failure to close during embryonic development. The term spina bifida "comes from Latin and means 'split' or 'open' spine." (Laser Spine Institute, 2009) Spina bifida is reported to occur most commonly at the end of the first month of the pregnancy "when the two sides of the embryo's spine fail to join together, leaving an open area." (Laser Spine Institute, 2009) It is additionally reported that in some cases, "the spinal cord or other membranes may push through this opening in the back. The condition usually id detected before a baby is born and treated right away." (Laser Spine Institute, 2009)
Types of Spina Bifida
The types of spina bifida are reported to include the following: (1) Spina Bifida Occulta; and (2) Spina Bifida Cystica/Manifesta. In Spina Bifida Occulta the spinal cord is stated to remain "intact and usually is not visible. Meninges are not exposed on the skin surface and neurological deficit are not usually present. In other words, most children with this type of defect never have any health problems, and the spinal cord is often unaffected." (Laser Spine Institute, 2009) In Spina Bifida Cystica/Manifesta it is reported that the "…vertebra and neural tube close incomplete resulting in a saclike protrusion in the lumbar or sacral area. The defect includes meningocele, myelomeningocele, lipomeningocel, and lipomeningomyelocele." (Laser Spine Institute, 2009) In Spina Bifida Cystica -- Meningocele it is reported that the "…protrusion involves meninges and a saclike cyst that contains CSF in the midline of the back. Spinal cord is not involved and neurological deficits are usually not present." (Laser Spine Institute, 2009) In Spina Bifida Cystica -- Myelomeningocel it is reported that the "protrusion involves meninges, CSF, nerve roots, and spinal cord. The sac is covered by a thin membrane that is prone to leakage or rupture. Neurological deficit are evident." (Laser Spine Institute, 2009)
II. Signs and Symptoms
Patients diagnosed with Spina Bifida are those, which have the following signs and symptoms:
1. Visible spinal defect;
2. Flaccid paralysis of the legs;
3. Hip and joint deformities;
4. Altered bladder and bowel function
5. Specific signs and symptoms depend on the spinal cord involvement. (Laser Spine Institute, 2009)
III. Nursing Interventions
1. Assess the sac and measure the lesion
2. Assess neurological system
3. Assess and monitor for increasing ICP
4. Measure head circumferences
5. Protect the sac, cover with sterile, moist (normal saline), nonadherent dressing and change the dressing every 2-4 hours
6. Place patient in prone position and head to one side
7. Use antiseptic technique
8. Assess and monitor the sac for redness, clear or purulent drainage, abrasions, irritation, and signs of infection
9. Assess the hip and joint deformities;
10. Administer medication: antibiotics, anticholinergics and laxatives as prescribed. (Laser Spine Institute, 2009)
III. Nursing Interventions
Nursing interventions for patients with spina bifida include providing psychological support to assist parents in their acceptance of the diagnosis as well as preoperative and postoperative care. (Illustrated Nursing Practice Manual, 2002) Long-term goals are stated to be inclusive of patient and family teaching and measures to prevent contractures, pressure ulcers, urinary tract infections (UTIs) and other complications." (Illustrated Nursing Practice Manual, 2002) Included in nursing interventions is patient teaching. The nurse teaches parents how to cope with the physical problems of the infant and to successfully meet long-range goals in treatment. The Spina Bifida Association (SBA) report findings from its survey including the following:
(1) Spina bifida clinics range widely in size and availability. A clinic may see from 4 to 60 patients during a clinic day.
(2) Fifty-five percent of spina bifida clinics receive 60% or more of their patient-generated revenue from Medicaid and a small proportion from Medicare. Twenty-five percent of reporting clinics rely completely on funding from patient-generated revenue. Of the 75% that rely to some extent on external financial resources (e.g., from the state in which they are located), 20% have experienced cuts in these sources.
(3) The many types of specialty care that persons with spina bifida may need are variably available in spina bifida clinics. For example, 91% of clinics have a urologist available, and 85% have a physical therapist, but only 37% have a wound ostomy continence nurse.
(4) About half of spina bifida clinics are involved in research, and almost 60% report participating in ongoing quality improvement activities.
(5) Spina bifida clinics reported both strengths and challenges in achieving patient outcomes, involvement of particular healthcare providers, staffing levels, ability to provide optimal and essential services, coordination of care for patients, patient transportation, patient wait times, and engagement with SBA and its local chapters. At the clinic leadership meeting, organizing and providing care for adult patients with spina bifida was mentioned as an immediate need. These services include youth transition to adult care. (Spina Bifida Association, 2012)
These findings serve to illustrate the varied role of the practicing nurse in the provision of care to a spina bifida patient and their family. The study reported by the Spina Bifida Association states that the survey and focus group discussions held with parents and clinic physicians and nurses as the SBA national meeting, revealed considerable variance in how clinics coordinate care, the types of care they provide, and the staff available to provide these services." (2012) Reported as well is that spina bifida care "is extremely complex and ranges in types of specialized care need." (Spina Bifida Association, 2012) Finally, it is stated that the types of specialty care that persons with spina bifida need are "variably available in spina bifida clinics." (Spina Bifida Association, 2012)
IV. Management of the Infant with Myelomeningocele
There is a specific protocol that has been developed for the management of the infant with myelomeningocele before and after surgical closure of the sac. Goals set prior to surgery include providing protection to prevent rupture of the sac and to protect the incision from damage and infection. The family members are educated on the infant's condition and needs for care. Pre-operative care involves the nurse practitioner notifying the Spina Bifida Social Worker and other team consultants. AS well antibiotics are begun and continue for 24 hours following surgical closure of the sac. Patient is placed in a prone position and the dressing is left in place over the sac until the infant is examined by the neurosurgeon and a saline soaked dressing is placed covering the sac. Post-operative care involves the maintenance of the infant in a prone or side-lying position until directed by the Neurosurgical team. The patient receives oral feedings when awake and alert. The patient is monitored for hydrocephalus. Plans that are necessary for patient discharge when the time comes include the Spina Bifida nurse practitioner arranging an appointment in the Spina Bifida Clinic for two weeks following discharge. As well the Spina Bifida Nurse Practitioner will also contact the primary care physician and the family will be instructed to arrange a well child care (WCC) appointment for five days after discharge." (Peterson, 2005) The Spina Bifida Nurse Practitioner makes sure that "newborn screen and Hepatitis B vaccine are completed and noted in discharge note." (Peterson, 2005) All infants are discharged on "prophylaxis Amoxicillin 15 mg/kg PO once daily for 8 weeks." (Peterson, 2005) Documentation for the care of the spina bifida patient includes the following:
(1) Documentation of nursing assessment and interventions on the nursing flowsheet as indicated.
(2) Document the plan, interventions and evaluation on the Interdisciplinary Plan of Care as indicated.
(3) Document family teaching on the Interdisciplinary Plan of Care, Multidisciplinary Discharge Summary or nursing flowsheet as indicated.
(4) Document medication administration on the Medication Administration…