Spina Bifida & Hydrocephalus – Flashcards
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What happens in spina bifida?
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-Neural tube disorder. -Defect of vertebral bodies - causing separation of bony elements allowing the spinal cord elements to possible poke out from in between.
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Spina bifida types
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Occulta: hair tuft of skin dimple Manifesta: Cystica, Meningocele, Myelomeningocele Aperta: open to spinal canal
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Mylodysplasia
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Refers to malformation of the spinal cord and spinal canal (myelomeningocele, etc.)
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Spina Bifida
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Refers to malformation of the verterbral elements
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Etiology-Pregnancy Related
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-Unknown but has been correlated with *alcohol and medication use*. -Seizure and other medications: -Valproic acid (Depakote) -Carbamazapine(Tegretol) -Isotretinion -acne medication -Type I Diabetes -Folate Deficiency
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Prenatal Lab & Diagnostic Tests
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-Maternal Blood Test or Amniotic fluid test: -Alphafetoprotein (increased = neural tube defect) -Fetal Ultrasound (visualize defect) -MRI, Myelography, CT -PREVENTION - Folic acid Daily from 1 month before getting pregnant!
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Treatment Surgery
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-Surgery -best outcome if done within 72 hrs
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Arnold Chiari Malformation
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Downward herniation of the brain stem.
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Tethered Cord Syndrome
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Spinal cord is attached and creating tension - can cause cord injury.
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Assess for Complications
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-*Key complications are UTI's and Meningitis!* -Paralysis and weakness related to the level of injury -Hip Dislocations -Knee Flexion Contractures -Foot and Ankle Deformities ( Example: Valgus) -Spinal Deformities -Kyphosis and Scoliosis -Assess for Developmental Delays -Sensory loss is worst on the back of the legs and common in the perineal area and the feet.
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Orthopedic Complications
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-Maintain physiologic positioning -Position: *prevent hip dislocation (abduct legs)* -ROM and Physical Therapy -Prevent skin breakdown -Maintain locomotor function -Assess and provide developmental stimulation -If occulta observe for disorders of gait, leg weakness, and bowel and bladder dysfunction
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Neurogenic Bladder
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-Preserve renal function and optimal continence -"Saddle Anesthesia" = bladder dysfunction occurs -Observe micteration pattern -Treat UTI's Promptly -Do Not CREDE Urinary Bladder -Vesciculo-Ureteral Reflux of Urine may occur
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To improve Bladder Storage and Continence
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Oxybutnin Cl (Ditropan) Tolterodine (Detrol) Surgery: -Stoma to abd wall -Augmentation cystoplasty for bladder capacity increase -Urinary diversion and construct a bladder from bowel
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Neurogenic Bowel
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Signs: Constipations and Over distention Incontinence / Rectal prolapse Management: Stool History Fluids, Bulk, and Stool Softeners Enemas, Digital Stimulation Toileting Program (schedule eating time and time for BM)
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Medical Diagnosis & Nursing Assessments
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Clinical Manifestations CT, MRI, Ultrasound, Myelogram ASSESS FOR INFECTIONS: (UTI, Menigitis, Pneumonia) BUN, Creatinine Orthopedic/ Musculoskeletal Assessment Vision Assessment Latex Allergy Assessment
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Nursing care immediately post birth:
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-Avoid cooling and maintain temperature -Assess intactness of membrane and observe for leaks, abrasions, infection ,irritation -Cover with a non-adhesive dressing -NS and/or antibiotics to sac if ordered -Keep clean & dressing change q 2-4 hr -Avoid use of diapers until defect is repaired and healed -Position child on abdomen to avoid pressure on sac -Assess motor and sensory function
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Nursing care:
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ASSESS URINE OUTPUT (Suprapubic distention inspite of voiding) Implement BLADDER PROGRAM Assess for signs of MENINGITIS TEMP Elevation (No rectal Temperature!) -Lethargic or Irritable -Nuchal Rigidity -Paradoxical Fussiness -Skin Assessment
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Pre-op nursing care:
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-Position Prone -No diaper -Skin checks -Clean intermittent catheterizations -Physical Therapy
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Post-op nursing care:
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-Vital signs, I&O, Check for CSF leaks -Avoid Infection, -Latex allergy frequent -Treat Pain and Provide Nourishment -Position Prone and possible side-lying
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How do you measure increased intercranial pressure on an infant? What does this mean?
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Infant will have a *firm, non-pulsating fontanel*. Means that intercranial pressure is increased and could indicate meningitis.
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What else can you measure?
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Head circumference (just above eyebrows)
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What else should I watch out for?
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-Seizure -Altered vital signs -Change on LOC -Poor feeding
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Summary of Care: Spina Bifida
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Follow up medical care is important for: -Immunizations (May cause seizures) -Screen for Growth (FOC /HC) -Development and scoliosis Skin care: -Daily checks, clean & dry, Pressure points -Gel filled cushions -Avoid Burns - Bath water, car seats, hot liquids +
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What allergy are patients with spina bifida prone to?
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Latex
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Care Summary/Home Care: Spina Bifida
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-Latex Precautions/Epinepherine "Pen" -Safe wheel chair and ambulation device use- -Watch for signs of Menigitis / UTI -Watch for signs of Increased ICP -Surgical postop care -Catherizations and Bowel Training -Diet - Nutritious without causing obesity
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Hydrocephalus
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A DISTURBANCE IN THE CSF Caused by: maldevelopment, infection, hemorrhage, trauma neoplasm and others
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Communicating Hydrocephalus
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-Impaired absorption (arachnoid villi) -Increased production (choroid plexus)
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Non-communicating Hydrocephalus
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-Obstruction to the flow of CSF
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Clinical Manifestations: Hydrocephalus
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-Increased HEAD CIRCUMFERINCE -Tense & Non-pulsatile ANTERIOR FONTANEL -Shrill CRY -MACEWEN SOUND (CRACK-POT) -Bossing Forehead / N&V -SETTING-SUN Sign -SEIZURES/ -IRRITABLE , LETHARGIC /POOR FEEDING
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Early signs of increased inter-cranial pressure
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-H/A -Vomiting (possibly projectile) -Blurred vision -Dizziness -Decreased pulse -Decreased respirations -Increased BP & pulse pressure -Pupils unequal and slower to react -Sunset eyes -*Changes in LOC* -Bulging, tense fonatnel -Wide sutures -Dilated scalp veins -High-pitched cry
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Late signs of increased inter-cranial pressure
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-Lowered LOC -Decreased motor & sensory responses -Bradycardia -Irregular resp.
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Medical Diagnosis & Nursing Care related to Dx
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-Head Circumference Daily -Pre and post procedure care -CT/MRI -Echoencephalogram: to measure Ventricles -Isotope Ventriculogram: to AssessCSF Flow
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Ventriculo-peritoneal Shunt
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Most common
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Signs of Shunt Obstruction
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-Headache, malaise, not feeling well -Vomiting, altered mental status -Increased blood pressure & head circumference -Cushing's triad (HR ; RR slow ; wide pulse pressure -Bulging fontanel, 6th cranial nerve palsy, -Macewen's sign, changes in gait -Changes in personality & school performance -Possible seizures and neck pain
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Complications
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-If you drain too fast - you can end up with a subdural hematoma. -Peritonitis: and or abdominal abscess - External ventricular drainage until CSF infection free -External drainage ~> level of drainage bag and clamping with movement of bag
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Nursing Care
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PREOP CARE Small Frequent Feedings Support HEAD if LARGE Assist with diagnostic tests Avoid scalp IV if to have surgery
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POST OP CARE
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-Position on NON-OPERATIVE SIDE -Do NOT PUMP SHUNT unless ordered -POSITION FLAT (Rapid decompression can cause subdural hematoma) -Observation as PRE-OP -NEURO SIGNS including PUPILS -Antibiotics PER ORDER/Assess infections -ASSESS INCISION FOR LEAKS -TEST DRAINAGE FOR GLUCOSE -Monitor IV +po Intake and All Output -Skin condition
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DISCHARGE TEACHING
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-Teach Signs of SHUNT MALFUNCTION and INFECTION IMMEDIATE CARE (Neuro status, temperature, skin care and family concerns) -Long-term- Follow discharge instructions -Avoid OVERPROTECTION -Avoid CONTACT SPORTS -Assess EDUCATIONAL NEEDS -Use car seat and seat belts
