SPINA BIFIDA

A Case Presentation

Presented to the

Nursing Service Department

By: 

Mark Kevin Felisilda, RNJun Rey Carlo Fundales,RN

Jonathan Gonzales, RNJulberry Juan, RN

Introduction

Spina bifida comes from the latin word “divided spine”. is a rare congenital condition where there is failure of closure of the spinal cord due to some factors that causes the spinal cord to create a sac-like cyst at the back of the person. The most common type of this condition is spina bifida occulta. It has been reported that in 1000 live births 1-2 babies have this kind of condition worldwide, in the Philippines it has been said that out of 86,241,691² of the population 5,174 were reported to have spina bifida in the year 2004 (curereaserch.com).  

Our patient belongs to the category of spina bifida cystica with meningocele, a mild and rare form of neural tube defect where the spinal cord is not involved in the herniation. He was admitted in the neuro female ward with a chief complain of headache and increase in the head circumference. We chose this case because this is a rare condition in which it is not commonly seen in the ward. It is an interesting case because not all have knowledge about this condition; we want to broaden our knowledge about this case so that we may be able to help prevent the occurrence of this condition in the community.

OBJECTIVES

General ObjectivesAfter two months of exposure at Davao Regional Hospital specifically

at Ortho / Neuro Ward, this case study aims to enhance our knowledge and understanding regarding the diagnosis of our client so as to develop new skills in dealing with this kind of illness and to improve our learning regarding Spina Bifida that would be helpful in our future nursing profession.

Specific Objectives

After this case study, we will be able to:• Establish good interpersonal relationship with the client and his family to gain their cooperation during the process of gathering data;• Determine the client health status through analyzing the nature of Spina Bifida and its deviation from the normal physiologic process;• Trace the health history of the client and his family by taking the past and present health history to know the predisposing and precipitating factors of client’s condition;• Define and discuss thoroughly the complete diagnosis of the client;

• Present a through physical assessment on the client’s condition which serves as a 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 the patient;• Interpret the results of congregated diagnostic procedures and laboratory examinations and its clinical significance;• Identify and discuss the different drugs used in the management of the client’s condition;• Formulate nursing care plan to provide adequate nursing interventions;• Make a detailed discharge planning necessary for the wellness of the client using 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 as well as retaining the supplemental knowledge that we were able to acquire throughout our 2 months exposure on the ward 

PERSONAL DATAName: 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 siblings 

CLINICAL DATAWard: 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, Obstructive Hydrocephalus Secondary to Chiari II Malformation

HISTORY OF THE PATIENT

Past Medical HistoryMother: - Visits pre natal check-up- Complete immunzations- ( -) medications during pregnancy- Experienced emesis gravidarum and UTI- Avoids taking vitamns and supplements - Sometimes stressed out from work

Patient:-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

History of Present Illness-Increasing head circumference and head ache

GENOGRAMFather’s Side Mother’s Side

Unknown ♂ Mario ♂

Arjie ♂ ♠ Arnel ♂ ♥ † Unknown ♂“Lolong” ♂

Patient S ♂ ←

Unknown ♀ Norma ♀ ◊

Sheryll ♀ ◊Sheila ♀

Arsheil ♀ ♥Mayumi ♀

Legend:

♂ - Male

♀ - Female

† - Deceased

♥ - Atrio – Septal defect

♠ - Hypertension

◊ - Diabetes

← - Patient

PHYSICAL ASSESSMENT

General Survey

Vital Signs

- 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 

Skin

Head

Eyes

Ears

Nose

Chest

Genito- urinary

Mouth

Neck and Throat

Abdomen

Upper Extremities

Lower Extremities

COURSE IN THE WARD

1/26/12 The doctor ordered to admit in neuro wardInsert IVFFor VP shunting

1/27/12 For official reading of CXRFor pedia clearance

1/28/12 Ordered ECG 12 leads

1/29/12 Discontinue IVF

1/30/12 For Cranial CT scan

1/31/12 To secure 1 unit PRBC for OR use

2/1/12 Pre op orders madeFor insertion of IVFProvided with pedia clearance

2/2/12 Post Op ordersOrdered CBC post operative

 

2/3/12 May have DAT with SAPStill flat on bed

2/4/12 May elevate head with 1 pillow

2/5/12 For dressing tomorrow

2/6/12 Decrease IVF to 50 cc/hrD/C Tramadol & Ranitidine

2/7/12 May now remove IVFShift IV Meds to P.O

2/8/12 MGH as ordered

ANATOMY AND PHYSIOLOGY

Brain

Brain Stem

Cerebellum

Cerebral Hemispheres

Cerebrosopinal Fluid

Diencephalon

Dermatomes and Mayotome

Meninges

Spinal Cord

PATHOPHYSIOLOGY

Predisposing factors:- Age- Heredity- Unknown

Precipitating factors:- Nutrition- Medications- Socio-economic factors-Diabetes- Increased body temp

1st month of pregnancy

Central Nervous System begins to

form

Defect in the spinal cord

Failure of spine to join the lumbosacral area

Defect in the closure of the neural tube

Spina bifida occulta

Dx:- X ray- CT scan- MRI

Protruding sac through the defect- containing

meninges

Protrusion with some parts of the spinal

cord

s/sx:- dimple formation of the affected area- tuft of hair in the affected area

Meningocele Myelomeningocele

Dx:-Translumination- CT scan- MRI

If Treated If Not

- Surgical repair of menigocele

and myelomeningocele

Good Prognosis

No diret flow of csf to the spinal cord

Obstruction of fluid in the brain

CSF unable to circulate

Accumulation of CSF in the brain

Hydrocephaluss/sx:- increased ICP- increase head circumference- sunken eyeballs- vomiting

If Treated If Not

-VP shunt

Good Prognosis Shunt Complication

s/sx:- headache- nausea & vomiting- fever

Fluid continues to accumulate in

the brain

Learning disabilities

Mental retardation

Fluid may possibly force their way out

Displacement of the foramen

magnum

Chiari malformation

s/sx:- headache - muscle weakness- nausea - increased ICP- dizziness

If not treated

Compression of the spinal cord

s/sx:choking, arm stiffness, difficulty in feeding, swallowing, and breathing

Myelomeningocele

Flaccid paralysis of the lower

limb

Loss of bowel control and bladder

control

Loss of sensation

Impaired mobility

Muscle atrophy

Impaired urinary

elimination

Impaired bowel elimination

DIAGNOSTIC EXAMINATION

Hematology Jan 26, 2012 – CBC, Blood typing

Blood component B +

Hemoglobin 126g/L Decreased

WBC 7.4 10^g/L Normal

Neutrophils .31 Decreased

Lymphocytes .60 Increased

Eosinophils .09 Increased

Hematocrit .35 Decreased

Protrombine time 14.0 Normal

APTT 34.5 secs Normal

Creatinine,Electrolytes Jan 26, 2012

Creatinine 56.9mmol/L Normal

Sodium 145.8 mmol/L Normal

Potassium 3.73 mmol/L Normal

Calcium 1.19 mmol/L Normal

UrinalysisColor Light yellow Normal

Leukocytes Negative Normal

Albumin Negative Normal

pH 6.0 Normal

Sugar Negative Normal

Sp. Gravity 1.005 Decreased

Blood Negative Normal

Pus cells 0 - 2 Normal

Jan 26, 2012

Cranial CTS Jan 31, 2012

- Non communicating hydrocephalus- No evident acute intracerebral hemorrhage

Hematology Feb 2, 2012 –CBC

Hemoglobin 126g/L Decreased

WBC 7.4 10^g/L Increased

Neutrophils .31 Increased

Lymphocytes .60 Normal

Hematocrit .35 Decreased

FBS Feb 2, 2012

2.48 mmol/L Normal

CSF analysis Feb 2, 2012

Color Colorless

Normal

Transparency

Cloudy Indicates increase in WBC or infection

Lymphocytes

92 Increased

Culture and Sensitivity Feb 5, 2012

No growth after 72 hours of incubating

DRUG STUDY

Ranitidine

Brand name: ZantacClassification: H2 Histamine Receptor AntagonistMode of Action: Inhibits action of H2 receptor sites,

decreases gastirc acid secretionIndication: Relieve GI discomforts Side Effects: CNS: headache, dizzinessOphtha: blurred visionGI: constipation, nausea, vomiting, diarrhea, hepatotoxicityGU: gynecomastiaSystemic: Anaphylaxis, Angioedema

Metoclopromide

Brand name: Apo-metoclopClassification: AntiemticMode of Action: Bocks chemoreceptor trigger zone

which prevents or minimize nausea and vomiting

Indication: Prevent or reduce vomiting during and after operation

Side Effects: CNS: sedation, fatigue, headacheGI: dry mouth, constipation, nausea and vomiting, diarrheaGU: decrease libidoCV: hypotension, bradycardiaSystemic: rashes

Cefixime

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

Cefuroxime

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, abdominal crampsGU: nephrotoxicitySystemic: anaphylaxis

Paracetamol

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

Tamadol

Brand Name: Toradol, Tramal, OltramClassification: Opioid analgesicMode of Action: Not completely known, binds to opioid

receptors, inhibits reuptake of norepinehrine

Indication: to relieve painSide Effects:CNS: dizziness, headache, anxietyGI: nausea and vomiting, GI bleeding, constipationCV: orthostatic hypotension, decrease blood pressure

PROGNOSIS

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 = GOOD  

CONCLUSION:

DISCHARGE PLAN

Medication

Exercise

Treatment

Hygiene

Out Patient Visit

Diet