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Gulfreen nursing college

Portfolio
Pediatric health nursing

Assigned by Sir Ahsan Elahi

Prepared by Tahira Yaqoob
GNC-BSN-19-46

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Acknowledgement

I bow also my head to Allah Almighty for This opportunity to work on this case & also provide
his limitless blessing for the Completion of The This project and to- Sincere with my work.

I would like to express my gratitude to my subject teacher Sir Ehsan Elahi who has able given
his value support to co-operation and suggestion so we successfully completing my project
work.

I am thankful to medical department a Avicenna Hospital for their guidance Constant

supervision and providing important info regarding my case study.

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GOAL

My aim is to develop essential as well as skillful nursing care which is based on better and
effective approach that will serve as catalyst to promote health, reduce illness and prevent
an/Eliminate such – Infectious diseases and to learn about its Prevention, Treatment as well
nursing & medical Managements

Objective

I choose spinal bifida as my case study to satisfy my curiosity. It is my 1st Time to Counter this
Kind Of case and so that Because I was So interested in it.I was willing to do This case to
challenge my mind in analyzing the problems , hidden knowledge & to gain experience which

will being new learning for me.

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S.no Table of Content Page

01 Acknowledgement 02
02 Goal and objectives of case study 03
03 Case study 06
04 History of case study 07
05 Head to toe assessment 09
06 Introduction of spinal bifida 10
07 Types of spinal bifida 11
08 Etiology of spinal bifida 12
09 Clinical manifestations of spinal bifida 13
10 Pathophysiology of spinal bifida 14
11 Diagnostic finding of spinal bifida 15
12 Therapeutic management of spinal bifida 16
13 Nursing management of spinal bifida 18
14 Prevention from spinal bifida 19
15 Nursing care plan 20
16 Critical care management 21

Spinal bifida

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Case study

My patient belongs to the category of spinal bifida with meningocele and hydrocephalus
admitted in pediatric ward of Avicenna hospital

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Pediatric assessment form

Biogeographical data

Name: A

Age: 3month old

Gender: female

Date of Birth: august 24, 2022

Address: Bahawalpur

Nationality: Pakistani

Mother’s Name: Shamila

Father’s Name: M. Musa

Siblings: atif

Ordinal Position: Second among the two

Patient presentation complain

“Spinal bifida and Microcephaly”

History of Present illness

1 months before admission, complain of head is larger than any other child his age. It was then
they decided to admitted in children hospital Lahore to seek for medical intervention and they
were advised to admit their patient for VP shunting and he was diagnosed Spinal Bifida with
Non-Communicating Hydrocephalus.

Past medical history

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During the pregnancy our patient’s mother always complies on the pre-natal check up. She
never took any medications that are harmful to her pregnancy and eats foods that are good to

her and to the baby. Sometimes she was also expose to stress due to her work and the lack of
taking supplementary vitamins and folic acid supplement

After giving birth to our patient they noticed that there is a mass growing at the upper back

Family Health history

No family history of spinal bifida and hydrocephalus

Complete vaccination according to schedules.

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Genogram

Red circle 🔴 for disease

Circle for female, rectangle for male

Growth chart

Head to toe Assessment

Our assessment took place on November 2022 at 3pm; the patient was lying side
position on lap of his mother. Her Head are Large size than normal 3 month
infant, his height is small and protrusion on back

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Vital Signs

Temperature 36.8°C

Heart rate 108 bpm

Blood pressure 90/60 mmHg

Respiration 50r/r

Skin Our patient has a fair complexion of his skin. with a capillary refill time of less
than 3 seconds.

Head: Head is slightly larger than normal with 52 cm in diameter.

Eyes: Eyes are symmetrical and are aligned at the upper pinnae of the ear. Iris is
color brown and pupils are equally round

Ears: Ears are symmetrical and are aligned at the outer canthus of the eye. No lesions,
discharges noted.

Nose: Nose is symmetrically aligned at the center of the head. No discharges noted

Inspection Neck and Throat: was able to swallow. Upon palpation there was no mass
noted.

Mouth: Lips and the oral mucosa are pinkish in color with no lesion noted.

Chest Chest: Chest is normal in shape, with AP diameter of 2:1. Right shoulder is
lower than the left shoulder. At the upper back, suture lines noted.

Abdomen: The abdomen is flat and is light brown in color with a bowel sound of
5. No lesions noted upon inspection.

Genito Urinary: At his age, patient is able to hold his bladder for a long time.

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Upper Extremities: Upper extremities are symmetrical in shape and size, and able
to move both extremities Without difficulty. No lesions noted upon inspection.

Lower Extremities: Lower extremities are symmetrical in shape and Size, with
small scars noted at the shin

Introduction of spinal bifida

Abnormalities that derive from the embryonic neural tube (neu- ral tube defects [NTDs])
constitute the largest group of congenital anomalies that are consistent with multifactorial
inheritance. Normal the spinal cord and cauda equine are encased in a protective sheath of
bone and meninges. Failure of neural tube closure produces defects of varying degrees. They
may involve the entire length of the neural tube or may be restricted to a small area.

The human nervous system develops from a small, specialized plate of cells along the back of an
embryo. Early in development, the edges of this plate begin to curl up toward each other,
creating the Neural tube-a narrow sheath that closes to form the brain and spinal cord of the
embryo the top of the tube becomes the brain and the remainder becomes the spinal cord.

Definition of spinal bifida

Any malformation of the spinal Canal and cord, Midline defects involving failure of the osseous
(bony) spine to close are called SB, the most common defect of the CNS.

Types of spinal bifida

 SB occulta
 SB cystica.
Meningocele.
Myelomeningocele

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Spinal bifida occulta

Refers to a defect that is not visible externally. It occurs most frequently in the lumbosacral
area (L5 and S1). SB occulta may not be apparent unless there are associated cutaneous
manifestations or neuromuscular disturbances

Spinal Bifida cystica

Refers to a visible defect with an external saclike protruSion.

The two major forms of SB cystica are;

meningocele, which encases meninges and spinal fluid but no neural elements and
Myelomeningocele (or meningomyelocele), which contains meninges, spinal fluid, and nerves.
Meningocele is not associated with neurologic deficit, which occurs varying, often serious,
degrees in Myelomeningocele. Clinically, the term spinal bifida is used to refer to
myelomeningocele

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Pathophysiology of spinal bifida

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Etiology of spinal bifida

 Radiation
 Mutation in folate pathway in some Cases
 Myelomeningocele may occur in Association with syndrome such as:
 Trisomy 18
 Phaver syndrome
 Meckel Gruber syndrome
 Maternal obesity
 Maternal diabetes mellitus
 Low Maternal vitamin B12 status
 Maternal hyperthermia
 The use of AEDs in pregnancy
 Maternal malnutrition
 Drugs

Clinical manifestations

Spinal Bifida Cystica

 Sensory disturbances usually parallel to motor dysfunction

 Below second lumbar vertebra:
 Flaccid, partial paralysis of lower extremities
 Varying degrees of sensory deficit
 Overflow incontinence with constant dribbling of urine
 Lack of bowel control
 Rectal prolapse (sometimes)
 Below third sacral vertebra:

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 Kyphosis
 Lumbosacral scoliosis
 Hip-dislocation or subluxation

Spinal Bifida Occulta

 Frequently no observable manifestations

 May be associated with one or more cutaneous manifestations: Skin depression
 Dark tufts of hair
 May have neuromuscular disturbances
 Progressive disturbance of gait with foot weakness
 Bowel and bladder sphincter disturbances

Diagnostic evaluation

 Diagnostic measure used to evaluate the brain and spinal

 Include
 MRI
 Ultrasound
 CT
 Neurologic evaluation, Prenatal detection

Therapeutic Management

Management of the child who has a Myelomeningocele requires a multidisciplinary team

approach involving the specialties of neurology, neurosurgery, pediatrics, urology, orthopedics,
rehabilitation, physical therapy, occupational therapy, and social services, as well as intensive
nursing care in a variety of specialty areas.

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The collaborative efforts of these specialists focus on

(1) the Myelomeningocele and the problems associated with the defect – hydrocephalus,
paralysis, orthopedic de- fomites (e.g., developmental dysplasia of the hip, clubfoot; scoliosis).
And genitourinary abnormalities;

(2) possible acquired problems that may or may not be associated, such as Chiari II
malformation, meningitis, seizures, hypoxia, tethered cord, and hemorrhage

(3) other abnormalities, such as cardiac or G1 malformation.

Associated problems are assessed and managed by appropriate surgical and

supportive measures. Shunt procedures provide relief from imminent or progressive
hydrocephalus.

Orthopedic Considerations. According to most orthopedists, musculoskeletal problems

that will affect later locomotion should be evaluated early, and treatment, when indicated,
should be instituted without

Management of Genitourinary Function. Myelomeningocele is one of the most common

causes of neuropathic (neurogenic) bladder dysfunction among children. In infants, the goal of
treatment is to preserve renal function. In older children, the goal is to preserve renal function
and achieve optimal urinary continence.

Bowel control

With diet modification

Regular toilet habits

Prevention from constipation and impaction

Dietary fiber supplement

Laxatives, enema, suppositories

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Nursing Care Management

At birth, an examination is performed to assess the integrity of the membranous cyst.

In addition to the routine assessment of the newborn, assess the infant for the level of
neurologic involvement.

Observation of urinary output, especially if a diaper remains dry, may indicate urinary
retention.

Abdominal assessment revealing bladder distension.

The head circumference is measured, and the fontanels are examined for signs of tension

Care of Myelomeningocele

Infant places in incubator, warmer so temperature can be maintained

Before surgical closure, the Myelomeningocele is prevented from drying by the application of
the sterile moist, non-adherent dressing

Prevent Complication.

The prone position affects other aspects risk of myelomegecele of infant's head is turned to one
side for feeding.

Postoperative Care.

 monitoring vital signs,

 monitoring intake and output,
 providing nourishment,
 observing for signs of infection,
 managing pain.
 The prone position is maintained after surgical closure, although

Support family And Educate about Home Care. As soon as the parents are able to cope
with the infant’s condition, they are encouraged to become involved in care.
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They need to learn how to continue at home the care that has been initiated in the hospital,
including positioning

Prevention

 Centers for Disease Control and Prevention (2009) continues to affirm that 50%-70% of
NTDs can be prevented by daily consumption of 0.4 mg of folic acid among women of
childbearing age.
 To ensure adequate daily intake
 Woman must be taken a folic acid supplement
 For woman who have had previous pregnancy effect
 Folic acid intake is increased to 4 mg under the supervision of practioner be beginning 1
month before a planned pregnancy
 Avoid the drug effect the oliec acid Metabolism.

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Nursing care plan

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Critical care management

Nursing diagnosis Case study

Spinal bifida
Alter body image My patient belongs to
Spinal bifida is a related to the category of spina
malformation of spinal Myelomeningocele bifida with meningocele
cord and Canal. and hydrocephalus
Impair mobility related
to decrease muscle admitted in pediatric
strength ward of Avicenna
hospital

Etiology factor

 Maternal Diagnostic test

malnutrition
 MRI
 Radiation Spinal bifida  Ultrasound
 Genetic matution
 CT scan
in folate pathway
 Cbc
 Drugs
 Neurologic
evaluation

Manifestation of SB. Therapeutic Nursing interventions

management
Lacks of bowel
Assess the integrity
movement Shunt procedure
Care of the
Flaccid, kyphosis Surgery closure of myelomeningocele
myelomeningocele
Lack of bowel control
Prevent complication

Pro

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