20 Flashcards
Casts
are used to immobilize a bone that has been injured or a diseased joint. When a fracture has occurred, a cast serves to hold the bone in reduction, thus preventing deformity as the fracture heals. Casts are constructed of a hard material, traditionally plaster but now more commonly fiberglass. The hard nature of the cast keeps the bone aligned so that healing may occur more quickly. In a fracture that would heal on its own without specific immobilization, a cast may be used to reduce pain and to allow the child increased mobility. The choice of cast material and type of cast will be determined by the physician or nurse practitioner or orthopedic surgeon
Nursing Management: Spine bifida
Nursing care will focus on educating the family. Inform parents of its presence and what the diagnosis means. Many times parents will confuse this diagnosis with spina bifida cystica, a much more serious defect. Occasionally, children with spina bifida occulta eventually need surgical intervention due to degenerative changes or involvement of the spine and nerve roots resulting in complications such as tethered cord, syringomyelia, or diastematomyelia. When these associated problems occur, the condition is often termed “occult spinal dysraphism” to avoid confusion.
Meningeocele
Meningocele, the less serious form of spina bifida cystica, occurs when the meninges herniate through a defect in the vertebrae. The spinal cord is usually normal and there are typically minor or no associated neurologic deficits. Treatment for meningocele involves surgical correction of the lesion (see Fig. 22.13).
Nursing Assessment: Meningocele
Initial assessment after delivery will reveal a visible external sac protruding from the spinal area. It is most often seen in the lumbar region but can be anywhere along the spinal canal. Most are covered with skin and pose no threat to the child. However, assessment to ensure that the sac covering is intact remains important. Assess neurologic status carefully. Before surgical correction the infant will be thoroughly examined to determine whether there is any neural involvement or associated anomalies. Diagnostic procedures such as computed tomography (CT), MRI, and ultrasound may be performed.
Nursing Management
Surgical correction may be delayed if the skin covering the sac is intact and the child has normal neurologic functioning (Kinsman & Johnston, 2016). However, as in a child with myelomeningocele, immediately report any evidence of leaking cerebrospinal fluid (CSF) to ensure prompt intervention to prevent infection. Nursing management will be supportive. Provide pre- and postoperative care similar to the child with myelomeningocele to prevent rupture of the sac, to prevent infection, and to provide adequate nutrition and hydration. Monitor for symptoms of constipation or bladder dysfunction that may result due to increasing size of the lesion. Resulting hydrocephalus has been associated with some cases of meningocele (Kinsman & Johnston, 2016). Therefore, monitor head circumference and watch for signs and symptoms of increased intracranial pressure (ICP).
Myelomingocele
Surgical correction may be delayed if the skin covering the sac is intact and the child has normal neurologic functioning (Kinsman & Johnston, 2016). However, as in a child with myelomeningocele, immediately report any evidence of leaking cerebrospinal fluid (CSF) to ensure prompt intervention to prevent infection. Nursing management will be supportive. Provide pre- and postoperative care similar to the child with myelomeningocele to prevent rupture of the sac, to prevent infection, and to provide adequate nutrition and hydration. Monitor for symptoms of constipation or bladder dysfunction that may result due to increasing size of the lesion. Resulting hydrocephalus has been associated with some cases of meningocele (Kinsman & Johnston, 2016). Therefore, monitor head circumference and watch for signs and symptoms of increased intracranial pressure (ICP).
Therapeutic Management: Myelomin
Surgical closure will be performed as soon as possible after birth, especially if a CSF leak is present or if there is a danger of the sac rupturing. The goal of early surgical intervention is to prevent infection and to minimize further loss of function, which can result from the stretching of nerve roots as the meningeal sac expands after birth. In utero fetal surgery to repair the myelomeningocele has been performed with the first randomized trial showing improved outcomes for the fetuses, such as improved psychomotor function and lower need for shunt placement in the first year of life, but is not without risks to the mother and fetus (McLone & Bowman, 2018). Ongoing management of this disorder remains complex. A multidisciplinary approach is needed, involving specialists in neurology, neurosurgery, urology, orthopedics, therapy, and rehabilitation along with intense nursing care. The chronic nature of this disorder necessitates lifelong follow-up. Nursing
Labs/ Diagnostic Test: Myelomeningocele
A myelomeningocele may be detected prenatally around 16 to 18 weeks’ gestation by ultrasound, by a blood test that detects AFP increases, or by analysis of amniotic fluid for AFP increases. Common laboratory and diagnostic studies ordered for the assessment of myelomeningocele include: MRI CT Ultrasound Myelography
Nursing Management: Prevent Infection
Risk for infection related to the presence of the meningeal sac and potential for rupture is a central nursing concern in the newborn with myelomeningocele. Until surgical intervention occurs, the goal is to prevent rupture or leakage of CSF from the sac. Keeping the sac from drying out is important, as is preventing trauma or pressure on the sac. Use sterile saline-soaked nonadhesive gauze or antibiotic-soaked gauze to keep the sac moist. Immediately report any seepage of clear fluid from the lesion, as this could indicate an opening in the sac and provide a portal of entry for microorganisms. Position the infant in the prone position or supported on the side to avoid pressure on the sac. To keep the infant warm, place the infant in a warmer or isolette to avoid the use of blankets, which could exert too much pressure on the sac. Pay special attention while the infant is in a warmer or isolette because the radiant heat can cause drying and cracking of the sac.
Keep the lesion free of feces and urine to help avoid infection. Position the infant so that urine and feces flow away from the sac (e.g., prone position, or place a folded towel under the abdomen) to help prevent infection. Placing a piece of plastic wrap below the meningocele is another way of preventing feces from coming into contact with the lesion. After surgery, position the infant in the prone or side-lying position to allow the incision to heal. Continue with precautions to prevent urine or feces from coming into contact with the incision.
NM: Promote Urinary Elimination
Children with myelomeningocele often have bladder incontinence, though some children may achieve normal urinary continence. The level of the lesion will influence the amount of dysfunction. Myelomeningocele remains one of the most common causes of neurogenic bladder in children. Therefore, evaluation of renal function by a pediatric urologist should be performed on each child with myelomeningocele. Refer to Chapter 21 for further information regarding neurogenic bladder and appropriate nursing interventions, including clean intermittent catheterization.
Promoting Bowel Elimination
Children with myelomeningocele often have bowel incontinence as well; the level of the lesion affects the amount of dysfunction. Many children with myelomeningocele can achieve some degree of bowel continence. Bowel training with the use of timed enemas or suppositories along with diet modifications can allow for defecation at predetermined times once or twice a day. Although bowel incontinence can be difficult for children as they grow older due to social concerns and self-esteem and body image disturbances, it does not pose the same health risks as urinary incontinence.
Promoting Adequate Nutrition
The risk for altered nutrition, less than body requirements, related to the restrictions on positioning of the infant before and after surgery is another nursing concern. Assist the family in assuming as normal a feeding position as possible. Preoperatively, the risk of rupture may be too high to warrant holding. Therefore, the infant’s head can be turned to the side or the infant can be placed in the side-lying position to facilitate feeding. If the infant is held, special care needs to be taken to avoid pressure on the sac or postoperative incision. Encourage the parents to interact as much as possible with the infant by talking to and touching the infant during feeding to help promote intake. If the mother was planning on breastfeeding the infant, assist her in meeting this goal, if possible. If the infant can be held, encourage her to do this, or assist her in pumping and saving breast milk to be given to the infant via bottle until the infant is able to be held. Feeding an infant in an unusual position can be difficult, and it is the nurse’s role to provide support, education, and modeling for the parents and family when needed.
Preventing Latex Skin Allergy
Sensitivity to latex or natural rubber is very common among children with myelomeningocele. They are at an increased risk of developing an allergy to latex related to the multiple exposures to latex products during surgical procedures and bladder catheterizations. A latex-free environment should be created for all procedures performed on children with myelomeningocele to prevent latex allergy. Also, children with a known latex allergy must be identified and managed in a latex-free environment. The nurse must ensure that these children do not come into direct contact with latex or equipment and supplies that contain latex. Be familiar with those products and equipment at your facility that contain latex and those that are latex free. The Food and Drug Administration (FDA) requires that all medical supplies be labeled if they contain latex (FDA, 2015), but this is not the case for consumer products. Many resources exist that list products that are latex free, and each hospital should have such a list readily available to healthcare professionals. For an updated list of latex-containing products and other helpful information for parents regarding consumer products, contact the Spina Bifida Association of America, a link to which can be found on . Children who are at a high risk for latex sensitivity should wear medical alert identification. Education programs regarding latex sensitivity and ways to prevent it need to be directed at those who care for high-risk children, including teachers, school nurses, relatives, babysitters, and all healthcare professionals
Maintaining Skin Integrity
Address the risk for altered skin integrity related to the infant’s prone position and impaired mobility. The prone position puts constant pressure on the knees and elbows, and it may be difficult to keep the infant clean of urine and feces. Diapering may be contraindicated preoperatively to avoid pressure on the sac. Therefore, ensure that the infant is kept as clean and dry as possible. This is made more difficult by the constant dribbling of stool and urine that may be present. Placing a pad beneath the diaper area and changing it frequently is important. Perform meticulous skin care. Place the infant on a special care mattress and place synthetic sheepskin under the infant to help reduce friction. Special attention to the infant’s legs needs to occur when positioning them, since paralysis may be present. Using a folded diaper between the legs can help reduce pressure and friction from the legs rubbing together.
Emotional Support
Myelomeningocele is a serious disorder that affects multiple body systems and produces varying degrees of deficits. It is a disorder that has lifelong effects. Thanks to medical advances and technology most children born with myelomeningocele can expect to live a normal life, but challenges remain for the family and child as they learn to cope and live with this physical condition. Adjusting to the demands this condition places on the child and family is difficult. Parents may need time to accept their infant’s condition, but as soon as possible they should be involved in the infant’s care. Teaching should begin immediately in the hospital. Teaching should include positioning, preventing infection, feeding, promoting urinary elimination through clean intermittent catheterization, preventing latex allergy, and identifying the signs and symptoms of complications such as increased ICP. Due to the chronic nature of this condition, long-term planning needs to begin in the hospital. These children usually require multiple surgical procedures and hospitalizations, and this can place stress on the family and their finances. The nurse has an important role in providing ongoing education about the illness and its treatments and the plan of care. As the family becomes more comfortable with the condition, they will become the experts in the child’s care. Respect and recognize the family’s changing needs. Providing intense daily care can take its toll on a family, and continual support and encouragement are needed. Referral to the Spina Bifida Association and a local support group for families of children with myelomeningocele is appropriate. See Healthy People 2030.
