Case Study 01 - delmarlearning.com

1 1-1 CASE Study 1:NewbornTHE NERVOUS SYSTEMO verview:This case requires knowledge of hydrocephalus, spina bifida, growth and devel-opment, as well as an understanding of the client s background, personal situation, and parent-child attachment from Thomson Delmar Learning s Case Study Series: Pediatrics, by Bonita E. Broyles, RN, BSN,MA, PhD. Copyright 2006 Thomson Delmar Learning, Clifton Park, NY. All rights HospitalETHNICITY Black AmericanCOEXISTING CONDITIONS MyelomeningocelePSYCHOSOCIAL Parental anxietyCase Study 3/30/06 3:34 PM Page 1-11-2 Client ProfileJerodis the name Joanna and Jim chose for their first child. Jim accom-panied Joanna to all of her prenatal visits. When the routine ultrasoundwas performed at 32 weeks gestation, Jerod was diagnosed with hydro-cephalus and a myelomeningocele. His parents were initially devastated,but remained very excited about their son s birth. Joanna was scheduledfor a caesarean section at 38 weeks gestation and the couple were anxiousabout Jerod s condition and his treatment following StudyJerod is delivered by caesarean section and transferred to the pediatricintensive care unit (PICU).

2 On admission to the nursery he weighs kg( lb) and is 8 cm (20 in.) in length. His vital signs are:Temperature: 37 C ( F)Pulse: 144 beats/minuteRespirations: 40 breaths/minuteHe has bulging fontanels and a high-pitched cry. His head circumferenceis 40 cm ( in.) and his chest circumference is 34 cm ( in.). In thelumbar region of his spine, the nurse notes a sac-like projection. WhenJoanna and Jim visit the nursery, they stroke Jerod and caress his fingersand toes. Joanna begins to cry and comments to the nurse, I so wanted tobreastfeed Jerod, but now I guess I can t. Copyright 2007 by Thomson Delmar Learning, a division of Thomson Learning, Inc. Permission to reproduce for classroom use the reason for Jerod beingdelivered by caesarean the significance of Jerod sclinical is hydrocephalus? is a myelomeningocele and howis it related to hydrocephalus? the incidence and etiology ofhydrocephalus and the complications associatedwith Jerod s are the priorities of care forJerod on admission?

3 Jerod s parents actions whenvisiting Jerod in the nursery and how thenurse should respond to Joanna s concernabout the priority nursing interven-tions when caring for Jerod smyelomeningocele prior to s myelomeningocele is surgicallyrepaired and a shunt is placed for hisCase Study 3/30/06 3:34 PM Page 1-2 CASE Study 1: NEWBORN1-3 Questions and Suggested the reason for Jerod being delivered by caesarean to deliver Jerod by caesarean section was made to protect theintegrity of the myelomeningocele from the stress of labor and a vaginaldelivery. If he was delivered vaginally, the passage through the tight birthcanal would compromise the integrity of the myelomeningocele, resultingin potential exposure of the sac contents to the vaginal canal and the would increase the risk of infection and further compromise the con-tents of the sac, leading to additional neurological deficits for the significance of Jerod s clinical mani-festations of hydrocephalus include bulging fontanels, a high-pitched cry,and an enlarged head circumference compared to the chest circumference(see Fig.)

4 1-1). A neonate s fontanels should be flat; bulging indicatesincreased pressure within the brain. A high-pitched cry also is a sign ofincreased intracranial pressure. The head circumference of a normalneonate is within cm (1 in.) of the chest circumference; Jerod s is 6 cm( in.) larger than his chest. This further indicates increased intracranialpressure. The sac-like projection in his lumbar region is consistent withspina bifida (see Fig. 1-2). Transillumination is a noninvasive procedure ofshining a flashlight beam on the lateral aspect of the sac to determinewhether the sac is filled with just fluid (meningocele) or if the sac containssolid contents (nerve roots, spinal cord, meninges, and fluid) which indi-cates a myelomeningocele. (Light beams can pass through fluid but notthrough solid tissue.) An ultrasound provides definitive differentiation,however. Jerod s vital signs are within normal limits for a neonate.

5 Unlikein adults, vital sign indicators of increased intracranial pressure are notpresent in neonates until the pressure exceeds the accommodation of theflexible cranial sutures and the is hydrocephalus?According to the National Institute ofNeurological Disorders and Stroke (NINDS), The term hydrocephalus isderived from the Greek words hydromeaning water and cephalusmeaninghead. As its name implies, it is a condition in which the primary character-istic is excessive accumulation of fluid in the brain. Although hydrocephaluswas once known as water on the brain, the water is actually cerebrospinalCopyright 2007 by Thomson Delmar Learning, a division of Thomson Learning, Inc. Permission to reproduce for classroom use Discuss the two types ofshunts used to treat hydrocephalus andwhich is most the complications that mayoccur in a child with a ventriculoperi-toneal (VP) shunt and an atrioventricular(AV) the teaching priorities forJerod s parents prior to his discharge fromthe hospital to Study 3/30/06 3:34 PM Page 1-31-4 Copyright 2007 by Thomson Delmar Learning, a division of Thomson Learning, Inc.

6 Permission to reproduce for classroom use (CSF) a clear fluid surrounding the brain and spinal cord. The exces-sive accumulation of CSF results in an abnormal dilation of the spaces in thebrain called ventricles. This dilation causes potentially harmful pressure onthe tissues of the brain. Hydrocephalus is usually congenital and is associ-ated with the following anomalies of the central nervous system:a. Arnold Chiari malformationb. Congenital arachnoid cystsc. Congenital tumorsd. Aqueduct stenosise. Spina bifida (meningocele and myelomeningocele)It also may result from conditions associated with preterm birth, neonatalmeningitis, subarachnoid hemorrhage, intrauterine infection, and peri-natal hemorrhage. It occurs when there is either impaired absorption ofthe CSF within the subarachnoid space (communicating hydrocephalus)or an obstruction of CSF flow within the ventricles, preventing CSF fromentering the subarachnoid space (noncommunicating hydrocephalus). is a myelomeningocele and how is it related to hydrocephalus?

7 Amyelomeningocele is a congenital neural tube defect resulting fromincomplete closure of the spinal column during the first 28 days of gesta-tion. It leads to neurological deficits similar to a spinal cord injury includ-ing neurogenic bladder and bowel and weakness of the lower extremitieswhen located in the lumbar region. Defects located higher result in moreBulging fontanelLateral ventricleThird ventricleAqueduct ofSylviusFourth 1-1 Comparison of size ventricles and ventricles associated with Study 3/30/06 3:34 PM Page 1-4 CASE Study 1: NEWBORN1-5 Copyright 2007 by Thomson Delmar Learning, a division of Thomson Learning, Inc. Permission to reproduce for classroom use of meningocele; neurological damage including those in the thoracic level and aboveand may cause preterm or neonatal death. Because the central nervous sys-tem develops early, including all of its components, hydrocephalus mostcommonly occurs in conjunction with neural tube Study 3/30/06 3:34 PM Page the incidence and etiology of hydrocephalus and affects approximately 1 in every 500 children, themajority occurring prenatally.

8 The cause of hydrocephalus is not com-pletely understood, but has been associated with genetic inheritance, com-plications of preterm birth, prenatal maternal infection, perinatal infectionor injury, childhood tumors, or subarachnoid hemorrhage. According tothe National Information Center for Children and Youth with Disabilities, Approximately 40% of all Americans may have spina bifida occulta, butbecause they experience little or no symptoms, very few of them ever knowthat they have it. The other two types of spina bifida, meningocele andmyelomeningocele, are known collectively as spina bifida manifesta, andoccur in approximately one out of every 1,000 births. Of these infants bornwith spina bifida manifesta, about 4% have the meningocele form, whileabout 96% have myelomeningocele form. The exact cause ofmyelomeningocele is not known; however, evidence indicates that geneticpredisposition, maternal folic acid deficiency during pregnancy, and viralinfections are strongly associated with the development of spina the complications associated with Jerod s can cause life-threatening infections in the neonate ifthe sac loses its integrity prior to surgical closure.

9 In addition,myelomeningocele leads to neurological deficits similar to a spinal cordinjury including neurogenic bladder and bowel, weakness of the lowerextremities, and paralysis when located in the lumbar region. Defectslocated higher result in more severe neurological damage including thosein the thoracic level and above and may cause preterm or neonatal the central nervous system develops early including all of its com-ponents, hydrocephalus most commonly occurs in conjunction with neuraltube defects. Latex allergies are common in these children as a result of theneed for daily intermittent urinary are the priorities of care for Jerod on admission? a. Ineffective cerebral tissue perfusion related to increased intracra-nial pressureb. Risk for impaired skin integrity related to fragility of myelomeningo-cele sacc. Risk for injury, neurological alterations, related to spinal cord injuryd. Risk for infection related to potential lack of integrity of myelo-meningocele sac, invasive lines, and surgical placement of shunte.

10 Risk for impaired parent/infant attachment related to Jerod s beingin critical care environmentf. Impaired urinary and bowel elimination related to interference ofnerve stimulationCopyright 2007 by Thomson Delmar Learning, a division of Thomson Learning, Inc. Permission to reproduce for classroom use Study 3/30/06 3:34 PM Page 1-6 CASE Study 1: NEWBORN1-7g. Deficient knowledge related to Jerod s condition, treatment, andhome care and should the nurse therapeutically respond to Jerod s mother?Jerod can be breastfed. Prior to surgery, the nurse can assist Joanna in posi-tioning Jerod on his side facing her breast, taking care not to apply anypressure to Jerod s back in the vicinity of the myelomeningocele. This posi-tion can be used postoperatively following Jerod s surgical repair and clo-sure of the myelomeningocele. Joanna should be taught to use a breastpump to express the breast milk that can be stored in the refrigerator andadministered to Jerod until the surgeon clears him for continuation ofbreastfeeding.