I.

HEALTH HISTORY A. DEMOGRAPHIC (BIOGRAPHICAL) DATA 1. Clients Name or Initial (Optional): N.B 2. Gender (Sex): Male 3. Age: 1 month and 2 weeks 4. Birth date: December 26, 2012 5. Birthplace: Bian Laguna 6. Marital (Civil) Status: Child 7. Race / Nationality: Filipino 8. Religion: Iglesia ni Cristo 9. Address: San Pedro, Laguna 10. Educational Background: n/a 11. Occupation: n/a 12. Usual Source of Medical Care: Hospital 13. Admission Diagnosis: Preterm Anomalies, Multiple Congenital Anomalies (Lumbos Sacra Meningocele and Clubfoot), Non-Communicating hydrocephalus, Neurogenic Bladder, Ventriculitis, Inguinal Hernia. 14. Final Diagnosis: Multiple Congenital Anomalies (Lumbos Sacra Meningocele and Clubfoot), Non-Communicating hydrocephalus, Neurogenic Bladder, Ventriculitis. B. SOURCE AND RELIABILITY OF INFORMATION The sources of information are the patients chart, the staff nurses, and the family. C. REASON(S) FOR SEEKING CARE CHIEF COMPLAINTS Preterm Anomalies, for PICU admission Completion of medications D. HISTORY OF PRESENT ILLNESS OR PRESENT HEALTH Upon admission, noted as the increase in head and size and was referred to neurology service. On repeat cranial ultrasound it was noted that patient had noncommunicating hydrocephalus and was planned to undergo insertion of ventriculoperitoneal shunt (VPS) after repair of meningocele. When the patient delivered, his head circumference was 39 cm in size and upon assessment we measured and it was 43 cm in size. Patient was co-managed with neurologist/neurosurgeon regarding lumbosacral meningocele. On fourth hospital day, the discharge on lumbosacral meningocele showed growth of coagulates negative staphylococcus which was considered as contaminant. In the assessment his meningocele was patch with tegaderm which is sterile gauze that was soaked in sterile normal saline solution and it was changed every three days by neurosurgery to prevent infection. Before the patient got discharged from the previous hospital, it was noted that there was a decrease of intermittent patching size of the meningocele. The plan was to do a repair of the meningocele, when the infection was treated. The clubfoot was noted since the patient was admitted. The plan was to refer to orthopedic for correction and he was referred to rehab medication for functional exercise for the foot. Upon assessment it appears swollen and reddish in color.
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Neurogenic bladder was noted on the 5th day of confinement, patient was noted to have urinary retention with distention of the hypo gastric area. Referral to nephrologists was done and they required laboratory tests such as urinalysis, BUN, serum creatinine and diagnostic test of KUB ultrasound. The laboratory work ups were normal and KUB ultrasound showed normal kidneys with noted of neurogenic bladder hence intermittent catheterization was done. Due to persistently increasing head size and fever, a ventricular tap was done on 13th hospital day, however no cerebrospinal fluid was obtained. Therefore another diagnostic test was done to have a baseline for another ventricular tap. The result of the ultrasound showed that there were thickened mantle and echoes on the ventricles, therefore postponing of the procedure and the consideration of the ventriculitis has been noted and shifting of the Amikacin to Vancomycin and decided to complete the treatment for 6 weeks. However neurogenic bladder and ventriculitis was associated with meningocele and hydrocephalus. E. PAST MEDICAL HISTORY OR PAST HEALTH Patient N.B was born in Bian Doctor Medical Center. He is 1 month and 2 weeks old baby boy. He was first admitted at PCMC. Upon admission patients CBC, Blood CS and GS due to leaking meningocele work up were done. He started Ampicillin and Cefotaxime as well as Oxacillin due to desquamation and discharge on the meningocele. On the first hospital day, Patient N.B. had jaundice however after intermittent phototherapy the jaundice upon observation however, after intermittent phototherapy the jaundice eventually resolves. On the third hospital day, Patient N.B. started feeding by OGT which was tolerated and eventually maintained. On the 9th hospital day, the patient persistently had intermittent fever (ranging 3839.5 degree celcius) he was given Paracetamol suppository as well as continuous TSB (tepid sponge bath) and eventually his antibiotic was shifted to Meropenem and Amikacin. On the 12th hospital day, Patient N.B. had episodes of seizure, described as upward rolling of eyeballs with preferential gaze at the right with stiffening of extremities lasting for few seconds. Management for seizure was done, CBC showed no increase in count of all the components of blood however serum electrolyte showed hyponatremia hence correction was done with adjustment of patients intravenous fluid component. On the 18th hospital day, a distention of the hypogastric area became pronounced and note of abdominal mass. On KUB-UTZ, it was also noted that on the hypogastric area there were bowel loops. Patient was referred to have a surgery. After 1 month confinement, he was transferred at Ospital ng Muntinlupa for completion of his medications. They chose Ospital ng Muntinlupa because it is more convenient for them especially when it comes to transportation. F. FAMILY HISTORY Patient N.B. is the only child of a 28 year old teacher and a 25 year old housewife. On the patients maternal side, his grandmother (53 years old) has Hypertension and his grandfather (55 years old) has Diabetes Mellitus and also Hypertension as well. They

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have two children which is the uncle of the patient who has Hypertension and the mother of the patient who is allergic to shrimp. On the patients paternal side, his grandmother (51 years old) experienced epilepsy, his grandfather (58 years old) has Hypertension. They only have one child which is the father of the patient. G. SOCIO-ECONOMIC HISTORY Patient N.B.s father was the one who make a living for them. He is a DepEd teacher and their gross monthly income is Php 20,000. They divide or use their monthly income on food for their whole day. The water that they drink is being delivered to their house while the water that they use for other chores is through the faucet. Theyre just renting their house for about 1 year. The apartment cost Php1,500 a month. It is near in the social amenities like basketball court, wet and dry market, church and baranggay hall. They use gas stove in cooking their everyday foods and they also spend their money for leisure. They also a lot some money intended for gas expenses for their own motor cycle. They use sack for their garbage which is collected by the garbage collector every day. H. DEVELOPMENTAL HISTORY Erick Ericksons Psychosocial Development Theory Erikson's psychosocial crisis stages Trust vs Mistrust (Oral)

It occurs from approximately birth to 1 year. Referred to infancy as the oral sensory stage (as any one might who watches a baby put everything in his mouth) where the major emphasis is on his mothers positive and loving care for the child, with a big emphasis on visual contact and touch. If we pass successfully through this period of life, we will learn to trust that life basically okay and have basic confidence in the future, if we fail to experienced trust and are constantly frustrated because our needs are not met, we may end up with a deep-seated feeling of worthlessness and mistrust in the world in general. Based on the observation, it is seen that Patient N.B becomes irritated whenever the nursing student monitor his vital signs and initiate morning care. His crying only stops whenever he feels his mothers presence. In this kind of stage, the infant develops trust to the person who gives him a sense of acceptance and love. Piagets Cognitive Development Stages of Cognitive Development Sensory-motor (Birth-2yrs. Old)

Piagets ideas surrounding the sensory motor stage are centered on the basis of a schema. Schemas are mental representations or ideas about what things are and how we deal with them. Piaget deduced that the first schemas of an infant are to do with movement. Piaget believed that much of a babys behavior is triggered by certain stimuli, in that they are reflexive. A few weeks after birth, the baby begins to understand some of

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the information it is receiving from its senses, and learns to use some muscles and limbs for movement. These developments are known as action schemas. Patient N.B was diagnosed with Multiple Congenital Anomalies. Because of this he has a problem with his senses. He cannot move his head and his lower extremities due to his present condition. It is very hard for an infant to have this kind of condition because they are having a hard time developing their motor senses. . I. REVIEW OF SYSTEM 1. Regional Examination February 5, 2013 System Normal Findings Vital Signs for infant: PR: 120-160 bpm RR: 30-60 cpm T: 36.8 37.5 C Smooth without lesions. Stretch marks (striae), healed scars, freckles, moles or birthmarks are common finding. Skin is normally a warm temperature. Actual Findings PR: 142 bpm RR: 36 cpm T: 35.8 C Weight: 5 kg Height: 147 cm Poor skin turgor is observed upon assessment. Pale color, excessive lanugo and cold clammy skin is observed upon assessment and also there is a wound on the left foot.

General

Integumentary

Head

Head size and shape vary. Usually Head circumference is 43 cm the head is symmetric, round, erect upon assessment. Head size and in midline. No lesion are visible and shape are not normal. Eyeballs are symmetrically aligned in sockets without protruding or sinking. Bulbar conjunction is clear moist and smooth. Underlying structures are clearly visible. Sclera is white. Pupils are equal round reactive to light. Ears are equal in size bilaterally (normal 4 to 10 cm). The auricles are aligns with the corner of each eye and within a 10 degree angle of the vertical position. Earlobe may be free, attached or soldered. PERRLA, pupils are equally round colored dark brown,its reactive to light, and accommodate. Sunken eye balls are observed upon assessment The ears are bilaterally equal in size and both auricles are also same in size with no deformities observed and aligned in the corner of each eye. Ears are line parallel to one another. Auricles skin is smooth without any presence of lesions, lumps
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Eyes

Ears

 Mouth & Throat:

Lips are smooth and moist without lesions or swelling. Pink lips are normal in light skinned clients as are bluish or flecked lips in some dark skinned clients, especially those of Mediterranean descent.

Pallor around the lips was been observed. There is no presence of sore tongue and ulcers upon assessment. No evidence of cleft and lip palate. Tonsils are both present without swelling and ulcers. No redness noted on both tonsils. Lips are dry.

Neck

Respiratory:

Cardiovascular

Neck is symmetric with head centered and without bulging Upon assessment there is an masses. There is no swelling or insertion of IV in the jugular enlargement and no tenderness on vein. lymph nodes. Nasal flaring is not observed. Nasal flaring is not observed. Normally the diaphragm and Normally the diaphragm and the the external intercostal muscles external intercostal muscles do most do most of the work of of the work of breathing this is breathing this is evidenced by evidenced by outward expansion of outward expansion of the the abdomen and lower ribs on abdomen and lower ribs on inspiration and return to resting inspiration and return to resting position on expiration. position on expiration. Normally no murmurs are heard. Cardiovascular is normal upon However, innocent and physiologic the assessment. No murmurs mid-systolic murmurs may be are heard. present in a healthy heart. Stool - Solid, Light Brown Light Yellow Urine Toes usually point forward and lie flat; however, they may point in or point out. Toes and feet are in alignment with the lower leg, smooth, rounded medial malleolar prominences with prominent heels and metatarsophalangeal joints. Skin is smooth and free of corns and calluses. Longitudinal arch; most of weights bearing is on foot midline No enlargement of veins is visible in the head. CNS is functioning well. Stool - Solid, Green Light Yellow Urine Presence of clubfoot is seen upon assessment. Toes are pointed downward. Hyperextension of the metatarsophalangeal joint and flexion of the proximal interphalangeal joint is apparent in hammer toe. Spine has presence of protrusion due to presence of meningocele. Upon assessment patient has neurologic problem. Visible vein in the scalp is noted.

Gastrointestinal Urinary

Musculoskeletal

Neurologic

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2. Laboratory Studies/ Diagnostic Procedure Date KUB UTZ (January 12, 2013) Normal Values / Findings Significance /Interpretation Nursing Responsibilities Explanation of the Findings Pelvocaliectasi PRE Before the a bilateral procedure the nurse probably due to will: reflux urinary of Verify Doctors retention 35%. order Identify the client Explain the procedure Provide client privacy INTRA Position patient supine on the bed. Remove clothing that will interrupt ultrasound procedure. Advice patients parents that the gel will be applied over the area where the transducer is placed. Keep patient still and provide with pacifier to remain calm. POST After the procedure the nurse will: Request for the results. Discuss the results to the mothers patient.
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Indication

Actual Findings

Official Imaging Report

The kidneys are normal in size and attenuation. No mass noted. The pelvocalyces of the kidneys are mild dilated. Right Kidney: 3.7 x 2.3 x 2.5 cm (LWH) Left Kidney: 3.6 x 2.5 x 2.8 cm (LWH) The Urinary Bladder is partially distended with a volume of 14.0cc post-void volume 5.7cc

 Evaluate results relation to patients symptoms other performed. NEUROSONOGRAM FINDINGS (January 12, 2013) Using 5.0 MHz sector transducer and 7.0 MHz linear transducer, all planes were performed as well as near field technology. Doctor made on sagittal and coronal planes. The ventricles are moderate to severely dilate. Presence of multiple septotions and intraventricular echoes. The parenchyma is euchoic. Identified sulci are flattened. The cerebral hemisphere are symmetrically and there is no shifting of the midline suture. On mid-sagittal section the fourth ventricle and aqueduct sylvius are not identified. On nearfield technology, the interhemisphere fissure, subarachnoid and subdural spaces overlying the cerebral convexities are obliterated. CUTZ REPORT

test in the and test Moderate to severe non communicating hydrocephalus secondary to aqueductal stenosis, ventriculitis

PRE Before the procedure the nurse will: Verify Doctors order Identify the client Review the procedure with the patients mother Explain the procedure to the patients parents. INTRA Lay patient on the bed. Keep patient head still. Keep patient still and provide with pacifier to remain calm. POST After the procedure the nurse will: Request for the results Discuss the results to the mother Monitor progression of the disease process. Evaluate test

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results in relation to the patients symptoms and other test performed.

Procedure Date

Indication

Normal Values/ Findings 138-166

Actual Findin gs

Nursing Responsibilities

Significance / Interpretation Explanation of the Findings Low; poor nutrition that is associated with the vitamin folic acid. Low; decreased production of hemoglobin. Low; lack of substances needed for red blood cells production. Low; too little vitamin or folic acid that made up partly of carbon that is essential in small amount for normal bodily functioning. High; an increased production of WBC to fight an infection Low; the body is not likely to be engaged in fighting off illness. Low; causes an underlying viral infection; the bone marrow isnt functioning properly. High; presence of infection.

HEMATOLO- HEMOGLOBIN GIC SECTION HEMATOCRIT (January 17, 2013) RBC

0.40-0.48 4.2-6.5

RDW

11.0-14.0

WHITE CELL COUNT

5-10 x 10^g/L

EUOSINOPHIL S LYMPHOCYT ES

0.02-0.07

0.25-0.35

MONOCYTES

0.02-0.06

85.0 g/L PRE Before the procedure the nurse will: 0.26 Check on the Doctors order Identify the client 3.08 Assess the patients conditions that might affect the test results. 16.80 Educate the client concerning preparation for the test. Explain the test procedure 16.4 g/L Explain why blood sample is taken Explain the slight discomfort may be 0.01 felt when the skin is punctures. INTRA 0.24 Instruct the mother to cooperate fully and to follow directions in doing the procedure to the client. 0.10 Encourage the mother to avoid making the patient to be stress or get irritated.

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 Ensure the patients safety Assist the mother in assisting the patient during the procedure Observe standard precautions and follow the general guidelines. Identify the patient and label the appropriate tubes with corresponding patients demographics, date and time of collection. Transport the specimen to the laboratory for processing and analysis. POST After the procedure the nurse will: Request for the results Discuss the result to the mother of the patient Managing patient during their routine. Conducting hospital rounds Monitor and document I & O Taking medical histories Check vital signs Monitor and record patients IV fluids. Determine the need for a change therapy Evaluate test results in relation to the patients symptoms
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and other performed.

tests

CLINICAL CHEMICAL DIVISION (January 17, 2013)

CREATININE

58-110

26 umol/L 3.0 mmol/L 37.3 g/L 19.4g/L 17.9g/L

BLOOD UREA NT T PROTEIN

3.2-7.1

63-82

ALBUMIN GLOBULIN

35-50 28-32

SODIUM

137-145

135 mmol/L

PRE Before the procedure the nurse will: Check on the Doctors order Identify the client Assess the patients conditions that might affect the test results. Educate the client concerning preparation for the test. Explain the test procedure Explain why blood sample is taken Explain the slight discomfort may be felt when the skin is punctures. INTRA Administer oral medication prescribed by the physician. Maintain proper nutrition levels by giving patient's proper diet advised by

Low; an efficient and effective pair of kidneys Low; kidney problems are suspected (kidney dysfunction) Low; indicates kidney problem disorder Low; renal/kidney disease Low; indication kidney disease Low;type of hyponatremia can be the result of chronic conditions such as kidney failure (when excessive fluid cannot be efficiently exerted)

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position. Monitor and record I & O. Monitor and record proper IV fluid levels. Deal with all requests from clinicians for laboratory information and interpretation. Participation in on call schedule in clinical pathology. Weekly clinical pathology case conference. Participate in morning rounds with a senior staff attending Instruct the mother to cooperate fully and to follow directions in doing the procedure to the client. Encourage the mother to avoid making the patient to be stress or get irritated. Ensure the patients safety Assist the mother in assisting the patient during the procedure Observe standard precautions and follow the general guidelines. Identify the patient and label the appropriate tubes with corresponding patients demographics, date and time of collection.
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Transport the specimen to the laboratory for processing and analysis. POST After the procedure the nurse will: Request for the results Discuss the result to the mother of the patient Managing patient during their routine. Conducting hospital rounds Monitor and document I & O Taking medical histories Check vital signs Monitor and record patients IV fluids. Determine the need for a change therapy Evaluate test results in relation to the patients symptoms and other tests performed.

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Procedure Date CLINICAL CHEMICA L DIVISION (January 23, 2013

Indication pH

Normal Values/ Findings 7.35-7.45 pH units

Actual Findin gs 7.46

Nursing Responsibilities

P CO2

35-48 mmHg

24

PO2

83-108 mmHg 18-23 mmol/L -2-3 mmol/L -1-1 mmol/L 17-20 mmol/L 95-98%

122

HCO3

17.1

BEb

5.1

BEecf

6.7

SBC

21

SO2c

99

PRE Before the procedure the nurse will: Check on the Doctors order Identify the client Assess the patients conditions that might affect the test results. Educate the client concerning preparation for the test. Explain the test procedure Explain why blood sample is taken Explain the slight discomfort may be felt when the skin is punctures. INTRA Administer oral medication prescribed by the physician. Maintain proper nutrition levels by giving patient's proper diet advised by position. Monitor and record I & O. Monitor and record proper IV fluid levels. Deal with all requests from clinicians for laboratory information and interpretation. Participation in on call schedule in clinical pathology. Weekly clinical

Significance / Interpretation Explanation of the Findings High; the water is turning more alkaline because water is lacking enough CO2 Low; the production was low due to hypothermia and decreased metabolic rate. High; increased O2 levels in inhaled air Low; metabolic acidosis

High High High High; deep/rapid breathing occurs

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pathology case conference. Participate in morning rounds with a senior staff attending Instruct the mother to cooperate fully and to follow directions in doing the procedure to the client. Encourage the mother to avoid making the patient to be stress or get irritated. Ensure the patients safety Assist the mother in assisting the patient during the procedure Observe standard precautions and follow the general guidelines. Identify the patient and label the appropriate tubes with corresponding patients demographics, date and time of collection. Transport the specimen to the laboratory for processing and analysis. Increased fluid intake POST After the procedure the nurse will: Request for the results Discuss the result to the mother of the patient Evaluate or monitor progression of the disease process Deals with all request
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from clinicians for laboratory information and interpretations. Participation in on call schedule in clinical pathology. Managing patient during their routine. Conducting hospital rounds. Monitor and document I & O. Taking medical histories. Check vital signs. Monitor and record patients IV fluids.

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Procedure Date

Indication

CLINICAL CHEMICA L DIVISION (January 23, 2013)

CREATININE

Normal Values /Findin gs 58-110 umol/L 3.2-7.1 umol/L

Actual Findings

25 umol/L

BLOOD UREA NT

2.4 umol/L

SODIUM

137-145 mmol/L

134 mmol/L

Significance /Interpretation Explanation of the Findings PRE Low; an efficient and Before the procedure effective pair of the nurse will: kidneys Check the Doctors Low; kidney problems order are suspected (kidney dsyfunction) Identify the patients name Assess the patients Low; type of condition hyponatremia can be the result of chronic Educate the mother of conditions such as the client concerning kidney failure (when the preparation for excessive fluid cannot the test and what will be efficiently exerted). be the purpose. Explain why blood example is taken Explain that discomfort maybe felt by the patient INTRA Instruct the mother to help the patient cooperate fully and to follow directions Ensure the patients safety Observe standard precautions Transport the specimen to the laboratory. Deals with all request from clinicians for laboratory information and interpretations. POST After the procedure the nurse will: Requests for the results Discuss to the mother
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Nursing Responsibilities

all f the findings/ results Participation in on call schedule in clinical pathology. Presentation at staff seminar, technologist in service seminar weekly clinical pathology case conference Participate in morning rounds with senior staff attending. Procedure Date
CLINICAL MICROSCOPY SECTION URINALYSIS (January 17, 2013)

Indication
MACROSCOPIC: COLOR TURBIDITY (CLARITY) GLUCOSE KETONE SPECIFIC GRAVITY BLOOD Ph PROTEIN UROBILINOGEN NITRATE LEUKOCYTE MICROSCOPIC: COLOR TURBIDITY (CLARITY) GLUCOSE KETONE SPECIFIC GRAVITY BLOOD Ph PROTEIN UROBILINOGEN NITRATE LEUKOCYTE

Actual Findings

Straw Clear (-) (-) 1.004 (-) 8.0 (-) (N) (-) (-)

Light yellow Clear

1.003 7.0

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ENVIRONMENTAL HISTORY (living/neighborhood circumstances) He lives in San Pedro Laguna, which they rented with one room and one bathroom. It is a small concrete house well ventilated and well fit with 3 household members. There source of water supply is through faucet and delivery and their garbage is collected daily. No nearby factory on the dwelling place. Their usual source of transportation is their own motorcycle and sometimes uses jeepney as a substitute. J. PEDIATRIC HISTORY Maternal & birth history Birth date: December 26, 2012 Birth weight: 2.6 kg Type of Delivery: Cesarean Section Condition after birth: Delivered preterm 35 weeks by LMP secondary to presence of multiple congenital anomalies Hospital: Binan Doctor Medical Center Mother: Complications of Delivery: None Anesthesia during labor: Epidural Anesthesia Exposure to teratogenic agents during pregnancy: secondhand smoke and fever

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II.

PATHOPHYSIOLOGY BOOK BASE

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Narrative Book Base Central Nervous System (CNS) defects for approximately one third of all apparent congenital malformations in live infants, and 90% of these are neural tube defects. CNS defects are responsible for 40% of infant deaths in the first year of life. At the first month of pregnancy the upper part of the spinal cord and the brain is formed, followed by the formation of lower spinal cord at 5 6 weeks during pregnancy. If theres any slight interruption during this development it will lead to a congenital defect. Spinal Bifida is one of these congenital defects, it refers to a defect in one or more vertebrae through which the spinal cord contents can protrude. The malformation is commonly occurs in the lumbar or sacral portion of the spine. It is the most common developmental disorder of the CNS for new born. Factors affecting spinal bifida would include inadequate folic acid intake which is used by the body for cell production and development; anticonvulsant which is a folic acid antagonist blocks the absorption of folic acid. Having a history of diabetes before or during pregnancy with high levels of glucose in the body would affect the closure of the spine as well as having a high body temperature during pregnancy. If it will occur, there will be a defect in the spinal cord in which the neural tube will fails to close thus creating an opening and forms a protrusion of the meninges through the spinal space and what is now called the Meningocele. If treated through surgical repair of meningocele it would lead to a good prognosis. But if not, the protrusion will create an obstruction. Due to the obstruction, there will be an indirect flow of cerebro-spinal fluid in and out of the spinal cord and it will accumulate in the brain creating now a hydrocephalus. Hydrocephalus if treated with VP shunt would either lead to a good prognosis or would create a shunt complication including shunt malfunction, clogged VP shunt or infection. If not treated, the CSF will still continue to accumulate in the brain and in the long term the person would develop learning disabilities and would further complicate to mental retardation. Meanwhile if there is a continuous accumulation of the CSF, it cannot circulate properly and would force its way below the spinal cord. If that happens there would be a displacement of the foramen magnum and creates a herniation of the cerebellum, this condition is called Chiari II malformation in which the person would experience headache, nausea and vomiting, dizziness, increased intra cranial pressure. If not treated there would be a compression of the spinal cord making the person feels choking sensation, arm stiffness, difficulty in feeding, swallowing and breathing and eventually would die.

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PAThOPHYSIOLOGY Client Base

Precipitating Factors: Fever at 1st Month of AOG Environment (second hand smoke) Antihistamine at 3 Months of AOG Deficiency of Vitamin B12 First Month of Pregnancy

Formation of CNS

Spinal Bifida Cystica

Defect in lumbo sacral

Failure to form intact neural tube

Vertebral arch fails to close

Meningocele

Protruding sac through defect in spinal cord

Loss of sensory

No direct flow of CSF to spinal

Neurogenic Bladder

Accumulation of CSF in brain Club foot Non Communicating Hydrocephalus Symptom: The foot may point downward

Signs and Symptoms: Ventriculit is Bulging fontanels Increase head size Increase ICP Seizure

Signs and Symptoms: Painful urination Uncontrolled urination

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Narrative Client Base The development of the Central Nervous System of the baby develops during the first month of pregnancy. Any interruption during this period can result to failure of the spinal cord to close, leaving a defect in the spine. Factors affecting failure to closure would include inadequate folic acid intake which is used by the body for cell production and development. Furthermore, 2nd hand smoke can also affect the development of the baby because of its teratogenic effects and having a high body temperature during pregnancy. Spinal bifida cystica is a complex situation; it is associated with a defect called Mengingocele. It creates an opening and forms a protrusion of the meninges through the spinal space. Damage of the spinal cord can also lead to neurologic bladder and club foot because this defect can cause sensory loss around the genitalia and feet. Meningocele can also create an obstruction. Because of this there will be an indirect flow of cerebro spinal fluid in and out of the spinal cord and it will accumulate in the brain creating a non communicating hydrocephalus. It is associated with ventriculitis, which is caused by the infection of the ventricles, leading to swelling and inflammation. The patient also experienced other signs and symptoms of non communicating hydrocephalus which includes increase head size because of abnormal flow of CSF; bulging fontanels and irritation. It has been diagnosed by the use of ultrasound. The patient was delivered by cesarean section during its 35th week because of these defects. He was diagnosed with Multiple Congenital Anomalies.

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III.

CONCEPT MAPPING

Impaired skin integrity related to present condition

Pain related to medical condition

Impaired physical mobility related to present condition

Key Demographic Data: Clients initial: N.B Age: 1 month Gender: Male Reason for Needing Health Care:

Risk for hypothermia related to immaturity of newborns temperature regulatory system dysfunction

Preterm Anomalies, for PICU admission Completion of medications

Medical Diagnosis :

Multiple Congenital Anomalies (Lumbos Sacra Meningocele and Clubfoot), Non-Communicating hydrocephalus, Neurogenic Bladder, Ventriculitis.
Key Assessments:

Disturbed sleep pattern related to interruption for therapeutic and monitoring

RR: 142 PR: 36 Temp: 35.8

Risk for injury related to sensory dysfunction

Risk for infection related to increase vulnerability of infant secondary to open wound
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IV.

PROBLEM LIST a. ACTUAL or Active

Problem No. 1

Problem Impaired tissue integrity related to present condition Pain related to medical condition

Remarks The patient was able to display improvement in wound healing. The mother was able to demonstrate positioning & relaxation techniques to lessen the pain of the patient. The patients mother has been able to verbalized understanding of situation and safety measures. The patient had a continuously sleep in the morning assessment by monitoring of sleep as evidence by continuously sleep only 4-5 hours as verbalized by the mother.

Impaired physical mobility related to present condition

Disturbed sleeping pattern related to interruption for therapeutic and monitoring

b.

HIGH RISK or Potential

Problem No. 1

Problem Risk for infection related to increased vulnerability of infant secondary to open wound Risk for injury related to sensory dysfunction Risk for hypothermia related to immaturity of newborns temperature regulatory system

Remarks The patients mother was able to acquire knowledge how to prevent and avoid further infection. The patients mother patially modified the environment as indicated to enhance dafety. The patientss body temperature will remain within normal axillary range 36.8C 37.5C

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V.

NURSING CARE PLAN

IMPAIRED TISSUE INTEGRITY RELATED TO PRESENT CONDITION Assessment O: Open wound at the left foot. Lack of cleanliness Diagnosis Impaired tissue integrity related to present condition (open wound at the lower left leg) Planning Intervention After 24 hrs. Observe for other of nursing distinguishing intervention characteristics of the patient inflamed tissue. will be able to have a Inspect wound daily progressive for any changes. improvements in wound Promote good healing. nutrition with adequate protein and calorie intake and vitamins with mineral supplements as indicated. Practice aseptic technique for cleaning, dressing and medicating the wound. Monitor studies. Rationale Document for present condition or any other changes. Evaluation After 24 hrs. of nursing intervention the patient wound had a To promote progressive improvement. timely The open intervention. wound turns To facilitate to dry. healing process. GOAL MET.

To reduce risk of contamination.

laboratory For changes of indicative healing, invasion of infection and complications.

Discuss importance of Promote early early detection and detection of reporting of changes in developing condition. complications. Described wound Necessary to drainage. determine extent of impairment.

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ACUTE PAIN RELATED TO MEDICAL CONDITION Assessment S: Sa tuwing hinahawakan o nagagalaw ko, umiiyak siya as verbalized by the mother. O: Irritable Restless Moaning Crying Facial grimace Pain scale of 3/5 Diagnosis Acute pain related to medical condition. Planning Intervention Rationale Evaluation After 1 hr of Note patients age Age relating After 1 hr of nursing and current factors such as nursing intervention condition affecting infants cant intervention, the mother ability to report demonstrate the the mother will pain parameters. level of pain they was able to demonstrate demonstrate feel. proper Determine Pahophysiological proper positioning presence of or psychological positioning and possible such as and relaxation relaxation pathophysiological inflammation, techniques or psychological tissue trauma, techniques to lessen the cause of pain. infection, fear and to lessen the pain of the anxiety can be a pain of the patient. big contribution patient. pain scale turned to pain. Note patients The nurse will be to 2/5. attitude toward able to assess the pain. level of pain of the patient. Obtain patients To rule out assessment of pain worsening of such as location, underlying characteristic, condition or duration, development of GOAL MET frequency, quality complications. and intensity. Reassess each time pain occurs. Note and investigate changes from previous reports. Use of pain rating To determine scale appropriate level of pain. from age: facial expression scale. Provide a quiet and Offers the patient safe environment. to relax.

*age: 1month,2wks

IMPAIRED PHYSICAL MOBILITY RELATED TO PRESENT CONDITION

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Assessment S: hindi siya halos gulagalaw, hindi rin nya natutupi yung mga daliri nya sa paa, as verbalized by the mother. O: Limited range of motion Functional Level: 4 Dependent, does not participate in activity.

Diagnosis Impaired physical mobility related to present condition

Planning After 2 hours of nursing intervention the patients mother will be able to verbalize understanding of situation and safety measures.

Intervention Rationale Evaluation Independent: To identify After 2 hours of nursing causative/ Determine intervention diagnosis that contributing the patients contributes to factors. mother has immobility Instruct the To promote been able to mother to use optimal level verbalized side rails. of function understanding and prevent of situation Teach the safety complication. and mother about measures. the safety To promote measures as optimal level GOAL MET. indicated by of function individual and prevent situation, complication including environmental management

DISTURBED SLEEP PATTERN RELATED TO INTERRUPTION OF THERAPEUTIC AND MONITORING

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Assessment S: Hindi maayos ang kanyang pagtulog. Nakakatulog siya sa gabi ng alas-10 tapos na gigising siya ng ala-6 ng umaga at kalimitan tuwing umaga nakakatulog sa mula dalawa hanggang 3 oras pero pagising gising siya. Samakatuwid mga labingdalawan g oras siyang nakakatulog as verbalized by the mother. O: Irritable Restless

Diagnosis Disturbed sleep pattern related to interruption of therapeutic and monitoring.

Planning After 8 hrs. of nursing intervention the patient will have a continuously sleep in the morning assessment by monitoring of sleep as evidence by continuously sleep for 6-8 hrs. as verbalized by the mother.

Intervention Rationale Monitor the Sleep cycle tells sleep pattern and the completeness cycle of the or normal sleep baby. pattern of the baby. Provide Increase comfort comfortable for sleep, provide beddings and physiological and environment. psychological support. Reduce noise To provide and light. atmosphere conducive to sleep. Limit Uninterrupted interruptions sleep is more such as restful, and awakening for patient maybe medication or unable to return therapies. to sleep when wakened. Slowly touch the To lessen patient when interruption doing such during time of procedure. sleep and to avoid irritation of the patient.

Evaluation After 8 hrs. of nursing intervention the patient had a continuously sleep in the morning assessment by monitoring of sleep as evidence by continuously sleep for only 4-5 hrs. as verbalized by the mother. GOAL PARTIALLY MET

RISK FOR INFECTION RELATED TO INCREASED VULNERABILITY OF INFANT SECONDARY TO OPEN WOUND Assessment Diagnosis Planning Intervention Rationale Evaluation
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O: Weak in appearance Poor skin turgor Pale PR: 142 bpm RR: 36 cpm Temp: 35.8 C Weight: 5 kg WBC: 16.4 g/L

Risk for infection r/t increase vulnerability of infant related to open wound.

After 2 hours of nursing Independent: intervention the patients Assess signs mother will be and symptoms able to acquire of infection knowledge how especially to prevent and temperature. avoid further infection Emphasize to the patient family the importance of hand washing technique. Maintain clean bed linen and clothes.

After 2 hrs. of nursing intervention Fever may the patient's mother was indicate able to acquire infection knowledge how to prevent and avoid further It serves as a first line of infection. defense GOAL MET. against infection

To avoid the severity of wound and to prevent infection

Dependent: Monitor white blood cell (WBC). Rising WBC indicates body's efforts to combat pathogens; indicates severe risk for infection because patient does not have sufficient WBCs to fight infection. Patients with poor nutritional status may be anergic, or unable to muster a
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Assess nutritional status, including weight, history of weight loss,

and serum albumin.

cellular immune response to pathogens and are therefore more susceptible to infection.

Emphasized necessity of taking antibiotics as ordered

Premature discontinuatio n of treatment when client begins to feel well may result in return of infection

RISK FOR INJURY RELATED TO SENSORY DYSFUNCTION Assessment Diagnosis Planning Intervention Rationale Evaluation
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O: (+) club foot (+) presence of meningocele (+) hydrocephal us (+) history of seizure

Risk for injury related to sensory dysfunction .

After 2 hrs. of Note patients age Affect patients After 2 hrs. of nursing ability to protect nursing intervention self and/or intervention the patients others and the patients mother will mother influences identify choice of partially environment intervention and identify the as indicated to environment teaching. enhance Perform through Failure to as indicated safety. assessments accurately assess to enhanced regarding safety and intervene safety. issues when refer these issues planning for can place the GOAL MET patients care. patient at needless risk and creates negligence issues for the health care practitioner. Provide health To prevent care within a errors resulting culture of safety. in patient injury Monitor To promote environment patients safety. potentially unsafe condition and modify as needed. Provide To promote safe information physical regarding environment and conditions that individual may result in safety. increased risk of injury.

RISK FOR HYPOTHERMIA RELATED TO IMMATURITY NEWBORNS TEMPERATURE REGULATORY SYSTEM

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Assessment O: T: 36.8 C Not fully develop thermoregulati on Cold extremeties (+) pallor (+) restlessness

Diagnosis Risk for hypothermia related to immaturity of newborns temperature regulatory system.

Planning

Intervention

Rationale Helps in determining the scope of interventions that may be needed.

Evaluation

Within 8 hrs. Determine if the patients present body condition results temperature from exposure will remain to within environmental normal factors, surgery, axillary infection, range, 36.8 trauma C 37.5 C monitor the temperature pf the client. Note age.

Within 8 hrs. the patients body temperature will remain within normal axillary to take note range, 35.8 C 36.8 immediately for possible C temperature GOAL changes. clients It can directly MET impact ability to maintain body temperature and respond to changes in environment.

Discuss with the Heat loss in patient's mother infants is about the greatest appropriate through head dressing. and by evaporation and convection. Provide heat or To promote warmth using warmth and swaddling or adequate. drop light. Monitor Regular axillary temperature temperature at monitoring will least every 2 identify hours. adequate thermoregulati
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on. Axillary temperature is good indicator of newborns surface temperature.

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VI.

PHARMACOTHERAPEUTICS Nursing Responsibilities include health teaching and implications Monitor patient for sign and symptoms of superinfection Instruct mother of patient to observe discomfort when receiving drug I.V Tell to the mother of patient to report adverse reaction to nurse immediately

GN(BN) Classification Stock GN: VANCOMYC IN BN: VANCOCIN CLASSIFICA TION: Antibiotic

Indication ( Client Specific) Dosage & Frequency

Mechanism of action

Side Effect Adverse Reaction

GN: MEROPENE M BN: MERREM CLASSIFICA TION: Antibiotic (carbapenem)

Route: IV Vancomycin acts by inhibiting Dosage: 40 mg proper cell wall synthesis in Q8 Gram-positive bacteria. The mechanism inhibited, and INDICATION : various factors related to Vancomycin is entering the outer membrane of indicated for the Gram-negative organisms mean treatment of that vancomycin is not active serious or severe against Gram-negative bacteria. infections caused Specifically, vancomycin by susceptible prevents incorporation of Nstrains of acetylmuramic acid (NAM)methicillinand N-acetylglucosamine resistant (beta- (NAG)-peptide subunits from lactam-resistant) being incorporated into the staphylococci. peptidoglycan matrix Route: IV Inhibits bacterial cell wall Dosage: 110g Q8 synthesis by binding to several of the penicillin-binding INDICATION : proteins, which in turn inhibit the final transpeptidation step of To reduce the peptidoglycan synthesis in development of bacterial cell walls, thus drug-resistant inhibiting cell wall bacteria and biosynthesis; bacteria maintain the eventually lyse due to ongoing effectiveness of activity of cell wall autolytic Meropenem for enzymes (autolysins and murein injection (I.V.) hydrolases) while cell wall and other assembly is arrested antibacterial drugs, Meropenem for injection (I.V.) should only be used to treat or prevent infections that are proven or

No reported side effects

No reported side effects

Obtain specimen for culture and sensitivity test before giving first dose. Stop drug and notify nurse if an allergic reaction occur. Serious anaphylactic reactions require immediate emergency treatment. If seizure occurs during drug therapy, stop infusion and notify nurse. Monitor patient fluid balance and weight carefully Instruct mother of patient to report
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strongly suspected to be caused by susceptible bacteria.

GN: MEROPENE M BN: MERREM CLASSIFICA TION: Antibiotic (carbapenem)

Route: IV Dosage: 110g Q8 INDICATION : To reduce the development of drug-resistant bacteria and maintain the effectiveness of Meropenem for injection (I.V.) and other antibacterial drugs, Meropenem for injection (I.V.) should only be used to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria.

Inhibits bacterial cell wall synthesis by binding to several of the penicillin-binding proteins, which in turn inhibit the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis; bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested

No reported side effects

adverse reaction or sign and symptom of superinfection Advise mother of patient to report loose of stool to nurse. Obtain specimen for culture and sensitivity test before giving first dose. Stop drug and notify nurse if an allergic reaction occur. Serious anaphylactic reactions require immediate emergency treatment. If seizure occurs during drug therapy, stop infusion and notify nurse. Monitor patient fluid balance and weight carefully Instruct mother of patient to report adverse reaction or sign and symptom of superinfection Advise mother of patient to report loose of stool to nurse.

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Indication ( Client Specific) Dosage & Frequency GN: Route: oral PHENOBARBITAL Dosage: 30g 1tab BN: Luminal Q12 Sodium INDICATION : CLASSIFICATION: Phenobarbital is barbiturate; anticonvulsant and anticonvulsant sedative for febrile seizures used to treat seizures that fail to respond to phenytoin GN(BN) Classification Stock

Mechanism of action Phenobarbitone is a short acting barbiturate. It depresses the sensory cortex, reduces motor activity, changes cerebellar function, and produces drowsiness, sedation and hypnosis. Its anticonvulsant property is exhibited at high doses. Contain a high concentration of soluterelative to another solution (e.g. the cell'scytoplasm). When a cell is placed in a hypertonic solution, the water diffuses out of the cell,causing the cell to shrive

Side Effect Adverse Reaction

Nursing Responsibilities include health teaching and implications Dont stop drug abruptly because this may worsen seizures. Call nurse immediately if adverse reactions develop. First withdrawal symptoms occurs within 8 to 12 hours and include weakness, nausea and vomiting after abruptly stopping drug. Drug may decrease bilirubin, patient with congenital non hemolytic, unconjugated hyperbilirubinemia. The physiologic effect of drug may impair the absorption of cyanocobalamin. Do not administer unless solution is clear and container is undamaged. Caution must be exercised in the administration of parenteral fluids, especially those containing sodium ions to patients receiving corticosteroids or corticotrophin. Solution containing acetate should be used with caution as excess administration may result in metabolic alkalosis. Solution containing dextrose should be used with caution in patients

No reported side effects

D5IMB

Route left IJ Dosage

CLASSIFICATION: Hypertonic solution Indication

No reported side effects

Slow administration essential to prevent over load (100 mL/hr) Water intoxication -Severe sodium depletion

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GN(BN) Classification Stock BN: HERACLENE GN: DIBENCOZIDE CLASSIFICATION: Appetite enhancer

Indication ( Client Specific) Dosage & Frequency Route Dosage 1 cap INDICATIONS: Premature babies, low birth weight, retarded growth, poor appetite in infants, children and adults, adjuvant to treatment of tuberculosis and other chronic ailments, convalescence from acute infection or surgery, faulty nutrition in older people.

Mechanism of action

Side Effect Adverse Reaction

Nursing Responsibilities include health teaching and implications Advise patient to avoid products that contain caffeine. Tell him to report evidence of excessive stimulation. Warn patient that drug may lose its effectiveness over time.

Dibencozide No reported Side increases the Effects protein efficiency coefficient, i.e., the percentage of bound nitrogen for protein build up in the body compared to ingested nitrogen with food intake. The initial sign of effectiveness is manifested by a marked increase in appetite.

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VII. ONGOING APPRAISAL DAY 1 February 05, 2013 Patient N.B was seen sleeping at the bed in a side lying position. Initial vital signs on that day were taken at exactly 8 am, pulse rate 124 bpm, respiratory rate 41 cpm and body temperature at 36.1 C. During the first student nurse-patient interaction, he was weak and pale in appearance. He was infused with D5IMB on his left internal jugular vein, KVO (5cc/hr). Theres an open wound noted on his left foot upon observation due to repeated insertion of IV catheter. The input and output of the patient were also monitored during the interaction. For 8 hours, Patient N.B take 30 mL of fluids and his mother changed his diapers twice, which include his urine and stool. Each diaper weighs 260 gramsand a total of 520 grams during the entire 8 hours of nursing intervention. Vital Signs of patient N.B was taken every 2 hrs: 10am: PR: 125bpm RR: 38 cpm Temp: 36.0 C 12pm: PR: 140 bpm RR: 46 cpm Temp: 36.3 C Medications that have been given to patient N.B were Vancomycin 40mg for every 8 hrs. via IV, Meropenem 110g for every 8 hrs. via IV, Phenobarbital 30g 1 tab for every 12 hours taken orally and Heracline 1 mg/capsule once a day. Before the end of the duty, the patient still looks weak and pale. All of his medicines were taken on time. DAY 2 February 6, 2013 Patient N.B was seen sleeping on the bed in a side lying position. He was still pale and weak. D5IMB was still infused in his left internal jugular vein,KVO (5cc/hr). Due to his open wound, the mother was given advices to improve her knowledge regarding proper ways in wound care. Antibiotic like Vancomycin and Meropenem were given via soluset. Input and output of the patient were also monitored. His intake was 40 mL and his mother changed his diaper twice. His urine and his stool weight 120 g. His initial vital signs for this day were; 135 bpm for his pulse rate, 43 cpm for respiratory rate and 36 for his temperature.
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2pm: PR: 142 bpm RR: 44 cpm Temp: 36.7 C

Vital signs of Patient N.B. were taken every 2 hours: 8am: PR: 130 bpm RR: 47 cpm T: 36.0 C 10am: PR: 138 bpm RR: 46 cpm T: 36.5 C DAY 3 February 12, 2013 Patient N.B was seen carried by his mother upon observation, he was still pale and weak since the first time that we handled him. D5IMB was still infused in his left internal jugular vein KVO (5cc/hr). There was a presence of scar due to healed wound on his left foot. Antibiotic like Vancomycin and Meropenem were infused via soluset. Input and output of the patient was also monitored. His intake was 36 mL and his mother changed his diaper once during the entire 8 hr of shift. Weighs 190g in total. His initial vital signs for this day were; 140 bpm for his pulse rate, 36 cpm for respiratory rate and 36.1 C for his temperature vital signs moniotoring were taken every 2 hours. At the end of our duty, his IV level was also checked; 86 cc soluset 100 D5IMB. 8am: PR: 124 bpm RR: 41 cpm T: 36.1 C 10am: PR: 125 bpm RR: 38 cpm T: 35.8 C 12pm: PR: 140 bpm RR: 46 cpm T: 36.3 C 2pm: PR: 142 bpm RR: 44 cpm T: 36.7 C 2pm: PR: 125 bpm RR: 38 cpm T: 36.1 C 12pm: PR: 132 bpm RR: 49 cpm T: 36.0 C

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Bibliography:
Doenges M., Moorhouse M., Murr A. (2010) Nursing Care Plans 8th Edition. Davi's Nursing Resource Center Doenges M., Moorhouse M., Murr A. (2009) Nursing Care Plans 12th Edition. Davi's Nursing Resource Center Pillitteri A. (2010) Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family 6th Edition. Lippincott Willians and Wilkins Weber J., Kelley J. (2010) Health Assessment in Nursing 4th Edition. Lippincott Willians and Wilkins Wilson, Shannon, Shields (2012) Nurse's drug guide. Pearson

Online Resources:
Retrieve data: February 17, 2013 http://thechart.blogs.cnn.com/2011/03/07/pregnant-women-secondhand-smoke-can-harm-yourunborn-baby/ Retrieve data: February 17, 2013 http://www.scribd.com/doc/28488117/Precipitating-Factor-Predisposing-Factors Retrieve data: February 17, 2013 http://www.slideshare.net/grimioire/case-study-of-spina-bifida#btnNext Retrieve data: February 17, 2013 http://www.scribd.com/doc/93396515/Ncp-Hydrocephalus-With-Rationale#outer_page_35 Retrieve data: February 18, 2013 http://www.youtube.com/watch?v=6Ii_v3t9hpU

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