A Nursing Care Plan on Spina Bifida

A Nursing Care Plan on SPINA BIFIDA March 12. 2022 Name of Patient: A.B Age/ Sex: F 4 y/o Ward: Holy Child Ward Chief Complaint: Diarrhea Physician: Dr. Manalo Diagnosis: Spina Bifida Date/ Time Cues Need M Subjective A cues: R “3 days ago C po nag start H yung diarrhea ng 9 anak E ko and basa basa yung 2 poop nya. 4 0 times a day po 2 siya 2 @ tumatae” As L I M I N A T I O N Nursing Diagnosis Patient Outcome Bowel The client will incontinence be related to poor improve anal sphincter regular tone pattern and control evidenced able Implementation Evaluation 1. Establish rapport 1 March 9, to with the patient 2022 a R: To create bond and @ 3 pm trust with your patient. “Goal Met” of The as bowel 2. Examine by movement as presence and possible loss anal within 8 hours degree the of neurogenic bowel, the of 2 improve a regular pattern of of control. intervention rehabilitation movement as as evidenced potential. possible Rationale: by the mother Bowel bowel nursing incontinence, and the client was able to sphincter verbalized by 7 Nursing Interventions diarrhea of Room & Bed: 123- 1 regular R: Provide details on bowel within 8 hours the disease to aid in of nursing incontinence or movement the development of a intervention A “hindi niya rin also known as and having a bowel elimination as M kayang i- fecal normal program. evidenced by regular control ang incontinence is consistency 3. Administer ORS to 3 bowel pag poop nya the failure to of the stool. the patient. hindi na control R: This is to prevent and having a umaabot ng movements of dehydration to patient normal cr.” As an with diarrhea. consistency bowel individual, verbalized by resulting in the mother stool to leaked 4. Place the child in a out potty in the movement of the stool. chair at the 4 ”Meron Objective rectum in an same time every day naman Cues: unpredicted for use of stimulation improvement manner. The and a suppository. sa pag poop capillary majority of refill of 4 people seconds spina With fecal have a problem ph of 5.3 in terms in their • • With a with bifida neurogenic bladder R: Establishes regular times nalang elimination yung bowel. poop nya and hindi used in waterproof underwear, movement diapers the nerve that was avoided. should but be pag na masyadong 5. Padding should be and baby 3x practice to clear the bowel because ni a 5 basa.” As verbalized by the mother. present in the R: spinal cord did embarrassment not the develop properly Prevents child that elimination cause to have controlled. if for bowel is not that can an involuntary soiling. 6. Foods cause diarrhea should Reference: be UCSF Health. eliminated (2021, June 16). Bladder and Bowel Issues Spina in Bifida. Ucsfbenioffchi ldrens.Org. identified To R: and 6 prevent diarrhea, constipation, and gas formation 7. Adjust enteral feedings or change formula, as indicated, R: To reduce diarrhea effect 7 8. Provide incontinence until control pads is 8 obtained. R: To avoid skin rashes 9. Monitor characteristics stool such 9 as color, size, amount, and consistency R: To know if there are any changes or improvement. 10. Discuss to the watcher why high fiber foods such as bananas, white rice, apples, and toast are 10 good for patient with diarrhea. R: To harden loose and watery fiber can reduce stools, help or to avoid diarrhea. Angeline Nicole Moreno, St.N Reference: • Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales. Philadelphia, PA: F.A. Davis. • Herdman, H. T., & Kamitsuru, S. (2019). Supplement to NANDA International Nursing Diagnoses: Definitions and Classification, 2018–2020 (11th Edition): New things you need to know (1st ed.). Thieme. • Martin, P. B. (2020, December 5). 7 Spina Bifida Nursing Care Plans. Nurseslabs. https://nurseslabs.com/7-spinabifida-nursing-care-plans/3/ • UCSF Health. (2021, June 16). Bladder and Bowel Issues in Spina Bifida. Ucsfbenioffchildrens.Org. https://www.ucsfbenioffchildrens.org/education/bladder-and-bowel-issues-in-spina-bifida Clustered Cues Health Perception- Health Management Pattern • Complaint of diarrhea Activity – Exercise Pattern • • • Vital signs Tempt: 36.5 CR: 85 RR: 16 PR: 80 With a capillary refill of 4 seconds fecal pH of 5.3 Self- Perception/ Self Concept Nutritional- Metabolic • There was a Pressure Pattern sores were observed on • The mother stated the bony prominences that her child tends to (elbow, knees, ankle, get irritable and throw sacrum). tantrums • She also has short attention span • The nurse observed that she is very shy • The patient is also not • Elimination • Experience of loss of anal sphincter control • With a watery stool able to move her lower extremities. She cannot walk since her body is paralyzed from waist to down.