Subjective and objective data collection on the nervous system disorders, in connection with spina bifida complications depends on other vital organs. Nursing assessment of spina bifida include anamnesis, medical history, physical examination, diagnostic studies, and psychosocial assessment.
1. Anamnesis
The identity of clients includes name, age, gender, education, address, occupation, religion, nationality, date and time of hospital admission, registration number, health insurance, medical diagnostics.
The main complaint is often the reason for a client to ask for help health is the presence of signs and symptoms similar to spinal cord tumors and neurological deficits. Complaints of lumbosacral lipoma on an important sign of spina bifida.
2. History of the disease at this time
Complaints of neurological deficits can manifest as impaired motor (motor paralysis of the lower limbs) and the inferior extremity sensory and / or disorders of the bladder and the sphincter of the stomach. Complaints of unilateral foot deformity and leg muscle weakness is the most common defect. Small feet can occur trophic ulcers and pes cavus. This condition may be accompanied by sensory deficits, especially in the distribution of L3 and S1. Complaints bladder sphincter disorders are found in 25% of infants with neurological involvement, lead to urinary incontinence, urinary dripping, and recurrent urinary tract infections. Usually accompanied by the anal sphincter weakness and sensory disturbance perianal area. Neurological disorders can gradually deteriorate, especially during adolescence mass growth.
3. History of previous illness
Assessment that need to be asked include a history of the growth and development of children, history meningomyelocele ever experienced before, a history of infection subarachnoid space (sometimes chronic or recurrent meningitis), a history of spinal cord tumors, poliomyelitis, spinal developmental disabilities, such as diastematomyelia and foot deformities.
4. Assessment of psychosocial
Assessment of coping mechanisms used and the client's family (parents) to assess the response to illness and changing roles in the family and society as well as responses or influence in their daily lives either in the family or in society. Are there impacts on the client and the parents that raised fears of disability, anxiety, a sense of inability to perform activities optimally.
5. Physical examination
After making the history that led to the complaint the client physical examination is very useful to support the assessment of data from history. Physical examination should be performed by the system (B1-B6) with a focus on examining physical examination B3 (brain) directed and connected with complaints from clients.
a. The general state
In case of spina bifida generally experience loss of consciousness (GCS less than 15), especially if it occurs widely neurological deficits and changes in vital signs.
b. B1 (Breathing)
Changes in the respiratory system associated with inactivity weight. In some circumstances, the results of the physical examination found no abnormalities.
c. B 2 (Blood)
Bradycardia is a sign of changes in brain tissue perfusion. Looked pale skin indicates a decrease in hemoglobin levels in the blood. Hypotension indicates a change in tissue perfusion and early signs of a shock.
d. B3 (Brain)
Spina bifida causes a variety of neurological deficit was primarily due to the effect of increased intracranial pressure. Assessment of B3 (Brain) is a focus and a more complete examination than assessments on other systems.
e. B4 (Bladder)
In the advanced stages of spina bifida, a client may experience urinary incontinence due to confusion and inability to use the urinary system due to damage motor and postural control. Sometimes the external urinary sphincter control is lost or diminished. During this period, intermittent catheterization performed with sterile technique. Urinary incontinence that persists showed extensive neurological damage.
f. B5 (Bowel)
The presence of fecal incontinence that continues to show widespread neurological damage. Bowel examination to assess the presence or absence of bowel sounds and the quality should be assessed prior to abdominal palpation. Bowel sounds are decreased or lost may occur in paralytic ileus and peritonitis.
g. B6 (Bone)
The presence of foot deformity is one important sign of spina bifida. The most common motor dysfunction is the weakness of the lower extremities. To assess the integrity of the skin lesions and sores. Be difficult to move because of weakness, sensory loss or spastic paralysis and fatigue cause problems on the pattern of activity and rest.
6. Diagnostic tests
Spine x-rays to identify any defect in the spine, usually occurs in the posterior arch of the vertebra in the spine midline amount varies. The presence of spinal dyspropism or widening of the spine is a typical sign of radiology at the lumbar (Perkin, 1999).
Nursing Diagnosis for Spina Bifida
1. Urinary incontinence r / t paralysis visceral
2. Risk for injury r / t spastic paralysis
3. Impaired Physical Mobility r / t motor paralysis
Komentar
Posting Komentar