Edapt: Nursing Care: Spina Bifida
For every evaluation finding, imply whether the patron's circumstance has advanced, has not
modified, or has declined. - ANS-Improved- Sacral region
Declined- Head circumference
Temperature
No alternate- No reaction to placement of pulse oximeter
For each locating, imply if the finding is consistent with clinical manifestations of
meningocele, spina bifida occulta, or myelomeningocele. Each locating may assist multiple
disorder.- ANS-Meningocele - Sac in sacral place at delivery
Spina Bifida Occulta- Tuft of hair in sacral place
Myelomeningocele - Club foot
Decreased sensation to extremities
Sac in sacral place at start
For each nursing movement, suggest if the movement is indicated or contraindicated.-
ANS-Indicated - Measure head at the widest possible circumference
Prepare consent form for surgical procedure
Request latex-loose stethoscope to maintain at little one's bedside
Contraindicated - Perform intermittent catheterization
Swaddle little one
Highlight the evaluation findings that are concerning to the nurse.- ANS-intact sac in sacral
vicinity
Bilateral membership foot stated
No reaction while pulse oximeter located on right foot
Match the sort of spina bifida with the defect presentation at beginning.- ANS-A sac
protrusion containing meninges, spinal fluid, and nerves- Myelomeningocele
A sac protrusion containing meninges and spinal fluid- Meningocele
No visible defect- Spina bifida occulta
Review the nurse's observe. For every evaluation finding, imply whether it helps the nursing
prognosis of ineffective coping or poor information. Each evaluation finding might also assist
more than one nursing diagnosis.- ANS-Ineffective coping -
Does now not understand wherein to find statistics
Feels exhausted
Tearful
Deficient information -
Does not realize in which to discover data
For every evaluation finding, imply whether the patron's circumstance has advanced, has not
modified, or has declined. - ANS-Improved- Sacral region
Declined- Head circumference
Temperature
No alternate- No reaction to placement of pulse oximeter
For each locating, imply if the finding is consistent with clinical manifestations of
meningocele, spina bifida occulta, or myelomeningocele. Each locating may assist multiple
disorder.- ANS-Meningocele - Sac in sacral place at delivery
Spina Bifida Occulta- Tuft of hair in sacral place
Myelomeningocele - Club foot
Decreased sensation to extremities
Sac in sacral place at start
For each nursing movement, suggest if the movement is indicated or contraindicated.-
ANS-Indicated - Measure head at the widest possible circumference
Prepare consent form for surgical procedure
Request latex-loose stethoscope to maintain at little one's bedside
Contraindicated - Perform intermittent catheterization
Swaddle little one
Highlight the evaluation findings that are concerning to the nurse.- ANS-intact sac in sacral
vicinity
Bilateral membership foot stated
No reaction while pulse oximeter located on right foot
Match the sort of spina bifida with the defect presentation at beginning.- ANS-A sac
protrusion containing meninges, spinal fluid, and nerves- Myelomeningocele
A sac protrusion containing meninges and spinal fluid- Meningocele
No visible defect- Spina bifida occulta
Review the nurse's observe. For every evaluation finding, imply whether it helps the nursing
prognosis of ineffective coping or poor information. Each evaluation finding might also assist
more than one nursing diagnosis.- ANS-Ineffective coping -
Does now not understand wherein to find statistics
Feels exhausted
Tearful
Deficient information -
Does not realize in which to discover data
