Use this nursing care plan and management guide to help care for patients with spina bifida. Learn about the nursing assessment, nursing interventions, goals and nursing diagnosis for spina bifida in this guide.
What is Spina Bifida?
Spina bifida involves the failure of the neural tube to develop or close during embryonic development causing defects in the spinal cord and in the bones of the spine. There are two types of spina bifida: spina bifida occulta is the most common and is a defect in the closure without the herniation and exposure of the spinal cord or meninges at the surface of the skin in the lumbosacral area. While spina bifida cystica (meningocele or myelomeningocele) is a defect in the closure of a sac and herniated protrusion of meninges, spinal fluid and possibly some part of the spinal cord and nerves at the surface of the skin in the lumbosacral or sacral area.
Hydrocephalus is often related with spina bifida cystica. The extent of neurologic impairment are associated to the location and nerves involved in the defect and range from varying degrees of sensory deficits, to partial or total loss of motor function resulting in flaccidity, partial paralysis of lower extremities, and bowel and urinary incontinence.
There are several different treatments that can be used to manage symptoms or conditions associated with spina bifida such as surgery to close the opening in the spine which may be done during infancy or later, physiotherapy, speech and occupational therapy, use of assistive devices and mobility equipment, such as a wheelchair, or walking aids, and urinary and bowel management.
Table of contents
- What is Spina Bifida?
- Nursing Care Plans and Management
- Nursing Problem Priorities
- Nursing Assessment
- Nursing Diagnosis
- Nursing Goals
- Nursing Interventions and Actions
- 1. Managing Hypothermia
- 2. Promoting Effective Urinary Elimination
- 3. Restoring Bowel Function
- 4. Promoting Positive Self-Body Image
- 5. Promoting Effective Coping
- 6. Preventing Infections and Injuries
- 7. Initiating Patient Education and Health Teachings
- 8. Administer Medications and Provide Pharmacologic Support
- See also
Nursing Care Plans and Management
Nursing care plans and management for clients with spina bifida include preventing infection, maintaining skin integrity, preventing trauma related to disuse, increasing family coping skills, education about the condition, and support.
Nursing Problem Priorities
The following are the nursing priorities for patients with spina bifida:
- Infection control
- Manage neurogenic bladder and bowel dysfunction
- Monitor for signs of hydrocephalus and manage ventricular shunts
- Assist with mobility and positioning
- Promote optimal nutrition and weight management
- Promote self-care and independence as appropriate.
- Coordinate multidisciplinary care and referrals to specialists as needed
- Ensure regular follow-up and monitoring of growth and development.
Assess for the following subjective and objective data:
- Visible defect on the back, such as a sac or opening in the spine
- Weakness or paralysis in the legs
- Sensory deficits, such as numbness or loss of sensation in the legs or feet
- Bowel and bladder problems, such as urinary or fecal incontinence
- Orthopedic issues, including joint deformities or scoliosis.
- Hydrocephalus, which may present with signs of increased intracranial pressure such as enlarged head size, vomiting, irritability, or changes in consciousness
- Developmental delays, including motor, cognitive, or speech delays
- Difficulty walking or using assistive devices
- Vision or hearing problems
- Latex allergy or sensitivity
Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with spina bifida based on the nurse’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.
Goals and expected outcomes may include:
- The child’s temperature will remain above (97.8°F).
- The child will have improved urinary elimination by school age.
- The child will participate in a bowel control regimen.
- The child will be able to control elimination.
Nursing Interventions and Actions
Therapeutic interventions and nursing actions for patients with spina bifida may include:
1. Managing Hypothermia
Hypothermia is a condition where the body temperature drops below normal levels in patients with spina bifida. Due to impaired thermoregulation and reduced mobility, individuals with spina bifida may be more susceptible to hypothermia, as they may have difficulty generating or conserving body heat. Hypothermia can lead to various complications and requires prompt intervention to restore normal body temperature and prevent further deterioration.
Monitor temperature pattern every 2 to 4 hours; Assess the temperature of extremity present.
Gives data as to the source of changes in temperature which may be below the normal if an infection is.
Provide a radiant warmer or place the infant in an incubator (isolette) based on hypothermia evaluation keeping the sac moist postoperatively.
Provides a controlled warmth and lessens the heat loss causing hypothermia.
Offer warm fluids frequently such as warm formula, breast milk, or warm water, and monitor fluid intake and output.
Warm fluids help raise the internal body temperature. This will ensure adequate fluid intake to prevent dehydration, as dehydration can exacerbate hypothermia.
Provide a warm environment by adjusting the room temperature, using warm blankets or clothing, and ensuring proper insulation.
Spina bifida have decreased sensation or impaired thermoregulation due to the spinal cord defect. This can make them more vulnerable to developing hypothermia, as they may have difficulty perceiving or responding to cold temperatures. These interventions help maintain body temperature within a normal range and prevent the risk of hypothermia.
Educate parents on how to take temperature and notify of any changes.
Early recognition of temperature fluctuations will lead to early intervention.
Educate parents regarding the appropriate amount of clothing and room temperature suitable for the infant/child.
Provides optimal environmental temperature.
2. Promoting Effective Urinary Elimination
Urinary elimination for patients with spina bifida can be affected due to neurogenic bladder dysfunction. The condition can lead to issues such as urinary retention, incontinence, or difficulties with voluntary control of urination. Management of urinary elimination in patients with spina bifida may involve interventions such as intermittent catheterization, medication to promote bladder function, and implementing a regular voiding schedule to maintain bladder health and prevent urinary tract complications.
Assess urine for color, amount, odor, and turbidity.
Cloudy, dark, bloody, or strange-smelling urine indicates a urinary bladder infection caused by urinary retention.
Assess the presence of neurogenic bladder, the degree of incontinence, the potential for rehabilitation, and the age of the child.
Provides information about the condition for use in the plan of establishing a urinary elimination routine.
Keep the genital and anal area clean after each elimination episode or as needed if incontinent.
Prevents the introduction of microorganisms into the urethra and urinary bladder.
Encourage adequate fluid intake of 30 ml/1lb/day including acid-containing beverages and the addition of foods high in acid content in the diet.
Promotes renal blood flow and acidifies urine to prevent infection.
Encourage parents to use pads and water-proof undergarments instead of the use of diapers for a child over 3 years of age.
Prevents embarrassment for the child.
Perform the scheduled rehabilitation program of placing the child on the toilet or potty chair at the same times each day.
Establishes a routine for urinary elimination if this is a possibility.
Perform intermittent catheterization every 3 to 4 hours if indicated to resolve incontinence.
Ensures emptying of the bladder to prevent incontinence and infection.
Perform Crede’s maneuver if indicated.
This is done by exerting manual pressure on the abdomen at the location of the bladder that promotes emptying of the bladder.
Educate parents and age-dependent child in the use of external urinary devices or procedures for intermittent self-catheterization; demonstrate and provide a return demonstration.
Provides a method for emptying the bladder routinely or managing incontinence by use of a collecting device connected to a closed system.
Administer anticholinergic, and antispasmodic medications as indicated.
See Pharmacologic Management
Advise parents on alternative procedures to control incontinence such as implantation of an artificial sphincter, creation of an artificial reservoir, or creation of a urinary diversion.
Provides information about other methods that can be performed if intermittent catheterization is not attained.
Educate parents and child about changes in urine characteristics indicating bladder infection and measures to take to prevent this complication.
Allows for early interventions to control infection and eventual renal complications.
Advice to keep a record of fluid intake/day and weight and report changes; Avoid foods and fluids that are acidic including meat, poultry, fish, citrus fruits, pasta, dairy, eggs, and grains.
Maintains a monitoring system to ensure control of possible complications.
3. Restoring Bowel Function
Bowel function for patients with spina bifida can be affected due to neurogenic bowel dysfunction. This can result in issues such as constipation, fecal incontinence, or difficulties with bowel control. Management of bowel function in patients with spina bifida may involve interventions such as dietary modifications, bowel training programs, medication to promote regular bowel movements, and the use of assistive devices like stool softeners or laxatives to ensure adequate bowel elimination and prevent complications such as bowel impaction.
Assess the presence of neurogenic bowel, the degree of incontinence, and the potential for rehabilitation.
Provides information about the condition for use in the plan of establishing a bowel elimination routine.
Place the child on a toilet or potty chair at the same time each day; use stimulation and suppository if needed.
Establishes a routine for elimination to empty bowel.
Teach parents to correct cleansing and diapering techniques for infants/toddlers.
Promotes understanding to maintain good skin integrity.
Change diapers as quickly as feasible; cleanse the perianal area carefully.
Dry, clean skin resist breakdown.
Apply barrier creams as prescribed to the perianal area during diapering.
Prevents skin breakdown.
Suggest clothing and undergarments to protect from staining accidents.
Promotes self-image and prevents embarrassing incidents.
Apply padding in waterproof undergarments but avoid the use of diapers.
Prevents embarrassment for the child if bowel elimination is not controlled.
Encourage fluid intake of up to 2,000 ml/day depending on age; include fiber and roughage in the diet.
Promotes bulk for easier and more manageable passage.
Teach parents and child about program for control of bowel incontinence (fluids, diet, routine toileting, use of stimulation).
Promotes success in bowel training.
Teach about behavior modification as a method to be used for bowel rehabilitation.
Promotes compliance with the routine to control bowel incontinence.
Administer stool softeners, laxatives, or fiber supplements as indicated.
See Pharmacologic Management
4. Promoting Positive Self-Body Image
Self-body image for patients with spina bifida can be influenced by physical differences and functional limitations associated with the condition. These individuals may face challenges in accepting and embracing their unique body characteristics, which can impact their self-esteem and overall body image. Supporting a positive self-body image involves providing emotional support, promoting self-acceptance, and encouraging the development of personal identity beyond physical appearance to foster a sense of empowerment and well-being.
Assess child for feelings about strengths and weaknesses in performing ADL, social interaction, and effect on self-concept.
Provides information about the potential for independence in thinking and functioning.
Encourage expression of feelings and concerns and support communication of the child with parents and peers.
Provides an opportunity to vent feelings to reduce anxiety and negative feelings.
Encourage parents to sustain support and care for the child.
Encourages acceptance of the child.
Encourage independence and maximize functioning with the use of aids for dressing, bathing, grooming, eating, mobility, toileting, and acknowledge on attempts at self-care activities.
Promotes ADL capability by use of assistive aids as needed depending on the disability.
Advise parents to maintain consistent behavior rules for the child as other children in the family and to integrate care and activities into the family routine.
Provides a sense of belonging to the family.
Notice any positive achievements and avoid mentioning negative comments.
Enhances body image and confidence.
Provide touching and hugging, age-appropriate activities with other children.
Conveys caring and concern for the child and enhances socialization.
Encourage and teach the use of assistive aids for ADL.
Promotes independence and enhances body image.
5. Promoting Effective Coping
Families of patients with spina bifida may experience various emotional, psychological, and practical challenges as they adapt to their child’s condition. Coping strategies can involve seeking emotional support from healthcare professionals, support groups, and other families facing similar situations, as well as engaging in education about spina bifida to enhance their understanding and ability to manage the condition.
Assess the anxiety level of family and child, perception of crisis situation, coping and problem-solving methods used, and effectiveness.
Identifies the need to develop new coping skills and realistic behaviors in goal setting and interventions necessary for family and child to adapt to crisis.
Assess the family’s ability to cope with the child, developmental level of the family, stress on family relationships, the response of siblings, knowledge of health practices, family role behavior and attitude about long-term care, economic burdens, resources to care for long-term condition and grieving process, signs of depression, feelings of powerlessness and hopelessness.
Provides information about family attitudes and coping abilities that directly affect the child’s health and feeling of well-being; chronic conditions affecting a child in a family may strengthen or strain relationships and members may develop emotional problems when the family is stressed.
Encourage family members to vent feelings and reactions to the appearance and condition of the infant/child.
Relieves anxiety and concern and allows a show of acceptance for their responses.
Encourage expression of feelings and provide accurate, honest information about care with or without surgical repair, abilities, and disabilities.
Allow reduction in anxiety and enhances family understanding of the condition and child’s needs.
Encourage to maintain the health of family members and social contacts.
Prevents adverse effects of chronic anxiety, fatigue, and isolation on the health and care capabilities of the family.
Communicate empathy for the client and family.
Promotes coping and positive adjustment to illness.
Support and encourage parental and family caretaking efforts.
Provides positive reinforcement of roles and reduces stress in family members.
Provide anticipatory guidance for crisis resolution.
Assists the family to adapt to the situation and develop a new coping mechanism.
Be aware of cultural differences in coping behaviors; need differs according to cultural and ethnic backgrounds.
Promotes cultural and developmental normalcy.
Assist to discuss family dynamics and the need to tolerate conflict and individual behaviors.
Assists to understand the family members leading to resolution.
Assist to identify helpful techniques to use to problem solve and cope with the problem and gain control over the situation.
Provides support for problem-solving and management of the situation.
Assist the family with identifying the realities of disabilities and suggest contact with community agencies, clergy, social services, and physical and occupational therapy.
Provides support, information, and assistance.
Teach that overprotective behavior may hinder growth and development, and that child should have limits and rules to live by.
Enhances the family’s understanding of the condition and the need for the integration of the child into family activities.
Reinforce positive coping behaviors.
Promotes behavior change and adaptation to care for the child.
If hospitalization is frequent, assign the same personnel to care for the child if appropriate.
Promotes trust and communication with family members.
Explain causes, treatment, and prognosis of the condition; inform parents that they are not at fault for the development of the congenital defect.
Reduces guilt and provides information about the condition.
Advise parents that surgery may be performed within 48 hours after birth or be postponed to the age of 3 months or until a further neurologic function is assessed, to allow for better epithelialization to occur, and to reduce the possibility of the development of hydrocephalus; use this information as reinforcement of physician information.
Provides information to assist the family in the decision about the surgical procedure.
Inform the need for follow-up appointments with physician and therapists.
Ensures compliance with the medical regimen.
6. Preventing Infections and Injuries
Patients with spina bifida are prone to infection due to the increased risk of urinary tract infections and the presence of exposed neural tissue, which can serve as a potential entry point for pathogens. Additionally, their reduced mobility and sensory deficits can make them more susceptible to injuries, such as falls or pressure sores. The combination of these factors underscores the importance of infection control measures, proper hygiene, and injury prevention strategies to mitigate the risks and promote the well-being of individuals with spina bifida.
Assess neural tube sac for breaks or leakage of CSF, irritation of sac, redness, swelling, and purulent drainage at or around sac area; Assess for fever, irritability, nuchal rigidity, cloudy foul-smelling urine.
Gives information about the potential infection of the sac site, and meningitis if the sac is ruptured, or is present.
Do handwashing before or after procedures involving the site and maintain sterile technique when caring for the client.
Avoids the proliferation of microorganisms on the site.
Use sterile saline or antibiotic solution as prescribed to make sure a moist sterile dressing is applied over the sac.
Avoids the sac membrane to be dried which could result in sac breakage and contamination.
Reinforce moist dressing with dry sterile dressing and change as needed; Remove moist dressing after it has dried to avoid damage to the sac.
Prevents contamination by capillary action through moisture.
Apply a shield over the sac dressing and tape a plastic sheet below the defect; following surgical closure on the defect, apply a transparent occlusive dressing over the area below the sac site.
Protects the sac from urine or fecal contamination.
Keep anal area clean and apply a sterile shield between anus and sac.
Prevent fecal contamination caused by poor anal sphincter control which allows for dribbling and incontinence of stool.
Avoid ureteral contamination with stool, and perform thorough perianal hygiene as needed.
Prevents urinary tract infection.
Alter routine nursing care activities such as feedings, changing linens, and comforting as needed.
Prevents trauma to the sac.
Following surgical repair of the defect, observe any changes in wound including redness, swelling, warmth, drainage, or fever.
Indicates wound infection.
Following surgery, cleanse wound with antiseptic as ordered and change dressings when needed using sterile technique for at least 24 hours.
Promotes cleanliness of wound and prevents infection.
Maintain the infant in a prone position or side-lying, as permitted, with head lower than buttocks or hips slightly flexed with a pad between the knees; anchor position with sandbags.
Reduces pressure on the sac to prevent possible rupture and prevents rolling on the side or back.
Administer antibiotics as ordered.
See Pharmacologic Management
14. Handle infant gently, hold and support back above the defect, or place on a pillow in a prone position to move from place to place.
Prevents pressure on the sac area.
Recognize children with latex allergies and make them wear a medical id alert bracelet.
Promote usefulness during treatment; May prevent an allergic reaction to happen.
Inquire all clients admitted about reactions to latex allergy during all initial interviews.
Promotes screening of all clients which may prevent severe allergic reactions in otherwise low-risk clients.
Keep a latex-free environment, especially with high-risk populations (children with spina bifida). Discourage the use of latex balloons in the healthcare facility.
Prevents the development of latex allergy; prevents an allergic reaction in those who are already sensitized.
Have emergency equipment ready, making sure the availability of supplies required to manage an anaphylactic reaction.
Promote immediate emergency treatment.
7. Initiating Patient Education and Health Teachings
Patient health teachings for spina bifida include educating patients and their families about the disease condition, as well as providing guidance on self-care tasks such as bowel and bladder management, skincare, and proper use of assistive devices. Moreover, teaching infection prevention strategies, injury prevention techniques, and promoting psychological well-being are vital components of patient education for spina bifida.
Educate patients with spina bifida and their family about the condition, its implications, and potential complications.
This is to enhance a better understanding of the condition, empower them to actively participate in the care, and promote informed decision-making for better management.
Provide teachings on injury prevention, including safe mobility techniques, and fall prevention.
Injury prevention for patients with spina bifida involves teaching safe mobility techniques, such as proper body mechanics, transfers, and using mobility aids like wheelchairs or braces. Fall prevention strategies include assessing the home environment for hazards, recommending modifications or adaptive equipment, and teaching patients and families about the importance of maintaining balance and stability.
Educate patients and families about infection prevention strategies, such as proper hand hygiene, clean intermittent catheterization techniques, and regular skin care.
Proper hand hygiene helps minimize the transmission of pathogens and reduces the risk of urinary tract and respiratory infections. Educating on clean intermittent catheterization techniques ensures the proper management of neurogenic bladder, minimizing the risk of urinary tract infections. Regular skin care, including cleaning and inspection, helps prevent skin breakdown and potential infections, particularly in areas prone to pressure sores.
Teach parents to cleanse the sac gently with moist cotton balls if soiled, and avoid diapering the infant until after surgery and healing has taken place.
Protects sac from contaminants and maintains cleanliness.
Teach parents about the proper positioning of infant and the application of protection around sac such as foam rubber doughnut.
Prevents damage to the sac and possible infection.
Teach parents about signs and symptoms of infection on the surgical site, and notify the health care provider accordingly.
Promotes early detection of an infectious process for early treatment.
Stress the importance of handwashing, dressing change, and use of clean or sterile linens, gloves, supplies when caring for the sac area.
Prevents transmission of infectious organisms; sterile technique may not be needed in giving care after surgery is performed.
8. Administer Medications and Provide Pharmacologic Support
Medications involved in the management of spina bifida can include antibiotics to prevent or treat urinary tract infections, antispasmodics to control bladder dysfunction, and stool softeners, laxatives, or fiber supplements to manage bowel dysfunction. The specific medications prescribed depend on the individual’s needs and may vary to address the various aspects of spina bifida-related complications such as neurogenic bladder and bowel dysfunction.
Antibiotics may be prescribed to prevent or treat urinary tract infections (UTIs) that are common in individuals with spina bifida due to neurogenic bladder dysfunction.
These medications can help control bladder spasms, increase bladder capacity, and improve bladder emptying.
Stool softeners; laxatives
These medications and supplements help promote regular bowel movements, prevent constipation, and alleviate discomfort associated with bowel irregularities.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These medications are used to alleviate pain associated with musculoskeletal issues, surgical procedures, or complications such as pressure sores.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
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