Question

Formulate a nursing care plan for the preoperative and postoperative care of a child with myelomeningocele.

Answer 1

Nursing Diagnosis-Decreased intracranial adaptive capacity related to compression of brain tissue due to increased CSF or cerebral edema secondary to increased ICP resulting from brain injury,congenital structural defects.

Outcome identification and Evaluation

Child will remain free of signs and symptoms of increased intracranial pressure as evidenced by remaining free of headache,vomiting,vision disturbances,vital signs within parameters for age.

Interventions

• Asssess the neurological status,monitor for signs and symptoms of increased ICP.
• Monitor vital signs.
• Measure head circumference in children greater than 3 years of age.
• Elevate head end of the bed 15-30 degrees to facilitate venous return.
• Minimize environmental stimuli.

2 Risk for infection related to surgical intervention.

Outcome identification and evaluation

• Child will exhibit no signs or symptoms of local or systemic infection and will not spread infection to others.

Interventions

• ,Monitor vital signs.
• Monitor incision sites for signs of local infection.
• Maintain aseptic technique.
• Administer antibiotics as prescribed.
• Encourage nutritious diet and proper hydration according to child preferences and ability to feed orally.
• Teach child and family preventive measures such as good handwashing,covering mouth and nose upon cough or sneeze.