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Guzmán-Caridad I, Landin-Guerra RC, Rico-Aguilar MT. Caso clínico de enfermería: mujer embarazada y recién nacido con defecto del tubo neural. Rev Enferm Inst Mex Seguro Soc. 2016;24(1):65-74.
Nurse case: pregnant women and newborn with neural tube defect
Irene Guzmán-Caridad,1 Rosa Clara Landin-Guerra,1 Marisol Teresa Rico-Aguilar1
1Gineco-Obtetricia U-112, Hospital General de México, Secretaría de Salud. Distrito Federal, México
Correspondence: Irene Guzmán Caridad
Email: princeirene@hotmail.com
Date received: September 14th, 2015
Date judged: October 18th, 2015
Date accepted: November 16th, 2015
Abstract
The contribution of the nurse in the promotion and dissemination of neural tube defects, is rele-vant because the prevalence of congenital malformations in Mexico is 4.9 per 10 000 defects and 75% of the cases correspond to myelomeningocele. The purpose was to provide comprehensive nursing care and collaboration to the binomial mother and son from the income of the mother of the baby until discharge to home. The case of a pregnant woman is 33.6 weeks gestation with labor entering the service of Gynecology and Obstetrics in order to improve the fetal prognosis and terminate the pregnancy through the abdomen. At 19:08 hours, masculine product 2,200g, height 48 cm, 30 cm head circumference, Apgar 4/8, Capurro and 33.5 weeks in the presence of lumbar myelomeningocele about 5x4 cm and lower extremities without mobility is obtained. Data were recorded on the sheet of nursing structured stages of the nursing process and based on the requirements of development, health deviation and universal conceptual model of Dorothea Orem. The plan of nursing care possible to integrate mother-son, mother in their clinical evolution is favorable and the infant withdraws reactive to external stimuli, sucking and swallowing reflexes present oral tolerance and surgical scar in region lumbar.
Keywords: Nursing care; Pregnant woman; Meningomyelocele.
Introduction
In the last 50 years, the infant mortality rate has declined in much of the world due to the adoption of various measures in the areas of public health, preventative medicine, and medical care. However, this decline is not homogeneous: while the current mortality attributable to intestinal and lung infections is much lower today than a decade ago, mortality associated with premature birth and congenital malformations (CM) has increased; the specific mortality rate for CM went from 2.2 to 3.5 per 1000 births (b = 0.05; p < 0.001); the rate of infant mortality from spina bifida increased to 0.35 per 1,000 births in 1989 and decreased to 0.05 per 1000 births in 2005 (CM = -0.09; p < 0.0001).1
The high mortality and morbidity rates associated with CM negatively affect health systems and are a cause of great concern, not only for the resources they consume, but also for the social damage they cause, especially to the mother, father, and those close to the patient.2 As such, it is considered a devastating event for parents, who require genetic counseling and action to refine the diagnosis and sometimes provide medical or surgical treatment.3
In Mexico the prevalence of CM is 4.9 per 10,000 defects and 75% of cases are myelomeningocele, these patients have other associated congenital malformations and often present hydrocephalus, in 90% of cases associated with Chiari malformation type ll.4
Myelomeningocele is characterized by a congenital malformation of the central nervous system caused by a failure of neural tube closure during embryogenesis, in which the posterior arch of the spinal cord is incomplete or absent (Figure 1); the defect contains within it spinal marrow, nerve roots, meninges, and cerebrospinal fluid, so depending on the level at which it is located and the type of neural tube involvement, the newborn can present motor and sensory injury of the lower extremities (Figure 2).5
Figure 1. Failure of the neural tube during embryogenesis
Figure 2. View of the interior of a meningocele
Neural tube defects can be reduced by up to 70% of cases, so it is recommended that all women with chances of becoming pregnant should consume 0.4 mg of folic acid per day during the period around conception (from three months before up to three months after gestation). If there is history of a child with a neural tube defect, the dose should increase to 4.0 mg / day.4,5
In the Hospital General de México (2000-2003), out of a total of 22,771 live births, 226 (0.99%) cases of newborns with external birth defects were identified, primarily in females with 52.7%, 67% full-term newborns and 33% preterm; in the classification by devices and systems, the most affected was the digestive system with 38.9%, second was nervous system malformations with 15.9%, and the third was genetic malformations with 15.0%.6 Another study (2000-2004) gathered 76 newborns with CM, and the most frequent were hydrocephalus with 34 cases and myelomeningocele with 16 cases, occurring more frequently in males; regarding maternal age, the most affected group were women between 16 and 20 years, predominantly primigravida women who attended prenatal care irregularly.7
Development
The methodology was based on the five stages of the nursing process,8 an instrument was used for recording valuation data based on Dorothea Orem’s conceptual model9 structured into three areas, the first framed the requirements of development (life stages), the second with the requirements of health deviation (cases of illness, injury, disability, or receiving medical care), and the third with the universal requirements, including the essential physiological, psychological, social, and spiritual elements of life (Tables I and II).
| Table I. Clinical case description of mother-child duo | |||
| Mother’s data | Newborn’s data | ||
| Age: 28 years | Vital signs | ||
| Marital status: Cohabitating | HR: 76/min, RR: 18/min, bp: 110/70 mm Hg and BT: 36.8 °C |
Weight: 2,200 g | Length: 48 cm |
| Occupation: Homemaker | Apgar score 4/8 | Head circumference 30 cm | |
| Education: Bachelor's degree | Capurro test 33.5 weeks | ||
| Hereditary or family history | Data from May 13 to 15, 2015 | Data from May 13 to 15, 2015 | |
| Diabetes and hypertension (father), asthma (mother), Alzheimer's disease (paternal grandfather). History of sporadic smoking since age 18. |
EF: 6 cm dilation and 80% effacement detected with labor in developing phase, so she was admitted to obstetrics department in conscious oriented state, skin and mucous membranes hydrated, seemed sad, afraid, and anxious about her son’s state of health. On the first day after surgical puerperium, breasts were symmetrical, plump, not painful on palpation, soft abdomen depressible with pain on palpation, surgical wound in infraumbilical midline, edges well aligned, vaginal blood loss, uterus below the umbilical scar, external genitalia normal for age and sex, vital signs within normal parameters. E15-05-15 patient went home due to good clinical development. |
19:08 h May 13th of the current year, child is obtained via abdomen to improve fetal prognosis. Newborn (NB) male, medically diagnosed preterm with myelomeningocele, likely hydrocephalus. EF: lumbar region with presence of myelomeningocele 5 x 4 cm, lower extremities with decreased tone and trophism without mobility, generalized cyanosis, intercostal retractions, desaturation, polypnea, and bradycardia. Admitted to intermediate neonatal therapy with mechanical ventilation by endotracheal cannula and surfactant administration. Lung fields with vesicular murmur, heart sounds without murmur. Slightly convex anterior fontanelle, well implanted ears, permeable choana, lip and palate intact, cylindrical neck. Globular soft abdomen, genitals normal for age and sex. Consultation with Pediatric Neurosurgery requested. |
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| Perinatal history | |||
| First pregnancy, unplanned pregnancy, but accepted due to family bond, irregular prenatal care with 4 visits to private doctor and 5 sonograms; complete vaccination scheme, intake of folic acid, iron, calcium, and vitamins starting third month of pregnancy, UTI in 5th month with nitrofurantoin treatment and remission of signs. Last sonogram May 2nd 2015 reported pregnancy of 31.2 weeks of gestation, fetal weight 2,100 g, amniotic fluid gain, and data suggesting myelomeningocele and likely Chiari Malformation type II. | |||
| Table II. Newborn clinical case description | |
| Evaluation May 19 th, 2015 | |
| Neonate in incubator, initial hours post-surgery showing a diagnosis of myelomeningocele plasty | |
| EF: jaundiced coloring, anterior fontanelle with discrete convexity, diaphoresis, furrowed brow and moderate pain 12 points according to PIPP scale, capillary refill 2-3 seconds, HR: 180/min, RR: 54/min, bp: 88-62 average 71, HC: 33cm, O2 Sat 80%, capillary glycaemia 96 mg/dl. Mechanical ventilation in assist-control mode, abundant thick whitish secretions from cannula and mouth. Fasting with parenteral nutrition, double antibiotics program (ampicillin and amikacin) with analgesia and sedation (paracetamol and fentanyl infusion to dose response, 8 5mcg I.V. given in 12 ml of physiological solution, 0.5 ml/h given in continuous infusion pump), surgical wound clean with waxy excretion, lower limbs without mobility. MRI report confirms diagnosis of hydrocephalus, therefore surgery scheduled. |
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| Evaluation June 12 th, 2015 | Evaluation June 22nd, 2015 |
| EF: normotensive fontanelles, capillary refill 2 seconds, HR: 160 min, bp: 73-40 average of 50, RR: 48/min, HC: 32 cm, O2 Sat 92 to 96%. Presence of bilateral inguinal hernia and request for evaluation by pediatric surgery. Surgical wounds with proper healing, lumbar wound without exudate, in process of granulation, and lower limbs without mobility. On the first day post-surgery with placement of a ventriculoperitoneal shunt for the hydrocephalus, he was mechanically ventilated in assist-control, with glucose levels 82 - 94 mg/dl, double antibiotics program (vancomycin and meropenem) as well as analgesics (paracetamol) and continuous fentanyl infusion. |
EF: 39 days of life, responsive to environment, normotensive fontanelles, sedation and analgesia with fentanyl infusion, in ventilatory phase I by cephalic camera 28% FIO2, O2 Sat 91 to 95%, micronebulization with bronchodilator (salbutamol) and steroids (fluticosona), lung fields have respiratory roughness, bp: 65-35 average 48, HR: 160/min, temperature: 36.8 °C, capillary refill 2 sec, glucose 78 mg/dl, HC: 31cm, continued giving parenteral and enteral nutrition in 25 ml of human milk or breast milk at 13% with mixed techniques, tolerated well, with weight gain 20 g per day, no antibiotics program, no signs of systemic infection, surgical wound edges well aligned; bilateral inguinal hernia and hypertonic upper limbs, lower limbs without mobility. Inguinal hernioplasty and rehabilitation therapy scheduled. E26-06-15 is admitted to growth and development nursery, presents good surgical evolution so he receives his first rehabilitation session. |
| Evaluation July 9 th, 2015 | Evaluation July 25 th, 2015 |
| Infant active and reactive to external stimuli, without presence of seizures, O2 saturation 90 and 93%, good suction and swallowing reflex with full contribution of human milk for preterm, oral tolerance, with weight gain 25 gr x day, HR: 142/min, RR: 56/min, bp: 75-45 half 53, BT: 36.9 °C, HC: 32 cm, capillary glucose 94 mg/dl, intravenous infusion with SG 5% 12 ml/24 h, with contribution of vitamins A, C, D and E, ferranin complex as well as theophylline and phenytoin. Without signs of abstinence secondary to fentanyl (48 hours), lumbar region with surgical scar, hypotonic lower limbs, uresis and evacuations present, with presence of bilateral inguinal hernia. E3-07-15 transfontanellar sonogram unchanged, control magnetic resonance rescheduled. | EF: infant underhydrated, reactive to external stimuli, acclimated, with normotensive fontanelle, HR: 142/min, RR: 56/min, bp: 68-48-56, capillary refill 2 seconds, suction and swallowing reflex present, oral tolerance, lumbar region with surgical scar, hypotonic lower limbs, continuous rehabilitation sessions, uresis and evacuations present, presence of bilateral inguinal hernia. Day July 27 th, 2015, control magnetic resonance without disorders. 28/07/2015, discharged home, outpatient management by different specialists followed by rescheduled bilateral hernioplasty. |
The statements of the nursing diagnosis, the expected outcomes, and the nursing interventions were made based on the NANDA-NOC-NIC interrelation, from the initials NANDA-I, Nursing Outcomes Classification NOC, Nursing Interventions Classification NIC.10-13
Nursing care plans for the newborn with myelomeningocele were made by the timing of care: a) immediate attention with surgical correction of the defect; b) care of the infant; and, c) long-term care through correction of musculoskeletal deformities, and sometimes regulation of bladder and bowel function as well to minimize psycho-emotional problems arising from the disability (Tables III and VI).14-19
| Table III. Nursing care plan for pregnant woman with child with myelomeningocele | |||||||||||||||||||||||||||||||||||||||||||
| Nursing diagnosis (ND) | Expected result (NOC) | Nursing interventions (NIC) | Assessment (NOC) Target score |
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| Domain 8 Class 3 Reproduction Nursing diagnosis Label (problem) (P) Risk of disorder in the duo Related factors (causes) (e) · Pregnancy complications (delayed prenatal care and child with neural tube malformation (myelomeningocele)) · Compromised oxygen transport (preterm labor) |
Antepartum maternal state · Blood pressure · Heart rate · Respiratory rate · Body temperature Prenatal fetal status Fetal heart rate ·Fetal movement frequency ·Variability in electronic findings of fetal monitor |
Vital signs monitoring ·Regularly evaluate: blood pressure, pulse, temperature, and respiratory status ·Evaluate oxygen saturation in normal parameter (greater than 92%) ·Periodically observe skin color, temperature, and moisture ·Check capillary refill ·Observe respiratory movements and listen to chest ·Evaluate changes related to breathing o Apnea: Temporary suspension of respiration o Bradypnea: abnormally slow breathing o Dyspnea: shortness of breath o Polypnea: increased respiratory rate o Tachypnea: rapid, shallow respiratory movements ·Identify possible causes of changes in vital signs (pathological, emotional, and/or pain state) ·Record data in clinical nursing record Electronic fetal monitoring before birth ·Review obstetric history to determine obstetric risk factors or consult doctors concerning fetal status ·Check fetal heart rate figure normal 120 to 160 beats per minute, using Pinard and fetal heartbeat detector-amplifier. ·Apply transducers in a comfortable way to observe frequency and duration of contractions ·Help doctor carry out ultrasound ·Inform multidisciplinary team of maternal-fetal conditions (child with myelomeningocele) to take appropriate measures at the level of each specialty ·Verify medical indications about service admission by (emergence of birth pains, spontaneous loss of fluid, bleeding, or decrease in fetal movements) |
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| Intervention (NIC) Monitoring at end of pregnancy |
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| Activities ·Review obstetrical history ·Determine health risks for mother and fetus through interview, physical examination, and laboratory and imaging studies ·Establish gestational age by ultrasound and calculate due date by menstrual period ·Monitor maternal vital signs (heart rate, blood pressure, respiratory rate, and temperature) ·Electronic fetal monitoring ·Observe presence of fetal movements ·Observe signs of premature labor pains (> 4 contractions per hour, back pain, abdominal pain) ·Take preoperative laboratory samples (blood biometrics, blood group and Rh, blood chemistry, and coagulation times) ·Interpret results ·Initiate intravenous therapy and medication interventions according to medical indications ·Check uterine activities (frequency, duration, and intensity of contractions) ·Perform Leopold maneuvers to determine fetal position ·Perform vaginal examination to assess dilatation of cervix, effacement, fetal position, and to determine if membranes have ruptured ·Set priority of actions depending on patient’s state of health (treat, continue observing, admit or register or prepare for caesarean section according to medical indication) |
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| Table IV. Nursing care plan for newborn born with neural tube defects (myelomeningocele) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Nursing diagnosis (ND) | Expected result (NOC) | Nursing interventions (NIC) | Assessment (NOC) Target score |
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| Domain 3 · Elimination and Exchange Class 4 · Respiratory function Label (problem) (P) ·Impaired gas exchange Related factors ·Imbalance in perfusion ventilation ·Pulmonary immaturity |
Respiratory status Gas exchange ·Oxygen saturation ·Balance between ventilation and perfusion ·Cyanosis Respiratory status: Ventilation ·Respiratory rate ·Breathing rate ·Use of accessory muscles |
Intubation and airway stabilization ·Assemble material and equipment necessary for endotracheal tube placement, this should include positive pressure device with oxygen reservoir and mask, (laryngoscope with blade No. 1 (term baby), No. 0 (premature baby), No. 00 (optional for extremely preterm newborn).) Straight blade is preferred, size of endotracheal tube must be selected according to weight or gestational age. The following table provides size and recommended tube.
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| Intervention (NIC) Intubation and airway stabilization |
Intervention (NIC) Mechanical ventilation |
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| Activities | Activities | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ·Place newborn in sniff position (neck slightly extended) ·Place pulse oximetry ·Listen for breathing sounds of equal intensity in both lung fields, after intubation ·Observe improved heart rate, muscle tone, skin color, and oxygen saturation ·Observe symmetrical chest movements with each ventilated breath ·Check that tube is inserted at correct distance using tip to lip measurement. The following table describes insertion depth based on newborn’s weight
·Add 6 to newborn’s estimated weight in kilograms and you will get a rough estimate of distance from tip of tube to upper lip |
·Observe presence of respiratory distress (intercostal retractions, nasal flaring, xifoidea retraction) ·Check all ventilator connections ·Make circuit changes every 24 h ·Monitor patient progress in settings of current ventilation and make appropriate changes according to medical indication ·Keep ventilator alarms on ·Assess respiratory sounds, presence of crackles, wheezing, hypoventilation, and snoring) ·Perform aspiration of secretions using sterile technique ·Assess pain and agitation: administer analgesics (fentanyl, paracetamol), sedatives (midazolam mg/kg I.V.) muscle relaxants (vecuronium bromide) according to medical indication in order to keep patient still, allowing muscle relaxation and keeping them from fighting against the ventilator, allowing adequate oxygenation ·Watch for adverse effects of mechanical ventilation: infection, barotrauma, and decreased heart rate ·Observe patient’s state of oxygenation (oxygen saturation levels) ·Frequently check attachment of endotracheal tube ·Change positions every 3 to 6 hours depending on stability of patient ·Place patient in such a way to facilitate ventilation perfusion equity (fowler and/or semifowler) ·Monitor arterial blood gas levels ·Register in nursing sheet oxygen saturation, characteristics of secretions, medications administration, and airway tolerance |
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A key aspect for the survival of the newborn with myelomeningocele is the integration and consolidation of multidisciplinary teams for their care, whose actions are aimed at ensuring the quality of life of the newborn and family, as well as appropriate physical, psychological, emotional, and social development, with autonomy to carry out the age-appropriate activities daily life.
Results
During the antepartum maternal condition, the patient maintains vital signs within the normal limits, as well as fetal heart rate in the normal range of 148-160 beats per minute, without periodic change and with an average baseline variability, maintained with target final score of 4; however, due to medical indication the patient is prepared for abdominal surgery because she is admitted with labor in the developing phase. Caesarean section is preferred to avoid complications from myelomeningocele rupture (Table III).
The patient is reassured by reducing the level of anxiety, she maintains the final target score of 3; however she is sent to psychological therapy and self-help groups, so follow-up from another specialist will be needed because the health condition of her child requires long-term resolution.
The newborn’s gas exchange improves through the use of conventional mechanical ventilation, whereby improvement is observed in respiratory rate and rhythm, heart rate, muscle tone, skin coloring, and increased oxygen saturation; the child maintains a final target score of 4 (Table IV).
During the time that the newborn was managed without surgical correction of the defect, no signs of systemic or local infection occurred, however the child was managed with a double program of antibiotic prophylaxis, the skin of the defect remained hydrated without added lesions, body temperature was monitored in the normal range of 36.5 to 37 °C, the final target score of 4 was maintained because he remained at risk (Table V).
| Table V. Nursing care plan Newborn baby with neural tube defects (myelomeningocele) |
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| Nursing diagnosis (ND) | Expected result (NOC) | Nursing interventions (NIC) | Assessment (NOC) Target score |
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| Domain 11 ·Security and protection Class 1 ·Infection Nursing diagnosis (NANDA) Label (problem) (P) ·Risk of infection Related factors (causes) ·Exposure of epithelial sac to pathogens ·Invasive procedures |
Tissue integrity: skin and mucous membranes ·Skin integrity ·Skin temperature Immune status · Current infections detained · Absolute leukocyte count |
Skin care · Assess degree of effect on skin (defect broken and/or intact) · Healing of lesion (change gauze and dressing) using sterile technique with warm physiological solution three times a day to prevent desiccation · Apply sterile dressing · Inspect state of epithelial sac (presence of cerebrospinal fluid leakage in significant amount) · Quantify amount and color of drainage present at each dressing change · Provide lateral or prone position changes every 2 to 3 hours, depending on stability of newborn · Avoid pressure ulcers Protection from infection · Determine patient’s degree of vulnerability to infections by evaluating state of primary barriers (skin, mucous membranes) and secondary barriers (immune system) · Maintain principles of asepsis (from clean to dirty, from center to periphery, from distal to proximal) · Have an infection prevention and control program that uses epidemiological surveillance, universal precautions, and rational use of antiseptics and disinfectants, patient isolation, and environmental sanitation · Manage immunotherapy according to medical indication (intravenous immunoglobulin from 200 to 800 mg/kg per 2 to 6 hours, dose and frequency vary according to desired IgG concentrations and clinical response) · Assist in sampling for cultures (if sack is broken) and report positive results of cultures · Encourage adequate nutritional intake · See if there are signs of systemic infection such as: hyperthermia or hypothermia, tachycardia, tachypnea, alterations in alertness, changes in hematic biometrics such as leukocytosis or leukopenia, bandemia, thrombocytopenia, and increased erythrocyte sedimentation rate; or local infection such as: examining color, presence of exudate, and inflammation of epithelial sac Temperature regulation · Place newborn in an incubator or radiant crib · Monitor newborn’s temperature until it stabilizes · Observe and record signs and symptoms of hypothermia, hyperthermia · Adjust temperature to patient's needs · Warm stethoscope before examining newborn · Change diaper when necessary, avoid it being wet for long periods · Control incubator temperature, lower or raise it progressively · Administer antipyretic medication, according to medical indication · Observe signs of dehydration: skin turgidity, mucous membranes, and diuresis |
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The infant’s pain was able to be controlled by administering analgesics via continuous infusion and bolus, improving heart rate, blood pressure in the normal range, and increased oxygen saturation, a final target score of 5 was maintained (Table VI).
| Table VI. Nursing care plan for newborn with neural tube defects (myelomeningocele) | ||||||||||||||||||||||||||||||||||||||||||||
| Nursing diagnosis (ND) | Expected result (NOC) | Nursing interventions (NIC) | Assessment (NOC) Target score |
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| Domain 12 ·Comfort Class 1 ·Physical comfort Nursing diagnosis (NANDA) Label (problem) ·Acute pain Related factors (causes) ·Surgical procedure Defining characteristics (signs and symptoms) ·Diaphoresis ·Tachycardia ·Decreased O2 saturation ·Increased bp ·Furrowed brow ·Moderate pain (PIPP scale) |
Pain control ·Recognize start of pain ·Recognize causal factors ·Use analgesics properly ·Report uncontrollable symptoms to health professional |
Pain management · Perform a thorough assessment of pain including features of pain onset/duration, frequency, intensity, or severity and triggering factors · Observe expressive behaviors especially in patients who cannot communicate verbally (restlessness, defeated expression, diaphoresis, irritability, intense moaning, crying) · Administer analgesics according to medical indication · Determine impact of the experience of pain on quality of life (sleep, appetite, mood, and cognitive function) · Explore with patient factors that improve / worsen pain · Stimulate periods of sleep for the patient during the day and in the evening in a relaxed atmosphere · Assess pain using PIPP scale (this instrument evaluates the pain profile in preterm infants, consisting of 7 indicators, 2 physiological (heart rate changes and oxygen saturation) 4 behavioral (child’s behavior faced with pain: awake/active, furrowed brow, eyes shut tight and nasolabial sulcus), and gestational age · Register total score of pain scale in nursing sheet (minimal, moderate, severe) Administration of analgesics ·Determine location, characteristics, quality, and severity of pain before medicating patient ·Verify medical indications about prescribed analgesics (name of medication, dosage, frequency, route of administration, and duration of medication) ·Assess behavioral and physiological changes, such as crying, moaning, agitation, changes in heart rate and oxygen saturation ·Monitor vital signs before and after analgesic/narcotic administration ·Administer complementary analgesics and/or drugs when optimal analgesic effect is necessary ·Attend to comfort needs and other activities that help the relationship, to facilitate response to analgesia ·Administer analgesia at the right time, evaluating intensity of pain, especially with severe pain ·Evaluate analgesic efficacy at regular intervals after each administration, but especially after initial dose, and also watch for signs and symptoms of adverse effects (respiratory depression, nausea, vomiting, dry mouth, and constipation) ·Register in nursing sheet analgesic response and any adverse effect |
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Conclusions
Newborns with myelomeningocele may present motor and sensory injuries to the lower extremities, depending on the location and extent of the spinal cord lesion (lumbar, dorsal, cervical, or a combination of these).20 Significantly, the lumbar and lumbosacral regions are associated with the presence of major complications.4
According to Aristizabal,21 the malformations most frequently associated with myelomeningocele are Arnold Chiari Syndrome type II in 100%, and hydrocephalus in 80% of cases, which is confirmed in this case. Multidisciplinary care is required given the magnitude and complexity of the physical limitations involved in the malformations, and therefore rehabilitation therapy must be initiated in order to prevent further deformities.
The nursing care plan applied to the duo of mother and child with myelomeningocele identified human responses, prioritizing pathophysiological, physiological, psychological, and social needs, in addition to the use of Dorothea Orem’s conceptual model. In order to improve these patients’ prognosis, peri-conceptional and prenatal folic acid intake should be promoted, as well as strengthening and promoting prenatal care; finally alpha-fetoprotein must be determined, as well as ultrasound for all pregnant women with a previous history of children with myelomeningocele.
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