Discuss the significance of Jackson’s clinical manifestation.

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1. Discuss the significance of Jackson’s clinical manifestation.

Hydrocephalus and myelomeningocele are a central nervous system defects.

Hydrocephalus is caused by an increase of cerebrospinal fluid in the brain. It can be congenital acquired, or of unknown. Congenital hydrocephalus causes occur as a result of genetic problems or problem with foetal development such as spina bifida. Spina Bifida is caused by a defect in the neural arch generally in the lumbosacral region , where the posterior laminar of the vertebrae fail to close. This leaves an opening through which the spinal meninges and spinal cord may protrude forming a cystic sac; this condition is termed as spins with myelomeningocele. Acquired Hydrocephalus can occur at any age, which can be as a result of head injuries, strokes, infections, tumour and bleeding in the brain. Unusually large head is the main sign of congenital Hydrocephalus (Hatfield 2009).

As the cerebrospinal fluid in the brain increases the head enlarges causing the suture line separate and the spaces may be felt through the scalp. The anterior fontanel becomes tense and bulging, the skull enlarges in all diameters, and the scalp becomes shiny and its veins dilate. If the pressure continues to increase without intervention , the eyes appear to be pushed downward slightly with the sclera visible above the iris , this is called setting sun sign (Hatfield 2009).

Without adequate drainage of excessive fluid , the head becomes increasingly heavy , the neck muscles fail to develop sufficiently , and the new born has difficulty raising or turning the head the neonate also present with high -pitched cry (Hatfield 2009) .

2. Describe the relationship between myelomeningocele and Hydrocephalus

Myelomeningocele is a condition where the fetus spinal column fails to close during development. This usually occurs about the 20th to 28th day of gestation, there is the formation of a sac filled with spinal fluid, meninges, nerve roots and spinal cord protruding through the opening in the spinal column. Due to this opening there is a loss of fluid surrounding the nervous system, causing the brain to position further down in the upper spinal column which results in the obstruction of flow of fluid in the brain. Thus resulting in an imbalance in the production or absorption of fluid in the brain, the fluid then gets trapped in the ventricles and cannot complete its circulation, causing the ventricle to expand, which causes the condition Hydrocephalus (James & Ashwill 2010).

3. Describe the nursing management for Jackson using the following Nursing Diagnostic labels:

a. Ineffective Cerebral Tissue Perfusion

b. Risk for Impaired Skin Integrity

Need Identification: oxygen

Objective data: Bulging fontanels, high-pitched cry, head circumference is 40cm, chest circumference 34cm, and sac-like projection in lumber region of spine.

Nursing diagnosis: In effective cerebral tissue perfusion related to decrease arterial or venous blood flow secondary to increased intracranial pressure as evidence by bulging fontanels, high-pitched cry, head circumference is 40cm, chest circumference 34cm, and sac-like projection in lumber region of spine.

Goal: Neonate will begin to show improvement in signs and symptoms of increased intracranial pressure at the end of the 8 hours shift. Following nursing and collaborative intervention as evidence by maintenance of level of consciousness, decreased head circumference of at least 0.5cm to 1cm and improvement of cry.

Nursing Interventions with rationale:

• Monitor vital signs especially hearts rate and respiration.

Rationale: Changes in heart rate can occur because of brain damage and irregular respiration can suggest increased intracranial pressure. Thus, identifying deviation early can help with quick intervention that will prevent complication (James & Ashwill 2010).

• Perform Glasgow coma scale every 2 hours.

Rationale: This allows for continuous monitoring of patient’s condition and allows for early detection of complications (Ackley & Ladwig 2014).

• Nurse patients with head slightly elevated thirty degree (30o).

Rationale: This will help to reduce arterial pressure by promoting venous drainage, thus improving cerebral circulation and perfusion (Ackley & Ladwig 2014).

• Maintenance bed rest and reduce disturbance Rationale: Continual Stimulation can increase intracranial pressure and cerebral oedema (Ackley & Ladwig 2014)..

• Administer Medication as ordered such as acetazolamide

Rationale: This medication helps to decrease production of cerebrospinal fluid. Thus, help in decreasing intracranial pressure (James & Ashwill 2010).

• Measure neonate’s head daily

Rationale: This is done to monitor and assess the increase of intracranial pressure (James & Ashwill 2010).

Need Identification: Safety and Security

Subjective data: (Does not apply to risk diagnosis)

Objective data: A sac-like projection observed in the lumbar region of the spine, bulging fontanelles, head circumference 40cm (15.8in) and chest circumference 34cm (13.4 in).

Nursing Diagnosis: Risk for Impaired Skin Integrity related to neurologic motor deficits.

Goals: At the end of the eight hours shift neonate’s skin will remain intact, as evidenced by absence of pressure areas or ulcerations to head and lumbar region, following nursing and collaborative care.

Nursing Interventions with rationale:

• Use a special mattress or pad for the infant’s bed. Preoperatively, place the infant in a prone or side-lying position with a small blanket or diaper roll under the ankles and between the knees.

Rationale: Special bedding can help alleviate pressure points caused by the required preoperative prone position. Blanket rolls help maintain anatomic position of the feet and

hips (James & Ashwill 2010).

• Apply dressing as ordered maintaining sterility with the use stoma adhesive on both sides of the sac to secure the dressing.

Rationale: Changing dressing often may irritate the skin, the potential for irritation will be less if the tape is stick to the stoma adhesive (James & Ashwill 2007).

• Provide cushion for head.

Rationale: To keep weight evenly distributed, thus preventing pressure ulcers, (Gulamick & Myers 2014)

• Assess the neonate’s skin and reposition every two hours.

Rationale: This will help to identify signs of skin breakdown early while frequent reposition help to relief from affected areas.

• Leave the diaper under the infant unfastened and change soil diaper immediately.

Rationale: Keeping the infant’s diaper open facilitates frequent cleansing of the perineal area because oozing of stool, urine and dribbling may happen. Also keeping the area clean and dry reduces skin breakdown (James & Ashwill 2010).

4. Jackson’s myelomeningocele is surgically repaired and a shunt is placed for his hydrocephalus.

Identify the most common complications that may occur in a child/infant with a VP shunt.

– Shunt blockage

– Shunt infection

– Shunt over drainage

5. Identify the teaching priorities for Jackson’s parents prior to discharge from hospital.

Myelomeningocele discharge teaching:

• Educate parents how to cope with the infant’s physical problems and successfully meet long-term treatment goals. For example, discuss how to identify early signs of complications such as pressure ulcers and urinary tract infection (James & Ashwill 2007).