Nursing Diagnosis and Interventions for Spina Bifida
Nursing Diagnosis
Urinary incontinence related to the inability to control the urge to urinate.
Knowledge deficit: parents about the disease process and their child's disease management related to less exposure to information.
Risk for impaired skin integrity related to immobilization.
Nursing Interventions :
1. Urinary incontinence related to the inability to control the urge to urinate.
Goal: Urinary incontinence can be reduced / resolved
Expected Outcomes :
- Enuresis, diurnal and nocturnal reduced / absent.
- The client urinates in a normal amount and frequency
Intervention:
1). Assess the client's urinary pattern and level of incontinence
Rationale: As basic data for further interventions
2). Give treatment to the client's skin that is wet with urine (wiped with warm water then wiped dry and given powder)
Rationale: Good care can prevent irritation to the client's skin
3). Check the client's diaper, if it is wet, change it immediately
Rationale: Diapers that are always wet can cause irritation and blisters on the skin.
2. Knowledge deficit: parents about the disease process and their child's disease management related to less exposure to information.
Goal: The client's parents can understand the disease process and the procedure for handling their child's disease
Expected Outcomes :
- The client's parents seem calm
- The client's parents can explain the disease process and the procedure for handling their child's disease
Intervention:
1). Assess the level of knowledge of the client's parents about the disease process and treatment of their child's disease
Rationale: As basic data in determining the next intervention.
2). Give the client's parents a chance to ask questions
Rationale: Provides a way to express feelings and know the client's parents' understanding of their child's illness
3). Explain well to parents about the disease process and its handling procedures
Rationale: Increase the understanding of the client's parents about their child's illness
4). Provide positive support to the client's parents
Rationale: Positive support can encourage parents to accept their child's illness and help the treatment process.
3. Risk for impaired skin integrity related to immobilization.
Goal: Impaired skin integrity does not occur
Expected Outomes:
- Skin looks smooth and soft
- No irritation / blisters, decubitus
Intervention:
1). Assess the level of limitation of movement (immobilization) of the client
Rationale: As basic data for further interventions
2). Change the client's position every two hours
Rationale: Prolonged pressure on one part of the body can cause pressure sores
3). Keep clothes and linen dry
Rationale: Wet clothes and linen can irritate the skin
4). Teach the client's parents to massage the depressed area, use lotion
Rationale: Accelerate blood circulation, promote relaxation and prevent irritation
