A pediatric patient with a VP shunt presents with increased lower limb weakness, unsteady gait, and urinary incontinence. The nurse notes a positive urinalysis for nitrites and leukocyte esterase, indicating a UTI. Which nursing intervention should take priority in managing this patient?

B) Perform hourly neurological assessments to monitor for signs of increased intracranial pressure.

A) Administer prescribed antibiotics for the UTI and monitor for allergic reactions.

B) Perform hourly neurological assessments to monitor for signs of increased intracranial pressure.

C) Encourage fluid intake to help flush out the urinary tract infection.

D) Educate the family on signs of shunt malfunction and when to seek emergency care.

A pediatric patient with a history of a VP shunt presents with increased lower limb weakness, unsteady gait, and urinary incontinence. Which of the following assessments should the nurse prioritize to evaluate for potential VP shunt malfunction?

B) Assess neurological status, including changes in level of consciousness.

A) Monitor blood pressure for hypotension.

B) Assess neurological status, including changes in level of consciousness.

C) Evaluate peripheral pulses for any discrepancies.

D) Check for signs of dehydration, such as dry mucous membranes.

A pediatric patient with a history of VP shunt placement is showing signs of increased intracranial pressure, including irritability and changes in consciousness. What is the priority nursing action to address these symptoms?

B) Elevate the head of the bed to 30 degrees to promote venous drainage.

A) Reassess the patient's vital signs every hour for 24 hours.

B) Elevate the head of the bed to 30 degrees to promote venous drainage.

C) Administer a prescribed dose of acetaminophen to manage potential fever.

D) Encourage the patient to rest quietly to reduce intracranial pressure.

A pediatric patient with a history of VP shunt placement is being monitored for potential shunt malfunction. The nurse observes an increase in irritability and a slight change in the patient's level of consciousness. What is the priority nursing action?

A) Notify the neurosurgical team immediately.

B) Administer prescribed antipyretics to reduce fever.

C) Encourage the patient to rest and monitor for changes.

D) Increase fluid intake to promote cerebrospinal fluid drainage.

A patient who recently underwent a shunt revision develops a low-grade fever and mild erythema around the surgical site. The complete blood count shows an elevated white blood cell count. Which nursing intervention is the priority in this situation?

B) Monitor the patient's neurological status closely.

A) Administer acetaminophen to reduce the fever.

B) Monitor the patient's neurological status closely.

C) Encourage the patient to increase oral fluid intake.

D) Educate the patient and family about signs of infection.

A patient who recently underwent a shunt revision is experiencing a low-grade fever, mild erythema around the surgical site, and a white blood cell count of 14,000 cells/mcL. Which nursing intervention is the most appropriate to prioritize at this time?

A) Monitor the patient's neurological status closely and report any changes.

B) Administer acetaminophen to manage the fever and provide comfort.

C) Increase the frequency of dressing changes to prevent infection.

D) Ensure the patient remains on bed rest to reduce intracranial pressure.

A post-operative patient with a shunt revision is showing signs of lethargy, increased heart rate, and positive blood cultures for Staphylococcus epidermidis. What is the most appropriate nursing action to prioritize in this situation?

D) Conduct a neurological assessment every hour to monitor for changes in intracranial pressure.

A) Administer prescribed vancomycin and monitor for signs of allergic reaction.

B) Increase the rate of IV fluid resuscitation to manage dehydration.

C) Encourage the patient to ambulate to prevent deep vein thrombosis.

D) Conduct a neurological assessment every hour to monitor for changes in intracranial pressure.

A patient who recently underwent a shunt revision presents with persistent low-grade fever, nausea, vomiting, and subtle neurological changes. Blood cultures indicate Staphylococcus epidermidis infection. What is the priority nursing action to address the patient's condition?

B) Administer the prescribed vancomycin and monitor for therapeutic effect.

A) Monitor the patient's neurological status every hour for changes.

B) Administer the prescribed vancomycin and monitor for therapeutic effect.

C) Increase fluid intake to combat dehydration.

D) Prepare the patient for a possible shunt replacement surgery.

A pediatric patient with a history of shunt placement is showing signs of shunt malfunction, including lethargy and diminished pupillary reflexes. An MRI reveals subtle ventricular enlargement. Which nursing intervention is most appropriate to prioritize while awaiting further surgical evaluation?

B) Elevate the head of the bed to 30 degrees to decrease intracranial pressure

A) Administer a hypertonic saline solution to correct hyponatremia

B) Elevate the head of the bed to 30 degrees to decrease intracranial pressure

C) Provide oral rehydration to address fluid imbalances

D) Administer an antipyretic to manage the patient's fever

A pediatric patient with a ventriculoperitoneal (VP) shunt presents with lethargy, sluggish responses to stimuli, and diminished pupillary reflexes. An MRI suggests subtle ventricular enlargement, and the patient has mild hyponatremia. What is the nurse's priority action when monitoring this patient?

B) Monitor the patient's neurological status closely and report any further decline immediately.

A) Increase the patient's oral fluid intake to address the hyponatremia.

B) Monitor the patient's neurological status closely and report any further decline immediately.

C) Encourage the patient to ambulate to prevent complications from inactivity.

D) Administer prescribed diuretics to reduce potential cerebral edema.

pediatric spina bifida - Nursing Case Study

Pathophysiology

• Primary mechanism: Spina bifida results from incomplete closure of the neural tube during embryonic development, typically occurring within the first 28 days of pregnancy, leading to varying degrees of spinal cord and vertebral malformation.

• Secondary mechanism: The exposed neural elements can lead to nerve damage and dysfunction, which may cause motor and sensory impairments depending on the level and severity of the defect.

• Key complication: Associated hydrocephalus is common, where cerebrospinal fluid accumulates due to disrupted flow, potentially increasing intracranial pressure and necessitating interventions like ventriculoperitoneal shunting to prevent neurological damage.

Patient Profile

Demographics:

8 years old, female, student

History:

• Key past medical history: Diagnosed with myelomeningocele form of spina bifida at birth, history of hydrocephalus with VP shunt placement, recurrent urinary tract infections

• Current medications: Oxybutynin for bladder management, Baclofen for muscle spasticity, prophylactic antibiotics for UTIs

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing difficulty with mobility and balance

• Key symptoms: Lower limb weakness, frequent falls, urinary incontinence, occasional headaches

• Vital signs: Temperature 99.1°F, Heart rate 110 bpm, Blood pressure 100/65 mmHg, Respiratory rate 22 breaths per minute

Section 1

During the initial assessment, the nurse noted that the patient exhibited increased lower limb weakness and had difficulty maintaining balance while ambulating, requiring assistance more frequently than during previous visits. The child's gait was unsteady, and she appeared to be compensating for her weakness by over-relying on her upper body for support. Despite her efforts, she had experienced multiple falls over the past week, as reported by her parents. The physical exam revealed decreased muscle strength in both legs, rated at 3/5, and diminished deep tendon reflexes. Sensory examination showed decreased sensation to light touch in the lower extremities.

Vital signs indicated a mild tachycardia with a heart rate of 110 bpm and an elevated respiratory rate of 22 breaths per minute, possibly reflecting the child's discomfort or pain. The mild fever of 99.1°F raised the suspicion of a concurrent infection, potentially a urinary tract infection given her history, which could be exacerbating her current symptoms. Laboratory tests, including a complete blood count and urinalysis, were ordered to investigate further. The urinalysis returned positive for nitrites and leukocyte esterase, suggesting a UTI, while the CBC indicated a mild leukocytosis.

The clinical team is concerned about the possibility of VP shunt malfunction given the recent onset of headaches and urinary incontinence, which could indicate increased intracranial pressure. A neurosurgical consult was requested for further evaluation, and an MRI of the brain and spine was scheduled to assess for any shunt complications or other structural changes. The team is considering a plan to address the UTI with an antibiotic that does not belong to the penicillin class, given her known allergy, while also closely monitoring for any signs of neurological deterioration. This multifaceted approach aims to stabilize her condition and prevent further complications, while also providing an opportunity to refine her ongoing management plan.

Section 2

Following the initial assessment, the clinical team proceeded with a comprehensive review of the new diagnostic results. The MRI results revealed no acute changes in the brain structure, but there was evidence of slight ventriculomegaly suggesting a potential issue with cerebrospinal fluid drainage. This finding, combined with the patient's recent onset of headaches and urinary incontinence, heightened the suspicion of a VP shunt malfunction. The neurosurgical team recommended close observation and potential shunt revision if symptoms persisted or escalated.

Meanwhile, the patient's UTI was addressed with a course of trimethoprim-sulfamethoxazole, an antibiotic chosen based on her allergy profile. Within 48 hours of initiating treatment, her fever resolved, and her heart rate normalized to 90 bpm, indicating a positive response to the intervention. However, the child's gait and lower limb strength continued to be compromised, underscoring the need for further investigation and management of her neurological status.

As the team monitored her progress, they noticed a subtle increase in irritability and a slight change in her level of consciousness, signaling a potential exacerbation of intracranial pressure. This prompted immediate re-evaluation by the neurosurgical team, who decided to expedite the shunt revision procedure. The interdisciplinary team emphasized the importance of monitoring for post-surgical complications and maintaining a holistic approach to her care, ensuring her recovery would be supported by both medical and rehabilitative efforts. This situation highlighted the need for vigilant clinical reasoning to adapt her management plan, focusing on her neurological stability and overall well-being.

Section 3

Following the expedited shunt revision procedure, the clinical team closely monitored the patient for any signs of improvement or new complications. Initially, the revision seemed successful, as the patient exhibited a decrease in headaches and a gradual return to her baseline level of consciousness. Her vital signs remained stable, with a heart rate of 88 bpm, respiratory rate of 18 breaths per minute, and blood pressure holding at 100/60 mmHg. However, within 24 hours post-surgery, the patient developed a low-grade fever of 38.2°C (100.8°F), raising concerns for potential post-operative infection. A thorough physical examination revealed mild erythema around the surgical site, but no obvious signs of drainage or swelling.

In response to these findings, the interdisciplinary team decided to perform a series of diagnostic tests to assess the source of the fever. Blood cultures, a complete blood count, and a urinalysis were ordered. The complete blood count indicated a white blood cell count of 14,000 cells/mcL, suggestive of an inflammatory response. While awaiting blood culture results, empirical antibiotic therapy with ceftriaxone was initiated to cover a broad spectrum of potential pathogens. The team also conducted a repeat MRI to evaluate the position and function of the revised shunt, which showed proper placement and no evidence of obstruction.

Despite the proactive management, the patient's condition evolved with new challenges. Her lower limb strength showed no improvement, and she began experiencing intermittent episodes of nausea and vomiting, potentially indicative of ongoing issues with her intracranial pressure. These symptoms necessitated a reassessment of her overall neurological status and prompted the care team to consider additional interventions, including potential adjustments to her rehabilitation plan. The case underscored the complexity of her condition, requiring dynamic clinical reasoning and a coordinated effort among healthcare providers to optimize her care trajectory.

Section 4

As the clinical team continued to monitor the patient, her condition took a concerning turn. Over the next 12 hours, her low-grade fever persisted, and her nausea and vomiting became more frequent, leading to signs of dehydration. Vital signs showed a slight increase in heart rate to 95 bpm, while blood pressure remained stable. Importantly, the patient's neurological status began to exhibit subtle changes; she appeared more lethargic and less responsive to stimuli, which signaled a potential escalation in her intracranial pressure. The team was faced with the challenge of distinguishing between post-operative infection, shunt malfunction, or a separate neurological complication.

New diagnostic results provided further insights. Blood cultures returned positive for Staphylococcus epidermidis, confirming the presence of a bacterial infection likely related to the shunt revision procedure. Concurrently, the urinalysis showed no abnormalities, ruling out a urinary tract infection as a source of fever. These findings prompted the infectious disease specialist to adjust the antibiotic regimen, incorporating vancomycin to specifically target the identified pathogen. The neurosurgical team reviewed the MRI findings again, searching for any subtle indications of shunt malfunction that might have been initially overlooked, conscious of the need to address both the infection and any potential mechanical issues.

The clinical team recognized the necessity for prompt and coordinated intervention, emphasizing the importance of maintaining a balance between aggressive infection management and careful monitoring of the patient's neurological status. Fluid resuscitation was initiated to address dehydration, and antiemetic medication was administered to control nausea. The case highlighted the interconnectedness of surgical interventions, infection control, and neurological assessment, requiring the healthcare team to engage in continuous clinical reasoning and adapt their strategies to navigate the complexities of the patient's evolving condition. As they awaited further developments, the focus shifted to evaluating the effectiveness of the revised treatment plan and preparing for the possibility of additional surgical intervention if the patient's status did not improve.

Section 5

As the clinical team monitored the patient over the next 24 hours, they observed both encouraging signs and new concerns. Initially, the response to the adjusted antibiotic regimen was promising; the patient's fever began to subside, and her heart rate decreased to a more stable 88 bpm. However, despite these improvements, her neurological status remained a significant concern. The patient continued to exhibit lethargy, and her responses to verbal and tactile stimuli were sluggish. A repeat neurological assessment revealed diminished pupillary reflexes, raising alarms about persistent elevated intracranial pressure despite infection control measures.

Further diagnostic imaging was ordered to evaluate the integrity of the shunt system and assess for any cerebral edema. The MRI revealed subtle ventricular enlargement, suggesting possible shunt malfunction or obstruction. This finding necessitated a careful re-evaluation by the neurosurgical team, who considered the possibility of a partial blockage within the shunt system that could be exacerbating the patient's symptoms. Concurrently, laboratory results indicated a slight decrease in serum sodium levels, pointing towards mild hyponatremia, likely secondary to ongoing nausea and fluid imbalances.

The clinical team was now at a crossroads, needing to decide whether a surgical intervention to revise or replace the shunt was warranted. This required weighing the risks of another procedure against the potential for further neurological deterioration if the current issues were not addressed. The focus remained on carefully monitoring the patient's neurological signs and symptoms while optimizing her fluid and electrolyte balance. As they deliberated the next steps, the team also prepared the patient's family for the possibility of additional surgery, ensuring they understood the rationale and potential outcomes of various interventions. This phase of the patient's journey underscored the importance of multidisciplinary collaboration and dynamic clinical reasoning in managing complex pediatric cases.