Figure 1: SPINA BIFIDA CARE PATHWAY

Day -1 0 1 2 3 4 7
Hx Gestational age, parity, family history of NTD, vaccinations, any antibiotics or folk remedies; feeding; voiding; stooling; vomiting; fevers; seizures   Feeding; vomiting; seizures; voiding; alertness
Exam Vitals: T/P/RR/Wt; toxic/non-toxic, irratable; HC; weight; mucous membranes; sunset eyes, vision; fontanelle; LE: motor level R & L, contractures, deformities; patulous anus?; SB lesion - site, open / covered / infected; other systems PRN Vitals q4h Temp; pulse; resp. rate each shift; HC daily
dressing appearance wound appearance
Tests CBC; serum creatinine       Renal & head US    
Procedures Antiseptic soap body wash tid; saline-soaked gauze to wound tid Surgery   Remove dressing Bladder evaluation    
Medications Start IV gentamycin 5 mg/kg/d & ceftriaxone 100 mg/kg/d (unless SB completely skin covered) Preop ceftriaxone 100 mg/kg if skin covered IV gentamycin 5 mg/kg/d & ceftriaxone 100 mg/kg/d (unless SB completely skin-covered
Counseling /
Social /
Spritual
Discuss disease & implications; assess family & social situation & discuss payment options; spiritual assessment Prayer with parent & child pre-op     CIC teaching if indicated Discharge planning; payment discussion Follow-up planning; folic acid teaching; folic acid, catheters & KY supplies
Pastoral care
Diet Nutritional assessment NPO past 4 AM Regular diet; supplement if necessary
Physiotherapy   Assessment     Casting & teaching as needed
Events Admission           Discharge if well & no hydrocephalus