[Care plan in a patient with spina bifida. Case report]

Spina bifida is a congenital malformation of the lumbar spine. We developed a nursing care plan in a 12-year-old girl with this malformation who attended a special education school. Using Gordon's health patterns, we assessed the patient and identified the following nursing diagnoses: imbalanced nutrition: more than body requirements, urinary incontinence, impaired transfer ability, risk for infection, risk of impaired skin integrity, risk for latex allergy, readiness for enhanced urinary elimination, and readiness for enhanced self-concept. Each nursing diagnosis was individualized, and related factors, risk factors and defining characteristics were identified for each. Likewise, we established the Nursing Outcomes Classification (NOC) outcomes and Nursing Intervention Classification (NIC) interventions, with descriptors and activities, respectively. The use of the nursing process will improve patient care and team work.