172203323 meningocele-case-study-emergency-nursing-theory-based

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ST. MARY’S COLLEGE
NURSING PROGRAM
Tagum City
A CASE STUDY
On

Meningocele
Presented to
Ma’am Cristin G. Ungab RN.MN
Clinical Instructor
In Partial Fulfillment of the Requirements
In
Related Learning Experience
(RLE)
By:
Van Kyssel R. Reyes
BSN-4A

i
Table of Contents
PAGE
Table of Contents i
Introduction 1
Assessment 5
A. Biographic data
B. Chief Complaints
C. Past Medical History
D. Present Medical History
E. Personal, Family And Socio-Economic History
F. Patients Need Assessment
Course in the ward 14
Laboratory Test 15
Symptomatology
23
Etiology 25
Pathophysiology 26
A. Diagram Pathophysiology
B. Written Pathophysiology
Nursing Care Plan 33
Synthesis of Clients Condition From admission presented 35
 Prognosis
 Recommendation
Bibliography 44

1
Chapter I
INTRODUCTION
Meningocele is the protrusion of a sac containing cerebrospinal
fluid, through a defect called cranium bifidum. Although the occipital and
frontal basis of the cranial cavity constitutes the two most frequent
localizations, this pathology may rarely be located in the naso-orbital
region. Commonly, this disease is asymptomatic. Other developmental
anomalies of the eyes may accompany the anomalies of the bony orbit.
The case described in the present paper had a right naso-orbital
meningocele associated with bilateral fistulae of the lacrimal passages
which represents a very rare
condition(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3389919/. Date
retrieved: September 29, 2013).
A congenital anomaly of the central nervous system in which a sac
protruding from the meninges contains cerebrospinal fluid (but no nerve
tissue) and usually occur in the frontal region, where they form broad-
based, elastic, and pulsatile tumours, which vary greatly in size
(http://www.labome.org/topics/diseases/nervous/nervous/neural/meningoc
ele-7061.html. Date retrieved: September 29, 2013).
The underlying cause of a meningocele is a neural tube defect.
The actual cause of this defect is unknown at this time. However, a low
level of folic acid in the mother is a likely contributing factor in many

2
cases. Every woman can have a child that has a meningocele formation.
However, there are certain risk factors that make it more likely in certain
cases. For women who have had other children withneural tube defects,
the chances of having another child with a similar defect are higher than
normal. Among certain ethnic and racial groups, Hispanic women are
more likely to have children with this particular birth defect. White women
are more likely than black women are and less likely than Hispanic women
are.There are certain medical conditions that appear to influence the
appearance of this condition such as medical obesity and insulin-
dependent diabetes. Women in lower socio-economic levels appear to
have a higher risk than those at higher levels. Certain medications, like
those to prevent seizures, may also play a part
(http://www.neuraltubedefect.com/2011/06/21/meningocele/. Date
Meningocele affects hundreds of thousands of people in the whole
world. In fact, in Asia (in Thailand mainly) – there is an incidence of 1:5000
live births who have meningocele. In America and Europe, the incidence
of the said disease amounts to 1:35000–40000 live births (http://nervous-
system.emedtv.com/meningocele/meningocele.html. Date retrieved:
September 29, 2013).
In the Philippines, it has been said that out of 86,241, 691 of the
population 5,174 were reported to have meningocele in the year 2004
(http://astp.jst.go.jp/modules/search/DocumentDetail/0386-

3
9687_38_1_A%2Bcase%2Bof%2Bmeningocele._N%252FA. Date
Based on Davao City Health Office, the rate of infant mortality on
meningocele in the year 2005 is 0.11% (http://davaohealth.brinkster.
net/HealthStatus-2005.asp. Date retrieved: September 29, 2013).
The researcher have decided to make a study on meningocele to
provide information regarding the patient’s condition from the data
collected through patient-nurse interaction and with thorough research
about the case; it will alleviate his condition and aid for others to improve
their well-being.
OBJECTIVES
Upon completion of this study and after data gathering, research and
analysis, the researcher shall have devised objectives that will guide her for the
proper understanding and fair interpretation of the case of the chosen patient and
will be able to:
 Gain knowledge about the disease process, predisposing factors, clinical
manifestation and the disease management and gain skills and appropriate
attitudes needed to function as a student nurse in the community.
 Be able to use the nursing process as framework for care of the patient and
develop teaching plan and strategies appropriate for the goal attainment.

4
 Prevent and manage potential complications that might occur and
emphasize health teachings and dietary instructions and restrictions as well
as performing appropriate exercises.

5
Chapter II
ASSESSMENT
I. Background of the Patient
BIOGRAPHICAL DATA
Name : Baby Uzumaki
Address : Prk. Taripe Drive, John Bosco District, Bislig, Surigao
del Sur
Age : 1 year old
Admitting Physician : Dr.Kristine Sereñina, MD
Admitting Diagnosis : Nasofronto-orbital Meningocele
Religion : Roman Catholic
Nationality : Filipino
Date/Time of Admission: September 25, 2013/11:00a.m
CHIEF COMPLAINT
Mass @ the nasal area
HISTORY OF PRESENT ILLNESS
Pt. was born with an anatomical defect (mass) @ the glabella
extending down to the nasal area and left medial canthus.
PAST MEDICAL AND NURSING HISTORY
Patient was born full term through normal vaginal delivery in Bislig,
Surigao del Sur on January 15, 2011. He weighed approximately 4 kls at
birth. He received complete immunizations. He also experienced illnesses

6
such as fever and diarrhea. He was brought for check-ups at their local
hospital due to the abovementioned illnesses.
PERSONAL, FAMILY AND SOCIO-ECONOMIC HISTORY
Baby Uzumaki is the youngest chi ld among two sibli ngs,
both parents have no work and business and only dependi ng on
the father’s parents. He is taken care by his parents and
grandparents. His grandparents has a sari-sari store and earning
approximately P5, 000.00/month
Their family has no history of meni ngocele and other
serious illnesses except that his grandparent has hypertension
and diabetes.

7
PATIENT NEED ASSESSMENT
Name : Baby Uzumaki Age: 1y.o. Sex: M
Admission Date / Time : September 25, 2013/11:00a.m
Admitting Medical Diagnosis: Nasofronto orbital meningocele
Arrived on unit by : per mother’s arm From : Emergency Room
Accompanied by : Parents
*VS : BP = 90/60mmHg PR = 110 bpm
RR = 24cpm Temp. = 36 °C
Client’s Perception of Reason for Admission: “Niadto mi ogospitalkay
gusto nanamoipatangalangiyangbukolsanawong”, as verbalized by
mother.
How was the problem being managed at home? : Bed rest
Medication taken at home : None.
PHYSIOLOGIC NEEDS
 Oxygenation *BP : 90/60 mmHg *PR : 110 bpm
*RR: 24cpm
*Lungs (per auscultation: character; lung sound; symmetry of chest
expansion; breathing character and pattern): Crackles heard upon
auscultation; equal rise and fall of abdomen / symmetrical chest
expansion.
*Cardiac Status (per auscultation: sound, character; chest pain : Normal
“lubdubb” sound is heard upon auscultation, no murmurs noted.
*Capillary Refill: Capillary refill returns after 1 second upon blanching.

8
*Skin Character and Color: Smooth and pinkish; with good skin turgor.
*Life-supporting apparatus: None
 Temperature Maintenance
*Temperature : 36°C
*Skin Character: Upper and lower extremities warm to touch.
 Nutritional Fluids
*Amt. of Food Consumed: Able to consume 2-4 bottles of milk formula a
day.
*Prescribed Diet: Diet for age.
*Problem: None.
*Eating Pattern (frequency, amount, character): 3 times a day; able to
consume 2-4 bottles of milk formula a day.
*Intake (IVF; fluid / water): IVF =D5 .3 NaCl 500 cc @ 40 cc/hr; H20 =
500cc/day.
 Elimination
*Last Bowel Movement (frequency, amount, character): September 25,
2013 with soft, brown stool.
*Normal Pattern: Once every day.
*Urination (frequency, amount, character, sensation): Changes diaper 2-3
times a day that approximately weighs 260 g.
 Rest and Sleep
*Bed Time: 07:00 pm *Waking Up: 07:00 am

9
*Sleep (pattern, amount of sleep): 12-13 hours every night; disturbed
when the diaper is full or if he defecates and whenever there is noise. He
also sleeps every afternoon for 2-3 hours.
*Problem (as verbalized): none
 Stimulation-Activity
*Recreation/Pastime: Playing.
*Hobbies : Playing and strolling per watcher’s arm
SAFETY AND SECURITY NEED
Patient’s mother and father doesn’t feel much secure of the
condition he is now experiencing but rest assured that they will always be
there for the patient.
LOVE-BELONGING NEED
Baby Uzumaki is loved and cared for by the people around him
specially his family. They are always there for him. His mother and
fathertook turns on watching over him at the hospital. His grandparents
are calling from time to time to monitor his condition.
SELF-ESTEEM NEED
The patient’s situation is whole-heartedly accepted by his family
who is always there to take care of him.

10
SELF-ACTUALIZATION NEED
The patient’s family thinks positively and entrust to God everything. He is
accepted and loved by others andhas deep loving bonds with the people
around him.
DEVELOPMENTAL TASKS / THEORIES
Erik Erikson
Erik Erikson adapted Freud’s theory of development to include the
entire life span, believing that the people continue to develop throughout
life. He describes eight stages of development. He envisions life as a
sequence of levels of achievement. Each stage signals a task that must
be achieved. The resolution of the task can be complete, partial or
unsuccessful. Erickson believes that the greater the task achievement, the
healthier the personality of the person; failure to achieve a task influences
the person’s ability to achieve the next task.
These developmental tasks can be viewed as a series of crises and
successful resolutions to these crises is supportive to the person’s ego.
Failure to resolve the crises is damaging to the ego. The resolution of the
conflicts at each stage enables the person to function effectively in the
society. Each phase has its developmental task, and the individual must
find balance.
The patient who is 1 year old falls under the 1st stage of Erikson’s
stages of development, the stage of infancy, which accounts for children
0-2 years old.

11
The first stage of Erik Erikson's theory centerson the infant's basic
needs being met by the parents and this interaction leading to trust or
mistrust. Trust as defined by Erikson is "an essential truthfulness of others as
well as a fundamental sense of one's own trustworthiness. The infant depends
on the parents, especially the mother, for sustenance and comfort. The
child's relative understanding of world and society come from the parents
and their interaction with the child. If the parents expose the child to warmth,
regularity, and dependable affection, the infant's view of the world will be one
of trust. Should the parents fail to provide a secure environment and to meet the
child's basic needs a sense of mistrust will result. Development of mistrust
can lead to feelings of frustration, suspicion, withdrawal, and a lack of
confidence. According to Erik Erikson, the major developmental task in infancy
is to learn whether or not other people, especially primary caregivers, regularly
satisfy basic needs. If caregivers are consistent sources of food, comfort, and
affection, an infant learns trust- that others are dependable and reliable. If
they are neglectful, or perhaps even abusive, the infant instead learns
mistrust- that the world is in an undependable, unpredictable, and possibly a
dangerous place. While negative, having some experience with mistrust
allows the infant to gain an understanding of what constitutes dangerous
situations later in life.
As observed in the patient, even though he is not with his mother
who must take significant responsibility on this developmental stage he
still has a sense of trust to other people specially those who show

12
affection but sometimes he doesn’t trust others specially from the
healthcare team for the reason that he is afraid they might hurt him
through injections and the likes. He is step by step achieving the
developmental task on this stage.
PHYSICAL ASSESSMENT
 GENERAL SURVEY
The patient is a 1-year old male, stands 31inchesand weighs
13 kg., has an anatomical defect(mass) on the nasal area and at
left medial canthus and with the following VS as monitored and
recorded BP=90/60mmHg, PR=110bpm, RR=24cpm, Temp.=36
ºC. He is conscious, and responsive.
 VITAL SIGNS
Date Shift Time
Temp
(°C)
BP
(mmHg)
RR
(cpm)
PR
(bpm)
02 Sat
09/25/13 7-3 11:00am 36.2 ------- 28 100 -------
 NUTRITIONAL STATUS
The patient is 31 inches in height and weighs 13 kg. He is on
diet for age. He’s able to drinks 2-4 bottles of milk formula a day.
Able to consume at least 500mL of water a day. With D5 .3 NaCl
500cc @ 40cc/hr.

13
 NEUROLOGIC STATUS
Patient is alert, and attentive; can only say the word “Mama”
With a PGCS score of 15/15.
 INTEGUMENTARY SYSTEM
Skin is pinkish and smooth; warm to touch. Hair is short, fine
and evenly distributed. With a short, clean and well-trimmed
fingernails and toenails. With capillary refill of 1 sec. upon
blanching.
 HEENT (Head, Eyes, Ears, Nose and Throat)
Head is normocephalic. Eyes are symmetrical; slight swelling in the
eye bags noted. Ears are patent and bilaterally hears sounds; both are
symmetrical. Nose is midline, fixed mass extending to nasal bridge and @
left nasal canthus. Lips are moist; gums are intact and non-bleeding with
midline uvula and non-inflamed tonsils. 16 teeth are present. Tongue is
pink and even; dorsal surface rough with papillae.
 PULMONARY SYSTEM
Crackles heard upon auscultation. Chest is bilateral symmetry in
general shape. There’s an equal rise and fall of the abdomen with
normal depth of respiration.
 CARDIOVASCULAR SYSTEM
Normal “lubdubb” sound is heard upon auscultation. No heaves and
thrills; no murmurs; regular cardiac rate and rhythm.

14
 GASTROINTESTINAL SYSTEM
Abdomen has an equal colour as the rest of the body; no pulsating
and protruding mass, no tenderness. Normoactive bowel sounds
noted.
 MUSCULOSKELETAL SYSTEM
Hands are small in size; smooth with no lesions noted. Arms are
able to move through active ROM. Muscle strength is 5/5. The size of
the feet is about 4 inches; symmetrical in shape. Upper and lower
extremities are warm to touch.
 GENITO-URINARY SYSTEM
Patient urinates with a diaper which is changed at least twice a day
with a weight of 260 g.
COURSE IN THE WARD
DATE/
SHIFT/
TIME
NURSE’S
ASSESSMENT
NURSE’S
INTERVENTION
MEDICAL MANAGEMENT
09-25-13/
7-3
11:00am
 Admitted this
1y.o child, per
mother’s arm;
came in due
to anatomical
defect (mass)
with glabella
extending
down to the
nasal area
and left
medial
canthus.
 Seen by Dr.
Sereñina with
orders made.
 VS checked and
recorded.
® To obtain baseline
data.
 Carried out orders.
® To implement
orders of the
 Admit to neuro surgery.
® For continuous
monitoring.
 DFA
® The patient can eat
nutritious foods that are
appropriate to his age.
 Diagnostics:
CBC with Plt, Bld. typing,
S. elect, urinalysis,
Protinase PTT, CXR-PA
® To obtain baseline data
and identify abnormalities
if there are any to provide
appropriate medical
intervention.

15
12:15pm
 Received
from ER, per
mother’s arm,
without IVF,
on DFA
physician.
 Ushered and placed
on bed comfortably.
® To provide safety
and comfort.
 Needs attended.
Watched and cared
for.
® To provide comfort.
For monitoring & to
identify unusualities if
there are any.
LABORATORY & DIAGNOSTIC EXAMINATIONS
BLOOD CHEMISTRY
Date: September 25, 2013
LAB
EXAM
NORMAL
VALUES
RESULT INTERPRETATION RATIONALE
CRE
A
53-115
umol/L
34.6
umol/L
Having a low level of blood
creatinine indicates nothing more
than an efficient and effective pair
of kidneys (http://www.
netdoctor.co.uk/ate/liverandkidney/
203123.html#ixzz2KTA4EWKA.
Tests that measure
the concentration of
electrolytes are
needed for both the
diagnosis and
management of renal,
endocrine, acid-base,
water balance, and
many other
conditions. Their
importance lies in part
with the serious
consequences that
follow from the
relatively small
changes that diseases
or abnormal
conditions may cause
(http://www.
surgeryencyclopedia.c
om/Ce-Fi/Electrolyte-
Tests.html#b.
September 29,2013).
Pota
ssiu
m
3.5-5.0
mmol/l
4.25
mmol/L
The result is normal. Potassium
helps the nerves and muscles to
communicate. It also helps move
nutrients into cells and waste
products out of the cell.
Calci
um
1.13-
1.32
mmol/L
1.16
mmol/L
The result is normal. Calcium helps
muscles and blood vessels to
contract and expand and maintains
strong bones.
Sodi
um
135-
148
mmol/L
140.7
The result is normal. Sodium
controls blood pressure. It is also
needed for the muscles and nerves
to work properly.

16
Hematology
LAB EXAM NORMAL
VALUES
RESULT INTERPRETATION RATIONALE
Blood Group ------ APos
The patient’s blood type is
A Positive.
A complete blood
count (CBC) gives
important information
about the kinds and
numbers of cells in the
blood, especially red
blood cells , white
blood cells ,
and platelets. A CBC
helps the doctor check
any symptoms, such
as weakness,fatigue,
or bruising, you may
have. A CBC also
helps him or her
diagnose conditions,
such as anemia,
infection, and many
other disorders
(http://www.webmd.co
m/a-to-z-
guides/complete-
blood-count-cbc.
Hemoglobin
140-170
g/L
116 g/L
The result is below
normal. Hemoglobin gives
blood its red color and
carries oxygen to the body
through the blood. This
may indicate
anemia(http://en.wikipedia
.org/ wiki/Hemoglobin,
September 29,2013).
WBC 5.0-10.0 9.2 The result is normal.
Neutrophils 0.55-0.65 0.38
The result is below
normal. Neutrophils are
one of the first-responders
of inflammatory cells to
migrate towards the site of
inflammation.One basic
cause of a high neutrophil
count is when a high level
of stress is placed on the
body. The stress can due
to many factors such as
nervousness, exercise, or
seizures. Another cause is
a sudden infection from
bacteria (http://www.
medfriendly.com/neutrophi
l.html. September 29,
2013)
Lymphocytes 0.25-0.35 0.56
The result is above
normal. An increased level
of lymphocytes would
usually indicate that the
body has experience an
influx or invasion of
foreign cells, thereby
prompting the
lymphocyctes to
aggressively respond. The

17
lymphocyte levels are run
as a standard portion of a
general blood workup (J.,
Christopher. http://www.
reference.com/motif/health
/causes-of-high-
lymphocytes.September
29, 2013).
Eosinophils 0.02-0.04 0.03
The result is normal.
Eosinophils are white
blood cells that are one of
the immune
system components
responsible for combating
multicellularparasites and
certaininfections in verteb
rates. They also control
mechanisms associated
with allergy and asthma.
They are granulocytes that
develop
duringhematopoiesis in
the bone marrow before
migrating into blood
(http://en.
wikipedia.org/wiki/
Eosinophil_granulocyte.Se
ptember 29, 2013).
Monocytes 0.02-0.06 0.06
The result is normal.
Monocytes replenish
resident macrophages and
dendritic cellsunder
normal states, and in
response
to inflammationsignals,
monocytes can move
quickly to sites of infection
in the tissues and
divide/differentiate into
macrophages and
dendritic cells to elicit an
immune response
(http://en.wikipedia.org/wik
i/Monocyte. September
29, 2013).

18
Platelet 150-450 206
The result is normal. The
function of platelets is the
maintenance
ofhemostasis. This is
achieved primarily by the
formation of thrombi, when
damage to
theendotheliumof blood
vessels occurs. On the
converse, thrombus
formation must be
inhibited at times when
there is no damage to the
endothelium
(http://en.wikipedia.org/wik
i/Platelet. September 29,
2013).
Hematocrit 0.40-0.50 0.33
The result is below
normal. The hematocrit
measures how much
space in the blood is
occupied by RBCs. A low
hematocrit level is one of
the clinical manifestations
of anemia. It coincides
with the pt’s low hgb
level.(http://en.wikipedia.or
g/ wiki/Hematocrit
September 29, 2013)
Prothrombin
time
11-17
sec
13.6
The result is normal. It
determi nes the clotti ng
tendency of blood and
any bleedi ng
abnormalities (http:/
/en.wikipedia.org/wiki/
Prothrombi n_time.

19
Radiography
Parts to be examined: Chest PA
Referred by: Dr.Kristine Sereñina, MD
Findings
Heart size is within normal limits. Alveolar infiltrates are
noted in both lungs. Pulmonary vascularity is normal. Hili are not
enlarged. The lateral costrophrenic sinuses are sharp. The
visualized osseous structures are unremarkable.
Impression: Pneumonia

20
Chapter III
PATHOPHYSIOLOGY
REVIEW OF ANATOMY AND PHYSIOLOGY
Fig. 1 Structure of the brain and spinal cord

21
Fig. 2 Structure of the Ventricles
The Brain
Our brain is well protected by:
 The scalp
 The skull
 The meninges
Layers includes:
- Dura mater: it’s tough, dense irregular connective tissue helps
protect the delicate structures of the CNS.
- arachnoid mater: very thin layer on the middle of the meninges,
the spaces between the dura mater and arachnoid mater is the subdural
mater, which is normally only a potential space containing a very
small amount of serous fluid.
- Pia mater: a transparent layer of collagen and elastic fibers that
adheres to the surface of the spinal cord and brain. It contains numerous
blood vessels. Between the arachnoid mater and the pia mater is the
subarachnoid space where cerebrospinal fluid circulates.

22
Ventricles
The CNS contains fluid-filled cavities called ventricles, that maybe
quite small in some areas and large in others.
 Lateral ventricle- each cerebral hemisphere contains a relatively
large cavity.
 Third ventricle- a smaller midline cavity located in the center of the
diencephalon between two halves of the thalamus and connected
to the foramina to the lateral ventricles.
 Fourth ventricle- located at the base of the cerebellum and is
connected to the third ventricle by a canal called the cerebral
aqueduct. It is continuous with the central canal of the spinal cord.
Cerebrospinal Fluid
CSF bathes the brain and spinal cord, providing cushion around the
CNS. it is produced by the choroid plexuses, specialized structures made
of ependymal cells, which are located in the ventricles.
Flow of CSF:
1. The CSF flows from the lateral ventricles into the third ventricle and
then through the cerebral aqueduct into the fourth ventricle.
2. A small amount of CSF enters the central canal of the spinal cord.
3. CSF flows through the subarachnoid space to the arachnoid
granulations (masses of arachnoid tissues penetrate into the superior
sagittal sinus, a dural venous sinus in the longitudinal fissure) in the
superior sagittal sinus, where it enters the venous circulation.

23
Fig. 3 Circulation of Cerebrospinalfluid
SYMPTOMATOLOGY
SYMPTOMAT
OLOGY
ACTUA
L
SYMPT
OMS
IMPLICATION
Tachypnea 
Is the increase of respiratory rate. If the meningocele
is in the nasal area, this can cause tachypnea due to
the compression of the nasal passages causing
minimal amount of oxygen inhaled
(http://www.nurses
learning.com/courses/nrp/NRP1608/Section%204/in
dex.htm. Date retrieved: September 29, 2013).

24
Visual
problems
Due to the increase accumulation of CSF causing
orbital meningocele, the the compression increases
in the orbit causing visual disturbances
(http://www.ncbi.
nlm.nih.gov/pmc/articles/PMC506127/. Date
Mass
formation

Meningocele is the protrusion of a sac containing
cerebrospinal fluid, through a defect called cranium
bifidum and usually form a mass in the frontal
region, where they form broad-based, elastic, and
pulsatile tumours, which vary greatly in size
(http://www.labome.org/topics/diseases/nervous/ner
vous/neural/meningocele-7061.html. Date retrieved:
Paralysis
Meningocele can occur anywhere along the spine,
and can cause a portion of the spinal cord and
surrounding structures to develop outside the
protection of the spinal column with causes paralysis
(http://www.
childrenshospital.org/az/Site1062/mainpageS1062P1
.html. Date retrieved: September 29, 2013).
Hydrocephalus A continuous excessive accumulation of CSF

25
causing the head to be enlarged as the mass gets
bigger
(http://treato.com/Hydrocephalus,Meningocele/?a=s .
Date retrieved: September 29, 2013).
ETIOLOGY OF THE DISEASE
ETIOLOGY ACTUAL
SYMPTOMS
IMPLICATION
Congenital 
This problem is commonly seen at birth, a
low level of folic acid in the mother,
uncontrolled diabetes during pregnancy,
high fever during pregnancy and a family
history of meningocele are contributing
factors in many cases. Every woman can
have a child that has a meningocele
formation (http://global.britannica.com/EB
checked/topic/375064/meningocele. Date

26
PATHOPHYSIOLOGY
A. Written
Meningocele is a form of spina bifida. It is a congenital malformation that
arises from an error in the normal development of the central nervous system,
particularly the skull, spinal cord and spine. It is an out-pouching of the coverings
of the skull and spinal cord that result in a defect in the bone and soft-tissue
coverings. Therefore, this sac filled with cerebrospinal fluid can lead to a bulging
mass on the head and on the back. The malformation does not include any
malformation of the spinal cord itself or any of the spinal nerves
(http://www.nervous-system-diseases.com/meningocele.html. Date retrieved:
This problem is commonly seen at birth, a low level of folic acid in the mother,
uncontrolled diabetes during pregnancy, high fever during pregnancy and a
family history of meningocele are contributing factors in many cases. Every
woman can have a child that has a meningocele formation
(http://global.britannica.com/EB checked/topic/375064/meningocele. Date
The meninges are the coverings of the brain and spinal cord, consisting of
three layers, the dura mater, the arachnoid membrane and the pia mater, from
outside to in. This malformation is due to the abnormal development of the
outermost coverings of the spinal cord, including the arachnoid, dura and the
outer bony and soft tissue parts of the spine. Normally in development, the
nervous system develops from a plate of cells those folds to become a tube, the

27
neural tube. If the lower end of the tube does not close normally, it can lead to
various forms of spina bifida, including a meningocele(http://www.nervous-
system-diseases.com/meningocele.html. Date retrieved: September 29, 2013).
A meningocele represents a moderate form of spina bifida. The most severe
form is a myelomeningocele which includes involvement of the spinal cord. The
mildest form is spina bifida occulta, which does not involve any of the nervous
system structures or the meninges, just the bony spine in the lower back
(http://www.nervous-system-diseases.com/meningocele.html. Date retrieved:
Severity is determined by the size and location of the malformation, whether
or not skin covers it, whether or not spinal nerves protrude from it, and which
spinal nerves are involved. Generally all nerves located below the malformation
are affected. Therefore, the higher the malformation occurs on the back, the
greater the amount of nerve damage and loss of muscle function and sensation
(http://www.disabled-world.com/disability/types/spinal/spina-bifida/complications-
spina-bifida.php#ixzz2KTjGb2qQ. Date retrieved: September 29, 2013).
In addition to loss of sensation and paralysis, another neurological
complication associated with meningocele is Chiari II malformation, a rare
condition (but common in children with myelomeningocele) in which the
brainstem and the cerebellum, or rear portion of the brain, protrude downward
into the spinal canal or neck area. This condition can lead to compression of the
spinal cord and cause a variety of symptoms including difficulties with feeding,
swallowing, and breathing; choking; and arm stiffness (http://www.disabled-

28
world.com/disability/types/spinal/spina-bifida/complications-spina-bifida.php#ixzz
2KTjGb2qQ. Date retrieved: September 29, 2013).
Meningocele repair is an operation to address a type of birth defect in which
there is no proper development and a small, swollen sac or cyst protrudes from a
newborn’s spinal column or in the head. The procedure usually takes place within
12 to 48 hours of a baby’s birth. During the procedure, the surgeon drains the
excess spinal fluid from the sac, closes the opening, and repairs the area of the
defect, which allows the child to grow and develop normally
(http://www.healthline.com/health/meningocele-repair. Date retrieved: September
29, 2013).
As with any surgery that involves general anaesthesia, meningocele repair
carries a small risk of allergic reactions to the anesthesia medication. Bleeding,
infection, and fluid build up, though rare, are also possible. Healthcare
professionals will advise you about how to care for your baby at home and what
symptoms to watch for to determine if there are any complications
(http://www.healthline.com/health/meningocele-repair. Date retrieved: September
29, 2013).
You may also be referred to a team of medical experts in spina bifida, who
will follow-up with you and your baby after you leave the hospital. These
professionals will work with you to help detect any additional problems that may
indicate muscle weakness, speech problems, or other potential issues related to
the neural tube defect (http://www.healthline.com/health/meningocele-repair.
Date retrieved: September 29, 2013).

29
B. Diagram of Pathophysiology
1st month of pregnancy
Central nervous system
begins to form
Defect/dehiscence of
the base of the skull
Predisposing factor:
 Genetics
Precipitating factors:
 Nutrition (deficiency of
folic acid)
 Socio-economic status
Defect in the closure of
the neural tube
CSF is continuously
produced

30
A protruding sac is formed
through the defect containing
CSF and meninges
Meningocele
Mass formation in
the nasofronto-
orbital area
Tachypnea
Diagnostic Examinations
CT Scan
Section
Radiography Urinalysis Hematology Blood
Chemistry
Nursing Management
1. Keep site clean and dry.
2. Assess the area every shift for
redness, edema and discharges.
3. Educate watcher to maintain hygienic
measures before having contact with
the client.
4. Instruct watcher to be at the patient’s
side at all times.
Medical Management
 Co-amoxiclav 160mg IVTT q8 ANST
 Ranitidine 10mg IVTT q8
 Paracetamol 10ml PO q6 RTC
Surgical Management
 Meningocele repair

31
Prognosis
If treated: If not treated:
Restoration of health
Good prognosis
If not treated:
No direct flow of CSF to the spinal cord
Obstruction of fluid in the brain
CSF unable to circulate
Accumulation of CSF in the brain
Hydrocephalus
Fluid continuous to accumulate in the brain
Learning disabilities

32
Figure 4. Pathophysiology Diagram
Mental retardation
Death
Bad prognosis

33
III. Management of the Disease
A. NURSING CARE PLAN
DATE/
SHIFT
ASSESSMENT NEED NURSING
DIAGNOSIS
OBJECTIVE
OF CARE
NURSING
INTERVENTIONS
EVALUATION
09-25-
13
7/3
Subjective:
“Nagapulihanay
mi
saakongbanaogba
ntay ,lihukan man
pudgudsiyakaayo”
, as verbalized by
mother.
Objective:
 Side rails
not raised
 patient left
unattended
 Irritable
P
H
Y
S
I
O
L
O
G
I
C
N
E
E
D
 Risk for fall
related to
lack of
knowledge
of
precautions
needed.
®Rationale:
Knowledge in
many aspects
gives power to
a person that
he would be
able to apply
Within 8 hours
of care
evidence of fall
is not observed
as evidence by:
a. raised side
rails
b. client was
not left
unattended
INDEPENDENT:
1. Keep side rails up in
locked position.
® Raised side rails will
somehow prevent falls.
2. Encouraged watcher
not to leave her child
unattended.
® To ensure that
someone will look after
client.
3. Discussed importance
of monitoring
conditions that
contribute to
After 8 hours
of nursing
intervention,
goal met as
evidenced by:
- raised
side
rails
noted
- Mother
always
on side
of the
client.

34
 Always
moving
from side to
side.
S
A
F
E
T
Y
A
N
D
S
E
C
U
R
I
T
Y
on his daily
living in order
to protect
himself from
any harm.
Reference:
Robert Porter.
Home health
handbook.
Merck
corporation.
2009
occurrence of injury.
® Education promotes
understanding and
prevention of fall.
COLLABORATIVE:
1. Instructed family
members to attend
needs of client
always.
® To prevent
occurrence of
injuries thus
promoting safety.

35
Discharge Plan
Medications
-Educate family members concerning right drug administration as
well as right time and dosage as prescribed.
-Explain the relevance of taking prescribed medications for fast and
better recovery.
- Instruct patient to continue home medications as ordered
Exercise
-Explain the importance of proper exercise to alleviate the
condition.
-Provide health teachings about exercises appropriate for patient’s
condition such as light exercises.
Treatment
-Instruct patient’s significant others to follow medical regimen
religiously as well as scheduled hospital visits when discharged for continuous
monitoring.
-Encourage to take Multivitamins for immunity.
- Instruct patient’s significant others to report any unusualities.
- Inform the significant others that they should be involved in the
treatment of the client.
Health Teachings
-Encourage family to provide proper and nutritious diet for the
patient.

36
-Provide health teachings on proper hygiene to prevent infections
and complications.
-Make the patient understand the importance seeking medical help
in case of any complications or abnormalities.
Out-patient
-Even without the presence of any health care member, the client
must still take his medications religiously and practice all health teachings
rendered.
- Encourage to follow medical advice for follow-up check up as
scheduled by physician.
-Provide adequate rest and sleep to the patient.
Diet
-Educate patient’s significant others to eat healthy foods in on a
regular schedule.
- Provide food rich in vitamins and minerals such as fruits and
vegetables to boost immune system and promote health.

37
IV. SYNTHESES OF CLIENT’S CONDITION/STATUS FROM ADMISSION TO
PRESENT
A. Conclusion
After a gradual evaluation of the patient’s condition from the first day of
our duty to the last, a conclusion was made that it is beyond doubt unpredictable
as to what happens in the whole period of nursing care.
The overall condition of the patient was illustrated to have achieved a high
level of wellness with the teamwork of the entire member of the health care team.
B. Patient’s Prognosis
POOR FAIR GOOD JUSTIFICATION
DURATION 
Patient has been admitted because of
nasofronto-orbital meningocele since
September 25, 2013 and was not yet
discharged during our duty last September
25, 2013.
ONSET 
The patient’s condition became better than
he was first admitted since he had already
undergone surgical management for his
condition.
WILLINGNESS 
The patient and his family is more than
willing to comply all medication and activities
conducive with faster healing and recovery.
ENVIRONMENT 
The nature of the environment is conducive
for faster recovery since there is proper
ventilation and proper medical attention is
provided.

38
Computation:
Poor – 1 x 0= 0
Fair – 2 x 1 = 2
Good – 3 x 3 = 9
----------------
11 / 4 = 2.75 (Fair Prognosis)
C. Recommendations
The following are the group’s suggestions for a faster therapeutic effect:
To the patient -Since the patient is a child, the
recommendations are directed to his family.
They were encouraged to follow medical
regimen by continuing medications as ordered
by the attending physician.
- Follow the health teachings rendered
by the health care team.
-Cooperate in everything that the health
care team advises.
To the family -It is recommended to the patient’s
immediate family members to provide
adequate support, care, love and
understanding to the patient’s situation.
-Develop knowledge about the patient’s
recovery status to avoid further
complications.

39
EVALUATION OF THE OBJECTIVES OF THE STUDY
After a step by step review on related topics on this case study, the
researcher is hereby presenting the evaluation with relation to the main
objectives that were affirmed at the start of this case study. It is settled
that the researcher was able to meet the chosen case with sensible data
gathered. Further documented related information that are important as
related to the nursing skills learned not only for this study but also for
future references, and that the informations gained about the case chosen
will be used to function as a student nurse in the community and the
nursing process was used as a framework for the care of the patient and
for goal attainment and that is to prevent and manage potential
complications.
With sufficient effort, this comprehensive case presentation was
made possible that deals not only on the basic facts of the topic but also of
the triumph in every detail mandated to have an abundant yield.

40
Lateral sacral meningocele presenting as a gluteal
mass: a case report
By: AfsounSeddighi and Amir S Seddighi
Reference: http://www.jmedicalcasereports.com/content/4/1/81. Date retrieved:
September 29, 2013.
Lateral meningoceles are considered as rare presentations of
craniospinaldysraphisms. These lesions were first described by Lehman in a
patient with other skeletal findings and distinctive craniofacial features. He
reported a 14-month-old girl with generalized osteosclerosis, distinctive
craniofacial features, and multiple lateral thoracic meningoceles. Subsequently,
more patients with the so-called lateral meningocele syndrome (LMS) have been
reported.
The existence of an affected mother and daughter supports the hypothesis
that LMS is a dominant disorder affecting primarily the connective tissue. Lateral
meningoceles commonly present during the fourth and the fifth decades of life.
Neurofibromatosis type 1 is present in approximately 85% of patients with lateral
thoracic meningoceles. Meanwhile, the position of the cord with respect to the
meningocele sac is variable.
The incidence of lateral meningoceles was reported to be 0.3%. Lateral
meningoceles are reported in the thoracic and lumbar regions followed by the
cervical area. Using various search engines such as Google, Pubmed, Alta vista,
and a review of the literature, we found the entity of lateral sacral meningocele

41
mentioned only once in the literature. It was presented by NavneetKaur et al. in
India.
Our patient did not show any evidence of abnormal pigmentation or
skeletal deformities. The prominent feature of our patient is the isolated
occurrence of the meningocele without any associated anomalies. The sac
communicated with the lateral spinal canal only through a tract in her iliac bone.
Lateral meningoceles are usually associated with vertebral defects such
as hemivertebrae, scoliosis, absence of neural arches on the affected side, and
widening of the spinal canal and intervertebral foramina. Scalloping of the
pedicles, laminae and vertebral bodies that are adjacent to the meningocele
result in an enlarged spinal canal. Butterfly vertebra and segmental anomalies of
the vertebral bodies may be found in as many as 43% of affected patients. Sacral
anomalies, such as confluent sacral foramina and partial sacral agenesis, occur
in up to 50% of reported cases.
In this case, the lumbosacral vertebrae showed normal appearance
except for L5 and S1 spina bifida. Both our patient and the patient described by
NavneetKaur had spina bifida, which supports the presentation of sacral
dysgenesis problems.
Lateral meningocele should be differentiated from other cystic sacral
masses. It may be mistaken for a lipoma in a patient with lipomeningocele or for
other cystic lesions such as cystic hygroma, synovial cysts, and large ovarian
cysts [10]. Perineural or Tarlov cysts are asymptomatic and are discovered
incidentally through myelogram or MRI originally intended for other reasons. In

42
diagnosing these cysts the contrast material does not readily enter the cyst
during myelography and CT scan. Delayed filling is also typical, and MRI can be
very useful in diagnosis.
In large ovarian cysts the determination of the origin of the mass can be
difficult. These lesions can be demonstrated on computerized tomography
scanning. They usually have a thin walls and attenuation values within the range
of water. On MRI they exhibit low signal intensity on the T1- weighted
sequences, high signal intensity on T2-weighted sequences, and are well-
circumscribed with a thin wall that may enhance after contrast administration on
T1-weighted images.
Summary:
A meningocele is an outpouching of leptomeninges through a
developmental defect in the dura. The arches of the vertebrae at one or more
levels are involved with protruded meningeal sac covered with only a layer of
skin.
Lateral meningocele is a very rare disorder. It has been reported in
patients with neurofibromatosis or Marfan's syndrome. Previous reports have
described lateral meningoceles in the thoracic or cervical region. Lateral
meningoceles are extensions of the dura and arachnoid through an enlarged
neural foramen. These often occur in the setting of Marfan syndrome or
neurofibromatosis type 1 but may also be seen as isolated anomalies. Although
they occur in the thoracic or sometimes in the cervical region, localization at the
sacral spine is very infrequent.

43
Reaction:
Although lateral meningocele especially in the sacral region is rare, its
possibility should always be considered in patients presenting with a
paravertebral or gluteal mass. The occurrence of a neurological deficit or the
presence of a spinal defect should make one suspicious of the presence of an
unusually located meningocele. Drainage through needle aspiration or by incision
may transform it into a cerebrospinal fluid fistula. Performing adequate imaging
studies such as CT myelography and MRI, therefore, are very helpful to avoid
mistakes and ensure correct diagnosis.
In congenital cases, the need for the mother to do prenatal check-ups is a
must in order for complications to be prevented and be avoided. Once the baby
is still in the mother’s womb, the mother is the most responsible person whom
will take care of the baby and to bare the child as healthy as he/she could be.

44
Bibliography
A. Textbooks
 Tortora, Gerard J. &Derrickson, Bryan. “Central Nervous
System, Spinal Nervs, and Cranial Nerves”. Essentials of
Anatomy and Physiology 8th Edition. John Wiley & Sons Inc.,
New Jersey. 2010. Pg. 256-263.
 Deglin, Judith Hopfer and Vallerand, April Hazard. Davis Drug
Guide for Nurses 10th edition. 2007
 Nurse’s Pocket Guide 10th Edition. DoengesMoorhouse
Murr.2008.
 Wilson, Billie Ann, Shannon, Margaret and Stang, Carolyn.
Nurse’s Drug Guide. Pearson Education South Asia. 2004. Pg.
1022-1025 and 1363-1365.
B. Electronic Media
 Shahinian, Kabil. http://en.wikipedia.org/wiki/Meningocele.
Retrieved on September 29, 2013.
 Oña, Cherry Ann.
http://www.scribd.com/doc/80533875/Anatomy-and-Physiology-
of-Meningocele. Retrieved on September 29, 2013.
 johnna_489. http://www.scribd.com/doc/25605661/meningocele-
pathophysiology. Retrieved on September 29, 2013.
 Edwards, Michael and Derechin, Margie.
http://www.hydroassoc.org/docs/Aboutmeningocele-
A_Book_for_Families_Dec08.pdf. Retrieved on September 29,
2013.

45
 Trickee, Robert.
http://www.skullbaseinstitute.com/meningocele/. Retrieved on
September 29, 2013.
 Neuroloveblog. http://neurolove.tumblr.com/post/1053910551/
ventricles -the-brain-has-a-series-of-ventricles. Retrieved on
September 29, 2013.
 http://en.wikipedia.org/wiki/Meningocele. Retrieved on
September 29, 2013
 http://www.hyperdictionary.com/dictionary/meningocele
Retrieved on September 29, 2013
 https://sites.google.
com/site/vylhphilippines/vylhadvocacies/meningocele/ quick-
guide-bds. Retrieved on September 29, 2013.
 http://davaohealth.brinkster. net/HealthStatus-2005.asp.
Retrieved on September 29, 2013
 http://www. surgeryencyclopedia.com/Repair of
meningocele.html#b. Retrieved on September 29, 2013
 http://www.webmd.com/a-to-z-guides/complete-blood-count-
cbc. Retrieved onSeptember 29,2013
 http:/ /en.wikipedia.org/wiki/Prothrombi n_time. Retrieved
on September 29, 2013
 AfsounSeddighi and Amir S Seddighi,
http://www.jmedicalcasereports.com/content/4/1/81. Date
retrieved: September 29, 2013

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