172205403 meningocele-case-study

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

Meningocele
Presented to
Sir Van Kyssel R. Reyes 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 constitute 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: February 08, 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: February 08, 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:
February 09, 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: February 09, 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 Cry
Address : Prk. Taripe Drive, John Bosco District, Bislig, Surigao
del Sur
Age : 1 year old
Admitting Physician : Dr.Roalan Rae Anthony P. Cambronero, MD
Admitting Diagnosis : Nasofronto-orbital Meningocele
Religion : Roman Catholic
Nationality : Filipino
Date/Time of Admission : January 31, 2013/11:00am
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,
Surigaodel 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 Cry is the youngest chi ld among two sibli ngs, both
parents have no work and business and only depending 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 grandparents has hypertension
and diabetes.

7
PATIENT NEED ASSESSMENT
Name : Baby Cry Age : 1y.o. Sex : M
Admission Date / Time : January 31, 2013/11:00am
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 ogospitalky gusto
nanamoipatangalangiyangbukolsanawong”., as verbalized by mother.
How was the problem being managed at home? :Bedrest
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.
*Skin Character and Color :Smooth and pinkish; with good skin turgor.

8
*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) :February 06, 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 Cry 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
01/31/13 7-3 11:00am 36.2 ------- 28 100 -------
01/31/13 3-11 4:00pm 36.5 ------- 31 125 -------
8:00pm 36.1 ------- 29 131 -------
02/01/13 11-7 1:00 am 36.4 ------- 30 130 -------
02/01/13 7-3 8:00 am 36.8 ------- 34 132 -------
12:00 nn 36.9 ------- 32 128 -------
02/01/13 3-11 4:00 pm 36.2 ------- 33 142 -------
8:000pm 36.4 ------- 34 140 -------
02/02/13 11-7 1:00 am 36.4 ------- 30 138 -------

13
02/02/13 7-3 8:00 am 36 ------- 48 148 -------
12:00nn 36.5 ------- 36 136 -------
02/02/13 3-11 4:00pm 37 ------- 25 110 -------
8:00pm 36 ------- 30 125 -------
02/03/13 11-7 1:00am 37 ------- 31 128 -------
02/03/13 7-3 8:00am 37 ------- 31 130 -------
12:00nn 36 ------- 32 128 -------
02/03/13 3-11 4:00pm 36.7 ------- 38 105 -------
8:00pm 37 ------- 35 100 -------
02/04/13 11-7 1:00am 36.4 ------- 32 138 -------
02/04/13 7-3 8:00am 36.7 ------- 35 128 -------
12:00nn 36.8 ------- 39 140 -------
02/04/13 3-11 4:00pm 36 ------- 34 148 -------
8:00pm 36.3 ------- 32 129 -------
02/05/13 11-7 1:00am 36.7 ------- 32 128 -------
02/05/13 7-3 9:00am 36.7 ------- 36 138 -------
02/05/13 3-11 4:00pm 37.1 ------- 35 129 -------
8:00pm 36 ------- 33 126 -------
02/06/13 11-7 1:30am 37 ------- 32 130 -------
02/06/13 7-3 8:00am 36.9 ------- 32 121 -------
12:00nn 36.9 ------- 30 129 -------
02/06/13 3-11 4:00pm 36.3 ------- 32 129 -------
8:00pm 36.8 ------- 28 114 -------

14
02/07/13 11-7 1:20am 36.6 ------- 30 120 -------
02/07/13 7-3 8:00am 36.6 ------- 32 110 -------
10:18am 36.4 ------- 33 126 -------
---PACU---
02/07/13 3-11 8:00pm 37.4 ------- 34 128 -------
02/08/13 11-7 1:10am 36.6 ------- 32 140 -------
3:45am 36.5 ------- 35 138 -------
02/08/13 7-3 8:00am 36.6 ------- 30 126 -------
12:00nn 36.3 ------- 32 128 -------
 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.
 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)

15
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.
 GASTROINTESTINAL SYSTEM
Abdomen has an equal color 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

16
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
01-31-13/
7-3
11:00am
12:15pm
 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.Cambroner
o with orders
made.
 Received
from ER, per
mother’s arm,
without IVF,
on DFA
 VS checked and
recorded.
® To obtain baseline
data.
 Carried out orders.
® To implement
orders of the
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.
 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.
01-31-13/
3-11
 Received
lying on bed,
 VS checked and
recorded.
 Prepare for pedia
clearance.

17
on DFA;
without IVF.
® To identify
abnormalities/
deviations from the
baseline data.
 Kept safe. Watched
for any unusualities,
watched and cared
for.
® To provide comfort
and to identify
appropriate
interventions if there
are unusualities.
® To evaluate the
patient’s physiologic
preparedness for surgery.
 Suggest repeat CXR-AP.
appropriate medical
intervention.
01-31-13/
11-7
11:00pm
 Received
lying on bed,
asleep, no
IVF.
 VS checked and
recorded.
® To obtain baseline
data.
 Bedside care done.
® To provide
comfort.
02-01-13/
7-3
7:00am
8:00am
 Received on
bed, awake,
conscious
and
responsive.
Not in anu
form of
respiratory
distress; on
DFA.
 Seen and
examined by
Dr.Cambron
ero, with
new orders
made.
 VS cheched and
recorded.
® For proper
monitoring and to
identify any
deviations from
baseline data.
® To implement
orders of the
physician.
 Suggest repeat CXR-AP.
appropriate medical
intervention.
02-01-13/
3-11
3:00pm
 Received
lying on bed,
asleep; with
heplock
patent and
intact; on
DFA.
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
 Hooked O2 inhalation
@ 2LPM

18
® For proper
oxygenation.
 Needs attended.
Watched and cared
for.
For monitoring & to
there are any.
02-01-13/
11-7
11:00pm
 Received on
bed asleep,
on DFA.
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
 Needs attended.
Watched and cared
for.
For monitoring & to
there are any.
 Pedia clearance done by
Dr. Ramirez.
® To evaluate the
02-02-13/
7-3
7:00am
2:15pm
 Received on
bed, wather
on side; on
DFA, with
heplock; no
unusualities
noted.
 Seen and
examined by
Dr.Cambron
ero, with
orders
made.
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
® To implement
orders of the
physician.
 Suggest repeat CXR-AP
Today.
appropriate medical
intervention.
02-02-13/
3-11
 On bed
awake, on
DFA, with
heplock; no
unusualities
noted.
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
 Needs attended to.
® To provide
comfort.
02-02-13/  Received on  VS checked and

19
11-7 bed, asleep;
on DFA, with
heplock“ left
arm. With
pedia
evaluation.
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
Kept safe. Watched
for any unusualities,
watched and cared
for.
® To provide comfort
and to identify
appropriate
interventions if there
are unusualities.
02-03-13/
7-3
 Received on
bed, awake,
conscious
and
coherent; on
DFA; not in
any form of
respiratory
distress.
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
Needs attended.
Watched and cared
for.
® To provide
comfort. For
monitoring & to
identify unusualities
if there are any.
 Continue present
management.
® To prevent
complications
02-03-13/
3-11
3:00pm
 Received on
bed, awake;
on DFA.
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
 Needs attended.
Watched and cared
for.
® To provide
comfort. For
monitoring & to
if there are any.
02-03-13/
11-7
11:00pm
 Received on
bed, asleep
with watcher
at side; on
 VS checked and
recorded.
® To identify
abnormalities/

20
DFA. deviations from the
baseline data.
02-04-13/
7-3
8:00am
 Received on
bed, alert
and
responsive
to any
stimuli; not
in any form
of
respiratory
distress; on
DFA.
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
 Needs attended.
Watched and cared
for.
® To provide
comfort. For
monitoring & to
if there are any.
 Continue present
management.
® To prevent
complications
02-04-13/
3-11
3:00pm
3:30pm
 Received on
bed, alert
and
responsive
to any
stimuli; not
in any form
of
respiratory
distress;
with heplock
at left
metacarpal
vein, on
DFA.
 Seen and
examined by
Dr. Ramirez
with new
orders
made.
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
 Needs attended.
Watched and cared
for.
® To provide
comfort. For
monitoring & to
if there are any.
® To implement
orders of the
physician.
 Prepare for pedia
clearance.
® To evaluate the
 Follow-up official CXR
result.
appropriate medical
intervention.
02-04-13/
11-7
11:00pm
 On bed
awake, with
heplock, on
DFA.
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
02-05-13/  Received on  VS checked and  For pedia clearance.

21
7-3
7:00pm
bed, awake
and
responsive;
on DFA.
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
 Needs attended.
Watched and cared
for.
® To provide
comfort. For
monitoring & to
if there are any.

® To evaluate the
02-05-13/
3-11
3:00pm
 Received on
bed, awake,
with heplock,
on DFA; with
pedia
evaluation.
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
 Health teachings
imparted to watcher
® To provide
knowledge about the
client`s condition
and for continuity of
care.
02-05-13/
11-7
11:00pm
 Received on
bed asleep,
with heplock,
on DFA.
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
02-06-13/
7-3
7:00am
 Received on
bed, alert
and
responsive
to any
stimuli; not
in any form
of
respiratory
distress;
with heplock
at left
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
 Needs attended.
Watched and cared
for.
® To provide
comfort. For
monitoring & to
 Pedia clearance provided.
® To evaluate the
 Schedule for elective
repair of meningocele
tomorrow (02-07-13),
secure concent.
® To aid the removal of
the mass.
 Secure 1 unit of Packed
RBC, crossmatched

22
metacarpal
vein, on
DFA.
if there are any.
® In case needed intra or
post-operative.
 Secure co-amoxiclav
330mg IVTT as loading
dose prior to OR, ANST
® Prophylaxis against
infection associated with
major surgical procedure.
02-06-13/
3-11
3:00pm
 On bed,
awake and
responsive,
with heplock.
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
Pre-op orders:
 IVF: D5 .3 NaCl 500cc
at 40cc/hr.
® It is a hypertonic
solution used in critical
care settings like
increased ICP. When a
cell is immersed into a
hypertonic solution, the
tendency is for water to
want to flow out of the cell
in order to balance the
concentration of the
solutes.
 Follow-up availability of
blood.
 NPO
® To prepare the
gastrointestinal tract. The
stomach and esophagus
relaxes when general
anesthesia is administered
which makes it possible for
food to move up into the
mouth from where a
patient may aspirate it
down their trachea into
their lungs. Such aspirate
is usually very acidic and
can cause severe damage
to the lungs requiring
artificial ventilation and
hospi-tallization. By placing
a patient on NPO status,
there will be nothing to
aspirate because any food
would have been absorbed

23
into the small intestines by
that time of surgery 6-8 hrs
later.
02-06-13/
11-7
11:00pm
 Received on
bed, asleep,
on NPO,
with heplock.
Schedule for
repair of
menigocele.
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
02-07-13/
7-3
7:00am
10:20am
10:30am
 Received on
bed, awake,
on NPO,
schedule for
repair of
meningocele
today, with
IVF #1 D5 .3
NaCl 500cc
@ 40cc/hr
infusing well
and
regulated.
 To OR.
Endorsed to
OR, NOD.
 Received
from
neurosurgery
ward per
stretcher with
IVF of D5 .3
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
 Needs attended.
Watched and cared
for.
® To provide
comfort. For
monitoring & to
if there are any.
 Prepared for
induction of
anesthesia. Level of
anesthesia
monitored.
® To assess the
 IVF: D5 .3 NaCl to run @
40 cc/hr.
® It is a hypertonic
solution used in critical
care settings like
increased ICP. When a cell
is immersed into a hypertonic
solution, the tendency is for
water to want to flow out of the
cell in order to balance the
concentration of the solutes.
Meds:
 Co-amoxiclav 160 mg IVTT q8
® Prophylaxis against
infection associated with
major surgical procedure.
 Ranitidine 10mg IVTT q8
® Tolessen any chance that
you might inhale some of the
acid contents of your stomach
into the lungs (pulmonary
aspiration of gastric acid),
either during or after
anesthesia.
 Paracetamol 10ml q6 RTC.
® To alleviate
fever/headache.
 Anesthesia inducted by
Dr.Barosa.
® To render the patient
unconscious and make
the pain during surgery
tolerable by blocking
nerve or group of nerves.

24
NaCl at
40cc/hr. For
repair of
meningocele
with concent.
effectiveness of the
anesthesia.
 Skin prep & draped
aseptically.
® To maintain
sterility and prevent
infections.
Endorsed to PACU
NOD.
® For close
monitoring.
 Incision made.
 Top dressing applied.
® To cover the surgical
site and prevent infection.
---PACU---
02-07-13/
3-11
6:25pm
 Received
from PACU
per mother`s
arm. Awake
and
responsive
to any
stimuli. Not
in any form
of
respiratory
distress.
Post repair
of
meningocele
, with top
dressing at
nasal area.
With on
going IVF of
D5 .3 NaCl
500cc at
40cc/hr
infusing well
@ left foot;
with heplock
@ right foot
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
 Needs attended.
Watched and cared
for.
® To provide
comfort. For
monitoring & to
if there are any.
 Due meds given as
ordered
® To treat underlying
cause.
 To ward
® For continuity of care.
 Continue meds.
cause.
02-07-13/
11-7
11:00pm
 On bed,
asleep, on
DFA; with
IVF #2 D5 .3
NaCl 500cc
@ 40cc/hr,
with heplock
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
 Needs attended.

25
@ right arm. Watched and cared
for.
® To provide
comfort. For
monitoring & to
if there are any.
02-08-13/
7-3
7:00am
10:20am
 Received
lying on bed,
conscious
and
responsive
to any
stimuli, fairly
groomed,
crackles
heard upon
auscultation;
with top
dressing @
nasal area,
dry and
intact; with
IVF #2 D5 .3
NaCl 500cc
@ 410cc
level
regulated @
40cc/hr.
 Seen and
examined by
Dr.Cambron
ero with new
orders
made.
 VS checked and
recorded.
® To identify
abnormalities/
deviations from the
baseline data.
 Needs attended.
Watched and cared
for.
® To provide
comfort. For
monitoring & to
if there are any.
 Due meds given as
ordered
cause.
 Health teachings
imparted to watcher
® To provide
knowledge about the
client`s condition
and for continuity of
care.
 On DFA.
® The patient can eat
nutritious foods that are
appropriate to his age.
 D/C Blood line.
LABORATORY & DIAGNOSTIC EXAMINATIONS
BLOOD CHEMISTRY
Date: January 31, 2013
LAB EXAM NORMAL
VALUES
RESULT INTERPRETATION RATIONALE
CREA 53-115 34.6 Having a low level of Tests that measure the

26
umol/L umol/L blood creatinine indicates
nothing more than an
efficient and effective pair
of kidneys (http://www.
netdoctor.co.uk/ate/liveran
dkidney/203123.html#ixzz
2KTA4EWKA. February
09, 2013).
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.
November 28, 2012).
Potassium
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.
Calcium
1.13-1.32
mmol/L
1.16
mmol/L
Calcium helps muscles
and blood vessels to
contract and expand and
maintains strong bones.
Sodium
135-148
mmol/L
140.7
Sodium controls blood
pressure. It is also needed
for the muscles and
nerves to work properly.
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
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,
February 09,2013).
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

27
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. February 09, 2013)
diagnose conditions,
such as anemia,
infection, and many
other disorders
(http://www.webmd.co
m/a-to-z-
guides/complete-
blood-count-cbc.
November 28, 2012).
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
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.February 09,
2013).
Eosinophils 0.02-0.04 0.03
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

28
duringhematopoiesis in
the bone marrow before
migrating into blood
(http://en.
wikipedia.org/wiki/
Eosinophil_granulocyte.Fe
bruary 09, 2013).
Monocytes 0.02-0.06 0.06
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. February 09,
2013).
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. February 09,
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

29
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
February 09, 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.
November 28, 2012).
Urinalysis
Date: February 01, 2013
Examination Normal value Result Interpretation
Color Pale yellow to
amber
Yellow Normal
Transparency Clear Clear Normal
RBC Negative Negative Normal
WBC Negative Negative Normal
Specific gravity 1.002-1.030 1.020 Normal
Albumin Negative Trace It may transmit elevation due
to an infection, medication, or
emotional or physical stress.
Pus 0-2 6-10 Presence of pus in the urine
means that there is infection.

30
Radiography
Parts to be examined: Chest PA
Referred by: Dr.Cambronero
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
CT Scan Section
Date: February 01, 2013
CT film number: 13-248
Parts examined: Cranium
Type of exam: CT Scan
Referred by: Dr. Cambronero
Findings
Multiple plain axial CT image of the head were obtained. No
abnormal density changes appreciated in the brain and brainstem
parenchyma.

31
No pathologic inta and extra axail fluid collection
demonstrated.
Gyri, sulci, fissures and cisterns are intact. The ventricles are
in normal size. Midline sutures are not displaced.
A bone and defect is noted at the medial wall of the lift orbit
and in both nasal and ethmoid bones.
A lobulated fluid-iso dense focus is seen herniating from the
calvarium to the previously mentioned bone defects. The left globe
is compressed laterally by the said fluid-iso dense focus occupying
the medial extraconal space. The left lateral extraconal space is
effaced.
Findings: Negative Intra-cranial CT Scan
Naso-ethmoid and Left frontal meningocele
Chapter III
PATHOPHYSIOLOGY

32
REVIEW OF ANATOMY AND PHYSIOLOGY
Fig. 1 Structure of the brain and spinal cord

33
Fig. 2 Structure of the Ventricles
The Brain
Our brain is well protected by:
 The scalp
 The skull
 The meninges
Layers includes:
- dura mater: its 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.
Ventricles

34
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 (mases
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.

35
Fig. 3 Circulation of Cerebrospinalfluid
SYMPTOMATOLOGY
SYMPTOMATOLOGY
ACTUAL
SYMPTOMS
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 amout
of oxygen inhaled(http://www.nurses
learning.com/courses/nrp/NRP1608/Section
%204/index.htm. Date retrieved: February
09, 2013).
Visual problems Due to the increase accumulation of CSF

36
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/nerv
ous/nervous/neural/meningocele-7061.html.
Date retrieved: February 08, 2013).
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/mainpageS
1062P1.html. Date retrieved: February 09,
2013).
Hydrocephalus A continuous excessive accumulation of CSF

37
causing the head to be enlarged as the mass
gets bigger
(http://treato.com/Hydrocephalus,Meningocel
e/?a=s . Date retrieved: February 09, 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, an
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

38
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 results 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:
February 09, 2013).
This problem is commonly seen at birth, a low level of folic acid in the mother,
an 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 that folds to become a tube, the

39
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: February 09, 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
most mild 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:
February 09, 2013).
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: Fabruary 10, 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-

40
world.com/disability/types/spinal/spina-bifida/complications-spina-bifida.php#ixzz
2KTjGb2qQ. Date retrieved: Fabruary 10, 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: February
10, 2013).
As with any surgery that involves general anesthesia, 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: February
10, 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: February 10, 2013).

41
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

42
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. Change wound dressing as
necessary.
3. Assess the area every shift for
redness, edema and discharges.
4. Educate watcher to maintain hygienic
measures before having contact with
the client.
5. 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

43
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

44
Figure 4. Pathophysiology Diagram
Mental retardation
Death
Bad prognosis

45
III. Management of the Disease
A. NURSING CARE PLAN
DATE/
SHIFT
ASSESSMENT NEED
NURSING
DIAGNOSIS
OBJECTIVES OF CARE
NURSING
INTERVENTIONS
EVALUATION
02-08-13/
7-3
Subjective:
“Gioperahannasiyas
anawongaronmatan
ggalnangiyangbulol.
”, as verbalized by
mother.
Objective:
 Surgical dressing
at nasal area.
 VS taken as
follows:
Temp: 36.6°C
PR: 126 bpm
RR: 30 cpm
S
A
F
E
T
Y
&
S
E
C
U
R
I
T
Y
N
E
E
D
 Impaired skin
integrity
related to
surgical
incision on
nasal area
due to
meningocele
repair
secondary to
meningocele.
® To correct
meningocele
surgical
interventions
are needed
 After 4 hours of
nursing intervention,
the following will be
observed:
a. Demonstration of
proper way of
wound care.
b. Understanding on
the importance of
caring the incision
site.
INDEPENDENT:
1. Keep the area clean
and dry.
® Moisture harbors
bacteria and
pathogens.
2. Assess the area
every shift for
redness, edema and
discharges.
® Frequent
assessment can
detect early signs &
symptoms of
infection.
 After 4 hours
of nursing
intervention,
goal met as
evidenced by:
- demons-
trating proper
way of wound
care.
- understand-
ding the
importance of
caring the
incision site
as verba-
lized:

46
such
meningocele
repair is
invasive and
leads to
impaired skin
integrity.
® Brunner and
Suddarth’s
Textbook of
Medical Surgical
Nursing 12th
Edition.
Lippincott
Williams &
Wilkins. 2012.
Pg. 1862.
3. Educate on the
purpose of proper
care practices.
® To increase
compliance.
4. Limit or avoid plastic
material.
® Moisture
potentiates skin
breakdown.
DEPENDENT:
5. Administer
prophylactic
antibiotics as
indicated.
® To inhibit
synthesis of
bacterial cell wall
causing cell death.
“
Pirminamonagin
a-
ampinganarondi
limaimpek-
syon.”

47
DATE/
SHIFT
ASSESSMENT NEED
NURSING
DIAGNOSIS
OBJECTIVES OF CARE
NURSING
INTERVENTIONS
EVALUATION
02-08-13/
7-3
Subjective:
“Gioperahannisiyasa
nawongparamatang
galangiyangbukol.”,
as verbalized by
mother.
Objective:
 Surgical incision at
nasal area.
 VS taken as
follows:
Temp: 36.6°C
PR: 126bpm
RR: 30cpm
S
A
F
E
T
Y
&
S
E
C
U
R
I
T
Y
N
E
E
D
 Risk for
infection
related to
break in skin
integrity (nasal
area) due to
meningocele
repair
secondary to
meningocele
® In
meningocele
there is a
defect in the
closure of the
neural tube
which causes
a protruding
 Within 8 hours of
nursing intervention
the following will be
observed:
a. Perform
independent
wound care.
b. Identify
interventions that
could prevent or
reduce the risk of
infection.
c. Achieve timely
wound healing,
free from signs of
infection.
d. Show feelings of
recovery and
INDEPENDENT:
1. Perform wound
dressing as
necessary.
® To prevent
occurrence of
infection and to
keep the site clean
and dry.
2. Monitor VS.
® To determine if
there has been
systemic infection
occurring inside the
body.
3. Assess the
significant others’
knowledge on
 Within 8 hours
of nursing
intervention,
goal met as
evidenced by:
- performing
indepen-
dent wound
care
- no signs of
infection
noted
- feelings of
recovery
and
comfort as
verbalized:
“Dilinasiyas

48
sac which
contains CSF
and meninges.
To correct
this,meningoc
ele repair is
needed. It is
an invasive
procedure that
necessitates
making a
break in the
skin which is
the first line of
defense by the
body and
could promote
the entrance of
microor-
ganism that
comfort. appropriate
actions.
® To determine the
ability to perform
independent
interventions
4. Assess changes of
wound site color,
smell, location,
temperature and
discharges.
® Provides
comparative
baseline for future
assessment &
promote timely
nursing
intervention of care
plan. To determine
the risk or risk of
igeughilka.
Mura
raganiugwa
lagioperah
ankaysigen
auglakawu
gdula.”

49
could cause
infection at
wound site if
not treated
properly.
® Brunner and
Suddarth’s
Textbook of
Medical
Surgical
Nursing 12th
Edition.
Lippincott
Williams &
Wilkins. 2012.
Pg. 1879.
wound infection.
5. Maintain adequate
hydration by proper
IVF regulation and
giving fluids as
indicated.
® To prevend
dehydration &
electrolytes &
minerals needed
by the body to
recover.
6. Promote early
mobility by
providing position
changes, active or
passive exercises
and assistive
exercises.
® Promote better

50
circulation at body
parts and prevent
excessive tissue
pressure thus
promoting
recovery.
DEPENDENT:
7. Administer and
monitor medication
regimen like
antibiotic as
ordered and note
ptient responses.
® Prevent infection
and determine
effectiveness and
presence of side
effects.
COLLABORATIVE:
8. Educate significant

51
others to do proper
wound caring.
® To enable
independent
wound care that
promotes recovery.

52
DATE/
SHIFT
ASSESSMENT NEED NURSING
DIAGNOSIS
OBJECTIVE
OF CARE
NURSING
INTERVENTIONS
EVALUATION
01-11-
13
7/3
Subjective:
“Nagapulihanay
mi
saakongbanaogba
ntay ,lihukan man
pudgudsiyakaayo”
, as verbalized by
mother.
Objective:
 Side rails
not raised
 patient left
unattended
 Irritable
 Always
moving
S
A
F
E
T
Y
And
S
E
C
U
R
I
T
Y
NEED
 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
on his daily
living in order
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
occurrence of injury.
® Education promotes
After 8 hours
of nursing
intervention,
goal met as
evidenced by:
- raised
side
rails
noted
- mother
always
on side
of the
client.

53
from side to
side.
to protect
himself from
any harm.
Reference:
Robert Porter.
Home health
handbook.
Merck
corporation.
2009
understanding and
prevention of fall.
COLLABORATIVE:
1. Instructed family
members to attend
needs of client
always.
® To prevent
occurrence of
injuries thus
promoting safety.

54
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.

55
-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.

56
C. Pharmacological Management
Date/
Shift
Generic
Name
Brand Name
Classification
Mechanism of
Action
Indication
Adverse
Effects
Time/Do
se
Nursing
Interventions
02-07-
13/
7-3
 Paraceta-
mol
 Biogesic  Analgesic/
Antipyretic
 Inhibits the
synthesis of
prostaglandins
that may serve
as mediators
of pain and
fever.
 Analgesia due
to peripheral
prostaglandin
inhibition.
 Mild to
moderate
pain.
 Fever
GI:
Hepatic
necrosis
Derm:
rash,
urticaria
 10mL
q6
 Assess overall
health status &
alcohol usage
before
administering.
Malnourished/ch
ronic alcohol
abusers are at
high risk of
developing
hepatotoxicity
with chronic
usual doses of
this drug.
 Assess type,
location, and
intensity prior to
and 30-60 min
following
administration.
 Assess fever.

57
Date/
Shift
Generic
Name
Brand Name Classification
Mechanism of
Action
Indication
Adverse
Effects
Time/
Dose
Nursing
Interventions
02-07-13/
7-3
 Augmentin  Co-
amoxiclav
 Antibiotic  Inhibits the
synthesis of
bacterial cell
walls. It has 2
active
ingredients:
Amoxicillin
&Clavulanic
Acid. Amoxicillin
inhibits bacterial
cell wall
mucopeptide
synthesis.
Clavulanic Acid
inactivates a
wide range of
beta-lactam
enzymes found
in bacteria
resistant to
beta-lactam
antibiotics.
 Antimicro
-
bialproph
yla-xis for
surgery
 Peritonitis
 Chlamy-
dial
infections
 UTI
 Upper
respirato-
ry tract
infection
 Skin
itchiness
 Rashes
 Skin
peeling
 Dizziness
 Headache
 Prolonged
bleeding
time
160
mg
IVTT
q12
 Obtain
patient’s history
of allergy.
 Assess for
signs and
symptoms of
infection.
 Assess for
allergic
reactions: rash,
pruritus, chills,
fever, join
pains.
 Monitor
VS.

58
Date/
Shift
Generic
Name
Brand
Name
Classification
Mechanism of
Action
Indication
Adverse
Effects
Time/
Dose
Nursing
Interventions
11-25-
12/ 7-3
 Ranitidine
Hydro-
chloride
 Zantac  H2-receptor
antagonist
 Antiulcera-
tive
 Competitively
inhibits action
of H2 at
receptor sites
of parietal
cells,
decreasing
gastric acid
secretion.
 Pathologic
hypersecre
-tory
condition
 Duodenal
and gastric
ulcer
 GERD
 Heartburn,
acid
ingestion,
and sour
stomach
CNS:
malaise,
vertigo
EENT:
blurred
vision
Hepatic:
jaundice
GI: altered
taste,
constipa-
tion,
diarrhea,
nausea
Misc:
Hypersen-
sitivity
reactions
 10
mg
IVTT
q8
 Assess
patient’s GI
condition
before
starting
therapy &
regularly
thereafter to
monitor
drug’s
effectiveness.
 Educate to ↑
OFI and fiber
intake to
minimize
constipation.
 Be alert for
adverse
reactions and
drug
interactions.

59
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
January 31, 2013 and was not yet
discharged during our duty last February 08,
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 to 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.

60
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.

61
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.

62
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:
February 20, 2013.
Lateral meningoceles are considered as rare presentations of
craniospinaldysraphisms [1,2]. 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 [3].
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 [4].
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% [4]. Lateral
meningoceles are reported in the thoracic and lumbar regions followed by the
cervical area [5-7]. Using various search engines such as Google, Pubmed, Alta
vista, and a review of the literature, we found the entity of lateral sacral

63
meningocele mentioned only once in the literature. It was presented by
NavneetKaur et al. in India [8].
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 [9,10].
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 [8].
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 [11].

64
In 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 [12].
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 [13].
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.

65
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.

66
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 February 09, 2013.
 Oña, Cherry Ann.
http://www.scribd.com/doc/80533875/Anatomy-and-Physiology-
of-Meningocele. Retrieved on February 08, 2013.
 johnna_489. http://www.scribd.com/doc/25605661/meningocele-
pathophysiology. Retrieved on February 08, 2013.
 Edwards, Michael and Derechin, Margie.
http://www.hydroassoc.org/docs/Aboutmeningocele-
A_Book_for_Families_Dec08.pdf. Retrieved on February 09,
2013.

67
 Trickee, Robert.
http://www.skullbaseinstitute.com/meningocele/. Retrieved on
February 09, 2013.
 Neuroloveblog. http://neurolove.tumblr.com/post/1053910551/
ventricles -the-brain-has-a-series-of-ventricles. Retrieved on
February 10, 2013.
 http://en.wikipedia.org/wiki/Meningocele. Retrieved on February
10, 2013
 http://www.hyperdictionary.com/dictionary/meningocele
Retrieved on February 10, 2013
 https://sites.google.
com/site/vylhphilippines/vylhadvocacies/meningocele/ quick-
guide-bds. Retrieved on February 10, 2013.
 http://davaohealth.brinkster. net/HealthStatus-2005.asp.
Retrieved on February 10, 2013
 http://www. surgeryencyclopedia.com/Repair of
meningocele.html#b. Retrieved onFebruary 10, 2013
 http://www.webmd.com/a-to-z-guides/complete-blood-count-
cbc. Retrieved onFebruary 08, 2013
 http:/ /en.wikipedia.org/wiki/Prothrombi n_time. Retrieved
on February 08, 2013
 AfsounSeddighi and Amir S Seddighi,
http://www.jmedicalcasereports.com/content/4/1/81. Date
retrieved: February 20, 2013

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