The overall nursing care provided to the patient was rated as GOOD based on the computation using the rating scale. Areas that can be improved include pain management and patient education. Continued monitoring and evaluation is recommended.

1. By:
Mark Kevin Felisilda, RN
Jun Rey Carlo Fundales,RN
Jonathan Gonzales, RN
Julberry Juan, RN

2. Spina bifida comes from the latin word “divided spine”. is a rare
congenital condition where there is failure of closure of the spinal cord due to
some factors that causes the spinal cord to create a sac-like cyst at the back of
the person. The most common type of this condition is spina bifida occulta. It has
been reported that in 1000 live births 1-2 babies have this kind of condition
worldwide, in the Philippines it has been said that out of 86,241,691² of the
population 5,174 were reported to have spina bifida in the year 2004
(curereaserch.com).
Our patient belongs to the category of spina bifida cystica with
meningocele, a mild and rare form of neural tube defect where the spinal cord is
not involved in the herniation. He was admitted in the neuro female ward with a
chief complain of headache and increase in the head circumference. We chose
this case because this is a rare condition in which it is not commonly seen in the
ward. It is an interesting case because not all have knowledge about this
condition; we want to broaden our knowledge about this case so that we may be
able to help prevent the occurrence of this condition in the community.

3. After two months of exposure at Davao Regional Hospital specifically
at Ortho / Neuro Ward, this case study aims to enhance our knowledge and
understanding regarding the diagnosis of our client so as to develop new skills
in dealing with this kind of illness and to improve our learning regarding Spina
Bifida that would be helpful in our future nursing profession.
After this case study, we will be able to:
• Establish good interpersonal relationship with the client and his family to gain
their cooperation during the process of gathering data;
• Determine the client health status through analyzing the nature of Spina Bifida
and its deviation from the normal physiologic process;
• Trace the health history of the client and his family by taking the past and
present health history to know the predisposing and precipitating factors of
client’s condition;
• Define and discuss thoroughly the complete diagnosis of the client;

4. • Present a through physical assessment on the client’s condition which serves as
a baseline data;
• Discuss the anatomy and physiology of the involved system in the disease;
• Trace the pathophysiology of the disease process by presenting the etiology,
predisposing and precipitating factors, its signs and symptoms present in the
patient;
• Interpret the results of congregated diagnostic procedures and laboratory
examinations and its clinical significance;
• Identify and discuss the different drugs used in the management of the client’s
condition;
• Formulate nursing care plan to provide adequate nursing interventions;
• Make a detailed discharge planning necessary for the wellness of the client
using the acronym METHOD;
• Interpret the general prognosis of the client base on a criteria; and
• Appreciate the experience we had upon accomplishing the said case study as
well as retaining the supplemental knowledge that we were able to acquire
throughout our 2 months exposure on the ward

5. Name: Patient S
Age: 4 years old
Gender: Male
Date of Birth: November 24, 2007
Address: Purok 4, Southern Davao, Panabo City, Davao Del Norte
Religion: Roman Catholic
Nationality: Filipino
Mother’s Name: Sheila
Father’s Name: Arjie
Siblings: Mayumi, Arsheil
Ordinal Position: Second among the three siblings
Ward: Neuro Ward
Date & Time Admitted: January 26, 2012 @ 3:30pm
Admitting Physician: Dr. Lucio Temonio Jr
Chief Complain: Increasing head circumference
Addmitting Diagnosis: Spina Bifida with Non – Communicating Hydrocephalus
Final Diagnosis: Meningocoele T4 – T6 with Syringomyelia T4 – T9, Obstructive
Hydrocephalus Secondary to Chiari II Malformation

6. Mother:
- Visits pre natal check-up
- Complete immunzations
- ( -) medications during pregnancy
- Experienced emesis gravidarum and UTI
- Avoids taking vitamns and supplements
- Sometimes stressed out from work
Patient:
-Cyst growing at the back of the patient
- Advised surgical treatment but refused d/t lack of financial support
- Complete immunizations, no known allergies on food and drugs
- Age 2: experienced convulsion
- Change in behavior: short temper
- Right eye and jaw cannot completely move
- Experience head ache and increase head circumference
-Increasing head circumference and head ache

7. Father’s Side Mother’s Side
Unknown Unknown Mario
Norma
Arjie Arnel † Sheila “Lolong” Unknown
Sheryll
Legend:
Patient S Arsheil - Male
Mayumi
←
- Female
† - Deceased
- Atrio – Septal defect
- Hypertension
- Diabetes
← - Patient

8. - Mesomorphic body built.
- Slightly kyphotic and the right shoulder is lower than the left.
-On DAT with SAP
-IVF of D5.03 Nacl 500cc @ 60cc/hr, infusing well at left metacarpal vein.
Temperature: 36.8°C
Heart Rate: 108 bpm
Pulse Rate: 100 bpm
Respiratory Rate: 25 cpm
Blood Pressure: 90/60 mmHg

9. 1/26/12 The doctor ordered to admit in neuro ward
Insert IVF
For VP shunting
1/27/12 For official reading of CXR
For pedia clearance
1/28/12 Ordered ECG 12 leads
1/29/12 Discontinue IVF
1/30/12 For Cranial CT scan
1/31/12 To secure 1 unit PRBC for OR use

10. 2/1/12 Pre op orders made
For insertion of IVF
Provided with pedia clearance
2/2/12 Post Op orders
Ordered CBC post operative
2/3/12 May have DAT with SAP
Still flat on bed
2/4/12 May elevate head with 1 pillow

11. 2/5/12 For dressing tomorrow
2/6/12 Decrease IVF to 50 cc/hr
D/C Tramadol & Ranitidine
2/7/12 May now remove IVF
Shift IV Meds to P.O
2/8/12 MGH as ordered

14. Predisposing Precipitating factors:
factors: - Nutrition
- Age - Medications
- Heredity - Socio-economic factors
- Unknown -Diabetes
- Increased body temp
1st month of
pregnancy
Central Nervous
System begins to
form
Defect in the spinal
cord
Failure of spine to join Defect in the closure
the lumbosacral area of the neural tube
Dx:
Spina bifida - X ray
occulta - CT scan Protruding sac through Protrusion with some
- MRI the defect- containing parts of the spinal
meninges cord

15. s/sx:
- dimple formation of Meningocele Myelomeningocele
the affected area
- tuft of hair in the
affected area Dx:
-Translumination
- CT scan
- MRI
If Treated If Not
- Surgical repair of
menigocele
No diret flow of csf
and myelomeningocele to the spinal cord
Good Prognosis Obstruction of fluid
in the brain
CSF unable to
circulate
s/sx:
- increased ICP Hydrocephalus
- increase head Accumulation of CSF
circumference in the brain
- sunken eyeballs
- vomiting

16. Fluid may
If Treated If Not possibly force
their way out
-VP shunt Fluid continues
to accumulate in Displacement of
the brain the foramen
magnum
Good Prognosis Shunt
Learning
Complication Chiari malformation
disabilities
s/sx: Mental s/sx:
- headache retardation - headache - muscle weakness
- nausea & vomiting - nausea - increased ICP
- fever - dizziness
If not treated
Myelomeningocele Compression of
the spinal cord
Flaccid paralysis Loss of bowel Loss of sensation s/sx:
of the lower control and bladder choking, arm
limb control stiffness, difficulty in
feeding, swallowing, and
Impaired mobility breathing
Impaired urinary Impaired bowel
elimination elimination
Muscle atrophy

17. Hematology Jan 26, 2012 – CBC, Blood typing Creatinine,Electrolytes Jan 26, 2012
Blood component B+ Creatinine 56.9mmol/L Normal
Hemoglobin 126g/L Decreased Sodium 145.8 mmol/L Normal
WBC 7.4 10^g/L Normal Potassium 3.73 mmol/L Normal
Neutrophils .31 Decreased
Calcium 1.19 mmol/L Normal
Lymphocytes .60 Increased
Eosinophils .09 Increased
Hematocrit .35 Decreased
Protrombine time 14.0 Normal
APTT 34.5 secs Normal
Cranial CTS Jan 31, 2012
Urinalysis Jan 26, 2012 - Non communicating hydrocephalus
- No evident acute intracerebral hemorrhage
Color Light yellow Normal
Leukocytes Negative Normal
Albumin Negative Normal
pH 6.0 Normal
Sugar Negative Normal
Sp. Gravity 1.005 Decreased
Blood Negative Normal
Pus cells 0-2 Normal

18. Hematology Feb 2, 2012 –CBC Feb 5, 2012
Culture and Sensitivity
Hemoglobin 126g/L Decreased
No growth after 72 hours of incubating
WBC 7.4 10^g/L Increased
Neutrophils .31 Increased
Lymphocytes .60 Normal
Hematocrit .35 Decreased
FBS Feb 2, 2012
2.48 mmol/L Normal
CSF analysis Feb 2, 2012
Color Colorles Normal
s
Transpar Cloudy Indicates increase in WBC
ency or infection
Lymphoc 92 Increased
ytes

19. Brand name: Zantac
Classification: H2 Histamine Receptor Antagonist
Mode of Action: Inhibits action of H2 receptor sites,
decreases gastirc acid secretion
Indication: Relieve GI discomforts
Side Effects:
CNS: headache, dizziness
Ophtha: blurred vision
GI: constipation, nausea, vomiting, diarrhea,
hepatotoxicity
GU: gynecomastia
Systemic: Anaphylaxis, Angioedema

20. Brand name: Apo-metoclop
Classification: Antiemtic
Mode of Action: Bocks chemoreceptor trigger zone
which prevents or minimize
nausea and vomiting
Indication: Prevent or reduce vomiting during and
after operation
Side Effects:
CNS: sedation, fatigue, headache
GI: dry mouth, constipation, nausea and vomiting,
diarrhea
GU: decrease libido
CV: hypotension, bradycardia
Systemic: rashes

21. Brand name: Suprax
Classification: 3rd Generation Cephalosphorin
Mode of Action: Inhibits cell wall synthesis
Indication: Prophylaxis for post op patients
Side Effects:
CNS: headache, dizziness
GI: nausea and vomiting, diarrhea, abdominal pain
GU: nephrotoxicity
Integ: rash, urticaria
Respi: dyspnea
Systemic: anaphylaxis

22. Brand name: Zinacef
Classification: 2nd Generation Cephalosphorin
Mode of Action: Inhibits cell wall synthesis
Indication: Prophylaxis for post op patients
Side Effects:
CNS: dizziness, headache
GI: diarrhea, nausea and vomiting, abdominal
cramps
GU: nephrotoxicity
Systemic: anaphylaxis

23. Brand name: Paracetamol, Acetaminophen, Tylenol
Classification: Antipyretic, Analgesic
Mode of Action: Block pain impulses peripherally that
occur in response to inhibition of
prostaglandin synthesis; anti pyretic
action results from inhibition of
prostaglandin in the CNS
Side Effects:
CNS: drowsiness
GI: nausea and vomiting, diarrhea, hepatotoxicity
Integ: rash, urticaria

24. Brand Name: Toradol, Tramal, Oltram
Classification: Opioid analgesic
Mode of Action: Not completely known, binds to opioid
receptors, inhibits reuptake of
norepinehrine
Indication: to relieve pain
Side Effects:
CNS: dizziness, headache, anxiety
GI: nausea and vomiting, GI bleeding, constipation
CV: orthostatic hypotension, decrease blood pressure

25. Computation: Rating Scale:
POOR –1 x 2 = 2 0 – 1.5 = Poor
FAIR – 2 x 2 = 4 1.5 – 2.0 = Fair
GOOD – 3 x 3 = 9 2.0 – 2.5 = Good
Total: 15 / 7 = 2 = GOOD
CONCLUSION: