ST.

MARYS COLLEGE NURSING PROGRAM Tagum City

A CASE STUDY On Meningocele

Presented to Maam 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

Table of Contents PAGE

Table of Contents Introduction Assessment 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 Laboratory Test Symptomatology 23 Etiology Pathophysiology A. Diagram Pathophysiology B. Written Pathophysiology Nursing Care Plan Synthesis of Clients Condition From admission presented Prognosis Recommendation

i 1 5

14 15

25 26

33 35

Bibliography

44

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 Date

condition(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3389919/. 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 broadbased, 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

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 insulindependent 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 Date

(http://www.neuraltubedefect.com/2011/06/21/meningocele/. retrieved: September 29, 2013).

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 1:3500040000 live births (http://nervoussystem.emedtv.com/meningocele/meningocele.html. 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/0386Date retrieved:

9687_38_1_A%2Bcase%2Bof%2Bmeningocele._N%252FA. retrieved: September 29, 2013).

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 patients 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.

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

Chapter II ASSESSMENT I. Background of the Patient BIOGRAPHICAL DATA Name Address : Baby Uzumaki : Prk. Taripe Drive, John Bosco District, Bislig, Surigao del Sur Age Admitting Physician : 1 year old : Dr.Kristine Sereina, MD

Admitting Diagnosis : Nasofronto-orbital Meningocele Religion Nationality : Roman Catholic : 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

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 child among two siblings, both parents have no work and business and only depending on the fathers 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 meningocele and other serious illnesses except that his grandparent has hypertension and diabetes.

PATIENT NEED ASSESSMENT Name : Baby Uzumaki Admission Date / Time Age: 1y.o. Sex: M

: September 25, 2013/11:00a.m

Admitting Medical Diagnosis: Nasofronto orbital meningocele Arrived on unit by Accompanied by *VS : per mothers arm From : Emergency Room : Parents : BP = 90/60mmHg PR = 110 bpm RR = 24cpm Temp. = 36 C

Clients Perception of Reason for Admission: Niadto mi ogospitalkay gusto mother. How was the problem being managed at home? Medication taken at home : None. PHYSIOLOGIC NEEDS Oxygenation *BP : 90/60 mmHg *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. *PR : 110 bpm : Bed rest nanamoipatangalangiyangbukolsanawong, as verbalized by

*Skin Character and Color: Smooth and pinkish; with good skin turgor. *Life-supporting apparatus: None Temperature Maintenance *Temperature : 36C

*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

*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 watchers arm

SAFETY AND SECURITY NEED Patients mother and father doesnt 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 patients situation is whole-heartedly accepted by his family who is always there to take care of him.

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SELF-ACTUALIZATION NEED The patients 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 Freuds 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 persons 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 persons 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 Eriksons stages of development, the stage of infancy, which accounts for children 0-2 years old.

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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 well as a fundamental sense of one's own trustworthiness. on the parents, especially the mother, for as

The infant depends

sustenance and comfort. The society come from the parents

child's relative understanding of world and

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 can lead to feelings of confidence. According to of mistrust will result. Development of mistrust

frustration, suspicion, withdrawal, and a lack of 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, they are mistrustan infant learns trust- that others are dependable and reliable. If neglectful, or perhaps even abusive, the infant instead learns 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

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affection but sometimes he doesnt 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 C. He is conscious, and responsive. VITAL SIGNS Temp Date Shift Time (C) 09/25/13 7-3 11:00am 36.2 (mmHg) ------(cpm) 28 (bpm) 100 ------BP RR PR 02 Sat

NUTRITIONAL STATUS The patient is 31 inches in height and weighs 13 kg. He is on diet for age. Hes 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.

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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. Theres 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.

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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/ NURSES NURSES SHIFT/ ASSESSMENT INTERVENTION TIME 09-25-13/ Admitted this VS checked and 7-3 1y.o child, per recorded. 11:00am mothers arm; To obtain baseline came in due data. to anatomical defect (mass) with glabella extending down to the nasal area and left medial canthus. Seen by Dr. Carried out orders. Sereina with To implement orders made. orders of the

MEDICAL MANAGEMENT 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

physician. 12:15pm Received from ER, per mothers arm, without IVF, on DFA 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 NORMAL RESULT EXAM VALUES INTERPRETATION 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. September 29, 2013). 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. The result is normal. Calcium helps muscles and blood vessels to contract and expand and maintains strong bones. The result is normal. Sodium controls blood pressure. It is also needed for the muscles and nerves to work properly. RATIONALE 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/ElectrolyteTests.html#b. September 29,2013).

CRE A

53-115 umol/L

34.6 umol/L

Pota ssiu m

3.5-5.0 mmol/l

4.25 mmol/L

Calci um

1.131.32 mmol/L

1.16 mmol/L

Sodi um

135148 mmol/L

140.7

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Hematology Date: September 25, 2013 LAB EXAM Blood Group NORMAL RESULT VALUES -----APos INTERPRETATION The patients blood type is A Positive. 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). The result is normal. 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) 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 RATIONALE

Hemoglobin

140-170 g/L

116 g/L

WBC

5.0-10.0

9.2

Neutrophils

0.55-0.65

0.38

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-zguides/completeblood-count-cbc. September 29, 2013).

Lymphocytes

0.25-0.35

0.56

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lymphocyte levels are run as a standard portion of a general blood workup (J., Christopher. http://www. reference.com/motif/health /causes-of-highlymphocytes.September 29, 2013). 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). 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).

Eosinophils

0.02-0.04

0.03

Monocytes

0.02-0.06

0.06

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Platelet

150-450

206

Hematocrit

0.40-0.50

0.33

Prothrombin time

11-17 sec

13.6

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). 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 pts low hgb level.(http://en.wikipedia.or g/ wiki/Hematocrit September 29, 2013) The result is normal. It determines the clotting tendency of blood and any bleeding abnormalities (http:/ /en.wikipedia.org/wiki/ Prothrombin_time. September 29, 2013).

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Radiography Date: September 25, 2013 Parts to be examined: Chest PA Referred by: Dr.Kristine Sereina, 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

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Chapter III PATHOPHYSIOLOGY REVIEW OF ANATOMY AND PHYSIOLOGY

F i g. 1 St ruct ure o f t he brai n and spi nal c ord

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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.

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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.

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Fig. 3 Circulation of Cerebrospinal fluid

SYMPTOMATOLOGY ACTUA L SYMPT OMS

SYMPTOMAT OLOGY

IMPLICATION 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

Tachypnea

minimal

amount

of

oxygen

inhaled

(http://www.nurses learning.com/courses/nrp/NRP1608/Section%204/in dex.htm. Date retrieved: September 29, 2013).

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Due to the increase accumulation of CSF causing orbital meningocele, the the compression increases Visual problems in the orbit causing visual disturbances

(http://www.ncbi. nlm.nih.gov/pmc/articles/PMC506127/. retrieved: September 29, 2013). 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 Date

Mass formation (http://www.labome.org/topics/diseases/nervous/ner vous/neural/meningocele-7061.html. Date retrieved: September 29, 2013). pulsatile tumours, which vary greatly in size

Meningocele can occur anywhere along the spine, and can cause a portion of the spinal cord and surrounding structures to develop outside the Paralysis 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

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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 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 Congenital 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 retrieved: September 29, 2013).

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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 Date retrieved:

(http://www.nervous-system-diseases.com/meningocele.html. September 29, 2013).

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 Date

(http://global.britannica.com/EB retrieved: September 29, 2013).

checked/topic/375064/meningocele.

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

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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.nervoussystem-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. September 29, 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/complicationsspina-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.disabledDate retrieved:

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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 newborns spinal column or in the head. The procedure usually takes place within 12 to 48 hours of a babys 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).

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B. Diagram of Pathophysiology Predisposing factor: Genetics Precipitating factors: Nutrition (deficiency of folic acid) Socio-economic status

1st month of pregnancy

Central nervous system begins to form

Defect/dehiscence of the base of the skull

Defect in the closure of the neural tube

CSF is continuously produced

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A protruding sac is formed through the defect containing CSF and meninges

Mass formation in the nasofrontoorbital area

Meningocele

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 patients 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

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Prognosis

If treated:

If not treated:

Restoration of health

If not treated:

Good prognosis

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

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Mental retardation

Death

Bad prognosis

Figure 4. Pathophysiology Diagram

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III. Management of the Disease A. NURSING CARE PLAN DATE/ SHIFT P 09-2513 7/3 Subjective: Nagapulihanay mi saakongbanaogba ntay ,lihukan man pudgudsiyakaayo , as verbalized by mother. H Y S I O L O G I Objective: Side rails not raised patient left unattended Irritable N E E D C Rationale: Knowledge in many aspects gives power to a person that he would be able to apply Risk for fall related to lack of knowledge of precautions needed. 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. After 8 hours of nursing intervention, ASSESSMENT NEED NURSING DIAGNOSIS OBJECTIVE OF CARE NURSING INTERVENTIONS EVALUATION

Raised side rails will goal met as 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 evidenced by: raised side rails noted Mother always on side of the client.

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Always moving from side to side.

S A F E T Y

on his daily living in order to protect himself from any harm. Reference: Robert Porter.

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.

A N D

Home health handbook. Merck corporation.

S E C U R I T Y

2009

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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 patients condition such as light exercises.

Treatment -Instruct patients 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 patients 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.

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-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 patients 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.

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IV. SYNTHESES OF CLIENTS CONDITION/STATUS FROM ADMISSION TO PRESENT A. Conclusion After a gradual evaluation of the patients 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. Patients Prognosis
POOR FAIR GOOD JUSTIFICATION Patient has been admitted because of nasofronto-orbital meningocele since DURATION September 25, 2013 and was not yet discharged during our duty last September 25, 2013. The patients condition became better than ONSET he was first admitted since he had already undergone surgical management for his condition. The patient and his family is more than WILLINGNESS willing to comply all medication and activities conducive with faster healing and recovery. The nature of the environment is conducive ENVIRONMENT for faster recovery since there is proper ventilation and proper medical attention is provided.

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Computation: Poor Fair Good 1 x 0= 0 2x1=2 3x3=9 ---------------11 / 4 = 2.75 (Fair Prognosis)

C. Recommendations The following are the groups 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 patients immediate adequate family support, members care, to love provide and

understanding to the patients situation. -Develop knowledge about the patients recovery status to avoid further complications.

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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 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. and that is to prevent and manage potential

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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

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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

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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 wellcircumscribed 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.

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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 mothers 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.

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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 Nurses Pocket Guide 10th Edition. DoengesMoorhouse Murr.2008. Wilson, Billie Ann, Shannon, Margaret and Stang, Carolyn. Nurses 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. Oa, Cherry Ann. http://www.scribd.com/doc/80533875/Anatomy-and-Physiologyof-Meningocele. Retrieved on September 29, 2013. johnna_489. http://www.scribd.com/doc/25605661/meningocelepathophysiology. Retrieved on September 29, 2013. Edwards, Michael and Derechin, Margie. http://www.hydroassoc.org/docs/AboutmeningoceleA_Book_for_Families_Dec08.pdf. Retrieved on September 29, 2013.

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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/ quickguide-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-countcbc. Retrieved onSeptember 29,2013 http:/ /en.wikipedia.org/wiki/Prothrombin_time. Retrieved on September 29, 2013 AfsounSeddighi and Amir S Seddighi, http://www.jmedicalcasereports.com/content/4/1/81. Date retrieved: September 29, 2013