ST. ANTHONY COLLEGE CALAPAN CITY, INC.

Bayanan I, Calapan City

B. Diagram of Pathophysiology Precipitating factors:

Predisposing factor:  Nutrition (deficiency of
folic acid)
 Genetics
 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

A protruding sac is formed

through the defect containing
CSF and meninges

Encephalocele

Types of encephalocele

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Bayanan I, Calapan City

Occipital Encephalocele Frontonasal Encephalocele

Prognosis

If treated: If not treated:

If not treated:
Restoration of health

No direct flow of CSF to the spinal cord

Good prognosis

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

Mental retardation

Death

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Bad prognosis
 ST. ANTHONY COLLEGE CALAPAN CITY, INC.

Bayanan I, Calapan City

NURSING PROCESS

A. PROBLEM LIST

PROBLEM DATE IDENTIFIED

Risk for Pressure, Injury and Infection related to skin

March 14, 2023
integrity of the neural tube sac

Deficit knowledge regarding the care of the patient with

March 14, 2023
occipital encephalocele

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
OBJECTIVE: Risk for After - Assess - Gives - Goal meet,
Occipital mass Pressure, performing the neural tube information After performing
with Injury and nursing sac for about the the nursing

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Bayanan I, Calapan City

measurement of Infection procedure, the breaks or potential interventions, the

3.9 x 1.7 x 3.7 related to skin baby’s occipital leakage, infection of the baby’s occipital
integrity of the mass will be irritation of sac site, and if mass has been
neural tube free from sac, redness, the sac is free from any
SUBJECTIVE: sac infection and and swelling ruptured, or is infection and
N/A injury around sac present. injury
area

- Do
handwashing
before or
- Avoids the
after
proliferation of
procedures
microorganisms
involving the
on the site.
site and
maintain
sterile
technique
when caring
for the client.

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Bayanan I, Calapan City

- Use sterile
saline or
antibiotic
solution as
prescribed to
- Avoids the sac
make sure a
membrane to
moist sterile
be dried which
dressing is
could result in
applied over
sac breakage
the sac.
and
contamination
- Teach
parents to
cleanse the
sac gently
with moist
cotton balls if
soiled, and
avoid
diapering the
infant until - Protects sac

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ST. ANTHONY COLLEGE CALAPAN CITY, INC.

Bayanan I, Calapan City

after surgery from

and healing contaminants
has taken and maintains
place. cleanliness.

- Alter routine
nursing care
activities
such as
feedings,
changing
linens, and
comforting as
needed.

- Following - Prevents
surgical trauma to the
repair of the sac.
defect,
observe any
changes in

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Bayanan I, Calapan City

wound
including
redness,
swelling,
warmth,
drainage, or
fever.

- Maintain the
infant in a
prone - To know if there
position or are any
side-lying, as Indications of
permitted, wound infection.
with head
lower than
buttocks or
hips slightly
flexed with a
pad between
the knees;

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Bayanan I, Calapan City

anchor
position with
sandbags.

- Teach
- Reduces
parents about
pressure on the
the proper
sac to prevent
positioning of
possible rupture
infant and the
and prevents
application of
rolling on the
protection
side or back.
around sac
such as foam
rubber
doughnut.

- Stress the
importance of
handwashing
, dressing
change, and
use of clean - Prevents

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Bayanan I, Calapan City

or sterile pressure on the

linens, sac area.
gloves,
supplies
when caring
for the sac
area.

- Prevents
transmission of
infectious
organisms;
sterile
technique may
not be needed

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Bayanan I, Calapan City

in giving care
after surgery is
performed.

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
SUBJECTIVE: Deficit After - Encourage - Allow reduction - Goal meet,
“wala po knowledge performing expression of in anxiety and after
akong idea regarding the the nursing feelings and enhances performing the
kung anong care of the interventions, provide family nursing
bukol yung patient with the family will accurate, understanding intervention,
nasa ulo ng occipital be able to honest of the condition the baby’s
baby ko” as encephalocel adapt to the information and child’s family has
verbalized by e patient’s about care needs. become
the patient’s disability and with or without knowledgeabl
mother exhibit surgical repair, e about the
motions to abilities, and occipital mass
OBJECTIVE: move disabilities. of their baby
N/A forward. and was able
- Communicate to adapt to the
empathy for condition of
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Bayanan I, Calapan City

client’s family. their baby.

- Promotes
coping and
positive
- Evaluate the adjustment to
patient and illness.
family’s level - Assessing the
of level of
understanding understanding
and perception and perception
of the crisis, will help the
their problem- healthcare
solving skills team formulate
and its strategies that
effectiveness. best address
their specific
- Evaluate the concerns.
family’s
capacity to
adapt with - Thorough
their patient, evaluation of
the family these

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Bayanan I, Calapan City

developmental dynamics will

level, provide crucial
associated information
stress of family about family
relationships, profile and
reaction of adaptive
other family capabilities
members, that will
understanding profoundly
of health affect the
practices, role patient’s health
behaviors and and well-being.
perception
about
prolonged
care, financial
burden,
resources to
prolonged care
for the
condition,

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Bayanan I, Calapan City

grieving
process, and
clinical
manifestations
of depression,
powerlessness
- Inform the
and
parents that
hopelessness.
congenital
defects are not
- Educate the
necessarily
family on the
their mistake.
causes,
treatment and
prognosis of
occipital
- Providing this
encephalocele
information to
.
the family, as
reinforcement
- Instruct
to doctor’s
parents that
expert advice,
surgical
will provide
intervention

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Bayanan I, Calapan City

should be crucial when

done after taking
birth, decisions to
postponed the appropriate
until the third surgical
month of life, intervention.
or until
adequate
neurologic
function

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