Prepared By: Rommel L. Manalo BSN 3-ACollege of Nursing and Health Sciences DepartmentHYDROCEPHALUS
is a medical condition in which there is an abnormal accumulation of Cerebrospinal fluid(CSF) in the ventricles, or cavities, of the brain. This may cause increased intracranial pressure inside the skull and progressive enlargement of the head, convulsion, tunnel vision and mental disability.
ASSESSMENTSubjective: “Napapansin ko na hindi normal ang laki ng ulo ng anak ko as verbalized by the mother”Objective: Increased head circumference Bulging fontanel Scalp veins dilated Sun setting eyes Restlessness Irritability GCS X-RAY- bones are thin and widely separated. MRI or Ct- Scan- dilated ventricle s and excess CSF T- 39.8 C
NURSING DIAGNOSIS Alteration in thermoregulation, hyperthermia related to increase vascular resistance. Ineffective Cerebral tissue perfusion related to decreased arterial or venous blood flow.
GOAL OF CAREAfter 1 hour of nursing intervention the client will maintain core temperature within normal range After 6 hours of nursing interventions the client will be able to demonstrate improve cerebral tissue perfusion and absence of complication such as sign of increased ICP.
NURSING INTERVENTION Independent: monitor vital sign especially temperature provide tepid sponge bath. Note skin turgor, status and mucous membrane.
Provide rest periods between care of activities and limit duration of procedures. Decreased extraneous stimuli and provide comfort measures such as back massage, quiet environment gentle touch.
Dependent Administer : Administer anti pyretic medication as ordered by the physician
Collaboration:Refer to neuro surgeon for surgical mgt.Refer to dietician for optimal nutrition for specific case.Coordinate to medical social worker for their bill hospitalization and especially to the physician for further fast recovery.
RATIONALE Fever may reflect damage to hypothalamus. Increased metabolic needs and oxygen consumption occur which can further increased ICP Useful indicators of body water, which is an integral part of tissue perfusion. Turning bed to one side compress the regular veins and inhibits cerebral venous drainage that may cause increased ICP Continual activity can increase ICP by producing a cumulative stimulant effect. Provides calming effect, reduces adverse physiological response, and promotes rest.
These activities increase intra thoracic and intra abdominal pressure. Promotes venous drainage from head, reducing cerebral congestion and edema and increased ICP Diuretics may be used in acute phase to draw water from brain cells, reducing cerebral edema and ICP Reduces hypoxemia, which may increase cerebral vasodilatation and blood volume.
INTERVENTION 2 Assess the head circumference, assess the bulging fontanel. Monitor intake and output weigh as indicated. Maintain head or neck in midline or in neutral position support with small towel rolls and pillows Help patient avoid or limit coughing, crying vomiting, and straining during defecation. Reposition the patient slowly. Elevate the head of bed gradually to 15-30 degrees as tolerated or indicated. Administer diuretics and supplemental oxygen as indicated antibiotics as ordered by the physician.
DISCHARGE PLANNINGM- Instruction about the use of medications and the possible side effects-diuretics and supplemental oxygen as indicated .E-Advise client/SO to perform simple exercises only.T- Advise the SO to bring M R I - magnetic resonance imaging. Computed Tomographic scanning result prior to follow-up check up H -Advise SO to provide skin care to prevent skin break down. -Advise SO to provide proper personal hygiene.
O –Advise SO/ Instruct client follow-up check up.D-Advise SO/ Instruct client to eat nutritious food rich in vit.C & proteinAdvise SO/ to consult spiritual adviser for any concern’s regarding spiritualityS - A child has the right to enjoy a full and decent life, in conditions which ensure dignity, promote self-reliance and facilitate the child’s active participation in the community.”
EVALUATION Goal metThe patient demonstrate, improve V/S with in normal range and absence of complication and sign of increased Icp