Hydrocephalus in children

1. HYDROCEPHALUS MS. S.GOMATHI

2. DEFINITION
 Hydrocephalus is a condition caused
by too much cerebrospinal fluid
(CSF) inside the ventricles of child's
brain. Imbalance between production
and absorption of CSF.
 Hydrocephalus is characterized by an
increased volume of cerebrospinal
fluid (CSF), which is associated with
progressive ventricular dilatation.

3. CAUSES
 Congenital:
 Arnold Chiari malformation:
 Herniation of cerebellum and brain
stem into cervical canal
 Tumors
 Arachnoid cysts
 Acqueductal stenosis
 Myelomeningocele
 Perinatal hemorrhage
 Intrauterine infection
 Dandy walker syndrome(posterior
fossa cyst)

4. ACQUIRED:
Meningitis
Tumor
Hemmorrhage(ICH)
Aneurysm

5. TYPES
 There are two main categories of
hydrocephalus:
 communicating and
noncommunicating.

6. 1. NONCOMMUNICATING HYDROCEPHALUS
 obstruction of CSF flow within the
ventricular system or blockage of
CSF flow from the ventricular
system to the subarachnoid space.
 a. May be partial, intermittent, or
complete.
 b. More common
Acquired causes.
i.Aqueductal gliosis (posthemorrhagic
or postinfectious).
ii. Space-occupying lesions (tumors or
cysts). iii. Head injuries
 c. Congenital causes.
 i.Aqueductal stenosis.
 ii. Congenital lesions (vein of
Galen malformation, congenital
tumors).
 iii.Arachnoid cyst.
 iv. Chiari malformations (with or
without myelomeningocele).
 v. Dandy-Walker malformation

7. COMMUNICATING HYDROCEPHALUS
 CSF circulates through the ventricular system into the subarachnoid space with no
obstruction.
 a. Congenital causes.
 i.Achondroplasia. ii.Arachnoid cyst. iii. Craniofacial syndromes.
 b.Acquired causes
 i. Post haemorrhagic (intraventricular or subarachnoid)
 ii. Choroid plexus papilloma or choroid plexus carcinoma
 iii.Venous obstruction (ex, superior vena cava syndrome)
 iv. Postinfectious

9. CLINICAL MANIFESTATIONS
 Clinical signs depend on the age of the child,
whether the anterior fontanelle has closed,
whether the cranial sutures have fused, and
the type and duration of hydrocephalus.
 Infants
 1. Excessive head growth (may be seen up to
age 3).
 2. Delayed closure of the anterior fontanelle.
 3. Fontanelle tense and elevated above the
surface of the skull.
 4. Signs of increased intracranial pressure
(ICP
 5.Alteration of muscle tone of the
extremities, including clonus or spasticity.

10. LATER PHYSICAL SIGNS:
 a. Forehead becomes prominent (“bossing”).
 b. Scalp appears shiny with prominent scalp veins.
 c. Eyebrows and eyelids may be drawn upward, exposing
the sclera above the iris. d. Infant cannot gaze upward,
causing “sunset eyes.”
 e. Strabismus, nystagmus, and optic atrophy may occur.
 f. Infant has difficulty holding head up.
 g. Child may experience physical or mental
developmental lag.
 7. Pseudobulbar palsy (difficulty sucking, feeding, and
phonation, which leads to regurgitation, drooling, and
aspiration).

11. OLDER
CHILDREN
 closed sutures and present with signs of
increased ICP.
 Vomiting
 Restlessness and irritability
 High-pitched, shrillcry (infants)
 Rapid increase in headcircumference
(infants)
 Tense,bulging fontanelle(infants)
 Changes in vitalsigns: • Increased
systolic blood pressure •
Decreased pulse • Decreased
and irregular respirations • Increased
temperature

12. OLDER
CHILDREN
 Pupillary changes
 Papilledema
 Possible seizures
 Lethargy,
 stupor,coma
 Older children may also experience:
 Headache, especially on awakening
 Lethargy, fatigue, apathy
 Personality changes
 Separation of cranial sutures (may be
seen in children up to age 10)
 Visual changes such as double
vision

13. DIAGNOSIS
 1. Percussion of the infant’s skull may
produce a typical “cracked pot” sound
(Macwen’s sign).
 2. Ophthalmoscopy may reveal papilledema.
 3. MRI is the diagnostic tool of choice.
 4. CT is also used for diagnosis in cases
where sedation poses added risk due to
need for general anaesthetic or in situations
in which MRI is not available.
 5. Ultrasonography is also used.

14. MANAGEMENT
Hydrocephalus can be treated through a variety of surgical
procedures, including
direct operation on the lesion causing the obstruction, such
as a tumor;
intracranial shunts for selected cases of noncommunicating
hydrocephalus to divert fluid from the obstructed segment of
the ventricular system to the subarachnoid space; and
extracranial shunts (most common) to divert fluid from the
ventricular system to an extracranial compartment,
frequently the peritoneum or right atrium.
CSF production may also be reduced by medication or
surgical intervention.

15. EXTRACRANIAL
SHUNT
PROCEDURES
 1.Ventriculoperitoneal (VP) shunt:
 a. Diverts CSF from a lateral ventricle or the
spinal subarachnoid space to the peritoneal cavity.
 b.A tube is passed from the lateral ventricle
through an occipital burr hole subcutaneously
through the posterior aspect of neck and
paraspinal region to the peritoneal cavity through
a small incision in the right lower quadrant.

16. 2.VENTRICULOATRIAL (VA) SHUNT:
c.A one-way pressure-sensitive valve will close to prevent reflux of
blood into the ventricle and open as ventricular pressure rises,
allowing fluid to pass from the ventricle into the bloodstream.
b. It then is passed under the skin behind the ear and into a vein
down to a point where it discharges into the right atrium or
superior vena cava.
a.A tube is passed from the dilated lateral ventricle through a burr
hole in the parietal region of the skull.

17. 3.VENTRICULOPLEURAL
SHUNT:
 a. Diverts CSF to the pleural cavity.
 b. Indicated when theVP orVA route
cannot be used.
 a. Diverts CSF to the common bile
duct. b. Used when all other routes
are unavailable.
4.VENTRICLE–GALL
BLADDER SHUNT

18. COMPONENTS
Most shunts have the following
components:
a.Ventricular tubing.
b.A one-way or unidirectional
pressure-sensitive flow valve.
c.A pumping chamber.
d. Distal tubing.

19. SHUNT
COMPLICATIONS
1. Need for shunt revision frequently occurs because of
occlusion, infection, or malfunction, especially in the first
year of life.
2. Shunt revision may be necessary because of growth of
the child.
3. Shunt dependency frequently occurs.
4. VA shunts, leading to bacterial endocarditis, bacteremia,
and ventriculitis or thromboembolism and cor pulmonale.
5. Children withVA shunts require biannual or annual
chest x-ray to check length of tubing. Chest x-ray is also
done

20. NURSING
ASSESSMENT
 Infants 1.Assess head circumference.
 a. Measure at the occipitofrontal circumference—
point of largest measurement.
 b. Measure the head at approximately the same time
each day
 2. Palpate fontanelle for firmness and bulging.
 3.Assess pupillary response.
 4.Assess level of consciousness (LOC).
 5. Evaluate breathing patterns and effectiveness.
 6.Assess feeding patterns and patterns of emesis.
 7.Assess motor function.
 8.Assess developmental milestones.

21.  Older Children
 1. Measure vital signs for signs of increased ICP.
 2.Assess patterns of headache, emesis.
 3. Determine pupillary response.
 4. Evaluate LOC using the Glasgow Coma Scale.
 5.Assess motor function.
 6. Evaluate attainment of milestones, school performance.
 7.Assess for behavioral changes.

22. NURSING DIAGNOSES
 • Ineffective Cerebral Tissue Perfusion related to increased ICP before surgery.
 Imbalanced Nutrition: LessThan body requirement related to reduced oral
intake and vomiting.
 • Risk for Impaired Skin Integrity related to alterations in LOC and enlarged
head.
 • Anxiety of parents related to child undergoing surgery.
 • Risk for Injury related to malfunctioning shunt.
 • Risk for Deficient FluidVolume related to CSF drainage, decreased intake
postoperatively.
 • Risk for Infection related to bacterial infiltration of the shunt.
 • Ineffective Family Coping related to diagnosis and surgery.

23. NURSING INTERVENTIONS
 Maintaining Cerebral Perfusion
 1. Observe for evidence of increased ICP and report immediately
 2.Assist with diagnostic procedures to determine cause of hydrocephalus and
indication for surgical intervention.
 a. Explain the procedure to the child and parents at their levels of
comprehension.
 b.Administer prescribed sedatives 30 minutes before the procedure to ensure
their effectiveness. Sedatives are contraindicated in many cases because
increased iCP predisposes the child to hypoventilation or respiratory arrest. if
they are administered, the child should be observed very closely for evidence of
respiratory depression.
 c. Organize activities so that the child is permitted to rest after administration of
the sedative.

24.  d. Observe closely after ventriculography for the following: i. Leaking CSF from
the sites of subdural or ventricular taps.These tap holes should be covered with
a small piece of gauze or other dressing per institutional policy. ii. Reactions to
the sedative, especially respiratory depression.
 iii. Changes in vital signs indicative of shock.
 iv. Signs of increased ICP, which may occur if air has been injected into the
ventricles.

25. PROVIDING ADEQUATE NUTRITION
 1. Be aware that feeding is frequently difficult because the child may be listless,
have a diminished appetite, and be prone to vomiting.
 2. Complete nursing care and treatments before feeding so that the child will not
be disturbed after feeding.
 3. Hold the infant in a semi-sitting position with head well supported during
feeding.Allow ample time for bubbling.
 4. Offer small, frequent feedings.
 5. Place the child on side with head elevated after feeding to prevent aspiration.

26. MAINTAINING SKIN INTEGRITY
 1. Prevent pressure sores by placing the child on a sponge rubber or pad or an alternating-
pressure to keep weight evenly distributed.
 2. Keep the scalp clean and dry.
 3.Turn the child’s head frequently; change position at least every 2 hours.
 a.When turning the child, rotate head and body together to prevent strain on the neck.
 b.A firm pillow may be placed under the child’s head and shoulders for further support when
lifting the child.
 c. Keep weight off incision during immediate postoperative period.
 4. Provide meticulous skin care to all parts of the body and observe skin for signs of breakdown
or pressure.
 5. Give passive ROM exercises to the extremities, especially the legs.
 6. Keep the eyes moistened with artificial tears if the child is unable to close the eyelids normally.
This prevents corneal ulcerations and infections.

27. IMPROVING CEREBRAL TISSUE PERFUSION
POSTOPERATIVELY
 1. Monitor the child’s temperature, pulse, respiration, blood pressure (BP), and pupillary size
and reaction every 15 minutes until stable; then monitor every 1 to 2 hours or as indicated
by child’s condition and institutional policy.
 2. Maintain normothermia. a. Provide appropriate blankets or covers, an Isolette or infant
warmer, or hypothermia blanket. b.Administer a tepid sponge bath or antipyretic medication
for temperature elevation.
 3.Aspirate mucus from the nose and throat, as necessary, to prevent respiratory difficulty.
 4.Turn the child frequently.

28.  5. Promote optimal drainage of CSF through the shunt by pumping the shunt and
positioning the child, as directed.
 Gradually elevate the head of child’s bed to 30 to 45 degrees, as ordered.
Initially, the child will be positioned flat to prevent excessive CSF drainage.
 6.Assess for excessive drainage of CSF. a. Sunken fontanelle, agitation,
restlessness (infant). b. Decreased LOC (older child).
 7.Assesss signs of increased ICP
 8. Prevent excessive pressure on skin overlying shunt by placing cotton behind
and over the ears under the head dressing and avoiding positioning the child on
the area of the valve or the incision until the wound is healed

29. MAINTAINING FLUID BALANCE
 1.Accurately measure and record total fluid intake and output.
 2.Administer intravenous (IV) fluids, as prescribed; carefully monitor infusion rate to prevent fluid
overload.
 3. Use a nasogastric tube, if necessary, for abdominal distention.This is most frequently used
when aVP shunt has been performed. a. Measure the drainage and record the amount and color.
b. Monitor for return of bowel sounds after nasogastric suction has been disconnected for at
least 30 minutes.
 4. Give frequent mouth care while the child is to have nothing by mouth.
 5. Begin oral feedings when the child is fully recovered from the anesthetic and displays interest. a.
Begin with small amounts of dextrose 5% in water.
 b. Gradually introduce formula.
 c. Introduce solid foods suitable to the child’s age and tolerance.
 d. Encourage a high-protein diet.
 e. Observe for and report any decrease in urine output, increased urine-specific gravity,
diminished skin turgor, dryness of mucous membranes, or lethargy, indicating dehydration

30. PREVENTING INFECTION
 1.Assess for fever (temperature normally fluctuates during the first 24 hours
after surgery), purulent drainage from the incision, or swelling, redness, and
tenderness along the shunt tract.
 2.Administer prescribed prophylactic antibiotics.

31.  Headache/ hemorrhage
 Distended scalp veins/ diplopia
 Respiratory pattern Altered
 Occipito frontal circumference
 Communicating/ non communicating/cranial stures delayed closure
 Enlarged fontanels/ frontal bossing
 Projectile vomiting/ papilledema
 Increased head circumference
 Arnold chiari malformation/ataxia
 Lethargy
 Unequal pupil size
 Seizures/sluggish pupillar response/sun set siogn/strabismus
