Hydrocephalus

2. HYDROCEPHALUS
•An excessive accumulation of CSF within the ventricular spaces of the
brain
•This accumulation leads to dilation of the ventricles, which causes
potentially harmful pressure on the brain tissue.
•Compression of the brain tissue and cerebral blood vessels may lead to
ischemia and, eventually, cell death.
•May be communocating or noncommunicating
-communicating hydrocephalus results from faulty absorption of CSF
-Noncommunicating hydrocephalusoccurs as a result of obstruction of CSF
flow

3. •Causes of hydrocephalus aren’t well understood; possible causes included:
-Genetic inheritance
-Neural tube defects,such as spina bifida and enancephalocele
-Complications of preterm birth such as intraventricular hemorrhage
-Meningitis
-Tumors
-Traumatic head injury
-Subarachnoid hemorrhage
-Prenatal maternal infections

4. PATHOPHYSIOLOGY
•With hydrocephalus, CSF production is increased, flow is obstructed, or
reabsorption is altered
•As s result, intracranial pressure (ICP) increases causing brain displacement
or motor and mental damage.

5. Laboratory and Diagnostic Study Findings:
1. Level II ultrasonography of the fetus will allow a prenatal diagnosis.
(Transuterine placement of ventriculoamniotic shunts during late pregnancy
is still being developed as a treatment modality).
2. CT scan will diagnose most cases postnatally.
3. MRI can be used if a complex lesion is suspected.

6. DIAGNOSTIC EVALUATION
•Infant’s head transilluminates, indicative of abnormal fluid collection.
•Percussion of the infant’s skull may produce a typical ‘’cracked pot’’
sound(Macewen’s sign)
•Ophthalmoscopy may reveal papilledema
•CT scan is the diagnostic tool of choice.
•With ventriculography (rarely used), abnormalities are visualized in the ventricular
system or the subarachnoid space.
•Skull x-rays show widening of the fontanelle and sutures and erosion of intracanial
bone.

7. ASSESSMENT FINDINGS
Increased head circumference
Bulging fontanels
‘’Sunset eyes’’
Widened sutures
Forehead prominence
Thin, shiny, fragile-looking scalp skin
Irritability
Weakness
Seizures
Sluggish pupils with unequal response to light
High-pitched, shrill cry
Projectile vomiting
Feeding problems

10. TREATMENT
Hydrocephalus can be treated using a piece of surgical equipment
called a shunt. A shunt is a thin tube that is implanted in the brain. The
shunt drains away any excess fluid to another part of the body, usually
the abdomen.
Once the shunt has been installed, further treatment for hydrocephalus
is usually not required. Occasionally, the shunt can become blocked or
infected and shunt repair surgery will be required.

11. TREATMENT
•Skin care to prevent breakdown and infection
•Careful head support during handling
•Measurement of head circumference
•Emotional support and education for the parents
•Assessment of neurologic status and progression of symptoms
•Shunt insertion to eliminate excess CSF
•Management of shunt and prevention of infection at the
surgical site

12. Nursing Interventions
Maintaining Cerebral Perfusion
•Observe for evidence of IICP, and report immediately.
•Assist with diagnostic procedures to determine cause of hydrocephalus and
indication for surgical intervention.
-Explain the procedure to the child and parents at their levels of
comprehension
-Administer prescribed sedatives 30 minutes before the procedure to ensure
their effectiveness.
-organize activities so the child is permitted to rest after administration of the
sedative.
-Observe closely after ventriculography for the following:
(i) Leaking of CSF from the sites of subdural or ventricular taps.

13. These tap holes should be covered with a small piece of gauze or cotton
saturated with collodion.
(ii) Reactions to the sedative, especially respiratory depression
(iii)Changes vital signs indicative of shock
(iv)Signs of IICP, which may occur if air has been injected into the ventricles
Providing Adequate Nutrition
1.Be aware that feeding is often a problem because the child may be listless,
anoretic, and prone to vomiting.
2.Complete nursing care and treatment before feeding so the child will not
be disturbed after feeding.
3.Hold the infant in a semisitting position with head well supported during
feeding. Allow ample time for bubbling.
4.Offer small, frequently feedings.

14. 5. Place the child on side with head elevated after feeding to prevent
aspiration.
Maintaining Skin Integrity
1.Prevent pressure sores (pressure sores of the head are a frequent problem)
by placing the child on a sponge rubber or lamb’s wool pad or an alternating-
pressure or egg-crate mattress 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.

15. 3. Prepare the child for surgery by using dolls or other forms of play to
describe what interventions will occur.
Improving Cerebral Tissue Perfusion
Postoperatively
1.Monitor the child’s temperature ,pulse,respiration, blood pressure, and
pupillary size and reaction every 15 minutes until stable; then monitor every
1 to 2 hours.
2.Avoid hypothermia or hyperthemia.
-Provide appropriate blankets or covers, and Isolette or infant warmer, or
hypothermia blanket.
-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.

16. 4. Provide meticulous skin care to all parts of the body, and observe skin for
the effects of pressure.
5.Give passive range-of-motion 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.
Reducing Anxiety
1.Prepare the parents for their child’s surgery by answering questions,
describing what nursing care will take place postoperatively, and explaining
how the shunt will work.
2.Encourage the parents to discuss all the risks and benefits with the
surgeon. Help them to understand the prognosis and what to expect of the
child’s neurologic and cognitive development.

17. 4. Turn the child frequently
5. Promote optimal drainage of CSF through the shunt by pumping the shunt
and positioning the child as directed.
-If pumping is prescribed, carefully compress the valve the specified number
of times at regularly scheduled intervals.
-Report any difficulties in pumping the shunt
-Gradually elevate the head of the 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
-sunken fontanelle, agitation,restlessness(infant)
-Decreased level of consciousness(older child)

18. 7. Assess closely for IICP, indicating shunt malfunction.
-Note especially change in level of consciousness, change in vital signs
(increased systolic blood pressure,decreased pulse rate, decreased or
irregular respirations), vomiting, pupillary changes.
-Report these changes immediately to prevent cerebral hypoxia and possible
brain herniation.
8.Prevent excessive pressure of the 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 well
healed.

19. 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 a V-P shunt has been performed.
-Measure the drainage, and record the amount and color.
-Monitor for return 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
(NPO)

20. 5. Begin oral feedings once the child is fully recovered from the anesthetic
and displays interest.
-begin with small amount of 5 % dextrose water
-gradually introduce formula
-Introduce solid foods suitable to child’s age and tolerance
-encourage a high –protein diet
-Observe for and report any decrease in urine output, increased urine specific
gravity,diminished skin turgor, fryness of mucous membranes, or lethargy,
indicating dehydration.

21. Preventing Infection
1.Assess for fever(temperature normally fluctuates during the first 24 hours
after surgery), purulent drainage from the incisionm, or swellng, redness,
and tenderness along the shunt tract.
2.2. administer prescribed prophylactic antiobiotics.