Hydrocephalus case

1. Introduction
Hydrocephalus is a condition in which excess cerebrospinal fluid (CSF) builds up within the fluid-containing cavities or ventricles of the brain. The term
hydrocephalus is derived from the Greek words "hydro" meaning water and "cephalus" meaning the head. Although it translates as "water on the brain," the word
actually refers to the buildup of cerebrospinal fluid, a clear organic liquid that surrounds the brain and spinal cord. CSF i s in constant circulation within the
ventricles of the brain and serves many crucial functions: 1) it acts as a "shock absorber" for the brain and spinal cord; 2) it acts as a vehicle for delivering nutrients
to the brain and removing waste from it; and 3) it flows between the cranium and spine to regulate changes in pressure.
Little is understood about the causes of hydrocephalus. Some cases of hydrocephalus are present at birth, while others develop in childhood or adulthood.
Hydrocephalus can be inherited genetically, may be associated with developmental disorders, like spina bifida or encephalocele, or occur as a result of brain
tumors, head injuries, hemorrhage or diseases such as meningitis.
The symptoms of hydrocephalus tend to vary greatly from person to person and across different age groups. Infants and young children are more susceptible to
symptoms from increased intracranial pressure like vomiting and adults can experience loss of function like walking or thinking.
Objectives
At the end of this case presentation, the participants will be able to acquire proper knowledge, skills and attitude in provi ding care and its nursing management to
the patient with Hydrocephalus.
Specific Objectives
Knowledge
1. Recognize the signs and symptoms of the patient’s condition.
2. Identify the causes and its clinical manifestations.

2. 3. Discuss the pathophysiology of the disease.
Skills
1. Formulate Nursing Care Plan in managing client signs and symptoms by critical skills
2. Identify appropriate nursing diagnosis according to the clinical manifestations.
3. Perform correct documentation regarding client’s condition and nursing intervention.
Attitude
1. Establish rapport with the client and members of the family.
2. Recognize client’s needs using a holistic approach.
3. Show outmost confidence in managing client’s bedside care.
Nursing Health History
A. Biographic Data:
 Patient’s Name: Baby Susie
 Age: Newborn
 Sex: Female
 Marital Status: Child
 Occupation: None

3. B. Chief Complaint:
 Born with a big head, in which the occipito frontal circumference is 49.5 (32-35cm normal range) and with an Apgar score
of 6 weight is 3.5kg. The score indicates a moderate respiratory distress due to asphyxia (Birth asphyxia happens when a
baby's brain and other organs do not get enough oxygen and nutrients before,during or right after birth.)
C. History of PresentIllness:
 She is irritable and lethargic at times. She cries when picked up or rocked by Mom and quiets when allowed to lie still.
 Upon examination, she had a widened anterior and posteriorfontanelle. Dilation of scalp veins and hypertonic lower
extremities and broadened face with frontal protrusion and eyes with a setting sun sign.
 On systemic examination of CNS, Susie was quite lethargic with poorsucking reflexand positive glabellar rooting grasp
both hands and plantar and Moro reflex. She has a hypertonic muscle tone.
 CT Scan reveal hydrocephalus
 The Doctor advised to repeat the CT Scan before discharge.The result shows restriction of brain cortical growth due to
fluid compressionthus the baby was surviving by her midbrain.
 Scheduled forVP shunt as ordered by the Doctor.
D. Past Health History
 N/A
E. Family MedicalHistory
 N/A

4. F. Lifestyle:
 Baby Susie has a poorsucking reflex, consumed 50 cc for every 2 hours only.
 The Baby was kept warm and with daily monitoring of the Respiration, Heart Rate and Temperature.
 The baby is irritable and cries when picked up by Mom
 The Mother washes her hands before and after carrying the baby.
 The baby has short interval of sleep.
 Milk formula feeding slowly through syringe.
Physical Examination
Systemic examination of the CNS:
 quite lethargic with poor sucking reflex
 positive glabellar rooting grasp both hands and plantar
 Positive moro reflex.
 Hypertonic muscle tone.
Examination of other systems:
 No abnormality detected.
Apgar score: 6 - indicates moderate respiratory distress due to birth asphyxia.
Occipito frontal Circumference = 49.5 cm (Normal - 32-35 cm)
Weight = 3.9 kgs

5. HEAD
-big head
-occipito-frontal circumference of 49.5 cm
-widen anterior and posterior fontanelle
-frontal protrusion
-separated sutures
SCALP - dilation of scalp veins
- thin and shiny scalp
FACE -broadened face
HAIR -sparse or thin hair
EYELIDS
-retracted upper lid
SCLERA -white sclera may be visible above the iris
IRIS
-more than half hidden beneath the lower lid
PUPILS
- close to the bottom of the eyelid
-setting sun sign
-sluggish
-unequal pupillary response to light
- Pupillary constriction of 5mm
EARS
-Color same as facial skin
-Symmetrical
-Auricle aligned with outer canthus of the eye from
vertical
-Mobile, firm, and not tender; pinna recoils after it is
folded
-CSF leakage through the ears noted

6. NOSE
-the external nose is symmetrical and straight
-color is the same with the entire face
-with pinkish nasal mucosa
- with patent both left and right nares
-cilia present in internal nares
-CSF leakage through the nose noted
MOUTH
- poor sucking reflex
- Soft, moist, smooth texture lips
-Pink, moist, firm texture of gums
NECK
- Trachea in midline
-free from lumps and no tenderness
LUNGS/CHEST
- Chest wall intact; no tenderness; no masses
-moderate respiratory distress due to birth asphyxia
-shortness of breath or difficulty breathing
UPPER EXTREMITIES
- positive glabellar rooting grasp of hands
LOWER EXTREMITIES
- hypertonic lower extremities
-positive glabellar rooting grasp of plantar
NAILS
-smooth and regular nail surface, not brittle or splitting
SKIN -Bluish skin

7. CRANIAL NERVES
I. Olfactory -smell
- newborn preference for the smell of their
own mother, especially to her breast milk
II. Optic -able to see things in both eyes
III. Oculomotor -pupils equally round
- unequal pupillary response to light
IV. Trochlear -both eyes able to move but has difficulty
in looking upward
V. Trigeminal -able to elicit corneal reflex
-sensitive to pain stimuli
VI. Abducens -eyes cannot be moved in coordination
-difficulty of looking up
VII. Facial -perform various facial expressions
VIII. Vestibulocochlear -able to hear ticking in both ears
IX. Glossopharyngeal -able to elicit gag reflex and swallow
without difficulty
X. Vagus -able to swallow
XI. Accessory -able shrug shoulder difficulty in moving
the head
XII. Hypoglossal -able to move tongue in different direction
Anatomy and Physiology
THE BRAIN
The brain and spinal cord form the central nervous system. These vital structures are surrounded and protected by the bones of the skull and the vertebral column.The bones of the skull are
often referred to as the cranium. In infants, the skull is actually composed of separate bones, and an infant’s soft spot (anterior fontanel) is an area where four skull bones nearly come
together. The places where the bones meet and grow are called sutures.

8. The vertebral column, which encases the entire spinal cord, is composed of bones called vertebrae. The spinal cord extends from the brain stem, through a very large opening (the
foramen magnum) in the base of the skull, and down the spine.
At the level of each vertebra in the spine, nerve fibers arise from the spinal cord and emerge through openings between the vertebrae. These are the spinal nerves, which carry messages to
and from various regions of our bodies.
The brain consists offour main structures: the Cerebrum, the Cerebellum, the Pons, and the Medulla.
The Cerebrum is the upper part of the brain and is arranged in two hemispheres called cerebral hemispheres. The cerebrum is thought to control conscious mental processes. The outer
layer of the cerebrum is called gray matter, the inner portion, white matter.
The cerebral hemispheres are divided into four sections or lobes: the frontal lobe, responsible for thinking, making judgments, planning,
decision-making and conscious emotions, the Parietal Lobe, mainly associated with spatial computation, body orientation and attention, the
Temporal Lobe, concerned with hearing, language and memory, and the Occipital Lobe, mainly dedicated to visual processing.
The Cerebellum is the part of the brain located between the brain stem and the back of the cerebrum. The cerebellum controls muscle
coordination and maintains bodily equilibrium.
The Pons is in front of the cerebellum and coordinates the activities of the cerebrum and the cerebellum by receiving and sending impulses
from them to the spinal cord.
The Medulla is part of the brainstem situated between the pons and the spinal cord and it controls breathing, heartbeat, and vomiting.
There are many other anatomical features of the brain which specialize in various activities. The Meninges consist of three membranes
which cover the brain and spinal cord including the dura mater, the arachnoid membrane and the pia mater. They completely surround
the brain and spinal cord.
Cerebrospinal fluid flows in the space between two of the layers in a space called the subarachnoid space. CSF is essentially salt water,
and it is in constant circulation and serves several important functions. The brain floats in CSF.
Anatomy Relevant to Hydrocephalus
Our brain is well protected by:
 The scalp
 The skull

9.  The meninges
Layers includes:
- dura mater (“tough or hard mother” since it is the strongest layer, the spaces within the fold of dura mater is called dural venous sinuses, which collect blood from
the small veins of the brain. The dura mater is surrounded by an epidural space between the dura mater and the periostum of the vertebrae.)
- 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 (very tightly bound to the surface of the brain and spinal cord, the spaces between the arachnoid mater and pia mater is the subarachnoid space, which is
filled with cerebrospinal fluid and containing blood vessels.)
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 diancephalon between two halves of the thalamus and connected to the foramina to the lateral
ventricles.
- Fourth ventricle – is located at the base of the cerebellum and is connected to the third ventricle by a narrow 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 a protective 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 subarrachnoid 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.

10. FLOW DIAGRAM OF CSF
CSF is produced by the choroid plexus of each ventricle

11. CSF flows through the ventricles and into the subarachnoid space via the median and
lateral apertures. Some CSF flows through the central canal of the spinal cord
Choroid plexus in the third ventricle adds more CSF
CSF flows down to cerebral aqueduct to fourth ventricle
Choroid plexus in the fourth ventricle adds more CSF
CSF flows out two lateral apertures and one median aperture
CSF fills subarachnoid space and bathes external surfaces of brain and spinal
cord
At subarachnoid villi, CSF resorbed into venous blood of dural sinuses

12. HYDROCEPHALUS
CONGENITAL
 Myelomeningocele
 Intrauterine infections (CMX,
Toxoplasmosis)
 Aqueduct stenosis chiari malformation
ACQUIRED
 Intraventicular
 Haemorrhage
 Tumor
 CSF infection
 Intracranial infection
Communicating
(Non- obstructive)
Non-Communicating
(Obstructive)
Communicating without obstruction of CSF
production
Communicating with obstruction of CSF
production
Normal pressure hydrocephalus overproduction
of CSF
Subarachnoid hemorrhage (SAH)
Meningitis (bacterial & aseptic)
Leptomeningeal carcinomatosis
SHUNT
Obstructed flow within ventricular system
Increased accumulation of CSF
Dilatation of ventricles and cortex atrophy
Increased CSF in ventricular system
Compressed brain against cranium
SHUNT ET± CPC
PATHOPHYSIOLOGY OF HYDROCEPHALUS

13. Diagnostic and Laboratory
DIAGNOSTIC AND LABORATORY
CT SCAN: HYDROCEPHALUS
-Size of both temporal horns is greater than 2 mm, clearly visible. In the absence of hydrocephalus, the temporal horns should be barely visible.
-Ratio of the largest width of the frontal horns to maximal biparietal diameter (ie, Evans ratio) is greater than 30% in hydrocephalus.
-Transependymal exudate is translated on images as periventricular hypoattenuation (CT)
-Ballooning of frontal horns of lateral ventricles and third ventricle (ie, "Mickey mouse" ventricles) may indicate aqueductal obstruction
Rationale: Computerized tomography (CT) scan is a specialized X-ray technology that can produce cross-sectional views of the brain.
CT scans are done to see the internal structures of various parts of the body. The common areas where the CAT scan is done is the head to look for bleeds,
stroke, infections, and accumulation of fluid (hydrocephalus), subdural collections, and abscesses
Drug Study
PRESCRIBED DRUG,
DOSAGE, ROUTE,
FREQUENCY, TIMING
CLASSIFICATION AND
MECHANISMOF ACTION
INDICATION AND
CONTRAINDICATION
SIDE EFFECT OR
ADVERSE REACTION
SPECIAL PRECAUTION
NURSING
RESPONSIBILITY
Drug:
Gentamycin
Classification:
Antibiotic
Indication:
To treat serious
bacterial infections
CNS: Acute organic
mental syndrome,
confusion,depression,
fever,headache,
Be aware that
premature infants,
neonates,
and elderlypatients
have an increasedrisk
-ForI.V.use,dilute each
dose with50 to
200 ml normal saline
solutionorD5W to

14. Dosage:
20mgs
Route:
IV ANST
Frequency:
OD (8:00)
Mechanismof Action:
Bindsto negatively
chargedsitesonthe
outercell membrane of
bacteria,thereby
disruptingthe
membrane’sintegrity.
Gentamicinalsobindsto
bacterial ribosomal
subunitsandinhibits
proteinsynthesis.Both
actionsleadto cell
death.
causedby aerobicgram-
negative organismsand
some gram-positive
organisms,including
Citrobacterspecies,
Enterobacterspecies,
Escherichiacoli,
Klebsiellaspecies,
Proteusspecies,
Pseudomonas
aeruginosa,Serratia
species,
Staphylococcusaureus,
and many
strainsof Streptococcus
species
Contraindication:
Hypersensitivityor
serioustoxicreactionto
otheraminoglycosides,
hypersensitivityto
gentamicinorits
components
increasedproteinin
cerebrospinal fluid,
lethargy,myasthenia
gravis–like syndrome,
neurotoxicity(dizziness,
hearingloss,
tinnitus,vertigo),
peripheral neuropathy
or encephalopathy
(muscle twitching,
numbness,seizures,skin
tingling),pseudotumor
cerebri
CV: Hypertension,
hypotension,
palpitations
EENT: Blurredvision,
increasedsalivation,
laryngeal edema,
ototoxicity,stomatitis,
visionchanges
of nephrotoxicity.
Usinggentamicin
injectiontogetherwith
numbingmedicinesmay
increase yourriskof
havingdifficultyin
breathing,drowsiness,
inabilitytobreathe
withoutassistance,or
unusual tirednessor
weakness.
Do not take other
medicinesunlessthey
have beendiscussed
withyourdoctor. This
includesprescriptionor
nonprescription(over-
the-counter[OTC])
medicinesandherbal or
vitaminsupplements.
yieldnomore than1
mg/ml.Administer
slowlyover30 to 60
minutes.
-Don’tgive gentamicin
throughsame I.V.
line asotherdrugs
withoutfirstconsulting
pharmacist.
-Don’tgive gentamicin
by subcutaneous
route because itmay be
painful.
-Whenassistingwith
intrathecal injection,
use only2 mg/ml of
preservative-free
preparation.Drugmay
be injecteddirectly
or deliveredby
implantedreservoir.

15. GI: Anorexia,nausea,
splenomegaly,
transienthepatomegaly,
vomiting
GU:Nephrotoxicity
HEME: Anemia,
eosinophilia,
granulocytopenia,
increasedordecreased
reticulocyte count,
leukopenia,
thrombocytopenia
MS: Arthralgia,leg
cramps
RESP: Pulmonary
fibrosis,respiratory
Depression
-Avoidlong-term
therapiesbecause of
increasedriskof
toxicities.Reductionin
dose may be clinically
indicated.
-Monitorhearingwith
long-termtherapy;
ototoxicitycanoccur.
-Assesspatientfor
evidence of other
infectionsbecause
gentamicinmaycause
overgrowthof
nonsusceptible
organisms.

16. SKIN: Alopecia,
generalizedburning
sensation,pruritus,
purpura,rash, urticaria
Other: Anaphylaxis,
injection-site pain,super
infection,weightloss
PRESCRIBED DRUG,
DOSAGE, ROUTE,
FREQUENCY, TIMING
CLASSIFICATION AND
MECHANISMOF
ACTION
INDICATION AND
CONTRAINDICATION
SIDE EFFECT OR
ADVERSE REACTION
SPECIAL PRECAUTION
NURSING
RESPONSIBILITY

17. Drug name:
Cloxacillin
Dosage:
195 mgs
Route:
IV ANST
Frequency:
BID for 7 days (8:00
and 4:00)
Classification:
Anti-infective,antibiotic
Mechanismof Action:
Inhibitscell wall
synthesisandcauses
cell lysisanddeathin
bacteriathat make
rigid,cross-linkedcell
wallsinseveral steps.
Cloxacillinaffectsthe
final stage of
crosslinking
by bindingwithand
inactivating
penicillin-binding
protein,the enzyme
that causeslinkage in
cell wall strands.
Indication:
Treatmentof infections
causedby
pneumococci,groupA
beta-hemolytic
streptococci,and
penicillinGsensitive
staphylococci.
Contraindication:
Historyof
hypersensitivityto
penicillinand
cephalosporin.Severe
pneumonia,
emphysema,
bacteremia,pericarditis,
meningitisandpurulent
and septicarthritis
duringthe acute stage.
CNS:Headache
EENT: Glossitis,oral
candidiasis
GI: Abdominal pain,
diarrhea,elevated
liverfunctiontest
results,nausea,
pseudomembranous
colitis,vomiting
GU: Hematuria,vaginal
candidiasis
MS: Muscle twitching
SKIN:Pruritis,rash,
urticaria
Before takingcloxacillin,tell
your doctoror pharmacistif
youare allergictoit: if you
are allergictoit;or to other
antibioticsincluding
penicillin-type medications
(e.g.,amoxicillin,ampicillin,
penicillin) or
cephalosporins(e.g.,
cephalexin,cefuroxime);or
if you have anyother
allergies.Thisproductmay
containinactive
ingredients,whichcan
cause allergicreactionsor
otherproblems.
Tell yourdoctor or
pharmacistyourmedical
history,especiallyof kidney
problems.
Cloxacillinmaycause live
bacterial vaccines (suchas
typhoidvaccine) tonot
workas well.Donot have
any
-Performskintesting
before givingthe
medication
-Administerdrugslowly
to the IV line
-Checkbaselineweight
and vital signs;
determine vestibular
and auditoryfunction
before therapyandat
regularintervals
-Make sure thatthe
drug istakenat the
same time of the day
and to preventthemto
beingdrugresistance.
-Assessforanysignsof
hypersensitivity

18. Subconjunctival
infections.
Other:Anaphylaxis
immunizations/vaccinations
while usingthismedication
unlessyourdoctortellsyou
to.
Kidneyfunctionisnotfully
developedinnewborns.
Thismedicationisremoved
by the kidneys.Therefore
newbornsmaybe more
sensitivetothisdrug.
reactionsuchas
purpura,rash, urticaria,
-Explainthatantibiotic
therapylastsfor7 days
and will take the drug
withoutanymiss.

19. PRESCRIBED DRUG,
DOSAGE, ROUTE,
FREQUENCY, TIMING
CLASSIFICATION AND
MECHANISMOF
ACTION
INDICATION AND
CONTRAINDICATION
SIDE EFFECT OR ADVERSE
REACTION
SPECIAL PRECAUTION
NURSING
RESPONSIBILITY
Drug:
D5IMB 500 ml
(Balanced multiple
maintenance
solution with 5%
dextrose)
Dosage:
40 cc/hour
Classification:
Hypertonicsolution
Mechanismof Action:
Containa high
concentrationof solute
relative toanother
solution(e.g.the cell’s
cytoplasm).Whenacell
isplacedina hypertonic
solution,the water
diffusesoutthe cell,
causingthe cell to
shrivel.
Indication:
-Slowadministration
essential toprevent
overload(100 ml/hr)
-Waterintoxication
-Severe sodiumdepletion
Contraindication:
Phlebitis,peripheral edema,
cellulardehydration
- Swelling(edema)
- Bloodclotin a vein
- Abnormal rapid
breathing
- Severe dehydrationin
diabetes
- Excessfluidinthe blood
- Inflammationof avein
- diarrhea
Shouldnotbe given
to newbornbabies
whose bodyweightis
low.
Excessive orrapid
administrationof
dextrose injection
may resultin
increasedserum
osmolalityand
possible intracerebral
hemorrhage.
- ObtainIV solution
and checkfor the
sedimentsandany
crack andleakfrom
the container.
-Maintainaseptic
technique
throughoutthe
procedure
-Ensure thatthe IV
was properlyfixed.
-Regulate IVFas
ordered.

20. -Chartthe procedure
includingtime,
name,dosage,and
the patient’s
response tothe
administration

21. Nursing Care Plan

27. Discharge Plan/ Health Teaching
Baby Susie was discharged in an improved condition after VP Shunt cuddled by mother. Going home instructions given.
Health Teachings:
1. Instruct the mother to keep the affected site clean and dry.
2. Advise the mother not to shower or shampoo Baby Susie’s head until the stitches and staples have been taken out.
Perform a sponge bath instead.
3. Elevate the baby’s head and give milk formula slowly to prevent aspiration.
4. Instruct the mother to report any signs and symptoms of increased intracranial pressure such as drowsiness, vomiting, headache, irritability, and anorexia.
5. Observe daily for any sign of swelling or redness on the VP shunt site.
6. Inform the mother to slightly elevate patient’s head at night to help ensure fluid flow through the tube.
7. Advise the mother to observe any signs of infection such as an increased temperature. Report to attending physician as soon as possible.
8. Have a regular follow up check-up for assessment of VP shunt.