Hydrocephalus is an excess accumulation of cerebrospinal fluid in the ventricular system resulting in the enlargement of the intracranial cavity. This occurs from an irregularity in the production and absorption of the fluid which causes an increase in intracranial pressure as the fluid builds up.
Hydrocephalus can be classified as communicating or noncommunicating. Communicating occurs when there is an impaired resorption of cerebrospinal fluid, usually at the level of the arachnoid villi. Noncommunicating hydrocephalus is caused by an obstruction within the ventricular system.
As the head enlarges to an abnormal size, the infant experiences changes in level of consciousness, irritability, shrill cry, lower extremity spasticity and opisthotonus and, if the hydrocephalus is allowed to progress, the infant experiences difficulty in sucking and feeding, emesis, seizures, sunset eyes, and cardiopulmonary complications as lower brainstem and cortical function are disrupted or destroyed. In the child, increased intracranial pressure (ICP) focal manifestations are experienced related to space occupying focal lesions and include headache, emesis, ataxia, irritability, lethargy, and confusion.
Nursing Care Plans
The nursing goals for a client with hydrocephalus may include improving cerebral tissue perfusion, reducing anxiety, preventing injury, and the absence of complications.
Here are five (5) nursing care plans (NCP) for hydrocephalus:
1. Ineffective Cerebral Tissue Perfusion
Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.
May be related to
- - Decreased venous or arterial blood flow
- - Increased intracranial pressure
Possibly evidenced by
- - Decreased pulse or respirations
- - High pitched cry
- - Irritability, Restlessness
- - Impaired brain blood flow
- - Lethargy
Desired Outcomes
- - Child/Infant will demonstrate improved brain function as evidenced by normal vital signs, improvement of alertness and cry, and no further deterioration in the level of consciousness.
| Nursing Interventions | Rationale |
|---|
| Assess vital signs hourly, noting for any irregularity in breathing and heart rate and rhythm and measure the pulse pressure. | Monitoring vital signs closely to recognize early signs of increased intracranial pressure (such as fluctuating blood pressure, tachycardia, and shallow breathing) or Cushing’s triad (bradycardia, apnea, and widening pulse pressure). |
| Assess neurological status (such as mental status, motor, and balance, reflexes (for newborns and infant), and cranial nerves. | These assessments will determine changes in child neurological conditions associated with ICP. |
| Examine the pupils by noting its size, shape, equality, and position of the pupils, and their response to light. | Pupil reaction which is controlled by the cranial nerve III (Oculomotor nerve) is beneficial for assessing brain stem function. |
| Note the quality and tone when children cry | A high pitched cry may indicate increased intracranial pressure. |
| Measure the client’s head circumference and appearance of anterior fontanelle. | Head circumference, if increasing, or a tense bulging fontanelle reveals CSF accumulation. |
| Provide a non-stimulating environment and adequate rest periods. | Continual activity and stimulation may increase intracranial pressure. |
| Elevate the head of the bed gradually about 15-45 degrees as indicated. Maintain the client’s head in neutral position. | This position will reduce arterial pressure by promoting venous drainage and enhance cerebral perfusion. |
| Provide oxygen therapy as needed. | Supplemental oxygen decreases hypoxemia levels which may improve cerebral vasodilation and blood volume. |
| Administer diuretics, carbonic hydrase, corticosteroids as ordered. | Acetazolamide (Diamox) and furosemide (Lasix) may control communicating hydrocephalus by reducing production of cerebrospinal fluid; Corticosteroids reduce inflammation. |
2. Anxiety
Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.
May be related to
- - Threat to or change in environment
- - Threat to or change in health status
Possibly evidenced by
- - Increased apprehension that condition of infant might worsen or condition may develop in child as a complication
- - Expressed concern and worry about preoperative preparation and the surgical procedure
- - Possible or actual physical, neurologic and mental deficits
Desired Outcomes
- - Child will experience decreased anxiety
| Nursing Interventions | Rationale |
|---|
| Assess source and level of anxiety and need for information and support about the condition and impending surgery. | Provides information about the severity of anxiety and need for interventions and support; allows for identification of fear and uncertainty about the condition and/or surgery and treatments and recovery; guilt about the condition, possible loss of infant/child or of parenteral responsibility. |
| Communicate therapeutically with parents and answer question calmly and honestly. | Promotes calm and supportive environment. |
| Allow expressions of concern and opportunity to ask questions about condition and recovery of ill infant/child. | Provides an opportunity to vent feelings, secure information needed to reduce anxiety. |
| Encourage parents to remain involved in care and decision-making regarding infant/child. | Promotes constant monitoring of infant/child for improvement or worsening of symptoms. |
| Encourage parents to stay with infant/child or visit when able if hospitalized, assist in care (hold, feed, diaper) and make suggestions for routines and methods of treatment. | Allows parents to care for and support child instead of becoming increasingly anxious because of absence from the child and wondering about infant/child’s condition. |
| Prepare child/parents for diagnostic tests and potential surgical procedures. | Promotes reduction in anxiety if they have knowledge of expectations. |
| When surgery is planned, answer all questions from parents and child with honesty; refer to physician for answers and explanations if needed. | Promotes supportive environment and reduce anxiety caused by fear of unknown. |
| Teach parents and child (age dependent) about the reason for and type of surgery to be done, site, and dressings, time of surgery, and length of time of the procedure, preoperative care, and treatments. | Provides information about surgery and desired effects as well as possible residual effects. |
| Explain the reason for and what to expect for each procedure or type of therapy; use drawings and pictures, videotapes for the child. | Reduces fear which causes anxiety. |
| Clarify any misinformation and answer all questions honestly and in simple understandable language. | Prevents unnecessary anxiety resulting from inaccurate information or beliefs. |
| Teach about shunt placement and reason; possible future revision of shunt placement, signs and symptoms of shunt complication or malfunction. | Shunt is placed to by-pass an obstruction or removes excess cerebrospinal fluid that predisposes to increased ICP; a shunt revision may be done to treat shunt complication such as infection or obstruction or as a result of child growth. |
3. Risk for Injury (Preoperative)
Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.
May be related to
- - Sensory, integrative and effector dysfunction preoperatively
Possibly evidenced by
- - Behavioral changes
- - CSF accumulation
- - Increased ICP
- - Neurosensory changes
- - Neuromuscular changes
- - Seizure activity
- - Vital signs changes
Desired Outcomes
- - Client will not experience injury by (date and time to evaluate).
| Nursing Interventions | Rationale |
|---|
| Perform neurologic and vital assessment every 4 hours or as needed. | Provides date indicating an increasing ICP causing decreased respirations, increased blood pressure and pulse. |
| Assess for a rapidly increased circumference of head, tense, bulging fontanels, widening suture lines, irritability, lethargy, “cracked pot” sound percussion, sunset sign, opisthotonus, spasticity of lower extremities, seizures, high-pitched cry, distended scalp veins, changes in normal feeding patterns. | Indicates increasing ICP in infant/small child. |
| Assess for early signs including headache, nausea, vomiting, diplopia, blurred vision, seizures, irritability, restlessness, decrease in school performance, decreased motor performance, sleep loss, weight loss, memory loss progressing to lethargy and drowsiness.Late signs: decreased level of consciousness, decreased motor response to commands, decreased response to pain, change in pupils, posturing, papilledema. | Indicates increasing ICP in children with symptoms related to cause of hydrocephalus. |
| Educate parents signs and symptoms of increased ICP and changes to reporting to the physician. | Promotes knowledge of the risk of developing increased ICP and encourages preventive measures. |
| Carry out seizure precautions including padding of crib/bed, remove toys and objects from the bed, maintain suction and oxygen at bedside, note and report characteristics of seizure, note and report characteristics of seizures. | Prevents injury to self during seizure activity caused by increased ICP and to treat apnea during seizure activity. |
| Position with head elevated 30 degrees and support head when handling or changing position; monitor skin integrity with position changes. | Promotes drainage of CSF and reduces accumulation of CSF; infant may not be able to lift and move the head. |
| Support an enlarged head by cradling it in an arm when holding, place the infant on a pillow when moving, move head and body of the infant at the same time. | Protect’s infant’s head from trauma and neck from the strain. |
| Inform parents that condition is lifelong and monitoring and follow-up care on a regular basis is required. | Provides realistic and honest information that promotes optimal health and function for the infant/child. |
4. Risk for Injury (Postoperative)
Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.
May be related to
- - Shunt placement
- - Potential complications of shunt functioning
Possibly evidenced by
- - Changing of position of tubing
- - Displacement with growth
- - Increased ICP
- - Kinking or plugging of shunt tubing
- - Obstruction of shunt
- - Separation of tubing
Desired Outcomes
- - Client will not experience any injury by (date and time to evaluate)
| Nursing Interventions | Rationale |
|---|
| Assess for signs and symptoms of increased ICP, swelling along shunt tract; note presence/severity of headache and neck pain; behavior changes (lethargy, irritability), physical changes (full fontanel, nausea, vomiting, edematous eyes, tender, swollen abdomen). | Provides data that indicates shunt malfunction. |
| Note vomiting, drowsiness, irritability, swelling at pump site, redness, exudate, and temperature of the child. | Indicates shunt blockage. |
| Instruct parent on hydrocephalus and shunt placement; teaching should include: Definition of hydrocephalus (brain anatomy), causes, diagnostic test, treatment, signs of shunt malfunction and infection, interventions and proper notifications of health professionals, and documentation; supplemental written materials are important; emphasize the importance of early identification of infection/malfunction and prompt notification. | Promotes understanding of illness/treatments which may decrease anxiety; knowledge of the prompt treatment of complications often lifesaving. |
| Teach parents about the need for bowel elimination at least every 2 days and steps to take to ensure bowel movement. | Prevents complications associated with a ventriculoperitoneal shunt. |
| Position carefully on nonoperative side postoperatively; maintain bed position and activity level as ordered depending on shunt dynamics. | Prevents trauma to the surgical site; maintain shunt patency. |
| Discuss and encourage parents to treat the child as a member of the family and instruct in activities to be avoided such as rough contact sports. | Promotes growth and development and feeling of belonging. |
| Inform parents of agencies for guidance and support such as National Hydrocephalus Foundation. | Provides assistance with management of a child with hydrocephalus. |
5. Risk for Infection
Risk for Infection: At increased risk for being invaded by pathogenic organisms.
May be related to
- - Invasive procedure of shunt insertion
Possibly evidenced by
- - Excessive drainage on dressing
- - Elevated temperature
- - Lethargy
- - Nausea
- - Vomiting
- - Poor feeding
- - Redness at shunt tract or operative site
- - Swelling
Desired Outcomes
- - Child/Infant will remain free of infection as evidenced by an absence of signs & symptoms of infection such as fever and laboratory studies related to infection within the normal limits.
| Nursing Interventions | Rationale |
|---|
| Assess site for inflammatory process, temperature elevation, increased WBC, characteristics of drainage on dressings. | Provides data indicating presence or potential for infection which affects shunt function. |
| Monitor temperature every four (4) hours. | Elevation of temperature indicates infection. |
| Teach about signs and symptoms of infection of site and shunt tract and to notify position if noted. | Promotes early detection of infection that may occur for up to 1 to 2 months after shunt insertion. |
| Follow principles of asepsis when performing procedures such as dressing changes. | Prevents transmission of microorganisms to shunt site. |
| Teach parents about wound care and dressing change, emphasize the importance of good handwashing techniques. | Provides clean, sterile dressings when soiled or wet. |
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