5 Hydrocephalus Nursing Care Plans

Hydrocephalus Nursing Care Plans|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.

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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.Hydrocephalus Nursing Care Plans.

Types

There are a number of types of hydrocephalus:

Congenital hydrocephalus

Approximately 1 in every 500 American babies is born with hydrocephalus. It may be caused by an infection in the mother during pregnancy, such as rubella or mumps, or a birth defect, such as spinal bifida. It is one of the most common developmental disabilities, more common than Down syndrome or deafness.

Acquired hydrocephalus

This develops after birth, usually after a stroke, brain tumor, meningitis, or as a result of a serious head injury.

Communicating hydrocephalus

This type of hydrocephalus occurs when the CSF becomes blocked after leaving the ventricles. It is called “communicating” because CSF can still flow between the brain’s ventricles.

Non-communicating hydrocephalus

Also called obstructive hydrocephalus, non-communicating hydrocephalus occurs when the thin connections between the ventricles become blocked.

Normal pressure hydrocephalus

This only affects people aged 50 or older. It may develop after stroke, injury, infection, surgery, or hemorrhage. However, in many cases, doctors do not know why it occurred. An estimated 375,000 older adults in America have normal pressure hydrocephalus.

Hydrocephalus ex-vacuo

This type occurs after stroke, traumatic brain injury, or degenerative diseases. As brain tissue shrinks, the ventricles of the brain become larger.

Symptoms

Symptoms of congenital hydrocephalus (present at birth):

Breathing difficulties

Arm and leg muscles may be stiff and prone to contractions

Some developmental stages may be delayed, such as sitting up or crawling

The fontanel, the soft spot on the top of the head, is tense and bulges outward

Irritability, drowsiness, or both

Unwillingness to bend or move the neck or head

Poor feeding

The head seems larger than it should be

The scalp is thin and shiny and there may be visible veins on the scalp

Pupils of the eyes may be close to the bottom of the eyelid, sometimes known as “the setting sun”

There may be a high-pitched cry

Possible seizures

Possible vomiting

Symptoms of acquired hydrocephalus, which develops after birth, are:

Rarely, bowel incontinence

Confusion, disorientation, or both

Drowsiness and lethargy

Headaches

Irritability, which may get worse

Lack of appetite

Nausea

Personality changes

Problems with eyesight, such as blurred or double vision

Seizures or fits

Urinary incontinence

Vomiting

Walking difficulties, especially in adults

Symptoms of normal pressure hydrocephalus. Signs and symptoms may take many months or years to develop.

Changes in gait: The person may feel as if they are frozen on the spot when taking their first step to start walking. They may appear to shuffle rather than walk.

Normal thinking process slows down: The person may respond to questions more slowly than normal, there may be delayed reactions to situations. The individual’s ability to process information slows down. Urinary incontinence: This usually comes after changes in gait.

Risk factors

The following factors increase the risk of hydrocephalus:

Premature birth: Infants born preterm have a higher risk of intraventricular hemorrhage, or bleeding within the ventricles of the brain, which may result in hydrocephalus

Problems during pregnancy: An infection in the uterus during pregnancy increases the risk of hydrocephalus in the developing fetus

Problems with fetal development: Examples include incomplete closure of the spinal column.

Other conditions that increase the risk include:

Lesion and tumors of the spinal cord or brain

Infections of the nervous system

Bleeding in the brain

Severe head injury

Causes

Hydrocephalus occurs when too much fluid builds up in the brain; specifically, excess CSF (cerebrospinal fluid) accumulates in the cavities (ventricles) of the brain.

There are more than 100 possible causes of hydrocephalus, but the underlying reasons are:

Too much CSF is produced.

One of the ventricles in the brain is blocked or narrowed, stopping or restricting the flow of CSF, so that it cannot leave the brain.

CSF cannot filter into the bloodstream.

Causes of congenital hydrocephalus (present at birth)

The baby is born with a blockage in the cerebral aqueduct, a long passage in the midbrain that connects two large ventricles. This is the most common cause.

The choroid plexus produces too much CSF.

Health conditions in the developing baby can cause problems in how the brain develops. For instance, hydrocephalus is common in children with severe spine bifida (a birth defect of the spinal cord).

Infections during pregnancy – these can affect the development of the baby’s brain. Examples include:

CMV (cytomegalovirus)

German measles (rubella)

Mumps

Syphilis

Toxoplasmosis

Causes of acquired hydrocephalus

This condition develops after birth and is usually caused by an injury or illness that results in blockage between the ventricles. The following may be causes:

Brain hemorrhage – bleeding inside the brain.

Brain lesions – areas of injury or disease within the brain. There are many possible causes, including injury, infection, exposure to certain chemicals, or problems with the immune system.Brain tumors – benign (noncancerous) or malignant (cancerous) growths in the brain.

Meningitis – inflammation of the membranes of the brain or spinal cord.

Stroke – a condition where a blood clot or ruptured artery or blood vessel interrupts blood flow to an area of the brain.

Causes of normal pressure hydrocephalus

This condition affects people aged at least 50 – in most cases, doctors don’t know what caused it. Sometimes, it may develop after a stroke, infection, or injury to the brain.

There are two theories:

CSF is not reabsorbed into the bloodstream properly. Because of this, the brain starts to produce less new CSF, resulting in a gradual rise in pressure over a long period. The gradual rise in pressure may cause progressive brain damage.

An underlying condition, such as heart disease, high blood cholesterol level, or diabetes affects normal blood flow, which may lead to a softening of brain tissue. The softened brain tissue results in increasing pressure.

Diagnosis

Regularly measuring a baby’s head may help to diagnose hydrocephalus.

Babies and young children (congenital hydrocephalus):

A routine prenatal ultrasound scan may detect hydrocephalus during pregnancy in the developing fetus.

After birth, the head of the baby is measured regularly. Any abnormalities in head size will probably lead to further diagnostic tests.

If an ultrasound scan shows any abnormality, further tests will be ordered, such as an MRI (magnetic resonance imaging) scan or a CT (computerized tomography) scan, which give more detailed images of the brain.

Acquired hydrocephalus (occurs after birth) – if the child or adult develops the signs and symptoms of hydrocephalus the doctor will:

Examine the patient’s medical history.

Carry out a physical and neurological examination.

Order an imaging scan, such as a CT or MRI scan.

Normal pressure hydrocephalus – diagnosing this type of hydrocephalus is more tricky because symptoms are more subtle and do not appear suddenly.

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Treatments

In this section, we will discuss treatments for congenital and acquired hydrocephalus and treatments for normal pressure hydrocephalus individually.

Treatments for congenital and acquired hydrocephalus

Both types of hydrocephalus require urgent treatment to reduce the pressure on the brain; otherwise, there is a serious risk of damage to the brainstem, which regulates functions such as our breathing and heartbeat.

A shunt is the surgical insertion of a drainage system. A catheter (a thin tube with a valve) is placed in the brain to drain away excess fluid from the brain into another part of the body, such as the abdomen, the chest cavity, or a chamber of the heart. Usually, this is all that is needed, and no further treatment is required.

Patients with hydrocephalus will usually need to have a shunt system in place for the rest of their lives. If the shunt is placed in a child, additional surgeries may be needed to insert longer tubing as they grow.

Ventriculostomy – the surgeon makes a hole in the bottom of a ventricle so that the excess fluid flows towards the base of the brain. Normal absorption occurs at the base of the brain. This procedure is sometimes performed when the flow of fluids between ventricles is obstructed.

Treatment for normal pressure hydrocephalus

Shunts may also be used for normal pressure hydrocephalus. However, shunts may not be suitable for some patients. Other procedures may be carried out to check suitability:

Lumbar puncture – some of the cerebrospinal fluid is removed from the base of the spine. If this improves the patient’s gait or mental abilities, fitting a shunt will probably help.

Lumbar infusion test – a needle is inserted through the skin of the lower back into the spine. Measurements are taken of CSF pressure as fluid is injected into the spine. Patients usually benefit from having a shunt fitted if their CSF pressure is over a certain limit.

Complications

Hydrocephalus severity depends on several factors, including when it develops and how it progresses. If the condition is advanced when the baby is born, it is more likely there will be brain damage and physical disabilities. If cases are not so severe and treatment is proper and prompt, the outlook is much better.

Babies with congenital hydrocephalus may experience some permanent brain damage, which can result in long-term complications. Examples include:

A limited attention span

Autism

Learning difficulties

Physical coordination problems

Problems with memory

Speech problems

Vision problems

Prevention

Ensuring that all vaccinations have been performed, in particular, the meningitis vaccination, may help reduce the risk of hydrocephalus.

Pregnancy – regular prenatal care can significantly reduce the risk of having a premature baby, which reduces the risk of the baby developing hydrocephalus.

Infectious diseases – make sure you have had all your vaccinations and attended all the screenings that are recommended for you.

Meningitis vaccine – meningitis used to be a common cause of hydrocephalus. Vaccination is recommended for some individuals, check with a doctor.

Preventing head injuries

Wear a seatbelt every time you drive your car or ride as a passenger.

Make sure children are buckled up.

Never drive when you are under the influence of alcohol.

Helmets or specific protective headgear should always be worn when:

Batting in baseball/softball or cricket

Engaged in contact sports.

Riding on a horse, motorbike, bicycle, snowmobile, scooter, or all-terrain vehicle (both riders and passengers).

Snowboarding, skiing, skating, or skateboarding.

Living areas for older adults:

Grab bars should be installed next to the bathtub, shower, and/or toilet.

Seniors should keep physically active to make sure lower body strength and balance is adequate (lowering the risk of falls).

Make sure lighting in the house is bright enough.

Use nonslip mats on bathtub and shower floors.

Remove throw rugs and other objects that could cause tripping.

Stairways should ideally have handrails on both sides.

Living areas for children:

Install window guards.

Place safety gates at the bottom and top of stairs if the children are young.

Children’s play areas:

The ground surface of a child’s playground should be made of hardwood mulch, sand, or some other shock-absorbing material.

Firearms:

Firearms should be stored unloaded in a locked safe or cabinet. Bullets should not be stored in the same location.

Hydrocephalus Nursing Care Plans 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) and nursing diagnosis (NDx) for hydrocephalus:

  1. Ineffective Cerebral Tissue Perfusion
  2. Anxiety
  3. Risk for Injury (Preoperative)
  4. Risk for Injury (Postoperative)
  5. Risk for Infection

Ineffective Cerebral Tissue Perfusion

Nursing Diagnosis

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.Hydrocephalus Nursing Care Plans.
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.

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