Transcript
Page 1: Hydrocephalus Updates

HYDROCEPHALUSHYDROCEPHALUS

BY:BY:

MURNIWATI BINTI ZAKARIAMURNIWATI BINTI ZAKARIA

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LEARNING OUTCOMESLEARNING OUTCOMES

AT THE END OF THIS TOPIC , THEAT THE END OF THIS TOPIC , THE

STUDENT WILL BE ABLE TO :STUDENT WILL BE ABLE TO :

1.Define what is hydrocephalus1.Define what is hydrocephalus

2. Explain cause and risk factors for 2. Explain cause and risk factors for hydrocephalus.hydrocephalus.

3. Explain the pathophysiology for hydrocephalus.3. Explain the pathophysiology for hydrocephalus.

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4.State symptoms for hydrocephalus.4.State symptoms for hydrocephalus.

5.Explain classification for hydrocephalus.5.Explain classification for hydrocephalus.

6.Explain laboratory and diagnostic test for 6.Explain laboratory and diagnostic test for hydrocephalus.hydrocephalus.

7.Explain treatment for hydrocephalus.7.Explain treatment for hydrocephalus.

8. Explain nursing management for patient with 8. Explain nursing management for patient with hydrocephalus.hydrocephalus.

9.Explain nursing care plan for patient with 9.Explain nursing care plan for patient with hydrocephalus.hydrocephalus.

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DEFINITIONDEFINITION

Condition caused by an imbalance in the Condition caused by an imbalance in the production and absorption of CSF in the production and absorption of CSF in the ventricular system.ventricular system.

When production exceeds When production exceeds absorption ,CSF accumulates ,usually absorption ,CSF accumulates ,usually under pressure ,producing dilation of the under pressure ,producing dilation of the ventricles.ventricles.

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Greek words “hydro” meaning water , and Greek words “hydro” meaning water , and “cephalus” meaning head .“cephalus” meaning head .

Sometime known as “water in the brain”Sometime known as “water in the brain”

People with hydrocephalus :People with hydrocephalus : - abnormal accumulation of CSF in the ventricles - abnormal accumulation of CSF in the ventricles

,or cavities ,of the brain.,or cavities ,of the brain. - this condition may increased intracranial - this condition may increased intracranial

pressure inside the skull and progressive pressure inside the skull and progressive enlargement of the head.,convulsion ,and mental enlargement of the head.,convulsion ,and mental disability. disability.

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hydrocephalus does not cause any hydrocephalus does not cause any intellectual disability if treated properly.intellectual disability if treated properly.

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CAUSE AND RISK FACTORSCAUSE AND RISK FACTORS

is usually the result of a brain infection or a malformation is usually the result of a brain infection or a malformation in the fetus prior to birth. in the fetus prior to birth.

Although the baby's head may not appear abnormally Although the baby's head may not appear abnormally large at birth, it expands rapidly from month to month.large at birth, it expands rapidly from month to month.

If untreated, the baby usually dies by the end of the If untreated, the baby usually dies by the end of the second year. second year.

If the blockage of CSF is only partial, the child may live If the blockage of CSF is only partial, the child may live for a number of years or may even live a normal life for a number of years or may even live a normal life span.span.

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ETIOLOGYETIOLOGY

Congenital hydrocephalus result from defects, Congenital hydrocephalus result from defects, such as Chairi malformations.such as Chairi malformations.

( abnormality of the lower part in the brain ( abnormality of the lower part in the brain ( cerebellum ).( cerebellum ).

Also associated with spina bifida.Also associated with spina bifida.

Acquired hydrocephalus results from space-Acquired hydrocephalus results from space-occupying lesions, hemorrhage, intracranial occupying lesions, hemorrhage, intracranial infections or dormant development defects.infections or dormant development defects.

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Hydrocephalus can be caused by impaired Hydrocephalus can be caused by impaired cerebrospinal fluid ( CSF ) flow, re- cerebrospinal fluid ( CSF ) flow, re- absorption ,or excessive CSF production.absorption ,or excessive CSF production.

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Common cause :Common cause : - CSF flow obstruction- CSF flow obstruction

- hindering the free passage of the CSF through the hindering the free passage of the CSF through the ventricular system and sub-arachnoids space.ventricular system and sub-arachnoids space.

( eg. stenosis of the cerebral aqueduct or ( eg. stenosis of the cerebral aqueduct or obstruction of the intervetricular foramina –obstruction of the intervetricular foramina –foramina of Monroforamina of Monro

((the small opening (on both the right and left the small opening (on both the right and left sides) that connects the third ventricle in the sides) that connects the third ventricle in the diencephalons with the lateral ventricle in the diencephalons with the lateral ventricle in the cerebral hemisphere )cerebral hemisphere )

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secondary to secondary to tumors ,hemorrhage ,infections or tumors ,hemorrhage ,infections or congenital malformations.congenital malformations.

Also cause by overproduction of CSF Also cause by overproduction of CSF

( relative obstruction ) eg. *papilloma of ( relative obstruction ) eg. *papilloma of choriod plexus.choriod plexus.

(*(*A benign epithelial tumor forming a A benign epithelial tumor forming a rounded mass)rounded mass)

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SYMPTOMSSYMPTOMS

Characteristic features of Characteristic features of hydrocephalushydrocephalus in in children include :children include :

cephalomegalycephalomegaly a thin, transparent scalpa thin, transparent scalp

a bulging forehead with prominent fontanella bulging forehead with prominent fontanell a downward gaze. a downward gaze.

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Other clinical findings include:Other clinical findings include: convulsionsconvulsions

abnormal reflexesabnormal reflexes a slowed heartbeat and respiratory ratea slowed heartbeat and respiratory rate

headacheheadache VomitingVomiting IrritabilityIrritability

WeaknessWeakness problems with vision. problems with vision.

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Blindness and continuing mental Blindness and continuing mental deterioration from brain atrophy can result deterioration from brain atrophy can result if treatment is not instituted. if treatment is not instituted.

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CLASSIFICATIONCLASSIFICATION

A) COMMUNICATINGA) COMMUNICATING

B) NON- COMMUNICATINGB) NON- COMMUNICATING

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A.COMMUNICATING HYDROCEPHALUSA.COMMUNICATING HYDROCEPHALUS::

Also known as non-obstructive Also known as non-obstructive hydrocephalushydrocephalus

ItIt is caused by impaired cerebrospinal is caused by impaired cerebrospinal fluid reabsorption in the absence of any fluid reabsorption in the absence of any CSF-flow obstruction. CSF-flow obstruction.

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It has been theorized that this is due to It has been theorized that this is due to functional impairment of the arachnoids' functional impairment of the arachnoids' granulations, which are located along the granulations, which are located along the superior sagittal sinus and is the site of superior sagittal sinus and is the site of cerebrospinal fluid reabsorption back into cerebrospinal fluid reabsorption back into the venous system. the venous system.

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Various neurologic conditions may result Various neurologic conditions may result in communicating hydrocephalus, in communicating hydrocephalus, including :including :

subarachnoid/intraventricular hemorrhage,subarachnoid/intraventricular hemorrhage, meningitis, meningitis,

Chiari malformationChiari malformation congenital absence of arachnoidal congenital absence of arachnoidal

granulations (Pacchioni’s granulationsgranulations (Pacchioni’s granulations). ).

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Normal pressure hydrocephalus (NPH) :Normal pressure hydrocephalus (NPH) :

- characterized by enlarged cerebral ventricles, with - characterized by enlarged cerebral ventricles, with only intermittently elevated cerebrospinal fluid only intermittently elevated cerebrospinal fluid pressure. pressure.

- The diagnosis of NPH can be established only with - The diagnosis of NPH can be established only with the help of continuous intraventricular pressure the help of continuous intraventricular pressure recordings (over 24 hours or even longer.recordings (over 24 hours or even longer.

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- - Dynamic compliance studies may be also Dynamic compliance studies may be also helpful. Altered compliance (elasticity) of the helpful. Altered compliance (elasticity) of the ventricular walls, as well as increased ventricular walls, as well as increased viscosity of the cerebrospinal fluid, may play viscosity of the cerebrospinal fluid, may play a role in the pathogenesis of a role in the pathogenesis of normal normal pressure hydrocephaluspressure hydrocephalus. .

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B.NON-COMMUNICATINGB.NON-COMMUNICATING

Also known as obstructive hydrocephalus:Also known as obstructive hydrocephalus:

cause by a CSF –flow obstruction cause by a CSF –flow obstruction

( either due to external compression or ( either due to external compression or intraventricular mass lesions.intraventricular mass lesions.

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Foramen of MonroForamen of Monro obstruction may lead obstruction may lead to dilation of one or, if large enough (e.g., to dilation of one or, if large enough (e.g., in colloid cyst), both lateral ventricles. in colloid cyst), both lateral ventricles.

The aqueduct of SylviusThe aqueduct of Sylvius, normally , normally narrow to begin with, may be obstructed narrow to begin with, may be obstructed by a number of genetically or acquired by a number of genetically or acquired lesions .lesions .

(e.g., atresia, ependymitis, hemorrhage, (e.g., atresia, ependymitis, hemorrhage, tumor) and lead to dilatation of both lateral tumor) and lead to dilatation of both lateral ventricles as well as the third ventricle. ventricles as well as the third ventricle.

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Fourth ventricleFourth ventricle obstruction will lead to obstruction will lead to dilatation of the aqueduct as well as the lateral dilatation of the aqueduct as well as the lateral and third ventricles. and third ventricles.

The foramina of LuschkaThe foramina of Luschka and foramen ofand foramen of MagendieMagendie may be obstructed due to congenital may be obstructed due to congenital failure of opening (e.g., Dandy-Walker failure of opening (e.g., Dandy-Walker malformation) malformation)

The subarachnoid space surrounding theThe subarachnoid space surrounding the brainstembrainstem may also be obstructed due to may also be obstructed due to inflammatory or hemorrhagic fibrosing inflammatory or hemorrhagic fibrosing meningitis, leading tomeningitis, leading to widespread dilatation, widespread dilatation, including the fourth ventricle. including the fourth ventricle.

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CONGENITALCONGENITAL

The cranial bones fuse by the end of the third The cranial bones fuse by the end of the third year of life. For head enlargement to occur, year of life. For head enlargement to occur, hydrocephalus must occur before then. The hydrocephalus must occur before then. The causes are usually genetic but can also be causes are usually genetic but can also be acquired and usually occur within the first few acquired and usually occur within the first few months of life, which include :months of life, which include :

1 ) intraventricular matrix hemorrhages in 1 ) intraventricular matrix hemorrhages in premature infantspremature infants

2) infections2) infections

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3) type II Arnold-Chiari malformation3) type II Arnold-Chiari malformation

4) aqueduct atresia and stenosis, and 4) aqueduct atresia and stenosis, and

5) Dandy-Walker malformation. 5) Dandy-Walker malformation.

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In newborns and toddlers with In newborns and toddlers with hydrocephalus, the head circumference is hydrocephalus, the head circumference is enlarged rapidly. enlarged rapidly.

Since the skull bones have not yet firmly Since the skull bones have not yet firmly joined together, bulging, firm anterior and joined together, bulging, firm anterior and posterior fontanel's may be present even posterior fontanel's may be present even when the patient is in an upright position. when the patient is in an upright position.

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The infant exhibits fretfulness, poor feeding, and The infant exhibits fretfulness, poor feeding, and frequent vomiting. frequent vomiting.

As the hydrocephalus progresses, torpor sets in, As the hydrocephalus progresses, torpor sets in, and the infant shows lack of interest in his and the infant shows lack of interest in his surroundings. surroundings.

Later on, the upper eyelids become retracted Later on, the upper eyelids become retracted and the eyes are turned downwards (due to and the eyes are turned downwards (due to hydrocephalic pressure on the `mesencephalic hydrocephalic pressure on the `mesencephalic tegmentum’ and paralysis of upward gaze).tegmentum’ and paralysis of upward gaze).

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Movements become weak and the arms Movements become weak and the arms may become tremulous. may become tremulous.

Papilledema is absent but there may be Papilledema is absent but there may be reduction of vision. reduction of vision.

The head becomes so enlarged that the The head becomes so enlarged that the child may eventually be bedriddenchild may eventually be bedridden. .

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About 80-90% of fetuses or newborn About 80-90% of fetuses or newborn infants with spina bifida—often associated infants with spina bifida—often associated with meningocele or myelomeningocele—with meningocele or myelomeningocele—develop hydrocephalus. develop hydrocephalus.

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ACQUIREDACQUIRED as a consequence of CNS infections, as a consequence of CNS infections,

meningitis, brain tumors, head trauma, meningitis, brain tumors, head trauma, intracranial hemorrhage (subarachnoid or intracranial hemorrhage (subarachnoid or intraparenchymal) and is usually extremely intraparenchymal) and is usually extremely painfulpainful. .

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PATHOPHYSIOLOGYPATHOPHYSIOLOGY

The primary site of CSF formation is believed to The primary site of CSF formation is believed to be the choroid plexusus of the lateral ventricles. be the choroid plexusus of the lateral ventricles.

CSF flows from the lateral ventricles through the CSF flows from the lateral ventricles through the foramen of Monroforamen of Monro to the third ventricle, then to the third ventricle, then through the through the aqueduct of Sylviusaqueduct of Sylvius into the fourth into the fourth ventricle through the ventricle through the foramen offoramen of LuschkaLuschka and and the midline the midline foramen of Magendieforamen of Magendie into the into the cisterna magna. cisterna magna.

From there it flows to the cerebral and cerebellar From there it flows to the cerebral and cerebellar subarachnoid spaces where it is absorped.subarachnoid spaces where it is absorped.

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Causes of Causes of HydrocephalusHydrocephalus are varied but are varied but result in either impaired absorption of CSF result in either impaired absorption of CSF within the arachnoid space (formerly within the arachnoid space (formerly referred to as referred to as communicating communicating hydrocephalushydrocephalus) or obstruction to the flow ) or obstruction to the flow of CSF through the ventricular system of CSF through the ventricular system (formerly referred as noncommunicating (formerly referred as noncommunicating hydrocephalus hydrocephalus

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Most cases of obstruction are the result of Most cases of obstruction are the result of developmental malformations; other developmental malformations; other causes include :causes include :

neoplasmneoplasm infection and traumainfection and trauma Obstruction to the normal flow Obstruction to the normal flow can occur at any point in the CSF can occur at any point in the CSF

pathway, which produces increased pathway, which produces increased pressure and dilation of the pathways pressure and dilation of the pathways proximal to the site of obstructionproximal to the site of obstruction..

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Impaired absorption can result from :Impaired absorption can result from : meningitismeningitis prenatal maternal infectionsprenatal maternal infections meningeal malignancy (secondary to meningeal malignancy (secondary to

leukemia or lymphoma)leukemia or lymphoma) an arachnoid cystan arachnoid cyst tuberculosis.tuberculosis.

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CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS Abnormal rate of head growth Abnormal rate of head growth Bulging fontanelle Bulging fontanelle Tense anterior fontanelle (often bulging and Tense anterior fontanelle (often bulging and

nonpulsatile) nonpulsatile) Dilated scalp veins Dilated scalp veins Macewen’s sign (“cracked pot”) Macewen’s sign (“cracked pot”) Frontal bossing Frontal bossing Setting sun sign Setting sun sign Sluggish and unequal pupils Sluggish and unequal pupils Irritability and lethargy with varying LOC Irritability and lethargy with varying LOC Abnormal infantile reflexes Abnormal infantile reflexes Possible cranial nerve damage Possible cranial nerve damage

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Manifestations in children include:Manifestations in children include: possible signs of increased ICPpossible signs of increased ICP

- which include headache on awakening with - which include headache on awakening with improvement following emesis,improvement following emesis,

PapilledemaPapilledema StrabismusStrabismus AtaxiaAtaxia IrritabilityIrritability LethargyLethargy ApathyApathy confusion.confusion.

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LABORATORY AND DIAGNOSTIC LABORATORY AND DIAGNOSTIC TESTTEST

1 ) A prenatal diagnosis1 ) A prenatal diagnosis

- Level II ultrasonography of the fetus.- Level II ultrasonography of the fetus.

*** (Transuterine placement of *** (Transuterine placement of ventriculoamniotic shunts during late ventriculoamniotic shunts during late pregnancy is still being developed as a pregnancy is still being developed as a treatment modality). treatment modality).

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2 ) CT scan 2 ) CT scan

- postnatal.- postnatal.

3) MRI 3) MRI

- can be used if a complex lesion is - can be used if a complex lesion is suspected. suspected.

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TREATMENTTREATMENT

Surgical correction is the Surgical correction is the only only treatment treatment for for hydrocephalushydrocephalus. .

consists of insertion of a consists of insertion of a ventriculoperitoneal shuntventriculoperitoneal shunt

- which transports excess fluid from the - which transports excess fluid from the lateral ventricle into the peritoneal cavity. lateral ventricle into the peritoneal cavity.

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A less common procedure :A less common procedure : insertion of a ventriculoatrial shuntinsertion of a ventriculoatrial shunt

- which drains fluid from the brain's lateral - which drains fluid from the brain's lateral ventricle into the right atrium of the heart, ventricle into the right atrium of the heart, where the fluid makes its way into the where the fluid makes its way into the venous circulation. venous circulation.

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- Periodic lengthening of the shunt is Periodic lengthening of the shunt is necessary to accommodate growth in necessary to accommodate growth in children. children.

- A clogged malfunctioning shunt will have A clogged malfunctioning shunt will have to be to be replaced. replaced.

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Complications of surgery include:Complications of surgery include:

shunt infectionshunt infection septicemia (after ventriculoatrial shunt)septicemia (after ventriculoatrial shunt) adhesionsadhesions and paralytic ileus and paralytic ileus shunt migrationshunt migration PeritonitisPeritonitis intestinal perforation (with peritoneal intestinal perforation (with peritoneal

shunt).shunt).

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Shunt placementShunt placement

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NURSING MANAGEMENTNURSING MANAGEMENT

Teach the family about the management required for Teach the family about the management required for the disorderthe disorder

Treatment is surgical by direct removal of an Treatment is surgical by direct removal of an obstruction and insertion of shunt to provide primary obstruction and insertion of shunt to provide primary drainage of the CSF to an extracranial compartment, drainage of the CSF to an extracranial compartment,

usually peritoneum usually peritoneum (ventriculoperitoneal shunt)(ventriculoperitoneal shunt)

The major complications of shunts are The major complications of shunts are infectionsinfections and and malfunctionmalfunction

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Other Other complicationscomplications include include subduralsubdural hematomahematoma caused by : caused by :

a too rapid reduction of CSFa too rapid reduction of CSFPeritonitisPeritonitis

abdominal abscessabdominal abscessperforation of organsperforation of organs

FistulasFistulashernias and ileus.hernias and ileus.

A A third ventriculostomythird ventriculostomy is a is a new non-new non-shuntingshunting procedureprocedure used used to treat children to treat children

with hydrocephalus.with hydrocephalus.

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Provide preoperative nursing careProvide preoperative nursing care

Assess head circumference, fontanelles, Assess head circumference, fontanelles, cranial sutures, and LOC; check also for cranial sutures, and LOC; check also for irritability, altered feeding habits and a high-irritability, altered feeding habits and a high-pitched cry.pitched cry.

Firmly support the head and neck when Firmly support the head and neck when holding the child.holding the child.

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Provide skin care for the head to prevent Provide skin care for the head to prevent breakdown.breakdown.

Give small, frequent feedings to decrease the Give small, frequent feedings to decrease the risk of vomiting.risk of vomiting.

Encourage parental-newborn bonding.Encourage parental-newborn bonding.

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Provide Postoperative nursing care (nursing Provide Postoperative nursing care (nursing interventions are the same as those for interventions are the same as those for increased ICP)increased ICP)

Assess for signs of increased ICP and check Assess for signs of increased ICP and check the following; head circumference (daily), the following; head circumference (daily), anterior fontanelle for size and fullness and anterior fontanelle for size and fullness and behavior.behavior.

Administer prescribed medications which may Administer prescribed medications which may include antibiotics to preventinclude antibiotics to prevent infection and infection and analgesics for pain.analgesics for pain.

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Provide shunt careProvide shunt care Monitor for shunt infectionMonitor for shunt infection and and

malfunctionmalfunction which may be characterized which may be characterized by rapid onset of vomiting, severe by rapid onset of vomiting, severe headache, irritability, lethargy, fever, headache, irritability, lethargy, fever, redness along the shunt tract, and fluid redness along the shunt tract, and fluid around the shunt valve.around the shunt valve.

Prevent infectionPrevent infection (usually from (usually from Staphylococcus epidermis or Staphylococcus epidermis or Staphylococcus aureus)Staphylococcus aureus)

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Monitor for Monitor for shunt overdrainageshunt overdrainage (headache, dizziness and nausea). (headache, dizziness and nausea).

Overdrainage may lead to slit Overdrainage may lead to slit ventricle syndrome whereby the ventricle syndrome whereby the ventricle become accustomed to a ventricle become accustomed to a very small or slitlike configuration, very small or slitlike configuration, limiting the buffering ability to limiting the buffering ability to increased ICP variationsincreased ICP variations

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Teach home careTeach home care

Encourage the child to participate in age-Encourage the child to participate in age-appropriate activities as tolerated. Encourage appropriate activities as tolerated. Encourage the parents to provide as normal lifestyle as the parents to provide as normal lifestyle as possible. possible.

Remind both the child and parents that Remind both the child and parents that contact sports are prohibitedcontact sports are prohibited..

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Explain how to recognize signs and Explain how to recognize signs and symptoms of increased ICP. Subtle signs symptoms of increased ICP. Subtle signs include changes in school performance, include changes in school performance, intermittent headache, and mild behavior intermittent headache, and mild behavior changes.changes.

Arrange for the child to have frequent Arrange for the child to have frequent developmental screenings and routine developmental screenings and routine medical checkups.medical checkups.

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NURSING CARE PLANNURSING CARE PLAN

LETS DISCUSS IT LETS DISCUSS IT TOGETHER….TOGETHER….

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NURSING DIAGNOSIS &NURSING DIAGNOSIS &INTERVENTIONSINTERVENTIONS

Nursing Diagnosis Nursing Diagnosis

1. Ineffective cerebral tissue perfusion 1. Ineffective cerebral tissue perfusion related to decreased arterial or venous related to decreased arterial or venous blood flow.blood flow.

Nursing Intervention Nursing Intervention

1.Monitor temperature. Administer tepid 1.Monitor temperature. Administer tepid sponge bath in presence of fever.sponge bath in presence of fever.

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2.Monitor intake and output. Weight as 2.Monitor intake and output. Weight as indicated. Note skin turgor, status indicated. Note skin turgor, status and mucous membrane.and mucous membrane.

3.Maintain head or neck in medline or 3.Maintain head or neck in medline or neutral position, support with small neutral position, support with small pillows or small towel rolls. Avoid pillows or small towel rolls. Avoid placing head on large pillow.placing head on large pillow.

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4.Provides rest period between care of 4.Provides rest period between care of activities and limit durations of activities and limit durations of procedures.procedures.

5.Decrease extraneous stimuli and 5.Decrease extraneous stimuli and provide comfort measures such as provide comfort measures such as back massage , quiet environment back massage , quiet environment and gentle touch.and gentle touch.

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6. Help patient avoid or limit coughing, 6. Help patient avoid or limit coughing, crying ,vomiting and straining at crying ,vomiting and straining at stool. Reposition the patient slowly.stool. Reposition the patient slowly.

7.Elevate the head of bed gradually 15-7.Elevate the head of bed gradually 15-30 degree as tolerated or indicated.30 degree as tolerated or indicated.

8.Collaborative : administer diuretic as 8.Collaborative : administer diuretic as indicated. Administer supplemental indicated. Administer supplemental oxygen as indicated.oxygen as indicated.

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RATIONALE RATIONALE

1.1.Check temperatureCheck temperature because fever can because fever can reflex damage to hypothalamus. Increased reflex damage to hypothalamus. Increased metabolic needs and oxygen consumption metabolic needs and oxygen consumption occur ( especially with fever and shivering) occur ( especially with fever and shivering) which can further increased ICP.which can further increased ICP.

2. 2. Monitor intake and outputMonitor intake and output – useful – useful indicators of body water which is an indicators of body water which is an integral part of tissue perfusion.integral part of tissue perfusion.

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3. 3. Maintain head in neutral Maintain head in neutral positionposition : turning bed to one site : turning bed to one site compresses the jugular veins and compresses the jugular veins and inhibits cerebral venous drainage inhibits cerebral venous drainage that may cause increased ICP.that may cause increased ICP.

4.Provides rest period between 4.Provides rest period between cares andcares and activitiesactivities : Continual : Continual activity can increased ICP by activity can increased ICP by producing a cumulative stimulant producing a cumulative stimulant effects.effects.

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5.Decrease extraneous and 5.Decrease extraneous and provide comfortprovide comfort : provides calming : provides calming effects , reduces adverse effects , reduces adverse psychological response and psychological response and promotes rest.promotes rest.

6.Help patient avoid or limit 6.Help patient avoid or limit coughing ,crying ect.coughing ,crying ect. : these : these activities increased intrathoracic and activities increased intrathoracic and intra- abdominal pressure.intra- abdominal pressure.

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7. 7. Elevate the head or bed to 15-Elevate the head or bed to 15-30 degrees30 degrees : Promotes venous : Promotes venous drainage from head ,reducing drainage from head ,reducing cerebral congestion and edema and cerebral congestion and edema and increased ICP.increased ICP.

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THANK YOUTHANK YOU


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