Nursing Care Plan (NCP) for Hydrocephalus

Understanding Hydrocephalus:
- Define and comprehend the pathophysiology of hydrocephalus, including the impaired cerebrospinal fluid (CSF) circulation and the resulting accumulation of fluid within the ventricles of the brain.
Etiology and Risk Factors:
- Identify the various causes and risk factors contributing to hydrocephalus, such as congenital anomalies, infections, tumors, or traumatic brain injuries. Understand how these factors influence the development of the condition.
Signs and Symptoms Recognition:
- Recognize the clinical manifestations and signs of hydrocephalus, both in infants and adults. This includes observing changes in head circumference (for infants), neurological symptoms, and signs of increased intracranial pressure.
Diagnostic Procedures:
- Learn and understand the diagnostic procedures used to confirm hydrocephalus, such as imaging studies (CT scans, MRI) and lumbar puncture. Comprehend the importance of these diagnostic tools in formulating an accurate care plan.
Comprehensive Nursing Care Strategies:
- Develop a comprehensive understanding of nursing interventions, including monitoring vital signs, providing comfort measures, administering prescribed medications, and collaborating with the healthcare team for potential surgical interventions like shunt placement.

Pathophysiology of Hydrocephalus

Impaired Cerebrospinal Fluid (CSF) Circulation:
- Hydrocephalus is characterized by a disruption in the normal circulation and absorption of cerebrospinal fluid (CSF), which is essential for maintaining a balanced intracranial pressure.
Accumulation of CSF in the Ventricles:
- The impairment in CSF circulation leads to an excessive accumulation of fluid within the ventricles of the brain. This buildup causes the ventricles to enlarge, exerting pressure on surrounding brain tissues.
Obstruction or Overproduction:
- Hydrocephalus can result from either an obstruction in the pathways through which CSF flows or an overproduction of CSF. Obstruction may occur due to congenital anomalies, tumors, or inflammation, hindering the normal flow of fluid.
Increased Intracranial Pressure (ICP):
- The enlarged ventricles and the accumulation of CSF elevate intracranial pressure. Increased pressure can lead to compression of brain structures, contributing to neurological symptoms and potential damage if not effectively managed.
Clinical Manifestations:
- The pathophysiological changes in hydrocephalus manifest clinically with symptoms such as headaches, nausea, vomiting, changes in consciousness, and, in infants, an increase in head circumference due to fontanelle bulging. Timely recognition and intervention are crucial to prevent complications.

Etiology of Hydrocephalus

Congenital Causes:
- Hydrocephalus can be congenital, occurring due to developmental anomalies during fetal growth. Conditions such as aqueductal stenosis, neural tube defects, or Dandy-Walker malformation can lead to impaired CSF circulation.
Acquired Obstructions:
- Acquired hydrocephalus may result from obstructions caused by conditions such as tumors, cysts, or vascular malformations that block the normal flow of cerebrospinal fluid through the ventricular system.
Infections and Inflammation:
- Infections affecting the central nervous system, such as meningitis or encephalitis, can lead to inflammation and scarring, causing blockages in the CSF pathways and subsequent hydrocephalus.
Hemorrhage:
- Intraventricular hemorrhage, often associated with premature birth or head trauma, can lead to the accumulation of blood in the ventricles, disrupting CSF flow and contributing to hydrocephalus.
Tumors:
- Both benign and malignant brain tumors can contribute to hydrocephalus by compressing or obstructing the normal flow of CSF. Tumors may also increase CSF production, further exacerbating the condition.

Desired Outcome for Hydrocephalus

Normalization of Intracranial Pressure (ICP):
- Ensure that interventions effectively reduce elevated intracranial pressure to within normal limits, preventing further damage to brain tissue.
Maintenance of Optimal Neurological Function:
- Preserve and promote neurological function by preventing or minimizing neurological deficits associated with hydrocephalus, such as cognitive impairments and motor dysfunction.
Prevention of Complications:
- Mitigate the risk of complications related to hydrocephalus, including seizures, impaired vision, and developmental delays, to enhance the overall quality of life for the patient.
Optimal Ventricular Size:
- Achieve and maintain an appropriate size for the cerebral ventricles, ensuring that they neither collapse nor become excessively dilated. This supports the normal flow and absorption of cerebrospinal fluid.
Promotion of Developmental Milestones:
- Support the achievement of developmental milestones in pediatric patients, focusing on age-appropriate growth, cognitive development, and psychosocial well-being.

Hydrocephalus Nursing Care Plan

Subjective Data:

The rapid increase in head circumference
Poor appetite or feeding
Headaches
Personality changes
Difficulty concentrating

Objective Data:

Large or oddly shaped head
Bulging fontanelles
Fussy (infants)
Excessive drowsiness
Vomiting
Seizures
Eyes fixed downward (sunsetting) or strabismus

Nursing Assessment for Hydrocephalus

Neurological Assessment:
- Conduct a thorough neurological examination to assess baseline cognitive function, motor skills, reflexes, and cranial nerve function.
Vital Signs Monitoring:
- Regularly monitor vital signs, with particular attention to changes in blood pressure, heart rate, and respiratory rate, as alterations may indicate increased intracranial pressure.
Head Circumference Measurements:
- In pediatric patients, monitor and record head circumference to identify abnormal growth patterns or rapid increases, which may indicate worsening hydrocephalus.
Fontanelle Assessment:
- In infants, assess the fontanelles for bulging or tension, as these signs may suggest increased intracranial pressure.
Observation for Behavioral Changes:
- Monitor for alterations in behavior, such as irritability, lethargy, changes in feeding patterns, or signs of discomfort, which may indicate neurological distress.
Gait and Motor Function Evaluation:
- Assess gait and motor function in older children and adults to identify any signs of weakness, imbalance, or coordination difficulties.
Papilledema Examination:
- If applicable, perform an ophthalmic examination to assess for papilledema, swelling of the optic disc, which is indicative of increased intracranial pressure.
Diagnostic Imaging Review:
- Collaborate with healthcare providers to review diagnostic imaging (CT scans, MRIs) to visualize the structure of the brain, ventricles, and cerebrospinal fluid flow.

Implementation for Hydrocephalus

Surgical Intervention:
- Coordinate and assist with surgical procedures such as ventriculoperitoneal (VP) shunt placement or endoscopic third ventriculostomy (ETV) to establish or improve cerebrospinal fluid drainage.
Postoperative Care:
- Provide diligent postoperative care, including monitoring vital signs, neurological status, and signs of complications (infections, shunt malfunction). Educate the patient and caregivers on recognizing and reporting concerning symptoms.
Medication Administration:
- Administer prescribed medications, such as diuretics or acetazolamide, as directed to manage intracranial pressure and reduce fluid accumulation.
Hydrocephalus Education:
- Educate patients and their families about the condition, its management, and the importance of adhering to medication regimens and follow-up appointments.
Rehabilitation Services:
- Collaborate with rehabilitation specialists, including physical therapists, occupational therapists, and speech therapists, to address any functional deficits and promote optimal recovery and development.

Nursing Interventions and Rationales

Assess vital signs hourly per facility protocol

To monitor for signs of increased intracranial pressure such as tachycardia, shallow breathing, or rapid changes in blood pressure.

Assess neurological status, examine pupils

To monitor for changes in mental status, reflexes, and motor function. Changes in pupil reaction may indicate altered brain stem functioning.

Assess head circumference and fontanelles

Increasing head circumference and bulging of fontanelles indicates accumulating fluid.

Initiate safety and seizure precautions
- Place an infant or toddler in a crib
- Keep oxygen and suction at the bedside
- Keep head of bed elevated
- Support enlarged head when holding an infant
- Position the patient on the opposite side of the operation

Increased cranial pressure can lead to seizures which may require oxygen supplementation or suction of secretions to clear airway.
Elevating the head of the bed promotes CSF drainage and breathing.
The weight of an enlarged head increases the difficulty for an infant to hold head upright. Maintain support of the head when holding an infant to prevent head and neck injuries.
Following surgery, position the patient to prevent injury to the surgical site, and maintain patency of the shunt.

Administer medications appropriately
- Diuretics
- Corticosteroids

Diuretics can help control the production of CSF in the case of non-obstructive hydrocephalus.
Corticosteroids help to reduce inflammation.

Prepare patient for surgery/shunt placement
- Maintain NPO status 2-4 hours before surgery per facility protocol
- Administer IV fluids

Patients may undergo surgery to place a Ventriculoperitoneal (VP) shunt that will drain fluid from the brain to the stomach.

Encourage frequent bowel movements by providing stool softeners as necessary

To reduce the risk of increasing cranial pressure due to constipation and straining. More appropriate for toddlers and children than infants.

Monitor for signs of infection of the surgical site and prove appropriate wound care

Prevent localized or systemic infection and prevents the development of sepsis.

Provide education for patients and parents/caregivers

Encourage parents to practice good hand hygiene to prevent the spread of infection.
Teach the importance of safety and to reduce the risk of brain injury.
Educate caregivers about warning signs of increased cranial pressure and when to seek medical help after discharge.

Evaluation for Hydrocephalus

Clinical Assessment:
- Regularly assess neurological status, including cognitive function, motor skills, and sensory abilities, to monitor improvements or detect any deterioration.
Imaging Studies:
- Schedule and review periodic imaging studies, such as MRI or CT scans, to evaluate the effectiveness of surgical interventions, assess shunt function, and identify any potential complications.
Monitoring Shunt Function:
- Evaluate and document signs of shunt malfunction or infection, such as headaches, vomiting, changes in behavior, or physical examination findings, to ensure timely intervention if needed.
Patient and Caregiver Feedback:
- Seek feedback from patients and caregivers regarding the impact of the care plan on their daily lives, functional abilities, and overall well-being. Address concerns and make necessary adjustments.
Developmental Milestones:
- Assess developmental milestones in pediatric patients regularly to track progress and address any delays or challenges promptly. Collaborate with developmental specialists as needed.

References

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Transcript

This is the nursing care plan for hydrocephalus. So hydrocephalus is a condition where the CSF is not absorbed by the brain, or it’s unable to drain and builds up inside or around the brain. This progressively increases the pressure on the brain without treatment to relieve this pressure. The patient can suffer growth in developmental abnormalities, infants and toddlers with this condition may develop abnormally large head circumference. So some nursing considerations that we want to be mindful of is we want to do frequent neuro checks. These patients are at risk for seizures. So we also want to make sure that we initiate seizure precautions. We want to administer any medications that are ordered as assess and monitor the intracranial regulation. We want to maintain safety and prevent injury, and we want to maintain fluid balance. The desired outcome for this patient is that this patient will have optimal brain function without developmental delays. And the patient will be free from injury. This patient will also be free from infection. So this patient comes in and this parent tells us, Hey, my child has hydrocephalus. What is some subjective data that you think this parent will tell us? Well, I do think that this parent will say that there was a rapid increase in their child’s head circumference. Maybe they’ll say that the child has a poor appetite, Headaches, personality changes, And they may have some difficulty concentrating. So when we see this, this child, what are we going to notice? Well, we’re going to notice a large or oddly shaped head.

And we’re going to notice the bulging fontanelles. Remember the fontanelles are those soft spots on the head where the skull is closing and fusing. So those should not be bulging. So we’re going to have bulging fontanelles. We’re going to also see infants are fussy and that’s for infants. They’re going to be very fussy. Remember infants tend to communicate by fussing if they have something that’s going wrong with them, there’ll be some excessive drowsiness. And some vomiting. Remember this patient is at risk for seizures. So you may see some seizures and eyes fixed downward, or sunsetting, and we call that sunsetting. So let’s take a look at some of the nursing interventions that we can do. Well, the first thing we want to do when the patient arrives at the hospital is we want to assess their neurological status and examine their pupils. Remember we see these patients and we want to monitor for changes in their mental status and their motor function changes with their pupil reaction may indicate the altered brainstem functioning

All right. The next thing we want to do is we want to assess their head circumference and their fontanelles. Remember, we should not see fontanelle bulgy. We shouldn’t see a rapid increase in head circumference. If, and if the head size is increasing, this is indicating excessive fluid buildup.

We want to initiate safety as seizure precautions. So these patients are at high risk for a seizure, and we want them to be protected and safe. So we want to monitor the intracranial pressure. We want to protect them from seizures. They may need some oxygen supplementation because of those seizures, but also may need suctioning. So we want to make sure that that is set up at the bedside as well, so we can clear the airway. Okay. The next thing that we want to do is to administer medication. Some medications that we may give the patient are diuretics or water pills. They want to remove the water and we want to administer steroids. Okay? The steroids control the production of CSF. In the case of nonobstructive hydrocephalus, if they are blocked because of any type of inflammation, those corticosteroids are going to help reduce that inflammation. We want to prepare this patient for surgery. This patient, if it is not going to be managed with the medications for the diabetes and the corticosteroids, they are going to prepare for surgery.

This patient needs to be NPO. So nothing by mouth, nothing by mouth two to four hours prior to the surgery; we want to make sure that we administer IV fluids once they’re NPO. And we want to realize that they may undergo surgery to put a VP drain or ventriculoperitoneal shunt. That’s going to drain fluid from the brain into the stomach. Okay. Let’s look at the key points. So cerebral spinal fluid is not absorbed by the brain. That’s when it’s a nonobstructive hydrocephalus or it’s unable to drain at all. That’s obstructive hydrocephalus that builds up inside or around the brain. Remember some other subjective data that they’re going to present with is they aren’t going to present as poor feeders. They’re going to have rapid rise in the head circumference. Some of the things that we are going to monitor, and we’re going to assess and observe is the objective data that they’re going to be fussy.

When they’re infants, they’re going to be vomiting. We may observe some seizures. We’re going to see those sunset eyes, those low eyes when they’re focusing downward, and we may see some falls in functionality, what are we going to do for these patients? Well, first we’re going to do frequent neuro checks. So we’re going to do frequent neuro exams, and we’re going to pay close attention to their pupils. Remember any changes with the pupils can indicate that the brainstem has been compromised with this. We’re also going to prepare for surgery. We’re going to keep the patient NPO. We’re going to monitor their EVD or their external ventricular drain. And we’re going to monitor for post op infection and to ensure that the drain is draining properly. We love you guys; go out and be your best self today. And, as always, happy nursing.