NCP Nursing Care Plan for Hydrocephalus. Hydrocephalus is an excessive accumulation of cerebrospinal fluid (CSF) in the ventricular spaces of the brain. Result from obstruction in CSF flow (noncommunicating hydrocephalus) or from faulty absorption of CSF (communicating hydrocephalus). It’s most common in neonates but can also occur in adults as a result of injury or disease. In infants, hydrocephalus enlarges the head; in both infants and adults, resulting compression can damage brain tissue. With early detection and surgical intervention, the prognosis improves but remains guarded. Even after surgery, such complications as developmental delay, impaired motor function, and vision loss can persist. Without surgery, the prognosis is poor: Mortality may result from increased intracranial pressure (ICP) in people of all ages; infants may also die prematurely of infection and malnutrition.
Characteristics of hydrocephalus in infants, changes characteristic of hydrocephalus include marked enlargement of the head; distended scalp veins; thin, shiny, and fragile-looking scalp skin; and underdeveloped neck muscles.
Causes for Hydrocephalus
Hydrocephalus may result from an obstruction in CSF flow (noncommunicating hydrocephalus) or from faulty absorption of CSF (communicating hydrocephalus). In noncommunicating hydrocephalus, the obstruction occurs most frequently between the third and fourth ventricles and at the aqueduct of Sylvius. It can also occur at the outlets of the fourth ventricle (foramina of Luschka and Magendie) or, rarely, at the foramen of Monro. This obstruction may result from faulty fetal development (myelomeningocele, congenital arachnoid cysts), infection (syphilis, granulomatous diseases, meningitis), tumor, cerebral aneurysm, or a blood clot. In communicating hydrocephalus, faulty reabsorption of CSF may result from surgery to repair a myelomeningocele, adhesions between meninges at the base of the brain, or meningeal hemorrhage.
Complications for Hydrocephalus
Potential complications of hydrocephalus include:
- Mental retardation,
- Impaired motor function, and vision loss.
- Death may result from increased intracranial pressure (ICP) in people of all ages
- In infants may also die of infection and malnutrition.
Nursing Assessment Nursing Care Plan for Hydrocephalus
The patient’s history may reveal the cause of hydrocephalus, infection (syphilis, granulomatous diseases, meningitis), tumor, cerebral aneurysm, In severe hydrocephalus, the infant’s parents may report irritability, anorexia, episodes of projectile vomiting, and a high-pitched, shrill cry. Inspection may reveal depression of the roof of the eye orbit, displacement of the eyes downward, and prominent sclera (sunset sign).
Physical examination: a focus area of the head
Inspection In an infant may reveal an enlarged head that is clearly disproportionate to the infant’s growth, an unmistakable sign of hydrocephalus. Neurologic examination may demonstrate abnormal muscle tone of the legs.
In adults and older children with a fused cranium, the patient history may uncover signs of increased ICP, including frontal headaches, nausea, and vomiting that may be projectile. If the patient or parents report that these symptoms cause wakening or occur on awakening, hydrocephalus should be suspected. The patient may also report diplopia and restlessness. Neurologic examination may detect a decreased level of consciousness, ataxia, and impaired intellect. Neurologic impairment may also cause incontinence.
Diagnostic tests for Hydrocephalus
- Skull X-ray.
- Computed tomography scanning, and magnetic resonance imaging
Nursing diagnosis Nursing Care Plan for Hydrocephalus
Common nursing diagnosis found in Nursing Care Plan for Hydrocephalus
- Acute pain
- Delayed growth and development
- Imbalanced nutrition: Less than body requirements
- Impaired gas exchange
- Ineffective tissue perfusion: Cerebral.
- Interrupted family processes.
- Infant Behavior, risk for disorganized.
- Risk for infection
Nursing Key outcomes Nursing Care Plan for Hydrocephalus
- The patient will exhibit no signs of pain or agitation.
- Family members will identify measures to reduce anxiety.
- The patient will achieve age-appropriate growth, behaviors, and skills to the fullest extent possible.
- The patient will show no signs of malnutrition.
- The patient will maintain adequate ventilation and oxygenation.
- The patient will maintain and improve current level of consciousness (LOC).
- Family members will verbalize the effect of the patient’s condition on their daily life.
- The patient will remain free from signs of seizure activity.
- The patient will remain free from signs and symptoms of infection.
Nursing Interventions Nursing Care Plan for Hydrocephalus
- Pain Management, Analgesic Administration, Environmental Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient: Use of pharmacologic agents to reduce or eliminate pain: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
- Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger, Calming Technique: Reducing anxiety in patient experiencing acute distress
- Developmental Enhancement, Nutritional Monitoring, Developmental Care: Child/Adolescent Facilitating or teaching parents/caregivers to facilitate the optimal gross motor, fine motor, language, cognitive, social, and emotional growth of preschool and school-age children/of individuals during the transition from childhood to adulthood; Collection and analysis of patient data to prevent or minimize malnourishment; Structuring the environment and providing care in response to the behavioral cues and states of the preterm infant
- Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids; Weight Gain Assistance: Facilitating gain of body weight
- Respiratory Monitoring, Oxygen Therapy, Airway Management; Collection and analysis of patient data to ensure airway patency and adequate gas exchange; Administration of oxygen and monitoring of Facilitation of patency of air passages
- Cerebral Perfusion Promotion of adequate perfusion and limitation of complications for a patient experiencing or at risk for inadequate cerebral perfusion
- Family Process Maintenance, Family Integrity Promotion, Normalization Promotion: Minimization of family process disruption effects, Facilitating family participation in the emotional and physical care of the patient, Assisting parents and other family members of children with chronic diseases or disabilities in providing normal life experiences for their children and families
- Developmental Care: Structuring the environment and providing care in response to the behavioral cues and states of the preterm infant. Environmental Management: Manipulation of the patient’s surroundings for therapeutic benefit
- Infection Protection, Infection Control, Surveillance: Prevention and early detection of infection in a patient at risk, Minimizing the acquisition and transmission of infectious agents, Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making
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