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
- Ineffective Cerebral Tissue Perfusion
- Risk for Injury (Preoperative)
- Risk for Injury (Postoperative)
- Risk for Infection
Ineffective Cerebral Tissue Perfusion
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
- 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.
|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.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans for pediatric conditions and diseases:
- Acute Glomerulonephritis | 4 Care Plans
- Acute Rheumatic Fever | 4 Care Plans
- Apnea | 4 Care Plans
- Brain Tumor | 3 Care Plans
- Bronchiolitis | 5 Care Plans
- Cardiac Catheterization | 4 Care Plans
- Cerebral Palsy | 7 Care Plans
- Child Abuse | 4 Care Plans
- Cleft Lip and Cleft Palate | 6 Care Plans
- Congenital Heart Disease | 5 Care Plans
- Congenital Hip Dysplasia | 4 Care Plans
- Croup Syndrome | 5 Care Plans
- Cryptorchidism (Undescended Testes) | 3 Care Plans
- Cystic Fibrosis | 5 Care Plans
- Diabetes Mellitus Type 1 (Juvenile Diabetes) | 4 Care Plans
- Dying Child | 4 Care Plans
- Epiglottitis | 5 Care Plans
- Febrile Seizure | 4 Care Plans
- Guillain-Barre Syndrome | 6 Care Plans
- Hospitalized Child | 5 Care Plans
- Hydrocephalus | 5 Care Plans
- Hypospadias and Epispadias | 4 Care Plans
- Intussusception | 3 Care Plans
- Juvenile Rheumatoid Arthritis | 4 Care Plans
- Kawasaki Disease | 6 Care Plans
- Meningitis | 7 Care Plans
- Nephrotic Syndrome | 5 Care Plans
- Osteogenic Sarcoma (Osteosarcoma) | 4 Care Plans
- Otitis Media | 4 Care Plans
- Scoliosis | 4 Care Plans
- Spina Bifida | 7 Care Plans
- Tonsillitis and Adenoiditis | 4 Care Plans
- Umbilical and Inguinal Hernia | 4 Care Plans
- Vesicoureteral Reflux (VUR) | 5 Care Plans
- Wilms Tumor (Nephroblastoma) | 4 Care Plans