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
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) for hydrocephalus:
- Ineffective Cerebral Tissue Perfusion
- Anxiety
- Risk for Injury (Preoperative)
- Risk for Injury (Postoperative)
- Risk for Infection
Ineffective Cerebral Tissue Perfusion
Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.
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. |
| 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. |
See Also
You may also like the following posts and care plans:
- Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list!
- Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale.
