5 Hydrocephalus Nursing Care Plans

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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) and nursing diagnosis (NDx) for hydrocephalus:

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  1. Ineffective Cerebral Tissue Perfusion
  2. Anxiety
  3. Risk for Injury (Preoperative)
  4. Risk for Injury (Postoperative)
  5. Risk for Infection
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Ineffective Cerebral Tissue Perfusion

Nursing Diagnosis

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 InterventionsRationale
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 cryA 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.
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Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses as reviewed and approved by the NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of it’s evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions show how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues and on electrolytes and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care 
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis…. subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health 
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

See also

Other recommended site resources for this nursing care plan:

Other nursing care plans for pediatric conditions and diseases:

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Paul Martin is a registered nurse with a bachelor of science in nursing since 2007. Having worked as a medical-surgical nurse for five years, he handled different kinds of patients and learned how to provide individualized care to them. Now, his experiences working in the hospital is carried over to his writings to help aspiring students achieve their goals. He is currently working as a nursing instructor and have a particular interest in nursing management, emergency care, critical care, infection control, and public health. As a writer at Nurseslabs, his goal is to impart his clinical knowledge and skills to students and nurses helping them become the best version of themselves and ultimately make an impact in uplifting the nursing profession.
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