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Published by Adela Lhuz

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Published by: Adela Lhuz on Jan 11, 2009
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Cerebrospinal fluid serves as a protective cushion around the brain and spinalcord. The fluid is secreted by the choroid plexuses of the ventricles. It flows from thelateral ventricles into the third ventricle, through the cerebral aqueduct (aqueduct of Sylvius) into the fourth ventricle and then out into the subarachnoid space through threesmall openings in the roof of the fourth ventricle. The fluid circulates around the cord andover the convexity of the brain and is resorbed into the large venous sinuses in the dura.Secretion of the CSF continues even if the flow of fluid through the ventricular system isblocked. Obstruction to the normal circulation of spinal fluid distends the ventriclesproximal to the site of obstruction, with associated compression atrophy of the braintissue around the dilated ventricles. Such condition is called hydrocephalus.Hydrocephalus is an excessive accumulation of cerebrospinal fluid (CSF) withinthe ventricular spaces of the brain. In infants, hydrocephalus enlarges the head; infantsand adults, resulting compression can cause damage brain tissue. With early detectionand surgical intervention, the prognosis improves but remains guarded. Even after surgery, such complications as mental retardation, impaired motor function, and visionloss can persist. Without surgery, the prognosis is poor: Mortality may result fromincreased intracranial pressure (ICP); infants may also die prematurely of infection andmalnutrition.
Cause and Incidence
 Hydrocephalus may result from an obstruction in CSF flow (noncommunicatinghydrocephalus) or from faulty absorption of CSF (communicating hydrocephalus). In noncommunicating hydrocephalus, the obstruction occurs most frequently between the thirdand fourth ventricles, at the aqueduct of Sylvius, but it can also occur at the outlets of fourth ventricles (foramina of Luschka and Magendie) or, rarely, at the foramen of Monro.This obstruction may result from faulty fetal development, infection (syphilis,granulomatous diseases, meningitis), a tuimor, cerebral aneurysm, or a blood clot (after intracranial hemorrhage).Communicating hydrocephalus occurs as the result of impaired reabsorption of CSF from the arachnoid villi into the venous system. Decreased absorption can resultfrom a block in the CSF pathway to the arachnoid villi or a failure of the villi to transfer the CSF to the venous system. It can occur if too few villi are formed, if postinfective
(meningitis) scarring occludes them, or if the villi become obstructed with fragments of blood or infectious debris. Normal-pressure hydrocephalus seen in older adults, it isaccompanied by ventricular enlargement with compression of cerebral tissue but normalCSF pressure.Hydrocephalus occurs most commonly in neonates but also occur in adults asresult of injury or disease. It affects 1 of every 1000 people.
Mental retardation, impaired motor function, vision loss, death
Signs and Symptoms
In infants, the unmistakable sign of hydrocephalus is rapidly increasing headcircumference, clearly disproportionate to infant’s growth. Other characteristic changesinclude widening and bulging of the fontanels; distended scalp veins; thin, shiny, andfragile-looking scalp skin; and under developed neck muscles that can’t support thehead. In severe hydrocephalus, the roof of the orbit is depressed, the eyes are displaceddownward, and the scleras are prominent. Sclera seen above the iris is called the“setting-sun sign.” A high-pitched, shrill cry, abnormal muscle tone of the legs, irritability,anorexia, and projectile vomiting commonly occur. In adults and older children, indicatorsof hydrocephalus include decreased level of consciousness (LOC), ataxia, incontinence,loss of coordination, and impaired intellect.The clinical manifestations include papilledema, spasticity, and ataxia affectingthe extremities and a progressive decline in judgement and reasoning aith acharacteristic “empty chatter” type of speech pattern.
In infants, abnormally large head size for the patient’s age strongly suggestshydrocephalus. Measurement of head circumference is a most important diagnostictechnique. Skull x-rays show thinning of the skull with separation of sutures andwidening of fontanels.Other diagnostic tests for hydrocephalus, including arteriography, computedtomography scan, and magnetic resonance imaging (MRI), can differentiate betweenhydrocephalus and intracranial lesions and can also demonstrate the Arnold-Chiarideformity, which may occur in an infant with hydrocephalus.
Treatment/ Medical-Surgical Management 
Hydrocephalus can often be treated successfully by inserting a plastic tube intoone of the dilated ventricles and rerouting (shunting) the fluid into another part of thebody where it can be absorbed. The fluid can be shunted into the right atrium(ventriculoatrial shunt) or into the peritoneal cavity (ventriculoperitoneal shunt). A smallopening is made in the skull to allow insertion of a plastic drainage tube through cerebralhemisphere into one of the dilated lateral ventricles. The other end of the tube is passedthrough the subcutaneous tissues behind the ear. In a ventriculoatrial shunt, the tube isinserted into the jugular vein and threaded down the vein so that the tip is positioned inthe right atrium. In the more commonly used ventriculoperitoneal shunt the tube ispassed through the subcutaneous tissues of the neck, chest, and upper abdomen andintroduced into the abdominal cavity through a small incision in the peritoneum.Whatever type of shunt is used, a one-way valve is incorporated in the tube to preventany reflux of blood or peritoneal fluid into the ventricles.
Nursing Management 
Observation is essential, as is conscientious collection of data, including dailymeasurement of the head circumference and check of the size and fullness of theanterior fontanel. Noting any change in the infant’s behavior is also important.Nurses have a direct responsibility for the nutritional requirements of thesenewborns, but feeding may be a particular time-consuming activity for the staff. Whenthe infant is irritable or vomiting, various techniques should be attempted to provideadequate nutrients and fluids. Techniques that are successful for a particular infantshould be shared with all persons involved in feeding him, including the parents. Feedingtimes should be flexible, and small feedings at frequent intervals may prove moresuccessful. The increased head size makes positioning a potential problem, especiallywhen the head circumference is increasing rapidly. Hydrocephalic neonates maydevelop decubiti if they are not turned often. Frequent linen changes and the use of lamb’s wool also help deter skin breakdown. The infant should be turned cautiously, for the increased head size places an additional strain on the neck.The primary nursing goal for an infant after a shunting procedure fohydrocephaly is the promotion of CNS intactness. The vital signs are frequently

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