HYDROCEPHALUS

Mr. Fadi J. Zaben RN MSN

IMET2000, Ramallah
February, 2013

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Outline:
• Overview.
• Classification
• Etiology.
• Clinical Manifestations.
• Diagnosis.
• Treatment.
• Shunts????.
• Prognosis.
• Complications.
• Nursing Considerations and Interventions.
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Definition:

• From Greek hydrokephalos, from hydr- + kephalE head.

• Hydrocephalus is a condition of altered production, flow,
or absorption of cerebrospinal fluid (CSF).
• It is characterized by an abnormal increase in CSF
volume within the intracranial cavity and by enlargement
of the head in infancy.
• The total volume of CSF approximate 50 ml in an infant
and 150 ml in an adult.
• Occurs in approximately three to four cases per 1,000
births, including those associated with spina bifida.

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Classification:

1. Obstructive or Non-communicating

Hydrocephalus.

2. Non-obstructive or Communicating

Hydrocephalus.

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Obstructive or Non-communicating Hydrocephalus:

Non-communicating hydrocephalus obstruction in the

system between the source of CSF production (ventricles)
and the area of its reabsorption (the subarachnoid space).
May be partial, intermittent, or complete.
Occurs in the majority of cases.
Caused by congenital defects, such as Arnold-Chiari
malformation, Dandy-Walker cyst (etiology largely
unknown), aqueductal stenosis (neurofibromatosis).
Also caused by acquired conditions, such as infections,
trauma, spontaneous intracranial bleeding, and
neoplasms.

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Non-obstructive or Communicating Hydrocephalus:
• Failure in the absorption system; cause
unknown.
• Excessive production of CSF tumor or
unknown causes (rare).
• Most commonly follows a subarachnoid
hemorrhage.
• Pnumococcal and tubrculous meningitis

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 Clinical Manifestations:
May be rapid, slow and steadily advancing, or
intermittent.
The clinical presentation of hydrocephalus is
variable and depends on many factors, including:
 The age at onset (anterior fontanels has closed, and
the cranial sutures have fused).
 The nature of the lesion causing obstruction.
 The duration and rate of rise of the ICP.
The clinical manifestation of hydrocephalus are
caused by ventricular distention and increased ICP.

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Infants
1. Excessive head growth (may be seen up to age 3).

2. Delayed closure of the anterior fontanels.

3. Fontanels tense and elevated above the surface of the skull.

4. Signs of increased intracranial pressure (ICP).

5. Alteration of muscle tone of the extremities, including clonus

or spasticity.

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 Continue…..

Later Physical Signs:

1. Forehead becomes prominent.
2. Scalp appears shiny with prominent scalp veins.
3. Eyebrows and eyelids may be drawn upward,
exposing the sclera above the iris.
4. Infant cannot gaze upward, causing sunset eyes.
5. Strabismus, nystagmus, and optic atrophy may
occur.
6. Infant has difficulty holding head up.
7. Child may experience physical or mental
developmental lag.
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Signs and Symptoms of Increased ICP in Infants and Children

• Vomiting
• Restlessness and irritability
• High-pitched, shrill cry (infants)
• Rapid increase in head circumference (infants)
• Tense, bulging fontanelle (infants)
• Changes in vital signs (+systolic BP, - P, Decreased and
irregular respirations, + Temp.).
• Pupillary changes
• Possible seizures
• Lethargy, stupor, coma

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Older Children:
Older children have closed sutures and present
with signs of increased ICP as Following:
1. Headache, especially on awakening
2. Lethargy, fatigue, apathy
3. Personality changes.
4. Separation of cranial sutures (may be seen in
children up to age 10).
5. Visual changes such as double vision.

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Diagnosis:
• Infant's head transilluminates, indicative of
abnormal fluid collection.
• Percussion of the infant's skull may produce a
typical cracked pot sound (Macewen's sign).
• Ophthalmoscopy may reveal papilledema.
• CT scan or MRI is the diagnostic tool of choice.
• With ventriculography (rarely used),
abnormalities are visualized in the ventricular
system or the subarachnoid space.
• Skull X-rays show widening of the fontanels and
sutures and erosion of intracranial bone.
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Management:
Hydrocephalus can be treated through a variety of
surgical procedures, including:
Direct operation on the lesion causing the
obstruction, such as a tumor.
Intracranial shunts for selected cases of non-
communicating hydrocephalus to divert fluid from
the obstructed segment of the ventricular system to
the subarachnoid space.
Extracranial shunts (most common) to divert fluid
from the ventricular system to an extracranial
compartment, frequently the peritoneum or right
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Extracranial Shunt:

1. Ventriculoperitoneal
(VP) shunt:
Diverts CSF from a lateral
ventricle or the spinal
subarachnoid space to the
peritoneal cavity.

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Shunt Components:

• Most shunts have the following components:

1. Ventricular tubing.
2. A one-way or unidirectional pressure-sensitive
flow valve.
3. A pumping chamber.
4. Distal tubing.

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Extracranial Shunt:

2. Ventriculoatrial (VA) shunt:

• Diverts CSF from a lateral
ventricle into the right
atrium or superior vena
cava.
• A one-way pressure-
sensitive valve will close to
prevent reflux of blood into
the ventricle and open as
ventricular pressure rises.
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3. Ventriculopleural shunt:
Diverts CSF to the pleural
cavity.
Indicated when the VP or VA
route cannot be used.

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4. Ventricle-gall bladder shunt:
Diverts CSF to the common bile duct.
Used when all other routes are unavailable.

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 Prognosis:
 Prognosis depends on early diagnosis and prompt therapy.
 With improved diagnostic and management techniques, the
prognosis is becoming considerably better.
 Many children experience normal motor and intellectual
development.
 The severity of neurologic deficits is directly proportional to
the interval between onset of hydrocephalus and the time of
diagnosis.
 Approximately two-thirds of patients will die at an early age if
they do not receive surgical treatment.

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Complications:
1. Seizures.
2. Herniation of the brain.
3. Spontaneous arrest due to natural compensatory
mechanisms, persistent increased ICP, and brain
herniation.
4. Developmental delays.
5. Depression in adolescents is common.

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Nursing Assessment:
1. Assess head circumference.
2. Palpate fontanelle for tenseness, bulging.
3. Assess pupillary response.
4. Assess level of consciousness (LOC).
5. Evaluate breathing patterns and effectiveness.
6. Assess feeding patterns and patterns of emesis.
7. Assess motor function, gait, coordination.
8. Determine attainment of developmental
milestones.

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Nursing Diagnoses:
1. Imbalanced Nutrition: Less Than Body Requirements
related to reduced oral intake and vomiting.
2. Risk for Impaired Skin Integrity related to alterations in LOC
and enlarged head.
3. Anxiety of parents related to child undergoing surgery
4. Risk for Injury related to malfunctioning shunt.
5. Risk for Deficient Fluid Volume related to CSF drainage,
decreased intake postoperatively.
6. Risk for Infection related to bacterial infiltration of the
shunt.
7. Ineffective Family Coping related to diagnosis and surgery.

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Nursing Interventions:
Providing Adequate Nutrition:
Be aware that feeding is frequently difficult
because the child may be listless, anorectic, and
prone to vomiting.
Complete nursing care and treatments before
feeding so the child will not be disturbed after
feeding.
Hold the infant in a semi-sitting position with head
well supported during feeding.
Offer small, frequent feedings.
Place the child on side with head elevated after
feeding to prevent aspiration.
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Nursing Interventions:

Maintaining Skin Integrity:

 Prevent pressure sores (pressure sores of the head are a
frequent problem) by placing the child on a sponge rubber or
lamb's wool pad or an alternating-pressure or mattress to keep
weight evenly distributed.
 Keep the scalp clean and dry.
 Turn the child's head frequently; change position at least every 2
hours.
 Give passive ROM exercises to the extremities, especially the
legs.
 Keep the eyes moistened with artificial tears if the child is
unable to close the eyelids normally to prevents corneal
ulcerations and infections.

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Reducing Anxiety:
Prepare the parents for their child's surgery by
answering questions, describing what nursing care
will take place postoperatively, and explaining how
the shunt will work.
Encourage the parents to discuss all the risks and
benefits with the surgeon. Help them to
understand the prognosis and what to expect of
the child's neurologic and cognitive development.
Prepare the child for surgery by using dolls or
other forms of play to describe what interventions
will occur.
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Improving Cerebral Tissue Perfusion Postoperatively:
Monitor the child's temperature, pulse, respiration,
blood pressure (BP), and pupillary size and reaction every
15 minutes until stable; then monitor every 1 to 2 hours.
Avoid hypothermia or hyperthermia.
Turn the child frequently.
Assess for excessive drainage of CSF (Sunken fontanels,
agitation, restlessness (infant), Decreased LOC (older
child).
Assess closely for increased ICP, indicating shunt
malfunction.
Promote optimal drainage of CSF through the shunt by
pumping the shunt and positioning the child as directed.
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Maintaining Fluid Balance:
 Accurately measure and record total fluid intake and
output.
 Administer I.V. fluids as prescribed; carefully monitor
infusion rate to prevent fluid overload.
 Use a nasogastric tube if necessary for abdominal
distention.
 Give frequent mouth care while the child is to have
nothing by mouth.
 Begin oral feedings when the child is fully recovered from
the anesthetic and displays interest.

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Preventing Infection:
 Assess for fever (temperature normally fluctuates during
the first 24 hours after surgery), purulent drainage from
the incision, or swelling, redness, and tenderness along the
shunt tract.
 Administer prescribed prophylactic antibiotics.

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