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Course Description:
This course is designed to give an overview of the care and management of the patient diagnosed
with hydrocephalus. Discussion will include the anatomy of the brains ventricular system as well
as the purpose and flow of cerebral spinal fluid (CSF). Focus will be placed on treatment options
for hydrocephalus such as Ventriculo-peritoneal (VP) shunting and/or the use of External
Ventricular Drainage (EVD) Systems. Nursing care and management including set up,
monitoring and trouble shooting and documentation for the patient with an External Ventricular
Drainage System will be the final focus of this course.
Course Objectives:
Upon completion of this course the student will be able to:
Define Hydrocephalus
Have a better understanding of Ventricular anatomy
Discuss the amount and flow of CSF
Describe the presenting signs and symptoms of hydrocephalus
Explain the purpose and function of a Ventriculo-peritoneal (VP) shunt
Discuss the care and management of the patient with an External Ventricular Drain
State the proper steps for setting an EVD system
Discuss the required documentation for the patient with an EVD system
Ventricular Anatomy:
The brains ventricular system is comprised of four ventricles (two lateral and a third and fourth).
Movement and flow of the CSF is as follows:
The lateral ventricles which are located deep within the sub-cortical tissue on each side of
the brains midline communicate with the third ventricle via the Foramen of Monro.
In turn the third ventricle communicates with the fourth ventricle (which is located in the
medulla) through the aqueduct of Sylvius.
The top of the fourth ventricle is where communication to the sub-arachnoid space occurs
via two lateral foramen called the Foramen of Luschka and one median foramen called
the Foramen of Magendie.
The floor of the fourth ventricle communicates with the spinal column.
Cerebral Spinal Fluid:
Cerebral Spinal Fluid is continuously produced in the lateral ventricles by the choroids
plexus.
The rate of production is estimated to be 20 to 25 ml per hour or 500 ml per day. It is also
estimated that under normal circumstances there is approximately 100 to 150 ml of CSF
circulating throughout the ventricles and spinal column.
As mentioned earlier, the Foramen of Luschka (located on the top of the fourth ventricle)
allows CSF to flow throughout the brain.
CSF provides flexibility and protection to the brain and spinal cord.
CSF is a vehicle for central nervous systems metabolic activity.
CSF provides a medium for the removal of unnecessary metabolites (away from
neurons).
CSF consists of water, glucose, protein, minerals and a few lymphocytes.
Pathophysiology of Hydrocephalus:
Under normal conditions the brain floats in a protective cushion of Cerebral Spinal Fluid (CSF).
In addition to surrounding the brain, CSF also surrounds the spinal cord and fills open spaces in
the brain such as the ventricles. Hydrocephalus which is a clinical syndrome (rather then an
actual disease process) occurs when the production of Cerebral Spinal Fluid (CSF) exceeds the
brains absorption rate. Accumulation of CSF in the ventricles causes them to swell and enlarge
with in turn causes increased intracranial pressure (ICP).
Set Up of EVD:
Using sterile gloves and towels; create a sterile field (on a procedure or bedside table).
In a sterile fashion open up LR or NS solution, IV tubing and drainage system and place
on the sterile field (the use of a second non-sterile person to open packaging is usually
required).
Spike LR or NS bag and prime IV tubing.
Connect IV tubing to drainage system and flush system (make sure drainage system
stopcocks are open for ease of flushing).
Assure that there are no air bubbles or leaks in the system.
Once the system is flushed, remove LR or NS bag and IV tubing and discard.
Assuring that the end of the drainage system that will connect to the patients External
Ventricular Catheter remains sterile, place drainage system on IV Pole.
Some drainage systems come with a measuring device, for those that do not, a manifold
(a pole that has incremented measurements) will need to be placed on the IV pole and the
drainage system is then placed on the manifold.
Connection of the drainage system and the Ventricular Catheter must be made using
sterile technique.
Required Physician Notification and Documentation for Patients with EVD systems:
Document Neuro Assessment Q 4 hours (or per MD order)
Immediately notify physician for changes in LOC.
Immediately notify physician for complaints of headache (sign of excessive CSF
drainage).
Immediately notify physician if any CSF leakage is noted around the catheter site.
If present, document dressing intactness Q 4 hours.
Document amount, color and transparency of CSF Q 2 hours (or per MD order).
Document the ordered level or height of drainage system.
Document if drainage is being collected continuously or intermittently.
Document patient and family education.
References:
National Institute of Health; Hydrocephalus fact sheet (2009). Retrieved on August 28, 2009
at: http://www.ninds.nih.gov/disorders/hydrocephalus/detail_hydrocephalus.htm
Goldenring, J. MD. (2004). Hydrocephalus. Retrieved on May 4, 2006 at:
http://www.healthline.com/adamcontent/hydrocephalus
Hart, J., P. MD. (2005). Division of Vascular Surgery, Department of Surgery, Medical College
of Wisconsin, Milwaukee, WI. ;
ADAM Health Illustrated Encyclopedia
Hickey, J. (2003). The clinical practice of neurological and neurosurgical nursing. (5th ed.),
(Chap. 14). Lippencott, Williams and Wilkins. Philadelphia
Johnson, E., & Stone, M. (2003). External ventricular drainage. Retrieved on May 5, 2006 at:
http://www.neuroitu.co.uk/evd.pdf#search='external%20ventricular%20drainage'
University of California Irvine. Intracranial pressure monitoring, using cordis external drainage
and monitoring system. Policy section number I-103. Revised 4-2005.