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HYDROCEPHALUS Introduction Hydrocephalus is a condition in which there is excessive fluid accumulation in the brain. The word Hydrocephalus derived from two words -hydro means water, cephalus means head Definition:is a condition in which portion of the entire ventricular system is abnormally dilated & the CSF has been under increased pressure. Incidence Sex Bickers adam syndrome male NPH Age Infancy Adulthood (40%) Mortality and morbidity Due to brain herniation and resp. arrest Related anatomy CSF circulation & pathway

Introduce the topic

Explaining

Define the condition

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Enlist the incidence

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Discuss the related Anatomy

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Identify the etiology Explaining using LCD slides

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Enumerate the classification

Classification and etiology: A. Depending on the type of block Non communicating (block is intraventricular) Mal development of the aqueduct Obstruction due to mass lesions Obstruction secondary to exudate , haemorrhage or paracsites Obstruction of the fourth ventricle outlet foramina- dandy Walker malformation Communicating type(block is extra ventricular) Post infectious, post hemorrhagic, or developmental adhesions of basal cisterns or surface arachnoid space Commonly after neonatal meningitis or intra ventricular haemorrhage Arachnoid villi obstruction by erythrocytes, exudates Skeletal defects- achondroplasia B ) depending on the time of presentation LCD

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pathophysiol ogy

Congenital hydrocephalus Intra utrerine infections- TORCH Congenital malformations of the aqueduct Congenital midline tumors of CNS Acquired hydrocephalus TB/ Bacterial meningitis Posterior fossa tumors Pathophysiology : internal

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Discuss the pathophysiol ogy

External hydrocephalus LCD slides

Identify the clinical features

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Explaining Enlist the diagnostic measures LCD slides Explaining using LCD slides

Discuss the goals of medical management

Clinical features Enlargement of the head(speed of enlargement proportional to ICP ) & small face Sunsetting eye sign Separation of the sutures & widening , fullness of ant. Frontanelle Prominent scalp vein Wasting is common with progression of hydro cephalus CRACK POT RESONANCE(Macewen sign) Epileptic attack Diagnosis Head circumference Radiographs CT

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management

USG MRI

Management : Goals To reduce the CSF pressure To reduce irritability To prevent infection To improve nutrition To improve the skin integrity Medical management Osmotic diuretic: cerebral edema Carbonic anhydrase inhibitors: Acetazolamide Antibiotics Slightly elevate the head end of the bed to 15 LCD slides Explaining using LCD slides

Enlist the complications of shunt Stationary or arrested type No surgical intervention is needed

Progressive type Site of block should be localised Repeated lumbar puncture Use of Acetazolamine 50-75 mg/kg/day

Discuss the nursing management

Expanding lesion Excision of the tumor Ventricular tapping Endoscopic 3rd ventriculostomy Cauterisation of the choroid plexes Surgical intervention required Ventriculoatrial shunt Ventriculoperitoneal shunt Ventriculogallbladder shunt Ventriculoureteric shunt Complications of shunt Outgrows tube length Subdural haematoma Mechanical failure Obstruction Over/ under drainage Failure of the valve Perforation Infections Collapse of the ventricular valve Other Complications like Physical injury, Delayed growth and development and Decreased intracranial adaptive capacity Nursing Nursing Management Assessment

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Increased HC , usually increases during infancy Full ,tense , bulging frontanels Widening suture lines Distended scalp vein Irritability , or lethargy , decreased attention span High pitched cry Sunset sign Inability to support the head when upright Cracked pot

Nursing diagnosis 1. Disturbance in comfort , irritability r/t disaese condition 2. High risk for respiratory arrest related to increased ICP 3. Risk for blockage of the shunt 4. Risk for infection related to the presence of shunt 5. Risk for impaired nutrition r/t poor feeding 6. Risk for complication(seizures) 7. Anxiety 8. Knowledge deficit 9. Altered parental coping Nursing intervention Disturbance in comfort , irritability r/t disaese condition -Provide a quiet environment with less stimuli. -Advice to use zero watt bulbs to minimize photosensitivity. -Avoid too much neck flexion or manipulation. -Sit near the child and speak in a low ,modulated voice -Minimal handling of the baby is advised

-Elevate head end to 300 to reduce cerebral oedema -Monitor TPR every two hourly High risk for respiratory arrest related to increased ICP Check signs of increased ICP Assess the respiratory status Monitor vital signs every 2 hrly Support the childs head when the child is upright Risk for blockage of the shunt Measure HC to aid in diagnosis of hydrocephalus Monitor vital signs and intake and out put Assess neurologic status Dont allow the child to lie on the same side of shunt Instruct to lay flat to avoid rapid decompression Signs of ICP Teach parents signs of increasing ICP Risk for infection related to the presence of shunt Observe signs of infection Provide proper skin care to the head , turn it frequently Monitor signs of infection like elevated W.B.C, E.S.R Follow strict aseptic techniques to minimize infection Maintain fluid volume through IV therapy Risk for impaired nutrition r/t poor feeding -Maintain fluid volume through IV therapy Discussing

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Discuss the nursing management

-Give expressed breast milk -Provide ryles tube feeding -Provide soft diet to avoid too much difficulty by mastication Risk for complication(seizures) Educate seizure precautions Administer anticonvulsants as prescribed. Raise the padded side rails of bed to prevent any falls Ensure that injurious toys and instruments are kept at a safer place. Monitor the pattern of seizures Teach the parents how to use padded spoons to clench between teeth during seizures Provide side-lying position after seizures to prevent aspiration. Avoid overcrowding during seizure episode. Administer O2 and do suction in case of status epileptics Anxiety -provide psychological support to parents -Be with the child and speak in a low and calm voice -Ensure the safety of the child in the absence of his parents -Support family members while explaining about the childs prognosis -Provide play articles or transitional objects to the child to avoid boredom and to make him feel comfortable Knowledge deficit - Teach parents signs of increasing ICP -Educate the family about need calm environment

-Provide them a copy of immunization protocol -Educate the need for HiB vaccine for unimmunized siblings at home -Encourage them to clarify their doubts -Teach them about the disease ,its prognosis and management Altered parental coping provide psychological support encourage them to verbalise feelings advise about supporting agencies BIBLIOGRAPHY: 1. Wong D.L etal . Essentials Of Paediatric Nursing. 6th edition. Missouri: Mosby;2001 2. Marlow D.R. Redding B. Textbook of Paediatric nursing. 1st edition.Singapore: Harwourt Brace & company; 1998 3. Dr.Chaudari KC. Indian Journa of Paediatrics. Nov22 2007 4. Parthasarathy IAP textbook of Paediatrics. 2nd edition. jaypee: NewDelhi; 2002

LESSON PLAN TOPIC SUBJECT GROUP METHODS VENUE DATE STUDENTR TEACHER: AVAIDS : : : : : : : HYDROCEPHALUS PAEDIATRIC NURSING II YEAR MSc NSG STUDENTS LECTURE CUM DISCUSSION MSc NSG CLASS ROOM 01. 05. 2013 Mrs. Nimisha Rajan LCD SLIDES

PREVIOUS KNOWLEDGE: Students have had classes on convulsion in children in their BSc nsg course General Objective On completion of the class the students will be able to understand the disease condition hydrocephalus so as to apply this knowledge in their future practice with a positive attitude. Specific objective: On completion of the class the students will be able to; 1. 2. 3. Define the condition Enlist the incidence Discuss the related Anatomy

4. 5. 6. 7. 8. 9. 10. 11. 12.

Identify the etiology Enumerate the classification Discuss the pathophysiology Identify the clinical features Enlist the diagnostic measures Discuss the goals of medical management Discss the medical management Enlist the complications of shunt Discuss the nursing management

Lesson plan on Hydrocephalus