Hydrocephalus

Hydrocephalus is a condition marked by an excessive accumulation of cerebrospinal fluid resulting in dilation of the cerebral ventricles and raised intracranial pressure; may also result in enlargement of the cranium and atrophy of the brain.

There are two types of hydrocephalus: communicating and non-communicating.

Communicating Hydrocephalus:

• It occurs as a result of impaired absorption within the subarachnoid space
• Interference of the cerebrospinal fluid within the ventricular system does not occur

Non-communicating Hydrocephalus:

• It is an obstruction of cerebrospinal flow within the ventricular system.

Signs and Symptoms Hydrocephalus in Infant:

• Increased head circumference
• Macewen’s sign: thin, widely separated bones of the head that produce a cracked-pot sound on percussion
• Dilated scalp vein
• Frontal bossing
• Sunsetting eyes
• Anterior fontanel tense, bulging, and non pulsating

Signs and Symptoms Hydrocephalus in Child:

• Changes of behavior: irritability and lethargy
• Nausea and vomiting
• Headache on awakening
• Ataxia
• Nystagmus

Surgical Intervention:
Surgical intervention of Hydrocephalus is to prevent further CSF accumulation by bypassing the blockage and draining the fluid from the ventricles to a location where it can be reabsorbed. There are two types of surgical intervention: Ventriculoperitoneal Shunt and Atrioventricular Shunt.

1. Ventriculoperitoneal Shunt: the CSF drains from the lateral ventricles into the peritoneal cavity.
2. Atrioventricular Shunt: the CSF drains into the right atrium of the heart from the lateral ventricle, bypassing the obstruction. It is mostly used in older children and in children with pathological conditions of the abdomen.

Nursing Intervention (post-op)

• Monitor and assess vital signs and neurological signs
• Position client on the un-operated side to prevent pressure on the shunt valve
• Keep the child flat: to avoid rapid reduction of intracranial fluid
• Observe for increased ICP, if ICP is increased, elevate the head of the bed to 15-30 degrees
• Monitor for signs of infections
• Assess dressings for drainage
• Monitor intake and output
• Measure head circumference
• Administer medications as prescribed
• Teach parents how to recognize shunt infection and shunt malfunction

Head Injury in Children

Head injury is pathological result of any mechanical force to the skull, scalp, meninges, or brain. The manifestations of head injury depend on the type of injury and the amount of increased intracranial pressure (ICP).


Sign and Symptoms of Head Injury:

Early Signs:

• Headache
• Nausea and vomiting
• Visual disturbances and diplopia
• Slight changes in vital signs
• Dizziness or vertigo
• Change in pupillary response and equality
• Slight change in level of consciousness
• Signs in infants: bulging fontanel, wide sutures, increased head circumference, high pitched cry, and dilated scalp vein

Late Signs:

• Cushing’s triad: increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respiration
• Significant decrease in level of consciousness
• Decorticate posturing (see picture)
  
• Decerebrate posturing (see picture)
  
• Fixed and dilated pupils

Nursing Intervention in Head Injury:

1. Monitor and assess the airway, breathing, and circulations
2. Assess the injury and immobilize the neck if a cervical injury is suspected
3. Monitor vital signs and neurological function
4. Monitor level of consciousness
5. Initiate seizure precaution
6. Keep patient a nothing by mouth status until determined that vomiting will not occur
7. Administer oxygen and intravenous fluid as prescribed
8. Elevate the head of bed at 15-30 degrees if not contraindicated
9. Keep head in midline position to facilitate venous drainage and avoid jugular vein compression
10. Monitor for nose or ear drainage which could indicate leakage of cerebrospinal fluid (CSF) as a sign of skull fracture
11. Avoid suctioning through the nares
12. Administers acetaminophen (Tylenol) for headache, anticonvulsants for seizures, antibiotic, and tetanus toxoid as prescribed
13. Monitor for signs of brainstem involvement: deep, rapid, or intermittent and gasping respirations; wide fluctuations or noticeable slowing of the pulse; widening pulse pressure or extreme fluctuations in blood pressure
14. Monitor for epidural hematoma: asymmetric pupils