Hydrocephalus NCLEX Review Care Plans
Nursing Study Guide on Hydrocephalus
Hydrocephalus is a medical condition wherein excessive fluid accumulates in the brain.
Two Greek words comprise the word hydrocephalus: hydro (water) and cephalus (head). The increase in the production of cerebrospinal fluid and the relaxation of the cerebral ventricles may result to an increase in intracranial pressure.
This can result to the development of hydrocephalus. These changes can bring upon physiologic and psychologic effects to the patient because of the alterations in the normal structure of the brain.
Hydrocephalus can happen to anyone at any age.
However, it occurs more frequently to infants and adults over 60. Surgical management is the gold standard in treating hydrocephalus with the main goal of decreasing fluid build-up and relieving intracranial pressure, thus alleviating functional impairments and preventing permanent damage.
Signs and Symptoms of Hydrocephalus
Physical changes include:
- Unusually large head (could be rapidly increasing in size) – for infants
- A bulging or soft spot in the head (fontanelle) – for infants
- GI problems (poor feeding/appetite, vomiting)
- Eyes fixed downward (sun-setting of eyes) – for infants and young children
- Blurred vision
- Inability or dysfunction in bladder control
Cognitive changes include:
- Irritability, change in personality, sleeplessness
- Delays in school performance
- Decline in cognitive abilities (memory, concentration, etc.)
- loss of motor coordination (difficulty walking, etc.)
- Poor coordination and balance
- Poor responsiveness
Causes of Hydrocephalus
Cerebrospinal fluid (CSF) is necessary for the normal functions of the brain for it acts as a cushion and buoyant to prevent injury.
It also aides in the removal of by-products of metabolism and in maintaining the balance of intracranial pressure.
However, excess in CSF in the ventricles could be through the following reasons:
- Obstruction in the normal flow of CSF from one ventricle to another, or within the spaces in the brain
- Poor absorption brought about by damage to surrounding blood vessels, thereby preventing proper reabsorption of CSF
- Rarely, through overproduction of CSF wherein more quantities are produced from what can be readily reabsorbed
Risk factors of Hydrocephalus
Most of the time, the main cause of hydrocephalus is unknown.
However, various triggers may predispose the patient in developing the condition.
For newborns, hydrocephalus at birth (congenital) may develop because of:
- Abnormal development of the nervous system causing obstruction in CSF flow
- Bleeding within the ventricles due to complications of premature birth
- Infections in the uterus during pregnancy, such as syphilis, that may cause inflammation in the fetal brain
Other factors may include:
- Presence of tumor or lesions in the CNS (brain and/or spinal cord)
- Infections of the CNS (e.g. bacterial meningitis)
- Bleeding (maybe caused by stroke or head injury)
- Other traumatic injury to the head
Because of the location of the condition, complications may vary widely and may bring about significant cognitive, intellectual, developmental, and physical disabilities to the patient.
This is especially true if the condition is not treated early on (i.e. at the time of birth) and will naturally have long-term effects on the infant.
Early and appropriate treatment of hydrocephalus was found to help reduce the risk of serious complications over those whose treatment was delayed.
Adults who had considerable decline in cognitive functioning due to hydrocephalus have poorer outcomes after treatment.
Therefore, it can be said that severity of complications is determined by:
- Underlying medical condition or pre-existing brain injury
- Seriousness of initial symptoms
- Timeliness of diagnosis and treatment
- A general physical exam
- Neurological exam – varies; usually based on the developmental age
- Brain imaging tests – will aide in diagnosing and knowing the underlying causes of the hydrocephalus. It can be through either or a combination of the following:
- Ultrasound – a simple and relatively low-risk procedure involving sound waves to detect presence of hydrocephalus to infants. This procedure can also be done prenatally during routine check-ups of the mother.
- MRI scan – utilizes radio waves and a magnetic field to produce multi-faceted images of the brain and its ventricles to detect presence of excessive CSF and its presumptive causes. Sedation may be given for young children to allow for proper imaging results.
- CT scan – like the MRI, can produce cross-sectional images of the brain, involving the use of specialized xray technology, but with less detailed images. Oftentimes, a cranial CT scan for hydrocephalus is done only in emergency situations.
Surgery is the gold-standard for treatment and could be through:
- Shunts – Involves the placement of a drainage system placed in one of the brain’s ventricles, with a long, flexible tube with valve, tunneled through the skin, and directed towards either a chamber in the heart or the abdomen for appropriate CSF drainage. Patients with shunt systems would need constant monitoring for life.
- Endoscopic third ventriculostomy – Involves a surgical technique through video assisted guidance to drill a hole in the bottom of one of the ventricles, to allow proper draining of CSF.
Problems in the shunt drainage system such as blockage or infection, or bleeding or infection in the ventriculostomy site are oftentimes the complications of the above procedures.
Any discrepancies should need immediate attention and corrective treatment, as necessary.
Other supportive treatment, especially for children, should also include:
- Pediatric neurologist
- Occupational and developmental therapist
- Psychologist or Psychiatrist
- Social worker
- Special education teacher
Nursing Care Plans for Hydrocephalus
Nursing Care Plan 1
Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral) related to increased intracranial pressure (ICP) secondary to hydrocephalus as evidenced by drowsiness, irritability, headache, and cognition problems
Desired Outcome: The patient will be able to re-establish cerebral tissue perfusion as evidenced by increased level of consciousness (i.e. awake and alert) and will have an oriented with persons, places, and things.
|Assess the patient’s vital signs and neurological status at least every 4 hours, or more frequently if there is a change in them.||To assist in creating an accurate diagnosis and monitor effectiveness of medical and surgical treatment for hydrocephalus.|
|Observe the patient for any signs and symptoms of increased ICP, such as sudden headache, vomiting, and decreased alertness.||To facilitate early detection and management of increased ICP.|
Increased ICP can be life-threatening as it may lead to brain damage, stroke, or coma.
|Prepare the patient for the surgery as instructed by the surgeon.||To treat the hydrocephalus, which is the underlying cause of the patient’s increased ICP.|
|Administer osmotic diuretics (e.g. Mannitol) as prescribed.||To promote blood flow to the brain and to reduce cerebral edema.|
|Elevate the head of the bed at 15-45 degrees.||To promote venous drainage from the patient’s head to the rest of the body in order to decrease ICP.|
Nursing Care Plan 2
Nursing Diagnosis: Disturbed Sensory Perception related to increased intracranial pressure secondary to hydrocephalus, as evidenced by pain score of 10 out of 10 leg weakness, headache, difficulty to focus vision, GCS 14, and cognition problems
Desired Outcome: The patient will regain usual level of consciousness and perceptual functioning with GCS score of 15.
|1. Assess the patient’s vital signs and sensory awareness, and monitor GCS.||To create a baseline set of observations for the patient. The Glasgow Coma Scale is the gold standard for neurological assessment of a person’s level of consciousness.|
|2. Agree a simple method of communication with the patient, such as placing the call bell within reach, and using the phone to inform the healthcare workers of his/her needs and wants.||To maintain proper communication between the patient and the healthcare team and ensure that needs are met and safety is maintained.|
|3. Remove any extraneous stimuli (such as very bright lighting or loud noises). Speak calmly and use short sentences when communicating. Leave the light on.||To reduce stress levels and confusion.|
|Re-orient the patient to people, places, time, and important info about his/her current treatment.||To eliminate confusion and gradually assist the patient to his/her normal level of consciousness.|
|Reposition the patient in his/her comfortable/preferred position. Encourage pursed lip breathing and deep breathing exercises.||To promote optimal patient comfort and reduce anxiety/ restlessness.|
Nursing Care Plan 3
Nursing Diagnosis: Risk for Infection post shunt insertion
Desired Outcome: The patient will be able to avoid the development of an infection after surgery.
|Assess vital signs and observe for any signs of infection.||Infection may be evidenced by fever and can be accompanied by respiratory distress.|
|Obtain daily blood samples as ordered.||To monitor neutrophil and white blood cell counts.|
|Teach the patient and carer how to perform proper hand hygiene.||To maintain patient safety and reduce the risk of infection.|
|Orient the patient (or child’s carer) on how to perform proper wound care.||To ensure that the principles of asepsis are carefully followed when changing wound dressings.|
Nursing Care Plan 4
Nursing Diagnosis: Risk for Injury
Desired Outcome: The child will continue to be safe and free from any injury.
|Assess vital signs and observe for any signs of increase in intracranial pressure.||Increase in ICP may trigger seizures which can result to injury.|
|Perform seizure precautions such as removing toys and other objects from the bed, padding the bed/crib, and maintaining oxygen and suction at bedside.||To ensure that the environment is risk-free and prepared if and when a seizure occurs.|
|Teach the patient and carer how to recognize the signs of increase in intracranial pressure.||To maintain patient safety and reduce the risk of injury.|
|Orient the patient (or child’s carer) on how to hold the child properly with the head elevated at 30 degrees and well-supported.||To facilitate drainage of CSF and reduce its accumulation.|
Other nursing diagnoses:
- Impaired Thought Processes
- Activity Intolerance
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.
This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.