 Hydrocephalus is an excess accumulation of cerebrospinal fluid in the ventricular system resulting in the enlargement of the intracranial cavity. This occurs from an irregularity in the production and absorption of the fluid which causes an increase in intracranial pressure as the fluid builds up. Hydrocephalus can be classified as communicating or noncommunicating. Communicating occurs when there is an impaired resorption of cerebrospinal fluid, usually at the level of the arachnoid villi. Noncommunicating hydrocephalus is caused by an obstruction within the ventricular system. As the head enlarges to an abnormal size, the infant experiences changes in level of consciousness, irritability, shrill cry, lower extremity spasticity and opisthotonus and, if the hydrocephalus is allowed to progress, the infant experiences difficulty in sucking and feeding, emesis, seizures, sunset eyes, and cardiopulmonary complications as lower brainstem and cortical function are disrupted or destroyed. In the child, increased intracranial pressure (ICP) focal manifestations are experienced related to space occupying focal lesions and include headache, emesis, ataxia, irritability, lethargy, and confusion. Nursing Care PlansThe nursing goals for a client with hydrocephalus may include improving cerebral tissue perfusion, reducing anxiety, preventing injury, and the absence of complications. Here are five (5) nursing care plans (NCP) and nursing diagnosis (NDx) for hydrocephalus:
Nursing Diagnosis
May be related to
Possibly evidenced by
Desired Outcomes
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See alsoOther recommended site resources for this nursing care plan: Other nursing care plans for pediatric conditions and diseases:
Children suffer a significant number of head injuries as a result of their high activity levels, immature developmental skills and increased head-to-body mass ratio. Primary brain injury is irreversible, but secondary insults can be limited. Central to this is the management of raised intracranial pressure (ICP). The pathophysiology of head injury can explain some of the causes of raised ICP. Monitoring of ICP is important and this is closely linked to the maintenance of an adequate cerebral perfusion pressure and the importance of normovolaemia. Other interventions that have been shown to limit rises in ICP are appropriate use of positioning, mechanical ventilation and drug therapy. Less common therapies include jugular venous bulb oxygen saturation monitoring and the use of trometamol (THAM). Most nursing interventions do not actively reduce ICP, but they are central to its management. Reducing stimuli, avoiding cluster care, manual hyperinflation and limiting routine endotracheal suction may prevent an accumulative rise in ICP. Based on this literature review, it is possible to divide these interventions into first and second tier treatments, as shown in the protocol. Much of the suggested management will occur simultaneously, but it is important to assess the child's own response to each intervention and thus tailor treatment to minimize secondary brain injury. |
What should be included in the nursing care of a child with increased intracranial pressure?
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