Case Presentation Hydrocephalus

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SUHAINA OSMAN WARD 6B PRINCE COURT MEDICAL CENTRE HYDROCEPHALUS (AQUEDUCT STENOSIS)

Transcript of Case Presentation Hydrocephalus

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SUHAINA OSMAN WARD 6B

PRINCE COURT MEDICAL CENTRE

HYDROCEPHALUS (AQUEDUCT STENOSIS)

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WHAT IS HDROCEPHALUS

HYDRO WATER

CEPHALUS HEAD

TOO MUCH CSF ACCUMULATES WITHIN THE VENTRICELS

ICP MAY OR MAY NOT ELEVATED

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CSF PHYSIOLOGY

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WHAT IS AQUEDUCT STENOSIS

AQUEDUCT NARROW CHANNEL THAT CONNECTS TWO OF THE

VENTRICLES AND PASSES THROUGH THE MIDBRAIN

STENOSIS BLOCKED

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WHAT IS ETV

SURGICAL PROCEDURE IN WHICH AN OPENING IS CREATED IN THE FLOOR OF THE THIRD VENTRICLE USING AN ENDOSCOPE PLACED WITHIN THE VENTRICULAR SYSTEM (BURR HOLE)

ETV ALLOWS CSF TO FLOW DIRECTLY TO THE BASAL CISTERNS, THEREBY SHORTCUTTING ANY OBSTRUCTION

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CASE PRESENTATION

NAME : RENA FUKUDAAGE : 12YGENDER : FEMALECOMPLAINS : HEADACHES FOR 2/12,

WORSEN IN LAST 2/52MRI/CT : OBSTRUCTIVE

HYDROCEPHALUS SECONDARY TO AQUEDUCT STENOSIS

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29 AUGUST 2010

ADMIT – ROUTINE WARD PROCEDURE PLAN

ENDOSCOPIC 3RD VENTRICULOSTOMY VISUAL ASSESSMENT ANAESTHESIA ASSESSMENT

NURSING RESPONSIBILITY QUESTIONNAIRE, CONSENT, CHEKLIST INFORM OT/ICU SURGEON / ANAESTHETIST ORDER PRE MED

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30 AUGUST 2010

PROCEED PROCEDURE AS PLAN

POST OPERATIVE CARE CLOSE NEURO OBSERVATION KEEP EVD CLAMP PT NUTRITION PROP UP

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31 AUGUST 2010

FOR REMOVAL EVD CM

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01 SEPTEMBER 2010

EVD REMOVED

NURSING RESPONSIBILITY SEDATION, ASEPTIC TECHNIQUE, CONSENT

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02 SEPTEMBER 2010

FOR REPEAT CT BRAIN & EYE ASSESSMENT

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03 SEPTEMBER 2010

PT D/C

TCA SCHEDULED

HEATH EDUCATION

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HYDROCPEPHALUS

NURSING MANAGEMENT

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OBSERVING & RECORDING DISEASE PROGRESS

INFANTS 1.Measure head

occipitofrontal circumference (OFC)approximately the same time each day

2. Palpate fontanelle for tenses, bulging3. Assess for pupilary changes4. Assess for change in level of consciousness5. Evaluate breathing pattern & effectiveness6. Assess feeding pattern7. Assess motor function, gait, coordination8. Determine attainment of developmental milestone

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OLDER CHILDRENMeasure vital sign for increase ICPAssess patterns of headache, emesisDetermine pupillary changesEvaluate LOCAssess motor functionEvaluate attainment of milestone, school

performanceObtain parent’s report of recent behavior

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Note especially changes in appearance :-Increase head sizeFull/ bulging fontanel‘Sunset Eyes’

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PROVIDING ADEQUATE NUTRITION

Feeding is often a problem because the child may be prone to vomiting

Complete nursing care & treatment before feeding so that the child will not be disturbed after feeding

Hold the infant in a semi – sitting position with head well supported during feeding, allow ample time for bubbling

Offer small , frequent feeding Place on his side with head elevated after

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SUPPORTIVE NURSING CARE

Providing supportive nursing care as indicated by the child conditionPrevent pressure sore & development of contractures-

Use ripple mattress to keep his wt evenly distributed Keep scalp clean & dry Turn child head frequently , change position at least 2hly

(rotate his head & body together to prevent strain on the neck)A firm pillow may be placed under the head & shoulder for further support when lifting the childSkin care to all parts of the body :-

Observe skin for evidence of pressure sores Pressure sore on the head are frequently problem

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ROM exercise to the extremities, especially the legsKeep the eyes moistened if the child is unable

to close his eye lids normally to prevents corneal ulceration

Provide for the child’s emotional need for love & affection Hold & cuddle the infant as much as possible Play with child according to his mental development

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EMOTIONAL SUPPORT (PARENTS)

Encourage parents to talk - child condition & how their feel

fearful of procedure, mental retardation or brain damage

Provide parents with appropriate informationconcerning the defect

Answer their question directly & honesty Correct any misconception such as fear that

the child head may burst

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Providing continued emotional support to the parents:-

1. Begin discharge planning early2. Accompany all instruction with reassurance

necessary to prevent the parents from becoming anxious or fearful about assuming the care of the child

3. Encourage parents to treat the child as normally as possible, providing him with appropriate toys & love

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4. Initiate appropriate referrals :- Social worker Community health nurse Parents group Community agencies Specialty clinics & schools

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IMMEDIATE POST OP CARE

1. Monitor GCS till patient stable/ review

2. Avoid hypothermia or hyperthermia:- Provide appropriate blanket or covers as indicated

by body temperature Administer a tepid sponge or antipyretic medication

3. Suction as needed - to prevent respiratory difficulty

4. Turn the child every 2 hours

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5. Use a NG tube if necessary for abdominal distention:-

When VP shunt has been performed Measure & record amount/color

6. Give frequent mouth care to prevent dryness of the mucous membrane

7. Observe – pallor / mottled condition of the skin

8. Administer antibiotic/medication as prescribed

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VP SHUNT

1. Pump the shunt and place pt as directed by the physician:-

If pumping is prescribe, carefully compress the valve the specified number of times at regularly scheduled intervals

Report any difficulties in pumping the shunt

Avoid positioning the child on the area of the valve or the incision until wound is well healed

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FLUID & ELECTROLYTE BALANCE

Maintaining :-1. Accurately measure & record total intake & output

2. Administer I/V fluid as prescribed

3. Begin oral feeding once child fully recovered from anesthetic :- Begin with small amount of water Gradually introduce formula Introduce solid foods suitable to child’s age & tolerance Encourage a high protein diet

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SIGN OF COMPLICATION

1. Increase ICP indicates shunt malfunction/ETV blocked Older children should also be observed for changes

in behavior, sleep patterns & development capabilities

2. Dehydration Less urine output, urine S.G high Diminished skin turgor & dryness of mucous

membrane Lethargy

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3. Infection Fever ( temp normally fluctuates during 1st 24 hrs after

surgery) Purulent discharge from incision Swelling, redness & tenderness along shunt tract

4. Excessive drainage of fluids from cranial cavity:- Sunken fontanels , agitation, restlessness Decrease level of consciousness

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PATIENT/FAMILY TEACHING

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Be sure that patient/family know and understand the following The nature of hydrocephalus & treatment The need to ambulate as tolerated Names of medication, dosages, frequency of administration,

purpose and side effects The possibility of re-operation

Teach patient & family members Signs and symptoms of increasing ICP Emphasize the importance of seeking immediate treatment

Ensure patient & family understand the importance of On going out patient care Maintaining well balance diet

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Parents should be encouraged to treat the child as normally as possible

Generally few restriction need to be placed on his daily activities

If appropriate, refer to the section on mental retardation for additional area of parent teaching

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GLASGOW COMA SCALE

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WHAT IS GLASGOW COMA SCALE?

scale which is used to measure the consciousness of a person

invented in 1974 by Teasdale G & Jennett B (University of Glasgow)

consist of 3 parameter :-Eye response (4)Verbal response (5)Motor response (6)

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BEST EYE RESPONSE (E)

No eye opening Eye opening in response to pain

(for example when his sternum is pressed firmly)

Eye opening to speech (that is, when he is called)

Eyes opening by himself (normally)

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BEST VERBAL RESPONSE (V)

No verbal response (not talking at all) Making meaningless sounds (that is, moaning but

no words) Inappropriate words (like random speech, without

being able to communicate correctly) Confused (The patient responds to questions but

there is some confusion) Oriented (Patient responds appropriately to

questions such as the patient’s name and age, where they are and why, the year, month, etc)

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BEST MOTOR RESPONSE (M)

No motor response (no movement at all) Extension in response to pain Flexion in response to pain (decorticate

response) Withdrawing from pain (pulling part of body away

when pinched) Localizing to pain(Purposeful movements towards

the painful location) Obeys commands

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Areas where you can apply painful stimulation

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HOW DO YOU CONVEY YOUR GCS FINDINGS

The phrase GCS of 11 is essentially meaningless

Important to break the figure down into its components such as E3 V3 M 5 = 11

Or describe the components such as eyes open to speech, verbal,

inappropriate words and localize to pain

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WHAT IS THE DIFFERENCE BETWEEN GCS AND NEUROSURGICAL OBSERVATION CHART?

Neurosurgical observation chart consist of:- Glasgow Coma Scale Vital Sign Pupillary response Limb movements

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CHECKING OF PUPILLARY RESPONSE

SizeReactionComparison of both pupilsTo give an accurate reading you need :

Bright pen torchlight Dim surroundings Shine from the temporal region an towards The pupil

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LIMB MOVEMENT OR MOTOR FUNCTION

It differs from the examination done by the doctor which includes a detailed examination of the motor system

Nursing assessment only provides a baseline and also to detect any significant change from the baseline

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HOW DO YOU PERFORM LIMB MOVEMENT?

Upper extremities :-Lift up both the hands and compare

Squeeze the examiner’s fingers

Push against resistance provided by the examiner

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Lower extremities :-Flex and extend the upper leg, knee and ankle on each side

Press on the pedal against the resistant provided by the examiner

Ask ambulating pt to walk & assess gait

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For unconscious and very drowsy patient Stimulating both limb together and at the same time Lifting both the arms and releasing them simultaneously Flexing both the leg and releasing them simultaneously

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HOW OFTEN DO YOU NEED TO ASSESS THE PATIENT?

Depends on the condition of the patientHourly for immediate post op and head

injury patientAs patient improves

frequency will be reduced – 2 hly,4hly and so on

Depends on the professional nurses judgment

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