Congenital Hydrocephalus Revised

CHAPTER IINTRODUCTION

Hydrocephalus is derived from the Greek words "hydro" meaning water and "cephalus" meaning head. As the name implies, it is a condition in which the primary characteristic is excessive accumulation of fluid in the brain. Although hydrocephalus was once known as "water on the brain," the "water" is actually cerebrospinal fluid (CSF)--a clear fluid that surrounds the brain and spinal cord. The excessive accumulation of CSF results in an abnormal widening of spaces in the brain called ventricles. This widening creates potentially harmful pressure on the tissues of the brain.

The ventricular system is made up of four ventricles connected by narrow passages.. Normally, CSF flows through the ventricles, exits into cisterns (closed spaces that serve as reservoirs) at the base of the brain, bathes the surfaces of the brain and spinal cord, and then reabsorbs into the bloodstream.

CSF has three important life-sustaining functions:

1) to keep the brain tissue buoyant, acting as a cushion or "shock absorber";

2) to act as the vehicle for delivering nutrients to the brain and removing waste; and

3) to flow between the cranium and spine and compensate for changes in intracranial blood volume (the amount of blood within the brain).

The balance between production and absorption of CSF is critically important. Because CSF is made continuously, medical conditions that block its normal flow or absorption will result in an over-accumulation of CSF. The resulting pressure of the fluid against brain tissue is what causes hydrocephalus.

The causes of hydrocephalus are still not well understood. Hydrocephalus may result from inherited genetic abnormalities (such as the genetic defect that causes aqueductal stenosis) or developmental disorders (such as those associated with neural tube defects including spina bifida and encephalocele). Other possible causes include complications of premature birth such as intraventricular hemorrhage, diseases such as meningitis, tumors, traumatic head injury, or subarachnoid hemorrhage, which block the exit of CSF from the ventricles to the cisterns or eliminate the passageway for CSF into the cisterns.

Congenital Hydrocephalus | 1

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RATIONALE

We chose this case because we wanted to have a further knowledge regarding this case, Congenital Hydrocephalus. We wanted to use the knowledge we had acquired to promote and provide care. We wanted to be aware on different aspects on how and why this case develops and what are the possible cares we can render to promote health.

LEARNING OBJECTIVES

Cognitive To define the meaning of the chosen case.

To learn the treatment and other related management regarding the said case.

To illustrate the anatomy and physiology and pathophysiology of the chosen case.

To raise the level of awareness of the student nurse regarding the information about the health problems of his/her patient.

Psychomotor To apply and enhance skills and attitude in rendering good nursing

care for the patient.

To practice the application of nursing process.

Behavioral To develop understanding and empathy on the client’s condition.

To provide support for the patient with hydrocephalus.

To establish good nurse-patient relationship with the use of therapeutic communication and building rapport.

To help patient in motivating her to continue the health care provided by the health workers.


CHAPTER IICLINICAL SUMMARY

A. GENERAL DATA (Newborn)

Category Demographic Data

Name : Baby G.Gender : Male

Age : NB – 4 daysBirth Date : November 20, 2011

Nationality : FilipinoReligion : Roman Catholic

Civil Status : SingleAddress : Malitbog, Bongabong, Oriental Mindoro

Admitting Diagnosis : Live Term NB Baby Boy by LTCS Hydrocephalus

Principal Diagnosis : Live Term NB Baby Boy by LTCS Hydrocephalus

Date of Admission : November 20, 2011Time of Admission : 11:20 pm

B. CHIEF COMPLAINT (Newborn)

The patient was admitted at New Oriental Mindoro Provincial Hospital immediately after the caesarian section delivery on November 20, 2011 at 11:20 pm with the chief complaint of Live Term NB Baby Boy by LTCS Hydrocephalus.

C. HISTORY OF PRESENT ILLNESS (Mother)

A 36 year old, female, a multigravida, on her AOG 39 weeks was admitted at the New Oriental Mindoro Provincial Hospital on November 19, 2011 at 10:58 pm, on a stretcher accompanied by her relatives with the chief complain of show.

“May lumalabas ng dugo sa puwerta ko” as verbalized by the patient.

Upon admission her vital sign was as follow: Respiratory Rate was 20 CPM, Pulse Rate was 97 BPM, and Temperature was 37.0C.

The patient’s mother stated that on November 15, 2011 at around 1:00 PM she felt that her back was aching, “Sumakit ang likod” as verbalized by the patient’s mother. At around 12:00 AM the next day the patient felt pain in her abdomen, “Humilab na yung tiyan ko” as verbalized by the patient’s mother. The


patient’s husband took the initiative in bringing her wife in the Hospital. The patient’s mother was first brought to the Pinamalayan Doctor’s Hospital on November 16, 2011 at 11 am. Then was referred to New Oriental Mindoro Provincial Hospital because the ultrasound detected the big head of the baby, “Inilipat kami dito sa Provincial kasi sabi malaki daw ang ulo ng baby ko” as verbalized by the patient’s mother.

D. PAST MEDICAL HISTORY (Mother)

The patient stated that she had a past hospitalization due to a spontaneous abortion last August 2009 at the Pinamalayan Doctor’s Hospital. Other than that she has no other hospitalization. The patient reported that her first baby with her first husband was delivered through a hilot and her first baby with her second husband was also delivered through a hilot.

The patient stated that she was on the 2nd month of her pregnancy with her 2nd pregnancy with her second husband when she went to the market and grocery. She bought several good for them. She went home and cooked food for their lunch. She sat down on their set and watched television while waiting for her husband and relatives. “Magtatanghali ga nun dalawang buwan ang tiyan ko, namalengke ako tapos pag-uwi ko niluto ko yung mga pinamili ko. Umupo ako sa sala set at nanuod ng tv habang hinihintay ko yung asawa at mga nanay ko,” as verbalized by the patient. She stated that she saw her legs with blood, she saw her panty with full of blood, “Nakita ko na may dugo sa hita ko at pagtingin ko sa panty ko madami ng dugo” as verbalized by the patient. The patient was then rushed to the Pinamalayan Doctor’s Hospital. The patient added that the doctor told her that her baby was miscarriage. “Sabi nung doctor nakunan daw ako” as verbalized by the patient. The patient stated that she had undergone on dilatation and curettage to expel the fragment of conception and to prevent the bleeding. “Niraspa ko sabi nung doctor para daw matanggal yung tira sa inunan at para hindi daw ako duguin” as verbalized by patient.

OB Score of the patient’s mother was G4 P3 (T3 P0 A1 L3).

E. FAMILIAL HISTORY

The patient’s mother stated that she had one child with her first husband. The child is with her alive and well. She had a second husband were she had 1 child


GRANDFATHERdeceased

GRANDMOTHER60 y/o - A&W

2nd HUSBAND41 y/o – A&W

8 y/oA&W

4 y/oA&W A

P4 days

Mother31 y/o

1st HUSBAND

alive and well plus the baby who was currently admitted at the New Oriental Mindoro Provincial. Her father was dead and her mother was alive and well. She has two brothers; they were both alive and well.

LEGEND:

- Male A&W – Alive and Well

- Female P - Patient

F. PHYSICAL ASSESSMENT (Newborn)

General Appearance: The patient was seen lying on his bed. Patient has heparin on his right hand. Patient looks restless.

VITAL SIGNS FINDINGSTemperature 36.8ᵒCCardiac Rate 137

Respiratory Rate 40

APGAR SCORE1 minute after birth 2

10 minute after birth 4


Mother31 y/o

1st HUSBAND

ANTHROPOMETICSHead Circumference 48 cmChest Circumference 34 cm

Abdomen Circumference 31 cmLength 53 cmWeight 4,200 grams

HEAD TO TOE ASSESSMENTAREA

ASSESSEDTECHNIQUE

USEDNORMAL FINDINGS

SIGNIFICANT FINDINGS

INTERPRETATION

INTEGUMENTARY SYSTEM

Hair

Skull And Face

Eyes And Vision

Inspection, Palpation


Inspection

Inspection

Inspection

Black Smooth Neither brittle nor dry

EYE Evenly placed and in line with each other

PUPIL Symmetrical in shape Reactive to light and accommodation Constricts when passed by light at 3mmCONJUNCTIVA Pinkish in color No inflammation Moist No ulcer

Thin, Scattered or Not evenly

hair

Head size enlarge,

elongated in shape,

Asymmetric facial

movements

“Sunset” eyes

Due to enlarge head

Due to congenital

hydrocephalus

Due to the increased

pressure in the skull pressing on

important nerves running from the brain to the muscles responsible for eye movement

No deviation

No deviation

No deviation


Ears And Hearing

Nose And Sinuses

Mouth And Oropharynx



Inspection

EYE LASHES Evenly distributed Turn outward

Symmetrical in shape, with no visible cerumen on the outer ear No discharge or lesion upon inspection No pain/tenderness upon palpation of auricle and mastoid process Pinna recoils when fold

In the midline No discharge Nares are symmetrical without inflammation andirritation noted Nose bridge intact, No tenderness noted on palpation No bone and cartilage deviation noted on palpation Moist lips Tongue is in the midline Without dentures

Flat pinna, low set ears

Due to prolonged side lying, due to enlarge head

No deviation

No deviation

NECK Inspection, Palpation

Trachea is in the middle Presence of carotid pulse No Jugular venous distention

No coordinated movement

Due to enlarge head cannot support head movement

UPPER EXTREMITIES

Skin And Nails Inspection, Palpation

No edema, no lesions

No deviation


Muscle And Strength

Inspection

No lumps or mass upon palpation

No contractures

No deviation

CHEST AND BACKSpinal Column

Lungs

Heart

Anterior And Posterior

Chest


Auscultation

Palpation


Chest symmetric Spinal column straight Skin intact No masses

Normal breath sounds upon auscultation Respiratory rate within normal range

No palpitation Cardiac Rate within normal range

Normal in size, shape, and color Without mass, lumps, and tenderness noted

No deviation

No deviation

No deviation

No deviation

ABDOMENSkin Inspection,

Palpationsymmetric movements caused by respirationno masses or lesion upon palpation and inspection

No deviation

LOWER EXTREMITIES

Skin and Toenails

Muscle and Strength


Inspection

No edema, no lesions No lumps or mass upon palpation

No contractures

No deviation

No deviation


G. LABORATORY AND DIAGNOSTIC EXAM

ULTRASOUND (Cranial Ultrasound)The cranium is fluid filled.The interhemispheric fissure is seen.Thinned out cerebral cortex is seen.No identifiable structure in the posterior fossa.

Impression: CONGENITAL HYDROCEPHALUSMRI of the brain is recommended.

CHAPTER IIICLINICAL DISCUSSION OF THE DISEASE

A. ANATOMY AND PHYSIOLOGY

The human brain has the same general structure as the brains of other mammals, but is larger than expected on the basis of body size among other primates. Estimates for the number of neurons (nerve cells) in the human brain range from 80 to 120 billion. Most of the


expansion comes from the cerebral cortex, especially the frontal lobes, which are associated with executive functions such as self-control, planning, reasoning, and abstract thought. The portion of the cerebral cortex devoted to vision is also greatly enlarged in human beings, and several cortical areas play specific roles in language, a skill that is unique to humans.

Despite being protected by the thick bones of the skull, suspended in cerebrospinal fluid, and isolated from the bloodstream by the blood-brain barrier, the human brain is susceptible to many types of damage and disease. The most common forms of physical damage are closed head injuries such as a blow to the head, a stroke, or poisoning by a variety of chemicals that can act as neurotoxins. Infection of the brain, though serious, is rare due to the biological barriers which protect it. The human brain is also susceptible to degenerative disorders, such as

Parkinson's disease, multiple sclerosis, and Alzheimer's disease. A number of psychiatric conditions, such as schizophrenia and depression, are thought to be associated with brain dysfunctions, although the nature of such brain anomalies is not well understood.

The cerebral hemispheres form the largest part of the human brain and are situated above most other brain structures. They are covered with a cortical layer with a convoluted topography. Underneath the cerebrum lies the brainstem, resembling a stalk on which the cerebrum is attached. At the rear of the

brain, beneath the cerebrum and behind the brainstem, is the cerebellum, a structure with a horizontally furrowed surface that makes it look different from any other brain area. The same structures are present in other mammals, although the cerebellum is not so large relative to the rest of the brain. As a rule, the smaller the cerebrum, the less convoluted the cortex. The cortex of a rat or mouse is almost completely smooth. The cortex of a dolphin or whale, on the other hand, is more convoluted than the cortex of a human.

Choroid Plexus

The choroid is a structure in the ventricles of the brain where cerebrospinal fluid (CSF) is produced. The cho roid plexus consists of modified ependymal cells.

Choroid plexus is present in all components of the ventricular system except for the


cerebral aqueduct, frontal horn of the lateral ventricle, and occipital horn of the lateral ventricle.

It is found in the superior part of the inferior horn of the lateral ventricles. It follows up along this boundary, continuous with the inferior of the body of the lateral ventricles. It passes into the interventricular foramen, and is present at the top of the third ventricle.

There is also choroid plexus in the fourth ventricle, in the section closest to the bottom half of the cerebellum.

he choroid plexus (CP) consists of many capillaries, separated from the ventricles by choroid epithelial cells. Liquid filters through these cells from blood to become cerebrospinal fluid. There is also much active transport of substances into, and out of, the CSF as it is made.

There are four choroid plexi in the brain, one in each of the ventricles. The CP consist of a layer of cuboidal epithelial cells su rrounding a core of capillaries and loose connective tissue. The CP epithelial layer is continuous with the ependymal cell layer that lines the ventricles, but unlike the ependyma the CP epithelial layer has tight junctions in between the cells on the side facing the ventricle (apical surface). These tight junctions prevent the majority of substances from crossing the cell layer into the CSF; thus the CP acts as a blood-CSF barrier. The CP folds into many villi around each capillary, creating frond-like processes that project into the ventricles. The villi, along with a brush border of microvilli, greatly increases the surface area of the CP. CSF is formed as plasma is filtered from the blood through the epithelial cells. CP epithelial cells actively transport sodium, chloride and bicarbonate ions into the ventricles and water follows the resulting osmotic gradient.

In addition to CSF production, the CP act as a filtration system, removing metabolic waste, foreign substances, and excess neurotransmitters from the CSF. In this way the CP have a very important role in helping to maintain the delicate extracellular environment required by the brain to function optimally.


VENTRICULAR-PERITONEAL SHUNT (VP Shunt)

Ventriculoperitoneal shunting is surgery to relieve increased pressure inside the skull due to excess cerebrospinal fluid (CSF) on the brain (hydrocephalus).

WHY IT IS PERFORMED?

In hydrocephalus, there is a buildup of fluid of the brain and spinal cord (cerebrospinal fluid or CSF). This buildup of fluid causes higher than normal pressure on the brain. Too much pressure, or pressure that is present too long, will damage the brain tissue.

A shunt helps to drain the excess fluid and relieve the pressure in the brain. A shunt should be placed as soon as hydrocephalus is diagnosed.

PROCEDURE:

This procedure is done in the operating room under general anesthesia. It takes about 1 1/2 hours.

The child's hair behind the ear is shaved off. A surgical cut in the shape of a horseshoe (U-shape) is made behind the ear. Another small surgical cut is made in the child's belly.

A small hole is drilled in the skull. A small thin tube called a catheter is passed into a ventricle of the brain.

Another catheter is placed under the skin behind the ear and moved down the neck and chest, and usually into the abdominal (peritoneal) cavity. Sometimes, it goes to the chest area. The doctor may make a small cut in the neck to help position the catheter.

A valve (fluid pump) is placed underneath the skin behind the ear. The valve is attached to both catheters. When extra pressure builds up around

the brain, the valve opens, and excess fluid drains out of it into the belly or chest area. This helps decrease intracranial pressure.

The valves in newer shunts can be programmed to drain more or less fluid from the brain.


RISKS:

Risks for any anesthesia are:

Reactions to medications Problems breathing Changes in blood pressure or breathing rate

Risks for any surgery are:

Bleeding Infection

Possible risks of ventriculoperitoneal shunt placement are:

Blood clot or bleeding in the brain Brain swelling The shunt may stop working and fluid will begin to build up in the brain again. The shunt may become infected. Infection in the brain Damage to brain tissue Seizures

PRE-OPERATIVE NURSING CARES:

Assess head circumference, fontanelles, cranial sutures, and LOC; check also for irritability, altered feeding habits and a high-pitched cry.

Firmly support the head and neck when holding the child. Provide skin care for the head to prevent breakdown. Give small, frequent feedings to decrease the risk of vomiting. Encourage parental-newborn bonding.

POST-OPERATIVE NURSING CARES:

Assess for signs of increased ICP and check the following; head circumference (daily), anterior fontanelle for size and fullness and behavior.

Administer prescribed medications which may include antibiotics to prevent infection and analgesics for pain.

Provide shunt care

Monitor for shunt infection and malfunction which may be characterized by rapid onset of vomiting, severe headache, irritability, lethargy, fever, redness along the shunt tract, and fluid around the shunt valve.


Prevent infection (usually from Staphylococcus epidermis or Staphylococcus aureus)

Monitor for shunt overdrainage (headache, dizziness and nausea). Overdrainage may lead to slit ventricle syndrome whereby the ventricle become accustomed to a very small or slitlike configuration, limiting the buffering ability to increased ICP variations.

B. PHYSIOLOGY OF CONGENITAL HYDROCEPHALUS


PREDISPOSING FACTORS: Genetics Age

PRECIPITATING FACTORS: Prematurity Infection Tumor Hemorrhage Idiopathic

CSF forms in the Choroid plexus of the lateral ventricles.

Obstruction in the aqueduct due to incomplete formation of the lateral and

medial foramina. Or it can get way out but not efficiently absorb in the lining of the

brain.

Fluid accumulates; the spaces on the ventricles get larger

C. DRUG STUDY

DRUG NAME

CLASSIFICATION

DOSAGE INDICATIONS/CONTRAINDICATIONS

ADVERSE REACTIONS

MECHANISM OF ACTION

NURSING CONSIDERATIONS

AMPICILLIN anti- infective 210 mg, IV q 8 hrs.

Indication:Treatment of infections caused by susceptible strains of the designated organisms.

Contraindication:Patients with allergic reaction to penicillin.Patients with hypersensitivity to drug and patients with viruses belonging to herpes-group.

Skin rashes, nausea and vomiting, diarrhea, and pain at injection site.

Inhibits cell-wall synthesis during bacterial multiplication.

Before giving the drug ask patient about allergic reactions to penicillin or a negative history of penicillin allergy.Watch for signs and symptoms of hypersensitivity.


DRUG NAME

CLASSIFICATION

DOSAGE INDICATION/CONTRAINDICATION

ADVERSE REACTION

MECHANISM OF ACTION

NURSING CONSIDERATIONS

Gentamicin sulfateGaramycin, G-myticin

Aminoglycoside 210 mg, IV q 8 hrs.

Indication:ParenteralSerious infections caused by susceptible strains of Pseudomonas aeruginosa, Proteus sp., Escherichia coli, Klebsiella-Enterobacter-Serratia species, Citrobacter, Staphylococcus sp.Intrathecal· For serious CNS infections caused by susceptible Pseudomonas speciesContraindication:Contraindicated with allergy to any aminoglycosides; renal or hepatic disease; preexisting hearing loss; active infection with herpes, vaccinia, varicella, fungal infections, myobacterial infections (ophthalmic preparations); myasthenia gravis; parkinsonism; infant botulism; lactation.

Ototoxicity--tinnitus, dizziness, vertigo, deafness (partially reversible to irreversible), vestibular paralysis, confusion, disorientation, depression, lethargy, nystagmus, visual disturbances, headache, numbness, tingling, tremor, paresthesias, muscle twitching, convulsions, muscular weakness, neuromuscular blockade.

Broad-spectrum aminoglycoside antibiotic derived from Micromonospora purpurea. Action is usually bacteriocidal.

Give by IM route if at all possible; give by deep IM injection.· Culture infected area before therapy.· Use 2 mg/mL intrathecal preparation without preservatives, for intrathecal use.· Cleanse area before application of dermatologic preparations.· Ensure adequate hydration of patient before and during therapy.


CHAPTER IVNURSING PROCESS

A. PROBLEM LIST

Problem Date Identified Date Resolved

Anxiety related to family situational crisis.

November 25, 2011 November 25, 2011

B. NURSING CARE PLAN


Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:“Parang hindi ata normal ang anak ko” as verbalized by the patient’s mother

Objective: Confused Worried Frightened Statement of

inability to meet child’s need

Anxiety related to

family situational

crisis, Abnormal

baby.

At the end of the shift the parents will: demonstrate

family coping techniques

participate in decision-making process

1. Facilitated open communication to the family members

2. Explained some information about the condition of their baby in a simple way

3. Encouraged family to verbalize feelings and concerns and encourage family to participate in patient’s care and decision making

4. Provided mother-infant relationship like in breast feeding and viewing time

5. Assisted family to focus on the child rather than on illness like talking the baby as a new member of the family

1. To established rapport and cooperation

2. To understand the condition of the patient

3. To provide guidelines and independency in caring with the patient

4. For Easily acceptance and bonding to the patient

5. To show acceptance

Goal met. At the end of the

shift the parents

demonstrated family coping techniques,

participated in decision-making process.


C. DISCHARGE PLANNING

The patient was not yet on discharge when we handled him. But in case that he will be discharge, this will be his discharge plan.

MEDICATIONS Describe the importance of regularly taking of prescribed medications to the

parents. Instruct the parents to continue with follow up medical care with their baby Advise the parents not to miss the

intake of medications given by the physician upon discharge with their baby

ENVIRONMENT/ EXERCISE Maintain a quiet, pleasant, environment to promote relaxation. Provide clean, comfortable and safety crib or bed.

TREATMENT Repeat for follow up check up

HEALTH TEACHING Explain the underlying disorder and treatment plan to the parents. General health measures (adequate sleep, proper diet, and maintaining a

clean surrounding).

OUT PATIENT Parents are advised to go back in the hospital in a specific date to have a

follow-up check up after discharge. Consult doctor for any problems or complications encountered by the patient.

DIET Exclusive breastfeeding

SPIRITUAL

Nursing actions to help parent’s patient meet their spiritual needs include:o providing presenceo supporting religious practiceso assisting clients with prayer o referring client for spiritual counseling


Congenital Hydrocephalus Revised

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