I. Introduction

Hydrocephalus or "water on the brain." is a build-up of fluid inside the skull,

leading to brain swelling, and ventriculoperitoneal shunt is a basic part of its

treatment. Hydrocephalus is due to a problem with the flow of cerebrospinal fluid

(CSF), the liquid that surrounds the brain and spinal cord. The fluid brings nutrients

to the brain, takes away waste from the brain, and acts as a cushion.

CSF normally moves through areas of the brain called ventricles, then around

the outside of the brain and the spinal cord. It is then reabsorbed into the

bloodstream. Buildup of CSF can occur in the brain if its flow or absorption is

blocked or if too much CSF is produced. This build-up of fluid puts pressure on the

brain, pushing the brain up against the skull and damaging or destroying brain

tissues.

Hydrocephalus may start while the baby is growing in the womb. It is

commonly present with myelomeningocele, a birth defect involving incomplete

closure of the spinal column. Genetic defects and certain infections that occur

during pregnancy may also cause hydrocephalus. In young children, hydrocephalus

may also be associated with the following conditions: Infections that affect the

central nervous system (such as meningitis or encephalitis), especially in infants,

bleeding in the brain during or soon after delivery (especially in premature babies),

injury before, during, or after childbirth, including subarachnoid hemorrhage,

tumors of the central nervous system, including the brain or spinal cord, Injury or

trauma.

The goal of ventriculoperitoneal shunting is to reduce or prevent brain

damage by improving the flow of CSF.

The blockage may be surgically removed, if possible. If the blockage cannot

be removed, a shunt (flexible tube) may be placed within the brain to allow CSF to

flow around the blocked area. The shunt tubing travels to another part of the body,

such as the abdomen, where the extra CSF can be absorbed. This procedure is done

in the operating room under general anaesthesia. 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

1

(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.

As Nurses, one should always be updated with current procedures, treatment,

and management applied in the clinical setting. One should be well informed in

advances in the field since this can be used in fulfilling the role of a Nurse as a

Health Educator. An In-depth study of this procedure should be advocated by the

Nurses since they are also involved in the Procedure. As a member of the Health

team and a member of the sterile team, it is important to be well educated and well

informed not only in skills but also in theory during practice since one is dealing

with life. . Research in this area can help shed light into the workings of the disease,

the predisposing factors, impact on the morbidity and mortality rates and the

measures taken by the health care team in the treatment and control of the

condition.

2

Anatomy

Cerebrospinal fluid or CSF surrounds the brain and spinal cord. This clear fluid

serves to cushion and protect the brain and spinal cord. CSF is produced in an area

of the brain, flows around the brain through special channels, and then is absorbed

in another location of the brain. Any blockage of the channels can result in fluid

buildup, or hydrocephalus. 

Brain Anatomy

The brain is well protected by:

The scalp 

The skull 

The dura 

o A tough 3-layer sheath that surrounds the

brain and spinal cord

o Layers include the dura mater (strongest layer), arachnoid mater (middle

layer), and pia mater (closest to the brain)

The brain is a complicated structure containing many parts. These include:

The cerebrum:

o Made up of two cerebral hemispheres that are connected in the middle 

o It is the largest part of the brain 

o Each area of the cerebrum performs an important function, such as

language or movement 

o Higher thought (cognition) comes from the frontal cortex (front portion of

the cerebrum)

o Outside of the cerebrum are blood vessels 

o There are fluid-filled cavities and channels inside the brain 

o

The cerebellum:

o Located in the lower, back part of the skull 

3

o Controls movement and coordination

The brainstem and pituitary gland:

o Responsible for involuntary functions such as breathing, body temperature,

and blood pressure regulation 

o Pituitary gland is the "master gland" that controls other endocrine glands in

the body, such as the thyroid and adrenal glands

The cranial nerves:

o Twelve large nerves exit the bottom of the brain

to supply function to the senses such as hearing,

vision, and taste 

The cerebral blood vessels:

o A complicated system that supplies oxygenated

blood and nutrients to the brain 

The blood supply to the brain is divided into two main parts:

Anterior cerebral circulation:

o The front of the brain is supplied by the paired carotid arteries in the neck. 

Posterior cerebral circulation:

The back portion of the brain is supplied by the paired vertebral arteries in

the spine. 

4

Hydrocephalus is a condition caused by an imbalance in the production and absorption of CSF in the ventricular system. When production exceeds absorption, CSF accumulates, usually under pressure, producing dilation of the ventricles.

It is a term derived from the Greek words “hydro” meaning water, and “cephalus” meaning head, and this condition is sometimes known as “water on the brain”.

People with hydrocephalus have abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles, or cavities, of the brain. This may cause increased intracranial pressure inside the skull and progressive enlargement of the head, convulsion, and mental disability.

Usually, hydrocephalus does not cause any intellectual disability if recognized and properly treated. A massive degree of hydrocephalus rarely exists in typically functioning people, though such a rarity may occur if onset is gradual rather than sudden.Hydrocephalus occurs with a number of anomalies, such as NTD’s.

Etiology:Congenital hydrocephalus usually results from defects, such as Chairi

malformations. It is also associated with spina bifida.Acquired hydrocephalus usually results from space-occupying lesions,

hemorrhage, intracranialinfections or dormant development defects.

People with hydrocephalus have abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles, or cavities, of the brain. This may cause increased

5

intracranial pressure inside the skull and progressive enlargement of the head, convulsion, and mental disability.Usually, hydrocephalus does not cause any intellectual disability if recognized and properly treated. A massive degree of hydrocephalus rarely exists in typically functioning people, though such a rarity may occur if onset is gradual rather than sudden.Hydrocephalus occurs with a number of anomalies, such as NTD’s.

6

PATHOPHYSIOLOGY

7

Choroid Plexuses of the Lateral Ventricles

CSF Formation

Impaired Absorption of CSF within the Arachnoid Space

(communicating hydrocephalus)

Obstruction to the flow of CSF through the ventricular system

(non-communicating hydrocephalus)

Increased ICP

Dilation of the pathways proximal to the site of obstruction

Abnormal increase in volume of CSF

Enlargement of the head in infancy

III. CLINICAL INTERVENTION

1.1 Description of prescribed surgical treatment performed

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

Description

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.

8

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.

THE PROCEDURE

Position of the child is important to correctly implant the shunt. The head is

turned sharply to the left to accommodate a right occipital placement. The burr hole is

placed approximately 4 cm up from the inion and 3-4 cm off the mid-line. This occipital

placement allows a relatively straight shot into the body of the ventricle so that the shunt

catheter is mostly within it. This trajectory avoids the risk of going too low, through the

internal capsule, which can happen with shunt placement sites that are more lateral and

inferior.

An adequate length of ventricular catheter needs to be selected to place the tip anterior

to the foramen of Munroe, where there is less choroid plexus. This is to lessen the risk

of occlusion. Generally, a 6 cm catheter is used in a small newborn; an 8 cm catheter in

an older infant and young child; and a 10 cm catheter is used in a children 18 months or

older. Perioperative antibiotics can be used, though definitive data showing that this is

mandatory is lacking.

The shoulder blades should be raised to elevate the chest and neck, and allow for a

straight passage of the shunt passer with no secondary incisions between the head and

the abdomen. The abdominal incision is a horizontal incision, either just below the rib

cage or just lateral to the umbilicus. Once the shunt is laid in position, the dura is

opened with a pinpoint cautery to have just a big enough opening to allow the passage

of the catheter (a large dural opening can allow CSF to flow around the shunt and cause

a subcutaneous fluid collection). The ventricle is tapped using a rigid brain cannula and,

once a good flow of CSF has been obtained, the ventricular catheter is fed into the

ventricle through this tract. This is done without a stylette.

9

Fluid should then be aspirated from the lower end of the shunt, to insure that the valve

system is opened, and then it should then be placed into the peritoneal cavity. A large

amount of tubing can be placed in the peritoneal cavity, even enough to allow for full

growth of the child. 15-20" of peritoneal catheter is usually inserted at the same time as

the initial shunt placements.

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

1.2 Indication of prescribed surgical treatment

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The procedure is indicated for people with hydrocepahalus. 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.

1.3 Required instruments, devices, supplies, equipment and facilities

The Operating Room

Surgical Drill

11

Used to created a burr hole.

Dissecting Instruments

In the first part of the surgery, incisions are made with dissectors, which are either sharp

or and are used to make precise incisions, the most well know example being the

scalpel. Blunt instruments, such as the elevator or the curette are mostly used to scrape

tissues.

Clamps

12

After the incision is made, the surrounding skin is clamped with the use of forceps or

clips. These instruments are also used to hold not only tissues, but also other

instruments.

Cauterization

An electrocautery machine is used to remove lesions and tissues that are highly

vascularized. The machine reduces the risk of bleeding, sealing off blood vessels by

using high frequency electric currents to instantly stop bleeding.

e. Suction

13

Oozing of blood and other fluids are inevitable in a surgical procedure, including

a ventriculoperitoneal shunt procedure. The suction machine is tied to a container

where the loss of fluid can be measured and monitored during the procedure.

f. Sutures, Staples, Needles

Closure of the incision site occurs after the procedure. The needles, along with the

sutures are used to properly close the site. Sutures can be absorbable or non-

absorbable. Staples, however, are used frequently nowadays to speed up the surgery

and reduce the chance of infection due to an open wound

g. Drains

Before surgical closure, a drain is attached to the site to remove the remaining fluid left

over from the procedure. It also allows the medical personnel to monitor the amount of

bleeding during the post-operative phase. Its drainage also helps a physician determine 14

if an infection is developing or healing. Removal of the drains is the prerogative of the

surgical team, which usually leave it in place for five to six post-operative days.

1.4 Perioperative tasks and responsibilities of the Nurse

PRE-OPERATIVE CARE

Preparing the operating theatre

Ensure that:

the operating theatre is clean (it should be cleaned after every procedure)

necessary supplies and equipment are available, including drugs and an oxygen

cylinder

emergency equipment is available and in working order

there are adequate supply of theatre dress for the anticipated members of the

surgical team

clean linens are available

sterile supplies (gloves, gauze, instruments) are available and not beyond expiry

date

Surgical handscrub

15

Remove all jewelry.

Hold hands above the level of the elbow, wet hands thoroughly and apply soap

(preferably an iodophre, e.g. betadine).

Begin at the fingertips and lather and wash, using a circular motion:

Wash between all fingers;

Move from the fingertips to the elbows of one hand and then repeat for the

second hand.

Wash for three to five minutes

Rinse each arm separately, fingertips first, holding hands above the level of the

elbows.

Dry hands with a clean or disposable towel, wiping from the fingertips to the

elbows, or allow hands to air dry.

Ensure that scrubbed hands do not come into contact with objects (e.g.

equipment, protective gown) that are not high-level disinfected or sterile. If the

hands touch a contaminated surface, repeat surgical handscrub.

INTRA OPERATIVE CARE

Assist in the sterile gowning and gloving of the surgeon and his or her assistant.

Prevent injury to the patient by removing heavy or sharp instruments from the

operative site as soon as the surgeon has finished using them.

Constantly be alert to any intraoperative dangers to the patient.

Take part in sponge, needle, and instrument counts, as needed. All of these

items must be accounted for during the procedure. The technologist takes part in

counting the items before, during, and after surgery to ensure that they are not

left in the wound. The count is done in an orderly way and is performed using

accepted technique.

16

Properly identify and preserve specimens received during surgery. The

technologist is responsible for maintaining the specimens in a prescribed manner

so that the material can be subsequently examined by the pathologist.

Anticipate the needs of the surgeon by watching the progress of the surgery and

knowing the various steps of the procedure. He or she passes instruments and

other supplies in an acceptable manner so that the surgeon does not have to turn

away from the wound site to receive them.

Assist the surgeon by tissue retraction, suture cutting, fluid evacuation, or

sponging the wound when asked to do so.

At the end of the procedure, assemble all instruments and supplies and prepare

them for decontamination and resterilization and assist in the safe clean-up of the

operating suite following Universal Precautions.

POST OPERATIVE CARE

At the recovery room, the nurse will monitor the blood pressure, pulse and

breathing of the patient

Place a dressing (bandage) over the surgery site

Provide instructions on how to care for the patient at home, including taking care

of the incision and drains, recognizing signs of infection and understanding

activity restrictions

Talk to the patient about when to resume wearing a bra or wearing a breast

prosthesis

Give prescriptions for pain medication and possibly an antibiotic

Remind the patient to meet with her doctor a week or two after surgery. The

drainage tubes will likely be removed at that time.

17

1.5 Expected outcomes of surgical treatment performed

Shunt placement is usually successful in reducing pressure in the brain. But if hydrocephalus is related to other conditions, such as spina bifida, brain tumor, meningitis, encephalitis, or hemorrhage, these conditions could affect the prognosis. The severity of hydrocephalus present before surgery will also affect the outcome.

Support groups for families of children with hydrocephalus or spina bifida are available in most areas.

The major complications to watch for are an infected shunt and a blocked shunt.

The patient will need to lie flat for 24 hours the first time a shunt placed. After that your child will be helped to sit up.

The usual stay in the hospital is 3 to 4 days.The doctor will check vital signs and neurological status often. Your child may get medication for pain. Intravenous fluids and antibiotics are given. The shunt will be checked to make sure it is working properly.

1.6 Medical management of physiologic outcomes

Pain Management

People experience different types and amount of pain or discomfort after surgery.

The goal of pain management is to assess the level of discomfort and to take

medication as needed. The patient will be given a prescription for analgesics for the

management of moderate pain. It is recommended to take medication for pain when

pain is experienced on a regular schedule. Ibuprofen (Advil) can be added to or replace

18

the analgesic. Everyone is different and if one plan to decrease pain is not working, it

will be changed. Healing and recovery improve with good pain control.

An icepack may also be helpful to decrease discomfort and swelling.

Incision and Dressing Care

Incision, or scar, has both stitches and steri-strips, which are small white strips of

tape, and is covered by a gauze dressing and tape or a plastic dressing. Advise the

patient not to remove the dressing, steri-strips or stitches. The nurse will remove the

dressing in seven to 10 days. The nurse will also remove the sutures in one to two

weeks unless they absorb on their own. If the dressing or steri-strips fall off, tell the

patient not to attempt to replace them.

Educate patient that bruising and some swelling are common after surgery. Also,

a low-grade fever that is below 100 degrees Fahrenheit is normal the day after surgery.

A home care nurse may be assigned to check your progress at home.

Activity

Inform patient to avoid strenuous activity, heavy lifting and vigorous exercise until

the stitches are removed. Walking is a normal activity that can be restarted right away.

Recommend exercises to regain movement and flexibility. Most people return to work

within three to six weeks.

Diet

The patient may resume regular diet as soon as you can take fluids after

recovering from anesthesia. Encourage to drink eight to 10 glasses of water and non-

caffeinated beverages per day, plenty of fruits and vegetables as well as lower fat

foods.

19

20

NURSING CARE PLAN

Deficient knowledge related to client and family understanding of the preoperative, operative, and

postoperative phases of ventriculoperitoneal shunt

Assessment Nursing

Diagnosi

s

Scientific

Explanation

Planning Nursing

Interventions

Rationale Evaluation

S>

“Napansin

ko na

hindi

normal ang

laki ng ulo

ng

anak ko” as

verbalized

by the

mother.

O> the

patient may

manifest:

Deficient

knowled

ge

related

to client

and

family

understa

nding of

the

preopera

tive,

operativ

e, and

postoper

Due to its

complicated

procedure,

the parents

of such

patients who

undergo this

surgery may

have many

misconceptio

n and lack of

information

which leads

to deficient

knowledge of

After 4

hours of

nursing

intervention

s, the family

will be able

to

participate

in learning

process and

exhibit

increased

interest/

assume

responsibilit

>Establish rapport 

 

>Assess patient’s

general condition

>Monitor and record

vital signs

>Obtain baseline

neurologic

assessment:

a. Motor and sensory

>To gain the trust and

cooperation of the

patient

>To obtain base line

data

>To obtain baseline

data

>Establishes baseline

motor and sensory

function for later

comparisons,

determines level of

Short-

term:

The family

shall have

participate

d in

learning

process

and

exhibited

increased

interest/

assumed

responsibil

21

-

Restlessnes

s

Irritability

-Changes in

VS

-

verbalizatio

n of

misconcepti

ons about

the

surgery of

So

ative

phases

of

ventricul

operiton

eal

shunt

the family. y for own

learning by

beginning to

look for

information

and ask

questions

Long-term:

After 3-5

days of

nursing

intervention

s, the client

and family

will be able

to have

sufficient

knowledge

regarding

the surgical

procedure,

preoperativ

function

b. Psychological

readiness 

 

>Discuss activity

limitation

>Review pain

management 

 

 

 

>Discuss proper

wound care 

ability and knowledge

>Prevents damage to

surgical site

>To gain knowledge

on treating / managing

postoperative pain

> to provide non

pharmacologic

interventions to

alleviate pain

>To prevent

ity for own

learning

by

beginning

to look for

informatio

n and ask

questions

Long-term:

The family

shall have

sufficient

knowledge

regarding

the

surgical

procedure,

preoperati

ve

preparatio

ns, and

22

e

preparations

, and the

postoperativ

e

precautions

and needs

to be able to

prevent the

developmen

t of

complicatio

ns

>Discuss changes in

home environment:

occurrence of infection

>Anticipate home care

needs

the

postoperat

ive

precaution

s and

needs to

be able to

prevent

the

developm

ent of

complicati

ons

23

Risk for infection secondary to surgical incision

Assessment Nursing

Diagnosis

Scientific

Explanation

Planning Nursing

Interventions

Rationale Evaluation

S> Ø

O>the

patient may

manifest:

-increased

body

temperature

-increased

WBC

-

inflammatio

n in the

surgical

Risk for

infection

secondar

y to

surgical

incision

The skin

considered as

the first line

of defense

against any

foreign

organism

when surgical

procedure

impaired the

skin, possible

entry of

microorganis

m therefore

may cause

infection

Short term:

After 4 hours of

nursing

interventions,

the patient will

identify and

demonstrate

intervention to

prevent

infection

Long term:

After 3-5 days

of nursing

intervention the

patient will

>Establish

rapport

>Monitor V.S.

>Note signs and

symptoms of

sepsis

>Provide wound

healing such as

cleaning of

wound

>Provide care,

change dressing

as needed

>To gain trust

>To obtain

baseline data

>To reduce

complication and

monitor for

infection

>To reduce risk

for infection

>To promote

healing to the

incision

>to prevent

occurrence of

Short term:

The patient

identified and

demonstrated

interventions to

prevent risk of

infection

Long-term:

the patient shall

have achieved

timely wound

healing without

developing

infections

24

incision

-bleeding in

the surgical

incision

achieve timely

wound healing

without

developing

infections

Prevent stress on

incision line,

cleanse site daily

as ordered, and

apply dry, sterile

dressing

> emphasize

importance of

proper hygiene

and wound care

>Encourage

ongoing

nutritional needs

> Emphasize

necessity of

taking antibiotics

to s.o as directed

infection

>To prevent

infection to

increase immune

resistance

>To increase

healing of wound

> Premature

discontinuation

of treatment

when client

begins to feel

well may result

in return of

infection

>To prevent

occurrence of

25

> Administer

prophylactic

antibiotics as

ordered

infection

Decreased Intracranial Adaptive Capacity r/t Space- Occupying Lesion secondary to reoccurrence of fluid accumulation due to shunt defect.

Assessment Diagnosis Scientific

Explanation

Planning Nursing

Interventions

Rationale Expected

Outcome

S>Ø Decreased Complications Short term: >Establish >To gain the client The SO shall

26

O> the pt.

manifested

the ff.

-Altered

mental

status

-Speech

abnormaliti

es

-

Restlessnes

s

-Changes in

mental

state AEB

(-) pupil

reaction to

light,

flexion on

pain, no

verbal

Intracrani

al

Adaptive

Capacity

r/t Space-

Occupying

Lesion

secondary

to

reoccurre

nce of

fluid

accumulat

ion due to

shunt

defect.

of

ventriculoperi

toneal

shunting can

occur. Some

patients may

experience

blood clot or

bleeding in

the brain,

swelling and

infection in

the brain,

brain tissue

damage,

reoccurrence

of fluid build

up in the

brain because

the shunt

may also stop

working, the

shunt may

After 1-2° of NI

the SO will be

able to

understand the

client’s

condition and

be able

perform

actively in

promoting the

clients

condition

having now a

higher level of

understanding

of the client’s

condition and

complications

that may occur.

rapport

>Monitor VS.

>Monitor/

document

changes in ICP

waveform and

responses to

stimuli.

>Assess eye

opening and

position/movem

ent, Pupils (size,

equality, light

reactivity),

purposeful and

non-purposeful

motor response

comparing left

and right sides,

presence of

and SO’s trust.

>To obtain data

for comparison.

>To alter care

appropriately.

> To note degree

of impairment

>To increase SO’s

understanding of

have

understand

the client’s

condition and

be able

perform

actively in

promoting the

clients

condition

having now a

higher level of

understanding

of the client’s

condition and

complications

that may

occur.

The client shall

have

demonstrated

stable ICP AEB

27

response. also become

infected and

seizures may

occur.

Intracranial

pressure,

(ICP), is the

pressure

exerted by

the cranium

on the brain

tissue,

cerebrospinal

fluid (CSF),

and the

brain's

circulating

blood volume.

ICP is a

dynamic

phenomenon

constantly

fluctuating in

Long term:

After 6-7 days

of NI the client

will be able to

demonstrate

stable ICP AEB

normalization

of pressure

waveforms/res

ponse to

stimuli.

reflexes, nuchal

rigidity,

consciousness

and mental

state.

>Provide

information

about the

client’s

condition

including the

complications

which may arise

once untreated

>Elevate HOB

and maintain

head/neck in

midline/neutral

position

>Decrease

the client’s

condition and will

be able to decide

properly for the

client’s care.

>To promote

circulation/venous

drainage

>To reduce CNS

stimulation and

promote

relaxation.

>To decrease

factors which may

contribute in

further increasing

ICP.

>To

pharmacologically

manage client’s

normalization

of pressure

waveforms/res

ponse to

stimuli.

28

response to

activities such

as exercise,

coughing,

straining,

arterial

pulsation, and

respiratory

cycle. An

increase in

pressure,

most

commonly

due to head

injury leading

to intracranial

hematoma or

cerebral

edema can

crush brain

tissue, shift

brain

structures,

extraneous

stimuli/provide

comfort

measures

>Limit activities

that increases

intrathoracic/ab

dominal

pressure

>Administer

medications as

ordered (e.g.

antihypertensiv

es, diuretics,

analgesics,

antipyretics,

vasopressors,

antiseizure,

neuromuscular

blocking agents,

and

condition and

maintain

homeostasis

>To reduce ICP

and enhance

circulation

>To have a

continuous client’s

care

29

contribute to

hydrocephalu

s, cause the

brain to

herniate, and

restrict blood

supply to the

brain, leading

to an

ischemic

cascade. If

left untreated

the patient

may result to

coma or worst

death.

corticostreiods)

>Prepare pt. for

surgery as

indicated (Space

Occupying

Lesion)

>Refer

accordingly

Impaired skin integrity related to surgical incision 2˚ ventriculoperitoneal shunting

30

ASSESSMENTNURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIONOBJECTIVES

INTERVENTIO

NSRATIONALE

EXPECTED

OUTCOME

S: Ø

O: The

patient

manifests:

>Surgical

incision on

head

The patient

may

manifest:

>redness

>heat on

incision

>inflammator

y process

Impaired skin

integrity related to

surgical incision 2˚

ventriculoperitone

al shunting

Ventriculoperitone

al shunting is

surgery to relieve

increased pressure

inside the skull due

to excess

cerebrospinal fluid

(CSF) on the brain

(hydrocephalus).

The procedure is

done by shaving

the hair behind the

ear, then a surgical

cut in the shape of

a horseshoe (U-

shape) is made

behind the ear and

another small

surgical cut is

made in the child's

belly. A small hole

SHORT

TERM:

After 4

hours of

nursing

intervention

s, patient’s

SO will be

able to

understand

and

participate

in

prevention

measures

and

treatment

program for

the pt

>Establish

rapport

>Assess vital

signs

>Monitor

Intake

and output.

Weigh as

indicated.

Note

skin turgor,

status, and

mucous

membrane.

> Maintain

head or

>To gain

trust

>To obtain

baseline

data

>Useful

indicators of

body water,

which is an

integral part

of

tissue

perfusion.

> Turning

bed to

one side

compresses

SHORT

TERM:

The

patient’s SO

shall have

understand

and

participated

in

prevention

measures

and

treatment

program for

the pt.

LONG

TERM:

31

is drilled in the

skull and 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.

LONG TERM:

After 6 days

of nursing

intervention

s, the

patient will

be able to

achieve

timely

healing of

surgical

incision.

neck in

midline or

in neutral

position,

support

with small

towel

rolls and

pillows.

Avoid placing

head on large

pillows.

>Identify

underlying

condition

involved

>Periodically

assess skin

and observe

the jugular

veins and

inhibits

cerebral

venous

drainage

that

may cause

ONCREASE

D icp

>To

determine

cause of

impairment

>To

monitor

progress of

wound

healing

The patient

shall have

achieved

timely

healing of

surgical

incision.

32

for possible

complications

>Keep the

area

clean/dry,

perform

proper wound

care, support

incision

>Use

appropriate

barrier

dressings and

wound

coverings,

skin-

protective

agents for

open/draining

>To assist

body’s

natural

process of

repair

>To protect

the wound

and/or

surrounding

tissues

33

wounds and

stomas

>Encourage

to increase

oral fluid

intake

>Promote

importance of

proper

nutrition of pt

>To boost

immune

system and

enhance

skin turgor

>To boost

immune

system and

address

ongoing

nutritional

needs of

pt .For

tissue

repair to

achieve

timely

healing

>Promotes

34

> Elevate the

head

of bed

gradually

to 15-30

degrees

as tolerated or

indicated.

venous

drainage

from

head,

reducing

cerebral

congestion

and

edema and

increased

ICP.

35

CONCLUSION:

Ventriculoperitoneal shunting is surgery to relieve increased pressure inside

the skull due to excess cerebrospinal fluid (CSF) on the brain (hydrocephalus).

Hydrocephalus may start while the baby is growing in the womb. It is

commonly present with myelomeningocele, a birth defect involving incomplete

closure of the spinal column. Genetic defects and certain infections that occur

during pregnancy may also cause hydrocephalus. In hydrocephalus, there is a build-

up of fluid of the brain and spinal cord (cerebrospinal fluid or CSF). This build-up 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. The procedure is

done by shaving the hair behind the ear, then a surgical cut in the shape of a

horseshoe (U-shape) is made behind the ear and another small surgical cut is made

in the child's belly. A small hole is drilled in the skull and 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. This will be attached to both catheters. When extra pressure builds

up around the brain, these valve opens, and excess fluid drains out of it into the

belly or chest area which then helps in decreasing intracranial pressure.

Complications can occur. Some patients may experience blood clot or

bleeding in the brain, swelling and infection in the brain, brain tissue damage,

reoccurrence of fluid build up in the brain because the shunt may also stop working,

the shunt may also become infected and seizures may occur.

After the procedure the patient will need to lie flat for 24 hours the first time

a shunt placed then the patient will be helped to sit up. The usual stay in the

hospital is 3 to 4 days. Recording vital signs and neurological status often is

36

needed. The patient may be given medications for pain. Intravenous fluids and

antibiotics are given to maintain hydration and prevent the occurrence of infection.

The shunt will be checked regularly to make sure it is working properly.

37