Hydrocephalus,Myelomeningocele,Papilledema, Nursing Management and Intervention

Hydrocephalus

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• An excess of CSF in the ventricles and subarachnoid spaces of brain. Increased intracranial pressure resulting from excess fluid leads to enlargement of the head in an infant whose sutures are not closed.

• Types of Hydrocephalus

– Communicating (Extra ventricular): If there is passage of CSF between ventricles and spinal cord.

– Noncommunicating (Intraventricular): If there is a block to CSF pathway.

Causes of Hydrocephalus

• Over production of fluid by choroid plexus

– tumor choroid

• Obstruction of the passage

– congenital atresia of aqueduct of sylvius, foramen Magendie or Luschca

– adhesions from meningitis or encephalitis

– hemorrhage

– growing tumor.

• Interference with the absorption of the fluid from subarachnoid space.

– following extensive subarachnoid hemorrhage

 

Myelomeningocele

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The spinal cord and meninges protrude through the vertebrae defect. Child can develop hydrocephalus following surgical correction.

 

ASSESSMENT of Myelomeningocele

• Infant

– Full and bulging fontanel

– Separated sutures

– Macrocrania

– Papilledema (edema of optic disc)

– High pitch cry

– Sunsetting eyes

– Convulsions

– Shinning scalp with dilated veins

– Nystagmus

– Irritability

– Vomiting

– Altered mental state

– Poor sucking

– Abnormal muscle tone

• Child

– Headache

– Projectile vomiting

– Papilledema

– Srabismus

– Drowsiness changing to stupor

– Intellectual dysfunction

– Ataxia

– Spasticity of legs

 

Papilledema

Papilledema

 

Prognosis of Papilledema

• If untreated 50-60% mortality.

• Survivors have high incidence of subnormal intelligence, physical handicap like ataxia, spastic diplexia. Spontaneous arrest occurs in 40% cases.

• Surgery: 80% survival. Highest mortality occur in the 1st year of life. 50% have normal intelligence. Additional problems like ocular defects and mental retardation are common.

Investigations for Papilledema

• Transillumination

• Skull X-ray

• CT scan

Management for Papilledema

• Relief of hydrocephalus surgically.

• Treatment of complications.

• Management of associated problems of psychomotor skills

Surgery

• Direct removal of obstruction – resection of tumor, cyst or hematoma.

• Plexectomy

• Shunt

– Ventriculo-peritoneal (VP shunt)

– Ventriculo-atrial (VA shunt)

– Ventricular bypass (into intracranial channels in noncommunicating type)

– Ventriculo-pleural (For children above 5 years)

• Parts of shunt

– Ventricular catheter

– Flush pump

– Unidirectional flow valve

– Distal catheter

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Nursing management

• Nursing diagnosis 1: High risk for altered cerebral tissue perfusion R/T increased intracranial pressure.

• Interventions

– Measure and record head circumference daily.

– Assess vital signs 4 h.

– Assess level of consciousness 4h.

– Assess anterior fontanel for tension and measure size 8h.

– Assess distended scalp veins and sunsetting eyes 8h.

– Assess pupillary reaction 4h.

– Provide oxygen and suction SOS.

– Keep ready for ventricular tap.

• Nursing diagnosis 2: High risk for altered nutrition less than body requirement R/T poor sucking.

• Interventions

– Encourage breast feeding infant.

– Support head while feeding.

– Assess intake and output.

– Place on side after feeding.

– Refeed if vomiting occurs.

• Nursing diagnosis 3: High risk for altered skin integrity R/T difficulty in turning the enlarged head.

• Interventions

– Place head on sheep skin pad.

– Change position 2h.

– Handle head gently to prevent injury.

– Protect from wrinkled or wet linen.

– Bathe daily

• Nursing diagnosis 4: High risk for ineffective family coping R/T child’s chronic illness.

• Interventions

– Explain the child’s condition to parents.

– Encourage parents to care for the child.

– Praise their positive efforts.

– Allow parents to verbalize concerns.

– Arrange with community support services.

 

Postoperative Nursing Intervention

• Nursing diagnosis 1: high risk for infection R/T surgical procedure.

• Interventions

– Change incision dressings as prescribed.

– Keep head incision dressing dry and free from oral secretions.

– Observe incisions for drainage or redness.

– Do not place infant in bath tub until abdominal incision is healed.

– Assess temperature 4h.

• Nursing diagnosis 2: High risk for altered cerebral perfusion R/T obstructed shunt.

• Interventions

– position infant as prescribed (Shunted side down)

– Keep head in flat position.

– Pump shunt as prescribed (3 times / day)

• Nursing diagnosis 3: Knowledge deficit R/T home care of the infant.

• Interventions

– Teach parents how to do pumping the shunt, while they are in hospital.

– Observe the feeding practices.

– Observe the care of the infant by the parent.

– Teach the signs and symptoms of increased ICP.

– Observe pump site daily for signs of infection.

– Allow the child to sleep with head slightly elevated, Do not make child sleep head hanging on a side.

– Prevent constipation.

– Encourage child participate in all age appropriate activities.

– Treat infections appropriately.

– Emphasize regular follow up visits.

–Assess for signs of increased ICP.

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