CASE PRESENTATION

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• CASE PRESENTATION
• HYDROCEPHALUS
• PRESENTED BY
• EDDELYN
  UPANTO(NICU)

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• DEMOGRAPHIC DATA
• case 190
• age 21 days
• sex male
• diagnosis severe hydrocephalus
• ward nicu

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• PHYSICAL ASSESSMENT
• General Appearance
• Weak in appearance
• Restless
• With OGT F5
• Wt.2.46kg, Lt.42cm, HC34.5cm

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• SKIN
• Pinkish
• Warm to touch
• Slightly dry
• Scaly
• Thin

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• HEAD AND NECK
• Bulging Fontanels
• Facial symmetry
• Iris is black, pupils are equal, round reactive
  to light
• Cloudy cornea
• Conjunctiva are pale
• No inflammation and discharges noted
• Has both patent and equal nosetrills
•  

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• DISCUSSION OF THE DECEASE
• Hydrocephalus also known as "water on the
  brain," is a medical condition in which there is
  an 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, tunnel
  vision, and mental disability. Hydrocephalus can
  also cause death. The name derives from the Greek
  words (hydro-) "water", and (kephalos) "head".

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• 
  CLASSIFICATION
• Based on its underlying mechanisms,
  hydrocephalus can be classified into
  communicating and non-communicating
  (obstructive). Both forms can be either
  congenital or acquired.
• Communicating
• Communicating hydrocephalus, also known as
  non-obstructive hydrocephalus, is caused by
  impaired cerebrospinal fluid resorption in the
  absence of any CSF-flow obstruction between the
  ventricles and subarachnoid space. Various
  neurologic conditions may result in communicating
  hydrocephalus, including subarachnoid/intraventric
  ular hemorrhage, meningitis and congenital
  absence of arachnoid villi. Scarring and fibrosis
  of the subarachnoid space following infectious,
  inflammatory, or hemorrhagic events can also
  prevent resorption of CSF, causing diffuse
  ventricular dilatation.

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• NON-COMMUNICATING
• Non-communicating hydrocephalus, or obstructive
  hydrocephalus, is caused by a CSF-flow
  obstruction ultimately preventing CSF from
  flowing into the subarachnoid space (either due
  to external compression or due to
  intraventricular mass lesions).

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• CONGENITAL
• The cranial bones fuse by the end of the third
  year of life. For head enlargement to occur,
  hydrocephalus must occur before then. The causes
  are usually genetic but can also be acquired and
  usually occur within the first few months of
  life, which include
• 1) Intraventricular matrix hemorrhages in
  premature infants,
• 2) Infections
• 3) Type II Arnold-Chiari malformation
• 4) Aqueduct Atresia and stenosis
• 5) Dandy-Walker malformation

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• ACQUIRED
• This condition is acquired as a consequence of
  CNS infections, meningitis, brain tumors, head
  trauma, intracranial hemorrhage (subarachnoid or
  intraparenchymal) and is usually extremely
  painful.

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ANATOMY AND PHYSIOLOGY
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• 
  PATHOPHYSIOLOGY OF HYDROCEPHALUS
•  
•  
• If there is obstruction in the ventricular system
  or the subarachnoid space, dilated cerebral
  ventricles, causing ventricular surface wrinkle,
  and tearing ependymal lines. White mater below it
  will atrophy and reduced to a thin ribbon. In the
  gray matter there is maintenance that is
  selective, so that although ventricular
  enlargement gray matter has been experiencing a
  disruption. Dilation process can be a sudden
  process / acute and can also selectively
  depending on the position of the blockage. The
  process was a case of acute emergency. In infants
  and small children cranial suture folds and
  widened to accommodate increased cranial mass. If
  the anterior fontanela not closed then it will
  not expand and feel tight in touch. Stenosis
  aquaductal (family illness / adrift offspring
  sex) causes dilation of the ventricles laterasl
  point and center, this dilation causes the
  appearance of distinctive shaped head protruding
  forehead is dominant (dominant frontal blow).
  Syndroma dandy walkker would happen if there is
  obstruction at the foramina outside the IV
  ventricle. Fourth ventricle dilated and prominent
  posterior fossae meet most of the space under the
  tentorium. Clients with type hydrocephalus above
  will have an enlarged cerebrum which is symmetric
  and disproportionately small face.
•  
• In older people, cranial sutures had closed thus
  limiting the expansion of the brain, as the
  result showed the symptoms increase in ICP
  before the cerebral ventricles, becomes greatly
  enlarged. Damage in the absorption and
  circulation of CSF in hydrocephalus incomplete.
  CSF exceeds the normal capacity of the
  ventricular system, every 6-8 hours and the total
  absence of absorption will cause death.
• In ventricular dilation causes tearing of the
  line normal ependyma, which allows an increase in
  the wall cavity absorption. If the route
  collateral sufficient to prevent further
  ventricular dilatation there will be a state of
  compensation.

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• 
  ETIOLOGY
• Blockage of cerebrospinal fluid (CSF) can be
  caused by a variety of conditions such as spina
  bifida and other birth defects of the brain
  certain brain infections like meningitis (pus can
  cause a blockage) hemorrhage within or around
  the brain, usually due to prematurity or a
  ruptured aneurysm and brain trauma, or
  tumouhyrors. The blockage can occur within the
  ventricles themselves (obstructive
  hydrocephalus), or outside the brain in the areas
  where the spinal fluid is reabsorbed back into
  the blood stream (communicating hydrocephalus).
• The term congenital refers to cases where
  hydrocephalus is present at birth, but without
  any genetic factors. In cases of congenital
  hydrocephalus, it is usually not possible to
  determine the cause, and this is referred to as
  'idiopathic'. In these cases, one assumes that
  the condition arose before birth, in the form of
  developmental problems due to infections,
  problems with blood supply, etc.

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• 
  
  SIGNS AND SYMPTOMS
• Signs and symptoms of infant with severe
  hydrocephalus
• Eyes that appear to gaze downward
• Irritability
• Seizures
• Separated sutures
• Sleepiness
• Vomiting
• Symptoms that may occur in older children can
  include
• Brief, shrill, high-pitched cry
• Changes in personality, memory, or the ability to
  reason or think
• Changes in facial appearance and eye spacing
• Crossed eyes or uncontrolled eye movements
• Difficulty feeding
• Excessive sleepiness
• Headache
• Irritability, poor temper control
• Loss of bladder control (urinary incontinence)
• Loss of coordination and trouble walking

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• 
  EFFECTS
• Because hydrocephalus can injure the brain,
  thought and behavior may be adversely affected.
  Learning disabilities including short-term memory
  loss are common among those with hydrocephalus,
  who tend to score better on verbal IQ than on
  performance IQ, which is thought to reflect the
  distribution of nerve damage to the brain.
  However the severity of hydrocephalus can differ
  considerably between individuals and some are of
  average or above-average intelligence. Someone
  with hydrocephalus may have motion and visual
  problems, problems with coordination, or may be
  clumsy. They may reach puberty earlier than the
  average child. About one in four develops
  epilepsy.

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• 
  TREATMENT
• Hydrocephalus treatment is surgical, generally
  creating various types of cerebral shunts. It
  involves the placement of a ventricular catheter
  (a tube made of silastic), into the cerebral
  ventricles to bypass the flow obstruction/malfunct
  ioning arachnoidal granulations and drain the
  excess fluid into other body cavities, from where
  it can be reabsorbed. Most shunts drain the fluid
  into the peritoneal cavity (ventriculo-peritoneal
  shunt), but alternative sites include the right
  atrium (ventriculo-Atrial shunt), pleural cavity
  (ventriculo-pleural shunt), and gallbladder. A
  shunt system can also be placed in the lumbar
  space of the spine and have the CSF redirected to
  the peritoneal cavity (Lumbar-peritoneal shunt).
  An alternative treatment for obstructive
  hydrocephalus in selected patients is the
  endoscopic third ventriculostomy (ETV), whereby a
  surgically created opening in the floor of the
  third ventricle allows the CSF to flow directly
  to the basal cisterns, thereby shortcutting any
  obstruction, as in aqueductal stenosis. This may
  or may not be appropriate based on individual
  anatomy.

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• SHUNT
  COMPLICATIONS
• Examples of possible complications include shunt
  malfunction, shunt failure, and shunt infection,
  along with infection of the shunt tract following
  surgery (the most common reason for shunt failure
  is infection of the shunt tract). Although a
  shunt generally works well, it may stop working
  if it disconnects, becomes blocked (clogged),
  infected, or it is outgrown. If this happens the
  cerebrospinal fluid will begin to accumulate
  again and a number of physical symptoms will
  develop (headaches, nausea, vomiting,
  photophobia/light sensitivity), some extremely
  serious, like seizures.
• Another complication can occur when CSF drains
  more rapidly than it is produced by the choroid
  plexus, causing symptoms -listlessness, severe
  headaches, irritability, light sensitivity,
  auditory hyperesthesia (sound sensitivity),
  nausea, vomiting, dizziness, vertigo, migraines,
  seizures, a change in personality, weakness in
  the arms or legs, strabismus, and double vision -
  to appear when the patient is vertical.
•  

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• NURSING PROBLEM PRIORITIZATION
• Acute pain
• Delayed growth and development
• Imbalanced nutrition Less than body requirements
• Gas exchange
• Ineffective tissue perfusion Cerebral.
• Interrupted family processes.
• Infant Behavior, risk for disorganized.
• Risk For Infection

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NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective I noticed that the size of my babys head is not normal as verbalized by the mother. Objective Restlessness Irritability Change in vital signs Vital signs taken as follows T37.8 degrees Celsius P158bpm RR52bpm Ineffective cerebral tissue perfusion related to decreased arterial or venous blood flow. After 12 hours of nursing interventions the patient will demonstrate improved vital signs and absence of increased ICP. Temperature monitored. Tepid sponge bath administered in presence of fever. Intake and output monitored. Weigh as indicated. Skin turgor, status and mucus membrane noted. Head/neck midline or neutral position, support with towel rolls or small pillow maintained. Provided rest periods between care and limit durations of procedures. Decreased extraneous stimuli and provide comfort measures such as quiet environment and gentle touch. Helped limit or avoid coughing, crying, vomiting and straining at stool. Elevated head of the bed gradually at 15-30 degrees as tolerated or indicated. Collaborative Diuretics administered as indicated. Supplemental oxygen administered as indicated. Fever may reflect damage to hypothalamus. Increased metabolic needs and oxygen consumption occurs which can further increase ICP. Useful indicator of body water which an important part of tissue perfusion. Turning head to one side compress the jugular veins and inhibits cerebral venous drainage that may cause increased ICP. Continuous activity can increased ICP by producing a cumulative stimulant effect. Provides calming effect reduces adverse physiological response and promotes rest. These activities increase intrathoracic and intra-abdominal pressure. Promote venous drainage from head, reducing cerebral congestion and edema and increased ICP. Diuretics may used in acute phase to draw water from brain cells reducing cerebral edema and ICP. Reduces hypoxemia which may increase cerebral vasodilation and blood volume. After 12 hours of nursing intervention the patient was able to demonstrate improved vital signs and absence of increased ICP.
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• 
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