HYDROCEPHALUS

(AQUEDUCT STENOSIS)

SUHAINA OSMAN
WARD 6B
PRINCE COURT MEDICAL CENTRE
 WHAT IS HDROCEPHALUS
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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
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AQUEDUCT
 NARROW CHANNEL THAT CONNECTS TWO OF THE
VENTRICLES AND PASSES THROUGH THE MIDBRAIN

STENOSIS
 BLOCKED

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 WHAT IS ETV
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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
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NAME : RENA FUKUDA

AGE : 12Y
GENDER : FEMALE
COMPLAINS : HEADACHES FOR 2/12,
WORSEN IN LAST 2/52
MRI/CT : OBSTRUCTIVE
HYDROCEPHALUS SECONDARY
TO AQUEDUCT STENOSIS

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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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PROCEED PROCEDURE AS PLAN

POST OPERATIVE CARE

 CLOSE NEURO OBSERVATION

 KEEP EVD CLAMP

 PT NUTRITION

 PROP UP

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FOR REMOVAL EVD CM

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EVD REMOVED

NURSING RESPONSIBILITY
 SEDATION, ASEPTIC TECHNIQUE, CONSENT

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FOR REPEAT CT BRAIN & EYE ASSESSMENT

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PT D/C

TCA SCHEDULED

HEATH EDUCATION

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 NURSING MANAGEMENT
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HYDROCPEPHALUS

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 OBSERVING & RECORDING DISEASE
PROGRESS
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INFANTS
1.Measure head
occipitofrontal circumference (OFC)
approximately the same time each day
2. Palpate fontanelle for tenses, bulging
3. Assess for pupilary changes
4. Assess for change in level of consciousness
5. Evaluate breathing pattern & effectiveness
6. Assess feeding pattern
7. Assess motor function, gait, coordination
8. Determine attainment of developmental milestone

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OLDER CHILDREN
 Measure vital sign for increase ICP
 Assess patterns of headache, emesis
 Determine pupillary changes
 Evaluate LOC
 Assess motor function
 Evaluate attainment of milestone, school performance
 Obtain parent’s report of recent behavior

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Note especially changes in appearance :-

Increase head size
Full/ bulging fontanel
‘Sunset Eyes’

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 PROVIDING ADEQUATE NUTRITION
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 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 feeding
to prevent aspiration
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 SUPPORTIVE NURSING CARE
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Providing supportive nursing care as indicated by

the child condition
Prevent 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 child
Skin 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 legs

Keep 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)
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 Encourage parents to talk - child condition &

how their feel
 fearful of procedure, mental retardation or brain
damage
 Provide parents with appropriate information
concerning 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 early
2. 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
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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
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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
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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
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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?
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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)
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 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)
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 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)
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 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
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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?
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Neurosurgical observation chart

consist of:-
 Glasgow Coma Scale
 Vital Sign

 Pupillary response

 Limb movements

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 CHECKING OF PUPILLARY RESPONSE
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Size
Reaction
Comparison of both pupils
To 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
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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?
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Upper extremities :-
Liftup 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?
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Depends on the condition of the patient

Hourly for immediate post op and head
injury patient
As patient improves
 frequency will be reduced – 2 hly,4hly and
so on
Depends on the professional nurses
judgment
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