VELEZ COLLEGE

COLLEGE OF NURSING

F. Ramos St. Cebu City

A CASE STUDY PRESENTATION ON CLIENT B.B., 12-WEEKS-OLD, DIAGNOSED WITH HYDROCEPHALUS

Submitted by:
Ledesma, Romeo Kirby
Padillo, Niña
Pulga, Aleighde Van
Roma, Richan
Santos, Erika
Sarigumba, Loren
Yap, Mary Anne

BSN-2E

Submitted to:

Ms. Stephanie Minoza, RN

INTRODUCTION
Client-in-Context
Client B.B., a 12-week-old Filipino female, Roman Catholic, currently residing in Barangay Guadalupe, Cebu City with her 27-year-old mother. She was born term, 37th week
AOG, on November 19, 2020. Client was admitted for the first time to the emergency department at Cebu Velez General Hospital on February 10, 2021 at 7:00 AM with the
complaints of progressive vomiting of ingested milk amounting to 60 ml, lethargy, difficulty feeding, and increasing head size, noted 2 days PTA, accompanied by bulging
fontanelle, weak high-pitched crying, irritability, and poor interaction. Client arrived in a private vehicle in her mother’s arms under the service of Dr. Chua of the Department
of Pediatrics admitted in Pedia 1 Ward with a hospital no. CVGH 10-23456 and case no. 23456. The client’s mother reports that client B.B. was born with no prenatal or perinatal
complications. Although there was poor prenatal care, the labor and delivery were unremarkable.

Hydrocephalus
Hydrocephalus, or “water on the brain,” is a condition associated with a buildup of cerebrospinal fluid (CSF) in or around the brain. If left untreated, this can lead to brain tissue
stretching, significantly affecting your child’s growth and development. Hydrocephalus is often congenital, meaning babies are born with it, but infants and children can develop
it as well. There is no one specific cause of congenital hydrocephalus. However, it may be linked to a genetic defect, or be the result of another disorder such as spina bifida or
encephalocele (sac-like protrusions of the brain).

Other risk factors include:

● aqueductal stenosis; when CSF flow between the ventricles inside the brain is blocked,
● infection during pregnancy,
● complications of prematurity (being born early),
● bleeding in the brain (from a stroke or brain injury), and
● a brain tumor.

Hydrocephalus is typically detected through a prenatal ultrasound between 15- and 35-weeks’ gestation. Physicians are able to confirm this
diagnosis with a fetal magnetic resonance imaging (MRI) exam, which provides more detailed images of the brain. A skull x-ray film will reveal
the separating sutures and thinning of the skull. Transillumination (holding a bright light such as a flashlight or a specialized light [a Chun gun]
against the skull with the child in a darkened room) will reveal the skull is filled with fluid rather than solid brain. If the hydrocephalus is a
noncommunicating type, dye inserted into a ventricle through the anterior fontanelle will not appear in CSF obtained from a lumbar puncture.

During pregnancy, hydrocephalus is usually managed with observation. At this time, there is no fetal treatment for this disorder. If your baby
has been diagnosed with hydrocephalus, healthcare providers will carefully watch them for signs of distress, which may indicate a need for early
delivery. After birth, hydrocephalus is treated with one of three surgical options:
 1. Shunt; device that allows the pressure in the brain to normalize by draining the fluid into the abdominal cavity, where the fluid can be
reabsorbed.
2. Endoscopic third ventriculostomy (ETV); minimally-invasive procedure that creates an opening in the floor of the third ventricle in the brain,
allowing fluid to flow into its normal pathway.
3. Combined endoscopic third ventriculostomy/choroid plexus cauterization (ETV/CPC); used as the primary treatment for most infants with
hydrocephalus. ETV/CPC is known to reduce the rate of cerebrospinal fluid production and provide a new pathway for the fluid to escape.

The impact of hydrocephalus on a newborn is somewhat unpredictable and can vary in severity. Because it injures the brain, children with
hydrocephalus may have epilepsy, learning disabilities, short-term memory loss, problems with coordination, vision problems, and early onset of
puberty. As a result, children with this condition often benefit from developmental therapy, such as physical therapy and occupational therapy. In
milder cases, or instances where treatment was previously possible, a baby with hydrocephalus may develop completely normally.

ANATOMY & PHYSIOLOGY

Central Nervous System
The brain and spinal cord form the central nervous system (CNS) and they’re surrounded and protected by the bones of the skull and the vertebral column. Your brain and spinal
cord are surrounded by a clear liquid called cerebrospinal fluid (CSF). It’s made and stored in cavities in your brain called ventricles. It circulates around your brain, moving from
ventricle to ventricle. It cushions and protects the brain and spinal cord, supplies them with nutrients, and removes some of their waste products. Extra fluid usually drains away
from the brain and is absorbed by veins at the top of the brain.

Excess cerebrospinal fluid in the ventricles occurs for one of the following reasons:
● Obstruction. The most common problem is a partial obstruction of the normal flow of cerebrospinal fluid, either from one ventricle to another or from the ventricles to
other spaces around the brain.
● Poor absorption. Less common is a problem with the mechanisms that enable the blood vessels to absorb cerebrospinal fluid. This is often related to inflammation of
brain tissues from disease or injury.
● Overproduction. Rarely, cerebrospinal fluid is created more quickly than it can be absorbed.
Brain & Spinal Cord
Between the brain and skull are three other protective coverings called the meninges, which are special membranes that completely
surround the brain and spinal cord. CSF flows between these membranes in an area called the subarachnoid space and cushions the brain
and spinal cord against forceful blows, distributes important substances, and carries away waste products. Cerebrospinal fluid is believed
to be primarily produced within the ventricles by delicate tufts of specialized tissue called the choroid plexus. The ventricles can be thought
of as chambers filled with fluid. There are four ventricles in all: two lateral ventricles, the third ventricle, and the fourth ventricle. The
ventricles are connected by narrow passageways.

Produced mainly in the lateral and third ventricles, CSF flows from the lateral ventricles through two narrow passageways into the third
ventricle. From the third ventricle, it flows down another long passageway known as the aqueduct of Sylvius into the fourth ventricle. From
the fourth ventricle, it passes through three small openings called foramina into the subarachnoid space surrounding the brain and the
spinal cord. It has traditionally been thought that CSF is primarily absorbed through tiny, specialized cell clusters called arachnoid villi near the top and midline of the brain.

The CSF then passes through the arachnoid villi into the superior sagittal sinus, a large vein, and is absorbed into the bloodstream. Once in the bloodstream, it’s carried away
and filtered by the kidneys and liver in the same way as other bodily fluids. Small amounts of CSF are also absorbed into lymphatic channels.

Our bodies produce approximately one pint of CSF every day, continuously replacing it as it’s absorbed. Under normal conditions, a delicate balance exists between the amount
of CSF produced and the rate at which it is absorbed. Recent research raises the possibility that the rhythm of cerebral blood flow and CSF pulsations may have bearing on this
delicate balance.

PEDIATRIC ASSESSMENT FORM

CLIENT-IN-CONTEXT PRESENT STATE

Informant: M.B., 27 years old, client's mother. PHYSICAL EXAMINATION

Admission Date: February 10, 2021 at 7:00 AM Date Performed: February 10, 2021 at 9:00 AM

Introduction of the Client General Appearance & Measurement

Client B.B., a 12-week-old Filipino female, Roman Catholic, currently residing in Barangay Client B.B. was seen in the hospital room in her mother’s arms awake, lethargic,
Guadalupe, Cebu City with her 27-year-old mother. She was born term, 37th week AOG, on with a weak high-pitched cry and poor interaction to surroundings. She has a
November 19, 2020. Client was admitted for the first time to the emergency department at bulging anterior fontanelle with her head being oddly shaped similar to that of an
Cebu Velez General Hospital on February 10, 2021 at 7:00 AM with the complaints of
progressive vomiting of ingested milk amounting to 60 ml, lethargy, difficulty feeding, and inverted pear. Prior to physical examination, the client experienced vomiting, and
increasing head size, noted 2 days PTA, accompanied by bulging fontanelle, weak high- the mother has difficulty feeding the client.
pitched crying, irritability, and poor interaction. Client arrived in a private vehicle in her
mother’s arms under the service of Dr. Chua of the Department of Pediatrics admitted in Height: 57 Weight: Head Abdominal
Pedia 1 Ward with a hospital number CVGH 10-23456 and case number 23456. The client’s
cm 5%, 4.20 Circumference: Girth:
mother reports that client B.B. was born with no prenatal or perinatal complications. kg 95%, 42.6 cm 33 cm
Although there was poor prenatal care, the labor and delivery were unremarkable.

History of Present Condition HR: 165 BP: RR: 45 TEMP IBW: 6 kg BMI: N/A
7 days PTA, the client’s mother reports client B.B. to be irritable, unlike herself, less bpm 98/65 bpm : 36.5
interaction, high-pitched cry, weaker than usual, and not breastfeeding well. mm C
Hg
2 days PTA, the client’s mother reports that client B.B. has been lethargic, vomiting, and the
mother has difficulty feeding the client.
Skin
Client B.B. has slightly dry and pale thin skin with bulging anterior fontanelle. Poor
Morning PTA, the client’s mother reports that there has been no bowel movements and less
skin turgor noted by skinfold persisting after release. Skin is at a warm
urine output. Client B.B. experienced above symptoms leading to present admission.
temperature. No skin variations noted
Past Medical History
Scalp and Hair
Client B.B. has no prenatal or perinatal complications, and was born at term 37 weeks AOG.
Client has natural black hair. Client’s scalp is dry with scalp veins prominent, and
She has no known allergy, no previous transfusion nor previous hospitalization and surgery
the anterior fontanelle is tense and bulging. Hair is thin and dry in the anterior
done. She received her 1st dose of Hepatitis B vaccine at birth, November 19, 2020, and her
fontanelle area. Fine, downy hair covers the body.
second dose in the second month, January 19, 2021, and her 1st dose of DtaP, Rotavirus, and
Haemophilus Influenzae Type B was also given on the 2nd month after birth at Cebu Velez
Head and Face
General Hospital. No adverse reactions noted upon administration of the vaccines. For
Client B.B.’s head is oddly shaped and looks like an inverted pear with bulging
medications, Erythromycin via ophthalmic route was given to the client only once after birth
anterior fontanelle. Face is proportionate and symmetric. Difficulty in head
for prevention of neonatal conjunctivitis and ophthalmia neonatorum.
movement noted by increased size above the normal range. Movements are
equal bilaterally. Parotid glands are normal size.
Prenatal History
The client’s mother, 27-years-old, gave birth to her 1st child at term and her obstetric score
Nails
is G1P1(1001). She had her first prenatal checkup at 7 weeks AOG. The frequency of her
prenatal checkup was followed according to her physician's instruction, which was 1 prenatal Client’s nails are pink, convex, and smooth. No missing or short nails noted.
visit a month until the end of her 28th week, every 2 weeks or twice a month until the end of
her 36th week and every week until her 40th week. The client’s mother did not experience Eyes, Ears, & Nose
any serious illnesses during her pregnancy, just common cold. She was instructed to take Client B.B.’s eyes show pupils which are equal and round but are sluggishly
orally, 400 micrograms (mcg) folic acid, 200 mg calcium and oral iron once a day. reactive to light. Red reflex is present bilaterally. Eyebrows are visible, evenly thin
on both sides. Her eyes are the same as her hair. Her irises are dark brown. No
Labor and Delivery History redness, swelling, or lesions noted. Bulbar conjunctivae are clear, moist, and
Client B.B. was born 37 weeks AOG. The client’s mother had a spontaneous labor that lasted smooth. Extraocular movements (EOM) are clearly dysconjugate. She has a
for 10 hours with a normal spontaneous vaginal delivery. She verbalized, “Makasbot najud ko downward gaze. No excessive cerumen, discharge, lesions, excoriations, or
na manganak nako kay sige nag sakit ako tiyan unya mao man gud ang due date nako.” The foreign body in the external canal. Client’s ear is equal bilaterally, and her auricles
mother’s labor and delivery took place in Cebu Velez General Hospital and was assisted by an are aligned with the corner of her ears. Earlobes are free. There were no lumps,
obstetrician. lesions, nodules, or discharges noted on the ears. Weak startle (Moro) reflex
upon ringing of bell. Nose is midline in face, septum is straight, and nares are
Birth History patent. No discharge or tenderness is present. Turbinates are pink and free of
Client B.B. weighed 2,900 g at birth, measured 47.8 cm in height, and had a head edema.
circumference of 34 cm at birth with a cephalic presentation. She had no any unusualities and
her respiratory effort was unassisted. At birth, one shot of vitamin K injection, first shot of Mouth and Throat
Hepatitis B vaccination, and erythromycin ophthalmic ointment was administered to the Client B.B.’s lips, gums, and mouth appear slightly pale and dry. Infant’s thorax is
client as newborn immunizations. smooth, rounded, and symmetric. Mild grunting can be heard during exhalation.
Slight nasal flaring noted.
Feeding History
The method of feeding used is full breastfeeding. There has been feeding unusualities; client Neck & Lymph Nodes
B.B. has not been breastfeeding well in the last 7 days PTA with only 80ml per feeding. She Client B.B.’s neck is symmetrical with skin folds between the head and shoulder.
feeds 7 times in a day. Her appetite is not good. She has had difficulty feeding over the past Isthmus is palpable with no lesions noted. The trachea is midline. Lymph nodes
2 days PTA. The mother states that client B.B. would latch on, then let go of her breast often are nonpalpable. Clavicles are symmetrical and intact.
during feedings. Client B.B. would fall asleep within 5 minutes of latch-on. The mother
verbalized, “Gikulbaan kayko, murag dili man si baby mu inom ug tarong sa gatas, paspas ra Chest and Lungs
siya musupsop niya katulgon nasad.” The mother notes that she performs hand hygiene, and Client B.B. has mild tachypnea with slight intercostal retractions and nasal flaring.
cleans her breast before and after feedings. She is sometimes hesitant in burping her baby Lung fields are clear to auscultation bilaterally. No tenderness, pain, crepitus,
due to fear of irritating client B.B.’s head. The vitamins/supplements taken by client B.B. are lesions, and masses noted. Client’s thorax is smooth, rounded, and
vitamin K (one shot given at birth), vitamin D, vitamin B12, and iron supplements. Dose and symmetric.
frequency of the vitamins were not frequent and unrecalled by mother verbalizing “Wala na Heart
ko makahinumdom sa ubang vitamins kay panagsa ra nako ihatag sa bata, na busy hinuon Client B.B.’s heart examination reveals tachycardia with a regular rhythm and a
ko sa pagpatotoy.” grade 2/6 systolic ejection murmur at the left sternal border. Capillary refill is 2
seconds.
Elimination Pattern
Client B.B. does not have toilet training and uses commercial diapers instead. She uses 4-5 Abdomen
diapers a day. She urinates once every 3-5 hours amounting to 600-750 ml/day. Urine is Client B.B.’s abdomen is protuberant, full and rounded. Umbilicus is pink, no
usually light to dark yellow and is not turbid. She usually defecates 1-2 times a day having a discharge, odor, redness, or herniation noted. Upon auscultation, minimal bowel
mustard yellowish-brown color and not turbid, but over the past 2 days PTA, she had no sounds were heard every 5 - 10 mins indicating poor bowel movement.
bowel movement.
Female Genitalia, Anus & Rectum
Developmental Milestones Client’s labia majora and minora are pink and moist. Client’s anal opening is visible
and slightly dry. Perianal skin is smooth and free of lesions.
AGE EXPECTED ACTUAL
(12 weeks old)
Back and Extremities
● Largely reflex ● The infant’s upper extremities show Client B.B.’s spine is straight without protrusions or apparent defects. Her upper
GROSS actions. good tone and full range of motion extremities show good tone and full range of motion with slightly brisk reflexes.
MOTOR ● Holds head up with slight brisk reflexes. Her lower extremities show increased tone with brisk reflexes bilaterally. There is
when prone. ● The infant’s lower extremities show 4+ clonus bilaterally.
● Holds head and increased good tone with brisk
chest when prone. reflexes bilaterally. NEUROLOGIC ASSESSMENT
● The Moro reflex of the infant is Mental Status / Cerebral Function
minimally present. Client B.B. has a Glasgow Coma Score (GCS) of 12/15 indicating moderate level of
● The Gag reflex of the infant is present, neurologic injury. She is lethargic with poor interaction, irritable at times and
which was observed by her elicits a weak high-pitched crying upon touching the face, trunk, and limbs with a
progressive vomiting. cotton-tip.
● The infant cannot readily turn head
side to side with and without support. Pediatric Glasgow Coma Scale
Behavior Response Score
 ● Keep hands fisted; ● The infant elicits poor rooting and EYE OPENING 4-Spontaneously 4
FINE able to follow sucking reflex upon breastfeeding.
MOTOR objects to midline ● The grasp and glabellar reflexes of the 3-To verbal command
with eyes. infant were observed.
2-To pain
● The infant shows a sluggish, slow
pupillary reaction to light. 1-No response
● Makes cooing ● The infant was able to cry with a MOTOR RESPONSE 6-Obeys 5
LANGUAGE sounds. weak, high-pitched tone.
● Differentiates cry ● The infant uses a range of signal 5-Localizes pain
needs such as hunger and pain.
4-Flexion-withdrawal
● Demonstrates ● The infant was irritable and was not
SOCIAL social smile. interactive. 3-Flexion-abnormal
● Laughs out loud.
2-Extension

Theoretical Development 1-No response

AGE Expected Actual VERBAL RESPONSE 5-Smiles/coos 3
(12 weeks old) appropriately
FREUD’S ● Oral Stage (Birth to 18 months) ● Client is lethargic,
PSYCHOSEXUAL ● Erogenous zone is the mouth, and with less 4-Cries and consolable
DEVELOPMENT sexual activity takes the form of interaction and
sucking, swallowing, chewing, and demonstrates 3-Persistent
biting. irritability. inappropriate crying/or
screaming
● Infant meets the world by crying, ● Client has poor
tasting, eating, and early sucking reflex; no 2-Grunts, agitated,
vocalization; biting, to gain a sense parachute reflex restless
of having a hold on and having can be elicited.
greater control of the ● Minimal Moro 1-No response
 environment; and grasping and reflex is present. TOTAL PGC SCORE: 12 (Moderate
touching to explore texture The grasp and Neurologic Injury)
variations in the environment. glabellar reflexes
are present Motor/Cerebellar Function
● Elicits a weak high- Client B.B. has poor sucking reflex upon breastfeeding. Babinski reflex is present.
pitched crying upon No parachute reflex can be elicited. Minimal Moro reflex is present. The grasp and
touching the face, glabellar reflexes are present. Head control is present but with difficulty in
trunk, and limbs response to increased head size.
with a cotton-tip.

ERIKSON'S’ ● Begins at birth and continues to ● Infant has not been CRANIAL NERVES
PSYCHOSOCIAL approximately 18 months of age. breastfeeding well, CN I (Olfactory):
DEVELOPMENT ● babies develop a sense of trust in difficulty of feeding Client B.B. is able to identify her mother’s scent and breastmilk.
(Trust Vs. other people, in themselves, and in over the past 2
Mistrust) the world around them. days CN II (Optic):
● The child is utterly dependent ● When the infant Both pupils are sluggishly reactive to light. Red reflex is present, full visual fields
upon adult caregivers for elicits weak, high- intact, and optic disc round with well-defined borders.
everything they need to survive pitched cry, the
including food, love, warmth, mother CN III, IV, & VI (Oculomotor, Trochlear, Abducens):
safety, and nurturing. automatically Extraocular movements (EOM) are clearly dysconjugate. Client has a downward
● The infant's cries communicate an rushed towards her gaze.
important message to caregivers. to give comfort
● If a child successfully develops ● Infant has been CN V (Trigeminal):
trust, they will feel safe and secure less interactive Client B.B. is lethargic with poor rooting and sucking reflex.
in the world. towards her
● caregiver’s response to the infant’s healthcare provider CN VII (Facial):
cries. ● Head is enlarged with a prominent bulging forehead. Weak high-pitched crying is
● caregiver responds right away to observed upon touch to forehead, cheek, and chin.
the infant’s distress of crying or
fussing CN VIII (Vestibulocochlear):
 Client B.B. exhibits blink eyes (acoustic blink reflex) in response to noise with
● Feeding plays a pivotal role in
minimal startle (Moro) reflex.
development of trust. When
feeding an infant when the child is
CN IX & X (Glossopharyngeal & Vagus):
hungry, they learn that they can
Client B.B.’s gag reflex is present. Poor swallowing and vomiting of milk
trust that their need for
afterwards are noted.
nourishment will be met.

PIAGET’S ● Sensorimotor Stage (Birth to 2 ● Weak rooting and CN XI (Spinal Accessory):

COGNITIVE years old) sucking reflex of Client B.B. has difficulty turning head side to side with and without support.
DEVELOPMENT ● Cooing begins by 1 to 2 months mother’s nipple. Symmetrical shoulder height.
● Laughing and babbling by 3 to 4 ● Able to show
months irritability through CN XII (Hypoglossal):
● Consonant sounds by 3 to 4 weak high-pitched Tongue symmetry present without fasciculation.
months. cries.
● Demonstrate anticipatory ● Cooing and LABORATORY TEST
behaviors, like rooting and sucking babbling are Ultrasound
at the site of a nipple or bottle present but with
● Use facial expressions to respond less interaction and
to their environment are lethargic.

KOHLBERG’S ● During the preconventional level, a The different stages of

MORAL child’s sense of morality is moral development cannot
DEVELOPMENT externally controlled. Children be observed during the
accept and believe the rules of infancy period.
authority figures, such as parents
and teachers, and they judge an
action based on its consequences.
● During the conventional level, an
individual’s sense of morality is
tied to personal and societal Fetal Cerebral Lateral Ventricle Range (11-14 wks.):
Imaging Finding:
 ↑ Lateral Ventricle: 14 mm = moderate VM
relationships. Children continue to
Normal: (< 10 mm)
accept the rules of authority
Hydrocephalus secondary to aqueductal stenosis
figures, but this is now because
they believe that this is necessary
NOTE: VM - Ventriculomegaly; refers to dilatation of the cerebral ventricles
to ensure positive relationships
and societal order.
Definition
● During the postconventional level,
Infant with hydrocephalus with dilatation of frontal horns of both lateral
a person’s sense of morality is
ventricles (yellow arrow) and temporal horn (white arrow). Ultrasound imaging,
defined in terms of more abstract
which uses high-frequency sound waves to produce images. Ultrasonography has
principles and values. People now
the most utility within the first 12 to 18 months after birth. The ultrasound device
believe that some laws are unjust
is placed over the soft spot (fontanel) on the top of a baby's head.
and should be changed or
eliminated.
Implication
The dilation of these ventricles indicates aqueductal stenosis since the aqueduct
of Sylvius channel is blocked, which connects the third ventricle to the fourth
ventricle. Obstruction of aqueduct of Sylvius will result in enlargement of lateral
ventricle, third ventricle, and aqueduct of the ventricular system thus leading to
hydrocephalus with manifestations of bulging of the anterior fontanelle of the
client.

Magnetic Resonance Imaging (MRI)

Fetal Cerebral 3rd Ventricle & Aqueduct Range (2-3 mons.):
Imaging Finding
↑ 3rd: 6.6 + 2.40mm
↑ AD: 3.0 + 1.20mm
Hydrocephalus secondary to aqueductal stenosis

Normal Finding:
3rd: 4.87 + 1.3mm
AD: 2.0 + 0.40mm

NOTE: VM - Ventriculomegaly; AD - Aqueduct

Definition
MRI uses radio waves and a magnetic field to produce detailed 3D or cross-
sectional images of the brain. MRI scans can show enlarged ventricles caused by
excess cerebrospinal fluid. Children may need mild sedation for some MRI scans.

Implication
(A&B) Fetal MR imaging demonstrating stenosis of the inferior cerebral aqueduct
with associated aqueductal funneling (arrow). As a result, there is marked
enlarged of the lateral and third ventricles with dilation of the inferior third
ventricular recesses (white arrowheads) depicted by bowing of the lamina
terminalis and inferior third ventricular floor. The corpus callosum is thin and
superiorly bowed (black arrowheads). Note also the normal size of the fourth
ventricle. If there is a physical blockage it's non-communicating hydrocephalus.
NURSING CARE PLAN
Key Issues:
1. Ineffective cerebral tissue perfusion related to increased intracranial pressure secondary to hydrocephalus as evidenced by increasing head size, bulging of anterior
fontanelle, lethargy, weak high-pitched cry, irritability, hyperactive reflexes, and mild rapid breathing with slight intercostal retractions.
2. Actual impaired skin integrity related to mechanical interruption of skin (presence of surgical wound) secondary to ventriculoperitoneal shunt procedure as evidenced
by a 1-inch suture located behind the right ear.
3. Ineffective infant feeding pattern related to increased intracranial pressure (excess cerebrospinal fluid) secondary to Hydrocephalus as evidenced by difficulty feeding,
progressive vomiting, irritability, and poor sucking reflex.
4. Risk for delayed growth and development related to impaired ability to achieve developmental tasks.
5. Mild anxiety related to the family’s fear of the infant's surgical outcome as evidenced by the mother verbalizing concern for her infant’s safety during surgery.

Prioritization: Severity of problem related to client’s condition.

NURSING DIAGNOSIS NURSING INTERVENTIONS DESIRED OUTCOMES & ACTUAL OUTCOMES

1. Ineffective cerebral tissue perfusion related to Independent Interventions: Desired Outcome:

increased intracranial pressure secondary to 1. Assess level of consciousness, mental status,
hydrocephalus as evidenced by increasing head crying, and behavior.
size, bulging of anterior fontanelle, lethargy, weak R: Clinical symptoms of decreased cerebral
high-pitched cry, irritability, hyperactive reflexes, perfusion include fluctuations in consciousness
and mild rapid breathing with slight intercostal and cognitive function. Evaluation of Ineffective
retractions. Tissue Perfusion defining characteristics provides
a baseline for future comparison.
Scientific Basis: 2. Assess if the infant is able to turn because of
Oxygen and nutrients diffuse from the blood into the increased head size.
interstitial fluid and then into the body cells. R: Lack of mobility can lead to pressure ulcers on
Hydrocephalus occurs from an irregularity in the head as well as insufficient 3-month
production and absorption of the fluid which causes an development.
increase in intracranial pressure as the fluid builds up. An 3. Evaluate eye opening of clients.
individual has a decrease in oxygen resulting in failure to R: Establishes arousal ability or level of
consciousness.
Within 8 hours of student nurse-client intervention the
client will demonstrate improved brain function as
evidenced by:
1. The client will have a GCS score of 14 indicating
an optimal level of consciousness.
2. The client will have improved alertness and cry
pattern, and positive PERRLA.
3. The client will be able to turn their head without
signs of pain and difficulty.
4. Client’s head circumference will return within
normal range: 40cm (25th percentile)
5. Client’s vital signs are within age-appropriate
parameters.
○ T: 36.5- 37.5 oC; PR: 100-160 bpm; RR: 30-
60 bpm; BP: 65-90/45-65 mm Hg
nourish the tissues at the capillary level which may 4. Measure the client’s head circumference and 6. Client’s cerebral perfusion pressure remains
compromise health. appearance of anterior fontanelle. above 50 mmHg.
R: Head circumference, if increasing, or a tense 7. The client's mother will verbalize understanding
Reference: bulging fontanelle reveals CSF accumulation. of her child’s condition.
Wayne, G., By, -, Wayne, G., & Gil Wayne. Ineffective 5. Provide a non-stimulating environment and 8. The client will undergo ventriculoperitoneal
tissue perfusion – Nursing diagnosis & care plan. adequate rest periods. shunt procedure performed by the
Retrieved February 11, 2021, from R: Continual activity and stimulation may neurosurgeon.
https://nurseslabs.com/ineffective-tissue-perfusion/ increase intracranial pressure.
6. Elevate the head of the bed gradually about 15- Actual Outcomes:
45 degrees as indicated. Maintain the client’s Within 8 hours of student nurse-client intervention, the
head in a neutral position. client was able to:
R: This position will reduce arterial pressure by 1. Achieve a GCS score of 14 indicating an optimal
promoting venous drainage and enhance level of consciousness.
cerebral perfusion. 2. Show alertness and breastfeed properly.
7. Encourage mother to breastfeed infant; assist 3. Decrease head circumference to the 25th
mother with positioning the infant properly. percentile. Anterior fontanelle is concave.
R: Breast milk is the optimal nutrition for an 4. Remain cerebral perfusion pressure above 50
infant. Proper positioning is important to avoid mm Hg.
neck vein compression, which could increase 5. The client's mother was able to demonstrate
intracranial pressure. post-surgery care of her child’s condition.
8. Administer diuretics, carbonic hydrase,
corticosteroids as ordered.
R: Acetazolamide (Diamox) and furosemide
(Lasix) may control communicating
hydrocephalus by reducing production of
cerebrospinal fluid; Corticosteroids reduce
inflammation.
9. Review the structure and function of the brain
and explain how hydrocephalus develops. Clarify
any misconceptions.
 R: Reviewing and clarifying aid in learning and
strengthening understanding.

Collaborative Interventions:
1. Arrange for consultation for mother with
neurosurgeon to discuss surgery and child’s
prognosis.
R: Viewing a child as totally disabled can cause a
parent to not appreciate the child’s capabilities.

2. Actual impaired skin integrity related to mechanical Independent Interventions:
interruption of skin (presence of surgical wound)
secondary to ventriculoperitoneal shunt procedure
as evidenced by a 1-inch suture located behind the
right ear.
Scientific Basis:
A ventriculoperitoneal (VP) shunt is a medical device that 3. Perform routine skin inspection.
relieves pressure on the brain caused by fluid
accumulation. VP shunting is a surgical procedure that
primarily treats a condition called hydrocephalus. This
condition occurs when excess cerebrospinal fluid (CSF)
collects in the brain's ventricles. The shunt is planted at
the head of the patient that leaves a suture after
procedure.
References:
Roth E., (2017). Ventriculoperitoneal shunt. Retrieved
February 11, 2021 from:
https://www.healthline.com/health/ventriculoperitone
al-
shunt#:~:text=A%20ventriculoperitoneal%20(VP)%20sh
1. Assess the client's level of discomfort.
R: Clarify intervention needs and prioritize
immediate care for the patient.
2. Assess the sutured and surrounding area.
R: Note for any abnormalities such as swelling.
R: Systematic inspection can identify developing
problems and promotes early interventions.
4. Maintain and instruct good hygiene.
R: Reduce risk of dermal trauma, improve
circulation and promote comfort.
5. Keep the surgical area clean and dry, support
incision, prevent infection and stimulate
circulation.
R: Assist the body’s natural process of repair
6. Change surgical dressing every day or when it
becomes damp or wet
R: Keeps wound clean and prevent infection
7. Ensure proper nutrition and lots of water intakes.
R: Ensure fast and efficient recovery of the
Desired Outcomes:
Within 2 days of the student nurse-client interventions,
1. The client’s mother would report less to no signs
of discomfort from the baby.
2. The client will show evident healing and shrinking
of the surgical wound.
3. There will be a minimized risk of infection or
swelling.
4. The client will return to normal head movements
and functions without displaying signs of pain.
5. The client’s mother will be aware and capable of
continuing incision care for the patient upon
discharge.
Actual Outcomes:
After 8 hours of the student nurse-client interventions,
1. The client shows signs of comfort.
2. The client’s surgical wound is clean and sanitary.
3. There are no noted infections nor swelling.
4. The client’s mother is able to return the health
teachings imposed to ensure continuation of
unt%20is,collects%20in%20the%20brain's%20ventricles surgical wound care upon discharge.
. 8. Take medicine as prescribed by the physician.
R: Relieve pain and discomfort and help facilitate
recovery
9. Apply safety measures on the head focusing on
the area of the surgical wound
R: Relieve pain and discomfort and prevent
further complications
10. Assist client/SO in following surgical wound care.
R: Enhances commitment to plan and optimizing
outcomes.

3. Ineffective infant feeding pattern related to Independent Interventions: Desired Outcomes:

increased intracranial pressure (excess 1. Assess parents’ knowledge on the importance
cerebrospinal fluid) secondary to Hydrocephalus as
evidenced by difficulty feeding, progressive
vomiting, irritability, and poor sucking reflex.
Subjective Data:
● Infant presents progressive vomiting, irritability
and difficulty feeding over the past 2 days.
Objective Data:
● There is a poor sucking reflex in infant’s
neurologic examination
Scientific Basis:
Hydrocephalus, also known years ago as “water on the
brain”, is a condition where the circulation system of the
body’s cerebrospinal fluid (CSF) is not functioning
properly. The CSF accumulates in the brain and causes
and correct infant feeding techniques
R: It will measure the depth and level of
understanding on following the correct feeding
pattern of the baby.
2. Assess parents about the infant’s feeding
difficulty
R: It will determine the presence of difficulties in
feeding the infant
3. Assess the need for alternative feedings if
needed
R: It will not disrupt the recommended feeding
pattern
4. Assess the infant’s sucking pattern during
breastfeeding
R: It will help determine the presence of an
ineffective feeding pattern.
5. Weigh the baby daily using the standard
Within 8 hours of the student nurse-client interaction,
1. The client will be able to achieve effective
breastfeeding.
2. The client’s mother will be able to verbalize and
demonstrate techniques to manage
breastfeeding problems.
3. The client’s mother will be able to manifest
positive self-esteem in relation to the infant
feeding process.
4. The client will be able to display adequate output
as measured by a sufficient number of wet
diapers daily.
5. The client will be able to demonstrate
appropriate weight gain.
Actual Outcomes:
After 8 hours of the student nurse-patient interaction,
1. The client achieved effective breastfeeding.
intracranial pressure. It’s a condition that more
commonly affects newborns and infants, but it can also
develop during childhood or in adults. Signs and
symptoms of hydrocephalus in infants include rapid
increase in head size, bulge on the soft spot (fontanel)
on the top of the head, vomiting, problems sucking or
feeding, sleepiness Irritability, eyes that are fixed
downward (also called "sun setting"), and seizures.
Reference:
Belleza, M. (2017). Hydrocephalus. Retrieved from
https://nurseslabs.com/hydrocephalus/
Bethesda, A. (2020). Hydrocephalus Fact Sheet.
Retrieved from
https://www.ninds.nih.gov/Disorders/Patient-
Caregiver-Education/Fact-Sheets/Hydrocephalus-Fact-
Sheet
weighing scale 2. The client’s mother verbalized and demonstrated
R: It will detect if the infant has excessive weight techniques to manage breastfeeding problems.
loss during the early stages and to note progress 3. The client’s mother manifested positive self-
6. Teach parents the correct positioning during esteem in relation to the infant feeding process.
feeding the infant 4. The client displayed adequate output as
R: It will promote correct feeding procedure and measured by a sufficient number of wet diapers
prevent newborn from aspiration. daily.
7. Emphasize the importance of a calm, relaxed 5. The client demonstrated appropriate weight
environment during feeding gain.
R: to reduce detrimental stimuli and enhance
mother’s and infant’s focus on feeding activity.
8. Adjust frequency and amount of feeding
according to the infant's response.
R: Prevents stress associated with under- or
overfeeding.
9. Evaluate and record the infant's ability to
properly grasp and compress the areola with lips,
tongue, and jaw.
R: The infant must have a "competent suck" in
order to achieve successful breastfeeding. The
jaws must compress the milk sinuses beneath the
areola. To do this the jaws must be well back on
the areola with the tongue over the lower gum,
forming a trough around the breast, and the lips
must be flanged and sealed around the breast
10. Discourage supplemental bottle feedings and
encourage exclusive, effective breastfeeding.
R: Supplemental feedings can interfere with the
infant's desire to breastfeed, increase the risk of
allergies, and convey the subtle message that the
mother's breast milk is not adequate
 11. Recommend monitoring the number of infant’s
wet/soiled diapers.
R: Stools should be yellow in color, and the infant
should have at least six wet diapers a day to
determine that the infant is receiving sufficient
intake.

Collaborative Interventions:
1. Refer the mother and newborn to the attending
physician if there is presence of unusual
symptoms which may need immediate
interventions.
R: This will help to prevent interference with the
proper feeding pattern and so as to maintain
infant’s proper nutrition.
2. Consult with a dietician.
R: Provides information and guidance in
determining individual nutritional needs
incorporating infant’s particular issues.

4. Risk for delayed growth and development related Independent Interventions: Desired Outcomes:
to impaired ability to achieve developmental tasks. 1. Assess neurological status, examine pupils. After 8 hours of the student nurse-client interventions,
R: To monitor for changes in mental status, 1. The client’s mother will verbalize understanding
Cues: reflexes, and motor function. Changes in pupil of potential for growth delay and plans for
● Lethargic client reaction may indicate altered brain stem prevention.
● Poor rooting and sucking reflex functioning. 2. The client’s mother will identify individual risk
● Client shows irritability upon hearing a bell and 2. Assess head circumference and fontanelles. factors for developmental delay.
room noises R: increasing head circumference and bulging 3. The client’s mother will initiate interventions and
● Mother verbalizes “my baby does not appear to fontanelles indicates accumulating fluid. lifestyle changes promoting appropriate
be himself” 3. Obtain daily weights. development.
R: To determine if feeding patterns are sufficient 4. The client’s mother will formulate plans for
Scientific Basis:
Hydrocephalus is a condition where cerebrospinal fluid
(CSF) is not absorbed by the brain (non-obstructive) or is
unable to drain (obstructive) and builds up inside or
around the brain, progressively increasing the pressure
on the brain. Without treatment to relieve this pressure,
the patient can suffer from growth and developmental
abnormalities. Infants and toddlers with this condition
may develop an abnormally large head circumference.
Reference:
Nursing.com. (n.d.). Nursing Care Plan for
Hydrocephalus. Retrieved February 11, 2021 from
https://nursing.com/lesson/nursing-care-plan-for-
hydrocephalus/
to promote adequate growth.
4. Position infant with proper support.
R: Promotes neurobehavioral integration.
5. Collaborate with related professional resources,
as indicated.
R: Multidisciplinary team care increases the After 8 hours of the student nurse-client interventions,
likelihood of client/family’s specialized and
varied needs, minimizing identified risks.
6. Encourage setting of short-term realistic goals for
achieving developmental potential.
R: Small incremental steps are often easier to
deal with.
7. Promote growth and development.
R: The newborn needs social interaction and
needs to be talked to, played with, and given the
opportunity for activity; and provide toys
appropriate for his mental and physical capacity.
8. Emphasize the importance of follow-up
screening appointments as indicated.
R: To promote ongoing evaluation, support, or
management of the situation.
9. Discuss proactive wellness actions to take.
R: To avoid preventable complications.
10. Maintain a positive, hopeful attitude.
R: Enhances hopefulness and well-being.
prevention of developmental deviation.
5. The client will receive appropriate nutrition as
indicated by individual needs.
Actual Outcomes:
1. The client’s mother was able to verbalize her
understanding of the potential for growth delay
and the plans for prevention.
2. The client’s mother was able to identify
individual risk factors for developmental delay.
3. The client’s mother began initiating interventions
and lifestyle changes that promote appropriate
development.
4. The client’s mother began formulating plans for
prevention of developmental deviation.
5. The client received the appropriate nutrition as
indicated by individual needs.

5. Mild anxiety related to the family’s fear of the Independent Interventions: Desired Outcomes:
infant's surgical outcome as evidenced by the 1. Assess the parents’ understanding of Within 1 hour of the student nurse-client interventions,
mother verbalizing concern for her infant’s safety hydrocephalus and treatment measures. 1. The client’s mother will appear relaxed and
during surgery. R: Reviewing and clarifying aid in learning and report that anxiety is reduced to a manageable
Strengthen understanding. level.
Scientific Basis:
Parents are responsible for recognizing the symptoms of
potential shunt malfunction in their child, which are
unpredictable, variable and similar to those of common
childhood illnesses, particularly viral infections.
Assessing a child for possible shunt malfunction requires
health professionals to listen to, and value parents'
concerns. However, health professionals often perceive
parents' assessment of their child's condition to be
inaccurate contributing to avoidable hospital
admissions. Understanding parents' experiences of living
with a child with hydrocephalus is essential in
understanding their decisions about where and when to
seek health‐care advice for suspected shunt
malfunction.
Reference:
Smith J, Cheater F, Bekker H. (2017). Parents'
experiences of living with a child with hydrocephalus: a
cross-sectional interview-based study. Retrieved
February 13, 2021 from doi: 10.1111/hex.12164
2. Communicate therapeutically with parents and
answer questions calmly and honestly.
R: Promotes calm and supportive environment.
3. Allow expressions of concern and opportunity to
ask questions about the condition and recovery
of the ill infant/child.
R: Provides an opportunity to vent feelings,
secure information needed to reduce anxiety.
4. Encourage parents to remain involved in care and
decision-making regarding the infant/child.
R: Promotes constant monitoring of the
infant/child for improvement or worsening of
symptoms.
5. Prepare child/parents for diagnostic tests and After 1 hour of the student nurse-client interventions,
potential surgical procedures.
R: Promotes reduction in anxiety if they have
knowledge of expectations.
6. Teach parents and child (age dependent) about
the reason for and type of surgery to be done,
site, and dressings, time of surgery, and length of
time of the procedure, preoperative care, and
treatments.
R: Provides information about surgery and
desired effects as well as possible residual
effects.
7. Clarify any misinformation and answer all
questions honestly and in simple understandable
language.
R: Prevents unnecessary anxiety resulting from
inaccurate information or beliefs.
8. Teach about shunt placement and reason;
2. The client’s mother would verbalize that she feels
comfortable in the proper way to breastfeed her
child before and after the surgery.
3. The client’s mother increases self-esteem related
to the infant post-surgery care process.
4. The client’s mother will explore possible
stressors and lifestyle changes she can change in
order to help with the anxiety before, during, and
after her infant’s surgery.
5. The client’s mother will identify healthy ways to
deal with and express anxiety.
Actual Outcomes:
1. The client’s mother appears relaxed and
verbalized, “I don’t feel worried anymore since I
am reassured that my child is in good hands.”
2. The client’s mother verbalized, “I am ready and
comfortable to breastfeed my child.”
3. The client’s mother’s self-esteem has increased
after the surgery.
4. The client’s mother has identified the short-term
and long-term stressors and made lifestyle
changes to calm her anxiety.
5. The client’s mother was able to identify healthy
ways to deal with and express her anxiety.
 possible future revision of shunt placement, signs
and symptoms of shunt complication or
malfunction.
R: Shunt is placed to by-pass an obstruction or
removes excess cerebrospinal fluid that
predisposes to increased ICP; a shunt revision
may be done to treat shunt complication such as
infection or obstruction or as a result of child
growth.
9. Avoid unnecessary reassurance; this may
increase undue worry.
R: Reassurance is not helpful for the anxious
individual.
10. Provide for a non-threatening, consistent
environment/atmosphere. Minimize stimuli.
Monitor visitors and interactions.
R: To lessen the effect of transmission of feelings.

DISCHARGE INSTRUCTIONS
Medication:
● Follow the physician’s instructions for the baby in feeding Furosemide (Lasix) or Acetazolamide (Diamox).
● Follow the physician’s instructions to administer Acetaminophen (Tylenol) if the client feels mild pain or mild fever after the surgery.
● Don’t stop administering to the baby unless the physician says so.
● Administer the given vitamins to the baby daily, the vitamin D, B12 and iron supplement.

Environment:
● Provide the infant a conducive sleeping environment.
● Provide an environment that supports the infant’s development, engagement, and overall well-being.
● Provide an environment for the infant that ensures safety and promotes health.
● Instruct the SO to ensure safety hazards are managed appropriately to avoid injury.
Treatment:
● Follow doctor’s orders in compliance of medications.
● Feed your child with the suggested diet.
● Wash child’s incision with mild soap once a day
● Prevent the child from soaking in water (bath tub, pool) until incision heals to prevent infection.
● Monitor incision regularly for signs of swelling, redness, discharge, and edema.
● Make adjustments to where the child rests and usually stays to cater to the comfort and safety of her head and to allow her to gradually return to normal daily activity
upon arrival.
● Always monitor the child’s temperature, urine and stool output, and her responsiveness.

Health Teachings:
● Instruct the mother to give the infant pain medications as prescribed by the doctor.
● Inform the mother to feed the infant regularly.
● Inform the mother that the infant can resume normal activities gradually after returning home.
● Advise the mother to make or attend the follow-up appointments.
● Advise the mother to immediately call the healthcare provider if the infant shows any observable signs and symptoms.
● Teach the mother how to take the infant’s rectal or forehead temperature.
● Encourage the family to practice good hygiene to prevent spread of infection.
● Teach the importance of safety and to reduce the risk of brain injury.
● Educate caregivers about warning signs of increased cranial pressure and when to seek medical help after discharge.

Observable Signs and Symptoms:

● Inform the mother that a bulging fontanel, which is the soft spot on the surface of the skull, is an emergency and should seek medical attention immediately.
● Inform the mother that a rapid increase in an infant’s head circumference is a sign of hydrocephalus.
● Educate the mother that seizures could be a sign of hydrocephalus in infants and should seek treatment immediately.
● Inform the mother that it is normal for a baby to cry very loud, but if it is a high-pitched cry, she should contact the physician immediately.
● Educate the mother that it is normal for the veins in an infant’s head to be visible because the fontanelles have not yet fused, but it is not normal for the veins to be
prominent in the infant's head. If the infant is experiencing this symptom, seek medical attention immediately.
● Inform the mother that other signs and symptoms for hydrocephalus in infants include: poor feeding, projectile vomiting, sleepiness or less alert than usual,
developmental delays, increased irritability, bulging eye, and an inability of the baby to look upward with the head facing forward.
 ● Inform the mother that pain, vomiting, and poor feeding is normal after surgery, but if symptoms persist contact the physician and seek for medical attention
immediately.

Diet:
● Encouraging the mother to breastfeed exclusively in the first 6 months of life is recommended.
● Instruct the mother to eat three balanced meals and two light snacks throughout the day. Avoid skipping meals.
● Instruct the mother to eat/choose nutrient-dense, nourishing foods such as vegetables, fruits, whole grains, beans, nuts and seeds, and lean protein.
● Encourage the mother to read food labels.
● Instruct mother to avoid fried, oily, spicy, salty, and too much sweet foods.
● Instruct the mother to drink 8 glasses (1920 ml) of water per day to ensure enough water to make breast milk.

Spiritual:
● Encourage the mother to maintain a good relationship with God.
● Encourage the mother to continue her spiritual practices.
● Encourage a positive outlook in life despite stressful situations.
● Encourage self-guiding activities like meditation.
● Encourage the family to seek guidance through prayer and worship.
● Emphasize the importance of prayer in healing.

DRUG STUDY
DRUG NAME CLASSIFICATIONS ACTIONS INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS NURSING
CONSIDERATIONS

Phytonadione PHARMACOTHERAPEUTIC: ● Coagulant adjunctive ● Oral anticoagulant ● Hypersensitivity ● Newborns, INTERVENTION/EVAL

(Vitamin K) ● Fat-soluble vitamin ● Promotes hepatic overdose especially UATION:
formation of ● Vitamin K premature infants ● Monitor PT,
CLINICAL: coagulations factors II, ● Hemorrhagic may develop international
● Nutritional supplement VII, IX, X disease in hyperbilirubine- normalized ratio
● Antibiotics (drug- newborns mia (INR) routinely in
induced Therapeutic Effect: ● Treatment of ● Severe reaction those taking
hypoprothrombinemia) ● Essential for normal anticoagulant (cramp-like pain, anticoagulants.
● Antihemorrhagic clotting of blood induced deficiency chest pain, ● Assess skin for
dyspnea, facial ecchymoses,
flushing, dizziness, petechiae.
rapid/weak pulse, ● Assess gums for
hypotension gingival bleeding,
progressing to erythema.
shock, and cardiac ● Assess urine for
arrest) occurs hematuria.
rarely, ● Assess Hct, platelet
immediately after count, urine/stool
UV culture for occult
administration. blood.
● Assess for decrease
in B/P, increase in
pulse rate,
complaint of
abdominal/back
pain, severe
headache (may be
evidence of
hemorrhage).
● Question for
increase in amount
of discharge during
menses.
● Assess peripheral
pulses.
● Check for excessive
bleeding from
minor cuts,
scratches.
PATIENT/FAMILY
TEACHING
● Discomfort may
occur with
parenteral
administration.
● Adults: Use electric
razor, soft
toothbrush to
prevent bleeding.
● Report any sign of
red or dark urine,
black or red stool,
coffee-ground
vomitus, red-
speckled mucus
from cough.
● Do not use any OTC
medication
without physician
approval (may
interfere with
platelet
aggregation).
● Consume foods
rich in vitamin K1,
including leafy
green vegetables,
meat, cow’s milk,
vegetable oil, egg
yolks, tomatoes.
Acetazolamide PHARMACOTHERAPEUTIC: ● Reduces formation of ● Open-Angle Contraindications Long-term therapy BASELINE
(Diamox) ● Carbonic anhydrase hydrogen and Glaucoma include: may result in acidotic ASSESSMENT
inhibitor bicarbonate ions by ● Seizures including ● Hypersensitivity tostate. Glaucoma:
inhibiting the enzyme absence seizures, sulfonamides ● Assess affected
CLINICAL: carbonic anhydrase. tonic-clonic ● Severe Nephrotoxicity or pupil for dilation,
● Anti-glaucoma seizures, and partial renal/hepatic hepatotoxicity occurs response to light.
● Anticonvulsant Therapeutic Effect: seizures disease occasionally, ● Question potential
● Diuretic ● Increases excretion of ● Edema including ● Adrenal manifested as dark for eye discomfort,
● Urinary alkalinizer sodium, potassium, high cerebral insufficiency urine/stools, pain in decrease in visual
bicarbonate, water in edema ● Hypochloremic lower back, jaundice, acuity.
kidney ● Epilepsy acidosis dysuria, crystalluria, Epilepsy:
● Decreases formation of ● Altitude Sickness ● Hypokalemia renal colic/calculi. ● Obtain history of
aqueous humor in eye; ● Renal Impairment ● Hyponatremia seizure disorder
retards abnormal ● Congestive heart ● Long-term Bone marrow (length, intensity,
discharge from CNS failure administration indepression may occur duration of seizure,
neurons ● Central vertebral pts with chronic manifested as aplastic presence of aura,
nystagmus non congestion
anemia, level of
● Increased angle-closure thrombocytopenia, consciousness.
intracranial glaucoma thrombocytopenic INTERVENTION/EVAL
pressure ● History of carbonicpurpura, leukopenia, UATION
anhydrase agranulocytosis, ● Monitor for
inhibitor hemolytic anemia. acidosis
sensitivity (headache,
lethargy
Cautions: progressing to
● Diabetes mellitus drowsiness, CNS
● Gout depres- sion,
● Obstructive Kussmaul’s
pulmonary disease respiration).
● Respiratory PATIENT/FAMILY
acidosis TEACHING
 ● Moderate renal ● Report
impairment tingling/tremor in
● Pregnancy hands or feet,
Category C. unusual bleeding
● Breastfeeding or bruising,
● Exposure to unexplained fever,
Sunlight (UV) sore throat, flank
● Geriatric pain.
● Avoid tasks that
require alertness,
motor skills until
response to drugs
is established.
● Use sunscreen,
wear protective
clothing.

Furosemide PHARMACOTHERAPEUTIC: ● Enhances excretion of ● Edema Contraindications Vigorous diuresis may BASELINE
(Lasix) ● Loop diuretic sodium, chloride, ● Heart Failure include: lead to profound ASSESSMENT
CLINICAL: potassium by direct ● Hypertension ● Anuria water loss/electrolyte ● Check vital signs,
● Diuretic action at ascending depletion, resulting in esp. B/P, pulse, for
limb of loop of Henle. Cautions: hypokalemia, hypotension
● Hepatic cirrhosis hyponatremia, before
Therapeutic Effect: ● Hepatic coma dehydration. administration.
● Produces diuresis, ● Severe electrolyte ● Assess baseline
lowers B/P. depletion Sudden volume serum electrolytes,
● Prediabetes depletion may result esp. for
● Diabetes in increased risk of hypokalemia.
● Systemic lupus thrombosis, circula- ● Assess skin turgor,
erythematosus tory collapse, sudden mucous
death. membranes for
 hydration status;
Acute hypotensive observe for edema.
episodes may occur, ● Assess muscle
sometimes several strength, mental
days after beginning status.
therapy. ● Note skin
temperature,
Ototoxicity (deafness, moisture.
vertigo, tinnitus) may ● Obtain baseline
occur, esp. in pts with weight.
severe renal ● Initiate I&O
impairment. Can monitoring.
exacerbate diabetes INTERVENTION/EVAL
mellitus, systemic UATION
lupus erythematosus, ● Monitor B/P, vital
gout, pancreatitis. signs, serum
Blood dyscrasias have electrolytes, I&O,
been reported. weight.
● Note extent of
diuresis.
● Watch for changes
from initial
assessment
(hypokalemia may
result in changes in
muscle strength,
tremor, muscle
cramps, altered
mental status,
cardiac
arrhythmias.
 Hypothermia may
result in confusion,
thirst,
cold/clammy skin.
PATIENT/FAMILY
TEACHING
● Expect increased
frequency, volume
of urination.
● Report
palpitations, signs
of electrolyte
imbalances (noted
previously),
hearing
abnormalities
(sense of fullness in
ears, tinnitus).
● Eat foods high in
potassium such as
whole grains
(cereals), legumes,
meat, bananas,
apricots, orange
juice, potatoes
(white, sweet),
raisins.
● Avoid sunlight
● Document the
medication given
● Observe for
 bleeding
● Observe for
jaundice and
kernicterus
● Observe for signs
of local
inflammation
● Protect drugs from
light.

Acetaminophen PHARMACOTHERAPEUTIC: ● Appears to inhibit ● Fever Contraindications Early Signs of BASELINE

(Tylenol) ● Central analgesic prostaglandin ● Pains such as include: Acetaminophen ASSESSMENT
synthesis in the CNS headache, ● Severe hepatic Toxicity: ● If given for
CLINICAL: and, to a lesser extent, backache, impairment or Anorexia, nausea, analgesia, assess
● Non-narcotic analgesic, block pain impulses toothache, severe active liver diaphoresis, fatigue onset, type,
antipyretic through peripheral muscular ache, disease (Ofirmev). within the first 12–24 location, duration
action. Acts centrally minor arthritis, hours. of pain. Effect of
on a hypothalamic premenstrual and Cautions: medication is
heat-regulating center, menstrual cramps ● Sensitivity to Later Signs of reduced if full pain
producing peripheral ● Common cold acetaminophen; Toxicity: Vomiting, response recurs
vasodilation (heat loss, ● Analgesia severe renal right upper quadrant prior to the next
skin erythema, ● Antipyresis impairment; tenderness, elevated dose.
diaphoresis). ● Renal impairment alcoholic hepatic hepatic function tests ● Assess for fever.
disease, hepatic within 48–72 hours ● Assess alcohol
Therapeutic Effect: impairment, or after ingestion. usage.
● Results in antipyresis. active hepatic INTERVENTION/EVAL
Produces analgesic disease; chronic Antidote: UATION
effect. malnutrition and Acetylcysteine. ● Assess for clinical
hypovolemia improvement and
(Ofirmev); G6PD relief of pain, fever.
deficiency. Limit ● Therapeutic serum
dose to less than 4 level: 10–30
g/day. mcg/ml; toxic
serum level:
greater than 200
mcg/ml. Do not
exceed maximum
daily
recommended
dose: 4 g/day.
PATIENT/FAMILY
TEACHING
● Consult a physician
for use in children
younger than 2 yrs,
oral use longer
than 5 days
(children) or longer
than 10 days
(adults), or fever
lasting longer than
3 days.
● Severe/recurrent
pain or high/
continuous fever
may indicate
serious illness.
● Advise not to take
more than 4 g/24-
hr period. Many
non prescription
combination
 products contain
acetaminophen.
● Avoid alcohol use.

Vitamin D PHARMACOTHERAPEUTIC: Calcitriol: Stimulates ● Inherited disorders Contraindications Early signs of BASELINE
(Drisdol) ● Fat Soluble vitamin calcium transport in ● Multiple sclerosis include: overdose manifested ASSESSMENT
intestines, resorption in ● Osteomalacia ● Vitamin D toxicity as: ● Obtain baseline
CLINICAL: bones, and tubular ● Osteoporosis ● Hypercalcemia ● Weakness serum calcium,
● Vitamin D analogue reabsorption in kidney; ● Psoriasis ● Malabsorption ● Headache phosphorus,
suppresses parathyroid ● Rickets syndrome ● Drowsiness alkaline,
hormone (PTH) secretion/ ● Nausea phosphatase,
synthesis. Cautions: ● Vomiting creatinine, iPTH.
● Immobilization ● Dry mouth INTERVENTION/EVAL
Doxercalciferol: Regulates (increases risk of ● Constipation UATION
blood calcium levels, hypercalcemia) ● Muscle/bone pain Monitor serum,
stimulates bone growth, ● Dehydration (in- ● Metallic taste urinary calcium levels,
suppresses PTH creases serum serum phosphate,
secretion/synthesis. creatinine, risk of Later signs of magnesium, cre- atine,
hypercalcemia overdose evidenced alkaline phosphatase,
Ergocalciferol: Promotes ● Dialysis pts by: BUN deter- minations
active ab- sorption of (increases risk of ● Polyuria (therapeutic calcium
calcium and phosphorus, hypermagnesemia ● Polydipsia level: 9–10 mg/dl),
increasing serum levels to /hyperphosphate ● Anorexia iPTH measurements.
allow bone mineralization; mia), pre existing ● Weight loss Es- timate daily dietary
mobilizes calcium and renal failure ● Nocturia calcium intake. En-
phosphate from bone, (ectopic ● Photophobia courage adequate fluid
increases reabsorption of calcification may ● Rhinorrhea intake. Monitor for
calcium and phosphate by occur) ● Pruritus signs/symptoms of
renal tubules. ● Impaired hepatic ● Disorientation vitamin D intoxi- cation
function ● Hallucinations PATIENT/FAMILY
Paricalcitol: Suppresses ● Renal ● Hyperthermia TEACHING
PTH secretion/synthesis. osteodystrophy ● Hypertension ● Adequate calcium
Therapeutic Effect: with ● Cardiac intake should be
Essential for absorption, hyperphosphatem dysrhythmias maintained.
utilization of calcium, ia. ● Dietary
phosphate, control of PTH phosphorus may
levels. need to be
restricted (foods
high in phos-
phorus include
beans, dairy
products, nuts,
peas, whole-grain
products).
● Oral formulations
may cause
hypersensitivity
reactions. Avoid
excessive doses.
● Report
signs/symptoms of
hypercalcemia
(head- ache,
weakness,
drowsiness,
nausea, vom- iting,
dry mouth,
constipation,
metallic taste,
muscle or bone
pain).
● Maintain
 adequate
hydration.
● Avoid changes
in diet or
supplemental
calcium intake
(un- less
directed by
healthcare
professionals).
● Avoid
magnesium-
containing
antacids in pts
with renal
failure.