Ineffective Cerebral Tissue Perfusion related to Hydrocephalus

Hydrocephalus also known as "water on the brain," is a buildup of fluid inside the skull that leads to brain swelling. Hydrocephalus is a medical condition in which there is an abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles, or cavities, of the brain.

This condition also could be termed a hydrodynamic disorder of CSF. Acute hydrocephalus occurs over days, subacute hydrocephalus occurs over weeks, and chronic hydrocephalus occurs over months or years.

CSF normally moves through the brain and the spinal cord, and is soaked into the bloodstream. CSF levels in the brain can rise if:

• The flow of CSF is blocked
• It does not get absorbed into the blood properly
• The brain makes too much of it

When hydrocephalus is present at birth, it can be the result of conditions like spina bifida (where the primary cause is abnormal development of the spinal cord) or aqueductal stenosis (a narrowing of the small passageway, called the "aqueduct of Sylvius," that connects two major ventricles in the brain).

As a result, a baby with hydrocephalus will appear to have an abnormally shaped head — usually much larger than other babies the same age. Other signs to look for include:

• bulging at the soft spots
• "split" sutures — a gap can be felt between skull bones
• rapid increase in head circumference
• swollen veins that are recognizable to the naked eye
• downward cast of the eyes (called "sunsetting")

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
• Muscle spasticity (spasm)
• Slow growth (child 0 - 5 years)
• Slow or restricted movement
• Vomiting

Nursing Care Plan for Hydrocephalus

Nursng Diagnosis for Hydrocephalus : Ineffective Cerebral Tissue Perfusion related to increased intracranial pressure

characterized by impaired blood flow to the brain.

Goal: Adequate cerebral tissue perfusion,

Expected outcomes:

• Improved level of consciousness (GCS: E4 M6 V5).
• Not a stiff neck.
• No seizures.
• Blood pressure within normal limits.
• Not vomiting progressive
• No headaches

Intervention

a) Maintain bed rest with the head flat and monitor vital signs as indicated after the lumbar puncture.
Rationale: Changes in cerebrospinal fluid pressure may be a potential risk of herniation of the brain stem, which requires immediate medical treatment.

b) Monitor / record neurological status, such as GCS.
Rationale: Assessment of trend changes and the potential of increasing the level of awareness of ICT is very useful in determining the location, distribution / extent and progression of cerebral damage.

c) Monitor the frequency / heart rhythm and heart rate.
Rationale: Changes in the frequency, dysrhythmias and heart rate may occur, which reflects brain stem trauma in the absence of underlying heart disease.

d) Monitor breathing, note the pattern, the respiratory rhythm and respiratory frequency.
Rationale: This type of pattern is a sign of heavy breathing from an increase in ICT / cerebral areas affected.

e) Elevate the head of the bed about 15-45 degrees as indicated. Keep the patient's head remains in neutral position.
Rationale: Increased venous outflow from the head to reduce ICT.

f) Monitor the GDA. Provide oxygen therapy as needed.
Rationale: The occurrence of acidosis may inhibit the entry of oxygen at the cellular level that aggravate cerebral ischemia.

g) Give the medication as indicated.