Hydrocephalus
INTRODUCTION
Hydrocephalus, characterized by enlargement of the head, bulge in the forehead, brain atrophy, and mental disorders - caused by the failure of the circulation of cerebrospinal fluid (CSF) which flows from the ventricles of the brain.
Obstruction or disruption resulting in increased cerebrospinal fluid absorption and an increase in intracranial pressure (ICP), which if not relieved, can lead to brain damage and died. Hydrocephalus can occur because of congenital or due to a tumor, infection, or bleeding.
Treatment includes surgery with placement of a shunt to reduce ICP. Possible complications include infection, blockage, or subdural hematoma.
ASSESSMENT
Malfunction of the shunt
Neurological
Baby
Sutura breakdown skull
Swelling along the shunt tract
High-pitched cry
Prominent crown
Veins bulge skin head
Irritability when you wake up
Increased circle of frontal-occipital
Sunset eyes (a sign setting-sun)
Toddler
Headache
Convulsions
Swelling along the shunt tract
Irritability
Sunset eyes (occurs if the hydrocephalus is still not corrected)
School age
Headache
Sutura cracked skull
Convulsions
Papiledema
Sunset eyes (occurs if the hydrocephalus is still not corrected)
Adolesent
Papiledema
Sunset eyes (occurs if the hydrocephalus is still not corrected)
Convulsions
Impaired level of consciousness
Cushing's triad (bradycardia, widening pulse pressure, and apnea)
Dilated pupil.
Gadtrointestinal
Baby
Throw up
Changes in appetite
Toddler
Throw up
School age
Throw up
Musculoskeletal
Baby
Lethargi
Spastis lower limb
Toddler
Lethargi
School age
Lethargi
Psychosocial
School age
The decline in school performance
Changes in attention span
Respiration
Adolessent
Cheyne-Stokes respiration
Shunt infection
Neurology
Tau swelling redness along the shunt tract
The signs and symptoms of shunt dysfunction (headache, convulsions, bulging fontanel (in infants), decreased LOC)
Gastrointestinal
Decreased appetite
Integumentary
Increased body temperature
Nursing Diagnosis
Impaired cerebral perfusion is associated with increased ICP.
Expected results
Children will maintain brain function and would not place any sign = sign-up ICP.
INTERVENTION
Neurological assessment done every 2 hours to 4 hours of pupillary response, grip, handling, pain response, interactive response (smile, talk, babble), and disposition (not fun and irritability).
Assess vital signs every 2 hours to 4 hours, record the irregular breathing and heart rate and rhythm and extent of the pressure pulse.
Perform cranial nerve assessment every 2 hours to 4 hours
Elevate the head of the bed 30 degrees
If the baby, assess the crown every 4 hours the possibility of a protrusion. Be sure to conduct the assessment during a quiet period because the crown is usually prominent during crying.
If children under age 2 years, measure head circumference daily
Assess and report any swelling along the shunt line every 8 hours
Prepare oxygen and suction equipment in place when children tidru mucus during the period of disturbance of consciousness (LOC).
Record the statements of parents about their children in relation to previous experiences related to shunt malfunction.
Note the quality and tone when children cry
If the child is an infant, keep the position of a child when the child picked up.
Rational
The study was conducted as often as possible will provide data to determine changes in child neurological conditions associated with ICP. When that happens will show that the child has shown a significant disruption ICP
Assessment of vital signs are as often as possible will help detect early signs of ICP (such as tachycardia, fluctuating blood pressure, and respiration Cheyne-Stokes) or the signs of the development of ICP (Cushing's triad: the expansion of pulse pressure, bradycardia, and apnea) .
Changes in cranial nerve function showed ICP. It often happens, C3 and C6menunjukkan the pereubahan pupil and eyeball movement. C7, C9 and C10 also memanifestasikanm with facial movements that are not symmetrical, ketidakmapuan speaking and swallowing, and stridor or crowing sound during inspiration.
Elevation head in the bed allow gravity to increase the flow of cerebral darak, will help to decrease ICP.
Bulging fontanelle-bun will affect the increase in ICP.
Enlarged head yangtidak normal in children under 2 years of age, especially infants indicated increased ICP. Normally, the growth of the average baby's head ¾ "(2 cm) per month until the age of 2 months, then 1 / 8" (0.3 cm) per month until age 1 year.
Swelling along the shunt tract or shunt around the pump to indicate that the shunt blocked.
Konsigen equipment and suction mucus is required when there child has seizures or apnea.
Because every child has the signs and symptoms of shunt malfunction, parents help nursing and medical staff to determine whether the shunt functioned Banar.
Increased tone in children cry biuasanya indicated increased ICP.
Because of enlargement of the head, baby boy is difficult to be picked up, although the body position is maintained in order to avoid tension in the neck.
Nursing Diagnosis
Risk of infection associated with the installation of shunt surgery.
Expected results
Children will demonstrate the absence of infection associated with placement of a shunt is characterized by a temperature less than 100 º F (37.8 º C) and no signs of swelling of the wound incision and no fluid comes out through injury, anxiety, fatigue, or loss of appetite eat.
Intervention
Assess the child's body temperature is not stable, decreased LOC, loss of appetite, vomiting, increased white blood cells, and swelling or redness along the shunt tract.
Monitor child's body temperature every 4 hours
The position of children who do not lay hold beraty on the valve in the first 24 to 48 hours after surgery.
Review the incision area every 4 hours, see the drainage of fluid from the wound and the swelling. Record the number and type of discharge from the incision wound.
Give antibiotics as directed.
Rational
This sign gives an indication of infection, usually occurs within the first month after shunt insertion.
Decrease in body temperature is an early sign of infection in neonates, and penimngkatan body temperature is an early sign of infection in children.
The position where the head in the right position helps prevent damage to the skin or around the shunt pump, -
Swelling around the pump, shunt tract, or surgical incision, with or without grainase-may be an early sign of infection in the shunt.
Antibitik which prophylaxis is usually given during surgery and continued at 48 to 72 hours after surgery.
Nursing Diagnosis
Risk reduction in fluid volume associated with nutritional status at the time and the postoperative stage and prabedah
Results are expected pliers
Children will demonstrate no signs of dehydration is characterized by stable weight, good skin turgor, electrolyte levels stable, tears abaik, moist mucous membranes, urine output of 1 to 2 ml / kg / hour
Intervention
Monitor carefully fluid intake and output
Weigh weight at the same time each day
Record the frequency and number of vomiting
Montior serum electrolyte levels in children every day if vomiting occurs. Give attention sesksama on sodium and potassium levels.
Give parenteral nutrition in accordance with the instructions, and monitor every hour of administration
If the child has surgery that is by placing a ventriculoperitoneal shunt, tunmggu more than 24 hours after the bowel sounds are active only then began to give liquid food.
Rational
Monitor carefully fluid loss
Increase or decrease in body weight indicate hydration status disorders
Vomiting menurpakan common sign of increased intracranial pressure (ICT), can indicate hydration status of children. Parenteral nutrition may be needed to help improve the loss of fluid, especially a baby that can not accept food orally
Losing large amounts of sodium, potassium, and other electrolytes as a result of vomiting.
Parenteral fluid administration will help restore the normal fluid and electrolyte balance.
Wait more than 24 hours after the return of bowel sounds indicate that the child did not experience any surgical ileus paraliticakibat.
Nursing Diagnosis
The risk of injury related to the occurrence of seizures.
Expected results
Children will not experience injury as a result of seizures
Intervention
Determine whether the child has a history of seizures
Perform prevention of seizures in children with increased ICT or shunt malfunction. Prepare suction equipment mucus.
During a seizure, do the actions:
Help your child lying towards the side, salh them on the bed or under the floor, and away from the area to disturb.
Do not try tying a child, but keep on its side.
Do not mengusahakanm put decree anything in the child's mouth
Assess the respiratory status of children
Record the duration of body movements and seizures.
Rational
Seizures occur in over 40% of children within 2 years after the installation of shunt
Seizures are a sign of improving ICT. Prevention of seizures is necessary to prevent injury in children.
This helps the child as a means of follow-up health.
This stage helps prevent injury due to falls san caused convulsions or seizures due to activity.
Binding strong ataugerakan in children can cause trauma
Trying to insert anything into your child's mouth can damage teeth and gums. .
The child may need respiratory resuscitation jiga have apnea during or after seizure
Gerakanm type and duration of seizures help explain whether the type of seizures in children.
Nursing Diagnosis
Excess fluid volume related to the act of ventriculoatrial shunt.
Expected results
Children will develop the absence of signs and symptoms of cardiac overload is marked loss of apnea, loss of Crackle, Tachypnoea, tachycardia and cyanosis.
Intervention
Assess the infant or child's respiratory and cardiovascular status every 2 to 4 jan possible signs of decreased cardiac and respiratory failure, including Tachypnoea, tachycardia, dyspnea, and arrhythmia (This assessment is important in infants).
Weigh weight badanb child every day.
Monitor fluid intake and output children.
Rational
During the installation of ventriculoatrial shunt, the distal end of the shunt is placed in the right atrium, where the liquid will flow otask. Because the increased volume of fluid in the right atrium, will cause excessive burden of heart and respiratory failure.
Weight gain may indicate fluid retention, which is associated with cardiac overload.
Action monitoring will assess the child's fluid status.
Nursing Diagnosis
Anxiety (parents and children) are associated with reduced understanding of hydrocephalus, the need for installation of shunt, and surgery.
Expected results
Parents and children (if tetapt) will express pemahamannnya about hydrocephalus, mandatory installation of a shunt, and surgery performed.
Intervention
1. Explaining about hydrocephalus, ventricular anatomy, the basic purpose of the shunt. Use diagrams and samples of the shunt, if available to help provide an acceptable explanation iformasi. Also explain the purpose of the various actions recommended diagnostic tests and procedures to be performed.
2. Give gamnbaran perioperative measures, including:
· Fasting
· Format pewrsetuajuan surgery
· Define an action of intra venous
· Transport the child to the surgery room
· Waiting room for parents
· Surgery timetable
· Long expected surgery
· Recovery room
· Montoring vital signs
· Place an incision made
· Bandage
3.Berikan time parents ask questions and express fears and concerns.
Help your child to prepare to stay hospitalization and surgery, use of puppets, hospital equipment available, and diagrams and videos that exactly match the level of child development.
Give a strengthening of the explanation surgeon
Refer parents on soisial worker or social service personnel as needed.
Rational
1. Provide an explanation will help decrease fear and anxiety and increase acceptance of the child's condition.
2. The explanation of this activity will reassure parents that they should be aware that the child will live it and help to provide encouragement to participate in preparatory activities prabedah, if possible.
3. Parents need time to adjust to the information so they can form the questions and express fears and concerns.
4. Demonstrate using dolls is ideal to use to help menngani children that occurred during the hospital stay. Diagrams, videos, books, and discussions may be more appropriate in older children.
5. Parents and children often receive too much information in a short time. Repeat explanations to help understanding the child's condition.
6. The social worker can provide counseling them carefully to help parents adjust to living conditions of children and nurse at the hospital and can help planners oraganisasi further and refers to the social.
Nursing Diagnosis
Lack of knowledge related to the disease and care at home
Expected results
The parents will express their understanding of illness and home care instructions and will perform maintenance procedures at home.
Intervention
1. Assess understanding of parents to the disease and how to shunt function
2. Instruct parents how to care for the shunt, including details of the signs and symptoms of shunt malfunction and the occurrence infreksi and special treatment of the shunt
3. It is important to continuously perform a neurologic examination
4. Give the parents time to ask questions and express concern.
5. Explain that the shunt can be modified in accordance with the child's development.
6. explain various seizure medications, such as carbamazepine (Tegretol) or phenytoin (Dilantin). Review the possibility of influence.
Rational
1. Assessment as a basis to launch health education
2. Requires an understanding of how your parents treat children who fitted the shunt and report signs and symptoms.
3.Anak will get a long surveillance for mengakji shunt and tube function and general condition of the child.
4. Ask questions and express concern will help parents understand the instructions.
5. The length of a shunt installed according to the level of child development.
6. brain injury can make children susceptible to seizures; with medication can help control seizures.
List documentation
During his stay patient in hospital, recording:
· Situation of children and the assessment made during entry
· Changes in the child's condition
· P {emeriksaan laboratory and diagnostic tests performed
· Intake and output fluid
· Function shunt
· Status of development of the child
· Reactions of children and parents to the disease and stay patient in hospital
· Teaching guide to masian and their families
Guidelines for patients to go home plans
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