The process of nursing care for clients with hydrocephalus begins with assessment, diagnosis, and nursing intervention.
Assessment
1. History
a. Data collection: name, age, gender, address, etc.
b. Assess history of illness / Main complaint: vomiting, restlessness, headache, lethargy, fatigue, apathy, double vision, pupillary changes, constriction of peripheral vision.
c. Assess developmental history: birth.
2. Physical examination
a. Inspection:
1) Can the child look up?
2) Is there head enlargement?
3) Is the forehead prominent and shiny? And the blood vessels are clearly visible?
b. Palpation:
1) Measure head circumference: The head is getting bigger.
2) Fontanelles: fontanelles are firm and slightly elevated from the surface of the skull.
c. Eye Examination:
1) Accommodation.
2) Movement of the eyeball.
3) Wide field of view.
4) Convergence.
Nursing Diagnosis
In pediatric patients with hydrocephalus, the diagnoses that can appear (Nanda Nic-Noc, 2013), are:
1. Ineffective cerebral tissue perfusion related to increased intracranial pressure.
2. Risk for Impaired skin integrity: head related to mechanical factors (installation of Vp shunt).
3. Risks for Imbalance Nutrition: less than body requirements related to anorexia, nausea, vomiting.
4. Acute pain related to biologic injury agent.
5. Risk for injury related to increased intracranial pressure.
Nursing Intervention
1. Ineffective cerebral tissue perfusion related to increased intracranial pressure.
After 2x24 hour nursing action is expected; effective cerebral tissue perfusion, with outcome criteria:
- The client does not complain of headache, nausea and vomiting.
- Vital signs within normal limits.
Intervention:
a. Assess causative factors of individual situation/condition or cause of coma/decreased tissue perfusion and possible causes of increased ICP.
Rationale: Early detection to prioritize intervention, assessing neurological status / signs of failure to determine emergency treatment or surgery.
b. Monitor vital signs every 4 hours.
Rationale: A normal condition when the cerebral circulation is well-maintained or fluctuations are characterized by systemic blood pressure, a decrease in autoregulation is mostly a sign of decreased local diffusion of cerebral blood vasculature.
c. Keep the patient's head/neck in a neutral position, try with a little pillow. Avoid using a pillow that is high on the head.
Rationale: Turning the head on one side can cause pressure on the jugular vein and block blood flow to the brain (inhibiting drainage of the cerebral veins) so that it can increase intracranial pressure.
d. Collaborative administration of oxygen as indicated
Rationale: reduces hypoxemia, which can increase cerebral vasodilation and blood volume and increase ICP.
2. Risk for Impaired skin integrity: head related to mechanical factors (installation of Vp shunt).
After 2x24 hour nursing action is expected : no disturbance of skin integrity with criteria: intact, clean and dry skin.
Intervention:
a. Assess scalp every 2 hours and monitor for areas of pressure.
Rationale: To monitor the condition of the skin integument early.
b. Changing the position every 2 hours may be considered to change the position of the head every hour.
Rationale: To increase skin circulation.
c. Maintain the use of linen on the bed.
Rationale: Linen can absorb sweat so the skin remains dry.
d. Lay the patient's head on a foam rubber pillow / use a water bed.
Rationale: To reduce the pressure that causes mechanical stress.
e. Provide nutrition as needed.
Rationale: The tissue will be easily necrotic when calories and protein are lacking.
3. Risks for Imbalance Nutrition: less than body requirements related to anorexia, nausea, vomiting.
After nursing actions for 1x24 hours is expected; no nutritional disturbances with the following criteria:
- No weight loss of 10%.
- No nausea and vomiting.
Intervention:
a. Maintain oral hygiene before and after chewing food.
Rationale: Unclean mouth affects the taste of food and nausea.
b. Give small portions of food but often.
Rationale: Small but frequent meals can ease the work of the stomach, the digestive tract can be disrupted due to hydrocephalus.
c. Observe the client's weight.
Rationale: Knowing the client's weight gradually.
d. Collaboration with nutritionists
Rationale: Knowing the nutritional status of the client.
4. Acute pain related to biologic injury agent.
After nursing actions 1x24 hours is expected ; acute pain resolved, with the outcome criteria:
- The client says the pain is reduced or no pain
- Pain scale : 0
- The client looks relaxed
- No grimace
- Vital signs within normal limits
Intervention:
a. Assess pain experience, area of pain and pain scale (1-5).
Rationale: Helps evaluate pain.
b. Observation of vital signs.
Rationale: Changes in vital signs indicate brainstem trauma.
c. Collaboration of pharmacological therapy
Rationale: Pharmacological therapy if the pain is unbearable.
5. Risk for injury related to increased intracranial pressure.
After nursing actions 1x24 hours is expected ; no injury, with the following criteria:
Normal vital signs, effective breathing pattern, positive light reflex, no disturbance of consciousness, no vomiting and no seizures.
Intervention:
a. Watch closely for signs of elevated ICP
Rationale: To detect early increase in ICP.
b. Determine the coma scale
Rationale: Decreased consciousness indicates an increase in ICP
c. Teach family about signs of increased ICP.
Rationale: Families can participate in the care of children with hydrocephalus.
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