Hydrocephalus Hydrocephalus is a condition caused by an imbalance in the production and absorption of CSF in the ventricular system.

When production is greater than absorption, CSF accumulates in the ventricular system, usually under increased pressure, producing passive dilation of the ventricles. Pathophysiology The two secretions by which CSF is formed include secretion by the choroid plexus and lymphatic-like drainage by the extracellular fluid of the brain.CSF circulation throughout the ventricular system and then is absorb within the subarachnoid spaces by a mechanism that is entirely clear. Prenatal diagnosis is undoubtedly having an impact on the current prevalence at birth by hydrocephalus. The advent impact of MRI and CT scanning has provided valuable information about the pathophysiology of various diseases. The causes are diverse; they are either congenital (maldevelopment or intrauterine infection) or acquired (neoplasm hemorrhage, or infection). Hydrocephalus is a symptom of an underlying brain disorder resulting in either (1) impaired absorption of CSF within the subarachnoid space (ventricles communication; communicating hydrocephalus) or (2) obstruction to the flow of CSF within the ventricles (do not communicate; noncommunicating hydrocephalus). Any imbalance of secretion and absorption causes an increased accumulation of CSF in the ventricles, which become dilated and compress the brain substance against the surrounding in the bony cranium. When this occurs before fusion of the cranial sutures, it produces enlargement of the skull, as well as dilation of the ventricles. In younger children from 10 to 12 years of age, previously closed suture lines, especially the sagittal suture, may become diastatic or opened. Most cases of noncommunicating hydrocephalus are a rest of developmental malformations. Although the defect usually is apparent in early infancy, it may be evident at the time from prenatal period to late childhood or early childhood. Other causes include neoplasms, infection, and trauma. An obstruction to the normal flow of CSF pathway causes increased pressure. Hydrocephalus is so often as with myelomeningocele that all such infants should be observed for its development. In the remainder of cases there is a history of intrauterine infections, hemorrhage, and neonatal meningoencephalitis. In other children hydrocephalus is most often a result of spaceoccupying lesions, intracranial infections, hemorrhage, or pre-existing developmental defects, such as aqueduct stenosis or the Arnold-Chiari malformation (a congenital anomaly in which the cerebellum and medulla oblongata extend down through the foramen magnum). Diagnostic Evaluation Two factors that influence the clinical picture in hydrocephalus are the time of onset and the presence of pre-existing structural lesions. In infancy, before closure of the cranial sutures, head enlargement is the predominant sign, whereas in older infants and children the lesions responsible for hydrocephalus produce other neurologic signs through pressure on adjacent structures before causing CSF on obstruction. In infancy the diagnosis of hydrocephalus is based on the head circumference that cross one or more grid lines on the measurement chart within a period of 2-4 weeks and on associated neurologic signs that are present and progressive. However, other diagnostic studies are needed to localize the site of CSF obstruction.

The signs and symptoms in early to late childhood are cause by increased ICP, and specific manifestations are related to the focal lesion. Most commonly resulting from posterior fossa neoplasms and adequate stenosis, the clinical manifestations are primarily those associated with space-occupying lesions. The primary diagnostic tools for detecting hydorocephalus are CT and MRI. Sedation is required since, the child must remain absolutely still for an accurate picture to be produce. Diagnostic evaluation of children who have symptoms of hydrocephalus after infancy is similar to that used in those with suspected intracranial tumour. In the neonate, enchoencephalography is useful in comparing the ratio of lateral ventricle to cortex. Therapeutic Management The treatment of hydrocephalus id directed toward relief of the hydrocephalus, treatment of complications, and management of problems related to the effect of the disorder on psychomotor development. The treatment is with few exceptions, surgical. This is accomplished by direct removal of an obstruction (such as tumour) or placement of a shunt that provides primary drainage of the CSF from the ventricles to an extracranial compartment, usually the peritoneum (ventriculoperitonial [VP] shunt). Most shunt systems consist of a ventricular catheter, a flush pump, a unidirectional flow valve, and a distal catheter. In all models the valves are designed to open at a predetermined intraventricular pressure and close when the pressure falls below that level, thus preventing backflow of secretions. The initial shunt is placed when necessary to relieve CSF obstruction, and revisions are needed when signs of malfunction appear. In all mechanism the initial success is relatively high; however, shunts are associated with complications that interfere with continued shunt function or threaten the life of the child. The major complications of VP shunts are infection and malfunction. All shunts are subjected to mechanical difficulties, such as kinking, plugging, or separation or migration of the tubing. Malfunction is most often caused by mechanical obstruction either within the ventricles from particulate matter (tissue or exudate) or at the distal end of the thrombosis or displacement as a result of growth. The most serious complication, shunt infection, can occur at any time, but the period of greatest risk is 1 to 2 months after placement. The infection is generally a result of intercurrent infections at the time of shunt placement. Infection include septecimia, bacterial endocarditis, wound infection, shunt nephritis, meningitis, and ventriculitis. Meningitis and ventriculitis are of greatest concern since, any complicating CNS infection is a significant predictor of intellectual outcome. Infection is treated with massive dose of antibiotics administered by the IV route. A persistent infection requires removal of the shunt until the infection is controlled. External ventricular drainage (EVD) is used until CSF is sterile. EVD allows removal of CSF through a tube place in the child s ventricle that flows by gravity into a collection device. Prognosis The prognosis of children with treated hydrocephalus depends largely on the rate at which hydrocephalus develops, the duration increased ICP, the frequency of complications, and the cause of the hydrocephalus, for example, malignant tumours may have a high mortality regardless of other complicating factors. Surgically treated hydrocephalus with continued neurological and medical management has a survival rate if 80%, with the highest incidence of mortality occur within the first year

of treatment. Of the surviving children, approximately one third are both intellectually and neurologically normal, and one half have neurologic disorders. Nursing Considerations Preoperatively the infant with diagnosed or suspected hydrocephalus is observed carefully for signs of increasing. In infants the head is measured daily at the point of measurement-the occipitofrontal circumference. Fontanels and suture lines are gently palpated fir signs of bulging, tenseness, and separation. An infant with abnormal ICP will display bulging under certain circumference such as straining or crying; therefore such accompanying behaviour should be noted. Irritability, lethargy as well as altered vital signs and feeding before, may indicate an advancing pathologic condition. The nurse is responsible for preparing the child for diagnostic tests such as tomography and for assisting the practice with procedures such as a ventricular tap, which is often performed to relieve excessive pressure during the operative period and CSF examination. Sedation is required since the child must remain absolutely still during diagnostic testing. IV pentobarbital or oral chloral hydrate is commonly used for these procedures. NURSING ALERT: If surgery is anticipated, IV lines should not be placed in a scalp vein on a child with hydrocephalus. Postoperative Care. Routine postoperative care and observation are instituted. In addition, the infant or child is positioned carefully in the unoperated side to prevent pressure in the shunt valve and pressure areas. The child is kept flat on bed to help avert complications resulting from too rapid reduction of intracranial fluid. When the ventricular size is reduce too rapidly, the cerebral cortex may pull away from the dura and tear the small interlacing veins, producing a subdural hematoma. This is nit a problem in children with elective shunt revision, since their intraventricular size and pressure have been normal. The surgeon indicates the position to be maintained and the extent of activity allowed. If there is increased ICP, the surgeon will prescribe elevation of the head of the bed and/or that the child be allowed to sit up to enhance gravity flow through the shunt. Pain management can usually be achieved with acetaminophen with or without codeine for mild-to-moderate pain and opioids for sever pain. NURSING ALERT: Arbitrary pumping of the shunt may cause obstruction or other problems and should not be performed unless indicated by the neurosurgeon. The child is also observed for abdominal distention, because CSF may cause peritonitis or a postoperative ileus as a complication of distal catheter placement. In addition, intake and output are carefully monitored. Children may be place on a fluid restriction with nothing by mouth for 24 hours. The IV infusion is closely monitored to prevent fluid overload. Routine feeding is resumed after the prescribed NPO period, but the presence of bowel sounds is determined before a child with a VP shunt. Since infection is the greatest hazard of the postoperative period, nurses are continually on the alert for the usual manifestations of CSF infection, which may include elevated vital signs, poor feeding, vomiting, decreased responsiveness, and seizure activity. There may be signs of local inflammation at the operative sites and along the shunt tract. The child s diaper should be kept off the peritoneal dressing site or suture line. Antibiotics are administered by the IV route as ordered, and the nurse may also need to assist the practitioner with intraventricular instillation. The incision site is inspected for leakage and any suspected drainage is tested for glucose, an indication of CSF. It is also better to use a pressure-preventing mattress or overlay pad to prevent pressure ulcers on bony prominent areas.

FAMILY SUPPORT. Specific needs and concern of parents during periods of hospitalization are related to the reason for the child s hospitalization (shunt revision, infection, diagnosis) and the diagnostic and/or surgical procedures to which the child must be subjected. Often parents have very little understanding of anatomy ; therefore they need further exploration and reinforcement of information that was given to them by the physician and neurosurgeon, as well as information about what they can expect. They are especially frightened of any procedure that involves the brain, and the fear of retardation or brain damage is very real and pervasive. Nurses can do much to allay their anxiety by explaining the rationale underlying the various nursing and medical activities, such as positioning or testing, and by simply being available and willing to listen to their concerns. To prepare for the child s discharge and home care, the parents are instructed on how to recognize signs that indicate shunt malfunction of infection and how to pump the shunt if necessary. Active children may have accidents, such as a fall, that can damage the shunt, and the tubing may pull out of the distal insertion site or become disconnected during normal growth. Safe transportation is an essential issue to discuss with parents. The tendency for the enlarged head to fall forward and to turn to the side, combined with poor head control, influences the type of child restraint system needed. Small infants can be restrained reclining in an approved car restraint bed. The management of child with hydrocephalus is a demanding task of both family and health care professionals, and helping the family cope with the child is an important nursing responsibility. It is important to emphasize that hydrocephalus is a lifelong problem and that the child will require evaluation in a regular basis. The overall aim is to establish realistic goals and an appropriate educational program that will help the child to achieve his or her optimal potential. Anticipatory guidance will prepare parents for possible problems and help them to avoid being overprotective if the child. Few restrictions (mainly contact sports) need be placed on the child s activities, and the child should of the same age and abilities. Parents need support and encouragement in coping with the child and with problems the child may encounter in relationships with peers and others. Reactions of other children when the child has a noticeably enlarged head or requires shaving at the times of revision are stressful situations for both child and parents. Families can be referred to community agencies for support and guidance.