Nursing Management: Preventing Injury At least every 2 to 4 hours, monitor the newborns level of consciousness.

Check the pupils for equality and reaction monitor the neurologic status, and observe for a shrill cry, lethargy, or irritability. Measure and record the head circumference daily. Carry out appropriate procedures to care for the shunt as directed. To prevent a rapid decrease in ICP, keep the newborn flat. Observe for signs of seizure, and initiate seizure precautions. Keep suction and oxygen equipment convenient at the bedside. (Hatfield, 2008) The position of the infant must be changed frequently to prevent hypostatic pneumonia and pressure sore. Hypostatic pneumonia occurs when there is poor circulation of the blood in the lungs and when the patient remains too long in one position. It is particularly prevalent in patients who are poorly nourished, weak, or have a debilitating disease. Whenever the nurse turns the patient with hydrocephalus, the head must always be supported.to turn the patient in bed, the weight of the head should be borne in the palm of one hand and the head and body should be rotated together to prevent a strain on the neck. When the child is lifted from the crib, the head must be supported by the nurses arm and chest. The head circumference (FOC) is measured daily. This measurement is critical, and it is necessary that the location of the measurement is marked with a marking pen on the childs head. (Price & Gwin, 2008) Promoting Skin Integrity Before surgery, pressure sores may occur if the patients position is not changed at least every 2 hours. The tissues of the head and ears and the bony prominences have a tendency to break down. A pad of lambs wool or a rubber sponge placed under the head may help avoid these lesions. If the skin becomes cracked, it should be given immediate attention to prevent infection. The patient must be kept dry, especially around the creases of the neck, where perspiration may collect. (Price & Gwin, 2008) After a shunting procedure, keep the newborns head turned away from the operative site until the physician allows a change in position. If the newborns head is enlarged, prevent pressure sore from forming on the side where the child rests. Reposition the newborn at least every 2 hours as permitted. Inspect the dressings over the shunt site immediately after the surgery, every hour for the first 3 to 4 hours, and then at least every 4 hours. (Hatfield, 2008) Promoting Balanced Nutrition In most cases, the nurse may hold the infant for feeding. The nurse sits with the arm supported because the babys head is heavy. A calm, unhurried manner is necessary. The

room should also be as quite as possible. After the feeding, the infant is placed on the side. Do not disturb the infant once he or she is settled because the baby vomits easily. The nurse must organize daily care so that it does not interfere with meals. Observations that need to be made include the type and the amounts of food taken, vomiting, condition of skin, motor abilities, restlessness, irritability, lethargy, and changes in vital signs. Fontanels are palpated for size and bulging. Changes in vital signs associated with increased ICP are usually a sign later in infancy. They include elevated blood pressure and a decrease in pulse and respirations. Signs of a cold or other infection should be reported to the nurse in charge immediately and recorded. (Price & Gwin, 2008) Preventing Infection Infection is the primary threat after surgery. Closely observe for and promptly report any signs of infection, which include redness, heat, or swelling along the surgical site, fever, and signs of lethargy. Perform wound care thoroughly as ordered. Administer antibiotics as prescribed. (Hatfield, 2008) Promoting Growth and Development Every newborn has the need to be picked up and held, cuddled, and comforted. An uncomfortable or painful experience increases the need for emotional support. A newborn perceives such support principally through physical contact made in soothing, loving manner. Always support the head of a newborn with hydrocephalus when picking up, moving, or positioning. Using egg-crate pads, lambs wool, or a special mattress can prevent pressure and breakdown of the scalp. The newborn needs social interaction and needs to be talked to, played with, and given the opportunity for activity. Provide toys appropriate for his or her physical and mental capacity. If the child has difficulty moving about the crib, place toys within easy reach and vision: a cradle gym, for example, may be tied close enough for the newborn to maneuver its parts. Unless the newborns nervous system is so impaired that all activity increases irritability, the newborn needs stimulation just as any child does. If repositioning from side-to-side means turning the newborn away from the sight of activity, the crib may be turned around so that vision is not obstructed. A newborn who is given the contact and support that all newborns require develops a pleasing personality because he or she is nourished by emotional stimulation. Use the time spent on physical care as a time for social interaction. Talking, laughing, and playing with the newborn are important aspects of the newborns care. Make frequent contacts, and do not limit them to the times when physical care is being performed. (Hatfield, 2008) Reducing Family Anxiety

Explain to the family the condition and the anatomy of the surgical procedure in terms they can understand. Discuss the overall prognosis for the child. Encourage family members to express their anxieties and ask questions. Giving accurate, nontechnical answers is extremely helpful. Give the family information about support groups such as the National Hydrocephalus Foundation (www.nhfonline.org) and encourage them to contact the groups. (Hatfield, 2008) Providing Family Teaching Demonstrate care of the shunt to the family caregivers and have them perform a return demonstration. Provide them with a list of signs and symptoms that should be reported. Review these with the family members and make sure they understand them. Discuss appropriate growth and developmental expectations for the child, ad stress realistic goals. (Hatfield, 2008) Postoperative Nursing Care Postoperative nursing care is complex, and in addition to routine postoperative care and observations, the nurse observes the patient for signs of increases ICP and for infection at the operative site or along the shunt line. Pain issues should be included in the care of the postoperative patient. Bacterial infection is a life-threatening complication that sometimes makes it necessary to remove the shunt. Signs of infection include poor feeding, elevated vital signs, decrease level of consciousness, vomiting, and seizure activity. The nurse should also observe for signs of inflammation at the shunt insertion site. The surgeon indicates the position desired and the activity level of the child. If the fontanels are sunken, the infant should be kept flat because too rapid a reduction in fluid may lead to seizures or cortical bleeding. If the fontanels are bulging, the patient is usually placed in the semi-Fowlers position to assist in drainage of the ventricles through the shunt. The patient is always positioned so as to avoid pressure on the operative site. Head and chest measurements are recorded. In the patients with peritoneal shunts, the abdomen should also be measured or observed to detect malabsorption of fluid. Skin care continues to remain a priority. As the patients condition improves, parent are instructed regarding the care of the shunt. In the presence of increased ICP, the shunt can be tested for patency by compressing the antechamber or reservoir. The physician may order the pump to be depressed a certain number of times per day to facilitate drainage. It is important to remember that as intracerebral pressure increases, cerebral perfusion decreases or is compromised. A decrease in cerebral perfusion causes less oxygen, a cell dies, and brain cells do not replace themselves as other cells may do. Hydrocephalus, even with a shunt, is a chronic condition, and the child needs to be followed throughout life. It is crucial to monitor this condition. It is also important that

family issues and the childs own growth and development be considered. (Price & Gwin, 2008)