Ishaan Mondal is a 5 week old male who presents with an increased head circumference, vomiting,
and irritability.
His mother, Ziva, reports that while Ishaan appears hungry, he has difficulty suckling
when attempting to breastfeed.
After an appointment with his pediatrician, Ishaan is directly admitted to the neonatal
intensive care unit, or NICU, for monitoring and treatment of hydrocephalus.
Hydrocephalus refers to the excessive buildup of cerebrospinal fluid, or CSF, within the
brain.
The CSF helps provide cushion and protection, as well as metabolic fuel for the brain.
Now, the brain has two lateral ventricles, as well as the third and fourth ventricles,
which are all interconnected, and each one contains a structure called a choroid plexus.
The choroid plexus is made up of ependymal cells, which produce the CSF that can drain
down to the fourth ventricle.
From there, the CSF enters the subarachnoid space, and gets reabsorbed by arachnoid granulations
into the dural venous sinuses, which are pools of venous blood.
Finally, the CSF and venous blood are drained together out of the skull and into the internal
jugular vein.
Now, since the skull is such a rigid structure, the volume of the brain, CSF, and blood must
be constant and in balance.
So, with hydrocephalus, the increased CSF volume causes the four ventricles to enlarge
and intracranial pressure to rise, which can compress and damage brain structures.
Now, there are two types of hydrocephalus.
Noncommunicating, or obstructive hydrocephalus, is caused by an obstruction of the CSF flow
anywhere along its path.
This can be caused by a brain tumor, cyst, or by congenital causes, like cerebral aqueduct
stenosis.
On the other hand, communicating, or nonobstructive hydrocephalus is most often caused by decreased
CSF reabsorption.
This occurs when there’s inflammation or obstruction of the arachnoid granulations,
which can be caused by infections, such as meningitis, as well as subarachnoid hemorrhage.
Less frequently, communicating hydrocephalus can be caused by increased CSF production,
like by a choroid plexus tumor.
Now, there are some factors that can put the client at increased risk of hydrocephalus.
Non-modifiable risk factors include male sex, having a family history of hydrocephalus,
and some congenital malformations affecting the CSF flow.
On the other hand, modifiable risk factors include being unvaccinated against common
bacteria that cause meningitis, as well as experiencing head trauma, which may lead to
subarachnoid hemorrhage.
Other possible modifiable risk factors include gestational diabetes mellitus, as well as
the lack of prenatal care before pregnancy, which may increase the risk of congenital
infections like congenital syphilis and rubella.
Now, the main symptoms of hydrocephalus result from the increased intracranial pressure and
include headache, nausea, vomiting, as well as seizures.
In addition, clients may have blurred vision, unsteady gait, and impaired consciousness,
which, in severe cases, may progress to coma.
In infants, additional symptoms can include irritability, high-pitched cry, and a downward
deviation of the eyes, which is called sunset eyes, as well as macrocephaly, which is an
increase in head circumference.
Moreover, infants can have bulging fontanelles, which are the soft spots in the infant’s
skull where the cranial bones have not fused yet.
Clients with hydrocephalus have a higher risk of developing long-term complications, such
as permanent visual impairment, speech impairment, and learning difficulties affecting the client’s
attention, thinking, and memory formation.
In children, this results in poor school performance.
Other potential complications include recurrent seizures, as well as physical disabilities,
such as balance problems, poor motor coordination, and muscle weakness.
Diagnosis of hydrocephalus begins with history and clinical findings.
In addition, fundoscopic examination may show papilledema, which is the swelling of the
optic nerve.
Next, in infants younger than 6 months of age, where fontanelles are still present,
cranial ultrasonography is typically done to visualize the enlarged brain ventricles,
while in older children and adults, MRI is preferred.
Finally, other tests can be performed based on the suspected cause, such as a lumbar puncture
for meningitis, or CT scan to rule out a subarachnoid hemorrhage.
Now, the main treatment of hydrocephalus focuses on draining the excess CSF from the brain
to decrease the intracranial pressure.
If hydrocephalus develops over a short period of time, the intracranial pressure should
be decreased with a lumbar puncture or by surgically placing a temporary shunt, such
as an external ventricular drain into the brain ventricles.
This allows monitoring of the intracranial pressure while also draining the excess CSF
into an external collection bag.
In young infants, an anterior fontanelle ventricular tap can be done, where a needle is inserted
through the anterior fontanel and into the ventricles, which allows the excess CSF to
drip out.
Now, if hydrocephalus persists, the client may need surgical placement of a permanent
shunt, which drains the excess CSF from brain ventricles to somewhere else in the body where
it can then be absorbed into the bloodstream.
The most commonly used shunt is ventriculoperitoneal shunt, or VP shunt for short, which drains
the CSF into the peritoneal cavity in the abdomen.
Finally, keep in mind that clients with a shunt need to be followed up for complications
like shunt obstruction, disconnection, and infection.
Ishaan has just been admitted to the NICU and you begin your assessment.
Ishaan appears listless as he rests in his mother’s arms, and you instantly notice
the macrocephaly.
You gently pick up Ishaan and place him on the prepared radiant warmer bed and attach
the cardiorespiratory monitor and pulse oximeter.
Light palpation of his head reveals firm, bulging fontanelles and widened cranial suture
lines.
Careful measurement of his skull reveals that his occipitofrontal circumference, or OFC,
is 15.6 inches or 39.6 cm.
Ishaan’s medical records indicate that his birth OFC measurement was within normal limits
at 13.5 inches or 34.3 cm.
Next, you perform a focused neurological assessment and observe sluggish pupils, as well as delayed
and decreased reflexes with mild lower extremity spasticity.
Throughout the physical assessment, you note that Ishaan has a shrill, high-pitched cry.
Ishaan’s vitals signs are: temperature 98.6 F or 37 C, apical heart rate is regular at
90 beats per minute, respirations are regular at 42 breaths per minute, blood pressure of
78/42 mmHg, and oxygen saturation of 93% on room air.
His pain level is 5 /10 on the FLACC behavioral pain assessment scale.
You administer 2 liters of supplemental oxygen via nasal cannula.
Next, you review his recent lab results and take note of the following: potassium 3.5mEq/L,
hematocrit 45%, hemoglobin 14.3 g/dL; ventriculomegaly is evident on anterior fontanelle ultrasound.
Ziva expresses fear about Ishaan not making a full recovery and how that would impact
their family’s future.
You reassure Ziva that hydrocephalus is a treatable condition and the healthcare team
is here to help Ishaan.
After documenting your findings, you let Ziva know that the neurosurgeon will be in soon
to obtain surgical consent for shunt placement.
With the assessment data you obtained, you identity these priority nursing diagnoses:
ineffective cerebral tissue perfusion related to increased intracranial pressure; fluid
and electrolyte imbalance related to vomiting and poor feeding; impaired comfort related
to increased intracranial pressure; risk for infection related to surgical procedure; and
compromised parental coping related to sudden onset of acute illness.
You next create a plan of care for Ishaan while collaborating with his mother and the
neurosurgical team.
By discharge, Ishaan will have stabilized intracranial pressure and an OFC measurement
trending toward normal parameters; cessation of vomiting with adequate oral intake; increased
consolability; and Ishaan’s mother will demonstrate adequate coping skills.
It is now time to begin implementing the plan of care.
You closely monitor intake, output, and laboratory values, and perform routine vital signs and
neurologic checks.
Next, you administer the ordered IV fluids and electrolytes, antibiotics, and antiemetic.
You provide comfort by swaddling him, and teach Ziva how to position Ishaan so his neck
remains in neutral alignment while his head is elevated at 30 degrees.You also keep environmental
stimuli and handling to a minimum and keep the lights around Ishaan’s bed dimmed.
Finally, you reinforce the neurosurgeon’s explanation about Ishaan’s condition and
the need for shunt placement while providing emotional support for Ziva.
Ishaan had a successful VP shunt placement and has been transferred back to the NICU
for continued monitoring and evaluation.
Intracranial pressure monitoring was initiated intraoperatively during the shunt placement
and will be continued postoperatively.
You observe that his fontanelles are soft and moderately rounded, and his cranial suture
lines are closer together.
The surgical sites on Ishaan’s head and abdomen are intact with no signs of bleeding
or infection.
Neurologic checks reveal reactive pupils and improved reflexes.
Ishaan has not vomited, and he suckled 20 mL of pumped breast milk without difficulty.
He has had one wet diaper, and his laboratory values have normalized.
Ishaan’s cry is now at a normal pitch and he is easily consoled.
His vital signs are: temperature 98.4 F or 36.8 C, heart rate 120 beats per minute, respirations
56 breaths per minute, blood pressure 80/44 mmHg, and oxygen saturation 96% on room air.
His pain level is now 3/10 on the FLACC scale.
While teaching Ziva to monitor for signs and symptoms of shunt malfunction or infection
such as fever, seizures or other neurological signs, she tells you she has been reading
about Ishaan’s condition and proper home management and care of his shunt.
You are happy that your interventions have been successful in supporting both Ishaan
and his mother.
As Ishaan continues to recover, the healthcare team will continue to monitor Ishaan’s and
revise his plan of care as needed.
All right, as a quick recap … Ishaan Mondal was admitted to the NICU with signs and symptoms
of hydrocephalus, which is an excessive buildup of CSF within the brain.
Your assessment revealed increased OFC, vomiting, suckling difficulty and a shrill cry.
The priority nursing diagnoses you established were: ineffective cerebral tissue perfusion,
fluid and electrolyte imbalance, impaired comfort, risk for infection, and compromised
parental coping.
Careful planning allowed you to create goals that focused on alleviating Ishaan’s symptoms
and supporting Ziva’s ability to cope.
Implementation of the plan of care involved decreasing intracranial pressure and providing
information and emotional support to his mother.
Finally, you evaluated that Ishaan’s plan of care was effective in promoting his well-being.