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NUR1440 Hydrocephalus Case study
Assessment of Foundational Knowledge in Maternal/Child Nursing and Psychiatric Nursing (NURS 399)
College of Southern Nevada
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NUR1440 Maternal Child Pediatrics Hydrocephalus Case Study
Scenario:
You admit L., a 2-month-old girl with a history of hydrocephalus and a ventriculoperitoneal (VP) Shunt placement 1 month earlier. Her parents report that she has been more irritable than usual and for the past 3 days has had emesis 5 or 6 times a day.
- What is the pathophysiology of hydrocephalus?
Causes are varied, one cause can be impaired absorption of CSF within the subarachnoid space, obliteration of subarachnoid cisterns, or malfunction of the arachnoid villi. Another cause could be an obstruction of to the flow od CSF through the ventricular system. Any imbalance causes an increased accumulation of CSF which dilates the ventricles and compresses the brain against the cranium. 2. How does a VP shunt help patient with hydrocephalus?
It provides primary drainage of the CSF from the ventricles to an extracranial compartment, usually the peritoneum.
Case Study Progression:
L.’s vital signs are 111/70, 182, 55, 38°C, Sao2 95% on room air. Her head appears large, the fontanel is slightly bulging, and pupils are equal and reactive. The occipital frontal circumference (OFC) is 44 cm, and her mother tells you that is 2 cm more than when she measured yesterday. Baby L. is awake, irritable, and fussy throughout your assessment. She has emesis, although her father tells you that she has not eaten for 5 hours while they were in the emergency department. Breath sounds are clear, pulses are 2+ and equal bilaterally, and capillary refill time is less than 2 sec.
- Which of the vital signs and assessments are abnormal, and what are their possible causes?
Her pulse is high normal pulse range for a 2 month old would be between 107-180. Her blood pressure is also extremely high, the normal range for an infant is systolic 65-78 and diastolic 41-52. Her temperature is also slightly high the normal range for her age is at about 37 Celsius. LM is also tachypneic, her respirations are supposed to be no more than 35. One possible cause could be an infection. Her fontanelles are bulging and are measuring 2 cm more than the previous day so another cause could be a malfunction of her shunt.
- In infants, why does the OFC increase when the pressure increases in the cranial vault?
Occipital frontal circumference increases when the pressure increases in the cranial vault because the cranial sutures haven’t yet fused, causing enlargement of the skull and dilation of the ventricles.
- The doctors order a CT scan and lumbar puncture with a cell count, culture, Gram Stain, glucose, and protein run on the cerebrospinal fluid. What is the rationale for each procedure?
These tests would confirm if there is an obstruction in the VP shunt or if LM may be suffering from an infection. The lumbar puncture is to see if she may have meningitis. The CBC would be able to differentiate if there is an increase in banded neutrophils versus segmented neutrophils confirming an
infection. The culture would tell us exactly what type of infection LM may be suffering from. The gram stain would tell us if the bacteria is gram + or gram – and depending on the result a broad spectrum or narrow spectrum antibiotic would be used. Protein run on the CSF may be done because the spinal fluid normally contains very little protein since serum proteins are large molecules that do not cross the blood-brain barrier. Most of the protein that is normally present is albumin. Mild protein elevation may be caused by viral meningitis, subdural hematoma, cerebral thrombosis, or brain tumor. Low glucose levels, as compared to plasma levels, are seen in bacterial meningitis, cryptococcal meningitis, malignant involvement of the meninges and sarcoidosis.
- L. is taken to surgery to have an extraventricular drain (EVD) placed. What categories of medications might you expect the physicians to order postoperatively? Give the rationale for each category.
Analgesia to alleviate LMs pain after the procedure. If no infection was identified in the culture I would expect a broad spectrum antibiotic to be started for prophylaxis. An antiemetic like metoclopramide to alleviate any nausea and help LM stay asleep during her recovery. An antiseizure medication to prevent any seizures.
- What should you teach the parents about the EVD?
An EDV is a small soft rube that drains the CSF from the brain to the collection bag outside the body. It helps reduce the pressure from the brain to the levels the surgeon ordered. The zero line must be level to the child’s ear. The drain will be adjusted every time your child changes position. This will help reduce the problems associated with either over drainage or under drainage of CSF. The collection system must stay at the right height so the right amount of fluid drains. Never move your child’s head or change the height without a nurses help
- Two days after the EVD is placed, L.’s father tells you that h is feeling discouraged because this is likely the first of many admissions due to shunt malfunctions. He states that he talked to some parents of a child with hydrocephalus who was admitted 14 times by the time he was 2 years old. How would you respond to this father’s feelings?
I understand that its discouraging to hear and learn about the shunt malfunctions and infections that could happen but it is for your child’s safety to be admitted and monitored.
- Later that day, Mrs. M. is changing L.’s diaper, and she tells you that she is worried because L. has started having diarrhea recently and it is getting worse. Based on the medications that the patient is getting, what is the most likely cause of the diarrhea? What is a possible concern you should consider, and what should your care plan include?
Antibiotics are frequently the cause of diarrhea in infants when used over time. Diarrhea has the potential to cause fluid and electrolyte imbalances. The care plan should include assessment of mucous membranes, decreased weigh, increased diarrhea output, and altered skin integrity and monitoring of electrolytes.
NUR1440 Hydrocephalus Case study
Course: Assessment of Foundational Knowledge in Maternal/Child Nursing and Psychiatric Nursing (NURS 399)
University: College of Southern Nevada
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