This document provides information about hydrocephalus including its causes, symptoms, nursing assessments, diagnoses, goals of care, interventions, and discharge planning. Hydrocephalus is a condition where cerebrospinal fluid accumulates in the brain ventricles, which can increase intracranial pressure and cause head enlargement, seizures, tunnel vision, and intellectual disability. The nursing assessments note increased head size, bulging fontanel, dilated veins, eye positioning, restlessness, and fever in the patient. The nursing diagnoses are related to altered thermoregulation and ineffective cerebral tissue perfusion. The goals are to maintain normal temperature and improve cerebral perfusion. Nursing interventions include monitoring, baths, positioning, medication administration,

1. Prepared By: Rommel L. Manalo BSN 3-A
College of Nursing and Health Sciences Department
HYDROCEPHALUS

2.  is a medical condition in which there
is an abnormal accumulation
of Cerebrospinal fluid
(CSF) in the ventricles, or cavities, of
the brain. This may cause
increased intracranial pressure inside
the skull and progressive enlargement
of the head, convulsion, tunnel vision
and mental disability.

3. ASSESSMENT
Subjective:
 “Napapansin ko na hindi normal ang laki ng ulo ng
anak ko as verbalized by the mother”
Objective:
 Increased head circumference
 Bulging fontanel
 Scalp veins dilated
 Sun setting eyes
 Restlessness
 Irritability
 GCS
 X-RAY- bones are thin and widely separated.
 MRI or Ct- Scan- dilated ventricle s and excess CSF
 T- 39.8 C

4. NURSING DIAGNOSIS
 Alteration in thermoregulation,
hyperthermia related to increase vascular
resistance.
 Ineffective Cerebral tissue perfusion related
to decreased arterial or venous blood flow.

5. GOAL OF CARE
After 1 hour of nursing intervention the
client will maintain core temperature within
normal range
 After 6 hours of nursing interventions the
client will be able to demonstrate improve
cerebral tissue perfusion and absence of
complication such as sign of increased ICP.

6. NURSING INTERVENTION
 Independent:
 monitor vital sign especially temperature
 provide tepid sponge bath.
 Note skin turgor, status and mucous
membrane.

7.  Provide rest periods between care of
activities and limit duration of
procedures.
 Decreased extraneous stimuli and
provide comfort measures such as
back massage, quiet environment
gentle touch.

8.  Dependent
 Administer :
Administer anti pyretic medication as
ordered by the physician

9.  Collaboration:
Refer to neuro surgeon for surgical mgt.
Refer to dietician for optimal nutrition for
specific case.
Coordinate to medical social worker
for their bill hospitalization and
especially to the physician for further fast
recovery.

10. RATIONALE
 Fever may reflect damage to hypothalamus.
 Increased metabolic needs and oxygen
consumption occur which can further increased
ICP
 Useful indicators of body water, which is an
integral part of tissue perfusion.
 Turning bed to one side compress the regular
veins and inhibits cerebral venous drainage
that may cause increased ICP
 Continual activity can increase ICP by
producing a cumulative stimulant effect.
 Provides calming effect, reduces adverse
physiological response, and promotes rest.

11.  These activities increase intra thoracic
and intra abdominal pressure.
 Promotes venous drainage from head,
reducing cerebral congestion and
edema and increased ICP
 Diuretics may be used in acute phase
to draw water from brain cells,
reducing cerebral edema and ICP
 Reduces hypoxemia, which may
increase cerebral vasodilatation and
blood volume.

12. INTERVENTION 2
 Assess the head circumference, assess the
bulging fontanel.
 Monitor intake and output weigh as indicated.
 Maintain head or neck in midline or in neutral
position support with small towel rolls and
pillows
 Help patient avoid or limit coughing, crying
vomiting,
and straining during defecation.
Reposition the patient slowly.
 Elevate the head of bed gradually to 15-30
degrees as tolerated or indicated.
 Administer diuretics and supplemental oxygen
as indicated antibiotics as ordered by the
physician.

13. DISCHARGE PLANNING
M- Instruction about the use of medications
and the possible side effects
-diuretics and supplemental oxygen as
indicated .
E-Advise client/SO to perform simple
exercises only.
T- Advise the SO to bring M R I - magnetic
resonance imaging. Computed Tomographic
scanning
result prior to follow-up check up
H -Advise SO to provide skin care to prevent
skin break down.
-Advise SO to provide proper personal
hygiene.

14. O –Advise SO/ Instruct client follow-up check
up.
D-Advise SO/ Instruct client to eat nutritious
food rich in vit.C & protein
Advise SO/ to consult spiritual adviser for any
concern’s regarding spirituality
S - A child has the right to enjoy a full and
decent life, in conditions which ensure dignity,
promote self-reliance and facilitate the child’s
active participation in the community.”

15. EVALUATION
Goal met
The patient demonstrate, improve V/S
with in normal range and absence of
complication and sign of increased Icp

16. THANK YOU