Transcript CASE PRESENTATION - Dr. Ahmad Abanamy Hospital

CASE PRESENTATION
HYDROCEPHALUS
PRESENTED BY:
EDDELYN UPANTO(NICU)
DEMOGRAPHIC DATA
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case #: 190***
age: 21 days
sex: male
diagnosis: severe hydrocephalus
ward: nicu
PHYSICAL ASSESSMENT
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General Appearance
Weak in appearance
Restless
With OGT F5
Wt.=2.46kg, Lt.=42cm, HC=34.5cm
SKIN
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Pinkish
Warm to touch
Slightly dry
Scaly
Thin
HEAD AND NECK
• Bulging Fontanels
• Facial symmetry
• Iris is black, pupils are equal, round
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reactive to light
Cloudy cornea
Conjunctiva are pale
No inflammation and discharges
noted
Has both patent and equal nosetrills
DISCUSSION OF THE DECEASE:
Hydrocephalus also known as "water on
the brain," 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. Hydrocephalus can also
cause death. The name derives from the
Greek words (hydro-) "water", and
(kephalos) "head".
CLASSIFICATION
Based on its underlying mechanisms, hydrocephalus can
be classified into communicating and non-communicating
(obstructive). Both forms can be either congenital or
acquired.
• Communicating
• Communicating hydrocephalus, also known as nonobstructive hydrocephalus, is caused by impaired
cerebrospinal fluid resorption in the absence of any
CSF-flow obstruction between the ventricles and
subarachnoid space. Various neurologic conditions may
result in communicating hydrocephalus, including
subarachnoid/intraventricular hemorrhage, meningitis
and congenital absence of arachnoid villi. Scarring and
fibrosis of the subarachnoid space following infectious,
inflammatory, or hemorrhagic events can also prevent
resorption of CSF, causing diffuse ventricular
dilatation.]
NON-COMMUNICATING
• Non-communicating hydrocephalus,
or obstructive hydrocephalus, is
caused by a CSF-flow obstruction
ultimately preventing CSF from
flowing into the subarachnoid
space (either due to external
compression or due to
intraventricular mass lesions).
CONGENITAL
• The cranial bones fuse by the end of the
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third year of life. For head enlargement
to occur, hydrocephalus must occur
before then. The causes are usually
genetic but can also be acquired and
usually occur within the first few months
of life, which include:
1) Intraventricular matrix hemorrhages
in premature infants,
2) Infections
3) Type II Arnold-Chiari malformation
4) Aqueduct Atresia and stenosis
5) Dandy-Walker malformation
ACQUIRED
• This condition is acquired as a
consequence of CNS infections,
meningitis, brain tumors, head
trauma, intracranial hemorrhage
(subarachnoid or
intraparenchymal) and is usually
extremely painful.
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY OF HYDROCEPHALUS
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If there is obstruction in the ventricular system or the subarachnoid space, dilated cerebral
ventricles, causing ventricular surface wrinkle, and tearing ependymal lines. White mater
below it will atrophy and reduced to a thin ribbon. In the gray matter there is maintenance
that is selective, so that although ventricular enlargement gray matter has been
experiencing a disruption. Dilation process can be a sudden process / acute and can also
selectively depending on the position of the blockage. The process was a case of acute
emergency. In infants and small children cranial suture folds and widened to accommodate
increased cranial mass. If the anterior fontanela not closed then it will not expand and feel
tight in touch. Stenosis aquaductal (family illness / adrift offspring sex) causes dilation of
the ventricles laterasl point and center, this dilation causes the appearance of distinctive
shaped head protruding forehead is dominant (dominant frontal blow). Syndroma dandy
walkker would happen if there is obstruction at the foramina outside the IV ventricle. Fourth
ventricle dilated and prominent posterior fossae meet most of the space under the tentorium.
Clients with type hydrocephalus above will have an enlarged cerebrum which is symmetric
and disproportionately small face.
In older people, cranial sutures had closed thus limiting the expansion of the brain, as the
result showed the symptoms: increase in ICP before the cerebral ventricles, becomes greatly
enlarged. Damage in the absorption and circulation of CSF in hydrocephalus incomplete. CSF
exceeds the normal capacity of the ventricular system, every 6-8 hours and the total
absence of absorption will cause death.
In ventricular dilation causes tearing of the line normal ependyma, which allows an increase
in the wall cavity absorption. If the route collateral sufficient to prevent further
ventricular dilatation there will be a state of compensation.
ETIOLOGY
• Blockage of cerebrospinal fluid (CSF) can be caused by
a variety of conditions such as: spina bifida and other
birth defects of the brain; certain brain infections like
meningitis (pus can cause a blockage); hemorrhage
within or around the brain, usually due to prematurity
or a ruptured aneurysm; and brain trauma, or
tumouhyrors. The blockage can occur within the
ventricles themselves (obstructive hydrocephalus), or
outside the brain in the areas where the spinal fluid is
reabsorbed back into the blood stream (communicating
hydrocephalus).
• The term congenital refers to cases where
hydrocephalus is present at birth, but without any
genetic factors. In cases of congenital hydrocephalus,
it is usually not possible to determine the cause, and
this is referred to as 'idiopathic'. In these cases, one
assumes that the condition arose before birth, in the
form of developmental problems due to infections,
problems with blood supply, etc.
SIGNS AND SYMPTOMS
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Signs and symptoms of infant with severe hydrocephalus:
Eyes that appear to gaze downward
Irritability
Seizures
Separated sutures
Sleepiness
Vomiting
Symptoms that may occur in older children can include:
Brief, shrill, high-pitched cry
Changes in personality, memory, or the ability to reason or think
Changes in facial appearance and eye spacing
Crossed eyes or uncontrolled eye movements
Difficulty feeding
Excessive sleepiness
Headache
Irritability, poor temper control
Loss of bladder control (urinary incontinence)
Loss of coordination and trouble walking
Muscle spasticity (spasm)
Slow growth (child 0–5 years)
Slow or restricted movement
Vomiting
EFFECTS
• Because hydrocephalus can injure the brain,
thought and behavior may be adversely
affected. Learning disabilities including
short-term memory loss are common among
those with hydrocephalus, who tend to score
better on verbal IQ than on performance IQ,
which is thought to reflect the distribution
of nerve damage to the brain. However the
severity of hydrocephalus can differ
considerably between individuals and some
are of average or above-average
intelligence. Someone with hydrocephalus
may have motion and visual problems,
problems with coordination, or may be
clumsy. They may reach puberty earlier than
the average child. About one in four
develops epilepsy.
TREATMENT
• Hydrocephalus treatment is surgical, generally
creating various types of cerebral shunts. It involves
the placement of a ventricular catheter (a tube made
of silastic), into the cerebral ventricles to bypass the
flow obstruction/malfunctioning arachnoidal
granulations and drain the excess fluid into other body
cavities, from where it can be reabsorbed. Most shunts
drain the fluid into the peritoneal cavity (ventriculoperitoneal shunt), but alternative sites include the
right atrium (ventriculo-Atrial shunt), pleural cavity
(ventriculo-pleural shunt), and gallbladder. A shunt
system can also be placed in the lumbar space of the
spine and have the CSF redirected to the peritoneal
cavity (Lumbar-peritoneal shunt). An alternative
treatment for obstructive hydrocephalus in selected
patients is the endoscopic third ventriculostomy (ETV),
whereby a surgically created opening in the floor of
the third ventricle allows the CSF to flow directly to
the basal cisterns, thereby shortcutting any
obstruction, as in aqueductal stenosis. This may or may
not be appropriate based on individual anatomy.
SHUNT COMPLICATIONS
• Examples of possible complications include shunt
malfunction, shunt failure, and shunt infection, along
with infection of the shunt tract following surgery (the
most common reason for shunt failure is infection of the
shunt tract). Although a shunt generally works well, it
may stop working if it disconnects, becomes blocked
(clogged), infected, or it is outgrown. If this happens the
cerebrospinal fluid will begin to accumulate again and
a number of physical symptoms will develop (headaches,
nausea, vomiting, photophobia/light sensitivity), some
extremely serious, like seizures.
• Another complication can occur when CSF drains more
rapidly than it is produced by the choroid plexus,
causing symptoms -listlessness, severe headaches,
irritability, light sensitivity, auditory hyperesthesia
(sound sensitivity), nausea, vomiting, dizziness, vertigo,
migraines, seizures, a change in personality, weakness
in the arms or legs, strabismus, and double vision - to
appear when the patient is vertical.
NURSING PROBLEM PRIORITIZATION
• Acute pain
• Delayed growth and development
• Imbalanced nutrition: Less than body
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requirements
Gas exchange
Ineffective tissue perfusion:
Cerebral.
Interrupted family processes.
Infant Behavior, risk for
disorganized.
Risk For Infection
NURSING CARE PLAN
Assessment
Diagnosis
Planning
Intervention
Subjective:
“I notIced that the
sIze of my baby’s
head Is not normal”
as verbalized by
the mother.
Objective:
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Restlessness
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Irritability
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Change in
vital signs
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Vital signs
taken as
follows:
T=37.8
degrees
Celsius
P=158bpm
RR=52bpm
Ineffective
cerebral
tissue
perfusion
related to
decreased
arterial or
venous blood
flow.
After 12 hours of 
nursing
interventions the
patient will
demonstrate
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improved vital
signs and
absence of
increased ICP.
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Temperature
monitored. Tepid sponge
bath administered in
presence of fever.
Intake and output
monitored. Weigh as
indicated. Skin turgor,
status and mucus
membrane noted.
Head/neck midline or
neutral position,
support with towel
rolls or small pillow
maintained.
Provided rest periods
between care and limit
durations of
procedures.
Decreased extraneous
stimuli and provide
comfort measures such
as quiet environment
and gentle touch.
Helped limit or avoid
coughing, crying,
vomiting and straining
at stool.
Elevated head of the
bed gradually at 15-30
degrees as tolerated
or indicated.
Collaborative:
Diuretics administered
as indicated.
Supplemental oxygen
administered as
indicated.
Rationale
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Fever may reflect
damage to hypothalamus.
Increased metabolic
needs and oxygen
consumption occurs which
can further increase ICP.
Useful indicator of body
water which an
important part of tissue
perfusion.
Turning head to one side
compress the jugular
veins and inhibits
cerebral venous
drainage that may cause
increased ICP.
Continuous activity can
increased ICP by
producing a cumulative
stimulant effect.
Provides calming effect
reduces adverse
physiological response
and promotes rest.
These activities increase
intrathoracic and intraabdominal pressure.
Promote venous drainage
from head, reducing
cerebral congestion and
edema and increased ICP.
Diuretics may used in
acute phase to draw
water from brain cells
reducing cerebral edema
and ICP.
Reduces hypoxemia which
may increase cerebral
vasodilation and blood
volume.
Evaluation
After 12 hours
of nursing
intervention
the patient was
able to
demonstrate
improved vital
signs and
absence of
increased ICP.
REFERENCE:
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^http://www.nlm.nih.gov/medlineplus/ency /article/001571.htm Accessed 19 June 2010
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^ abcd Alfred Aschoff, Paul Kremer, BahramHashemi, Stefan Kunze (October 1999). "The scientific history of
hydrocephalus and its treatment". Neurosurgical Review (Springer) 22 (2–3): 67–93 [67]. doi:10.1007/s101430050035.
ISSN1437-2320
^ "The scientific history of hydrocephalus and its treatment.".United States National Library of Medicine.
^"Hydrocephalus Fact Sheet", National Institute of Neurological Disorders and Stroke. (August 2005).
^ Cabot, Richard C. (1919) Physical diagnosis , William Wood and company, New York, 7th edition, 527 pages, page 5.
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^Yadav YR, Mukerji G, Shenoy R, Basoor A, Jain G, Nelson A (2007). "Endoscopic management of hypertensive
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PMID17204141. http://www.biomedcentral.com/1471-2377/7/1.
^ Greenberg, Mark S (2010-02-15). Handbook of Neurosurgery. ISBN9781604063264.
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^wwww.spinabifidamoms.com
^http://www.hydroassoc.org/media/stats
^ Warf, Benjamin C. (2005). "Comparison of 1-year outcomes for the Chhabra and Codman-Hakim Micro Precision shunt
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^"Man with Almost No Brain Has Led Normal Life", Fox News (2007-07-25). Also see "Man with tiny brain shocks doctors",
NewScientist.com (2007-07-20); "Tiny Brain, Normal Life", ScienceDaily (2007-07-24).
^"Man Lives Normal Life Despite Having Abnormal Brain". The Globe and Mail. July 19, 2007. Archived from the original on
August 28, 2007.
http://web.archive.org/web/20070828013153/http://www.theglobeandmail.com/servlet/story/RTGAM.20070719.wbrain0
719/BNStory/Science/home. Retrieved July 15, 2012.
^"Man with tiny brain shocks doctors", New Scientist online, 20 July, 2007
^ Brain of a white-collar worker. Feuillet, L., Dufour, H. & Pelletier, J., et al. The Lancet, Volume 370, Issue 9583, Page
262, 21 July 2007 pmid=17658396
^http://www.startribune.com/entertainment/books/11435616.html