Care Plan Hydrocephalus Nursing Diagnosis: Comprehensive Guide

Hydrocephalus, characterized by an abnormal buildup of cerebrospinal fluid (CSF) in the brain’s ventricles, can lead to increased intracranial pressure (ICP) and significant neurological complications. This condition affects individuals across all age groups, with infants and older adults being particularly vulnerable. Understanding the nuances of hydrocephalus is crucial for healthcare professionals, especially nurses, in delivering optimal patient care. This article provides an in-depth exploration of hydrocephalus, focusing on its etiology, diagnosis, treatment, and most importantly, the nursing care plan and associated nursing diagnoses.

Understanding Hydrocephalus: Etiology and Epidemiology

Hydrocephalus arises from an imbalance in CSF production, circulation, and absorption. This imbalance results in excessive CSF accumulation within the ventricular system, leading to ventricular enlargement and increased ICP. Hydrocephalus can be broadly classified into congenital and acquired forms.

Congenital hydrocephalus, prevalent in infants, occurs in approximately 1 out of every 500 births (Flannery & Mitchell, 2014). A hallmark sign in infants is macrocephaly, an abnormally enlarged head circumference. Other signs and symptoms in infants include:

• Irritability and fussiness
• A distinctive, high-pitched cry
• A bulging fontanelle (soft spot on the head)
• Widening of cranial sutures
• Vomiting, often projectile
• Strabismus (crossed eyes)
• Downward deviation of the eyes, known as the “sun-setting” phenomenon
• Lethargy and reduced alertness
• Seizures, indicative of neurological distress
• Papilledema, a late sign of optic nerve swelling

Congenital hydrocephalus often stems from obstructions related to:

• Genetic factors: X-linked aqueductal stenosis, a narrowing of the aqueduct of Sylvius.
• Chiari type II malformation: Frequently associated with spina bifida (myelomeningocele), involving the downward displacement of brain tissue.
• Dandy-Walker malformation: A congenital condition developing in utero, characterized by cystic enlargement of the fourth ventricle.

Acquired hydrocephalus develops after birth and can occur at any age. Common causes include:

• Head trauma, leading to disruptions in CSF flow or absorption.
• Stroke, potentially causing intraventricular hemorrhage or impaired CSF pathways.
• Infections, such as meningitis or ventriculitis, which can obstruct CSF circulation.
• Brain or spinal cord tumors, compressing CSF pathways.
• Cerebral hemorrhage, particularly subarachnoid or intraventricular hemorrhage, often resulting from birth complications, maternal infections during pregnancy (meningitis), or traumatic childbirth. Impaired CSF resorption in subarachnoid spaces is a key factor.

In older children and adults, hydrocephalus may manifest with different signs and symptoms, including:

• Persistent headache, often worsening in the morning.
• Nausea and vomiting, which can be recurrent.
• Blurred or double vision, indicating increased ICP affecting the optic nerve.
• Balance problems and gait disturbances.
• Neurological deficits, such as cognitive impairment, memory issues, and slowed thinking.
• Developmental delays or regression in children.
• Lethargy and excessive sleepiness.
• Personality changes and irritability.

Normal pressure hydrocephalus (NPH) is a distinct form characterized by ventricular enlargement with “normal” CSF pressure. While the majority of NPH cases are idiopathic, secondary causes include subarachnoid hemorrhage (SAH), meningitis, or traumatic brain injury. NPH is estimated to affect 700,000 adults over 60 in the U.S. (Alzheimer’s Association, n.d.). A significant concern is misdiagnosis, with up to 20% of NPH patients initially diagnosed with Alzheimer’s or Parkinson’s disease due to overlapping dementia symptoms (Hydrocephalus Association, n.d.). The classic triad of NPH symptoms develops gradually:

• Gait disturbances, often the earliest and most prominent symptom, presenting as a wide-based, shuffling gait.
• Mild dementia, characterized by cognitive decline and impaired executive function.
• Urinary incontinence, often starting as urgency and progressing to complete incontinence.

It’s important to note that not all individuals with NPH exhibit all three classic symptoms; many present with only one or two. Suspected NPH warrants evaluation by a neurologist specializing in movement and cognitive disorders.

Untreated hydrocephalus can lead to severe complications, including:

• Permanent physical and intellectual disabilities, especially in infants and children.
• Progressive neurological dysfunction.
• Death.

The ICD-10 code for unspecified hydrocephalus is G91.9.

Alt text: Macrocephaly in infant with hydrocephalus, illustrating enlarged head circumference due to cerebrospinal fluid buildup.

Hydrocephalus Diagnosis: Identifying the Condition

Diagnosing hydrocephalus involves a combination of clinical evaluation and neuroimaging techniques (NLM, 2021). Diagnostic methods include:

• Computed tomography (CT) scans: Provide rapid and detailed images of the brain, readily showing ventricular enlargement.
• Magnetic resonance imaging (MRI): Offers more detailed anatomical views, crucial for identifying underlying causes and assessing CSF flow.
• Prenatal ultrasonography: Allows for in-utero detection of hydrocephalus, enabling early planning and intervention.
• Cranial ultrasound (for neonates): A non-invasive method to assess ventricles through the fontanelles in newborns.
• Skull X-rays: Can reveal signs of increased ICP in older children and adults, such as widened sutures or “beaten copper” skull appearance.
• Arteriography: Used in specific cases to evaluate blood vessels and rule out vascular malformations.
• Lumbar puncture: May be performed to analyze CSF and, in some NPH cases, as a diagnostic tap to assess symptom improvement after CSF removal.
• Brain imaging using radioisotopes: Less common now, but can assess CSF flow dynamics in complex cases.
• Fundoscopic examination: Essential to detect papilledema, indicating optic nerve swelling due to increased ICP.
• Neuropsychological testing (for NPH): Evaluates cognitive function to differentiate NPH from other dementias.
• Neurological examination: Comprehensive assessment of balance, coordination, mental status, mood, behavior, vision, eye movements, and hearing to identify neurological deficits associated with hydrocephalus.

Hydrocephalus Treatment and Management: Restoring CSF Balance

Hydrocephalus treatment strategies are tailored to the individual’s age, symptom severity, and underlying cause. Management ranges from conservative observation to surgical interventions:

• Observation: In mild cases, particularly in adults with stable NPH symptoms, observation and close monitoring may be initially appropriate.
• Shunt insertion: The most common surgical treatment for both congenital and acquired hydrocephalus. Shunts are flexible plastic tubes that divert CSF from the brain ventricles to another body cavity for absorption (NLM, 2021). Common shunt types include (Bauer et al., 2020; SBA, n.d.):
  • Ventriculoperitoneal shunt (VPS): The most frequently used shunt, draining CSF into the peritoneal cavity in the abdomen.
  • Ventriculoatrial (VA) shunt: Drains CSF into the right atrium of the heart, typically used when peritoneal drainage is not feasible.
  • Ventriculopleural shunt: Drains CSF into the pleural space around the lungs, another alternative drainage site.
  • Ventriculogallbladder shunt: A less common option, draining CSF into the gallbladder.
• Endoscopic third ventriculostomy (ETV): A minimally invasive surgical procedure, particularly effective for obstructive hydrocephalus in children and adults. ETV creates a small opening in the floor of the third ventricle, allowing CSF to bypass the obstruction and flow into the subarachnoid space for absorption.

For individuals with NPH, treatment decisions consider symptom impact and surgical risk. While some may manage with conservative measures, a VPS may be recommended if symptoms significantly impair quality of life and surgical risks are acceptable.

Alt text: Ventriculoperitoneal shunt placement diagram, illustrating CSF diversion from brain ventricle to peritoneal cavity for hydrocephalus treatment.

Hydrocephalus Nursing Care Plan: Addressing Patient Needs

Nursing care for patients with hydrocephalus is multifaceted, focusing on neurological monitoring, preventing complications, and providing comprehensive patient and caregiver education. A well-structured nursing care plan is essential for optimizing patient outcomes. Key components of the care plan include assessment, nursing diagnoses, interventions, expected outcomes, and patient/caregiver education.

Assessment: Comprehensive Neurological Monitoring

Thorough assessment is paramount in hydrocephalus nursing care. Neurological assessments, tailored to the patient’s age, focus on indicators of ICP and neurological function:

• Mental status assessment: Evaluating level of consciousness, orientation, cognitive function, and presence of irritability or lethargy.
• Motor function assessment: Assessing muscle strength, tone, movement, and coordination.
• Balance and gait assessment: Evaluating stability and walking patterns, especially crucial in NPH.
• Reflex assessment (for newborns and infants): Checking reflexes like Moro, suckling, and grasp, which can be affected by increased ICP.
• Cranial nerve function assessment: Evaluating pupillary response, eye movements, facial symmetry, swallowing, and gag reflex.
• Pupillary reaction to light: Assessing pupil size, equality, and reactivity to light as a key indicator of neurological status.
• Vital signs monitoring: Closely monitoring vital signs, including blood pressure, heart rate, respiratory rate, and temperature. Observe for:
  • Fluctuating blood pressure, indicative of ICP changes.
  • Tachycardia (increased heart rate).
  • Shallow or irregular breathing patterns.
  • Cushing’s triad, a late and ominous sign of severely increased ICP:
    • Bradycardia (slow heart rate).
    • Respiratory depression (slow, irregular respirations).
    • Widening pulse pressure (increased difference between systolic and diastolic blood pressure).
• Head circumference measurement and fontanelle assessment (infants): Regularly measuring head circumference and palpating fontanelles for bulging or tenseness, signs of increased ICP in infants.

Nursing Diagnosis/Risk For: Identifying Patient Problems

Based on assessment findings, relevant nursing diagnoses for patients with hydrocephalus may include:

• Risk for Impaired Skin Integrity: Related to immobility or prolonged pressure, especially in infants with macrocephaly or patients with shunts. As evidenced by immobility.
• Risk for Shunt Infection: A significant post-surgical complication. As evidenced by potential exposure during surgery.
• Actual/Risk for Shunt Infection: If infection is suspected or confirmed. As evidenced by fever, lethargy, irritability, headache, increased ICP.
• Ineffective Cerebral Tissue Perfusion: Related to increased ICP and reduced blood flow to the brain. As evidenced by brief, high-pitched cry (infants), lethargy, restlessness.
• Delayed Growth and Development (infants and children): Related to neurological impairment from hydrocephalus. As evidenced by impaired neurological function, inability to reach developmental milestones.
• Risk for Shunt Malfunction: A potential long-term complication requiring ongoing monitoring. As evidenced by presence of shunt and potential for mechanical failure or obstruction.
• Actual/Risk for Shunt Malfunction: If shunt malfunction is suspected or confirmed. As evidenced by increased ICP, headache, vomiting, lethargy, irritability, esotropia (inward eye deviation), upward gaze paralysis.

Interventions: Implementing Nursing Actions

Nursing interventions are directed at managing ICP, preventing complications, and supporting the patient and family:

• Positioning: Elevate the head of the bed to semi-Fowler’s position (15° to 45°) to promote venous drainage and reduce ICP.
• Neutral head position: Maintain the patient’s head in a midline, neutral position to avoid jugular vein compression and facilitate CSF drainage.
• Oxygen administration: Provide supplemental oxygen via nasal cannula as needed to maintain adequate oxygen saturation, especially if respiratory patterns are compromised due to ICP.
• Shunt infection monitoring: Closely monitor for signs and symptoms of shunt infection post-insertion, including fever, redness at the incision site, CSF leakage, and changes in neurological status.
• Vital signs monitoring: Record vital signs hourly or as ordered, noting trends and reporting significant changes promptly.
• Medication administration: Administer medications as prescribed, such as diuretics (e.g., furosemide, mannitol) to reduce CSF production or ICP, and antibiotics if shunt infection is present.
• ICP monitoring: Continuously monitor for signs and symptoms of increased ICP and report any changes immediately.
• Seizure and falls precautions: Implement seizure precautions if the patient is at risk for seizures. Implement falls precautions due to potential balance and gait disturbances.
  • Reduce stimuli: Create a calm and quiet environment to minimize external stimuli that can exacerbate ICP.
  • Promote bed rest: Encourage bed rest to reduce metabolic demands and ICP fluctuations.
• Stool softeners: Administer stool softeners to prevent constipation and straining, which can increase ICP.
• Head circumference monitoring (infants): Monitor head circumference daily in infants to track for rapid increases, indicating potential CSF accumulation.

Expected Outcomes: Evaluating Care Effectiveness

Expected outcomes for hydrocephalus nursing care aim to achieve:

• Resolution of increased ICP, as evidenced by improved neurological status and vital signs.
• Improvement of CSF drainage, indicated by stable or decreasing head circumference (infants) and resolution of symptoms.
• Decreased head circumference (infants) toward normal range for age.
• Improvement of balance and motor functions, reflecting neurological recovery.
• Possible continued incontinence and cognitive impairment (NPH only), acknowledging that NPH symptoms may not fully resolve with treatment.

Patient/Caregiver Education: Empowering Self-Management

Patient and caregiver education is crucial for long-term hydrocephalus management. Education should cover:

• General hydrocephalus education (for all forms):
  • Discharge instructions review: Thoroughly review all discharge instructions, medication schedules, and follow-up appointments.
  • Proper hand hygiene: Emphasize the importance of hand hygiene to minimize infection risk, especially related to shunt care.
  • Safety measures: Educate on safety precautions to prevent head injuries, particularly for active children.
  • Signs and symptoms of increased ICP: Instruct patients and caregivers on recognizing signs of increased ICP and shunt malfunction, emphasizing when to seek immediate medical attention.
  • Importance of follow-up: Stress the necessity of regular follow-up appointments with healthcare providers for ongoing monitoring and shunt maintenance.
  • Referral to occupational and developmental therapy (infants and children): Connect families with therapists to address developmental delays and maximize functional abilities.
  • Referral to mental health provider: Offer resources for emotional support for patients and families coping with a chronic condition.
  • Referral to social worker: Provide access to social work services to assist with resources, financial aid, and support networks.
• Medical management review:
  • Basic pathophysiology of hydrocephalus: Explain the underlying condition in understandable terms.
  • Purpose of shunt (if applicable): Describe the function of the shunt and its role in managing hydrocephalus.
  • Shunt complications: Discuss potential shunt complications, including infection and malfunction, and their signs and symptoms.
• NPH-specific education:
  • Safety and supportive measures: For NPH patients and caregivers, emphasize safety modifications at home to prevent falls and promote independence.
  • Structured routine: Recommend establishing a structured daily routine to aid individuals with dementia-related symptoms and promote a sense of security.
  • Caregiver self-care: Address the importance of caregiver self-care to prevent burnout, especially when caring for individuals with dementia.
  • Referral to organizations: Provide referrals to organizations like the Alzheimer’s Association or Hydrocephalus Association for additional information and support.

By implementing a comprehensive nursing care plan and providing thorough patient and caregiver education, nurses play a vital role in improving the quality of life and outcomes for individuals with hydrocephalus.

Alt text: Nurse assessing infant with hydrocephalus, demonstrating neurological examination and monitoring for signs of increased intracranial pressure.