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NURSING CARE PLAN

ASSESSMENT

DIAGNOSIS

INFERENCE

 

PLANNING

INTERVENTION

RATIONALE

EVALUATION

   

Hydrocephalus is characterized by an abnormal increase in cerebrospinal fluid (CSF) volume within the intracranial cavity and by enlargement of the head in infancy. Pressure from increased fluid volume can damage the brain tissue. Hydrocephalus results from two major causes:

 

INDEPENDENT:

   

SUBJECTIVE:

Ineffective cerebral tissue perfusion related to decreased arterial or venous blood flow.

After 8 hours of nursing interventions, the patient will demonstrate improved vital signs and absence of signs of increased ICP.

Monitor temperature. Administer tepid sponge bath in presence of fever.

Fever may

After 8 hours of nursing interventions, the patient was able to demonstrate improved vital signs and absence of signs of increased ICP.

reflect damage

“Napansin ko na hindi normal ang laki ng ulo ng anak ko” (My

to

hypothalamus.

Increased

metabolic

son’s head is abnormally large) as

verbalized by the mother.

   

needs and

oxygen

consumption

occur

   

(especially with

OBJECTIVE:

fever and

 

shivering),

Restlessness

which can

Irritability

further

Changes in vital signs

obstruction of CSF flow (noncommunicating hydrocephalus) or faulty CSF absorption or overproduction of CSF (communicating hydrocephalus). In the noncommunicating type, obstruction may result from congenital defects, infections, trauma, spontaneous intracranial bleeding, and neoplasms. In the communicating type, faulty CSF absorption may result from

increased ICP.

V/S taken as follows:

Monitor Intake

Useful indicators of body water, which is an integral part of tissue perfusion.

 

and output.

 

T: 37.5

Weigh as

P: 90

indicated. Note

R: 22

skin turgor,

 

status, and

mucous

membrane.

 

Maintain head or neck in midline or in neutral position, support with small towel rolls and pillows. Avoid placing head on large pillows.

Turning bed to one side compresses the jugular veins and inhibits cerebral venous drainage that may cause

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meningeal adhesions or excessive production of CSF fluid caused by a tumor or from unknown
meningeal
adhesions or
excessive production
of CSF fluid caused
by a tumor or from
unknown causes.
Complications of
hydrocephalus
includes seizures,
spontaneous arrest
due to natural
compensatory
mechanisms,
persistent increased
intracranial pressure
(ICP), brain
herniation,
developmental
delays.
increased ICP.
∑ Provides rest
periods between
care of activities
and limit duration
of procedures.
∑ Continual
activity can
increase ICP
by producing a
cumulative
stimulant
effect.
∑ Decrease
∑ Provides
extraneous
calming effect,
stimuli and
reduces
provide comfort
adverse
measures such
physiological
as back
response, and
massage, quiet
promotes rest.
environment,
gentle touch.
∑ Help patient
avoid or limit
coughing, crying,
vomiting, and
straining at stool.
Reposition the
patient slowly.
∑ These
activities
increase
intrathoracic
and intra-
abdominal
pressure.
∑ Elevate the head
of bed gradually
to 15-30 degrees
as tolerated or
indicated.
∑ Promotes
venous
drainage from
head, reducing
cerebral
congestion and
edema and
increased ICP.

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COLLABORATIVE: ∑ Administer diuretics as indicated. ∑ Diuretics may be used in acute phase to
COLLABORATIVE:
∑ Administer
diuretics as
indicated.
∑ Diuretics may
be used in
acute phase to
draw water
from brain
cells, reducing
cerebral
edema and
ICP.
∑ Administer
∑ Reduces
supplemental
hypoxemia,
oxygen as
which may
indicated.
increase
cerebral
vasodilation
and blood
volume.