Structural Defects: Hydrocephalus (Nursing)

by Elizabeth Stone, PHD, RN, CPEN, CHSE, FAEN

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    00:01 Hi. This is the lecture on pediatric hydrocephalus.

    00:04 We're going to start by going over the definition of it and the word hydrocephalus.

    00:10 Then, we're gonna talk about some of the causes, the manifestations of it, and the major treatments for it.

    00:16 Let's start with a definition or rather, the word.

    00:20 Hydro and cephalus means water in the head or in the brain in this case.

    00:28 Basically, the definition is that it's a not normal accumulation of CSF or cerebrospinal fluid in the brain.

    00:36 You can see how the normal brain has ventricles that are full of CSF.

    00:42 Hydrocephalus on the right actually has expanded ventricles which are putting pressure on the brain because they have too much fluid in them.

    00:50 This is actually a fairly common abnormality in newborns.

    00:56 It occurs in about one to two out of every thousand infants.

    01:00 Enlarged ventricles from the excess fluid causes the ventricles to widen.

    01:08 Then, they press on the brain. Pressing on the brain is never a good thing.

    01:14 It puts pressure on the tissues and that can keep the brain from functioning properly.

    01:21 It can also cause serious disability or death if not treated.

    01:26 All right. Let's review some of the major causes.

    01:28 There are several congenital causes of hydrocephalus.

    01:33 One of the first ones is neural tube defects.

    01:37 The neural tube is basically the early brain and spinal cord during fetal development.

    01:42 When there's a defect in it, it can lead to hydrocephalus.

    01:46 Arachnoid cysts are cysts or fluid-filled sacs that grow on the brain and/or spinal cord.

    01:56 That can also happen during fetal development and lead to congenital hydrocephalus.

    02:02 Dandy-Walker syndrome is a congenital brain malformation that affects the cerebellum and the ventricle near it.

    02:10 Arnold-Chiari Malformations are a group of deformities of the posterior fossa and the hind brain which is where most of the cranial nerves are found.

    02:22 And finally, congenital syphilis can cause congenital hydrocephalus because congenital syphilis can cause irritation and inflammation of the fetal brain.

    02:34 All right. Let's talk about some acquired causes for hydrocephalus.

    02:37 And this is fairly intuitive, I think, because basically, it's anything that can cause pressure, bleeding, injury, or infection to the brain.

    02:49 The brain just does not have a lot of tolerance for abnormalities.

    02:53 And when they occur, more pressure can build up and more fluid can build up or get blocked.

    02:59 intracranial hemorrhages, meningitis, brain tumors, shunt malformations, we'll talk about shunts in a moment, and just traumatic brain injuries can all cause hydrocephalus.

    03:14 All right. Let's review some of the common manifestations of a child who has hydrocephalus.

    03:21 In an infant, the first sign that may be noticed is an enlarged head circumference.

    03:26 Head circumferences should be taken at every routine check-up and also taken if a child comes in for an illness or injury that may have affected the brain.

    03:38 Early on, if a child has hydrocephalus, they may start displaying subtle signs of illness or altered mental status such as irritability, inconsolability, lethargy, not wanting to wake up or poor feeding is a really common sign of serious illness or injury in a young infant especially.

    03:59 The frontal area of the head will eventually start protruding.

    04:02 A term for this is called bossing.

    04:05 The head would grow at an abnormal rate if the hydrocephalus was not treated.

    04:12 Eventually, it would be obvious and as this happens, intracranial pressure would increase within the brain.

    04:21 A bulging fontanel may be present with or without an enlarged head.

    04:25 The bulging fontanel results from the hydrocephalus that causes that increased pressure in the brain.

    04:31 Sometimes a fontanel is just slightly bulging or more tense.

    04:35 Increased intracranial pressure might cause the eyes to actually rotate down.

    04:42 We call that a setting sun sign. It's more common in infants, in young infants.

    04:47 It looks as if they're trying to look at their lower eyelids.

    04:50 You see more of the white than you really should normally.

    04:55 The pupils may also be sluggish and unequal in response to light.

    04:59 The manifestations or signs and symptoms of hydrocephalus in a child or infant depends on several factors such as their age, the cause of it, the location of the legion in the brain, and the degree of increased intracranial pressure that has resulted as well as any resulting brain damage.

    05:20 All right. Let's review the major treatment for hydrocephalus.

    05:26 Without treatment, death or permanent disability can occur.

    05:29 The main treatment for hydrocephalus is a VP Shunt.

    05:35 The long word for that is Ventriculoperitoneal Shunt and that name is basically representative of how it goes through the body from the ventricles of the brain down to the peritoneum of the abdomen or the peritoneal space.

    05:50 Many people with shunts lead normal, healthy lives. These shunts are internal.

    05:57 They're inside the body. None of it is on the outside.

    06:00 The only downside is that they may require some revisions throughout life as the child grows.

    06:07 Shunts can also get blocked and need to be surgically repaired or replaced.

    06:14 So anybody that has a VP Shunt and comes in to a hospital or to a doctor's office, or any kind of healthcare facility needs to be seen urgently if they're having any kind of signs and symptoms that might indicate a problem with the shunt such as head pain or vomiting, or other signs and symptoms of neurologic problems.

    06:34 This is another type of drain, an external ventricular drain.

    06:38 That's a more short-term measure.

    06:41 It's used in hospitals but nobody would go home with this.

    06:44 Basically, it's a drain that's on the outside of the child.

    06:48 So it would go from their ventricles where the excess fluid is and take some of the excess fluid out, would help drain it.

    06:55 It would also help monitor the intracranial pressure, so it provides monitoring and fluid drainage.

    07:04 There's also a third type that's not a drain, but actually, it's just a really quick way of monitoring increased ICP if somebody has hydrocephalus especially from a trauma, head injury and if there's a need to see what their ICP actually is inside their brain urgently and that's called a bolt. That is sometimes put in by a neurosurgeon or intensivist in an emergency department at the bedside.

    07:30 It's very dramatic. You may hear about it, so I just wanted to mention that.

    07:34 But the external ventricular drain and the Ventriculoperitoneal Shunt are the two major types of shunts used for hydrocephalus.

    07:44 If hydrocephalus does not resolve by using an external ventricular drain, they may need to convert it to a VP Shunt.

    07:53 Because again, you wouldn't go home with this but you can go home with a VP Shunt and many people live with them.

    08:00 This is the NCSBN Clinical Judgement Measurement Model.

    08:04 It's a framework being used in many next general NCLEX exam questions and case studies.

    08:09 You may hear about it in nursing school and you may see test questions framed using it in your nursing school exams.

    08:17 So we're going to relate some of the content in this lecture to this model, especially, the first two steps, recognizing cues and analyzing cues.

    08:25 In order to recognize and analyze cues of potential hydrocephalus in an infant, you must first be aware of how to recognize an abnormally shaped head or an abnormally growing head.

    08:39 You may need to know their baseline or their birth head circumference and compare it to any measurement you take.

    08:46 The head circumference, the measurement, and the procedure for how to do that is in our normal newborn head lecture but a quick review is basically you take a tape measure over the eyebrows around the widest part of the head.

    09:00 At birth, the average full-term head circumference is about 33 to 35 centimeters.

    09:07 You should also be able to identify potential signs and symptoms of hydrocephalus that are external and internal.

    09:16 So in other words, if you see or feel a bulging fontanel, that could be a sign of hydrocephalus.

    09:23 If you see bossing or protrusion of the frontal area of the head, that could be a sign of hydrocephalus.

    09:29 And if there are clinical signs and symptoms that indicate possible increased intracranial pressure, it could be due to hydrocephalus.

    09:37 Some of those in a neonate may be very subtle, may include difficulty or refusal of feeding, irritability, lethargy, or a weak cry.

    09:48 Other signs in an older child might be a little more prominent.

    09:52 May include vomiting, head pain, and some of the same other signs, lethargy, irritability.

    10:01 Also remember, in newborns and young infants, they may show very - some subtle signs of intracranial pressure buildup such as eye - eye deviation or the setting sun sign that might indicate increased intracranial pressure.

    10:17 The eye deviation or Nystagmus could be a sign of a seizure which could also be a result from increased intracranial pressure.

    10:27 Children of any age with increased intracranial pressure from hydrocephalus could have a seizure if it goes on too far without being identified.

    About the Lecture

    The lecture Structural Defects: Hydrocephalus (Nursing) by Elizabeth Stone, PHD, RN, CPEN, CHSE, FAEN is from the course Neurologic Disorders – Pediatric Nursing.

    Included Quiz Questions

    1. It involves higher than normal amounts of cerebrospinal fluid.
    2. The increase in pressure on the brain impacts brain function.
    3. It is relatively rare.
    4. It causes smaller than normal ventricles.
    5. The effects of hydrocephalus are not permanent.
    1. Syphilis
    2. Dandy-Walker syndrome
    3. Arachnoid cyst
    4. Meningitis
    5. Shunt malfunction
    1. Enlarged head circumference
    2. Poor feeding
    3. Frontal area protrusion
    4. Sunken fontanelles
    5. Pinpoint pupils
    1. Ventriculoperitoneal shunt
    2. External ventricular drain
    3. Diuretics
    4. Ventricle removal
    1. External ventricular drain
    2. Ventriculoperitoneal shunt
    3. Ventricle removal
    4. Bolt monitor

    Author of lecture Structural Defects: Hydrocephalus (Nursing)

     Elizabeth Stone, PHD, RN, CPEN, CHSE, FAEN

    Elizabeth Stone, PHD, RN, CPEN, CHSE, FAEN

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