CHAPTER I

INTRODUCTION
Hydrocephalus is derived from the Greek words "hydro" meaning water and "cephalus" meaning head. As the name implies, it is a condition in which the primary characteristic is excessive accumulation of fluid in the brain. Although hydrocephalus was once known as "water on the brain," the "water" is actually cerebrospinal fluid (CSF)--a clear fluid that surrounds the brain and spinal cord. The excessive accumulation of CSF results in an abnormal widening of spaces in the brain called ventricles. This widening creates potentially harmful pressure on the tissues of the brain. The ventricular system is made up of four ventricles connected by narrow passages.. Normally, CSF flows through the ventricles, exits into cisterns (closed spaces that serve as reservoirs) at the base of the brain, bathes the surfaces of the brain and spinal cord, and then reabsorbs into the bloodstream. CSF has three important life-sustaining functions: 1) to keep the brain tissue buoyant, acting as a cushion or "shock absorber"; 2) to act as the vehicle for delivering nutrients to the brain and removing waste; and 3) to flow between the cranium and spine and compensate for changes in intracranial blood volume (the amount of blood within the brain). The balance between production and absorption of CSF is critically important. Because CSF is made continuously, medical conditions that block its normal flow or absorption will result in an over-accumulation of CSF. The resulting pressure of the fluid against brain tissue is what causes hydrocephalus. The causes of hydrocephalus are still not well understood. Hydrocephalus may result from inherited genetic abnormalities (such as the genetic defect that causes aqueductal stenosis) or developmental disorders (such as those associated with neural tube defects including spina bifida and encephalocele). Other possible causes include complications of premature birth such as intraventricular hemorrhage, diseases such as meningitis, tumors, traumatic head injury, or subarachnoid hemorrhage, which block the exit of CSF from the ventricles to the cisterns or eliminate the passageway for CSF into the cisterns.

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RATIONALE We chose this case because we wanted to have a further knowledge regarding this case, Congenital Hydrocephalus. We wanted to use the knowledge we had acquired to promote and provide care. We wanted to be aware on different aspects on how and why this case develops and what are the possible cares we can render to promote health. LEARNING OBJECTIVES Cognitive To define the meaning of the chosen case. To learn the treatment and other related management regarding the said case. To illustrate the anatomy and physiology and pathophysiology of the chosen case. To raise the level of awareness of the student nurse regarding the information about the health problems of his/her patient.

Psychomotor To apply and enhance skills and attitude in rendering good nursing care for the patient. To practice the application of nursing process.

Behavioral To develop understanding and empathy on the clients condition. To provide support for the patient with hydrocephalus. To establish good nurse-patient relationship with the use of therapeutic communication and building rapport. To help patient in motivating her to continue the health care provided by the health workers.

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CHAPTER II
CLINICAL SUMMARY
A. GENERAL DATA (Newborn) Category Name : Gender : Age : Birth Date : Nationality : Religion : Civil Status : Address : Admitting Diagnosis : Demographic Data

Baby G. Male NB 4 days November 20, 2011 Filipino Roman Catholic Single Malitbog, Bongabong, Oriental Mindoro Live Term NB Baby Boy by LTCS Hydrocephalus Principal Diagnosis : Live Term NB Baby Boy by LTCS Hydrocephalus Date of Admission : November 20, 2011 Time of Admission : 11:20 pm

B. CHIEF COMPLAINT (Newborn) The patient was admitted at New Oriental Mindoro Provincial Hospital immediately after the caesarian section delivery on November 20, 2011 at 11:20 pm with the chief complaint of Live Term NB Baby Boy by LTCS Hydrocephalus.

C. HISTORY OF PRESENT ILLNESS (Mother) A 36 year old, female, a multigravida, on her AOG 39 weeks was admitted at the New Oriental Mindoro Provincial Hospital on November 19, 2011 at 10:58 pm, on a stretcher accompanied by her relatives with the chief complain of show. May lumalabas ng dugo sa puwerta ko as verbalized by the patient. Upon admission her vital sign was as follow: Respiratory Rate was 20 CPM, Pulse Rate was 97 BPM, and Temperature was 37.0C.

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The patients mother stated that on November 15, 2011 at around 1:00 PM she felt that her back was aching, Sumakit ang likod as verbalized by the patients mother. At around 12:00 AM the next day the patient felt pain in her abdomen, Humilab na yung tiyan ko as verbalized by the patients mother. The patients husband took the initiative in bringing her wife in the Hospital. The patients mother was first brought to the Pinamalayan Doctors Hospital on November 16, 2011 at 11 am. Then was referred to New Oriental Mindoro Provincial Hospital because the ultrasound detected the big head of the baby, Inilipat kami dito sa Provincial kasi sabi malaki daw ang ulo ng baby ko as verbalized by the patients mother.

D. PAST MEDICAL HISTORY (Mother) The patient stated that she had a past hospitalization due to a spontaneous abortion last August 2009 at the Pinamalayan Doctors Hospital. Other than that she has no other hospitalization. The patient reported that her first baby with her first husband was delivered through a hilot and her first baby with her second husband was also delivered through a hilot. The patient stated that she was on the 2nd month of her pregnancy with her 2nd pregnancy with her second husband when she went to the market and grocery. She bought several good for them. She went home and cooked food for their lunch. She sat down on their set and watched television while waiting for her husband and relatives. Magtatanghali ga nun dalawang buwan ang tiyan ko, namalengke ako tapos paguwi ko niluto ko yung mga pinamili ko. Umupo ako sa sala set at nanuod ng tv habang hinihintay ko yung asawa at mga nanay ko, as verbalized by the patient. She stated that she saw her legs with blood, she saw her panty with full of blood, Nakita ko na may dugo sa hita ko at pagtingin ko sa panty ko madami ng dugo as verbalized by the patient. The patient was then rushed to the Pinamalayan Doctors Hospital. The patient added that the doctor told her that her baby was miscarriage. Sabi nung doctor nakunan daw ako as verbalized by the patient. The patient stated that she had undergone on dilatation and curettage to expel the fragment of conception and to prevent the bleeding. Niraspa ko sabi nung doctor para daw matanggal yung tira sa inunan at para hindi daw ako duguin as verbalized by patient. OB Score of the patients mother was G4 P3 (T3 P0 A1 L3).

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E. FAMILIAL HISTORY The patients mother stated that she had one child with her first husband. The child is with her alive and well. She had a second husband were she had 1 child alive and well plus the baby who was currently admitted at the New Oriental Mindoro Provincial. Her father was dead and her mother was alive and well. She has two brothers; they were both alive and well.

GRANDFATHER deceased

GRANDMOTHER 60 y/o - A&W

1st HUSBAND

Mother 31 y/o

2nd HUSBAND 41 y/o A&W

8 y/o A&W

4 y/o A&W

P 4 days

LEGEND: - Male - Female A&W Alive and Well P - Patient

F. PHYSICAL ASSESSMENT (Newborn) General Appearance: The patient was seen lying on his bed. Patient has heparin on his right hand. Patient looks restless. VITAL SIGNS Temperature Cardiac Rate Respiratory Rate FINDINGS 36.8C 137 40

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APGAR SCORE 1 minute after birth 10 minute after birth 2 4

ANTHROPOMETICS Head Circumference Chest Circumference Abdomen Circumference Length Weight 48 cm 34 cm 31 cm 53 cm 4,200 grams

AREA ASSESSED INTEGUMENTARY SYSTEM Hair

HEAD TO TOE ASSESSMENT TECHNIQUE USED NORMAL SIGNIFICANT FINDINGS FINDINGS

INTERPRETATION

Inspection, Palpation

Black Smooth Neither brittle nor dry

Thin, Scattered or Not evenly hair

Due to enlarge head

Skull And Face

Inspection, Palpation

Head size enlarge, elongated in shape, Asymmetric facial movements EYE Evenly placed and in line with each other Sunset eyes

Due to congenital hydrocephalus

Eyes And Vision

Inspection

Due to the increased pressure in the skull pressing on important nerves running from the brain to the muscles responsible for eye movement No deviation

Inspection

PUPIL Symmetrical in shape Reactive to light and

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Inspection

accommodation Constricts when passed by light at 3mm CONJUNCTIVA Pinkish in color No inflammation Moist No ulcer EYE LASHES Evenly distributed Turn outward Symmetrical in shape, with no visible cerumen on the outer ear No discharge or lesion upon inspection No pain/tenderness upon palpation of auricle and mastoid process Pinna recoils when fold In the midline No discharge Nares are symmetrical without inflammation and irritation noted Nose bridge intact, No tenderness noted on palpation No bone and cartilage deviation noted on palpation Moist lips Tongue is in the midline Without dentures

No deviation

Flat pinna, low set ears

No deviation

Ears And Hearing

Inspection, Palpation

Due to prolonged side lying, due to enlarge head

Nose And Sinuses

Inspection, Palpation

No deviation

Mouth And Oropharynx

Inspection

No deviation

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NECK

Inspection, Palpation

Trachea is in the middle Presence of carotid pulse No Jugular venous distention

No coordinated movement

Due to enlarge head cannot support head movement

UPPER EXTREMITIES Skin And Nails Inspection, Palpation No edema, no lesions No lumps or mass upon palpation No contractures No deviation

Muscle And Strength CHEST AND BACK Spinal Column

Inspection

No deviation

Inspection, Palpation

Chest symmetric Spinal column straight Skin intact No masses Normal breath sounds upon auscultation Respiratory rate within normal range No palpitation Cardiac Rate within normal range Normal in size, shape, and color Without mass, lumps, and tenderness noted symmetric movements caused by respiration no masses or lesion upon palpation and inspection

No deviation

Lungs

Auscultation

No deviation

Heart

Palpation

No deviation

Anterior And Posterior Chest

Inspection, Palpation

No deviation

ABDOMEN Skin

Inspection, Palpation

No deviation

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LOWER EXTREMITIES Skin and Toenails

Inspection, Palpation

No edema, no lesions No lumps or mass upon palpation No contractures

No deviation

Muscle and Strength

Inspection

No deviation

G. LABORATORY AND DIAGNOSTIC EXAM

ULTRASOUND (Cranial Ultrasound) The cranium is fluid filled. The interhemispheric fissure is seen. Thinned out cerebral cortex is seen. No identifiable structure in the posterior fossa. Impression: CONGENITAL HYDROCEPHALUS MRI of the brain is recommended.

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CHAPTER III
CLINICAL DISCUSSION OF THE DISEASE
A. ANATOMY AND PHYSIOLOGY The human brain has the same general structure as the brains of other mammals, but is larger than expected on the basis of body size among other primates. Estimates for the number of neurons (nerve cells) in the human brain range from 80 to 120 billion. Most of the expansion comes from the cerebral cortex, especially the frontal lobes, which are associated with executive functions such as self-control, planning, reasoning, and abstract thought. The portion of the cerebral cortex devoted to vision is also greatly enlarged in human beings, and several cortical areas play specific roles in language, a skill that is unique to humans. Despite being protected by the thick bones of the skull, suspended in cerebrospinal fluid, and isolated from the bloodstream by the blood-brain barrier, the human brain is susceptible to many types of damage and disease. The most common forms of physical damage are closed head injuries such as a blow to the head, a stroke, or poisoning by a variety of chemicals that can act as neurotoxins. Infection of the brain, though serious, is rare due to the biological barriers which protect it. The human brain is also susceptible to degenerative disorders, such as Parkinson's disease, multiple sclerosis, and Alzheimer's disease. A number of psychiatric conditions, such as schizophrenia and depression, are thought to be associated with brain dysfunctions, although the nature of such brain anomalies is not well understood.

The cerebral hemispheres form the largest part of the human brain and are situated above most other brain structures. They are covered with a cortical layer with a convoluted topography. Underneath the cerebrum lies the brainstem, resembling a stalk on which the

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cerebrum is attached. At the rear of the brain, beneath the cerebrum and behind the brainstem, is the cerebellum, a structure with a horizontally furrowed surface that makes it look different from any other brain area. The same structures are present in other mammals, although the cerebellum is not so large relative to the rest of the brain. As a rule, the smaller the cerebrum, the less convoluted the cortex. The cortex of a rat or mouse is almost completely smooth. The cortex of a dolphin or whale, on the other hand, is more convoluted than the cortex of a human. Choroid Plexus The choroid is a structure in the ventricles of the brain where cerebrospinal fluid (CSF) is produced. The cho roid plexus consists of modified ependymal cells. Choroid plexus is present in all components of the ventricular system except for the cerebral aqueduct, frontal horn of the lateral ventricle, and occipital horn of the lateral ventricle. It is found in the superior part of the inferior horn of the lateral ventricles. It follows up along this boundary, continuous with the inferior of the body of the lateral ventricles. It passes into the interventricular foramen, and is present at the top of the third ventricle. There is also choroid plexus in the fourth ventricle, in the section closest to the bottom half of the cerebellum. he choroid plexus (CP) consists of many capillaries, separated from the ventricles by choroid epithelial cells. Liquid filters through these cells from blood to become cerebrospinal fluid. There is also much active transport of substances into, and out of, the CSF as it is made. There are four choroid plexi in the brain, one in each of the ventricles. The CP consist of a layer of cuboidal epithelial cells su rrounding a core of capillaries and loose connective tissue. The CP epithelial layer is continuous with the

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ependymal cell layer that lines the ventricles, but unlike the ependyma the CP epithelial layer has tight junctions in between the cells on the side facing the ventricle (apical surface). These tight junctions prevent the majority of substances from crossing the cell layer into the CSF; thus the CP acts as a blood-CSF barrier. The CP folds into many villi around each capillary, creating frond-like processes that project into the ventricles. The villi, along with a brush border of microvilli, greatly increases the surface area of the CP. CSF is formed as plasma is filtered from the blood through the epithelial cells. CP epithelial cells actively transport sodium, chloride and bicarbonate ions into the ventricles and water follows the resulting osmotic gradient. In addition to CSF production, the CP act as a filtration system, removing metabolic waste, foreign substances, and excess neurotransmitters from the CSF. In this way the CP have a very important role in helping to maintain the delicate extracellular environment required by the brain to function optimally.

VENTRICULAR-PERITONEAL SHUNT (VP Shunt)

Ventriculoperitoneal shunting is surgery to relieve increased pressure inside the skull due to excess cerebrospinal fluid (CSF) on the brain (hydrocephalus).

WHY IT IS PERFORMED? In hydrocephalus, there is a buildup of fluid of the brain and spinal cord (cerebrospinal fluid or CSF). This buildup of fluid causes higher than normal pressure on the brain. Too much pressure, or pressure that is present too long, will damage the brain tissue. A shunt helps to drain the excess fluid and relieve the pressure in the brain. A shunt should be placed as soon as hydrocephalus is diagnosed.

PROCEDURE: This procedure is done in the operating room under general anesthesia. It takes about 1 1/2 hours. The child's hair behind the ear is shaved off. A surgical cut in the shape of a horseshoe (U-shape) is made behind the ear. Another small surgical cut is made in the child's belly.

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A small hole is drilled in the skull. A small thin tube called a catheter is passed into a ventricle of the brain. Another catheter is placed under the skin behind the ear and moved down the neck and chest, and usually into the abdominal (peritoneal) cavity. Sometimes, it goes to the chest area. The doctor may make a small cut in the neck to help position the catheter. A valve (fluid pump) is placed underneath the skin behind the ear. The valve is attached to both catheters. When extra pressure builds up around the brain, the valve opens, and excess fluid drains out of it into the belly or chest area. This helps decrease intracranial pressure. The valves in newer shunts can be programmed to drain more or less fluid from the brain.

RISKS: Risks for any anesthesia are:

Reactions to medications Problems breathing Changes in blood pressure or breathing rate

Risks for any surgery are:

Bleeding Infection

Possible risks of ventriculoperitoneal shunt placement are:

Blood clot or bleeding in the brain Brain swelling The shunt may stop working and fluid will begin to build up in the brain again. The shunt may become infected. Infection in the brain Damage to brain tissue Seizures

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PRE-OPERATIVE NURSING CARES: Assess head circumference, fontanelles, cranial sutures, and LOC; check also for irritability, altered feeding habits and a high-pitched cry. Firmly support the head and neck when holding the child. Provide skin care for the head to prevent breakdown. Give small, frequent feedings to decrease the risk of vomiting. Encourage parental-newborn bonding. POST-OPERATIVE NURSING CARES: Assess for signs of increased ICP and check the following; head circumference (daily), anterior fontanelle for size and fullness and behavior. Administer prescribed medications which may include antibiotics to prevent infection and analgesics for pain. Provide shunt care Monitor for shunt infection and malfunction which may be characterized by rapid onset of vomiting, severe headache, irritability, lethargy, fever, redness along the shunt tract, and fluid around the shunt valve. Prevent infection (usually from Staphylococcus epidermis or Staphylococcus aureus) Monitor for shunt overdrainage (headache, dizziness and nausea). Overdrainage may lead to slit ventricle syndrome whereby the ventricle become accustomed to a very small or slitlike configuration, limiting the buffering ability to increased ICP variations.

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B. PHYSIOLOGY OF CONGENITAL HYDROCEPHALUS PRECIPITATING FACTORS: Prematurity Infection Tumor Hemorrhage Idiopathic

PREDISPOSING FACTORS: Genetics Age

CSF forms in the Choroid plexus of the lateral ventricles. Obstruction in the aqueduct due to incomplete formation of the lateral and medial foramina. Or it can get way out but not efficiently absorb in the lining of the brain.

Fluid accumulates; the spaces on the ventricles get larger Intracranial pressure increases due to continues accumulation of fluid Expansion of the skull and thinning and atrophy Contraction of the cerebral blood volume Enlarged head, bulging fontanelle, shiny scalp, dilated scalp veins

Alteration of cerebral circulation, thus, CSF circulation is altered Diagnostic Exam through Ultrasonography (Ultrasound)

Irritability, lethargy, sleepiness, reduced activity

CONGENITAL HYDROCEPHALUS

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C. DRUG STUDY DRUG NAME AMPICILLIN CLASSIFICATION anti- infective DOSAGE 210 mg, IV q 8 hrs. INDICATIONS/ CONTRAINDICATIONS Indication: Treatment of infections caused by susceptible strains of the designated organisms. Contraindication: Patients with allergic reaction to penicillin. Patients with hypersensitivity to drug and patients with viruses belonging to herpes-group. ADVERSE REACTIONS Skin rashes, nausea and vomiting, diarrhea, and pain at injection site. MECHANISM OF ACTION Inhibits cellwall synthesis during bacterial multiplication. NURSING CONSIDERATIONS Before giving the drug ask patient about allergic reactions to penicillin or a negative history of penicillin allergy. Watch for signs and symptoms of hypersensitivity.

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DRUG NAME Gentamici n sulfate Garamycin , G-myticin

CLASSIFICATION Aminoglycoside

DOSAGE 210 mg, IV q 8 hrs.

INDICATION/ CONTRAINDICATION Indication: Parenteral Serious infections caused by susceptible strains of Pseudomonas aeruginosa, Proteus sp., Escherichia coli, KlebsiellaEnterobacter-Serratia species, Citrobacter, Staphylococcus sp. Intrathecal For serious CNS infections caused by susceptible Pseudomonas species Contraindication: Contraindicated with allergy to any aminoglycosides; renal or hepatic disease; preexisting hearing loss; active infection with herpes, vaccinia, varicella, fungal infections, myobacterial infections (ophthalmic preparations); myasthenia gravis; parkinsonism; infant botulism; lactation.

ADVERSE REACTION Ototoxicity-tinnitus, dizziness, vertigo, deafness (partially reversible to irreversible), vestibular paralysis, confusion, disorientation, depression, lethargy, nystagmus, visual disturbances, headache, numbness, tingling, tremor, paresthesias, muscle twitching, convulsions, muscular weakness, neuromuscular blockade.

MECHANISM OF ACTION Broadspectrum aminoglycosi de antibiotic derived from Micromonosp ora purpurea. Action is usually bacteriocidal .

NURSING CONSIDERATIONS Give by IM route if at all possible; give by deep IM injection. Culture infected area before therapy. Use 2 mg/mL intrathecal preparation without preservatives, for intrathecal use. Cleanse area before application of dermatologic preparations. Ensure adequate hydration of patient before and during therapy.

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CHAPTER IV
NURSING PROCESS
A. PROBLEM LIST Problem Anxiety related to family situational crisis. Date Identified November 25, 2011 Date Resolved November 25, 2011

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B. NURSING CARE PLAN Assessment Subjective: Parang hindi ata normal ang anak ko as verbalized by the patients mother Objective: Confused Worried Frightened Statement of inability to meet childs need Diagnosis Anxiety related to family situational crisis, Abnormal baby. Planning At the end of the shift the parents will: demonstrate family coping techniques participate in decisionmaking process Intervention 1. Facilitated open communication to the family members 2. Explained some information about the condition of their baby in a simple way 3. Encouraged family to verbalize feelings and concerns and encourage family to participate in patients care and decision making 4. Provided motherinfant relationship like in breast feeding and viewing time 5. Assisted family to focus on the child rather than on illness like talking the baby as a new member of the family Rationale 1. To established rapport and cooperation 2. To understand the condition of the patient 3. To provide guidelines and independency in caring with the patient Evaluation Goal met. At the end of the shift the parents demonstrated family coping techniques, participated in decisionmaking process.

4. For Easily acceptance and bonding to the patient 5. To show acceptance

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C. DISCHARGE PLANNING The patient was not yet on discharge when we handled him. But in case that he will be discharge, this will be his discharge plan.

MEDICATIONS
Describe the importance of regularly taking of prescribed medications to the parents. Instruct the parents to continue with follow up medical care with their baby Advise the parents not to miss the intake of medications given by the physician upon discharge with their baby

ENVIRONMENT/ EXERCISE
Maintain a quiet, pleasant, environment to promote relaxation. Provide clean, comfortable and safety crib or bed.

TREATMENT
Repeat for follow up check up

HEALTH TEACHING
Explain the underlying disorder and treatment plan to the parents. General health measures (adequate sleep, proper diet, and maintaining a clean surrounding).

OUT PATIENT
Parents are advised to go back in the hospital in a specific date to have a follow-up check up after discharge. Consult doctor for any problems or complications encountered by the patient.

DIET
Exclusive breastfeeding

SPIRITUAL
Nursing actions to help parents patient meet their spiritual needs include: o providing presence o supporting religious practices o assisting clients with prayer o referring client for spiritual counseling

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