Unit 5 Sensory

1. Hydrocephalus
   • Introduction: Hydrocephalus, known to the layperson as “water on the brain,” is actually a syndrome resulting from disturbances in the dynamics of CSF. The accumulation of this fluid causes enlargement and dilation of the ventricles of the brain and increased intracranial pressure (ICP). If untreated, severe brain damage will result; treatment is a surgical shunting procedure that allows CSF to drain from the ventricles of the brain to another, less harmful area withm the body: jugular vein, right atrium of the heart, or peritoneal cavity. Hydrocephalus can develop as the result of a congenital malformation (e.g., Arnold-Chiari malformation); can be associated with other congenital defects (e.g., spina bifida); or can be acquired secondary to infection (e.g., meningitis), trauma, or neoplasm.
   • Assessment:
     1. Head: increased circumference - earliest sign of hydrocephalus in the infant (more than 1 in/mo).
     2. Fontanels: tense and bulging without head enlargement.
     3. Veins: dilated scalp veins.
     4. "Setting-sun" sign: sclera visible above pupil; pupils are sluggish with unequal response to light.
     5. Cry: shrill, high pitched.
     6. Developmental milestones: delayed.
     7. Reflexes: persistence of neonatal reflexes; hyperactive reflexes.
     8. Feeds poorly.
     9. Signs of increased ICP:
        • Vomiting.
        • Irritability
        • Seizures
        • Decreased pulse.
        • Decreased respirations.
        • Increased blood pressure.
        • Widened pulse pressure.
     10. History may reveal other CNS defects (e.g., spina bifida), infection (e.g., meningitis), trauma, or neoplasm.
   • Analysis/nursing diagnosis:
     1. Altered cerebral tissue perfusion related to increased intracranial pressure.
     2. Impaired skin integrity related to enlarged head size and lack of motor coordination.
     3. Altered nutrition, less than body requirements, related to anorexia and vomiting.
     4. Anxiety related to diagnosis and uncertain outcome.
     5. Knowledge deficit regarding care of the child with a shunt and follow-up care.
   • Nursing care plan/implementation:
     1. Goal: monitor neurological status.
        • Measure head circumference daily, and note any abnormal increase.
        • Perform neurological checks at least every 4 hours to monitor for signs of increased ICP.
        • Report signs of increased ICP stat to physician.
        • Assist with diagnostic procedures/treatments: ventricular tap, computed tomography (CT) scan, etc.
     2. Goal: health teaching to reduce parental anxiety.
        • Do preoperative teaching regarding the shunt procedure: stress need to remove excessive CSF to relieve pressure on brain; done as soon as possible after diagnosis is established.
        • Stress early diagnosis and prompt shunting procedure to minimize the risk of long-term neurological complications.
        • Offer realistic information regarding prognosis:
          1. Surgically treated, with continued follow-up care: 80% survival rate.
          2. Of these survivors, 50% are completely normal and 50% have some degree of neurological disability (such as inattentiveness or hyperactivity).
     3. Goal: provide postoperative shunt care.
        • Position:
          1. Flat in bed for 24 hours, to prevent subdural hematoma.
          2. Gradually increase the angle of elevation of HOB, as ordered by surgeon.
          3. On the unoperative side, to prevent mechanical pressure and obstruction to shunt.
        • Monitor head circumference daily to note any abnormal increase that might indicate malfunctioning shunt.
        • Monitor vital signs; monitor for signs of increased ICP.
        • Monitor for possible complications:
          1. Infection.
          2. Malfunction of shunt: increased ICP.
     4. Goal: provide discharge teaching to parents regarding home care of the child with a shunt.
     • Stress need for long-term follow-up care
     • Discuss feeding techniques, care of skin (especially scalp), need for stimulation.
     • Prepare parents for shunt revisions to be done periodically as child grows.
     • Teach parents signs and symptoms of shunt malfunctioning (i.e., of increased ICP or infection) and to report these promptly to physician.
     • Encourage parents to enroll infant in “early infant stimulation” program to maximize developmental potential.
     • Stress need to monitor development at frequent intervals, make referrals prn.
   • Evaluation/outcome criteria:
     1. Neurological functioning is maintained or improved.
     2. Adequate nutrition is maintained.
     3. No impairment of skin integrity occurs.
     4. Parents’ anxiety is relieved; they verbalize understanding of how to care for child after discharge.

2. Febrile seizures
   • Introduction: Febrile seizures are transient neurological disorders of childhood, affecting perhaps as many as 3% of all children. Although the exact cause of febrile seizures remains uncertain, they seem to be a relatively transient problem that occurs exclusively in the presence of high, spiked fevers. Children in the infant and toddler stages (6 months-3 years) appear to be most susceptible to febrile seizures, and they are twice as common in boys as in girls. There also appears to be an increased susceptibility within families, suggesting a possible genetic predisposition.
   • Assessment:
     1. History usually reveals presence of URI or gastroenteritis.
     2. Occurs with a sudden rise in fever: often spiked and quite high (102°F or higher) vs. prolonged temperature elevation.
   • Analysis/nursing diagnosis:
     1. Risk for injury related to seizures.
     2. Knowledge deficit related to prevention of future seizures, care of child having a seizure and possible long-term effects.
   • Nursing care plan/implementation:
     1. Goal: reduce fever/prevent further increase in fever.
        • Administer antipyretics, as ordered: acetaminophen only (not aspirin).
        • Use cool, loose, cotton clothes to decrease heat retention.
        • Sponge with tepid water 20-30 minutes; avoid shivering, which increases metabolic rate and temperature.
        • Encourage child to drink cool fluids.
        • Monitor temperature hourly.
        • Minimize stimulation, frustration for child.
     2. Goal: teach parents about care of child who experiences febrile seizure.
        • Discuss how to prevent seizures from recurring: best method is to prevent temperature from rising over 102°F .
        • Discuss how to handle seizures if they do recur: prevent injury, maintain airway, etc.
        • Answer questions simply and honestly:
          1. 25% of children with one febrile seizure will experience a recurrence.
          2. 75% of recurrences occur within 1 year.
          3. Reassure parents of the benign nature of febrile seizures; 95-98% of children with febrile seizures do not develop epilepsy or neurological damage.
   • Evaluation/outcome criteria:
     1. Fever is kept below 102°F; additional seizures are prevented.
     2. Parents verbalize their understanding of how to care for child at home.