A 6-year-old child with a history of congenital hydrocephalus and VP shunt placement presents with lethargy, severe morning headaches, vomiting, and an ataxic gait. Which nursing action is the priority?

B) Prepare the child for a CT scan to evaluate shunt function.

A) Administer acetaminophen to reduce the child's fever.

B) Prepare the child for a CT scan to evaluate shunt function.

C) Initiate seizure precautions to prevent potential convulsions.

D) Provide the child with oral rehydration solutions to address vomiting.

A pediatric patient with a history of congenital hydrocephalus and VP shunt placement presents with increasing lethargy, headaches, vomiting, and a recent onset of ataxia. Based on the symptoms and clinical findings, which nursing intervention is the highest priority?

B) Prepare the patient for immediate neuroimaging to assess shunt function.

A) Administer an antiemetic to manage vomiting and provide comfort.

B) Prepare the patient for immediate neuroimaging to assess shunt function.

C) Initiate broad-spectrum antibiotics to address potential infection.

D) Conduct a detailed neurological assessment and document changes.

A pediatric patient with a history of ventriculoperitoneal shunt presents with signs of shunt malfunction. Which of the following nursing actions should take priority to prevent further neurological deterioration?

C) Monitor and document changes in the child's neurological status

A) Administer analgesics to manage the child's pain

B) Prepare the child for immediate CT scan to confirm diagnosis

C) Monitor and document changes in the child's neurological status

D) Educate the parents about the potential need for shunt replacement surgery

A child with a malfunctioning ventriculoperitoneal shunt is being prepared for surgical revision. Which of the following nursing interventions is the most crucial to perform before the child is taken to the operating room?

B) Monitor and document the child's neurological status frequently.

A) Administer a sedative to ensure the child remains calm during transport.

B) Monitor and document the child's neurological status frequently.

C) Elevate the head of the bed to reduce intracranial pressure.

D) Ensure the child is kept NPO (nothing by mouth) to prevent aspiration during surgery.

A child in the immediate postoperative period is slow to awaken from anesthesia, shows decreased responsiveness, and has weakness in the left upper extremity. Vital signs reveal mild tachycardia, slightly elevated blood pressure, and a low-grade fever. What is the priority nursing intervention while awaiting further diagnostic results?

C) Elevate the head of the bed to 30 degrees to promote venous drainage.

A) Administer antipyretics to address the fever.

B) Initiate seizure precautions in case of increased intracranial pressure.

C) Elevate the head of the bed to 30 degrees to promote venous drainage.

D) Administer IV fluids to maintain hydration status.

A pediatric patient is in the immediate postoperative period following a neurosurgical procedure. The patient exhibits decreased responsiveness, mild tachycardia, slightly elevated blood pressure, low-grade fever, delayed pupil response, and weakness in the left upper extremity. Which nursing intervention is the priority while awaiting the CT scan results?

B) Elevate the head of the bed to 30 degrees and monitor for increased intracranial pressure.

A) Administer prescribed antipyretics to address the fever.

B) Elevate the head of the bed to 30 degrees and monitor for increased intracranial pressure.

C) Initiate IV fluid resuscitation to manage potential hypovolemia.

D) Provide passive range of motion exercises to the affected extremity.

A child with a small subdural hematoma and mild cerebral edema is being monitored for signs of increased intracranial pressure (ICP). Which nursing intervention is most critical in preventing further increase in ICP?

B) Elevating the head of the bed to 30 degrees

A) Administering mannitol to reduce cerebral edema

B) Elevating the head of the bed to 30 degrees

C) Performing hourly neurological assessments

D) Keeping the child sedated to decrease metabolic demands

A pediatric patient presents with mild cerebral edema and a small subdural hematoma, with concerns for increased intracranial pressure (ICP). Which nursing intervention should be prioritized to help reduce ICP?

B) Position the head of the bed at 30 degrees and ensure the neck is in a neutral position.

A) Administer intravenous mannitol immediately.

B) Position the head of the bed at 30 degrees and ensure the neck is in a neutral position.

C) Initiate hourly neurological assessments including Glasgow Coma Scale monitoring.

D) Provide supplemental oxygen to maintain oxygen saturation above 95%.

A nurse is caring for a child with a decreased Glasgow Coma Scale score and symptoms suggestive of increasing intracranial pressure. Which nursing intervention is most appropriate to implement following the administration of mannitol to the child?

A) Elevate the head of the bed to 30 degrees and monitor the child's neurological status closely.

B) Restrict fluids to prevent further increase in intracranial pressure.

C) Administer a sedative to keep the child calm and prevent further increase in intracranial pressure.

D) Encourage the child to participate in physical activity to increase cerebral blood flow.

A nurse is caring for a child with a recent decrease in Glasgow Coma Scale (GCS) score and signs of increased intracranial pressure. Which nursing intervention is the most appropriate to perform immediately after administering mannitol?

B) Monitor for signs of fluid volume overload.

A) Position the child supine with the head of the bed flat.

B) Monitor for signs of fluid volume overload.

C) Place ice packs on the child's forehead to reduce fever.

D) Encourage the child to drink fluids to maintain hydration.

child hydrocephalus - Nursing Case Study

Pathophysiology

• Primary mechanism: Hydrocephalus in children is often caused by an imbalance between cerebrospinal fluid (CSF) production and absorption, leading to excessive accumulation. This can occur due to obstruction of CSF flow, often by congenital malformations like aqueductal stenosis.

• Secondary mechanism: Impaired CSF absorption at the arachnoid villi can also contribute, often due to inflammation or hemorrhage that disrupts normal drainage pathways, compounding the accumulation of fluid within the ventricles.

• Key complication: The resultant increased intracranial pressure can cause brain tissue compression, leading to symptoms such as enlarged head size, irritability, developmental delays, and potentially severe neurological deficits if not treated promptly.

Patient Profile

Demographics:

6 years old, male, elementary school student

History:

• Key past medical history: Diagnosed with congenital hydrocephalus at birth; underwent ventriculoperitoneal (VP) shunt placement at 3 months old

• Current medications: Acetazolamide, 125 mg twice daily

• Allergies: No known drug allergies

Current Presentation:

• Chief complaint: Increasing headaches and nausea

• Key symptoms: Lethargy, irritability, blurred vision, and balance difficulties

• Vital signs: Temperature 38.3°C (100.9°F), Heart Rate 115 bpm, Respiratory Rate 22 breaths per minute, Blood Pressure 105/70 mmHg

Section 1

During the initial assessment, the nurse observes that the child's symptoms have progressively worsened over the past few days. Upon examination, the child appears increasingly lethargic and is difficult to rouse, with sluggish pupillary responses noted in both eyes. The parents report that he has been complaining of more severe headaches, particularly in the mornings, and has been vomiting without relief. A focused neurological assessment reveals that the child has developed a pronounced ataxic gait, struggling to maintain balance when attempting to stand or walk. There is also noticeable irritability and confusion, with the child frequently asking repetitive questions, suggesting increased intracranial pressure may be impacting cognitive functions.

The child's vital signs indicate a concerning trend: his temperature has risen to 38.9°C (102°F), and his heart rate has climbed to 125 bpm, while his blood pressure remains stable at 110/72 mmHg. These signs, coupled with new-onset bradykinesia and a sunsetting sign in his eyes, raise significant suspicion of shunt malfunction or infection. Given his history of congenital hydrocephalus and VP shunt placement, these findings necessitate urgent neuroimaging to assess for potential shunt obstruction or infection. The nurse promptly communicates these critical findings to the attending physician, highlighting the need for immediate intervention to prevent further neurological compromise.

Recognizing the potential for rapid deterioration, the healthcare team swiftly arranges for a CT scan of the head to evaluate the status of the ventricles and shunt system. This decision is informed by the classic signs of shunt failure, which can lead to dangerous levels of intracranial pressure if not addressed. The clinical reasoning process here emphasizes the need to differentiate between shunt obstruction and underlying infection, as each would require distinct management strategies. As the case unfolds, the team prepares to address the possible complications, including the administration of broad-spectrum antibiotics if infection is suspected, and plans for potential surgical intervention should the imaging confirm shunt malfunction.

Section 2

As the CT scan results return, they reveal marked enlargement of the ventricles, confirming significant ventriculomegaly consistent with shunt malfunction. The scans also show no immediate signs of infection, such as abscess formation or ventriculitis, but the possibility of a subtle infection cannot be entirely ruled out without further evaluation. These findings indicate that the shunt is likely obstructed, leading to the accumulation of cerebrospinal fluid and resulting in increased intracranial pressure. The healthcare team discusses these results, emphasizing the need for urgent surgical intervention to either revise or replace the malfunctioning shunt to prevent further neurological damage.

In response to the CT findings, the attending neurosurgeon is consulted, and the child is prepared for surgery. Preoperative preparations include the administration of intravenous fluids to maintain hydration status and careful monitoring of intracranial pressure. Antibiotics are also initiated prophylactically to cover potential infection until cultures can be obtained during surgery. Throughout this process, the child's condition remains closely monitored, with vital signs showing persistent tachycardia and low-grade fever. The nursing team provides continuous reassessment of neurological status, noting any changes in mental alertness or worsening motor skills, which could indicate further deterioration.

As the child is taken to the operating room, the multidisciplinary team remains vigilant for any new complications that may arise. The surgery itself carries inherent risks, including potential infection, bleeding, or further shunt failure. Postoperatively, the clinical reasoning process will involve a thorough evaluation of the child's recovery trajectory, monitoring for signs of successful shunt function restoration and any adverse outcomes. The child’s parents are kept informed and supported throughout the process, with the healthcare team addressing their concerns and explaining each step of the intervention clearly. The focus remains on ensuring a swift and effective response to stabilize the child’s condition and facilitate a return to normal cognitive and physical functioning.

Section 3

In the immediate postoperative period, the child is transferred to the pediatric intensive care unit for close observation. Initial assessment findings reveal that the child is slow to awaken from anesthesia, exhibiting decreased responsiveness compared to preoperative baseline. Vital signs show a persistent mild tachycardia with a heart rate of 120 beats per minute, slightly elevated blood pressure at 130/85 mmHg, and a low-grade fever of 100.4°F. The nursing team notes that the child's pupils are equal and reactive to light, but there is a noticeable delay in response time. Motor function is also assessed, with the child demonstrating weakness in the left upper extremity, a new finding that warrants further evaluation.

Clinical reasoning leads the healthcare team to consider the possibility of postoperative complications such as a small bleed or edema, which could contribute to the neurological changes observed. An urgent repeat CT scan is ordered to assess for any acute changes in the intracranial environment. The decision to continue prophylactic antibiotics is reinforced due to the presence of fever, although cultures obtained during surgery have yet to show any growth. Electrolyte levels and blood glucose are checked to rule out metabolic causes for the altered mental status. The team remains cognizant of the potential for shunt malfunction, despite the recent intervention, and prepares to address any findings swiftly.

As the diagnostic results are awaited, the focus remains on stabilizing the child’s condition. Supportive measures continue, including maintaining adequate hydration and monitoring for signs of increased intracranial pressure. The multidisciplinary team discusses the need for potential interventions based on the forthcoming CT results, including possible medical management of intracranial pressure or additional surgical intervention if necessary. Throughout this period, the child’s parents are continuously updated, with reassurance provided regarding the steps being taken and the vigilant care being provided to monitor and address any complications. The team remains committed to ensuring the child's safe recovery and optimal neurological outcome.

Section 4

New Diagnostic Results:

The repeat CT scan results return, revealing mild cerebral edema and a small subdural hematoma on the right side, which likely explains the child's altered mental status and left-sided weakness. The hematoma is not exerting significant midline shift, but its presence in conjunction with edema necessitates careful monitoring and a potential adjustment in the management plan. The neurosurgical team is consulted, and they decide to manage the hematoma conservatively, given its small size and the absence of severe symptoms like significant midline shift or herniation.

The child's laboratory results show stable electrolytes and a normal blood glucose level, ruling out metabolic disturbances. However, the mild tachycardia, elevated blood pressure, and low-grade fever persist, raising concerns about the early signs of increased intracranial pressure (ICP). The healthcare team decides to initiate measures to reduce ICP, including elevating the head of the bed to 30 degrees and ensuring that the child's neck is in a neutral position to promote venous drainage. Additionally, mannitol is considered for use if further signs of increased ICP develop, but the team opts to monitor closely for now.

In response to the new findings, the nursing team intensifies neurological assessments, checking the child's Glasgow Coma Scale (GCS) score every hour and watching for any changes in pupil size or new motor deficits. The family is informed about the CT results, and the healthcare team explains the plan to manage the hematoma conservatively while focusing on reducing cerebral edema. The parents are reassured that the child's condition is being meticulously monitored and that steps are in place to address any changes swiftly. As they await signs of stabilization or improvement, the team remains vigilant, prepared to escalate care if necessary, while continuing to provide emotional support to the family.

Section 5

As the nursing team continues their vigilant monitoring, they observe a subtle but concerning change in the child's condition. Approximately six hours after implementing measures to reduce intracranial pressure, the child's Glasgow Coma Scale (GCS) score drops from 14 to 12, indicating a decrease in responsiveness. The child now opens their eyes only to voice and shows inappropriate verbal responses, although motor responses remain intact. The nurse notes a slight anisocoria, with the right pupil being slightly larger than the left, raising concerns about potential exacerbation of intracranial pressure or evolving neurological injury.

Vital signs reveal persistent mild tachycardia with a heart rate of 110 beats per minute and blood pressure elevated at 130/85 mm Hg. The low-grade fever persists at 38.2°C (100.8°F). Laboratory results return showing a slight increase in white blood cell count, now at 12,000/mm³, which could indicate a stress response or early infection. These findings suggest that despite the conservative management, the child's condition may be deteriorating, prompting the healthcare team to reconsider the intervention plan.

Given the changes in neurological status and vital signs, the team decides to initiate osmotherapy with mannitol to aggressively manage the potential increase in intracranial pressure. Additionally, they plan to repeat the CT scan to assess any changes in the size of the hematoma or cerebral edema. The neurosurgical team is re-engaged to evaluate the need for further intervention. The nursing staff updates the family, explaining the new developments and reinforcing the importance of close monitoring and timely response to any changes. They emphasize the collaborative effort of the multidisciplinary team to ensure the child's safety and recovery, while also providing emotional support to the family during this uncertain time.