Case Study On Obstructive Hydrocephalus
Case Study On Obstructive Hydrocephalus
Nilcar Domingo, 6 years old from Barangay Laslasong, Santa Maria, Ilocos
Sur was my client. His case is initially diagnosed as Bacterial Meningitis, PTB,
Typhoid Fever, and Urinary Tract Infection. The final diagnosis of his
obstructive hydrocephalus.
ventricular system prevents the CSF from reaching the arachnoid villi. CSF
head enlargement does not occur in older children and increase in ICP
1
in diagnostic imaging technology allow more accurate diagnoses in individuals
pressure hydrocephalus
• Be able to trace the etiology, how the disease progresses, its clinical
2
PATIENT’s PROFILE
CASE NUMBER:054435
NAME OF PATIENT: Nilcar Domingo
SEX: Male
CITIZENSHIP: Filipino
CATEGORY: Charity
UTI
TIME: 2:30 PM
3
NURSING HISTORY OF PAST AND PRESENT ILLNESS
A. PRESENT ILLNESS
Maria,Ilocos Sur.
Meningitis as revealed in his chart. He was then venoclyzed with D5 0.3 NaCl
solution. He was ordered with complete blood count (CBC) and the results
were normal. Urinalysis was also done to him revealing urinary tract
infection. Several diagnostic procedures like widal’s test was also performed
which revealed thypoid fever. He was started with ampicillin 400 mg TID
mefenamic acid syrup 1 tsp. PRN for headache, paracetamol 120 mg/5 ml
every 4 hours for fever. All those informations were based on the client’s
2005, again a diagnostic procedure was ordered particularly Skull X-ray. The
result was normal. Headache and fever still persist. Ampicillin dosage was
increased to 500 mg every 6 hours. His condition improved and his parents
mother. They rushed him again at Sto. Nino Hospital. He was venoclyzed with
4
mg IV every 8 hours and Diazepam 3 mg IV. He was also connected to O2
Hospital at around 10:15 in the morning. Same IVF was maintained and some
drugs by his doctor were INH 200 mg/5 ml OD, PZA 250 mg/5 ml OD, RIF
200 mg/ 5 ml, 5.5ml OD, Phenobarbital 30 mg ½ tablet BID, Hexatidine oral
Diazepam 3.2 mg IVF and Ampicillin 800 mg IV every 6 hours ANST (-).
Skull/head scan, lumbar puncture or CSF analysis and widal’s test (Refer
B. PAST ILLNESS
Nilcar’s mother verbalized that her son was very sickly during his
early childhood years. She added that Nilcar was diagnosed with primary
taken fore granted and was managed with plain analgesic 8paracetamol for
admitted that she couldn’t give Nilcar a good nutrition because of the fact
that they belong family below poverty level. Nilcar’s mother also verbalized
that they don’t have a family history of the disease and believes that the
5
PEA/RSON ASSESSMENT
(February 25,2005)
6
the stool is normal
(formed to semi
formed).
7
• Respiratory rate of
40 cycles per minute
was noted (not
consistent)
PR: 150 bpm
T: 37.4-37.8oC.
• Prefers semi-fowlers
position.
8
DIAGNOSTIC PROCEDURES
A. THEORY
successive layers.
2. VENTRICULOGRAPHY
cerebrospinal fluid.
cells.
5. LUMBAR PUNCTURE
9
6. CEREBROSPINAL FLUID ANALYSIS
NORMAL RESULTS:
Chloride: 120-130mEq/L
10
B. ACTUAL
1. LIVER FUNCTION
Function is generally
measured in terms of
enzyme activity and serum
concentrations of
proteins, bilirubin,
ammonia, clotting factors
and lipids. However, the
nature and extent of
hepatic dysfunction
cannot be determined by
these tests alone.
11
TRANSAMINASE the course of hepatitis or to the watcher.
stomatitis.
test as indicated.
12
drugs. of the test.
2.CEREBROSPINAL
FLUID ANALYSIS (CSF
ANALYSIS)
01-10-2006
• Usually specimens are
obtained for cell count,
culture, glucose and
protein testing.
• Explain the
CSF
Slightly xanthochromatic Clear and colorless • A deviation in color of significance of the
COLOR/APPEARANCE
the CSF from clear to procedure to the
indicates an patient.
13
meningitis.
Patient is positioned
14
there is acute
meningitis or
hemorrhage.
• Normal
TOTAL PROTEIN
3.URINALYSIS
12-30-2005
• Explain the purpose of
15
5.0 4-6 taken by the client. specimen. It should be
midstream urine.
negative negative
• Normal
PH
1.030 1.010-1.025
ALBUMIN
• Normal
SPECIFIC GRAVITY
1-2 1-2 • Signifies concentrated
RBC • Normal
16
• Fine streaky infiltrates • The lungs should be
cardiomegaly. machine.
procedure is painless.
17
5.COMPUTERIZED • Multiple plain and • CT scanning should
AXIAL TOMOGRAPHY
contrast enhanced reveal no dilatation of
(01-05-2006)
axial slices of the head the ventricles, no • Explain the purpose of
• CT scanning is non
demonstrates lesions or abscess and • Results showed that the procedure to the
invasive and painless
and has a high degree dilatation of the there should be no Obstructive nearest kin.
of sensitivity for
lateral and 3rd signs of IICP. hydrocephalus • Instruct client to lie
detecting lesions.
ventricles but normal probably secondary to quietly throughout the
18
• The posterior fossa successful study.
pressure
19
ANATOMY AND PHYSIOLOGY OF THE ORGAN INVOLVED
occupying the anterior and middle cranial fossae in the skull and
20
cardiovascular systems.
The Cerebellum overlies the pons and medulla, extending beneath the
Gray (grey) matter: almost all neuron cell bodies and axons
21
astrocytes: star-shaped with heavy metal impregnation; most
environment in CNS
mater)
to neurolemmocytes in nerves
phagocytic cells
myelinated
22
myelinated nerve fibers: increased velocity of action potential; ÎMyelin
sheath formation begins in the CNS of the human embryo at about 4 months
about the age of one year. From this time, successive layers continue to be
laid down with final myelin sheath thickness being achieved by the time of
physical maturity.â
Meninges
Pons: middle portion brain stem; btwn midbrain and medulla; two parts in
23
molecular layer contains few neurons and lg number unmyelinated fibers;
piriform (pear shaped) cells = Purkinge cells; fine axon extends downward
superficial part granular cell layer (more like deep part molecular layer)
cerebral peduncles into dorsal and ventral parts; easily recognized by black
24
A.ALGORITHM
CAUSES
Obstruction of CSF flow
Congenital malformation
Secondary to injury
Infection*
Ductal stenosis*
Radiologic
Vomiting*
Gradual thinning of the brain substance studies*
Full
fontanelle
CSF analysis*
Papilledema
Decreased
Blood
pulse* SIGNS AND SYMPTOMS
chemistry*
Anorexia*
CT scan*
Convulsion*
* Note: inputs with asterisk were observed to the patient to the patient.
25
B. EXPLANATION
obstruction in the ventricular system prevents the CSF from reaching the
organisms replicate and undergo lysis in the CSF releasing endotoxins or cell
mediators, which set the stage for a complete but coordinated sequence of
diagnostic procedures.
26
MANAGEMENT
secretion of CSF and its absorption. If it does not, treatment is carried out
drug that reduces the production of cerebrospinal fluid. But since the cause
accumulation of CSF in the brain. In cases in which a decision has been made
• Removal of obstruction
27
shunt is an artificial device, made mostly of plastic (although some parts may
one-way valve that allows the unidirectional flow of CSF out of the brain, and
a distal catheter that drains the CSF to an extra cranial location in the
body. The most preferred distal site remains the peritoneum, although, for
difficult cases with other coexisting abdominal problems, other options are
available, such as the right atrium, the gall bladder, the ureter, or the
ventriculoperitoneal.
28
NURSING CARE PLAN
S>”Nasakit kanu ti P> Acute pain risk for Pain is 01-22-06 INDEPENDENT: 01-22-06
considered an
ulo na ken maulaw E> related to increase Within the • Monitor vital • Vital signs are Level of
unpleasant sensory
shift with proper signs. general attainment: goal
ulaw suna nga IICP, tissue and nerve perception and
medical and indicators of partially met
emotional
tumakder idi damu trauma. nursing circulatory
experience
management, the status and AEB: Pain
na nga marikna toy S> as evidenced by associated with
patient will adequacy of experienced by
actual or potential
sakit na adding” as changes in sleep verbalize perfusion. the patient is
tissue damage.
decrease pain reduced from
verbalized by the patterns. Acute pain lasts
from 4 to at least • Document • Aids in severe to mild.
for a relatively
mother. > Dizziness 1 using the Wong location and evaluating need
short period of
baker Faces scale intensity of for and
O> Pain rating > Headache (on and time and remits as
0-5, 5 being the pain (0-5) and effectiveness
the pathology
scale using the off) highest. investigate of
29
Wong baker faces resolves. Pain could changes in pain interventions.
be attributed to characteristics. Changes may
rating scale
IICP because as indicate
reveals that the the pressure developing
increases in the complications.
level of pain is
cranial vault, there
grade 4(It hurts a is no other way to • Proper • With this kind
release the positioning of position,
whole lot more).
pressure; as a (semi-fowlers). pressure will
> The patient result there is be lessened
compression of because it
looks weak.
nerves and the prevents the
> Dizzy brain itself congestion of
(Medical Surgical blood in the
> On and Off
Nursing 6th ed.) head region.
headache
• Avoid coughing • Coughing or
or straining. straining will
further
increase ICP.
30
COLLABORATIVE:
• Administer • Analgesics
medications as relieve pain by
ordered e.g. blocking the
analgesics and pain impulses
antibiotics. at the pain
receptor sites.
• Refer to the • By referring to
physician the physician,
regarding the he may order
pain an appropriate
experienced by diagnostic
the client for procedure to
further determine the
diagnosis. cause of the
pain.
31
P> Injury risk for 01-22-2006 INDEPENDENT: 01-22-2006
Causes Within my
E> r/t muscle weakness,
Presence of health shift, the mother • Provide safe • Safe room Level of
dizziness and convulsion threats will be able to environment or environment attainment: Goal
Dizziness acquire knowledge room for the helps eliminate met.
or seizure.
Seizure regarding the client the risk for
S> as evidenced by (not consequences of injury. AEB: The
Body is lacking of falling and injury • Advise the • Bedside rails mother
applicable, presence of
energy to sustain with proper mother to raise may help understands the
signs and symptoms body’s needs health teachings. the bedside prevent the health teachings
rails during patient from regarding the
establishes an actual
seizure falling from risk of injury to
diagnosis. Body weakness the bed. the patient.
• Observe signs • Assessing the
Risk for falling of seizure time and
disorders correct
Possible symptoms of
consequences like seizure may
injury help in the
(med surge Nsg.6th diagnosis of
ed) what kind of
seizure
disorder that
the client had.
32
COLLABORATIVE:
33
contraindicated
to the patient.
34
• Mental • Encourage small • Small frequent
retardation frequent feeding may
(Medical feeding. help to
Surgical decrease
Nursing 6th ed.) gastric motility
because a full
stomach
excites to
digest the
contents thus
less hyper
motility.
35
COLLABORATIVE:
• Administer • Anti-emetic
anti- emetics as drugs works by
ordered if reducing the
vomiting and hyperactivity
nausea persist. of the vomiting
36
reflex.
37
membrane space losses.(Med will be skin turgor is
& Surge Nursing replenished. moderately
> Decreased skin
6th ed). improved. Level
turgor. • Monitor I & O • Sustained of hydration also
diuresis could improved.
> Weakness
cause patients
total fluid
volume to
become
depleted.
COLLABORATIVE:
38
shift causing
hyponatremia.
S> “Manipud idi P> Fear/anxiety
Anxiety is 01-24-2006 INDEPENDENT: 01-24-2006
naospital isuna ket E> R/T changes in emotional illness
characterized by Within the • Establish • Demonstrates Level of
managbut buteng health status,
fear, autonomic shift, the patient trusting concern and attainment:
met isunan, no possibility of surgical neuron system will be able to relationship to willingness to Goal partially
symptoms and demonstrate the patient. help the client. met.
kuma adda procedures and
avoidance behavior appropriate range Encourages
umasideg kenyana embarrassment. (ABC’s of of feelings and discussion of
Psychiatric lessened fear or sensitive AEB: The
nga saan na nga S> as evidenced by fear
Nursing, Ray A. the anxiety will subjects. patient still
am-ammu ket of non-specific Gapuz). be reduced to a manifest fear
manageable level • Explain to the • Helps patient although it is
agkumot suna ti consequences.
client whatever understand reduced to
ules” as verbalized procedure will purpose of almost
be done and what is being manageable
by the mother.
demonstrate done and level.
first with a reduces
doll. concerns
O> Fear
associated
> Anxiety with the
unknown.
> Prefers to be
alone. COLLABORATIVE:
39
• This could help
• Informing the the physician
physician about to decide
the whether he will
fear/anxiety refer the
experienced by patient to a
the patient. specialist in
psychiatry.
40
(Medical Surgical
Nursing, 6th ed.) • Explain the • For the faster
importance of recovery of
treatment the patient.
regimen.
COLLABORATIVE:
41
PROMOTIVE AND PREVENTIVE MANAGEMENT
PROMOTIVE
provided.
nutrition.
PREVENTIVE
kind disease.
hydrocephalus).
42
DRUG STUDY
Isonicotinic acid 200 mg/5 Unknown. Appears Actively growing Contraindicated to Seizures, optic • Always give isoniazid
hydrozide ml 5.5 OD to inhibit cell wall tubercle bacilli. patients with acute neuritis, hepatitis, with other
Isoniazide (INH) PO biosynthesis by hepatic disease or hemolytic anemia, antituberculotics to
interfering lipid isoniazid liver damage. jaundice. prevent development
and DNA of resistant
synthesis. organisms.
Bactericidal. • Explain the action of
the drug to the
watcher.
• Instruct client or
the watcher to take
drug exactly as
prescribed.
Pyrazinamide 250 mg/5 Unknown. Adjunct Contraindicated to Anorexia, nausea,
ml 9 ml OD Bactericidal treatment of patients hypersensitive vomiting, dysuria, • Tell the watcher
PO tuberculosis to drug and in those hyperuricemia, rash that the drug may
(Primary with hepatic disease. urticaria, pruritus. change the color of
complex). the urine, feces or
43
sputum or saliva.
44
transmission in porphyria. about the mechanism
the CNS and of action of the
increases the drug.
threshold for
seizure activity in
motor reflex.
Mannitol 40 ml every An osmotic Reduction of Contraindicated to Seizures, dizziness, • Monitor vital signs
8 hours IV diuretic that intraocular or patients hypersensitive hypotension, heart including fluid intake
increases the intracranial to drug and in those failure, tachycardia, and output. Instruct
osmotic pressure pressure. with anuria, severe blurred vision, dry client that he may
of glomerular dehydration and mouth, nausea and feel thirsty.
filtrate inhibiting metabolic edema. vomiting. • Instruct the watcher
tubular to report adverse
reabsorption of reactions and
water and discomfort at IV
electrolytes. site. Instruct also
the client.
45
GABA.Depresses rash, urine abruptly stop drug
CNS at the limbic retention. because withdrawal
system and sub symptoms may occur.
cortical levels of
the brain and
suppresses the
spread of seizure
activity.
46
PATIENT DISCHARGE INSTRUCTION SHEET
A. DIET
47
DIETARY INSTRUCTIONS:
1. The patient can eat all he wishes as long as he can tolerate those foods.
3. High fiber, high calorie and high protein diet is preferred for faster recovery of the patient.
NAME OF DOSAGE AND TIME FREQUENCY DURATION SIDE EFFECTS WHAT TO DO MEDICATIONS AND
AVOIDED
48
200 mg/5ml 3ml PO
Rifampicin • Anti Once a day 2 months • Avoid acetaminophen,
tuberculotic 8 am Headache, • Give 1 hour analgesics,
drug. drowsiness, before or 2 anticonvulsants, beta
generalized hours after blockers,chlorampheni
numbness, meals for col, diazepam,
anorexia, optimal narcotics.
nausea, absorption • No food is
vomiting, acute contraindicated.
renal failure,
hyperuricemia,
Isoniazid 200 mg/5 ml 3ml 8 am Once a day 2 months Peripheral • Instruct • Contraindicated with
PO neuropathy, the parents antacids, laxatives,
• Antituberculotic memory to give meperidine,
drug impairment, meds as anticonvulsants,
optic neuritis, prescribed phenytoin, disulfiram.
nausea,
vomiting, • Advise the • Foods containing
hyperglycemia. mother to Tyramine
give the
drug 1 hour
before or 2
hours after
49
meals.
• Tell the
mother or
the patient
to report
adverse
reactions.
Pyrazinamide 250 mg/5ml 6.5 ml 8 am Once a day 2 months Malaise, • Use • None
PO anorexia, cautiously
• Anti nausea, in patients
tuberculotic vomiting, with DM.
drug dysuria,
hyperuricemia,
rashes and
urticaria
50
leukopenia, and amonoglycosides.
apnea, sensitivity
anaphylaxis test before
giving the
first dose.
• Watch out
for signs
and
symptoms
of
superinfecti
on.
51
children
D. SPECIAL CARE INSTRUCTIONS
1. Body weakness
2. Seizure
3. Vertigo
4. Nausea and vomiting
5. Productive cough
52
E. FOLLOW UP CARE
Gabriela Silang General Hospital, February 10, 2006 Dr. Jean T. Mahor • Continue medications as
OPD prescribed.
• Increase fluid intake
• Socialize with other children.
________________________________________ ________________________________________
SIGNATURE OF PARENT/S OVER PRINTED NAME SIGNATURE OF STUDENT OVER PRINTED NAME
____________________________________
DATE AND TIME
53
SUMMARY AND COPY OF UPDATES
fluid in the brain. Although hydrocephalus was once known as "water on the
surrounding the brain and spinal cord. The excessive accumulation of CSF
This dilation causes potentially harmful pressure on the tissues of the brain.
narrow pathways. 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 is absorbed into
the bloodstream.
vehicle for delivering nutrients to the brain and removing waste; and 3) to
which will inhibit its normal flow. When this balance is disturbed,
54
BIBLIOGRAPHY
BOOKS:
2009
INTERNET:
www.yahoo.com
www.google.com
55
APPENDICES
56
DOCUMENTATIONS
HOME VISIT
57