Maternal Child- Pediatrics Hydrocephalus Case Study PDF

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ATI Maternal child- Pediatric hydrocephalus case study including ventriculoperitoneal shunt or VP shunt on a two month old infant....

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Maternal Child Pediatrics Hydrocephalus Case Study Scenario: You admit L.M., a 2-month-old girl with a history of hydrocephalus and a ventriculoperitoneal (VP) Shunt placement 1 month earlier. Her parents report that she has been more irritable than usual and for the past 3 days has had emesis 5 or 6 times a day. 1. What is the pathophysiology of hydrocephalus? Hydrocephalus is a condition caused by an imbalance in the production and absorption of CSF in the ventricular system. Any imbalance of secretion and absorption causes an increased accumulation of CSF in the ventricles. This causes the ventricles to become dilated, which is called ventriculomegaly, they then compress the brain substance against the cranium. When this happens before the cranial sutures fuse it causes dilation of the ventricles and enlargement of the skull. In kids under 12 that have had their suture lines closed the pressure can cause the suture lines to reopen called diastatic. After 12 the sutures will not reopen. There are different causes of hydrocephalus. The following are the results of hydrocephalus: (1) Impaired absorption of Cerebral Spinal Fluid (CSF) within the subarachnoid space, obliteration of the subarachnoid cisterns, or malfunction of the arachnoid villi. (2) Obstruction to the flow of CSF through the ventricular system. 2. How does a VP shunt help patients with hydrocephalus? A VP shunt drains the CSF from the ventricles to an extracranial compartment, usually the peritoneum. Case Study Progression: L.M.’s vital signs are 111/70, 182, 55, 38.8°C, Sao2 95% on room air. Her head appears large, the fontanel is slightly bulging, and pupils are equal and reactive. The occipital frontal circumference (OFC) is 44 cm, and her mother tells you that is 2 cm more than when she measured yesterday. Baby L.M. is awake, irritable, and fussy throughout your assessment. She has emesis, although her father tells you that she has not eaten for 5 hours while they were in the emergency department. Breath sounds are clear, pulses are 2+ and equal bilaterally, and capillary refill time is less than 2 sec. 3. Which of the vital signs and assessments are abnormal, and what are their possible causes?

The abnormal vitals are HR 182, RR 182, T 38.8°, BP 111/70. Abnormal assessment findings are bulging fontanel, occipital frontal circumference 44 cm, and emesis even though she has not eaten for 5 hours. 4. In infants, why does the OFC increase when the pressure increases in the cranial vault? Since the sutures are not fused the skull is able to expand due to the pressure of the accumulation of the CSF. 5. The doctors order a CT scan and lumbar puncture with a cell count, culture, Gram Stain, glucose, and protein run on the cerebrospinal fluid. What is the rationale for each procedure? Brain CT scans can provide more detailed information about brain tissue and brain structures than standard X-rays of the head. It can tell if there is any kind of obstruction in the VP shunt. The lumbar puncture would identify if the child has meningitis. The CBC would identify if there is an increase in WBC, specifically bands which would indicate infection. The culture would identify what kind of infection is going on in the child. The Gram Stain would identify if the bacteria is gram negative or gram positive. And whether we would use a broad-spectrum antibiotic or narrow spectrum antibiotic. If glucose levels are low, it may indicate bacterial meningitis, cryptococcal meningitis, malignant involvement of the meninges or sarcoidosis. Checking protein level on CSF is done because normally there is very little in the CSF. If there is an elevation in protein levels it could be caused by a brain tumor, subdural hematoma, viral meningitis, or cerebral thrombosis. 6. L.M. is taken to surgery to have an extraventricular drain (EVD) placed. What categories of medications might you expect the physicians to order postoperatively? Give the rationale for each category. If a VP shunt is removed and an EVD is placed that means that there is an infection going on and the EVD is used until CSF is sterile again. Knowing that the child should be placed on an antibiotic. She may also be given antipyretic medications to reduce her fever, antiemetic medications for nausea and vomiting. 7. What should you teach the parents about the EVD? An EVD is a tube that is inserted into the brain to drain excess CSF. It flows by gravity into a collection container. Since it flows by gravity the height of the drain will be adjusted every time your child changes positions. Alert your nurse immediately if your child changes position (sits up or lies down), or if you want to pick your child up. The nurse will have to clamp the drain, adjust your child's position, adjust the height of the drain then unclamp the drain so that it continues to flow properly. Never change the height of the drain without your nurses help.

8. Two days after the EVD is placed, L.M.’s father tells you that h is feeling discouraged because this is likely the first of many admissions due to shunt malfunctions. He states that he talked to some parents of a child with hydrocephalus who was admitted 14 times by the time he was 2 years old. How would you respond to this father’s feelings? I understand that it is discouraging to hear that. But not everyone's situation is the same. There may have been other things going on with that child that may not be going on with yours. This may be the first of many admissions for your child, hopefully not, but it would be for your child's best interest and safety. 9. Later that day, Mrs. M. is changing L.M.’s diaper, and she tells you that she is worried because L.M. has started having diarrhea recently and it is getting worse. Based on the medications that the patient is getting, what is the most likely cause of the diarrhea? What is a possible concern you should consider, and what should your care plan include? Antibiotics can cause diarrhea. One concern would be dehydration leading to fluid and electrolyte imbalances. We should assess the patient's hydration status. Monitor I&O’s, assess mucous membranes, daily weights, IV fluids as ordered, assess the child's skin for any redness or break down, apply barrier creams to prevent breakdown, monitor labs for electrolyte imbalances, check the patient every 30 minutes to an hour for a soiled diaper....