Clinical Manifestations: 1. Abnormal rate of head growth 2. Bulging fontanelle 3.

Tense anterior fontanelle (often bulging and nonpulsatile) 4. Dilated scalp veins 5. Macewens sign (cracked pot) 6. Frontal bossing 7. Setting sun sign 8. Sluggish and unequal pupils 9. Irritability and lethargy with varying LOC 10. Abnormal infantile reflexes 11. Possible cranial nerve damage Manifestations in children include possible signs of increased ICP, which include headache on awakening with improvement following emesis, papilledema, strabismus, ataxia, irritability, lethargy, apathy and confusion. Laboratory and Diagnostic Study Findings: 1. Level II ultrasonography of the fetus will allow a prenatal diagnosis. (Transuterine placement of ventriculoamniotic shunts during late pregnancy is still being developed as a treatment modality). 2. CT scan will diagnose most cases postnatally. 3. MRI can be used if a complex lesion is suspected. Nursing Management: 1. Teach the family about the management required for the disorder a. Treatment is surgical by direct removal of an obstruction and insertion of shunt to provide primary drainage of the CSF to an extracranial compartment, usually peritoneum (ventriculoperitoneal shunt) 1. The major complications of shunts are infections and malfunction 2. Other complications include subdural hematoma caused by a too rapid reduction of CSF, peritonitis, abdominal abscess, perforation of organs, fistulas, hernias and ileus. b. A third ventriculostomy is a new nonshunting procedure used to treat children with hydrocephalus. 2. Provide preoperative nursing care a. Assess head circumference, fontanelles, cranial sutures, and LOC; check also for irritability, altered feeding habits and a high-pitched cry. b. Firmly support the head and neck when holding the child. c. Provide skin care for the head to prevent breakdown. d. Give small, frequent feedings to decrease the risk of vomiting. e. Encourage parental-newborn bonding. 3. Provide Postoperative nursing care (nursing interventions are the same as those for increased ICP) a. Assess for signs of increased ICP and check the following; head circumference (daily), anterior fontanelle for size and fullness and behavior.

b. Administer prescribed medications which may include antibiotics to prevent infection and analgesics for pain. c. Provide shunt care 1. 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. 2. Prevent infection (usually from Staphylococcus epidermis or Staphylococcus aureus) 3. 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. 4. Teach home care a. Encourage the child to participate in age-appropriate activities as tolerated. Encourage the parents to provide as normal lifestyle as possible. Remind both the child and parents that contact sports are prohibited. b. Explain how to recognize signs and symptoms of increased ICP. Subtle signs include changes in school performance, intermittent headache, and mild behavior changes. c. Arrange for the child to have frequent developmental screenings and routine medical checkups. Hydrocephalus is a condition caused by an imbalance in the production and absorption of CSF in the ventricular system. When production exceeds absorption, CSF accumulates, usually under pressure, producing dilation of the ventricles. It is a term derived from the Greek words hydro meaning water, and cephalus meaning head, and this condition is sometimes known as water on the brain. People with hydrocephalus have abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles, or cavities, of the brain. This may cause increased intracranial pressure inside the skull and progressive enlargement of the head, convulsion, and mental disability. Usually, hydrocephalus does not cause any intellectual disability if recognized and properly treated. A massive degree of hydrocephalus rarely exists in typically functioning people, though such a rarity may occur if onset is gradual rather than sudden.

Shunts
The treatment of hydrocephalus generally focuses on remedying CSF overproduction or diverting CSF buildup away from the head by way of surgically placed tubes called shunts. Though effective, shunts require invasive open surgery with incisions in both the scalp and abdomen, and shunts are occasionally associated with serious complications, including infection, over-drainage, and shunt malfunction. For these reasons, hydrocephalus patients with shunts need to be regularly seen by a specialized physician to ensure proper shunt function.

Minimally Invasive Approach

A modern minimally invasive alternative to the shunt is the endoscopic third ventriculostomy (ETV). In this procedure, an endoscope is introduced through a small hole in the skull into the third ventricle of the brain where a perforation is made in a membrane to restore normal flow of CSF. The entire procedure is performed using video guidance, and no device or hardware is implanted in the body. Therefore, if successful, no revisions or replacements are necessary, and subsequent hospitalizations are markedly reduced. Though not all hydrocephalus patients are eligible, approximately 70-80% of properly selected patients are successfully treated by ETV.