Intervention for Hydrocephalus nursing diagnosis Hydrocephalus

Intervention for Hydrocephalus

a) Maintain bed rest with the head flat and monitor vital signs as indicated after the lumbar puncture.
Rationale: Changes in cerebrospinal fluid pressure may be a potential risk of herniation of the brain stem, which requires immediate medical treatment.

b) Monitor / record neurological status, such as GCS.
Rationale: Assessment of trend changes and the potential of increasing the level of awareness of ICT is very useful in determining the location, distribution / extent and progression of cerebral damage.

c) Monitor the frequency / heart rhythm and heart rate.
Rationale: Changes in the frequency, dysrhythmias and heart rate may occur, which reflects brain stem trauma in the absence of underlying heart disease.

d) Monitor breathing, note the pattern, the respiratory rhythm and respiratory frequency.
Rationale: This type of pattern is a sign of heavy breathing from an increase in ICT / cerebral areas affected.
e) Elevate the head of the bed about 15-45 degrees as indicated. Keep the patient’s head remains in neutral position.
Rationale: Increased venous outflow from the head to reduce ICT.
f) Monitor the GDA. Provide oxygen therapy as needed.
Rationale: The occurrence of acidosis may inhibit the entry of oxygen at the cellular level that aggravate cerebral ischemia.

g) Give the medication as indicated.