Ineffective Cerebral Tissue Perfusion Nursing Care Plan for Hydrocephalus

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Ineffective Cerebral Tissue Perfusion Nursing Care Plan for Hydrocephalus

Hydrocephalus

Hydrocephalus is a condition wherein there is an interruption to the normal flow, absorption, and production of the brain's CSF (Cerebrospinal Fluid), which is the medium that carries all the nutrients needed by the brain to remain healthy and fully-functional. If there's an interruption or overproduction of CSF - such as in hydrocephalus - it will build up inside the brain that is shown through the swelling of a child's or adult's skull.


Hydrocephalus of one kind or another is especially prevalent at the two extremes of the life cycle -- in the very young and the very old -- but can occur at any age. In infancy, hydrocephalus can be caused by malformed brain-tissue. In contrast, adults with hydrocephalus were usually born with normal brain anatomy, but acquired a blockage due to a tumor, injury, bleed or infection. However, many cases of hydrocephalus in adults occur without a history of these preceding illnesses.

All of these ventricles, passageways, and spaces are filled with a special fluid called cerebrospinal fluid (CSF). This fluid is constantly moving. It begins in one of the ventricles. Located inside each of the four ventricles is a structure called a choroid plexus. An essential component of the choroid plexus is a compact network of blood capillaries. The function of the choroid plexus is to remove fluid from the blood inside the capillaries and place that fluid inside the ventricle. Once the fluid is inside the ventricle, it is called cerebrospinal fluid.


Nursing Diagnosis Nursing Care Plan for Hydrocephalus

Ineffective cerebral tissue perfusion related to increased volume of cerebrospinal fluid

NOC: Circulation Status

Expected outcomes NOC

1. Indicates the status of circulation, characterized by the following indicators:
   • Systolic and diastolic blood pressure in the range expected
   • No orthostatic hypotension
   • No noisy large blood vessels
2. Demonstrate cognitive abilities, characterized by indicators:
   • Communicate clearly and in accordance with the age and ability
   • Show attention, concentration and orientation
   • Demonstrate long-term memory and is currently
   • Process information
   • Making the right decision

NIC interventions

Monitor the following matters :

• Vital signs
• Headache
• Level of awareness and orientation
• Nystagmus diplopia, blurred vision, visual acuity
• Monitoring ICT
  • Monitoring of ICT and the patient's neurological response to maintenance activities
  • Monitor the pressure of tissue perfusion
  • Note the change in the patient in response to stimulus

1. Management of peripheral sensation
   • Monitor the presence of paresthesias: a sense of numbness or tingling
   • Monitor the status of fluid intake and output including
2. Collaborative activity
   
   • Keep the thermodynamic parameters within the recommended range
   • Give the drugs to increase intravascular volume, as requested
   • Give the drug which causes hypertension to maintain cerebral perfusion pressure according to demand
   • Elevate the head of the bed 0 to 45 degrees, depending on the patient's condition and medical demands
   • Give loap and osmotic diuretics, according to demand.

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