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NURSING CARE PLAN
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Hydrocephalus is INDEPENDENT:
SUBJECTIVE: Ineffective characterized by an • After 8 hours • Monitor • Fever may • After 8 hours of
cerebral tissue abnormal increase in of nursing temperature. reflect damage nursing
“Napansin ko na perfusion related cerebrospinal fluid interventions, Administer tepid to interventions,
hindi normal ang to decreased (CSF) volume within the patient will sponge bath in hypothalamus. the patient was
laki ng ulo ng arterial or venous the intracranial demonstrate presence of Increased able to
anak ko” (My blood flow. cavity and by improved vital fever. metabolic demonstrate
son’s head is enlargement of the needs and improved vital
signs and
as
abnormally large) head in infancy. absence of oxygen signs and
verbalized by the Pressure from signs of consumption absence of
mother. increased fluid increased ICP. occur signs of
volume can damage (especially with increased ICP.
OBJECTIVE: the brain tissue. fever and
Hydrocephalus shivering),
• Restlessness results from two which can
• Irritability major causes: further
• Changes in obstruction of CSF increased ICP.
vital signs flow
• V/S taken as (noncommunicating
follows: hydrocephalus) or • Monitor Intake • Useful
faulty CSF and output. indicators of
T: 37.5 absorption or Weigh as body water,
P: 90 overproduction of indicated. Note which is an
R: 22 CSF (communicating skin turgor, integral part of
hydrocephalus). In status, and tissue
the mucous perfusion.
noncommunicating membrane.
type, obstruction
may result from • Maintain head or • Turning bed to
congenital defects, neck in midline or one side
infections, trauma, in neutral compresses
spontaneous position, support the jugular
intracranial bleeding, with small towel veins and
and neoplasms. In rolls and pillows. inhibits
the communicating Avoid placing cerebral
type, faulty CSF head on large venous
absorption may pillows. drainage that
result from may cause
Nursingcrib.com – Student Nurses’ Community
meningeal increased ICP.
adhesions or
excessive production • Provides rest • Continual
of CSF fluid caused periods between activity can
by a tumor or from care of activities increase ICP
unknown causes. and limit duration by producing a
Complications of of procedures. cumulative
hydrocephalus stimulant
includes seizures, effect.
spontaneous arrest
due to natural
compensatory • Decrease • Provides
mechanisms, extraneous calming effect,
persistent increased stimuli and reduces
intracranial pressure provide comfort adverse
(ICP), brain measures such physiological
herniation, as back response, and
developmental massage, quiet promotes rest.
delays. environment,
gentle touch.

• Help patient • These


avoid or limit activities
coughing, crying, increase
vomiting, and intrathoracic
straining at stool. and intra-
Reposition the abdominal
patient slowly. pressure.

• Elevate the head • Promotes


of bed gradually venous
to 15-30 degrees drainage from
as tolerated or head, reducing
indicated. cerebral
congestion and
edema and
increased ICP.
Nursingcrib.com – Student Nurses’ Community
COLLABORATIVE:
• Administer • Diuretics may
diuretics as be used in
indicated. acute phase to
draw water
from brain
cells, reducing
cerebral
edema and
ICP.

• Administer • Reduces
supplemental hypoxemia,
oxygen as which may
indicated. increase
cerebral
vasodilation
and blood
volume.