The most common operations that children with hydrocephalus undergo are shunt placement, shunt revision, and endoscopic third ventriculostomy. Because these children frequently have other diseases related to the hydrocephalus they often undergo other surgeries to treat a multitude of other problems.
Neurological Assessment
The assessment must occur in a developmentally appropriate manner. The nurse must also consider what is developmentally appropriate behavior for the infant or child, based upon his age. It is vital to also consider the individual child and his baseline. Many conditions related to hydrocephalus are also associated with significant delays, and because complications of hydrocephalus may worsen such delays, these children have a wide range of developmental abnormalities. A detailed history of developmental skill and baseline function is a vital part of being able to assess the infant/child.
The assessment must occur in a developmentally appropriate manner. The nurse must also consider what is developmentally appropriate behavior for the infant or child, based upon his age. It is vital to also consider the individual child and his baseline. Many conditions related to hydrocephalus are also associated with significant delays, and because complications of hydrocephalus may worsen such delays, these children have a wide range of developmental abnormalities. A detailed history of developmental skill and baseline function is a vital part of being able to assess the infant/child.
Parents and families are an excellent resource to provide information about their particular child’s developmental level. The signs and symptoms of increasing intracranial pressure may initially be very subtle. Hence, the child’s caretaker is a valuable resource in such assessment and may notice subtle changes before nursing and medical staff.
Neurological assessment of the child after surgery to treat the hydrocephalus needs to be done frequently. The surgeon will usually specify the frequency, but assessment should occur every 1–4 h, depending on the condition of the child. An exam that is changing subtly over time may be an indication of a failed surgical treatment or postoperative complication. The first signs of increasing intracranial pressure are usually subtle and related to mildly increasing somnolence, lack of interest in activities (feeding) or play, and subtle behavioral changes. Level of consciousness is the most important single indicator of neurological status. Altered level of consciousness may progress to confusion, disorientation, somnolence, lethargy, obtundation, stupor, and coma.
A thorough neurological assessment starts with watching the child play and interact with those around him. Assessment also includes asking the child if he has a headache. The child should be examined for his ability to answer questions appropriately and follow directions. Asking a child to move his arms and legs will also allow the examiner to assess muscle strength, tone, and movement. Vital signs should also be assessed. Bradycardia can be a sign of increased intracranial pressure. Increased blood pressure is usually not a common finding in children until late in the process of increasing intracranial pressure.
It is important to carefully examine the eyes, noting that checking pupils without further exam is never an adequate exam. The pupils are checked for equality, roundness, and reactivity to light. Dilated and nonreactive pupils are a very late sign of increased intracranial pressure. A “sun-setting” appearance to the eyes or the loss of upward gaze is an abnormal finding. The extraocular movements should be intact.
The infant’s head should be examined. The occipital frontal circumference should be measured and documented on a daily basis to determine appropriate head growth. The fontanels should be palpated with the child upright and calm. The anterior fontanel should feel soft and pulsatile. A tense or bulging fontanel is suspicious for increased intracranial pressure. The suture lines of the skull should also be examined. Normal suture lines are palpable and apposed. If they are overriding, the infant may have overdrainage of the system. If the sutures are splayed there is likely increased intracranial pressure.
Wound and Dressing Care
The child will usually come from the operating room with a dressing over the incision. The dressing is normally removed, or changed, during the first few postoperative days. If a dressing is soiled or saturated with blood, most surgeons agree that it should be replaced. If the child is likely to pick at the incision, a dressing may be left on to prevent infection. Before a child goes home, most surgeons agree the dressing should be changed and the wound inspected for any erythema, drainage, swelling, or infection.
The child will usually come from the operating room with a dressing over the incision. The dressing is normally removed, or changed, during the first few postoperative days. If a dressing is soiled or saturated with blood, most surgeons agree that it should be replaced. If the child is likely to pick at the incision, a dressing may be left on to prevent infection. Before a child goes home, most surgeons agree the dressing should be changed and the wound inspected for any erythema, drainage, swelling, or infection.
Medications
A substantial majority of neurosurgeons will order intravenous antibiotics for 24–48 h after the surgery to prevent shunt infection. Cefazolin or nafcillin are the most commonly used antibiotics, as Gram-positive organisms demonstrate a sensitivity to them. Vancomycin may also be used.
A substantial majority of neurosurgeons will order intravenous antibiotics for 24–48 h after the surgery to prevent shunt infection. Cefazolin or nafcillin are the most commonly used antibiotics, as Gram-positive organisms demonstrate a sensitivity to them. Vancomycin may also be used.
Pain management starts with good pain assessment. Age-appropriate pain assessment scales such as CRIES (crying, requires increased oxygen administration, increased vital signs, expression, sleeplessness), the Objective Pain Scale, and Oucher may be used. There is a wide variety of pain experienced by children after surgery for hydrocephalus. Pain may be related to the cranial incision(s), the abdominal incision, the amount of intra-abdominal manipulation, and the tunneling of the distal catheter through the subcutaneous tissue. Other factors influencing pain may include the age of the child, the child and/or family’s prior experience with pain, and the child and family’s anxiety. Pain is usually managed with medications, although other techniques may be helpful. The first drug of choice is usually acetaminophen. It should be adequately dosed at 15 mg/kg/dose and can be given orally or rectally. Nonsteriodal anti-inflammatory drugs (NSAIDS) may be used, but they can inhibit platelet aggregation and prolong bleeding time. For this reason, some neurosurgeons do not use NSAIDS during the immediate postoperative period.
If the child needs additional medication for pain, the surgeon’s beliefs about pain control in neurosurgical patients will be a factor. Some neurosurgeons will order opiates such as morphine sulfate, oxycodone, and codeine. Other surgeons do not want to alter the patient’s neurological exam with these drugs. The nurse should not administer these drugs if there is concern that the pain is due to increasing intracranial pressure or the neurological exam is changing. Other modalities to relieve pain may include age-appropriate relaxation techniques, play therapy, music therapy, massage, distraction, and acupuncture or acupressure.
No comments:
Post a Comment