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Nursing Guide to Hydrocephalus: Nursing Diagnosis, Interventions, & Care Plans

Updated On 8 Minute Read

Hydrocephalus Etiology and Epidemiology

Hydrocephalus is caused by an accumulation of too much cerebrospinal fluid (CSF) on the brain, which can increase intracranial pressure (ICP). Hydrocephalus can occur at any age; however, infants and older adults over the age of 60 are most affected (Mayo Clinic Staff, n.d.). 

Congenital hydrocephalus is common in infants, occurring in about every 1 in 500 children (Flannery & Mitchell, 2014). Infants with hydrocephalus can be identified by their overly large head (macrocephaly). However, other signs and symptoms include: 

  • Irritability 
  • High-pitched cry 
  • Bulging fontanelle 
  • Separation of sutures 
  • Vomiting 
  • Strabismus (crossed eyes) 
  • Downward gaze (“sun-setting” phenomenon) 
  • Lethargy 
  • Seizures 
  • Papilledema (late sign of optic nerve swelling) 

Causes of congenital hydrocephalus include obstruction from: 

  • Genetic x-linked aqueductal stenosis 
  • Chiari type II malformation (from spina bifida [i.e., myelomeningocele]) 
  • Dandy-Walker malformation, which occurs in-utero, due to progressive cystic enlargement of the fourth ventricle 

Acquired hydrocephalus occurs after birth at any age. Common causes include: 

  • Head trauma 
  • Stroke 
  • Infection 
  • Tumors (e.g., brain or spinal cord) 
  • Cerebral hemorrhage 
    • Impaired resorption of CSF in subarachnoid spaces that can result from birth complications due to: 
      • A meningitis infection during pregnancy 
      • Subarachnoid or intraventricular hemorrhage during childbirth 

Signs and symptoms of hydrocephalus in children and adults may include: 

  • Headache 
  • Nausea and vomiting 
  • Blurry or double vision 
  • Issues with balance 
  • Neurologic deficits (i.e., issues with thinking and memory) 
  • Impaired development progression (children) 
  • Lethargy 
  • Altered personality 

Normal pressure hydrocephalus (NPH) is caused by ventricular enlargement in the brain due to an excess of CSF, but the pressure within the ventricles remains “normal.” Most causes of NPH are idiopathic, but secondary causes of NPH can be due to underlying conditions, such as subarachnoid hemorrhage (SAH), meningitis, or brain injury. NPH occurs in about 700,000 adults over the age of 60 in the U.S. (Alzheimer’s Association, n.d.). However, 20% of individuals are misdiagnosed with Alzheimer’s or Parkinson’s disease due to symptoms of dementia (Hydrocephalus Association, n.d.). There are three classic signs of NPH that can gradually occur: 

  • Gait disturbances (first sign) 
  • Mild dementia with impaired cognition 
  • Urinary incontinence 

Some individuals may have all three symptoms, but most will only have one or two signs of NPH. Individuals with suspected NPH should be examined by a neurologist who specializes in neurological disorders that affect motor skills and cognition. 

Untreated hydrocephalus may lead to other complications, including: 

  • Physical and mental development issues (in infants and children) 
  • Continued neurological dysfunctions 
  • Death 

Hydrocephalus ICD-10 Code (unspecified): G91.9

Hydrocephalus Diagnosis 

Diagnosis for hydrocephalus includes (NLM, 2021): 

  • Computed tomography (CT) 
  • Magnetic resonance imaging (MRI) 
  • Prenatal ultrasonography 
  • Cranial ultrasound (for neonates) 
  • X-rays of the skull 
  • Arteriography 
  • Lumbar puncture to exam and drain CSF 
  • Brain imaging using radioisotopes 
  • Fundoscopic examination 
    • Observes for swelling of the optic nerve 
  • Neuropsychological testing (for NPH) 
  • Neurological exam for: 
    • Impaired balance and coordination 
    • Impaired mental status 
    • Altered mood or behavior 
    • Impaired vison or eye movement 
    • Impaired hearing 

Hydrocephalus Treatment & Management 

The course of treatment depends on the symptom severity and progression. Some individuals may only require observation, where others may require more invasive procedures: 

  • Shunt insertion: Is a common way to manage congenital and acquired hydrocephalus. Shunts are usually made out of sturdy, flexible plastic that act as a drainage system to allow CSF to flow from the brain to other parts of the body (National Library of Medicine [NLM], 2021). There are several different shunts that can be used depending on where the fluid is shifted to in the body (Bauer et al., 2020; Spina Bifida Association [SBA], n.d.): 
    • Ventriculoperitoneal shunt (VPS): The most common type of shunt allows fluid to drain into the peritoneal cavity 
    • Ventriculoatrial (VA) shunts: Allows fluid to drain in the neck or under the collarbone 
    • Ventriculo-pleural shunts: Allows fluid to drain around the lungs 
    • Ventriculo-gall bladder shunts: Allows fluid to drain to the gall bladder 
  • Endoscopic third ventriculostomy (ETV): Is another method used to treat hydrocephalus in children. ETV involves creating a hole in the bottom of one the ventricles in the brain to allow CSF drainage. 

Individuals with NPH may not require medical interventions if their symptoms are manageable, and they can maintain their quality of life. However, a VPS may be warranted if risks for surgery are minimal. 

Hydrocephalus Nursing Care Plan

Assessment 

  • The neurological assessment for ICP indicators is age-dependent and include assessment of: 
    • Mental status 
    • Motor function 
    • Balance 
    • Reflexes (for newborns and infants) 
    • Cranial nerve function 
    • Pupillary reaction to light 
  • Full set of vital signs, which should be observed for: 
    • Fluctuating blood pressure 
    • Tachycardia 
    • Shallow breathing 
    • Cushing’s triad: 
      • Bradycardia 
      • Respiratory depression 
      • Widening pulse pressure 
  • Measurement of head circumference and assessment of fontanelles 

Nursing Diagnosis/Risk For 

  • Impaired skin integrity, as evidenced by: 
    • Immobility 
  • Shunt infection, as evidenced by: 
    • Fever 
    • Lethargy 
    • Irritability 
    • Headache 
    • Increased ICP 
  • Ineffective tissue perfusion, as evidenced by: 
    • Brief, high-pitched cry (infants) 
    • Lethargy 
    • Restlessness 
  • Delayed growth and development (infants and children), as evidenced by: 
    • Impaired neurological function 
    • Inability to reach developmental milestones 
  • Shunt malfunction, as evidenced by: 
    • Increased ICP 
    • Headache 
    • Vomiting 
    • Lethargy 
    • Irritability 
    • Esotropia (eyes gaze turns inward) 
    • Upward gaze paralysis 

Interventions 

  • Position the head of the bed in semi-Fowler’s (i.e., 15° to 45°) 
  • Keep the individual’s head in a neutral position 
  • Provide oxygen cannulation, as needed 
  • Monitor for sign and symptoms of shunt infection post-insertion 
  • Record vital signs hourly 
  • Administer medications, per orders 
  • Monitor for increased ICP 
  • Initiate seizure and falls precautions: 
    • Reduce stimuli 
    • Promote bed rest 
  • Administer stool softeners 
  • Monitor head circumference 

Expected Outcomes 

  • Resolution of increased ICP 
  • Improvement of CSF drainage 
  • Decreased head circumference 
  • Improvement of balance and motor functions 
  • Possible continued incontinence and cognitive impairment (NPH only) 

Patient/Caregiver Education 

  • For all forms of hydrocephalus: 
  • Review the discharge instructions with individuals and/or their caregivers: 
    • Proper hand hygiene to reduce the spread of infection 
    • The importance of safety to prevent brain injuries 
    • The signs and symptoms of increased ICP 
    • The importance of regular follow up with their healthcare provider and when to seek medical advice 
    • Referral to an occupational and development (for infants and children) therapist 
    • Referral to a mental health provider (for emotional support) 
    • Referral to a social worker 
  • Review the medical management of hydrocephalus: 
    • Basic pathophysiology of hydrocephalus 
    • Purpose of a shunt 
    • Complications of a shunt insertion 
    • Signs and symptoms of shunt malfunction and infections 
  • For NPH specifically: 
    • Review safety and supportive measures with individuals and their caregivers: 
      • Avoid excessive stimulation 
      • Provide structure and routine, especially if dementia persists, to promote the feeling of independence 
      • Promote self-care for caregivers looking after individuals with dementia- induced NPH 
      • Referral to organizations for further information on NPH and dementia (e.g., Alzheimer’s or Hydrocephalus Associations) 

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Additional Information

Content Release Date 

4/1/2022

Content Expiration

12/31/2025

Course Contributors 

The content for this course was created/revised by Alia Lutz, BSN, RN. 

Alia Lutz, BSN, RN, has over 10 years of experience as a Registered Nurse with a focus on cardiothoracic, respiratory, and coronary care. She has also had experience in med-surg, step- down, and ICU. Prior to joining Relias as a SME and Content Writer for acute care, she provided virtual education and injection training on injectable biologics to patients, reported adverse events, and was a patient advocate. She has collaborated with peers on creating job aids, writing policies, and improving quality of care and documentation. Alia received her bachelor's in nursing from Otago Polytechnic in New Zealand in 2011. 

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Alia Lutz, BSN, RN

Alia Lutz, BSN, RN, has over 10 years of experience as a Registered Nurse with a focus on cardiothoracic, respiratory, and coronary care. She has also had experience in med-surg, step- down, and ICU. Prior to joining Relias as a SME and Content Writer for acute care, she provided virtual education and injection training on injectable biologics to patients, reported adverse events, and was a patient advocate. She has collaborated with peers on creating job aids, writing policies, and improving quality of care and documentation. Alia received her bachelor's in nursing from Otago Polytechnic in New Zealand in 2011.