Pressure Hydrocephalus-2 Nursing CEs Author:
Kristi Hudson RN MSN CCRN
course is designed to give an overview of the care and management of
the patient with Normal Pressure Hydrocephalus (NPH). Statistics
surrounding NPH and a description of the overall scope of the problem
will be presented. The anatomy, pathophysiology, etiology,
signs/symptoms and diagnosis of this syndrome will also be presented.
Treatment options including the placement of a ventriculo-peritoneal
shunt (VPS) and nursing care and management of the post-op VPS patient
will also be presented. NANDA nursing diagnoses appropriate for the
patient with NPH will be the final focus of this course. Course
completion of this course the student will be able to:
List the statistics
surrounding the diagnosis of NPH
Gain a better
understanding of the scope of the problem surrounding NPH
Describe how CSF flows
throughout the brain and spinal cord
pathophysiology of NPH
Explain 2 possible
causes for NPH
Describe the classic
triad of symptoms found with NPH
Explain the diagnostic
process for NPH
Describe the treatment
option of VPS
Discuss the nursing
care and management of the patient post VPS
Describe 3 possible
complications of a VPS
List 2 appropriate
NANDA nursing diagnoses for patients with NPH
and Scope of the Problem:
Hydrocephalus (NPH) is a debilitating syndrome that affects an
estimated 5% of population over the age of 65, who suffer from
dementia. Some experts estimate that as many as 375,000 Americans who
currently have NPH have actually been misdiagnosed with either
Alzheimer’s or Parkinson’s disease.
this syndrome is often misdiagnosed (with either Parkinson’s
disease or Alzheimer’s disease); many people are forced to
live with the symptoms associated with this syndrome without relief or
expectation for subsequent recovery. Because NPH is one of the only
forms of dementia that can be controlled and even reversed, it is
imperative that an accurate diagnosis be made.
NPH is a brain disorder
that causes blockage of the cerebral spinal fluid (CSF) which causes
enlargement of the ventricles and compression of brain tissue. What is
unique about this syndrome is that even with the noted enlargement of
the ventricles and compression of brain tissue, the patient displays
normal CSF opening pressures on lumbar puncture and normal intracranial
NPH is a
syndrome that begins gradually and presents with a triad of symptoms
that include: gait disturbance, urinary incontinence and dementia. The
onset of symptoms are insidious and often go unnoticed by the patient
and/or family members, and if noted are often attributed to the
“normal aging process”.
and Etiology of NPH: Anatomy
(travel of CSF): The majority of CSF is formed in specialized areas
within the ventricle which is known as the “choroid
plexus”. The choroid plexus produces CSF at a rate of
approximately 20ml to 25ml per hour. The CSF circulates from the two
lateral ventricles through the third ventricle (a single mid-line
ventricle) to the fourth ventricle which is located within the
posterior fossa of the brain. After exiting the ventricular system the
CSF is then circulated to the subarachnoid space surrounding the brain
and spinal column (this provides a cushion or protection). From the
subarachnoid space and spinal column, CSF is absorbed into the venous
The pathophysiology for NPH is still being debated but most experts
will agree that aberrations of cerebral spinal fluid (CSF) flow and
absorption are central to the pathophysiology of this syndrome. The
following are suggested Pathophysiologic causes of NPH:
One suggested mechanism
is that the transmantle pressure gradient of CSF within the ventricle
is greater then CSF pressure in the subarachnoid space.
A second mechanism
suggests that the transmantle pressure impairment is at the level of
the aqueduct (which would cause non-communicating NPH) or distal to the
aqueduct (which would cause communicating NPH).
As with the pathophysiology of NPH, the actual cause of this syndrome
is also unknown. It is estimated that approximately 50% of the cases
are truly idiopathic. The following are suggested causes of NPH that
can be found in the literature:
A history of events
exists that can alter CSF flow dynamics, such as previous subarachnoid
hemorrhage, trauma, meningitis, or surgery.
The arachnoid villi
fail to maintain an adequate removal of CSF.
NPH often begins in
infancy as benign external hydrocephalus.
Fibrosis and scarring
of brain tissue inhibits the absorption of CSF.
inhibits the production and or absorption of CSF.
and Symptoms of NPH: One
thing that is clear regarding NPH is the classic triad of symptoms that
present with this syndrome. These symptoms include:
(history of falls, gait instability, balance disturbances, decreased
endurance, walking with very small steps and shuffling).
bladder function is assessed and tested; the urinary incontinence that
is associated with NPH is thought to be primarily a result of the gait
and dementia components of this syndrome).
(Although the symptoms of NPH are similar to those of other dementias;
there are differences. While NPH patients often show a more severe
impairment in the areas of attention, psychomotor movement and
calculation; they often score higher in the areas of memory, delayed
recall and overall orientation when compared to patients with other
forms of dementia such as Alzheimer’s disease).
of NPH: In
the outpatient setting most experts agree that radiologic findings such
as Computerized Tomography (CT) or Magnetic Resonance Imaging (MRI)
alone are too subjective to diagnose NPH. The combination of radiologic
testing with inpatient evaluation of those who are suspected of having
NPH may prove to be the most successful way to accurately diagnose NPH.
The following is a description of an inpatient 4 day diagnostic program:
Upon admission the
patient is individually evaluated by physical therapy (PT),
occupational therapy (OT) and speech therapy (ST) to gather baseline
assessments are complete; a Neurosurgeon places a lumbar drain and
continuous CSF drainage is started (usually 4-8 ml/hr).
Using the same
therapists and the same testing methods; PT, OT and ST evaluations are
repeated once a day for each of the following three days to evaluate
and document any improvement in the patient’s initial
After the final set of
evaluations is complete on day four, the lumbar drain is discontinued
and the patient is discharged home.
Not until the patient
is discharged from the hospital are the results of this testing
evaluated (this is done post discharge to avoid any bias or
pre-conceived opinions regarding improvement).
To determine if a
patient showed significant improvement in gait, urinary incontinence
and/or symptoms of dementia after continuous CSF drainage; a
multi-disciplinary team consisting of physicians (Neurosurgery and
Neurology), therapist (PT, OT and ST) and nurses meet to review the
When a diagnosis of NPH
has been made and analysis of the data confirms improvement of symptoms
after continuous CSF drainage; an internal continuous CSF drain or
ventriculo-peritoneal shunt (VPS) can by offered.
Because NPH can mirror other neurological disorders, the following
should be ruled out prior to diagnosing NPH with certainty:
arteriosclerotic encephalopathy (SAE)
Combination of several
diseases (orthopedic deficits, prostate disorders, and mild dementia
may present similar to NPH)
(such as abscess, subdural empyema, meningitis)
(Addison’s disease, hypothyroidism) or malignancy
Intervention (VPS Placement): Surgical
placement of a VPS can be offered to patients diagnosed with NPH as to
an effective and permanent treatment option. The surgical procedure for
placement of a VPS drain is as follows:
General anesthesia is
The patient is placed
on their back with head tilted to the left.
Hair over the scalp is
clipped and shaved.
Two incisions are made
(a small abdominal incision and a curved scalp incision). The scalp is
pulled back and a burr hole is drilled through the skull.
The VP shunt is usually
threaded first through the abdominal incision.
The VP shunt is then
upwardly threaded under the skin through the chest, neck, behind the
ear and into the enlarged ventricle.
After the tubing is in
place a reservoir is attached and fitted into a space between the scalp
and the skull.
The shunt can be set to
remove a specified amount of CSF per hour (this amount can also
adjusted externally using a magnetic device).
When complete the shunt
is completely internal and cannot be felt or seen.
Care and Management VPS Surgery: Nursing
care and management should focus on returning the patient to a state of
normal health and well being as soon as possible. Nursing
Frequent Vital Signs (Q
2 hrs initially)
Frequent Neuro checks
(Q 2 hrs initially)
Sensory and Motor
Assessment of Pain
Assessment of Surgical
Incisions (head and abdomen)
care and Management:
Development of a Pt.
Specific Nursing Care Plan
Turning the Pt. Q 2
Sequential Compression Devices
HOB @ 30%
Early Ambulation and
Participation in Activities of Daily Living
Complications Associated With VPS Surgery: All
of the following are considered to be potential post-op complications
associated with ventriculo-peritoneal shunting. Identifying the onset
of these complications should also be part of the nursing assessment.
(Subdural hematoma is usually not apparent in the immediately post-op
phase. Patients often present with a headache or progressive neurologic
deficit days or even weeks after insertion of a VP shunt).
Neck Hematoma (Injury
to the external jugular vein or other vascular structures in the neck
can result in bleeding and swelling of the neck in the post-op phase).
Skin Perforation (The
VPS is located in the subcutaneous tunnel, just a few millimeters below
the skin surface. It is in the space between the subcuticular and
superficial muscule fascial layers of the head, neck, chest, and
abdomen. Skin perforation is rare, but should be assessed for during
routine nursing assessment).
Lung Injury (Because
the shunt is passed below the clavicle it is possible to perforate the
inner visceral region of the lung and cause a pneumothorax. Complaints
of chest pain or shortness of breath should be followed up immediately).
Ileus (Ileus is a
frequent and almost always transient complication of surgery in the
abdomen. Auscultate for active bowel sounds and report hypoactive or
absent bowel sounds immediately).
(Peritonitis resulting in irritation to the abdominal wall secondary to
bowel rupture is an immediate post-op concern. Patients will present
with a stiff, extremely sensitive abdomen and absent bowel sounds.
Immediate surgical intervention to repair bowel rupture is required).
Infection (Infection of
a VP shunt is a dreaded complication because it frequently requires
revision or removal and replacement of the entire system. Patients with
an infected VPS often display fever, malaise and neurological
(Shunt systems include several components in a sequence in order to
provide a continuous pathway for drainage. S/S for disconnection of a
VPS include headache, increased ICP, Neurophysiologic compromise).
Nursing Diagnosis for NPH:
Immobility r/t gait
Potential for skin
breakdown r/t incontinence
Self-care deficit r/t
Potential for injury
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Assistant Professor, Department of Neurology, University of Chicago
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