Hydrocephalus and Cerebral Spinal Fluid Drainage - 2 RN CEs
Author: Kristi Hudson RN MSN CCRN
Written: 5/15/05
Updated: September 25, 2009
Course Description:
This course is designed to give an overview of the care and management of the patient diagnosed with hydrocephalus. Discussion will include the anatomy of the brains ventricular system as well as the purpose and flow of cerebral spinal fluid (CSF). Focus will be placed on treatment options for hydrocephalus such as Ventriculo-peritoneal (VP) shunting and/or the use of External Ventricular Drainage (EVD) Systems. Nursing care and management including set up, monitoring and trouble shooting and documentation for the patient with an External Ventricular Drainage System will be the final focus of this course.
Course Objectives:
Upon completion of this course the student will be able to:
- Define Hydrocephalus
- Have a better understanding of Ventricular anatomy
- Discuss the amount and flow of CSF
- Describe the presenting signs and symptoms of hydrocephalus
- Explain the purpose and function of a Ventriculo-peritoneal (VP) shunt
- Discuss the care and management of the patient with an External Ventricular Drain
- State the proper steps for setting an EVD system
- Discuss the required documentation for the patient with an EVD system
Ventricular Anatomy:
The brains ventricular system is comprised of four ventricles (two lateral and a third and fourth). Movement and flow of the CSF is as follows:
- The lateral ventricles which are located deep within the sub-cortical tissue on each side of the brains midline communicate with the third ventricle via the Foramen of Monro.
- In turn the third ventricle communicates with the fourth ventricle (which is located in the medulla) through the aqueduct of Sylvius.
- The top of the fourth ventricle is where communication to the sub-arachnoid space occurs via two lateral foramen called the Foramen of Luschka and one median foramen called the Foramen of Magendie.
- The floor of the fourth ventricle communicates with the spinal column.
- Cerebral Spinal Fluid:
- Cerebral Spinal Fluid is continuously produced in the lateral ventricles by the choroids plexus.
- The rate of production is estimated to be 20 to 25 ml per hour or 500 ml per day. It is also estimated that under normal circumstances there is approximately 100 to 150 ml of CSF circulating throughout the ventricles and spinal column.
- As mentioned earlier, the Foramen of Luschka (located on the top of the fourth ventricle) allows CSF to flow throughout the brain.
- CSF provides flexibility and protection to the brain and spinal cord.
- CSF is a vehicle for central nervous systems metabolic activity.
- CSF provides a medium for the removal of unnecessary metabolites (away from neurons).
- CSF consists of water, glucose, protein, minerals and a few lymphocytes.
Pathophysiology of Hydrocephalus:
Under normal conditions the brain floats in a protective cushion of Cerebral Spinal Fluid (CSF). In addition to surrounding the brain, CSF also surrounds the spinal cord and fills open spaces in the brain such as the ventricles. Hydrocephalus which is a clinical syndrome (rather then an actual disease process) occurs when the production of Cerebral Spinal Fluid (CSF) exceeds the brains absorption rate. Accumulation of CSF in the ventricles causes them to swell and enlarge with in turn causes increased intracranial pressure (ICP).
Classification and Causes of Hydrocephalus:
Hydrocephalus can be subdivided into the following two categories:
Non-Communicating Hydrocephalus – this is a condition where CSF that is located in the ventricle does not communicate properly within the sub-arachnoid space (the center for CSF absorption). This is usually due to some obstructive process such as a brain mass, congenital obstruction (as seen in children) or from obliteration caused by an inflammatory process.
Communicating Hydrocephalus – this is a condition in which too few or non-functional arachnoid villi are available to assist with the reabsorption of CSF. Aneurysm rupture (sub-arachnoid hemorrhage) or traumatic brain injury are major causes of either transient or lasting communicating hydrocephalus.
Signs and Symptoms of Hydrocephalus:
Symptoms of hydrocephalus vary depending on the type of hydrocephalus, the age of the patient and the extent of brain tissue damage that is caused by swelling. For example; with infants the most common sign of hydrocephalus is an enlarged head; where as in children and adults there is no enlargement of the head because the bones of the skull are fused. Commons signs and symptoms that adults with hydrocephalus present with include the following:
- Headache
- Nausea/Vomiting
- Blurred Vision
- Gait Disturbances
- Difficulty with Coordination
- Irritability
- Fatigue
- Mood or Personality Changes
- Inability to Concentrate
- Memory Loss
- Drowsiness
Treatment Options for Hydrocephalus:
Surgical intervention to remove the primary obstructive problem is usually required for non-communicating hydrocephalus. For communicating hydrocephalus, temporary drainage of CSF (to clear the arachnoid villi of exudate) can be attempted with an External Ventricular Drainage System (placed in the ventricle). If temporary EVD is unsuccessful, a more permanent intervention such as a Ventriculo-peritoneal Shunt (VPS) can be placed.
Placement of a Ventriculo-peritoneal Shunt:
For patients requiring a more permanent CSF drainage system a VPS can be surgically placed (most often in right lateral ventricle). The location and procedure for placement is as follows:
- General anesthesia is administered.
- 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.
External Ventricular Drainage Systems:
Necessary Equipment for a “Non-monitored” External Ventricular Drainage System:
- IV Pole
- Sterile Gloves
- Sterile Towels (to create a sterile work space)
- 500 ml bag of Lactated Ringers or Normal Saline Solution
- IV Tubing
- Drainage System (system products vary)
- Manifold (depending on product used)
- Additional Drainage Bags
Set Up of EVD:
- Using sterile gloves and towels; create a sterile field (on a procedure or bedside table).
- In a sterile fashion open up LR or NS solution, IV tubing and drainage system and place on the sterile field (the use of a second non-sterile person to open packaging is usually required).
- Spike LR or NS bag and prime IV tubing.
- Connect IV tubing to drainage system and flush system (make sure drainage system stopcocks are open for ease of flushing).
- Assure that there are no air bubbles or leaks in the system.
- Once the system is flushed, remove LR or NS bag and IV tubing and discard.
- Assuring that the end of the drainage system that will connect to the patients External Ventricular Catheter remains sterile, place drainage system on IV Pole.
- Some drainage systems come with a measuring device, for those that do not, a manifold (a pole that has incremented measurements) will need to be placed on the IV pole and the drainage system is then placed on the manifold.
- Connection of the drainage system and the Ventricular Catheter must be made using sterile technique.
Monitoring and Care of the patient with an EVD:
The following are usual requirements of EVD monitoring (check specific physician orders):
- EVD drains can be leveled at the top of the ear or more commonly at the lateral canthus of the eye.
- Check physician order for height or level of drainage system (commonly physicians order drainage system to be 5-10 cm above lateral canthus).
- Adjust drainage system on IV Pole or Manifold to assure that the desired level is reached.
- Once desired drainage system height is reached, it is imperative to maintain this level. Careful observation of patient position (level of bed and head of bed) must be considered. If patient requires a different position, the drainage system needs to be adjusted as well in order to continuously maintain the ordered drainage height. (Meal time when patient is sitting upright for example).
- Family education to avoid re-positioning patient with notifying the nurse must be also provided.
- The physician will also order the amount or timeframe for monitoring CSF drainage. Check orders to see if continuous or intermittent drainage has been ordered. If intermittent drainage is ordered the drainage device should be clamped and only open to drain at specified times (usually q 1-2 hours).
- If draining intermittently check with physician to determine desired amount of CSF drainage when system is open.
- CSF drains into the Buretrol portion of the drainage system for accurate measuring of output. After amount is measured and documented, the CSF can be drained into the collection bag (there is a stopcock between the Buretrol and collection bag). When not draining CSF into the collection bag, this stopcock must be closed.
- The systems collection bag should only be emptied when full. To change bag (using sterile gloves and mask) assure that stopcock between Buretrol and collection bag is closed, disconnect old collection bag and wipe connection with betadine or chlorprep (3 times), allow connection to dry before securing new bag.
- CSF drainage bag should be placed in hazardous waste bin (check your hospital policy).
- Assure the EVD is clamped for all patient transports.
- Patients should avoid valsalvo maneuvers during (coughing, suctioning, vomiting etc.)
Troubleshooting External Ventricular Drainage Systems:
Lack of CSF Drainage:
- Check all connections.
- Check that all stopcocks are in the proper position.
- Check level of drainage system.
- Check for kinks in the tubing.
- Call MD if unable to resolve problem (all patients should have some CSF drainage).
Procedure for Sending a CSF Sample for Culture:
The nurse should only collect a CSF sample for culture from the stopcock that is between the Buretrol and the collection bag. Access to all other stopcocks should be done by a physician (unless your hospital policy states otherwise). To gather a sample for culture, sterile technique and fresh CSF is required.
Required Physician Notification and Documentation for Patients with EVD systems:
- Document Neuro Assessment Q 4 hours (or per MD order)
- Immediately notify physician for changes in LOC.
- Immediately notify physician for complaints of headache (sign of excessive CSF drainage).
- Immediately notify physician if any CSF leakage is noted around the catheter site.
- If present, document dressing intactness Q 4 hours.
- Document amount, color and transparency of CSF Q 2 hours (or per MD order).
- Document the ordered level or height of drainage system.
- Document if drainage is being collected continuously or intermittently.
- Document patient and family education.
NANDA Nursing Diagnosis:
- Alteration in LOC related to increased hydrocephalus
- Altered tissue perfusion: Cerebral
- Alteration in comfort: Pain
- Immobility
- Potential for skin breakdown
- Potential for altered nutrition
- Potential for injury
- Knowledge deficit
- Ineffective individual and/or family coping
- Body image disturbance
References:
National Institute of Health; Hydrocephalus fact sheet (2009). Retrieved on August 28, 2009 at:
http://www.ninds.nih.gov/disorders/hydrocephalus/detail_hydrocephalus.htm
Goldenring, J. MD. (2004). Hydrocephalus. Retrieved on May 4, 2006 at:
Hart, J., P. MD. (2005). Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI. ;
Hickey, J. (2003). The clinical practice of neurological and neurosurgical nursing. (5th ed.), (Chap. 14). Lippencott, Williams and Wilkins. Philadelphia
University of California Irvine. Intracranial pressure monitoring, using cordis external drainage and monitoring system. Policy section number I-103. Revised 4-2005.
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