INSTITUTE OF NURSING

EVIDENCE-BASED NURSING

Submitted by:

Abad, Maria Kathleen S.

Alana, Krizzia Camille L.

Alcoriza, Janine L.

Almazan, Trisha M.

Aliviz, Jeffrey M

Ancheta, Janine Angelica

Aricayos, Lea P.

Basilio, Phylord B.

Benito, Ann Jeka P.

Canlas, Jillian Yvonne

Raon, Maria Angelica

(BSN 202)

SUBMITTED TO:

Prof. Joepher Reuben Alcantara

DEFINITION OF THE DISEASE

Hydrocephalus is the buildup of too much cerebrospinal fluid in the brain.

Normally, this fluid cushions your brain. When you have too much, though, it puts
harmful pressure on your brain.

There are two kinds of

hydrocephalus. Congenital
hydrocephalus is present at
birth. Causes include genetic
problems and problems with
how the fetus develops. An
unusually large head is the
main sign of congenital
hydrocephalus. Acquired
hydrocephalus can occur at
any age. Causes can include
head injuries, strokes,
infections, tumors and
bleeding in the brain.
Symptoms of acquired
hydrocephalus can include:

• Headache

• Vomiting and nausea

• Blurry vision

• Balance problems

• Bladder control
problems

• Thinking and memory problems

Hydrocephalus can permanently damage the brain, causing problems with physical
and mental development. If untreated, it is usually fatal. With treatment, many
people lead normal lives with few limitations. Treatment usually involves surgery to
insert a shunt. Medicine and rehabilitation therapy can also help.

AANATOMY AND PHYSIOLOGY

 A second method for classifying brain regions is by
their organization in the adult brain. The following four
divisions are recognized

DIVISIONS OF THE BRAIN

The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve

fibers, the corpus callosum. The largest and most visible part of the brain, the
cerebrum, appears as folded ridges and grooves, called convolutions. The following
terms are used to describe the convolutions

A gyrus (plural, gyri) is an elevated ridge among the convolutions.

A sulcus (plural, sulci) is a shallow groove among the convolutions.

A fissure is a deep groove among the convolutions.

The deeper fissures divide the cerebrum into five lobes (most named after
bordering skull bones)—the frontal lobe, the parietal love, the temporal lobe, the
occipital lobe, and the insula. All but the insula are visible from the outside surface
of the brain.

A cross section of the cerebrum shows three distinct layers of nervous tissue:

The cerebral cortex is a thin outer layer of gray matter. Such activities as speech,
evaluation of stimuli, conscious thinking, and control of skeletal muscles occur here.
These activities are grouped into motor areas, sensory areas, and association areas.

The cerebral white matter underlies the cerebral cortex. It contains mostly
myelinated axons that connect cerebral hemispheres (association fibers), connect
gyri within hemispheres (commissural fibers), or connect the cerebrum to the spinal
cord (projection fibers). The corpus callosum is a major assemblage of association
fibers that forms a nerve tract that connects the two cerebral hemispheres.

Basal ganglia (basal nuclei) are several pockets of gray matter located deep inside
the cerebral white matter. The major regions in the basal ganglia—the caudate
nuclei, the putamen, and the globus pallidus—are involved in relaying and
modifying nerve impulses passing from the cerebral cortex to the spinal cord. Arm
swinging while walking, for example, is controlled here.

The diencephalon connects the cerebrum to the brain stem. It consists of the
following major regions:

The thalamus is a relay station for sensory nerve impulses traveling from the spinal
cord to the cerebrum. Some nerve impulses are sorted and grouped here before
being transmitted to the cerebrum. Certain sensations, such as pain, pressure, and
temperature, are evaluated here also.

The epithalamus contains the pineal gland. The pineal gland secretes melatonin, a
hormone that helps regulate the biological clock (sleep-wake cycles).

The hypothalamus regulates numerous important body activities. It controls the

autonomic nervous system and regulates emotion, behavior, hunger, thirst, body
temperature, and the biological clock. It also produces two hormones (ADH and
oxytocin) and various releasing hormones that control hormone production in the
anterior pituitary gland.

The following structures are either included or associated with the hypothalamus.

The mammillary bodies relay sensations of smell.

The infundibulum connects the pituitary gland to the hypothalamus.

The optic chiasma passes between the hypothalamus and the pituitary gland. Here,
portions of the optic nerve from each eye cross over to the cerebral hemisphere on
the opposite side of the brain.

The brain stem connects the diencephalon to the spinal cord. The brain stem
resembles the spinal cord in that both consist of white matter fiber tracts
surrounding a core of gray matter. The brain stem consists of the following four
regions, all of which provide connections between various parts of the brain and
between the brain and the spinal cord. (Some prominent structures are illustrated in
Figure 2).
 Prominent structures of the brain stem

The midbrain is the uppermost part of the brain stem.

The pons is the bulging region in the middle of the brain stem.

The medulla oblongata (medulla) is the lower portion of the brain stem that merges
with the spinal cord at the foramen magnum.

The reticular formation consists of small clusters of gray matter interspersed within
the white matter of the brain stem and certain regions of the spinal cord,
diencephalon, and cerebellum. The reticular activation system (RAS), one
component of the reticular formation, is responsible for maintaining wakefulness
and alertness and for filtering out unimportant sensory information. Other
components of the reticular formation are responsible for maintaining muscle tone
and regulating visceral motor muscles.

The cerebellum consists of a central region, the vermis, and two winglike lobes, the
cerebellar hemispheres. Like that of the cerebrum, the surface of the cerebellum is
convoluted, but the gyri, called folia, are parallel and give a pleated appearance.
The cerebellum evaluates and coordinates motor movements by comparing actual
skeletal movements to the movement that was intended.

The limbic system is a network of neurons that extends over a wide range of areas
of the brain. The limbic system imposes an emotional aspect to behaviors,
experiences, and memories. Emotions such as pleasure, fear, anger, sorrow, and
affection are imparted to events and experiences. The limbic system accomplishes
this by a system of fiber tracts (white matter) and gray matter that pervades the
diencephalon and encircles the inside border of the cerebrum. The following
components are included:

The hippocampus (located in the cerebral hemisphere)

The denate gyrus (located in cerebral hemisphere)

The amygdala (amygdaloid body) (an almond-shaped body associated with the
caudate nucleus of the basal ganglia)

The mammillary bodies (in the hypothalamus)

The anterior thalamic nuclei (in the thalamus)

The fornix (a bundle of fiber tracts that links components of the limbic system)
 EVIDENCE BASED NURSING

I. Clinical Question: Can intracranial hemmorhage progress to

hydrocephalus?

II. Citation: A longitudinal study of post-hemorrhagic ventricular dilatation in

the newborn by Malcolm I. Levene and David R. Starte

III. Study Characteristics

1. Population and Sample

Two hundred and two consecutive admissions to a regional neonatal

unit were scanned
by real-time ultrasound. Sixty-eight (34 %) infants had intracranial
hemorrhage, 39 (57 %) of whom
were scanned repeatedly until they were at least 30 days old. Fifteen
infants showed some degree of
ventricular dilatation. Four had transient dilatation with complete recovery
without any form of
treatment (group 1), 7 showed persistent but non-progressive dilatation
with no treatment (group 2),
3 had rapidly progressive hydrocephalus (group 3), and 1 had cerebral
atrophy (group 4). Occipitofrontal head circumference was also followed
sequentially from birth and was not abnormal in
groups 1 and 2, but abnormal rates of head growth were seen in groups 3
and 4.

2. Interventions Compared and outcomes monitored

interventions compared include:

1. This study describes the incidence of ventricular dilatation after

intracranial hemorrhage and the subsequent natural history of this
condition in 202 consecutively-born neonates

IV. Methodology/Design

1. Methodology Used, Design, Setting and Data Sources

All infants admitted to the neonatal unit at
Hammersmith Hospital during a period of 10 months from November 1979
were scanned sequentially with a Kranzbuhler ADR linear array real-time
ultrasound machine. Duration of gestation was calculated according to
maternal dates and gestational assessment.3 Infants were scanned at
least weekly and often daily while in the neonatal unit, and thereafter at
 all follow-up clinic attendances. Maximal occipitofrontal head
circumference was measured weekly on all 202 infants. A flexible metal or
glass fiber-coated linen tape was used, and each infant was measured by
one person only (MIL or DRS) during his stay in the neonatal unit.

The results were plotted on composite occipitofrontal circumference

charts which used the longitudinal growth data of Largo and Duc4 for
infants of 32 weeks' gestational age and older, and similar data prepared
by one of us (DRS) from two west London hospital populations of infants
under 32 weeks' maturity. Ultrasound scans were performed (by MIL) in
an axial plane through the temporoparietal region using a 5 MHz
transducer and the methods for diagnosis of intracranial hemorrhage
have been previously reported.2 Measurement was made of the distance
between the lateral ventricle and the falx, this distance being referred to
as the ventricular index. In addition, transfontanelle coronal scans of the
body of the lateral ventricle were also performed with a 7 MHz transducer.
A measurement of less than 6 mm from the floor of the lateral ventricle to
its roof at this point was considered to be normal. An infant was judged to
have dilated ventricles if the ventricular index measurement showed an
increase from a normal figure to one above the 97th centile for its
gestational age on growth charts of the lateral ventricle,5 or if the
distance from the roof to the floor of the lateral ventricle exceeded 6 mm.
Both these measurements could be made rapidly and with little difficulty.

2. Inclusion and Exclusion Criteria.

Three term infants were included in this study in which the intracranial
hemorrhage arose from subarachnoid, subdural, and choroid plexus
bleeds respectively. The etiology of such conditions is different from that
of subependymal hemorrhage and reflects a wider range of
pathophysiological events leading to the hemorrhagic lesion. In our study,
3 (8 %) of the 39 survivors of intracranial hemorrhage developed rapidly
progressing hydrocephalus requiring shunting, but considerably more (31
%) babies than this showed some degree of ventricular dilatation.

V. Results of the Study

Intracranial hemorrhage was diagnosed on ultrasound examination in
68 (34%) infants. In 13 (6%) infants the diagnosis of IVH could not be
made with certainty because of technical difficulties. Only preterm infants
or ones who were ill were admitted to our neonatal unit, and Table 1
shows the distribution of intracranial hemorrhage according to gestational
age for this highly selected population. In all but 2 of these babies the
origin of the bleeding was from the lateral ventricles. Subdural
hemorrhage was diagnosed on ultrasound scanning in one patient (Case
14), and in another term infant, a large subarachnoid hemorrhage was
diagnosed on the clinical findings of neck stiffness in conjunction with
 uniformly stained spinal fluid without IVH on ultrasound (Case 9).

Thirty-nine of the surviving infants with intracranial hemorrhage were

seen at age 30 days or more. Fifteen (39 %), of these 39 survivors
developed dilated ventricles, and all but 3 were 34 weeks or less, 8 of
whom were 30 weeks or less. None of the infants with dilated ventricles
received any treatment except for 3 with excessively rapid head growth
and bulging fontanels in whom ventricular shunts were inserted. Four
patterns of ventricular enlargement were noted: group 1 (n = 4) showed
transient dilatation with complete resolution, group 2 (n = 7) showed
persistent but non-progressive dilatation, group 3 (n= 3) showed
progressive dilatation of ventricles shortly after hemorrhage requiring
shunting, and group 4 (n = 1) showed ventricular dilatation but poor head
growth because of cerebral atrophy.

VI. Author’s Conclusions

The validity of undertaking treatment is most questionable in
the sorts of infants similar to those in groups I and 2. These babies in our
study received no treatment because the risks of shunting and lumbar
puncture or other procedures were considered to outweigh the potential
advantages of treatment. Follow-up data must be considered in evaluating
the efficacy of treatment versus non-treatment of this condition. Although
our follow-up results are incomplete, the initial impression is that compared
with matched infants with IVH but without ventricular dilatation, they are not
functioning as well. However, this may be due to the extent of the initial
hemorrhage as much as to ventricular size. In our opinion, to resolve
adequately the question of whether and when to treat non-progressive
ventricular dilatation, a controlled clinical trial must be undertaken and
neurological outcome be closely monitored. Have no foreseen bad effects on
the client’s health status.

VII. Applicability

The study can be carried out in the real setting, the study have been able to
answer our clinical question which is about the progression of subarachnoid
hemorrhage into hydrocephalus.

VII. Reviewer’s Conclusions

Conservative methods of intervention for idiopathic scoliosis should be
considered first before opting for surgery. Surgery can also cause port-
operative problems that may complicate the problem. Bracing should never
be disregarded as a solution though it may take time and lot of discomfort
when using it. Still, it is a very effective method or tool for decreasing the
need for surgery.

EVALUATING NURSING CARE PROCESS

1. Safety
 There is little agreement about the management of infants with dilated
ventricles. Those in whom there is rapid head growth, bulging fontanels, and
splayed sutures may receive ventricular shunts. If the infant is frail, medical
management with glycerol18 or isosorbide7-has been undertaken. And other
treatments-such as regular cerebrospinal fluid taps13 19 or compressive head
wrappings20 21-have been used in some centers. Those infants shown to have
dilated ventricles on ultrasound before a rapid increase in head size has occurred
may also be treated by these methods, and arrest of the hydrocephalus incorrectly
ascribed to treatment when ventricular dilatation might have been transient or
subject to spontaneous arrest. The risk of transportation, sedation, and radiation
exposure inherent in CT scanning should make ultrasound the method of choice to
diagnose and follow post- hemorrhagic hydrocephalus.

2. Competence of the nursing care provider

Not Applicable.

3. Acceptability

The study is acceptable because it deals in a way that it will determine

whether the hemorrhages can lead to hydrocephalus.

4. Effectiveness

The study is effective because it is proven that hemorrhage can lead to

hydrocephalus.

5. Appropriateness

The study is appropriate to the goal of researcher to identify or to prove that

post- hemorrhagic can be as predisposing factor for having hydrocephalus in
newborn. They introduced CT scanning that allows accurate diagnosis of IVH and
early detection of hydrocephalus.

6. Efficiency

Follow-up data must be considered in evaluating the efficacy of treatment

versus nontreatment of this condition. Although our follow-up results are
incomplete, the initial impression is that compared with matched infants with IVH
but without ventricular dilatation, they are not functioning as well. However, this
may be due to the extent of the initial hemorrhage as much as to ventricular size.
In our opinion, to resolve adequately the question of whether and when to treat
nonprogressive ventricular dilatation, a controlled clinical trial must be undertaken
and neurological outcome be closely monitored.