HYDROCEPHALUS

WHAT IS HYDROCEPHALUS?
derived

from the Greek words "hydro" meaning water "cephalus" meaning head a condition in which the primary characteristic is excessive accumulation of fluid in the brain. once known as "water on the brain

 the

"water" is actually cerebrospinal fluid (CSF) a clear fluid that surrounds the brain and spinal cord. The excessive accumulation of CSF results in an abnormal widening of spaces in the brain called ventricles. This widening creates potentially harmful pressure on the tissues of the brain. The ventricular system is made up of four ventricles connected by narrow passages.

PATHOPHYSIOLOGY
Hydrocephalus

results from obstructed flow of CSF (noncommunicating hydrocephalus) or an imbalance between production and reabsorption of CSF (communicating hydrocephalus). There is increased intracranial pressure, and head size increases abnormally if sutures and fontanels have not closed.

CSF
1.

HAS THREE IMPORTANT LIFESUSTAINING FUNCTIONS:

2.

3.

to keep the brain tissue buoyant, acting as a cushion or "shock absorber"; to act as the vehicle for delivering nutrients to the brain and removing waste; and to flow between the cranium and spine and compensate for changes in intracranial blood volume (the amount of blood within the brain).

WHAT ARE THE DIFFERENT TYPES OF HYDROCEPHALUS?

Hydrocephalus may be congenital or acquired.
1.

Congenital hydrocephalus

is present at birth and may be caused by either events or influences that occur during fetal development, or genetic abnormalities.

2. Acquired hydrocephalus
develops at the time of birth or at some point afterward. This type of hydrocephalus can affect individuals of all ages and may be caused by injury or disease.

Hydrocephalus may also be communicating or non-communicating. Communicating hydrocephalus an imbalance between production and reabsorption of CSF 2. Non-communicating hydrocephalus obstructed flow of CSF
1.

WHO GETS THIS HYDROCEPHALUS?

experts

estimate that hydrocephalus affects approximately 1 in every 500 children.

WHAT CAUSES HYDROCEPHALUS?

due

to a problem with the flow of CSF myelomeningocele genetic defects certain infections that occur during pregnancy

WHAT
The

ARE THE SYMPTOMS OF HYDROCEPHALUS?

most obvious indication of hydrocephalus is often a rapid increase in head circumference or an unusually large head size.

Other symptoms may include: vomiting sleepiness irritability downward deviation of the eyes (also called "sunsetting") seizures separated sutures

HOW

IS HYDROCEPHALUS DIAGNOSED?

When

a health care provider taps fingertips on the skull, there may be abnormal sounds that indicated thinning and separation of skull bones. Scalp veins may appear stretched or enlarged.

Through clinical neurological evaluation and by using cranial imaging techniques such as:
Ultrasonography

computed

tomography (CT) magnetic resonance imaging (MRI) pressure-monitoring techniques.

WHAT IS THE CURRENT TREATMENT FOR HYDROCEPHALUS?

1.

Shunt system This system diverts the flow of CSF from the CNS to another area of the body where it can be absorbed as part of the normal circulatory process.

2. Endoscopic Third Ventriculostomy (ETV)

which relieves pressure without replacing the shunt.

3. Removing or burning away

(cauterizing) the parts of the brain that produce CSF may reduce CSF production.

NURSING MANAGEMENT
1. Provide preoperative nursing care Assess head circumference, fontanelles, cranial sutures, and LOC; check also for irritability, altered feeding habits and a highpitched cry. Firmly support the head and neck when holding the child. Provide skin care for the head to prevent breakdown. Give small, frequent feedings to decrease the risk of vomiting. Encourage parental-newborn bonding.

2. Provide Postoperative nursing care

Assess

for signs of increased ICP and check the following; head circumference (daily), anterior fontanelle for size and fullness and behavior. Administer prescribed medications which may include antibiotics to prevent infection and analgesics for pain.

3. Provide shunt care

Monitor

for shunt infection and malfunction which may be characterized by rapid onset of vomiting, severe headache, irritability, lethargy, fever, redness along the shunt tract, and fluid around the shunt valve. Prevent infection (usually from Staphylococcus epidermis or Staphylococcus aureus)

Monitor for shunt overdrainage (headache, dizziness and nausea). Overdrainage may lead to slit ventricle syndrome whereby the ventricle become accustomed to a very small or slitlike configuration, limiting the buffering ability to increased ICP variations.

OTITIS MEDIA

Acute Otitis Media

OTITIS

MEDIA

(Latin) is inflammation of the middle ear, or a middle ear infection. It occurs in the area between the tympanic membrane and the inner ear, including a duct known as the eustachian tube. It is one of the two categories of ear inflammation that can underlie what is commonly called an earache, the other being otitis externa. Though painful, otitis media is not threatening and usually heals on its own within 26 weeks.

CLASSIFICATION
Otitis

media has many degrees of severity, and various names are used to describe each. The terminology is sometimes confusing because of multiple terms being used to describe the same condition. A common misconception with ear infection is that sufferers think that a symptom is itchy ear. Although sufferers may feel discomfort, an itchy ear is not a symptom of ear infection.

ACUTE
Acute otitis media (AOM) is most often purely viral and self-limited, as it usually accompanies viral URI (upper respiratory infection). There is congestion of the ears and perhaps mild discomfort and popping, but the symptoms resolve with the underlying URI. If the middle ear, which is normally sterile, becomes contaminated with bacteria, pus and pressure in the middle ear can result, and this is called acute bacterial otitis media.

Viral acute otitis media can lead to bacterial otitis media in a very short time, especially in children, but it usually does not. The individual with bacterial acute otitis media has the classic "earache", pain that is more severe and continuous and is often accompanied by fever of 102 F (39 C) or more. Bacterial cases may result in perforation of the ear drum, infection of the mastoid space (mastoiditis) and in very rare cases further spread to cause bacterial meningitis.

1st phase - exudative inflammation lasting 12 days, fever, rigors, meningism (occasionally in children), severe pain (worse at night), muffled noise in ear, deafness, sensitive mastoid process, ringing in ears (tinnitus) 2nd phase - resistance and demarcation lasting 3 8 days. Pus and middle ear exudate discharge spontaneously and afterwards pain and fever begin to decrease. This phase can be shortened with topical therapy. 3rd phase - healing phase lasting 24 weeks. Aural discharge dries up and hearing becomes normal.

SEROUS
Otitis media with effusion (OME), also called serous or secretory otitis media (SOM), is simply a collection of fluid that occurs within the middle ear space as a result of the negative pressure produced by altered Eustachian tube function. This can occur purely from a viral URI, with no pain or bacterial infection, or it can precede and/or follow acute bacterial otitis media. Fluid in the middle ear sometimes causes conductive hearing impairment, but only when it interferes with the normal vibration of the eardrum by sound waves.

Over weeks and months, middle ear fluid can become very thick and glue-like (thus the name glue ear), which increases the likelihood of its causing conductive hearing impairment. Early-onset OME is associated with feeding while lying down and early entry into group child care, while parental smoking, too short a period of breastfeeding and greater amounts of time spent in group child care increased the duration of OME in the first two years of life.

CHRONIC

SUPPURATIVE

involves a perforation (hole) in the tympanic membrane and active bacterial infection within the middle ear space for several weeks or more. There may be enough pus that it drains to the outside of the ear (otorrhea), or the purulence may be minimal enough to only be seen on examination using a binocular microscope. This disease is much more common in persons with poor Eustachian tube function. Hearing impairment often accompanies this disease.

SIGNS AND SYMPTOMS

When the middle ear becomes acutely infected, pressure builds up behind the eardrum (tympanic membrane), frequently causing intense pain. It may result in bullous myringitis, which means that the tympanic membrane is blistered and inflamed. In severe or untreated cases, the tympanic membrane may rupture, allowing the pus in the middle ear space to drain into the ear canal. If there is enough of it, this drainage may be obvious. Even though the rupture of the tympanic membrane suggests a traumatic process, it is almost always associated with the dramatic relief of pressure and pain.

In a simple case of acute otitis media in an otherwise healthy person, the body's defenses are likely to resolve the infection and the ear drum nearly always heals. Instead of the infection and eardrum perforation resolving, however, drainage from the middle ear can become a chronic condition. As long as there is active middle ear infection, the eardrum will not heal. The World Health Organization defines chronic suppurative otitis media (CSOM) as "a stage of ear disease in which there is chronic infection of the middle ear cleft, a non-intact tympanic membrane (i.e. perforated eardrum) and discharge (otorrhoea), for at least the preceding two weeks" (WHO 1998).

Notice WHO's use of the term serous to denote a bacterial process, whereas the same term is generally used by ear physicians in the United States to denote simple fluid collection within the middle ear behind an intact eardrum. Chronic otitis media is the term used by most ear physicians worldwide to describe a chronically infected middle ear with eardrum perforation.)

CAUSES
Otitis media is most commonly caused by infection with viral, bacterial, or fungal pathogens. The most common bacterial pathogen is Streptococcus pneumoniae Others include Pseudomonas aeruginosa, nontypeable Haemophilus influenzae, and Moraxella catarrhalis. Among older adolescents and young adults, the most common cause of ear infections is Haemophilus influenzae.

Viruses such as respiratory syncytial virus (RSV) and those that cause the common cold may also result in otitis media by damaging the normal defenses of the epithelial cells in the upper respiratory tract. A major risk factor for developing otitis media is Eustachian tube dysfunction, which leads to the ineffective clearing of bacteria from the middle ear. The role of the anti-H. influenzae vaccine that children are regularly given is to prevent invasive disease such as meningitis and pneumonia.

This vaccine is active only against strains of serotype b, which has been found to cause meningitis and pneumonia in children under five years, with children between 4 and 18 months the most susceptible. Isolates of serotype b rarely cause otitis media.

PROGRESSION
Typically, acute otitis media follows a cold: after a few days of a stuffy nose, the ear becomes involved and can cause severe pain. The pain will usually settle within a day or two, but can last over a week. Sometimes the ear drum ruptures, discharging pus from the ear, but the ruptured drum will usually heal rapidly. At an anatomic level, the typical progression of acute otitis media occurs as follows: the tissues surrounding the Eustachian tube swell due to an upper respiratory infection, allergies, or dysfunction of the tubes.

The Eustachian tube remains blocked most of the time. The air present in the middle ear is slowly absorbed into the surrounding tissues. A strong negative pressure creates a vacuum in the middle ear, and eventually the vacuum reaches a point where fluid from the surrounding tissues accumulates in the middle ear. This is seen as a progression from a Type A tympanogram to a Type C to a Type B tympanogram. The fluid may become infected. It has been found that dormant bacteria behind the tympanic membrane (eardrum) multiply when the conditions are ideal, infecting the middle ear fluid.

INFANTS

AND

CHILDREN

Infants and children younger than seven are much more prone to otitis media due to shorter Eustachian tubes, which are at a more horizontal angle than in the adult ear. They also have not developed the same resistance to viruses and bacteria as adults. Numerous studies have correlated the incidence in children with various factors such as nursing in infancy, bottle feeding when supine, parental smoking, diet, allergies, and automobile emissions; but the most obvious weakness of such studies is the inability to control the variable of exposure to viral agents during the studies .

breastfeeding for the first twelve months of life is associated with a reduction in the number, and duration of all OM infections. Pacifier use has been associated with more frequent episodes of AOM.

DIAGNOSIS
Acute otitis media is usually diagnosed via visualization of the tympanic membrane in combination with the appropriate clinical history. The use of a monocular otoscope and perhaps a tympanometer may not be able to distinguish bacterial versus viral etiology, especially if the canal is small and there is wax in the ear that obscures a clear view of the eardrum. Also, an upset child's crying can cause the eardrum to look inflamed due to distension of the small blood vessels on it, mimicking the redness associated with otitis media. The occurrence, duration, or severity of symptoms is not predictive of an ear infection in the absence of examination of the eardrum.

Prevention
Pneumococcal conjugate vaccines when given during infancy decrease rates of acute otitis media by 67% and if implemented broadly would have a significant public health benefit. Evidence does not support zinc supplementation as an effort to reduce otitis rates except maybe in those with severe malnutrition such as marasmus. Long term antibiotics, while they decrease rates of infection during treatment, have an unknown effect on long term outcomes such as hearing loss. Breastfeeding can reduce the rates of OM from 19% to 6% in children that were breastfed for at least one year. Reduction of risk factors in combination with medicinal or surgical methods are necessary to reduce the recurrence of OM and prevent persistent MEE.

TREATMENT
Symptomatic Oral and topical analgesics are effective to treat the pain caused by otitis media. Oral agents include ibuprofen, paracetamol (acetaminophen), and narcotics. Topical agents shown to be effective include antipyrine and benzocaine ear drops. Decongestants and antihistamines, either nasal or oral, are not recommended due to the lack of benefit and concerns regarding side effects.

ANTIBIOTICS
The first line antibiotic treatment, if warranted, is amoxicillin. If there is resistance, then amoxicillin-clavulanate or another penicillin derivative plus beta lactamase inhibitor is second line. While less than 7 days of antibiotics have less side effects more than seven days appear to be more effective. Among short-course antibiotics, longacting azithromycin was found more likely to be successful than short-acting alternatives.

TYMPANOSTOMY TUBE
In chronic cases with effusions, insertion of tympanostomy tube (also called a "grommet") into the eardrum reduces recurrence rates in the 6 months after placement but have little effect on long term hearing. Thus tubes are recommended in those who have more than 3 episodes of acute otitis media in 6 month or 4 in a year associated with an effusion.

ALTERNATIVE THERAPIES
Complementary and alternative medicine is not recommended for otitis media with effusion because there is no evidence of benefit. There is an osteopathic manipulation technique called the Galbreath technique that can be done at home which is intended to improve drainage. The technique was evaluated in one randomized controlled clinical trial; one reviewer concluded that it was promising, but a 2010 evidence report found the evidence inconclusive.

PROGNOSIS
Acute bacterial otitis media can cause pain that leads to sleepless nights for both children and parents, can cause eardrum perforations, not all of which heal, and can spread to cause mastoiditis and/or meningitis, brain abscess, and even death if a severe infection goes untreated long enough. High fever can occur and can cause febrile seizures. Appropriate antibiotic administration prevents most such complications.

HEARING

LOSS

Children with recurrent episodes of acute otitis media and those suffering from otitis media with effusion or chronic otitis media, have higher risks of developing conductive and sensorineural hearing loss. This hearing loss is mainly due to fluid in the middle ear or rupture of the tympanic membrane. Prolonged duration of otitis media is associated with ossicular complications, and together with persistent tympanic membrane perforation contributes to the severity of both the disease and the hearing loss. When a cholesteatoma or granulation tissue is present in the middle ear, the degree of hearing loss and ossicular destruction is even greater.

Periods of conductive hearing loss from otitis media may have a detrimental effect on speech development in children. Recent studies have also linked otitis media to educational problems, attention disorders, and problems with social adaptation. Furthermore it has been demonstrated that patients suffering from otitis media have more depression/anxiety-related disorders compared to individuals with normal hearing. Once the infections resolve and hearing thresholds return to normal, childhood otitis media may still cause minor and irreversible damage to the middle ear and cochlea.

MENINGITIS

DEFINITION
It

is an inflammation of the meninges. it is the most common infection in children

CAUSES
Bacteria

OF

MENINGITIS

: e.g., meningococcus, pneumococcus, influenza bacillus, tubercle baccilus. Viral: A wide variety of viruses.

PATHOPHYSIOLOGY
Meningitis

OF

MENINGITIS

occurs as a result of the extension of a body infection or directly from wound into skin, skull fracture or through surgical procedures, lumbar puncture. Once the organism implanted, it spreads into the CSF then to subarachnoid space. As any bacterial infection, the infection process is inflammation, exudation, accumulation of the white blood cells and varying degree of tissue damage.

 The

brain becomes edemetous and the brain entire surface is covered with purulent exudates. If infection extends to brain ventricles, thick pus and adhesion will obstruct the CSF flow.

MANIFESTATIONS OF MENINGITIS
In

infants and young children: Children between 3 months and 2 yrs are rarely developing the classical picture of meningitis. Fever, poor feeding and vomiting. Marked irritability, restlessness, and seizures which is accompanied with high pitch cry. Bulging fontanel is the significant finding. The young child may have nuchal rigidity and positive Brudzinski and Kernig signs.

 In

Kernig signs the child easily extends the leg when in supine position. When the thigh is flexed toward the abdomen, pain prevents complete extension of the leg. In Brudzinski sign, while the child in supine position, he bends his head toward his chest. In younger child the nurse can bend the childs head.

Bulging fontanelles

DIAGNOSTIC TESTS OF MENINGITIS

Lumbar

puncture Elevated spinal fluid pressure, turbid CSF, culture of CSF is recommended. White blood count (elevated). Blood glucose is reduced. Blood culture.

MEDICAL TREATMENT
Antibiotics,

OF

MENINGITIS

given intravenously. 7 days and often up to 14 days (newborn babies may require 3 weeks of treatment). If your child is drowsy or there is concern that there is an associated encephalitis (brain infection): aciclovir (acyclovir) is an antiviral medication that is useful in treating encephalitis caused by one particular virus (herpes simplex).

 Dexamethasone,

a steroid, is sometimes given as well for the first 48 hours of treatment studies have shown that in some cases of meningitis, dexamethasone reduces the complication of hearing loss.

THERAPEUTIC MANAGEMENT OF MENINGITIS

The initial therapeutic management includes:
Isolation

precautions. Initiation of antimicrobial therapy, usually through IV infusion and in large doses. Maintenance of optimum hydration through IV infusion. Reduction of increased ICP.

Control

of seizures. Maintenance of ventilation. Control of hypothermia or fever. Correction of anemia. Treatment of complications.

KAMSAHAMNIDA!!!
(THANK YOU )
TIN

& ZHA