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Post-Hemorrhagic Hydrocephalus — Nursing Care — Clinical Pathway: ICU

Post-Hemorrhagic Hydrocephalus in Pre-Term Infants Clinical Pathway — N/IICU

Nursing Care

Pre-Operative Care

Daily Care for All Patients

  • Daily Head Circumference
  • Fontanelle checks with care/vital signs
  • Nursing neuro assessments with vital signs as per orders

Pre-Operative Care

  • CHG bath and Johnson & Johnson head wash before OR
  • Transport on GE warmer bed/ omnibed with the shuttle to maintain heat during transport; baby should wear hat and be on a transwarmer with warm blankets.

Post-Operative Care

Assessments

  • Administer post-op antibiotics per orders (usually cefazolin q8 hours x 3 doses)
  • Head of bed elevated for fresh post-op patient to prevent site leaking
  • Assess site q 4 hours for leakage/drainage (no routine dressing over site)
  • Monitor for seizures
  • Monitor for infection

Bathing

  • Johnson & Johnson wash with sterile water 2-3x daily for first 2 weeks and then daily until all sutures have dissolved per orders.

Caring for an External Drain

In addition to above:

  • Monitor drainage hourly
  • Neuro assessment hourly or per order
  • ICP monitoring is not routine

Caring for a Reservoir

For tapping:

  • Topical lidocaine per orders (must be > 5 kg or ≥ 30 weeks corrected age)
  • Sucrose for procedural pain relief
  • Containment for physical support

Consults

PT/OT

 

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