Health Service Applications Planning for a Child with Hydrocephalus: A Guidefor the School Nurs Salva Failla, Ann Witt Todaro
C
hildren with special health care needs in classrooms have become a familiar situation to educational and school health care personnel. Legislation such as the Education for All Handicapped Children Act of 1975 (Public Law 92-142) and the Education of the Handicapped Act Amendments of 1986 (Public Law 99-457) mandate that health care services be provided to these children at school.’.* Programs focusing on child-specific information are vital to the growth and development of children with special needs. Prior to developing an Individual Educational Plan (IEP) and/or an Individual Health Plan (IHP), the school nurse should collect data on the child’s health condition and needs. Information sources include, but are not limited to the child (if appropriate), parents or other caregivers, school personnel such as teachers, special educators and classroom assistants, and community health providers such as the physician and clinic staff. By obtaining information from these resources. the child’s needs are addressed more accurately. In addition, knowledge obtained and shared will help prepare school personnel to meet the child’s needs in the school setting . The information that can be shared should be specific to the child. Areas of concern should focus on: basic facts, cause, treatment, and prognosis of the health condition; problems for the child; problems for the family; information needs; skill needs; common educational implications; physical education activity considerations; emergency procedures including warning signs and symptoms, as well as situations of immediate danger; and emergency information. These focal points provide a generic outline for any child-specific condition. The following example of a child with hydrocephalus is adapted from Community Provider’s Guide: An Information Outline for Working with Children with . ~case Special Health Care Needs, 1991 a d d e n d ~ mA history and appropriate emergency procedures also are illustrated (Figure 1 and Figure 2). Salva Failla, RN, DNS, Assistant Professor of Nursing, Louisiana State University Medical Center, School of Nursing, 1900 Gravier St., New Orleans, L A 70112-2262 and Nurse Consultant, National Maternal and Child Health Resource Center, Children’s Hospital, New Orleans, La.: and Ann Wilt Todaro, MN, R N , Nurse Consultant, National Maternal and Child Health Center, Children% Hospital. 200 Henry Clay Ave.. New Orleans, L A 70118. This project is supported by project MCJ-225047 from the Maternal and Child Health Bureau program (Title V, Social Security Act), Health Resources and Services Administration. U.S. Dept. of Health and Human Services, Rockville, Md. This article was submitted August 12, 1991, and revised and accepted for publication November 4, 1991.
WHAT IS HYDROCEPHALUS? Hydrocephalus is characterized by an excess of cerebrospinal fluid, the watery cushion that protects the brain and spinal cord. If hydrocephalus develops in infancy, the head usually becomes enlarged, and the anterior fontanelle, the soft spot on top of the head, may bulge and the infant will be irritable and listless. In the older child, other signs and symptoms may be present such as headache, irritability, lethargy, and confusion. An x-ray or scan of the head is usually obtained to diagnose hydrocephalus. Cause. Hydrocephalus develops when cerebrospinal fluid (CSF) is produced and absorbed at an unequal rate causing increased pressure in the child’s head. This occurs when the flow of CSF is blocked or when absorption is impaired. Hydrocephalus is commonly seen in children with spina bifida. Other causes include structural defects of the brain, infections (meningitis), intracranial hemorrhage (bleeding in the brain), and tumors. Treatment. In most cases, hydrocephalus is treated by surgery, specifically placement of a shunt, a tube that carries CSF from the brain to another part of the body, typically the abdomen. This procedure allows adequate absorption of CSF. If an obstruction, such as a tumor, causes the hydrocephalus, the obstruction may need to be removed surgically. Fjgure 1
Hvdroceohalus: Case ExamDle Pletcrlpllon Date
RE: D.O.B.: Diagnosis: Hydrocephalus
‘s health Consider this a prescription for maintenance procedures in school. To assure the child’s safety and reduce the risk of your liability. documentation of individualized prescriptions, procedures, training, and monitoring within your setting is recommended. History:
Diagnosed with hydrocephalus at birth when a shunt was placed; experiences difficulties with visual focusing and tracking; and has strabismus (one eye looks forward while the other looks in or out) which is being treated with an eye patch.
Shunt:
Be alert to signs of malfunction: headache, vomiting, behavioral changes (quiet or irritable)
Seizure activity: Follow seizure precautions. Activate emergency system Medications:
Tegretol: At Home Potential Side Effects: nausea, visual disturbances, d i m ness.
Activity:
Child should avoid contact sports. Other physical activities should be discussed with physician Physician Signature
Journal of School Health
Dale
March 1992, Vol. 62, No. 3
107
Prognosis. With proper medical and surgical treatment, these children can survive. Ultimately, their growth and development will depend on the cause and duration of the illness, the time interval before treatment was instituted, and the potential complications that may occur. Increased pressure may result in damage to the brain. Problems for Child. Children with shunts are at risk for infection and malfunction. Thus, it is not uncommon for the child to require additional surgery to revise the shunt as necessary. Depending on the child and the physician, hospitalizations may be planned for particular times of the child’s growth and development. Hospitalizations will require school absences that interrupt the educational process and socialization. The child’s self-image may be altered due to the need to shave the head for surgery. Other disabilities may accompany the hydrocephalus, such as spina bifida, seizures, and cerebral palsy. Figure 2 Hydrocephalus: Emergency Procedures Warning Signs 8 Symptoms Common Symptoms Child’s Normal Symptoms 1. Fever 2. Vomiting 3. Change in Level of Alertness and Behavior 4. Decrease in Appetite 5. Lethargy 6. Visual Disturbance 7. Unsteady Gait (walk) Treatment 1 . Contact Parent@) 2. Contact Physician lmmedhti Danger Common Symptoms 1. Seizure 2. Cessation of Breathing
Child’s Normal Symptoms
Treatment 1 . Seizure Precautions 2. Initiate CPR if Breathing Stops 3. Contact Emergency Room and Transport 4. Contact Parent@)
Provider’s Signature
Date
Emergency informalon Ambulance Service
Name
Number
Emergency Room
Number
Physician
Name
Parent or Guardian
Number
Name home number
Alternate Contact
Name
home number
work number
available, the school principal or alternate will have my child transported to the emergency room I will pay the expenses 01 this transportation ParentIGuardian
Original School Nursing
108
As illustrated in this example, specific training is necessary for each child. Though one individual may be responsible for the “hands-on” care of the child, all school personnel who have contact with these children should be aware of their needs. For example, in the hydrocephalus case, all personnel involved should be knowledgeable and trained in seizure precautions. To meet the educational and health care requirements of children with special health care needs, a collaborative effort must be put forth by all involved with the child. This challenge necessitates implementing a comprehensive program that meets the needs of the child in the least restrictive environment.
work number
I am aware that if my child has an emergency in school and I am not
Signature
NEEDS OF SCHOOL PERSONNEL lnformation Needs. Individuals involved with the child during school hours need general information about hydrocephalus, presence of other anomalies (spina bifida), signs/symptoms of shunt complications, seizure precautions, activity restrictions, and medications and side effects. Skill Needs. Performing certain skills will be required including detection of an emergency, implementation of emergency procedures, administration of medications (if applicable), and intervention during seizure. Educational Implications. Several educational implications must be considered: peer and teacher education, observation of confusion or changes in level of alertness, complaints of headache, observation of irritability, observation of mood or personality changes, activity restrictions, special education instruction and related services, visual problems, and medication side effects. Physical Education Considerations. Children with hydrocephalus typically are treated with shunt placements. The child should not participate in contact sports that may damage the shunt. Though the child should participate in most other activities, the physician should be contacted for further information. CONCLUSION
Form was individualized by: Parent’s Signature
Problems for Families. Caring for a child with hydrocephalus presents a challenge for the family. They must be alert t o complications that arise from placement of the shunt, including malfunction and infection. Financial concerns, as well as anxiety that the family must face with each hospitalization, are stressful. Support through education, encouragement, and resources can assist the family in dealing with their responsibilities.
Journal of School Health
Dale
Copy Principal, Teacher
March 1992, Vol. 62, No. 3
References I . Baird SM, Ashcroft SC. Need based educational policy for chronically ill children. In: Hobbs N, Perrin J . eds. Issues in the Care of Children with Chronic Illness. San Francisco, Calif: Jossey-Bass Publishers; 1985:656-671. 2. Whaley LF, Wong DL. Nursing Care of Infants and Children, 4th ed. St Louis, Mo: CV Mosby Co; 1991:996. 3. Caldwell TH, Todaro AW, Gates AJ, Failla SA. Kirkhart KA. Community Provider’s Guide: A n information outline for working with children with special health care needs, 1991 addendum. New Orleans, La: Children’s Hospital; In press.
C
hildren with special health care needs in classrooms have become a familiar situation to educational and school health care personnel. Legislation such as the Education for All Handicapped Children Act of 1975 (Public Law 92-142) and the Education of the Handicapped Act Amendments of 1986 (Public Law 99-457) mandate that health care services be provided to these children at school.’.* Programs focusing on child-specific information are vital to the growth and development of children with special needs. Prior to developing an Individual Educational Plan (IEP) and/or an Individual Health Plan (IHP), the school nurse should collect data on the child’s health condition and needs. Information sources include, but are not limited to the child (if appropriate), parents or other caregivers, school personnel such as teachers, special educators and classroom assistants, and community health providers such as the physician and clinic staff. By obtaining information from these resources. the child’s needs are addressed more accurately. In addition, knowledge obtained and shared will help prepare school personnel to meet the child’s needs in the school setting . The information that can be shared should be specific to the child. Areas of concern should focus on: basic facts, cause, treatment, and prognosis of the health condition; problems for the child; problems for the family; information needs; skill needs; common educational implications; physical education activity considerations; emergency procedures including warning signs and symptoms, as well as situations of immediate danger; and emergency information. These focal points provide a generic outline for any child-specific condition. The following example of a child with hydrocephalus is adapted from Community Provider’s Guide: An Information Outline for Working with Children with . ~case Special Health Care Needs, 1991 a d d e n d ~ mA history and appropriate emergency procedures also are illustrated (Figure 1 and Figure 2). Salva Failla, RN, DNS, Assistant Professor of Nursing, Louisiana State University Medical Center, School of Nursing, 1900 Gravier St., New Orleans, L A 70112-2262 and Nurse Consultant, National Maternal and Child Health Resource Center, Children’s Hospital, New Orleans, La.: and Ann Wilt Todaro, MN, R N , Nurse Consultant, National Maternal and Child Health Center, Children% Hospital. 200 Henry Clay Ave.. New Orleans, L A 70118. This project is supported by project MCJ-225047 from the Maternal and Child Health Bureau program (Title V, Social Security Act), Health Resources and Services Administration. U.S. Dept. of Health and Human Services, Rockville, Md. This article was submitted August 12, 1991, and revised and accepted for publication November 4, 1991.
WHAT IS HYDROCEPHALUS? Hydrocephalus is characterized by an excess of cerebrospinal fluid, the watery cushion that protects the brain and spinal cord. If hydrocephalus develops in infancy, the head usually becomes enlarged, and the anterior fontanelle, the soft spot on top of the head, may bulge and the infant will be irritable and listless. In the older child, other signs and symptoms may be present such as headache, irritability, lethargy, and confusion. An x-ray or scan of the head is usually obtained to diagnose hydrocephalus. Cause. Hydrocephalus develops when cerebrospinal fluid (CSF) is produced and absorbed at an unequal rate causing increased pressure in the child’s head. This occurs when the flow of CSF is blocked or when absorption is impaired. Hydrocephalus is commonly seen in children with spina bifida. Other causes include structural defects of the brain, infections (meningitis), intracranial hemorrhage (bleeding in the brain), and tumors. Treatment. In most cases, hydrocephalus is treated by surgery, specifically placement of a shunt, a tube that carries CSF from the brain to another part of the body, typically the abdomen. This procedure allows adequate absorption of CSF. If an obstruction, such as a tumor, causes the hydrocephalus, the obstruction may need to be removed surgically. Fjgure 1
Hvdroceohalus: Case ExamDle Pletcrlpllon Date
RE: D.O.B.: Diagnosis: Hydrocephalus
‘s health Consider this a prescription for maintenance procedures in school. To assure the child’s safety and reduce the risk of your liability. documentation of individualized prescriptions, procedures, training, and monitoring within your setting is recommended. History:
Diagnosed with hydrocephalus at birth when a shunt was placed; experiences difficulties with visual focusing and tracking; and has strabismus (one eye looks forward while the other looks in or out) which is being treated with an eye patch.
Shunt:
Be alert to signs of malfunction: headache, vomiting, behavioral changes (quiet or irritable)
Seizure activity: Follow seizure precautions. Activate emergency system Medications:
Tegretol: At Home Potential Side Effects: nausea, visual disturbances, d i m ness.
Activity:
Child should avoid contact sports. Other physical activities should be discussed with physician Physician Signature
Journal of School Health
Dale
March 1992, Vol. 62, No. 3
107
Prognosis. With proper medical and surgical treatment, these children can survive. Ultimately, their growth and development will depend on the cause and duration of the illness, the time interval before treatment was instituted, and the potential complications that may occur. Increased pressure may result in damage to the brain. Problems for Child. Children with shunts are at risk for infection and malfunction. Thus, it is not uncommon for the child to require additional surgery to revise the shunt as necessary. Depending on the child and the physician, hospitalizations may be planned for particular times of the child’s growth and development. Hospitalizations will require school absences that interrupt the educational process and socialization. The child’s self-image may be altered due to the need to shave the head for surgery. Other disabilities may accompany the hydrocephalus, such as spina bifida, seizures, and cerebral palsy. Figure 2 Hydrocephalus: Emergency Procedures Warning Signs 8 Symptoms Common Symptoms Child’s Normal Symptoms 1. Fever 2. Vomiting 3. Change in Level of Alertness and Behavior 4. Decrease in Appetite 5. Lethargy 6. Visual Disturbance 7. Unsteady Gait (walk) Treatment 1 . Contact Parent@) 2. Contact Physician lmmedhti Danger Common Symptoms 1. Seizure 2. Cessation of Breathing
Child’s Normal Symptoms
Treatment 1 . Seizure Precautions 2. Initiate CPR if Breathing Stops 3. Contact Emergency Room and Transport 4. Contact Parent@)
Provider’s Signature
Date
Emergency informalon Ambulance Service
Name
Number
Emergency Room
Number
Physician
Name
Parent or Guardian
Number
Name home number
Alternate Contact
Name
home number
work number
available, the school principal or alternate will have my child transported to the emergency room I will pay the expenses 01 this transportation ParentIGuardian
Original School Nursing
108
As illustrated in this example, specific training is necessary for each child. Though one individual may be responsible for the “hands-on” care of the child, all school personnel who have contact with these children should be aware of their needs. For example, in the hydrocephalus case, all personnel involved should be knowledgeable and trained in seizure precautions. To meet the educational and health care requirements of children with special health care needs, a collaborative effort must be put forth by all involved with the child. This challenge necessitates implementing a comprehensive program that meets the needs of the child in the least restrictive environment.
work number
I am aware that if my child has an emergency in school and I am not
Signature
NEEDS OF SCHOOL PERSONNEL lnformation Needs. Individuals involved with the child during school hours need general information about hydrocephalus, presence of other anomalies (spina bifida), signs/symptoms of shunt complications, seizure precautions, activity restrictions, and medications and side effects. Skill Needs. Performing certain skills will be required including detection of an emergency, implementation of emergency procedures, administration of medications (if applicable), and intervention during seizure. Educational Implications. Several educational implications must be considered: peer and teacher education, observation of confusion or changes in level of alertness, complaints of headache, observation of irritability, observation of mood or personality changes, activity restrictions, special education instruction and related services, visual problems, and medication side effects. Physical Education Considerations. Children with hydrocephalus typically are treated with shunt placements. The child should not participate in contact sports that may damage the shunt. Though the child should participate in most other activities, the physician should be contacted for further information. CONCLUSION
Form was individualized by: Parent’s Signature
Problems for Families. Caring for a child with hydrocephalus presents a challenge for the family. They must be alert t o complications that arise from placement of the shunt, including malfunction and infection. Financial concerns, as well as anxiety that the family must face with each hospitalization, are stressful. Support through education, encouragement, and resources can assist the family in dealing with their responsibilities.
Journal of School Health
Dale
Copy Principal, Teacher
March 1992, Vol. 62, No. 3
References I . Baird SM, Ashcroft SC. Need based educational policy for chronically ill children. In: Hobbs N, Perrin J . eds. Issues in the Care of Children with Chronic Illness. San Francisco, Calif: Jossey-Bass Publishers; 1985:656-671. 2. Whaley LF, Wong DL. Nursing Care of Infants and Children, 4th ed. St Louis, Mo: CV Mosby Co; 1991:996. 3. Caldwell TH, Todaro AW, Gates AJ, Failla SA. Kirkhart KA. Community Provider’s Guide: A n information outline for working with children with special health care needs, 1991 addendum. New Orleans, La: Children’s Hospital; In press.
