Hydrocephalus and VP Shunts on the NCLEX
Increased ICP signs by age, post-op shunt care, and how to spot malfunction and infection.
Hydrocephalus questions are really increased-ICP questions, and the signs differ by age because infant sutures are open. Shunt malfunction is those same signs coming back.
Increased ICP by age
Infant (open sutures): bulging tense fontanel, increasing head circumference, widened/split sutures, sunset eyes (sclera visible above the iris), high-pitched cry, poor feeding, vomiting, irritability or lethargy, prominent scalp veins. Older child (closed sutures): headache worst in the morning, vomiting (may be projectile), diplopia, papilledema, behavior change, falling school performance. Late and ominous in both: Cushing triad - bradycardia, widened pulse pressure, irregular respirations. That is herniation territory, not a trend to watch.
VP shunt post-op care
A ventriculoperitoneal shunt drains CSF from the ventricle to the peritoneum. Post-op: position flat initially (per surgeon) so CSF does not drain too fast, and lie the child on the non-operative side to protect the valve. Measure head circumference daily in infants, mark the fontanel assessment, strict neuro checks. Do not pump the shunt unless specifically ordered. Monitor the abdomen too - the distal end lives there.
Malfunction vs infection
Malfunction = the ICP signs return: vomiting, headache, bulging fontanel, lethargy, sunset eyes. Obstruction or disconnection can happen anytime, including years later as the child grows. Infection risk is highest in the first 1-2 months after placement: fever, irritability, poor feeding, redness or swelling along the shunt tract, plus ICP signs. Treated with IV antibiotics and often shunt removal/replacement. Parent teaching: these warning signs, for life. Most children need shunt revisions as they grow.
Frequently asked
Earliest sign of shunt malfunction in an infant?
Often subtle: irritability, poor feeding, vomiting, a fuller fontanel. Trust the parent who says the child is not acting right.
Why keep the child flat after shunt placement?
Sitting upright too soon can drain CSF too quickly and collapse the ventricles. Elevate gradually per surgeon orders.
Is a shunt permanent?
Usually yes, with revisions expected over a lifetime as the child grows or the catheter obstructs.
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