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학습 자료 둘러보기 →In a child with a VP shunt, the classic triad of irritability, vomiting, and a high-pitched cry indicates a potential shunt malfunction leading to increased intracranial pressure (ICP). The nurse's priority is to directly assess for signs of rising ICP.
The most critical and immediate assessments are palpating the fontanelles for bulging and measuring head circumference. A bulging fontanelle is a key predictor of shunt block, even if the fontanelle is small or closing in a 2-year-old. A rapid increase in head circumference confirms an expanding intracranial volume.
Do not delay the neurological assessment to check for fever or shunt site appearance. While infection is a common cause of malfunction, the immediate life-threat is brain herniation from uncontrolled ICP. Neurological status changes are the earliest and most reliable indicators of a malfunction.
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