Sal Romano

The story of his triumph over NPH

Republished with permission of Medical Economics Publishing Co., Inc. from 'RN' , Fraser, Cira, (v59 n1) Start Page: p38(5) ISSN: 0033-7021, Jan 1996; permission conveyed through Copyright Clearance Center, Inc.

Sal Romano, a 78-year-old with type II diabetes, lives alone, but his family has been keeping very close tabs on him for about a year. According to his daughter, that's when he started to 'think more slowly' and become forgetful. He lost interest in his favorite pastimes, too - writing letters to the editor of the local paper and participating in political campaigns. He also started walking differently - in very small, slow, unsteady steps as if his feet were glued to the floor.

In recent months, Mr. Romano has had trouble handling simple tasks. He needs help balancing his checkbook, for example, because he can no longer do the math. He's also started to behave oddly, at times using his car to move personal items from his house to a similar-looking one nearby.

These problems prompted Mr. Romano's daughter to take him to his primary care physician. Without ordering any diagnostic tests, the physician diagnosed senile dementia, and told her that nothing could be done to help him.

Since that visit, Mr. Romano's short-term memory, concentration, and dementia have continued to worsen. He frequently misplaces household items and then accuses others, usually his grandchildren, of taking them. He often gets lost in his own neighborhood. And he goes to sleep twice a day instead of just at night.

Falls are becoming a frequent problem for Mr. Romano because of his increasingly unsteady gait. He has developed occasional urinary incontinence. Fearing for his health and safety, his daughter made another appointment with the doctor - who again maintained that Mr. Romano has an untreatable dementia. Unwilling to accept that sentence, the daughter has brought Mr. Romano to the new geropsychiatric unit at the local hospital.

Once Mr. Romano is admitted, a team consisting of the attending physician, nurses, a psychiatrist, a neurologist, and a social worker begin trying to identify the cause of his dementia. This crucial step is one that many doctors in general practice omit, as did Mr. Romano's private physician.

Within an hour of undergoing the lumbar puncture, which typically includes the removal of 40 - 50 ml of cerebrospinal fluid, Mr. Romano shows improvement, mainly in gait, that lasts almost a day. That' a positive sign, and it means there's a good chance he'll benefit from the standard intervention for NPH-insertion of a ventriculoperitoneal (VP) shunt to drain excess cerebrospinal fluid.

There's a lack of data on the success rate of this procedure, but what is available suggests that anywhere up to 80% of NPH patients experience at least some improvement in cognition, gait, and continence that can begin as soon as two days post-op and progresses for months. And although it's unclear why, studies suggest that improvement tends to be best in patients who developed gait disturbances before the onset of dementia.

Before Mr. Romano undergoes insertion of the VP shunt, a nurse provides routine pre-op teaching. Aware that Mr. Romano's dementia may make communicating difficult, she approaches him slowly and maintains direct eye contact. She speaks simply and directly - lowering the pitch of her voice and avoiding complex gestures - and occasionally touches his hand or shoulder to keep his attention.

The nurse asks Mr. Romano questions one at a time, and allows up to 20 seconds for a response. If she needs to repeat a question, she uses the same words to avoid confusing him. She supplements her teaching with written materials.

She makes sure all water pitchers, cups, and drinking glasses have been removed from the room as well, since Mr. Romano must remain NPO. When helping to prepare him for transfer to the OR, she proceeds in an unhurried manner to minimize the likelihood that he will become anxious or aggressive.

The nurse also takes time to provide emotional support to Mr. Romano's daughter. That's essential because many family members of NPH patients are angry and frustrated over their loved one's condition and the fact that they'd been initially misinformed about the chances for recovery.

Once Mr. Romano is under general anesthesia, the shunt is placed in the lateral ventricle on the non-dominant side of the brain. That's the location of choice because it minimizes the likelihood of damage to the dominant side during surgery - although the risk of any damage is small to begin with.

When the surgery is complete, the shunt is working just as it should be. Cerebrospinal fluid is flowing into the collection catheter, which has a one-way valve that prevents backflow, and emptying into a small reservoir. The fluid then flows into an exit catheter, which is tunneled beneath the skin and leads to the peritoneal cavity.

Mr. Romano stays in the neurological ICU for the first 24 hours postop with a cranial dressing covering the incision on his head. There's a small dressing on his abdomen, too. It covers an incision made during catheter placement.

Every two hours for the first eight hours postop, and then once a shift, Mr. Romano's nurses monitor the cranial dressing for bleeding and drainage of cerebrospinal fluid. They assess both his incision sites for signs of infection like redness, drainage, and foul odor. They also review the neurosurgeon's instructions for positioning the head of the bed, and follow them closely. This is vital for preventing sudden drainage from the shunt, which can lead to cerebral hemorrhaging.

Every 15 - 30 minutes for the first eight to 12 hours postop and then once an hour for the next 12 hours, the nurses do a neurological assessment to monitor for early signs of increased intracranial pressure and intracranial bleeding. These include headache, restlessness, reduced level of consciousness, sluggish pupillary response, and muscle weakness. Aware that epilepsy is a possible complication of VP shunt insertion, albeit an unlikely one, Mr. Romano's nurses maintain seizure precautions. These include storing the equipment needed for giving oxygen at the bedside, taping an appropriate-sized airway over the head of the bed, and keeping the bed in a low position with the side rails up.

Since Mr. Romano's gait disturbance makes him vulnerable to falls, he's placed on a falls prevention program following transfer from the NICU to the med/surg floor. This includes a room assignment near the nurses station to facilitate frequent safety checks by the staff. His nurses also make sure personal items and the call-light are within easy reach.

To maintain muscle strength and endurance and thereby make falls less likely to occur, the nurses regularly assist Mr. Romano in performing range-of-motion exercises. When the physician says he's readyto get up, they make sure to walk him to the bathroom at least every two hours, providing a walker for stability when necessary.

Because Mr. Romano's attention span is reduced, he's at risk for accidental injury - for example, by inadvertently spilling a hot liquid on himself during mealtime. His nurses take precautions wherever possible, in this case removing hot liquids from the patient's meal tray until they cool.

A week after his surgery, Mr. Romano is ready for discharge, although he'll be back in a few days to have his sutures removed. Before he leaves, a nurse provides discharge teaching, making sure to include his daughter in the session since she'll be caring for him at home. The nurse informs them that Mr. Romano will need physical therapy to minimize the risk of falling. She also suggests ways to prevent falls at home, such as wearing sturdy shoes, using a walker, maintaining clear pathways around the house, and, if possible, not leaving the patient unattended.

Infection at the incision sites is a possibility, so she teaches them the signs to watch for. She informs them, too, that while most VP shunts operate trouble-free for years, patients can experience complications. Malfunction is the most common, and may occur when tissue or exudate occlude the shunt, or the device becomes dislodged. This may lead to a relapse of NPH. Infection of the shunt itself is the next most common complication, and often produces fever, weakness, lethargy, and irritability. The nurse instructs Mr. Romano and his daughter to report signs of shunt infection or any recurrence of NPH symptoms to the physician immediately.

A month after surgery, Mr. Romano is well on the road to recovery. His attention span is longer and he's better able to interact with others. Six months postop, his memory is better and he's again managing his finances and doing his own shopping. His gait is markedly improved and he can take long walks without getting lost. He no longer has problems with incontinence as well. In a year, Mr. Romano is once again immersed in his favorite activities, writing letters to the editor and hitting the campaign trail.

Mr. Romano is particularly fortunate, however. Many family members accept a loved one's dementia without question when told that nothing can be done.

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