Nursing care
Normal Pressure Hydrocephalus nursing care: what to assess and what to do first
Written and reviewed by Dana Whitfield, RN, MSN · 5 min read · Updated September 2026
Short answer
Normal pressure hydrocephalus is enlargement of the brain's ventricles from impaired cerebrospinal fluid absorption, despite normal opening pressure on lumbar puncture. It presents with gait disturbance first, then urinary incontinence, then cognitive decline, in that order. Unlike most dementias, it is often reversible with a ventriculoperitoneal shunt, which is why recognising the pattern early matters.
What it is and why it happens
Normal pressure hydrocephalus occurs when cerebrospinal fluid absorption at the arachnoid villi is impaired, causing the ventricles to enlarge and press outward on surrounding brain tissue. Despite this enlargement, CSF pressure measured on lumbar puncture is typically normal, which is what gives the condition its name and what makes it easy to overlook on a single pressure reading.
It can be idiopathic, arising with no clear prior event, or secondary to a prior subarachnoid haemorrhage, meningitis, or head injury that scarred the arachnoid villi and reduced absorption. It most commonly affects adults over 60. The reason it deserves specific attention on a general medicine or geriatric unit is that its presentation overlaps heavily with more common causes of cognitive decline, yet its underlying mechanism is mechanical and structural rather than degenerative, which is exactly what makes it treatable.
How it presents — what you will actually see
The classic triad appears in a specific order, and that order is the single most useful diagnostic clue: gait disturbance first, urinary incontinence second, and cognitive impairment third. The gait is often described as magnetic or shuffling, with the feet appearing to stick to the floor and short, wide-based steps, distinct from the shuffling of Parkinson's disease because rigidity and tremor are usually absent.
Urinary incontinence develops later, typically urgency progressing to frank incontinence, and is often present before the family or patient volunteers it. Cognitive changes come last, presenting as slowed thinking, apathy, and reduced attention, more consistent with a subcortical pattern than the memory-predominant profile typical of Alzheimer's disease. Any patient labeled with progressive dementia should have the gait history checked carefully, since gait preceding cognitive decline is the detail most likely to have been missed on a prior visit.
Nursing assessment priorities
Take a careful history of symptom order directly from the patient and family, asking specifically which came first: the walking difficulty, the bladder symptoms, or the thinking changes. This sequence is the clue that distinguishes NPH from other dementias and is often the detail that prompts the referral for imaging.
On the unit, conduct a fall risk assessment with every shift given the gait instability, and document gait quality in specific terms, such as step width, step length, and whether the patient appears to lift the feet or shuffle. Assess continence status and any urinary symptoms as part of the same visit rather than a separate concern, since in NPH they are part of one underlying process. After a CT or MRI confirms ventriculomegaly, a large-volume lumbar puncture or extended lumbar drain trial is often performed, and nursing assessment before and after this trial, specifically gait speed and cognitive testing, is what determines whether the patient is a shunt candidate.
Interventions and what to do first
The first nursing priority for any patient with suspected NPH is fall prevention, since the gait disturbance places them at high risk before any definitive treatment begins. Bed alarms, assistive devices, and a low bed height are reasonable first steps while diagnostic workup proceeds.
The definitive treatment is surgical placement of a ventriculoperitoneal shunt to divert excess CSF, and this is where the reversibility of the condition becomes clinically important: gait often improves within days of shunting, sometimes before cognition or continence catches up. Postoperative nursing care centres on monitoring for overdrainage, which presents as a positional headache worse when upright, and underdrainage, which presents as recurrence of the original triad. Neurological checks and shunt valve setting verification are part of routine postoperative monitoring.
Complications to watch for
Shunt malfunction is the primary postoperative complication to watch for, and it can present as either obstruction, with return of gait disturbance and worsening cognition, or overdrainage, with a headache that improves when lying flat and worsens on standing. Either presentation warrants prompt notification of the neurosurgical team.
Shunt infection is a serious complication, typically presenting within the first month with fever, redness or swelling along the shunt tract, or new confusion, and requires urgent evaluation. Subdural haematoma can occur from overdrainage in older adults with more fragile bridging veins, so any new headache accompanied by a change in level of consciousness after shunt placement should be treated as urgent rather than attributed to routine postoperative discomfort.
Patient teaching before discharge
Teach the patient and family to recognise the specific signs of shunt malfunction: a headache that changes with position, return of the gait pattern they had before surgery, or new confusion, and to seek care immediately rather than waiting for the next scheduled follow-up.
Reinforce fall precautions at home even after shunting, since gait improvement can be gradual rather than immediate, and the home environment should be assessed for hazards such as loose rugs or poor lighting before discharge. Explain that continence and cognitive symptoms may take longer to improve than gait, or may not fully resolve, so families should expect gradual rather than complete recovery and should not interpret a slower return of continence as a failed shunt.
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Common questions
What is the classic symptom order in normal pressure hydrocephalus?
Gait disturbance appears first, followed by urinary incontinence, followed by cognitive decline. This order is the key clue that separates NPH from other forms of dementia, where memory loss is usually the first symptom noticed.
Is normal pressure hydrocephalus reversible?
Yes, unlike most causes of dementia, NPH symptoms, particularly the gait disturbance, often improve significantly after ventriculoperitoneal shunt placement. Early recognition and treatment improve the odds of meaningful recovery.
How is normal pressure hydrocephalus different from Alzheimer's disease?
NPH begins with gait changes and a subcortical pattern of slowed thinking and apathy, while Alzheimer's typically begins with memory loss. NPH also shows ventriculomegaly on imaging with normal CSF opening pressure, a mechanical rather than degenerative cause.
What should a nurse do first for a patient with suspected NPH?
Prioritise fall prevention given the gait instability, and document the specific order in which gait, bladder, and cognitive symptoms appeared. That symptom sequence often guides the diagnostic workup toward imaging and a lumbar drain trial.
What are the signs of shunt malfunction after surgery?
Watch for a positional headache, worse when upright and better lying flat, which suggests overdrainage, or a return of the original gait and cognitive symptoms, which suggests obstruction. Fever or redness along the shunt tract suggests infection and needs urgent evaluation.