Encephalitis NCLEX Review Care Plans
Encephalitis NCLEX Review and Nursing Care Plans
Encephalitis is a disease characterized by the inflammation and infection of the brain.
The most common cause of encephalitis is a viral infection, so the signs and symptoms usually start as those similar with flu – headache, fever, body ache and weakness.
However, some cases can be asymptomatic at the beginning. The symptoms worsen as the patient may develop changes in the level of consciousness, seizures, or trouble with speech, movement, eyesight, and hearing. Encephalitis can affect infants and young children.
Early detection and treatment is necessary to reverse its effect on the patient.
Signs and Symptoms of Encephalitis
- Fever or hyperthermia
- Muscle or joint ache
- Myalgia or body weakness
- Decline in mental status, such as confusion, agitation, or hallucinations
- Paralysis or loss of sensation, usually on the face
- Trouble with speech or hearing
Infants may have symptoms of bulging fontanels or soft spots in the skull, as well as poor feeding. Young children may show irritability, nausea and vomiting.
Causes of Encephalitis
Primary encephalitis happens when a virus or another pathogen causes an infection in the brain.
The common viruses that may cause encephalitis include herpes simplex virus (HSV), Epstein-Barr virus, enteroviruses, tick-borne viruses, rabies virus, and mosquito-borne viruses,
On the other hand, secondary encephalitis involves a dysfunction immune response to an infection that is happening in another part of the body. The immune cells attack and damage the brain cells, instead of going to the infected body cells.
This can happen 2 to 3 weeks after an infection.
Measles and mumps are infections that can cause secondary encephalitis in children. However, the vaccination programs for these childhood infections have caused the decline in the case of secondary encephalitis.
Complications of Encephalitis
Encephalitis can progress to coma and can be fatal as well. Since it affects the brain, the patient may also develop speech impairments, paralysis, lack of muscle coordination, personality changes, and problems with hearing, vision, and memory.
Diagnosis of Encephalitis
- Imaging – to visualize any signs of inflammation in the brain using MRI or CT scan
- Lumbar puncture or spinal tap – to analyze the cerebrospinal fluid (CSF) from the lumbar spine area for signs of infection and inflammation in the brain
- Electroencephalogram (EEG) – to analyze the electrical activity of the brain
- Lab tests – urine, stool, sputum, blood, and other liquid samples may be required to check for any presence of virus or other pathogens
- Brain biopsy – the physician may sometimes require a small sample of brain tissue if symptoms become worse while the patient is already on active treatment
Treatment for Encephalitis
- Antivirals. Viral encephalitis needs to be treated with antivirals, which include Acyclovir (Zovirax), Ganciclovir (Cytovene), and Foscarnet (Foscavir). These antivirals may not be effective for insect-borne viruses, but the usual treatment of choice is Acyclovir.
- Supportive treatment. Mild encephalitis is usually treated with fluid hydration, bed rest, anti-inflammatory medications such as ibuprofen or acetaminophen, and close monitoring.
- Anticonvulsants. To prevent or treat seizures, anticonvulsants like phenytoin (Dilantin) may be given.
- Therapies. The complications of encephalitis may require the patient to undergo physical and occupational therapy, psychotherapy, and/or speech therapy in order to maintain an optimal quality of life.
Prevention of Encephalitis
- Vaccinations. Children and adults need to get vaccinated against mumps and measles, as these can cause secondary encephalitis. Before traveling to countries where insects such as ticks and mosquitoes are prevalent, specific vaccinations against these may be required.
- Avoid mosquitoes. DEET is a chemical found in mosquito repellents and is effective in preventing mosquitoes from getting near the skin. It is important to remove stagnant water in and around the house to remove the possible breeding grounds of mosquitoes.
Nursing Diagnosis for Encephalitis
Nursing Care Plan for Encephalitis 1
Nursing Diagnosis: Hyperthermia secondary to infective process of encephalitis as evidenced by temperature of 38.5 degrees Celsius, rapid breathing, profuse sweating, and chills
Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.
|Encephalitis Nursing Interventions||Rationales|
|Assess the patient’s vital signs at least every 4 hours.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antivirals/ antibiotics and fever-reducing drugs (e.g. Paracetamol) administered.|
|Remove excessive clothing, blankets and linens. Adjust the room temperature.||To regulate the temperature of the environment and make it more comfortable for the patient.|
|Administer the prescribed antibiotic and anti-pyretic medications.||Use the antiviral or antibiotic to treat infection (encephalitis), which is the underlying cause of the patient’s hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.|
|Offer a tepid sponge bath.||To facilitate the body in cooling down and to provide comfort.|
|Elevate the head of the bed.||Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.|
Nursing Care Plan for Encephalitis 2
Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral) related to cerebral edema and increased intracranial pressure (ICP) secondary to encephalitis as evidenced by drowsiness, hallucinations, irritability, and memory problems
Desired Outcome: The patient will maintain cerebral tissue perfusion as evidenced by increased level of consciousness (i.e. awake and alert) and will have an oriented with persons, places, and things.
|Encephalitis Nursing Interventions||Rationales|
|Assess the patient’s vital signs and neurological status at least every 4 hours, or more frequently if there is a change in them.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment for encephalitis.|
|Observe the patient for any signs and symptoms of increased ICP, such as sudden headache, vomiting, and decreased alertness.||To facilitate early detection and management of increased ICP.|
Increased ICP can be life-threatening as it may lead to brain damage, stroke, or coma.
|Administer the prescribed antibiotic medications.||Use the antiviral or antibiotic to treat encephalitis, which is the underlying cause of the patient’s increased ICP.|
|Administer osmotic diuretics (e.g. Mannitol) as prescribed.||To promote blood flow to the brain and to reduce cerebral edema.|
|Elevate the head of the bed at 30 degrees.||To promote venous drainage from the patient’s head to the rest of the body in order to decrease ICP and reduce cerebral edema.|
Nursing Care Plan for Encephalitis 3
Nursing Diagnosis: Disturbed Sensory Perception related to cerebral edema secondary to encephalitis as evidenced by sensorium changes in the patient.
Desired Outcome: The patient will be able to regain or maintain normal level of consciousness for the duration of hospital admission as evidenced by no deductions of two or more to the usual Glasgow Coma scale of the patient.
|Encephalitis Nursing Interventions||Rationale|
|Evaluate the patient’s level of consciousness utilizing the Glasgow Coma scale.||The Glasgow coma scale is a scientific tool with the goal of assessing the motor, verbal, and sensory details of a patient with regard to the level of consciousness (LOC). Neurological assessment that assists in evaluating the condition of the patient with encephalitis.|
|Monitor and inform the physician for the continuous degradation of the patient’s consciousness.||Changes in the patient’s therapeutic management may be edited once consciousness further degrades. Mental changes, seizures, elevated blood pressure, bradycardia, or respiratory deviations may connote an elevating intracranial pressure (ICP), with associated diminishing brain tissue perfusion pressure.|
|Evaluate for clinical manifestations of cerebral edema like headache, dizziness, neck pain, irregular breathing, vomiting, or nausea.||Conditions such as anoxia, vascular stasis or vasodilation can result in cerebral edema because of the elevated intracellular and extracellular fluid in the brain as the manifestations advance.|
|Evaluate the patient’s ability to comply with simple or complex instructions.||Cognitive function impairment may happen if the brain’s cerebral hemisphere is compromised.|
|Assess for clinical manifestations of encephalitis such as photophobia, headache, stiff neck, mental confusion, and seizures.||Clinical manifestations of encephalitis are manifested by various neurological symptoms due to the associated inflammation of the brain tissues that hinder its normal functioning and physiology.|
|Raise the head of the bed between 30 to 45 ° while maintaining the patient’s head in neutral placement.||This position allows for appropriate venous blood flow from the brain that will assist in decreasing latent intracranial pressure.|
|Recondition the patient to the current environment as necessary.||Repeated guiding of the patient to reality by the healthcare team is beneficial for patients with impaired neurological functions (due to encephalitis) so as to maintain cognitive functions and reduce long-term disability.|
|Anticipate in helping the team do the following diagnostics: ElectroencephalogramLumbar puncture for cerebrospinal fluid (CSF) collectionMagnetic resonance imaging (MRI), Computed tomography (CT) or ventriculogram||The mentioned diagnostic exams are utilized to assess the brain’s physiology by evaluation of intracranial pressure, identification of causative agents, and visualization of the involved cerebral structures.|
|Place the patient on seizure precautions. Monitor and render care during seizure activities.||Patients with neurologic conditions are predisposed to exhibiting seizure activity. Ensuring that seizure precautions are in place would prevent unnecessary complications and maintain patient safety.|
|Ensure in keeping the patient’s environment quiet and calm. Keep the lights dim in the patient’s surroundings as much as possible.||Patients with neurologic conditions such as encephalitis are highly sensitive to external stimuli like bright lights. Ensuring a quiet and calm environment will help in preventing the occurrence of convulsion episodes triggered by external stimuli.|
|Evaluate the patient’s pupil size every 3 hours for the initial 24 hours, then every 6 hours for the succeeding, or unless ordered otherwise.||Elevated intracranial pressure will present as having uneven sizes with fixed dilated pupils.|
|Take note and record the quality of seizure episodes, focusing on the frequency and type. Inform the doctors of every seizure episode.||Recognizing changes in the patient’s seizure patterns would indicate the need to improve on the therapeutic management of the patient. Adjustments to anticonvulsants, re-assessment of neurological function, and reevaluation of therapies would be the areas where improvement will be done. During a seizure, an increase in ICP will happen. This, together with inadequate antibiotic therapy will promote uncontrolled seizure activity, consequently, will result to further neurologic deterioration.|
|Allow the significant others to assume active roles in the care of the patient.||Active participation would elicit better coping for the family in taking care of their debilitated family member. It also further decreases anxious feelings for they are involved directly with the care.|
|Render ordered anti-convulsant as indicated. Anticipate monitoring of the anticonvulsant drug serum levels.||Anticonvulsant therapy is part of the treatment plan for patients with encephalitis. They are used both as prevention and treatment for seizures in patients with encephalitis. Anticipate monitoring of the serum levels of anticonvulsants to ensure that therapeutic values are within range and effectivity of therapy is maintained.|
Nursing Care Plan for Encephalitis 4
Nursing Diagnosis: Anxiety related to changes in neurologic functioning and physiology secondary to encephalitis as evidenced by increased apprehension regarding the disease progression and its debilitating side effects.
Desired Outcome: The patient will be able to express decreased levels of anxiety as evidenced by verbalizations of reducing anxious behavior and committing to planned therapeutic management and care.
|Encephalitis Nursing Interventions||Rationale|
|Evaluate the degree and source of the patient’s anxiety. Take note of the clinical manifestations and the need for more data and support for the patient.||Assessing for the reason of anxiety and its associated severity is crucial in the formulation and implementation of therapeutic interventions needed to address the patient’s anxiety and concern. Possible sources of anxiety, that needs to be recognized and addressed accordingly, include uncertainty of the treatment and recovery goals of the patient, feelings of guilt due to the illness, and the possibility of debilitating effects that will prevent the resumption of previous roles.|
|Evaluate feelings of guilt by the patient and significant others for delayed recognition of encephalitis and its seriousness. Allow them to discuss freely their opinions and feelings about the condition.||Assessing the patient and significant other’s guilt feelings creates opportunities for the healthcare team to properly guide and correct misinformation that they may have. It also lessens feelings of guilt and prevents blaming behavior.|
|Allow the patient or significant others to verbalize their concerns and inquiries regarding the condition.||Allowing the patient and significant others to verbalize their feelings provides an opportunity for venting out feelings, correcting of misconceptions, and provision of accurate data in order to lessen anxiety.|
|Allow the significant other to stay with the patient as much as allowed. Let the significant other participate in the patient’s activities of daily living (ADL’s) and provide the needed data regarding routine while admitted.||Allowing the family to participate in the patient’s care activities will allow for better family relationships and lessen anxiety levels.|
|Motivate the significant other to be involved in the therapeutic management and decision-making regarding the rendered care to the patient.||Involvement with the care needs of the patient will promote continuous monitoring by the family to their patient, whether improving or worsening.|
|Educate the patient and the significant others about the pathophysiologic process, instances, effects, and manifestations of encephalitis.||Educating the patient on the appropriate mechanisms of the disease allow for the alleviation of anxiety that could potentially affect the care plan goals of the patient.|
|Instruct the patient and significant others of the relevance of the different procedures, forms of intervention, and diagnostic tests to be done.||Informing the patient and family of the therapeutic interventions that will be employed will keep them updated and oriented to the pan of care thereby reducing any anxious thoughts they may have.|
|Instruct significant others that the patient will be placed on isolation precautions for at least 24 hours or until the confirmatory diagnosis is reached and the antibiotic regimen has commenced in producing therapeutic effects.||Placing the patient under isolation precautions will promote safety to others by providing the opportunity to identify the causative agent. It also prevents transmission of the disease to others who may come in contact with the patient.|
|Correct any misinformation that the patient and family may have. Take time to answer queries in the vernacular, especially those involving the therapeutic management of the condition.||Inaccurate information and beliefs may cause unnecessary anxiety to the patient. Ensuring that consistent and correct information is given will allow for better outcomes and improved compliance with the treatment plan.|
Nursing Care Plan for Encephalitis 5
Nursing Diagnosis: Deficient Knowledge related to lack of exposure to correct information secondary to encephalitis as evidenced by information-seeking behavior regarding medications clinical manifestations, and treatment plan to encephalitis.
Desired Outcome: The patient will be able to verbalize the rationale of the therapeutic plan and show comprehension of the causes of the disease process.
|Encephalitis Nursing Interventions||Rationale|
|Evaluate the knowledge base of the patient and relative considering the disease process and how it is therapeutically managed. Consider their willingness and interest to participate actively in the care.||Assessing the knowledge base will prevent from repeating information that is already known to the patient. Furthermore, it can promote compliance once a concrete therapeutic management plan has been devised for the patient.|
|Give out information and rationale in the common / vernacular language. As much as possible utilize pictures, videos, and other teaching models in teaching about the disease.||Visual aids are useful in connecting with the learner for it reinforces acquired knowledge that was taught. Giving out information in common language ensures better comprehension and compliance with the treatment plan.|
|Educate regarding medications administered indicated for encephalitis, including the dosages, timing, frequency, expected side effects, manner of how it’s given, etc. Ensure to give out written instructions and appropriate schedule with regards to medications.||Compliance with the prescribed medication therapy is crucial in treating encephalitis. Providing information will ensure for compliance in order to prevent untoward complications from the disease (e.g., seizure, etc.)|
|Aid in the patient’s feeding plan, make sure to consider the food type, caloric contents, etc. in relation to the nutritional needs of the patient. Anticipate use of other forms of nutritional support (e.g., enteral feeding, etc.) as ordered appropriately.||Assisting the family in meal plans ensures that the patient receives adequate and optimal nutrition in relation to the needs of a patient with encephalitis.|
|Remind parents or significant others of the need for follow-up with hearing assessment for patients with encephalitis.||Because of the nature of the condition, patients are prone to develop impairments in their senses, one of which is the auditory acuity. Assessing the 8th cranial nerve is needed to identify potential hearing loss due to encephalitis.|
|Educate the need for adequate rest periods for these patients. Also, emphasize the need in continuing previously done activities as tolerated by the patient.||Adequate rest is important for patients with encephalitis so as to promote healing of the body from a debilitating disease. Allowing the patient to perform his usual activities of daily living (ADLs) may help stimulate brain function so as to preserve latent neurological status.|
|Educate the significant others about the isolation needs of the patient. Advise them to avoid interacting with the patient if still with respiratory symptoms or until the culture is negative.||Educating on the isolation precautions of the patient will prevent transmission of the causative agent and the unnecessary exposure of other members of the family to the disease.|
|Educate the significant others on the timely reporting of the relevant manifestations such as: hyperthermia, anorexia, irritability, irrational behavior, decrease in consciousness, and reduced acuity of the senses (e.g., hearing loss).||Timely reporting of significant clinical manifestations is crucial so that appropriate interventions are given. Early recognition and presentation of these symptoms will reveal if the infection has already spread.|
|Render ordered medications as soon as possible, guided by the culture results from CSF, throat samples, etc.||Administration of appropriate antibiotic therapy and medications will help in preventing the spread of infection and in managing the current condition of the patient.|
|Anticipate administration of stool softener, or laxatives as ordered. Advise the relatives on the limitations of restraints.||Laxatives and stool softeners are necessary to prevent straining during bowel movements, that may otherwise increase the patient’s intracranial pressure (ICP). Any elevations in the patient’s ICP may trigger the worsening of the neurological symptoms of the patient.|
More Nursing Diagnosis for Encephalitis
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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