Encephalopathy Nursing Care Plans Diagnosis and Interventions
Encephalopathy NCLEX Review and Nursing Care Plans
Encephalopathy refers to brain damage or disease that occurs when a variation in the way the brain operates or a change in the body affects the brain, resulting in a distorted mental state, leaving the patient confused and not acting normally. Encephalopathy is not a single disease but rather a group of disorders caused by a variety of factors; it is a severe medical condition that, if left untreated, can result in temporary or permanent brain damage.
Encephalopathy and encephalitis might be confusing for some since the words sound alike, but actually, they are not the same thing. Encephalitis pertains to an inflamed or ulcerated brain, whereas encephalopathy is a mental state that can occur due to various health issues.
Signs and Symptoms of Encephalopathy
The symptoms that the patient experience will vary depending on the type and cause of the encephalopathy, but the following are some of the most prevalent:
- Memory lapses
- Personality shifts
- Having difficulty thinking clearly or focusing
Some individuals may also have:
- Having difficulty speaking
- They have muscle weakness or uncontrollable twitches.
- They have no control over their eye movements.
- Having difficulty swallowing
- If the patient exhibits these symptoms, contact the doctor or go to the emergency room.
Causes of Encephalopathy
There are categories of causes of encephalopathy: reversible and irreversible causes. Among the reversible causes are:
- Toxins accumulate in the body when the liver cannot remove them from the blood as effectively as it should. This condition makes it difficult for the brain to function correctly. It can occur in people with chronic liver disease, such as cirrhosis, or after pain relievers or another medication overdose.
- Hashimoto’s encephalopathy. This type is linked to Hashimoto’s disease, a thyroid condition. The cause is unknown, but it is possible that the immune system attacks the brain and alters its functioning.
- Metabolic encephalopathy. Metabolic encephalopathy occurs when another medical condition, such as diabetes, liver damage, renal failure, or cardiovascular disease, makes it difficult for the brain to function correctly. In diabetes, for example, high blood glucose levels can create frustration and even unconsciousness.
- Infections of the brain. Brain infections like encephalitis or meningitis, or infections in other parts of the body, such as a urinary tract infection, Sepsis, or an overreaction to an infection, can also result in encephalopathy.
- Tumors of the brain
- Long-term contact with toxins such as solvents, stimulants, radioactivity, varnishes, dangerous chemicals, and certain metals
- Status epilepticus without convulsions. This condition occurs when the patient has repeated seizures in the brain, even if they do not cause any physical symptoms.
Irreversible causes of encephalopathy include:
- Chronic traumatic encephalopathy (CTE). This condition is characterized by recurrent head injuries that cause brain damage. It is now best known for its connections to high-impact sports such as football and boxing.
- Hypoxic-ischemic encephalopathy. This condition happens when the brain does not receive sufficient oxygen, resulting in brain damage. It can occur due to a cardiogenic shock, carbon monoxide intoxications, a drug overdose, or a near-drowning.
Types of Encephalopathy
- Chronic traumatic encephalopathy (CTE). This type of encephalopathy arises when the brain is subjected to various traumas or concussions. These head blows cause nerve damage in the brain. It is most predominantly reported in boxers, football players, and military personnel who have been injured in fire and explosion.
- Glycine Encephalopathy. Glycine encephalopathy is a genetically acquired condition characterized by unusually elevated glycine (an amino acid) levels in the brain. Glycine encephalopathy symptoms generally occur in infants shortly after birth.
- Hashimoto’s encephalopathy. This condition is a rare form of encephalopathy associated with Hashimoto’s thyroiditis’s autoimmune disorder. The body’s immune system damages the thyroid gland in Hashimoto’s thyroiditis. Many of the body’s regulating hormones are produced by the thyroid gland. Scientists are still unsure how the two conditions are related.
- Hepatic encephalopathy. Liver problems cause hepatic encephalopathy. Whenever the liver is not functioning normally, the toxins customarily eliminated from the body are allowed to accumulate in the blood and probably reach the brain.
- Hypertensive encephalopathy. Hypertensive encephalopathy develops due to inadequately treated severe hypertension for an extended period. This condition can cause the brain to swell, resulting in neurological damage and hypertensive encephalopathy.
- Hypoxic-ischemic encephalopathy. This disorder is a type of brain impairment caused by a lack of oxygen in the brain. This condition can lead to chronic brain damage or disturbance. Insufficient oxygen supply to the brain, such as when a developing baby is exposed to liquor in the womb, can cause it.
- Toxic-metabolic encephalopathy. Infections, toxins, or organ failure can all cause toxic-metabolic encephalopathy. When hormones, electrolytes, or other chemicals in the body are unstable, they can affect brain mechanisms. This could include an infection or toxic substances in the body. Encephalopathy usually improves when the underlying chemical imbalance is repaired or the threatening infection/toxin is eliminated.
- Infectious encephalopathies. Prion diseases are another name for transmissible spongiform encephalopathies. Prions are naturally occurring proteins in the body, but they can eventually evolve and cause diseases that progressively harm and deteriorate the brain (neurodegenerative diseases). Prion diseases include the following:
- Chronic wasting disease
- Fatal familial insomnia
- Creutzfeldt-Jakob disease (CJD)
- Uremic encephalopathy. Kidney failure induces uremic encephalopathy. This type of encephalopathy is caused by an accumulation of uremic toxins in the blood. This condition can range from mild confusion to complete unconsciousness.
- Wernicke’s encephalopathy. This condition, also known as Wernicke’s disease, is caused by a lack of vitamin B-1. A vitamin B-1 insufficiency can be associated with long alcohol addiction, poor nutritional intake, and poor food digestion. Wernicke encephalopathy, if not treated promptly, can progress to Wernicke-Korsakoff syndrome.
Risk Factors to Encephalopathy
Encephalitis can affect anyone. The following factors may increase the likelihood:
- Age. Certain types of encephalitis are more prevalent or drastic in specific age groups. Generally, young children and the elderly are more vulnerable to viral encephalitis.
- Immune system deficiency. People who have HIV/AIDS, use immune-suppressing drugs or have another condition that causes a weakened immune system are more likely to develop encephalitis.
- Geographical areas. Viruses transmitted by mosquitoes or ticks are common in some geographical regions.
- The time of year. Mosquito and tick-borne diseases are more common in many parts of the United States during the summer.
Diagnosis of Encephalopathy
Encephalopathy is typically diagnosed through clinical tests performed during a medical assessment (mental stability tests, cognitive tests, and coordination tests) that demonstrate a distorted mental state.
Clinical test results either diagnose or presumptively diagnose encephalopathy in most cases. The diagnosis is usually made when the altered mental state is accompanied by another initial diagnosis, such as fatty liver, renal failure, oxygen depletion, or other diagnoses.
The doctor will perform a comprehensive physical examination and review the patient’s medical history.
- Brain imaging. Brain imaging is a technique for examining the brain. An MRI or CT scan can identify any brain enlargement or another illness that triggers the symptoms, such as a tumor.
- Spinal tap or lumbar puncture. A small quantity of cerebrospinal fluid (CSF), the protective fluid covering the brain and spinal column, is removed using a needle put into the lower back. Abnormalities might indicate infection and inflammation in the brain in this fluid. CSF samples can sometimes be examined to determine the viruses or other pathogens that cause the infection.
- Other laboratory tests. Viruses and other infectious agents can be detected in blood, urine, or excretions from the back of the neck.
Treatment for Encephalopathy
- Hospitalization. The patient will be admitted and the following common treatments for mild encephalitis may be employed:
- Sufficient bed rest and enough sleep
- Adequate water intake
- Anti-inflammatory medicines are used to treat headaches and fevers.
- Antiviral medications
- Assistive care.Patients with severe encephalitis who are hospitalized may require:
- Breathing therapy, as well as vigilant heart and breathing function monitoring
- Intravenous fluids to maintain hydrated and necessary mineral levels
- Corticosteroids and other anti-inflammatory medicines relieve inflammation and pressures within the skull.
- Anticonvulsant drugs are used to treat or prevent seizures.
- Follow-up treatment. If the patient has complications of encephalitis, he or she may need additional treatment, such as the following therapies:
- Muscle, agility, posture, balance and coordination, and movement can all be improved with physical therapy.
- Occupational therapy is used to help people improve everyday skills and employ adapted goods to aid them in their daily tasks.
- Speech therapy is used to retrain muscular control and coordination so that speech can be produced again.
- Psychotherapy improves mood problems or addresses personality changes by learning coping techniques and new behavioral skills.
Prevention of Encephalopathy
Some types of encephalopathy cannot be avoided, such as inherited encephalopathy. For the other types, here are the ways to prevent encephalopathy:
Several of the causal factors of encephalopathy can be avoided by making the modifications listed below:
- Avoiding excessive alcohol consumption
- Lowering the number of hazardous chemicals, such as pharmaceuticals, that people are exposed
- Consuming a nutritious diet
- Visiting the doctor regularly
- A sustainable and healthy lifestyle can help lower the risk of developing a brain disease.
Encephalopathy Nursing Diagnosis
Nursing Care Plan Encephalopathy 1
Nursing Diagnosis: Confusion related to toxins secondary to encephalopathy as evidenced by misconceived notions, cognition fluctuation, increased irritability, a shift in the sleep-wake cycle, and hallucinations, either auditory or visual.
- The patient’s delirium occurrences have subsided.
- The patient’s reality perception and level of consciousness return to normal.
- When recognized, the patient verbalizes his or her understanding of the potential causes.
- The patient initiates lifestyle/behavioral changes to prevent or reduce the reoccurrence of the condition.
- The patient exhibits suitable motor function.
- The patient engages in daily living activities (ADLs).
|Encephalopathy Nursing Interventions||Rationale|
|Assist in treating the underlying health issue, for example, drug intoxication/abuse, infectious procedure, cerebral hypoxia, biochemical imbalances, nutritional deficiencies, and pain management.||It is critical to assist with the treatment of the underlying problem in order to maximize function and reduce further degeneration.|
|Orient the patient to his or her surroundings, staff, and any necessary activities. Present the reality to the patient succinctly and straightforwardly. Avoid challenging illogical thinking; this approach could result in defensive reactions.||Increased orientation provides the patient with a higher level of safety.|
|Adjust sensory exposure. Create a calm environment by removing unnecessary noise and stimuli.||Patients suffering from encephalopathy may misinterpret increased levels of visual and auditory stimulation.|
|Encourage family members or significant others to engage in the reorientation process and provide ongoing input such as current events and family happenings.||The patient with encephalopathy may be confused and not fully comprehend what is going on. The presence of family members and other significant others may increase the patient’s degree of comfort.|
|Restore optimum fluid and electrolyte balance; develop normal nutrition, body temperature, oxygen levels (if patient experiences hypoxia, supplement with oxygen), blood sugar levels, and blood pressure.||In cooperation with the medical team, this approach aims to treat the root causes of delirium in patients with encephalopathy|
|Assist the family and other important people in improving coping strategies.||The family must allow the patient to do everything he or she can do to maximize the patient’s level of functioning and quality of life.|
|Teach the patient’s family to acknowledge warning indications of confusion and seek medical attention.||Early intervention helps to avoid long-term complications of encephalopathy-related confusion.|
Nursing Care Plan Encephalopathy 2
Nursing Diagnosis: Impaired Memory related to alterations of cognitive abilities, chemical deficiency, and neuronal breakdown in the brain secondary to encephalopathy as evidenced by decreased reasoning or conceptualization ability, memory loss, and refusal to collaborate.
- The patient with encephalopathy will have appropriate psychological and emotional function maintenance for as long as necessary and behavior patterns reversal when applicable.
- Family members will demonstrate knowledge of required care, appropriate coping skills, and the use of community resources.
- With adjustments and modifications within his environment to compensate for deficits, the patient with encephalopathy will achieve functional ability at his optimal levels.
|Encephalopathy Nursing Interventions||Rationale|
|Suppose the patient’s short-term memory is intact; orient the patient to the environment as needed. Calendars, radio, newspapers, television, and other media are also appropriate.||Reality orientation methodologies to patients with encephalopathy-related confusion help improve patients’ awareness of self and environment.|
|Examine the patient’s general cognitive abilities and memory.||This intervention aims to ascertain the patient’s cognitive performance, cognitive assessment tools such as the General Practitioner Assessment of Cognition (GPCOG) can be used. The assessment findings are used for further assessment and to alleviate symptoms.|
|Examine the patient for sensory deprivation, CNS drugs concurrently, poor nutrition, fluid loss, infection, or other concurrent disease processes.||These circumstances may cause impaired memory and change the mental status of patients with encephalopathy.|
|Strength training, relaxation techniques, and massage are examples of alternative and complementary therapies.||These activities can help patients with encephalopathy reduce mental anguish; stress can exacerbate cognitive problems.|
|Assist the encephalopathy patient in establishing a medication box.||A medication box can help remind patients to take their medications at the appropriate times and replenish the box.|
Nursing Care Plan Encephalopathy 3
Nursing Diagnosis: Deficient knowledge related to a lack of cognitive information or psychomotor ability required for health reconstruction, maintenance, or advancement secondary to encephalopathy as evidenced by lack of comprehension and progress of serious complications.
The patient will be able to understand what encephalopathy is and will also learn its management, treatment, and prevention.
|Encephalopathy Nursing Interventions||Rationales|
|Determine who the learner is: the patient, a family member, a significant other, or a caregiver.||Some patients, particularly the elderly or terminally ill, see themselves as reliant on the care provider and, as a result, refuse to participate in the learning process.|
|Examine the patient’s ability to learn or undertake desired healthcare tasks.||Cognitive impairments must be identified to develop an effective teaching plan for the patient with encephalopathy.|
|Determine the patient’s motivation and eagerness to learn about encephalopathy.||Energy is required for learning. Patients must see the need or a reason to learn. They have the option to reject educational services as well.|
|Identify the significance of learning needs within the context of the overall treatment plan.||This intervention aims to determine what needs to be clarified, especially if the patient has prior knowledge of the situation. Knowing what to prioritize will help the patient focus on the essential things he or she needs to know about encephalopathy.|
|Allow the patient to speak freely about prior experiences and health education.||Older patients frequently bring their experiences in life to each learning session. They learn best when education builds on prior knowledge and experience.|
|Observe and document any existing misconceptions about encephalopathy.||Evaluation is a crucial starting point in learning. Knowledge is used to correct erroneous assumptions about encephalopathy.|
|Allow for repeated practice of the information or skill.||Repetition allows the patient to build confidence in their ability to care for themselves.|
|Encourage the patient to inquire about encephalopathy.||Questions about their condition allow for practical discussion between healthcare professionals and patients and confirm comprehension of information given.|
Nursing Care Plan Encephalopathy 4
Disturbed Thought Process
Nursing Diagnosis: Disturbed Thought Process related to insufficient oxygen supply to the brain, head trauma, infections, and alcohol or substance abuse secondary to encephalopathy as evidenced by the incorrect perception of stimuli, whether internal or external, deficiencies in cognition, and disorientation or confusion.
- The patient maintains a realistic perspective and communicates clearly with others.
- The patient notices changes in his or her thinking or behavior.
- The patient acknowledges and comprehends potential misinterpretations of others’ behaviors and verbalizations.
- The patient recognizes situations that occur prior to the disturbed thought process.
|Encephalopathy Nursing Interventions||Rationales|
|Aid in treating underlying health issues such as brain injury or increased intracranial pressure, sleep disturbances, and biochemical insufficiencies.||Treatment and correction of medical or psychiatric problems frequently improve comprehension or thinking of patients with encephalopathy.|
|Examine the attention span distractibility of the patient and their ability to make a good decision.||This intervention determines the patient’s ability to participate in the planning and execution of care for the management of encephalopathy.|
|Assist with testing and reviewing results to determine mental status based on age and neurocognitive capacity.||This intervention is done to determine the degree of impairment.|
|Interview the significant or caregiver to determine the patient’s ordinary reasoning skills, behavioral changes, the length of time the problem has been going, and any other relevant information.||This intervention serves as a baseline for comparison.|
|When the case of encephalopathy becomes progressive or chronic, assist the patient and significant others in developing a plan of care.||Advanced planning for home care, transportation, guidance with care activities, assistance, and respite for caregivers improve patient management in the home setting.|
Nursing Care Plan Encephalopathy 5
Nursing Diagnosis: Risk for Injury related to hypoxia, cognitive function changes, physical impediments, and toxic chemical exposure secondary to encephalopathy. Risk for Injury is entirely unrelated to any signs and symptoms as a risk nursing diagnosis since it has not yet developed in the patient, and safety precautions will be initiated instead.
- Within 8 hours of nursing diagnosis and treatment, the patient will evaluate the causes that significantly raise their risk of injury and illustrate injury-avoidance behaviors.
- After 4 hours of nursing actions and teaching, the patient will be free of injuries.
|Encephalopathy Nursing Interventions||Rationales|
|Determine the patient’s age, developmental stage, health status, lifestyle, impaired communication, sensory-perceptual impairment, mobility, cognitive awareness, and decision-making ability.||These factors influence the patient’s ability to protect themselves from harm. When developing a care plan or teaching patients about safety precautions, nurses must thoroughly assess each factor.|
|Assist the patient in becoming acquainted with their surroundings.||Place the call light in easy reach and teach the patient how to use it to summon help. To avoid accidents, the patient should be familiar with the environment’s layout. Items that are too far away from the patient may pose a risk.|
|Placing the patient in a room near the nurses’ station is good.||Moving the patient’s room closer to the nurse station allows the health care provider to closely observe patients with encephalopathy that are at high risk of injury and falls and intervene as soon as possible.|
|When interacting with a patient with encephalopathy, maintain reality orientation. Bring in familiar objects, clocks, and watches from home to help the patient maintain their orientation.||When a patient becomes agitated, reality orientation can help limit or reduce the confusion that increases the risk of injury. Validation therapy is a practical approach and mode of communication for people in the mild-moderate stages of encephalopathy, and it reduces patient’s stress and behavioral disturbances.|
|Correctly identify patients.||Use at least two identifiers (such as the patient’s name, date of birth, medical record number, or phone number) to verify the patient’s identity during hospital admission or transfer and before administering medications, blood products, or providing treatment or treatment procedures. This method will improve the patient’s identification system’s reliability and reduce the likelihood of misidentification.|
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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. (2018). 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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