As a result of various illnesses or toxins in the body, metabolic encephalopathy, also known as toxic metabolic encephalopathy, is a disorder in which brain function is temporarily or permanently impaired.
Typically, but not always, symptoms appear unexpectedly. Patients could be disoriented, uncooperative, and lethargic. The signs and symptoms might develop gradually if the patient has an underlying chronic disease.
The likelihood of developing this may be increased by advanced age and cognitive impairment. If the underlying problems are treated, metabolic encephalopathies can be reversible. However, they could cause brain damage if neglected.
Signs and Symptoms of Metabolic Encephalopathy
- Multilevel central nervous system dysfunction
- Delirium. It is regarded as metabolic encephalopathy’s most prevalent symptom. Hallucinations and disordered speech are frequently present, and it is characterized by confused thinking and disturbed attention.
- Decreased level of consciousness. The impact on consciousness might result from the neocortex’s diminished potential for integration.
- Seizures. It can happen following drug withdrawal, along with hypoglycemia, hepatic failure, uremia, aberrant calcium levels, or toxin intake.
- Normal pupillary and ocular reflexes with conjugate eye movements
- Dementia or memory loss
- Disorientation
- Mood disorders
- Depression
- Agitation
- Inability to sleep
- Breathing difficulties. A result of loss of brainstem respiratory control.
- Bilateral and symmetrical motor abnormalities. Seen especially in cases of hepatic disease, uremia, and sedative overdose as the encephalopathy worsens.
- Flapping tremors
- Asterixis
- Multifocal myoclonus
- Ataxia or coordination issues when performing motor tasks like walking, eating, writing, or some other daily activities.
- Impaired thermoregulation. May happen as a result of autonomic dysfunction.
Causes of Metabolic Encephalopathy
- Hypoxia. Chronic disorders include anemia, lung illnesses such as chronic obstructive pulmonary disease, and alveolar hypoventilation all result in hypoxia.
- Ischemia. Happens due to cardiovascular illnesses such acute congestive heart failure, cardiac arrhythmia, microvascular disease, and hypo- or hypertension
- Various toxic agents. Toxins can harm the brain if they accumulate in the circulation and get there. An underlying illness, an infection, or exposure to harmful substances may be the cause of this.
- Alcohol
- Sedatives
- Heavy metal toxicity
- Organic phosphates
- Preexisting health conditions. It may cause toxic substances to build up in the body. Hence, it might enlarge brain cells and impair their functionality.
- Diabetes
- Liver disease
- Kidney failure
- Heart failure
- High blood pressure
- Medications and Illicit drugs. The use of multiple drugs that affect the brain, major surgery, organ failure, electrolyte disruption, and endocrine disorders are all frequent contributing factors.
- Anticonvulsants
- Corticosteroids
- Electrolyte imbalance
- Hyponatremia. Adds to hyperosmolar stress, which causes cerebral edema by forcing water into the intracellular space by osmotic pressures.
- Hypernatremia. Cells shrink as a result of the movement of water and electrolytes out of the intracellular compartment.
- Hypocalcemia and Hypercalcemia. The excitability of neurons, synaptic transmission, and the operation of different organelles are all affected by dysregulation of calcium homeostasis.
- Hypophosphatemia
- Hypomagnesemia
- Hypermagnesemia
- Inborn problems of metabolism
- Organic acidemia
- Urea cycle disorders
- Mitochondrial cytopathy
- Reye syndrome
- Endocrine disorders
- Hypoglycemia. One of the frequent causes of encephalopathy in newborns and young children is hypoglycemia. It is defined as blood sugar levels below 50 mg/dL and 60 mg/dL in neonates less than 48 hours and after 48 hours of life, respectively, in cases where symptoms are present.
- Diabetic ketoacidosis
- Adrenal crisis
- Hypothyroidism
- Hyperthyroidism
- Nutritional deficiency. Thiamine, vitamin B12, folic acid, and niacin nutritional deficits in children can cause altered levels of consciousness, memory problems, seizures, ataxia, and uncontrollable movements.
- Posterior Reversible Encephalopathy Syndrome (PRES). Children and adults with uncontrolled hypertension of various etiologies, immunosuppressive medication use, blood transfusion, hypercalcemia, eclampsia, hemolytic uremic syndrome, and exposure to contrast media are all risk factors for developing PRES. Endothelial injury, poor cerebrovascular autoregulation, and vasogenic edema are potential causes.
Risk Factors to Metabolic Encephalopathy
- Medications. The use of several medications that affect the brain, major surgery, organ failure, electrolyte disruption, and endocrine disorders are all frequent contributing factors. The impact of pharmaceuticals, notably sedative-hypnotics, opioids, and psychiatric medications on the brain is the most crucial of these elements.
- Advanced age
- Infection
- History of neurologic or mental illness
- Severe dietary deficiencies
- Perioperative complication. Metabolic encephalopathy is a perioperative complication that is relevant to small bowel-liver transplantation since it is particularly frequent in liver transplants. The frequently diverse etiologies underlying the encephalopathy might be caused by immunosuppressive medications, hypoxemia, abnormalities in blood chemistries (such as hypoglycemia and hyponatremia), volume depletion, sepsis, and other reasons. Even though the infection never penetrates the cerebrospinal fluid (CSF) region, unsatisfactory treatment of an infection prior to transplantation may result in a hyperacute infection and sepsis that manifests right away after surgery along with alterations in mental status.
Diagnosis of Metabolic Encephalopathy
- History taking. To create an accurate history, reports from family and friends and a review of the medical records are frequently required.
- Physical examination. It is challenging to conduct a thorough physical examination on a confused or uncooperative patient; instead, a focal exam that focuses only on particular elements, such as vital signs, the patient’s level of hydration, the condition of their skin, and any potential infectious foci, may be carried out.
- Functional assessment. To determine the degree of the deficiencies found during the exam and to help in formulating a treatment plan and rehabilitation objectives, it is important to measure premorbid functional baseline, which includes cognitive state, level of independence, and current functional status.
- Laboratory studies
- Complete blood count
- Coagulation studies
- Electrolyte panel including calcium, magnesium, phosphate, glucose, blood urea nitrogen (BUN), creatinine.
- Urine, and cerebrospinal fluid (CSF) cultures. If infection is suspected.
- Arterial blood gas analysis. Used to evaluate respiratory, cardiovascular, and metabolic functioning. Being able to quickly determine the amount of oxygen and carbon dioxide in the blood constitutes a crucial step for emergency services.
- Imaging. When a diagnosis is unclear, neuroimaging should be employed sparingly rather than on a regular basis. If there is a clear medical problem that can be treated, there is no evidence of trauma, there are no focal neurological signals, the patient is alert and able to follow instructions, and the condition gets better with therapy, neuroimaging may not be necessary.
- Computed tomography (CT)
- Magnetic resonance imaging (MRI)
- Electroencephalogram (EEG)
Treatment for Metabolic Encephalopathy
The care of the underlying illness that was identified through the evaluation of the neurological symptoms and signs is necessary for the treatment of metabolic encephalopathy.
- Plasmapheresis. Suggested as an alternative to the traditional treatment of glucocorticoids in cases of encephalopathy brought on by thyrotoxic crisis.
- Dialysis. Treatment for uremic encephalopathy involves dialysis. This kind of encephalopathy is always accompanied by other metabolic diseases rather than occurring alone. Because of this, the clinical presentation in these circumstances always combines the symptoms of many metabolic diseases. Children with uremic encephalopathy should be given dialysis consideration, and their related dyselectrolytemia needs to be urgently managed.
- Fluid restriction. Treatment for hyponatremia involves fluid restriction together with sodium replenishment. However, due to the risk of central pontine myelinolysis and because rigorous compensation favors the progression of encephalopathy, serum sodium concentration correction has been restricted to 12mEq/L/day.
- Urgent therapeutic procedures. Ensuring adequate respiration and circulation, an arterial blood gas analysis, the biochemical analyses of blood, as well as blood and urine tests to detect toxins, should be carried out in cases of unknown etiology.
- Correction of hypoglycemia. In cases where a patient is in a coma or experiencing acute consciousness disorders of unknown causes.
- Physical medicine and rehabilitation. To encourage optimum strength, balance, coordination, mobility, and mental function rehabilitation. This will occur while treating the underlying medical condition that causes metabolic encephalopathy to develop so that symptoms do not return or get worse after the patients finish their therapy.
Nursing Management for Metabolic Encephalopathy
- Treat the patient’s delirium as a medical emergency.
- Evaluate the patient’s level of consciousness. The progression and deterioration of the disease can be indicated by abrupt changes in a patient’s state of consciousness.
- Monitor the patient’s respiratory and cardiovascular functions along with neurological, laboratory, and neuroimaging examinations.
- Place the patient in a serene, stress-free environment and urged to partake in cognitive activities.
- Administer analgesics as prescribed for pain management.
- Administer medications to lessen the frequency and duration of delirium episodes as prescribed.
- Keep the patient on a low-protein diet to reduce the blood ammonia levels.
- Assist the patient to participate in activities to prevent them from developing complications such as bed sores or muscle weakness.
- Determine the decision-making capacity of the patient.
- Minimize the chest and limb restrictions for the patient.
- Ensure patient safety by asking a family member to accompany the patient especially when agitated or impulsive.
- Avoid conditions including polypharmacy, dehydration, and sleep disturbances that are known to cause or exacerbate disorientation, abnormal mentation, and/or delirium.
- Reorient the patient daily as possible. To reduce anxiety and ensure safety, more reorientation may be necessary. Although it may seem redundant, this is essential for the patient who is confused.
- Arrange for consultation with case managers and social workers who should tell patients and families about all of the choices accessible to them, such as at-home PT and OT, day programs, and cognitive rehabilitation programs.
- Advice the patient to avoid alcohol intake.
- Advice the patient’s family to assist the patient in daily activities.
- Provide the patient with optimal electrolytes and fluids. Unbalanced electrolytes can make body functioning worse. Ensure sufficient fluid intake and glucose levels to sustain brain functions and hemodynamic processes.
Metabolic Encephalopathy Nursing Diagnosis
Metabolic Encephalopathy Nursing Care Plan 1
Nursing Diagnosis: Acute Confusion related to alcohol abuse secondary to metabolic encephalopathy as evidenced by anxiety, delirium, inappropriate interpretation, altered states of consciousness, and changes in physical movement.
Desired Outcomes:
- The patient will be able to keep their focus on reality and identify differences in their behavior and mental patterns.
- The patient will be able to function at his highest potential by making changes to compensate for deficiencies.
| Metabolic Encephalopathy Nursing Interventions | Rationale |
| Assess and monitor the patient’s mental status. | A full mental state examination can be performed by the nurse to recognize the difference between mental disease, intellectual impairment, and mood disturbances. |
| Assess the patient’s cognitive abilities and behavior routinely and continuously throughout the day and at night as necessary. | Knowing the patient’s baseline mental health status is essential to diagnosing delirium since delirium always accompanies an abrupt change in mental status. |
| Observe the laboratory results. In order to detect hypoxemia, electrolyte imbalances, BUN/creatinine, ammonia levels, blood sugar levels, infection symptoms, and medication levels, it is crucial to monitor laboratory findings (including maximum average as necessary). | It’s important to find and address the underlying reasons for acute confusion once it has been identified. |
| Take note of the occurrence and duration of agitation, hallucinations, and violent behaviors. Check for any sundown syndrome. | This confusion-related occurrence takes place in the late afternoon. The patient’s agitation, agitation, and confusion are all growing worse. Symptoms of sundowning could include sleep problems, hunger, dehydration, or an inability to meet bowel and bladder demands. |
| Introduce the patient to the environment, the personnel, and any necessary elements. Provide the information simply and briefly. Avoid confronting incorrect thoughts; this may result in defensive behaviors. | An increased degree of orientation guarantees the patient’s safety. |
| Invite family members to participate in the reorientation and to keep providing comments (e.g., latest events and family gatherings). | The disoriented patient may not fully comprehend what is going on. The comfort level of the patient may be increased by the presence of family and close friends. |
| Ensure that safety requirements are met, including those for monitoring, side rails, seizure prevention, positioning a call button within range, placing necessary items within reach/clearing pedestrian areas, and walking with assistive equipment. | This is done to avoid accidents and increase safety. |
Metabolic Encephalopathy Nursing Care Plan 2
Nausea related to stomach upset due to alcoholism secondary to metabolic encephalopathy as evidenced by gagging, an unpleasant taste in the mouth, and increased swallowing.
Desired Outcomes:
- The patient will report alleviation from nausea.
- The patient will be able to identify methods for preventing nausea.
| Metabolic Encephalopathy Nursing Interventions | Rationale |
| Evaluate the extent, frequency, duration, and history of nausea. | Detailed analysis and evaluation of nausea can contribute to the identification of strategies to alleviate or reduce the problem. |
| Provide the patient with easy access to an emesis basin. | Vomiting and nausea often occur together. If nausea has a psychogenic factor, keep the emesis basin out of the field of vision but within the patient’s reach. |
| Keep track of the patient’s hydration condition, blood pressure, intake and output, and skin turgor. | Nausea is frequently associated with vomiting, which can alter a patient’s hydration levels due to fluid loss. |
| Discuss oral hygiene with the patient and give encouragement. | This is connected to excessive salivation. Oral hygiene helps to relieve symptoms and provide comfort. |
| Let the patient apply nonpharmacological methods of controlling their nausea, including breathing techniques, relaxation techniques, guided imagery, or meditation. | These treatments have helped patients with the illness, however, they must be implemented before it develops. |
| Offer the patient appealing foods on a regular basis in small amounts. | Maintaining nutritional status will be made easier by this strategy. For some patients, nausea is made worse by an empty stomach. |
| Maintain the patient in an elevated position during meals and for 1 to 2 hours afterward. | This may assist to lower the trigger of nausea. |
| Regularly monitor the patient’s weight. | To assess nutritional needs and, if required, treat malnutrition and dehydration. |
Metabolic Encephalopathy Nursing Care Plan 3
Risk for trauma
Nursing Diagnosis: Risk for Trauma related to possible seizure secondary to metabolic encephalopathy.
Desired Outcomes:
- The patient will express comprehension of the contributing factors to the risk of trauma and take steps to resolve the issue.
- The patient will exhibit behavioral and lifestyle modifications to lower risk components and safeguard themselves against harm.
- The patient will comply with the treatment plan in order to reduce or stop seizure activity.
| Metabolic Encephalopathy Nursing Interventions | Rationale |
| Determine and explain common seizure patterns as well as seizure warning indicators (if applicable). Guide the family members on how to see the warning symptoms of a seizure, become familiar with them, and how to take care of the patient both during and after one. | Allows the patient to protect themselves from harm and notice changes that necessitate reporting to the physician and additional action. Understanding what to do in the event of a seizure might reduce SO’s feelings of powerlessness and assist prevent harm or consequences. |
| Observe abnormalities and irregularities in test results or diagnostic testing. | Conditions like disorientation, tetany, pathological fractures, etc. may come from this or be made worse by it. |
| Provide cushion side rails while the bed is in its lowest position, or, if rails are unavailable or inappropriate, position the bed up against a wall and cushion the floor. | Prevents or reduces harm if seizures happen while the patient is in bed. |
| Maintain complete bed rest if onset symptoms or an aura are observed. Describe why taking these activities is necessary. | During the aural phase, the patient may become agitated or require walking or even defecate, accidentally removing himself from a safe area and convenient monitoring. Realizing how important it is to meet one’s own safety needs may improve patient participation. |
| Never leave the patient unattended during and after a seizure, | Encourages precautionary measures. |
| During a seizure, support the patient’s head, position the patient on a soft surface, or help them to the floor if they are out of bed. Never try to restrain the patient. | When a patient loses voluntary muscle control, supporting the extremities reduces the chance of physical harm. Note: If an attempt is made to confine the patient while they are having a seizure, their unpredictable movements may worsen and they risk hurting themselves or others. |
Metabolic Encephalopathy Nursing Care Plan 4
Nursing Diagnosis: Impaired Physical Mobility related to ataxia secondary to metabolic encephalopathy as evidenced by difficulty in movement with purpose in one’s physical surroundings, including bed mobility, transferring, and walking; Inability to carry out instructions; a restricted range of motion.
Desired Outcomes:
- The patient will engage in physical activity on their own or within their condition’s limitations.
- The patient will exhibit techniques for enhancing movement.
- The patient will display the usage of adaptive equipment to improve movement.
| Metabolic Encephalopathy Nursing Interventions | Rationale |
| Assess the patient’s functional mobility. | Knowledge of the specific level directs the development of the finest possible management program. |
| Determine the patient’s capacity for carrying out daily living activities safely and effectively on a regular basis. | The ability to carry out the majority of daily tasks is impacted by restricted movement. Safety when ambulating is an important aspect. Provides information about recovery and identifies strengths or insufficiencies. |
| Provide a safe atmosphere by raising the bed rails, lowering the bed, and of keeping important items nearby. | These measures establish a safe and secure environment and may reduce the probability of falls. |
| Support the patient when doing muscular exercises as they are able or when they are allowed out of bed; perform abdominal-tightening exercises and knee bends; jump on one foot; stand on one toe. | Strengthens the body areas that compensate for the loss of balance and helps the patient feels more balanced. |
| Assist the patient in performing passive or active ROM exercises on all extremities. | Exercise preserves muscle strength and endurance while also promoting improved venous return, preventing stiffness, and preventing fatigue. Additionally, it prevents contracture deformity, that can quickly accumulate and impair the use of a prosthesis. |
| Encourage and assist in early ambulation when it is feasible. Assistance with each initial transition: ambulation, sitting in a chair, and dangling legs. | These movements maintain the patient’s ability to perform as much as feasible. Early mobility builds confidence in regaining independence and lowers the likelihood of debilitation. |
| Demonstrate the use of any necessary assistive devices, such as a trapeze, crutches, or walkers. | These types of equipment can accommodate dysfunction and increase activity levels. The goals of employing such devices are to keep the patient safe, improve movement, prevent injuries, and save energy. |
Metabolic Encephalopathy Nursing Care Plan 5
Nursing Diagnosis: Ineffective Coping related to changes in mental state secondary to metabolic encephalopathy as evidenced by expressing being unable to deal with a new reality, incapable of handling responsibilities from day to day, and disregarding personal hygiene.
Desired Outcomes:
- The patient will utilize practical coping skills to handle unforeseen circumstances.
- The patient will report how comfortable they feel handling challenging circumstances in the future.
- The patient will state that the new techniques are useful for handling their existing issues.
| Metabolic Encephalopathy Nursing Interventions | Rationale |
| Examine the patient for causes of unsuccessful coping, such as low self-esteem, sadness, a deficiency of problem-solving skills, a lack of support, or a recent change in life circumstances. | Situational elements must be recognized in order to comprehend the patient’s current circumstance and to help the patient cope successfully. |
| Examine previous coping mechanisms, such as decision-making and problem-solving. | Previous coping success affects how well an adjustment goes. Additional resources could be required for patients who have a history of unhealthy coping. Similarly, previously good coping strategies may be insufficient in the current scenario. |
| Assess the potential for harm to oneself or others and take the proper action. | Suicide is commonly attempted by a patient who is depressed and unable to solve problems. |
| Establish a working connection with the patient by providing continuity of care. | The development of trust, a diminished sense of isolation, and potential for coping are all aided by continued relationships. |
| Give the patient a chance to express their worries, anxieties, emotions, and expectations. | The verbal expression of actual or perceived dangers can assist lessen anxiety and open the door to further discussion. |
| Promote patient participation in decision-making, care planning, and planned activities. | A sense of control and higher self-esteem are provided by participation. |
Nursing References
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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