Nursing Care Plan (NCP) for Encephalopathy
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Outline
Lesson Objective for Encephalopathy
- Understanding Encephalopathy:
- Gain a comprehensive understanding of encephalopathy, including its etiology, pathophysiology, and the diverse range of symptoms it presents, to facilitate effective nursing care planning.
- Identification of Underlying Causes:
- Learn to identify the various underlying causes of encephalopathy, such as infections, metabolic disorders, or toxic exposures, to guide targeted interventions and address the root cause.
- Assessment and Monitoring Skills:
- Develop proficient assessment and monitoring skills to recognize early signs and symptoms of encephalopathy, enabling timely intervention and prevention of complications.
- Implementing Therapeutic Interventions:
- Acquire knowledge about evidence-based therapeutic interventions, medications, and supportive measures to manage encephalopathy effectively and improve patient outcomes.
- Evaluation of Nursing Care:
- Learn to evaluate the effectiveness of nursing interventions and adjust the care plan as needed, considering the dynamic nature of encephalopathy and the varying responses of patients.
Pathophysiology of Encephalopathy
- Brain Dysfunction:
- Encephalopathy involves generalized dysfunction of the brain, affecting cognitive and motor functions. It is often a secondary condition resulting from an underlying illness or systemic disorder.
- Toxic Metabolite Accumulation:
- Accumulation of toxic metabolites in the bloodstream, such as ammonia in hepatic encephalopathy or uremic toxins in renal encephalopathy, can lead to impairment of neurological function.
- Inflammatory Processes:
- Inflammatory responses, either due to infections or autoimmune reactions, can contribute to encephalopathy. Inflammation disrupts normal brain function and may lead to alterations in consciousness and behavior.
- Neurotransmitter Imbalance:
- Disruption of neurotransmitter balance, particularly gamma-aminobutyric acid (GABA) and glutamate plays a crucial role. This imbalance can result in altered neuronal signaling and contribute to cognitive disturbances.
- Impaired Blood Flow and Oxygen Delivery:
- Conditions causing impaired blood flow or oxygen delivery to the brain, such as ischemic events or severe hypoxia, can lead to encephalopathy. Reduced oxygen availability affects cellular metabolism and function.
Etiology of Encephalopathy
- Liver Dysfunction (Hepatic Encephalopathy):
- Liver diseases, such as cirrhosis or acute liver failure, can lead to the accumulation of toxic substances like ammonia in the blood, affecting the brain and causing hepatic encephalopathy.
- Renal Dysfunction (Uremic Encephalopathy):
- Kidney failure results in the accumulation of uremic toxins in the bloodstream. These toxins, when not effectively cleared by the kidneys, can contribute to encephalopathy and neurological symptoms.
- Infections:
- Severe infections, particularly those affecting the central nervous system, can lead to encephalopathy. Examples include viral encephalitis, bacterial meningitis, or systemic infections causing sepsis.
- Metabolic Disorders:
- Disorders affecting metabolism, such as inborn errors of metabolism or disturbances in electrolyte balance, can lead to encephalopathy. Metabolic imbalances disrupt normal cellular functions in the brain.
- Toxic Substances:
- Exposure to toxic substances, including certain medications, chemicals, or environmental toxins, can cause encephalopathy. These substances may directly affect neuronal function or contribute to inflammation.
Desired Outcome for Encephalopathy
- Resolution of Neurological Symptoms:
- The primary goal is to alleviate and eliminate the neurological symptoms associated with encephalopathy, such as confusion, altered consciousness, seizures, or motor dysfunction.
- Normalization of Biochemical Markers:
- Achieve and maintain normal levels of relevant biochemical markers, such as ammonia in hepatic encephalopathy or urea in uremic encephalopathy, indicating improved organ function and reduced toxic accumulation.
- Stabilization of Underlying Condition:
- If encephalopathy is secondary to an underlying condition (e.g., liver disease, renal failure), the goal is to stabilize and manage that condition effectively to prevent further neurological complications.
- Prevention of Recurrence:
- Implement measures to prevent the recurrence of encephalopathy episodes by addressing and managing the underlying causes, monitoring biochemical markers, and adjusting treatment plans as needed.
- Improvement in Quality of Life:
- Enhance the overall quality of life for the individual by managing symptoms, minimizing the impact of encephalopathy on daily functioning, and providing support for any residual neurological deficits.
Encephalopathy Nursing Care Plan
Subjective Data:
- Mood/Personality changes
- Memory problems
- Loss of balance
- Weakness
Objective Data:
- Altered LOC
- Dysphagia
- Dysphasia
- Elevated ammonia levels (Hepatic)
- Low thiamine levels (Wernicke’s)
- Tremors
- Seizures
- Ataxia
- Nystagmus (Wernicke’s)
Nursing Assessment for Encephalopathy
- Neurological Examination:
- Conduct a thorough neurological assessment, including evaluation of mental status, cognitive function, motor skills, reflexes, and sensory perception.
- Vital Signs Monitoring:
- Monitor vital signs closely, with a particular focus on changes in blood pressure, heart rate, and respiratory rate, as alterations may indicate worsening neurological status.
- Biochemical Markers:
- Regularly assess relevant biochemical markers associated with the underlying cause of encephalopathy (e.g., serum ammonia levels in hepatic encephalopathy) to gauge the severity and progression of the condition.
- Fluid and Electrolyte Balance:
- Evaluate fluid status and electrolyte balance, as disturbances can contribute to encephalopathy. Pay attention to signs of dehydration or fluid overload.
- Gastrointestinal Symptoms:
- Assess gastrointestinal symptoms, especially in cases of hepatic encephalopathy, including nausea, vomiting, and changes in bowel habits.
- Psychosocial Assessment:
- Perform a psychosocial assessment to identify factors that may impact the patient’s mental well-being, including stressors, social support, and coping mechanisms.
- Medication Review:
- Review the patient’s current medications to identify any that may contribute to encephalopathy or interact adversely with prescribed treatments.
- Family/Caregiver Input:
- Obtain input from family members or caregivers regarding the patient’s baseline cognitive function, recent changes, and observations of behavior that may indicate neurological deterioration.
Implementation for Encephalopathy
- Medical Interventions:
- Administer prescribed medications, such as lactulose for hepatic encephalopathy to reduce ammonia levels or antiepileptic drugs for seizure control if applicable.
- Nutritional Support:
- Collaborate with the dietitian to ensure the patient receives appropriate nutritional support, especially in cases of hepatic encephalopathy where dietary modifications, such as protein restriction, may be necessary.
- Fluid and Electrolyte Management:
- Implement measures to maintain fluid and electrolyte balance, addressing any abnormalities detected during the assessment. Intravenous fluids may be administered as needed.
- Neurological Monitoring:
- Implement continuous neurological monitoring to detect any changes promptly. This may include frequent checks of mental status, pupil reactions, and assessments for signs of increased intracranial pressure.
- Seizure Precautions:
- Implement seizure precautions if the patient is at risk. Ensure a safe environment, pad the bedrails, and educate the patient and family on seizure signs and precautions.
- Family Education:
- Educate the patient’s family on the nature of encephalopathy, signs of worsening symptoms, and the importance of medication adherence and follow-up appointments.
Nursing Interventions and Rationales
- Give medications to treat the cause of encephalopathy
- Hepatic → Lactulose
- Wernicke’s → Thiamine
- Monitor for changes in LOC with detailed, frequent neuro exams
- Monitor ICP/CPP if applicable
- Perform interventions to minimize ICP:
- Maintain HOB 30-45°
- Decrease stimuli
- Avoid Valsalva maneuvers
- Maintain HOB 30-45°
- HOB < 30 = increased blood flow to brain → Increased ICP
- HOB > 45 = increased intrathoracic pressure → decreased venous outflow from brain → increased ICP
- Decrease stimuli
- Agitation or stress can cause increased ICP
- Avoid Valsalva maneuvers
- Coughing or bearing down can cause increased ICP
- Place the patient in seizure precautions
- Monitor respiratory status & protect airway as needed
- May require restraints if agitated and confused and becomes a danger to self or others
Evaluation for Encephalopathy
- Neurological Status:
- Assess the patient’s neurological status regularly, including mental status, orientation, and responsiveness, to determine any improvement or deterioration.
- Laboratory Values:
- Monitor relevant laboratory values, such as ammonia levels in hepatic encephalopathy cases, to assess the effectiveness of interventions and guide further adjustments.
- Seizure Activity:
- If applicable, evaluate the presence and frequency of seizures. Adjustments to antiepileptic medications or other interventions may be needed based on the evaluation.
- Fluid and Electrolyte Balance:
- Evaluate fluid and electrolyte balance to ensure that interventions are maintaining or restoring a normal balance. Adjustments may be necessary based on ongoing assessment.
- Patient and Family Feedback:
- Obtain feedback from the patient and their family regarding any observed changes in symptoms, adherence to the treatment plan, and the overall impact of the care provided.
References
- Davis, C.P. (n.d.). Encephalopathy. Retrieved from https://www.medicinenet.com/encephalopathy/article.htm#encephalopathy_facts
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Example Nursing Diagnosis For Nursing Care Plan (NCP) for Encephalopathy
- Acute Confusion: Metabolic encephalopathy often presents with acute confusion and altered mental status due to metabolic imbalances. This diagnosis reflects the observable symptoms.
- Risk for Aspiration: Patients with encephalopathy may have impaired swallowing reflexes, putting them at risk for aspiration. This diagnosis addresses the potential danger of aspiration.
- Risk for Injury: Altered consciousness and confusion in metabolic encephalopathy can lead to accidents and injuries. This diagnosis highlights the risk of patient harm.
Transcript
This here is the nursing care plan for encephalopathy. So, the pathophysiology. Encephalopathy is a general term for disease of the brain tissue. It’s a syndrome of brain dysfunction caused by damage to brain tissue and failure. This damage can be done by atrophy, lack of oxygen, edema, or toxins. So some nursing considerations, there are a few things that we want to consider when taking care of these patients, we want to consider putting them on seizure precautions. So we want these patients to be protected. The best way to do that is with seizure precautions. We want to do vital signs. We want to monitor their vitals. We want to do frequent neuro checks and if available and if necessary, we would need to monitor their ICP. And we want to draw labs; more importantly, ammonia and finding levels to see if that is the root cause. The desired outcome for these patients is to treat or reverse the cause in order to restore proper brain function, it returns the patient to their usual baseline mental status. So when this patient comes in to you, this encephalopathic patient comes in to see you. There’s going to be a few things that we see, but there’s going to be some things that either them or their family tells us. Some of the subjective data that we see is that they are going to complain about mood or personality changes.
Okay, they’re going to have some memory loss. There’s going to be a loss of balance and weakness. Okay. The next thing is what we are going to observe. What is our objective data that we’re going to pull? Well, I can tell you that one of the first things that we’re going to see is we’re going to see an altered level of consciousness. Okay. We’re going to see some dysphagia. So they’re going to have some difficulty swallowing dysphagia, which they’re going to have some difficulties speaking or expressing the words. If it is hepatic, meaning if the liver is the cause of the encephalopathy, then these patients are going to have elevated ammonia levels in their labs. So we’re going to have elevated ammonia levels, but remember, that’s only if it’s hepatic in nature. If it is because of wernicke, if it’s the wernicke encephalopathy, we are going to see decreased thiamine levels Again, that’s Wernicke’s. Okay. A few other things we’re going to see is we’re going to see some tremors, seizures and some ataxia. So some nursing considerations; some interventions that we can do is we’re going to give medications to treat the cause of the encephalopathy so remember it could be hepatic encephalopathic it can be wernicke encephalopathy. There are two things that we can do with hepatic.
We are going to give lactulose. Remember lactulose is given, it’s going to bind to the ammonia. If it is caused by wernicke encephalopathy, we are going to give Thiamine. And that’s just the vitamin that we can give because they are deficient. It’s going to reverse this wernicke. The last thing we can do is we can monitor for changes in level of consciousness. These patients are very laid back and they can go from being wide awake, to being altered really quickly. So we’re going to monitor their LOC. We’re going to do detailed frequent neuro exams. Remember, it’s very important to do these frequent neuro checks because we can recognize quickly, um, the change so we can intervene right away. The next thing we want to do is we want to monitor the ICP. Remember anytime there’s brain involvement, the increased intracranial pressure is always a risk. It could put the patient at risk for seizures or even herniation. The next thing we want to do is we want to do seizure precautions. These patients are at risk for seizures and side whales need to be padded. We need to prevent injury suction set up at the bedside. We want to make sure that these patients do not aspirate. And in order for them to have a good outcome, we want to have all of these things set up.
These patients tend to get pretty confused. So when they are confused and agitated and combative
Safety restraints may be necessary. Okay. Remember you want to follow the facility’s protocol for rationale, for placement. You want to make sure you have those provider’s orders and you want to make sure you’re monitoring those patients. You want to assess for skin breakdown and want to make sure that they are actually getting adequate perfusion to those extremities that are restrained. So let’s take a look at the key points. Remember encephalopathy is just a general term for disease of the brain tissue. Some of the subjective and objective things that we are going to see is they’re going to have some mood changes. They’re gonna have some memory issues, memory loss, and loss of balance. And some weakness, the things that we’re going to see. We’re going to draw some blood as soon as they come in and we’re going to see that they are either suffering from hepatic encephalopathy.
That’s going to have some increased ammonia or wernicke encephalopathy, it’s going to be caused because of the ammonia in the blood. They’ll also want to have some altered level of consciousness, and some tremors or seizures. What we want to do is we want to do frequent neuro checks. It’s important to do these frequent neuro checks so we can catch those changes in level of consciousness. They may have some mood and personality changes, and that may indicate increased intracranial pressure. Restraint care is very important because if restraints are applied, it’s very important to do more frequent assessments for safety. We want to make sure this patient gets turned every two hours and we want to offer them hydration. And it’s very important for us to follow these care plans per your facility’s protocol. We love you guys; go out and be your best self today. And, as always, happy nursing.
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