Nursing Care Plan on Encephalopathy

Encephalopathy is a general term used to describe damage or disease affecting brain function. The causes are varied and can be related to infection, liver conditions, drug toxins, and more. Some of the major types include the following:

• Chronic Traumatic Encephalopathy: This condition occurs due to direct injury to the brain, leading to nerve damage. This type is commonly found in athletes.
• Hepatic Encephalopathy: Often caused by liver cirrhosis, when the liver is not able to filter and function properly, toxins accumulate in the blood and brain.
• Glycine Encephalopathy: This type of encephalopathy is genetic with symptoms appearing after birth.
• Toxic Metabolic Encephalopathy: This type of encephalopathy results from toxins, infections, or organ failure. When chemical composition in the body becomes imbalanced, it can impact the brain’s normal function. 
• Hypoxic-Ischemic Encephalopathy: When the brain does not get enough oxygen, permanent brain damage can result.
• Hypertensive Encephalopathy: Prolonged hypertension that is not treated can cause the brain to swell resulting in neurological damage.
• Uremic Encephalopathy: If the kidneys are not functioning properly, they cannot filter harmful substances. The buildup of uremic toxins can cause confusion and other symptoms.

Symptoms of encephalopathy include:

• Worsening confusion
• Loss of memory
• Drowsiness and changes in consciousness
• Difficulty speaking
• Poor coordination

If not treated, encephalopathy can progress to seizures, coma, irreversible brain damage, and death.

Blood tests, imaging studies like CT scans or MRI, spinal fluid examination, and electroencephalograms (EEG) may be performed to help diagnose the condition and determine its underlying cause.

Nursing Process

Nurses play an important role in the care of patients with encephalopathy as they require individualized care specific to the patient’s condition while promoting patient safety, and comfort, assisting in treatment regimens, providing accurate information about the condition, and determining potential risks and needs.

Meticulous assessment and proper diagnosis are important in the management and care of patients with encephalopathy so appropriate interventions can be initiated promptly. Treating the underlying cause of the condition is vital as this can improve the patient’s symptoms and prevent permanent structural changes and irreversible damage to the brain. 

The treatment of encephalopathy varies, depending on the underlying cause of the condition. Treatment may include medications like anticonvulsants to treat symptoms like seizures and other treatment modalities targeting the underlying cause. Dialysis or surgery may be indicated for severe cases.

Nursing Assessment

Encephalopathy is a broad term that refers to any disorder or disease of the brain that affects mental status, cognitive function, or consciousness. It can be caused by a variety of factors, including infections, toxins, metabolic disturbances, and structural abnormalities. Nurses play a pivotal role in the assessment of encephalopathy, ensuring that patients receive appropriate care and support to improve their outcomes.

Patient History

A thorough patient history is essential for effective management of encephalopathy. Nurses should gather detailed information about the patient’s medical background, including:

• Onset: When did the symptoms of encephalopathy begin?
• Symptoms: What specific symptoms is the patient experiencing (e.g., confusion, altered consciousness, memory loss)?
• Medical History: Are there any underlying medical conditions or recent infections?
• Medications: What medications is the patient currently taking?
• Substance Use: Is there any history of alcohol or drug use?

Physical Examination

A comprehensive physical examination is crucial to identify any signs that may indicate the cause or severity of encephalopathy. Key aspects include:

• Neurological Assessment: Evaluating mental status, level of consciousness, orientation, and cognitive function.
• Vital Signs: Monitoring blood pressure, heart rate, respiratory rate, and temperature to detect any abnormalities.
• Laboratory Tests: Ordering blood tests, liver function tests, and toxicology screens to identify underlying metabolic or toxic causes.
• Imaging Studies: Utilizing CT scans or MRI to assess for structural abnormalities in the brain.

Nursing Interventions

Nurses are integral to the care and management of patients with encephalopathy. Through effective medical intervention, patient and family education, and psychosocial support, nurses ensure that patients receive holistic and compassionate care. By coordinating with the healthcare team and advocating for the patient’s needs, nurses play a vital role in improving patient outcomes and quality of life

Medical Interventions

Effective management of encephalopathy often requires a multidisciplinary approach. Nurses collaborate with physicians and other healthcare professionals to implement the following interventions:

• Medication Administration: Administering medications to manage symptoms, such as anticonvulsants, antibiotics, or antipsychotics.
• Fluid and Electrolyte Management: Ensuring proper hydration and correcting any electrolyte imbalances.
• Monitoring and Support: Continuously monitoring the patient’s vital signs and neurological status, providing oxygen therapy if needed.

Patient and Family Education

Educating patients and their families is a key component of nursing care. Nurses should provide information on:

• Understanding Encephalopathy: Explaining the condition, its causes, and potential outcomes.
• Treatment Plan: Outlining the prescribed treatments, their purposes, and any potential side effects.
• Preventive Measures: Advising on lifestyle changes and strategies to prevent recurrence or exacerbation of encephalopathy.

Psychosocial Support

Providing emotional and psychological support to both patients and their loved ones is crucial in managing encephalopathy. This includes:

• Emotional Support: Offering a listening ear, empathy, and reassurance to patients and their families.
• Counseling Services: Facilitating access to counseling services or support groups for emotional and mental health support.
• Spiritual Care: Respecting the patient’s beliefs and facilitating access to spiritual care providers if desired.

Nursing Care Plans

Once the nurse identifies nursing diagnoses for encephalopathy, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for encephalopathy.

Acute Confusion

An altered mental state is one of the main symptoms of encephalopathy, causing confusion and changes in consciousness. When a patient is confused, there are disturbances in cognition, attention, and perception.

Nursing Diagnosis: Acute Confusion

Related to:

• Hypoxia 
• Disturbance in cerebral metabolism 
• Accumulation of toxins in the brain
• Structural changes in the brain

As evidenced by:

• Cognitive dysfunction 
• Altered psychomotor performance 
• Tremors
• Fluctuation in the level of consciousness
• Agitation
• Misperception
• Neurobehavioral manifestations
• Difficulty initiating purposeful behavior

Expected Outcomes:

• The patient will have decreased episodes of delirium as evidenced by reduced agitation and combativeness, and improved follow-through with commands
• The patient will remain alert and oriented

Assessment:

1. Assess for causative and contributing factors.
It is critical to evaluate and determine conditions that may be causing the patient to experience confusion. This will help in formulating an effective treatment regimen for the patient.

2. Assess and monitor the level of consciousness.
Sudden changes in a patient’s level of consciousness can indicate the progression and worsening of the disease.

3. Monitor lab work.
Ammonia levels, BUN and creatinine, urinalysis, white blood counts and more can signal abnormalities in the liver, kidneys, and infectious processes contributing to symptoms of confusion.

Interventions:

1. Assist in the treatment of the underlying conditions.
Once the underlying cause is determined, administer necessary interventions. Lactulose is often given to reduce ammonia in the blood. Oxygenation can be given for hypoxia. Antibiotics can be administered to treat infectious processes. Drug intoxication or withdrawal can be treated with medications.

2. Reorient the patient as necessary.
Increased reorientation may be required to decrease anxiety and provide safety. This can seem repetitive but is necessary for the confused patient.

3. Promote a calm environment.
The patient suffering from encephalopathy tends to misinterpret high levels of auditory and visual stimulation. Prevent overstimulation by eliminating loud noises and constant interruptions.

4. Encourage family members to engage in the reorientation process.
The presence of family members will increase the patient’s degree of comfort and promote a trusting relationship. They can help with supporting the patient to cooperate with care.

5. Provide optimal fluids and electrolytes.
Electrolyte imbalances can worsen bodily functions. Ensure adequate glucose levels to support brain functions and fluid intake to restore hemodynamic processes.

Disturbed Thought Processes

Patients with encephalopathy exhibit altered mental status, causing them to experience disturbed thought processes. This refers to the alteration of perception and cognition, interfering with the patient’s activities of daily living.

Nursing Diagnosis: Disturbed Thought Processes

Related to:

• Insufficient oxygen supply to the brain secondary to encephalopathy
• Head trauma related to encephalopathy
• Infections 
• Alcohol or substance abuse

As evidenced by:

• Incorrect perception of stimuli
• Difficulty performing activities of daily living 
• Difficulty communicating verbally
• Impaired interpretation of events
• Impaired judgment
• Impaired decision making
• Inadequate emotional responses
• Disorientation

Expected Outcomes:

• The patient will maintain a realistic perspective and be able to communicate clearly with others
• The patient acknowledges and understands potential misinterpretations of other people’s verbalizations and behaviors

Assessment:

1. Assist with testing to evaluate mental capabilities.
Assist with the application or reviewing of results to determine the patient’s ability to understand abstract thoughts, decision-making, judgment, and insights.

2. Assess the patient’s attention span and ability to make good decisions.
This will help identify the patient’s ability to plan and comply with his or her treatment regimen and follow through with care after discharge.

3. Review medications.
Ensure the patient’s medication regimen is not contributing to their disturbed thought processes on top of their diagnosis.

Interventions:

1. Maintain safety.
The patient may not be able to make rational decisions and is at risk for poor judgment calls. As a top priority, maintain their safety by implementing fall precautions and keeping sharp objects out of reach.

2. Encourage the patient’s family to participate in patient care.
Patients with disturbed thought processes need to feel secure and safe. Involving the family in patient care can prevent anxiety and combative behavior.

3. Give simple instructions.
Allow the patient to participate in care by giving them simple directions to follow, using short sentences, and allowing them to make decisions using yes/no questions.

4. Do not force.
Respect the patient’s space and do not force activities or communication. This may cause the patient to feel threatened and they may withdraw.

Impaired Memory

Memory loss is considered the most disabling effect of encephalopathy and can be a long-term result of severe encephalopathy.

Nursing Diagnosis: Impaired Memory

Related to:

• Neurological disturbances related to encephalopathy
• Inadequate intellectual stimulation
• Changes in brain structure and processes
• Irreversible brain damage
• Depressive symptoms 

As evidenced by:

• Reports experiences of forgetfulness
• Consistently forgets to schedule or keep appointments 
• Difficulty recalling events
• Difficulty recalling familiar names, objects, and words
• Inability to learn or retain new skills or information
• Inability to perform a previously learned skill

Expected Outcomes:

• The patient will report increased satisfaction with memory as evidenced by recalling facts or events
• The patient will be able to identify 2 techniques that help improve memory

Assessment:

1. Assess the patient’s cognition, perception, and memory.
This helps determine the patient’s general thinking and reasoning abilities. The patient’s cognitive abilities influence support provision, communication, and treatment.

2. Assess causative factors of the condition.
Assess other contributing factors of impaired memory along with encephalopathy such as dementia, substance abuse, or psychiatric conditions.

3. Determine the effect of impaired memory on daily life.
This can also be obtained from family members. Determine the severity of the impaired memory and if it affects the patient’s ability to perform tasks, participate in conversation, and remain safe.

Interventions:

1. Use memory aids.
Technological devices such as smartphones, watches, and medication-reminding systems can keep the patient on schedule and safe.

2. Make their home memory-friendly.
This can be accomplished by labeling cabinets to indicate where items are, hanging calendars, keeping important phone numbers by the phone, and keeping notes by the door to remind them to take their wallet, phone, etc.

3. Assist patients in establishing a routine.
Establish a structured routine that aids the patient in performing certain tasks at specific times without deviation. This can support independence.

4. Educate the patient and family members about the patient’s condition.
Memory may or may not improve. Involving the family members in the patient’s treatment regimen helps the patient feel safe, comfortable, and supported. This will also improve the patient’s compliance with the treatment regimen.

5. Consider a psychologist.
A mental professional who specializes in memory disorders may be able to help implement strategies to improve memory and ease the burden on family members.

Nursing Diagnoses and Rationales for Encephalopathy

1. Altered Mental Status

Rationale: Encephalopathy often presents with changes in cognitive function, ranging from confusion to coma. Assessing the patient’s level of consciousness using tools such as the Glasgow Coma Scale can help in monitoring the progression of the condition. Prompt recognition and intervention are essential to prevent further deterioration.

2. Risk for Injury

Rationale: Patients with encephalopathy are at increased risk for falls and other injuries due to altered mental status and impaired coordination. Implementing safety measures, such as bed rails, non-slip footwear, and environmental modifications, can reduce the risk of injury. Close monitoring and assistance with activities of daily living may also be necessary.

3. Impaired Memory

Rationale: Memory deficits are common in encephalopathy and can affect the patient’s ability to recall recent events and follow instructions. Providing written reminders, using visual aids, and involving family members in care can support memory function and improve the patient’s ability to adhere to treatment plans.

4. Knowledge Deficit

Rationale: Patients and their families may not fully understand the causes, symptoms, and management of encephalopathy. Offering comprehensive education about the condition, its potential complications, and the benefits of treatment can empower patients to participate actively in their care. Utilizing various educational methods, such as pamphlets, videos, and one-on-one teaching, can enhance understanding.

5. Risk for Ineffective Coping

Rationale: The diagnosis of encephalopathy can be overwhelming for patients and their families. Assessing coping mechanisms, providing emotional support, and referring to counseling services can help patients and families manage the stress associated with the condition. Encouraging the use of relaxation techniques and support groups can also be beneficial.

6. Risk for Imbalanced Nutrition: Less Than Body Requirements

Rationale: Encephalopathy may impair the patient’s ability to eat and drink adequately due to cognitive and physical impairments. Assessing dietary intake, providing assistance with feeding, and collaborating with a dietitian can ensure that nutritional needs are met. Monitoring weight and laboratory values can also help in identifying nutritional deficits.

7. Risk for Impaired Skin Integrity

Rationale: Patients with encephalopathy may have limited mobility and be at risk for developing pressure ulcers. Regular repositioning, use of pressure-relieving devices, and meticulous skin care can prevent skin breakdown. Monitoring for signs of pressure ulcers and implementing early interventions are essential in maintaining skin integrity.

8. Risk for Infection

Rationale: Encephalopathy can compromise the immune system, making patients more susceptible to infections. Strict adherence to infection control practices, such as hand hygiene and sterile techniques, can reduce the risk of infection. Monitoring for signs of infection and providing prompt treatment are crucial in managing the patient’s health.

9. Risk for Fluid Volume Imbalance

Rationale: Patients with encephalopathy may experience fluid imbalances due to changes in cognitive function and physical ability. Monitoring fluid intake and output, assessing for signs of dehydration or fluid overload, and providing appropriate interventions can maintain fluid balance. Collaborating with the healthcare team to adjust fluid management based on the patient’s condition is essential.

10. Risk for Ineffective Breathing Pattern

Rationale: Encephalopathy can affect the central nervous system, leading to respiratory complications. Assessing respiratory function, monitoring oxygen saturation, and providing respiratory support as needed can ensure adequate oxygenation. Teaching the patient and family about recognizing signs of respiratory distress and when to seek help is also important.

REFERENCES

1. Chronic traumatic encephalopathy. Mayo Clinic. May 25, 2021. https://mayoclinic.org/diseases-conditions/chronic-traumatic-encephalopathy/symptoms-causes/syc-20370921
2. Encephalopathy. National Institute of Neurological Disorders and Stroke. Last reviewed on April 22, 2022. https://www.ninds.nih.gov/health-information/disorders/encephalopathy
3. García-García, R., Cruz-Gómez, Á.J., Urios, A. et al. Learning and Memory Impairments in Patients with Minimal Hepatic Encephalopathy are Associated with Structural and Functional Connectivity Alterations in Hippocampus. Sci Rep 8, 9664 (2018). https://doi.org/10.1038/s41598-018-27978-x
4. Hepatic Encephalopathy. Updated: May 18, 2020. Author: David C Wolf, MD, FACP, FACG, AGAF, FAASLD; Chief Editor: BS Anand, MD. https://emedicine.medscape.com/article/186101-overview
5. Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, PhD, FAADN, CNE. 2020. Elsevier, Inc.
6. Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.

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