Nursing Care Plan (NCP) for Encephalopathy

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Outline

Pathophysiology

Encephalopathy is a general term for a disease of the brain tissue. It is a syndrome of brain dysfunction caused by damage to brain tissues/cells. This damage can be done by atrophy, lack of oxygen, edema, or toxins.

Etiology

Encephalopathies could be caused by a variety of insults including toxemia, anoxia, and trauma. Examples include hepatic encephalopathy (elevated ammonia levels), Wernicke’s encephalopathy (thiamine deficiency), and chronic traumatic encephalopathy (caused by repeated blows to the head). Encephalopathies are best treated by preventing or reversing the initial cause.

Desired Outcome

To treat or reverse the cause in order to restore proper brain function and return the patient to their usual baseline mental status.

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 Interventions and Rationales

  • Give medications to treat the cause of encephalopathy
    • Hepatic → Lactulose
    • Wernicke’s → Thiamine
  Lactulose is given to bind to ammonia in the gut so it can be excreted.  If PO is unavailable, get an NG tube or request enema dose. Wernicke’s encephalopathy is caused by a thiamine deficiency and can be reversed by giving thiamine.
  • Monitor for changes in LOC with detailed, frequent neuro exams
  Neurological changes related to increasing ICP or damage to brain cells may occur rapidly. Frequent detailed neuro checks allow changes to be recognized quickly so that interventions can be initiated.
  • Monitor ICP/CPP if applicable
  Cerebral edema can cause an increase in ICP, which can put the patient at risk for seizures or even herniation.
  • 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
  Side rails should be padded to prevent injury, suction should be available in case of aspiration during a seizure.
  • Monitor respiratory status & protect airway as needed
  If there is brainstem involvement, patients may experience difficulty regulating their breathing or protecting their airway. The airway may also be compromised if the patient has a seizure.
  • May require restraints if agitated and confused and becomes a danger to self or others
  Follow facility protocol for rationale for placement, provider orders, and monitoring.

Writing a Nursing Care Plan (NCP) for Encephalopathy

A Nursing Care Plan (NCP) for Encephalopathy starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

  • Davis, C.P. (n.d.). Encephalopathy. Retrieved from https://www.medicinenet.com/encephalopathy/article.htm#encephalopathy_facts
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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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