Nursing care plan for acute encephalopathy

Introduction

Acute encephalopathy is an acute neurological disorder that requires prompt and skillful treatment. It usually represents an insult to the brain resulting in a rapid deterioration of consciousne ss and may progress to coma, seizures and death. Its etiology includes multiple causes such as virus infections, metabolic disorders, toxins, and ischemia. This article will discuss a nursing care plan for acute encephalopathy.

Assessment

Monitor vital signs: Vital signs must be monitored every 15 to 30 minutes to assess patient stability and detect any deterioration in condition.

Perform neurological assessment: The nurse should check for pupillary light reflex, level of consciousness, orientation, strength and responses to specific stimuli.

Check blood glucose levels: Blood glucose must be checked every 4 – 6 hours so as to maintain a normal range of values.

Evaluate mental status: A mental status evaluation is needed to assess the patient’s cognitive functions like concentration, memory, comprehension and judgment.

Nursing Diagnosis

Impaired physical mobility related to muscle weakness: This diagnosis is applicable when the patient is immobilized due to muscle weakness and an inability to move in bed.

Decreased cardiac output related to hypotension: Hypotension can affect the cardiovascular system, resulting in a decrease in cardiovascular functions.

Risk for aspiration related to dysphagia: Dysphagia or difficulty in swallowing can put the patient at a risk for aspirating liquid food or saliva.

Outcomes

The patient will maintain optimal cardiac output: The patient’s vital signs and lab results will remain within their specified ranges, thus maintaining an optimal level of cardiac output.

The patient will demonstrate adequate nutrition: The patient will consume a sufficient amount of calories and other nutrients in order to maintain their optimum nutrition.

The patient will demonstrate improved physical mobility: The patient will be able to move around and perform activities of daily living with minimal limitations.

Interventions

Administer medications as ordered: The nurse should administer vasopressors and diuretics as ordered by the physician.

Assist with passive range of motion exercises: These exercises should be done regularly to maintain muscle strength and to promote good joint and limb mobility.

Promote good nutrition: The nurse should provide nutritionally balanced meals to ensure the patient is getting enough calories and other nutrients.

Provide psychosocial support: The nurse should provide emotional support and encouragement to the patient and their family.

Rationales

Administering medications: Medications are needed in order to treat the underlying cause of the encephalopathy and to control seizures and other symptoms.

Assistance with range of motion exercises: Range of motion exercises help to maintain flexibility and strength of the musculoskeletal system.

Promoting good nutrition: A nutritious diet helps in maintaining the body’s energy levels and aids in the repair and regeneration of damaged tissues.

Providing psychosocial support: Emotional support is important for the patient in order to cope with the illness and its effects on the family.

Evaluation

The nurse should observe and assess the patient’s condition regularly to determine the effectiveness of the care plan. The patient’s response to the interventions must be documented in order to evaluate the outcome of the treatment.

Conclusion

As discussed, a comprehensive nursing care plan is needed to provide proper care and management for a patient with acute encephalopathy. The implementation of these interventions helps to promote the patient’s recovery and quality of life.

FAQs

• What is acute encephalopathy? Answer: Acute encephalopathy is an acute neurological disorder that requires prompt and skillful treatment.
• How is acute encephalopathy caused? Answer: The causes of acute encephalopathy include virus infections, metabolic disorders, toxins, and ischemia.
• What interventions can be used to treat acute encephalopathy? Answer: Interventions that can be used to treat acute encephalopathy include administering medications, providing range of motion exercises, promoting good nutrition, and providing psychosocial support.
• Can the patient's condition be improved with treatment? Answer: Yes, with proper treatment, the patient's condition can be improved.
• What should the nurse observe for during the treatment? Answer: The nurse should observe and assess the patient's vital signs, neurological responses, mental status, and physical mobility.