Nursing Care Plan for Encephalopathy

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

  1. Give medications to treat the cause of encephalopathy

    • Hepatic → Lactulose
    • Wernicke’s → Thiamine
  2. 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.

  3. Monitor for changes in LOC with detailed, frequent neuro exams

  4. 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.

  5. Monitor ICP/CPP if applicable

  6. Cerebral edema can cause an increase in ICP, which can put the patient at risk for seizures or even herniation.

  7. 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

  8. Place patient in seizure precautions

  9. Side rails should be padded to prevent injury, suction should be available in case of aspiration during a seizure.

  10. Monitor respiratory status & protect airway as needed

  11. 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.

  12. May require restraints if agitated and confused and becomes a danger to self or others

  13. Follow facility protocol for rationale for placement, provider orders, and monitoring.


References

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

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