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Friday, March 18, 2011

NCP Nursing Care Plan For Encephalitis

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NCP Nursing Care Plan For Encephalitis. Encephalitis is a severe inflammation of the brain characterized by intense lymphocytic infiltration of brain tissues and the leptomeninges. This process causes cerebral edema, degeneration of the brain's ganglion cells, and diffuse nerve cell destruction. Viruses transmitted by arthropods are arboviruses (arthropod-borne). Transmission by means other than arthropod bites may occur through ingestion of infected goat's milk and accidental injection or inhalation of the virus. Eastern equine encephalitis may produce permanent neurologic damage and is commonly fatal.

Causes For Encephalitis

Encephalitis usually results from infection frequently caused by enteroviruses (coxsackievirus, poliovirus, and echovirus). Other causes include herpesvirus, mumps virus, adenoviruses, and demyelinating diseases after measles, varicella, rubella, or vaccination

Complications For Encephalitis
Potential complications associated with viral encephalitis include:
• Bronchial pneumonia,
• Urine retention
• Urinary tract infection
• Pressure ulcers.
• Coma.
• Epilepsy, parkinsonism, and mental deterioration may also occur

Nursing Assessment Nursing Care Plan For Encephalitis
Depending on the severity of the disease, all forms of viral encephalitis have similar clinical features. The severity of arbovirus encephalitis may range from subclinical to rapidly fatal necrotizing disease. Herpes encephalitis also produces signs and symptoms that vary from subclinical to acute and often fatal fulminating disease.
Patient History. Obtain a history of recent illnesses, which may include an upper respiratory infection or a minor systemic illness that caused headache, muscle ache, malaise, sore throat, and runny nose. Note if the patient has other sites of infection, such as a recent skull fracture or head injury, middle ear infection, or sinus infection. Ask if the patient has had a recent immunization, exposure to mumps or hsv, animal bites, recent travel, or exposure to epidemic outbreaks or mononucleosis. Ask if a child has been playing in a rural area where exposure to ticks or mosquitoes was possible
Neurologic examination, The patient appears acutely ill with an altered mental status that may range from mild confusion to delirium and coma. Tremors, cranial nerve palsies, exaggerated deep tendon reflexes, absent superficial reflexes, and paresis or paralysis of the extremities. The patient may complain of a stiff neck when the head is bent forward.Vital signs usually reveal fever.

Diagnostic tests For Encephalitis
The following tests help establish a diagnosis.

  • Blood analysis or,
  • Rarely, cerebrospinal fluid (CSF) analysis
  • Serologic studies in herpes encephalitis.
  • Lumbar puncture CSF analysis
  • EEG.
  • Computed tomography scanning
  • Magnetic resonance imaging.

Nursing diagnosis Nursing Care Plan For Encephalitis

  • Acute pain
  • Anxiety
  • Disturbed thought processes
  • Hyperthermia
  • Imbalanced nutrition: Less than body requirements
  • Impaired gas exchange
  • Impaired physical mobility
  • Risk for deficient fluid volume
  • Risk for impaired skin integrity

Nursing outcomes Nursing Care Plan For Encephalitis
Nursing outcomes Nursing Care Plan For Encephalitis The patient will:

  • Express feelings of comfort and relief of pain.
  • Identify strategies to reduce anxiety.
  • Remain oriented to person, place, time, and situation.
  • Exhibit fluid balance within normal limits.
  • Consume adequate daily calories as required
  • Maintain adequate ventilation and oxygenation.
  • Maintain joint mobility and muscle strength.
  • Exhibit temperature within normal limits.
  • Maintain intact skin with no signs of breakdown.

Nursing interventions Nursing Care Plan For Encephalitis

  • Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient
  • Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain
  • Environmental Management: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
  • Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger
  • Provision of a modified environment for the patient who is experiencing a chronic confusional state
  • Calming Technique: Reducing anxiety in patient experiencing acute distress
  • Delusion Management: Promoting the comfort, safety, and reality orientation of a patient experiencing false, fixed beliefs that have little or no basis in reality
  • Environmental Management: Safety: Manipulation of the patient’s surroundings for therapeutic benefit
  • Temperature Regulation: Attaining and/or maintaining body temperature within a normal range
  • Fever Treatment: Management of a patient with hyperpyrexia caused by nonenvironmental factors
  • Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids
  • Weight Gain Assistance: Facilitating gain of body weight
  • Eating Disorders Management: Prevention and treatment of severe diet restrictions and over exercising or binging and purging of foods and fluids
  • Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
  • Oxygen Therapy: Administration of oxygen and monitoring of its effectiveness
  • Airway Management: Facilitation of patency of air passages
  • Exercise Therapy:  Use of active or passive body movement to maintain or restore flexibility; use of specific activity or exercise protocols to enhance or restore controlled body movement
  • Fluid Monitoring: Collection and analysis of patient data to regulate fluid balance
  • Hemodynamic Regulation: Optimization of heart rate, preload, afterload, and contractility
  • Skin Surveillance: Collection and analysis of patient data to maintain skin and mucous membrane integrity
  • Pessure Management: Minimizing pressure to body parts
  • Pressure Ulcer Prevention: Prevention of pressure ulcers for a patient at high risk for developing them


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