Ineffective Tissue Perfusion : Cerebral - Encephalitis Care Plan

Encephalitis is infection of the brain, usually due to viral infection; however, it may also be caused by bacteria, fungi, protozoa or other parasites. It is a life-threatening disease, especially in infants, children and the elderly. Some 1.500 to 2,000 cases are reported yearly in the United States.

An acute onset, fever, headache, nausea, neck pain and neck rigidity, and - in the late stage- altered consciousness, tremors and convulsions are typical symptoms of this condition.

Types of Encephalitis :

• Primary encephalitis is when the virus directly invades the brain and the spinal cord. This is transmitted by insects like ticks, mosquitoes, lice and flies that carry the virus from infected animals to humans.
• Secondary encephalitis is when the virus affects another part of the body and later attacks the brain. This may follow childhood diseases like mumps, measles and rubella. Other cases are caused by herpes viruses that are responsible for cold sores or fever blisters, shingles and chickenpox.

Symptoms of Encephalitis :

• Acute fever.
• Vomiting.
• Headache.
• Impaired judgment.
• Photosensitivity.
• Weak muscles.
• Drowsiness.
• Unsteady gait

There is no specific treatment for encephalitis since the viruses that cause the disease don't respond to medications. For mild cases, bed rest, plenty of liquids and a healthy diet can help your immune system fight the disease.


Nursing Care Plan for Encephalitis

Nursing Diagnosis : Ineffective Tissue Perfusion : Cerebral related to inflammatory processes, increased ICT

Supporting data:

• Changes in consciousness.
• Changes in vital signs.
• Changes in the pattern of breathing, bradycardia.
• Headache.
• Nausea and vomiting.
• Motor weakness.
• Damage to the cranial nerves III, IV, VI, VII, VIII.
• Pathological reflexes.
• Changes in the value of blood gas analysis.
• The results of a CT scan of their cerebral edema, abscess.
• Blurred vision.

Outcomes:

• Maintain a level of awareness and orientation.
• Vital signs within normal limits.
• No neurological deficit.

Intervention:

1. Monitor neurological status every 2 hours: level of consciousness, pupil, reflexes, motor skills, headache, stiff neck.
2. Monitor vital signs and temperature every 2 hours.
3. Reduce activities that can lead to an increase in ICT: coughing, straining, vomiting, hold the breath.
4. Provide adequate rest periods and reduce environmental stimulus.
5. Elevate the head position of 30-45 ° keep the head in a neutral position, avoiding neck flexion.
6. Collaboration in the provision of osmotic diuretics, steroids, antibiotics.