Nursing Care Plan for Encephalitis
Definition
- Encephalitis is an infection of the CNS caused by a virus or other microorganism that non-purulent.
- Encephalitis is an infection of the brain tissue by a variety of microorganisms. Encefalopati terminology that was used for the same symptoms, no signs of infection are now no longer in use. (Abdoerrachman, et al, 1985).
Etiology
A wide variety of organisms can cause encephalitis, such as bacteria, protozoa, worms, fungi, spirokaeta, and viruses. The most common cause is a virus. Infection can occur due to virus attacks the brain directly or acute inflammatory reaction due to systemic infection or previous vaccination. Encephalitis can also be caused by the direct invasion of the cerebrospinal fluid during a lumbar puncture. Various types of viruses can cause encephalitis, despite similar clinical symptoms. According to the type of virus and its epidemiology, known to a wide variety of viral encephalitis.
Signs and Symptoms
- The clinical symptoms of encephalitis is not specific, depending on the cause and extent of the areas affected by the infection. Generally obtained sudden temperature rise, before consciousness decreased, often complain of headache, vomiting frequently found, lethargi, photofobi, sometimes a stiff neck desertai if infection of the meninges.
- Children appear irritable, agitated sometimes accompanied by changes in behavior. May be accompanied by impaired vision, hearing, speech, and seizures. Seizures may be general or focal or just twitching alone. Seizures can last for hours, diverse cerebral symptoms may occur individually or together, such as paresis or paralysis, aphasia, and so on.
- Cerebrospinal liquor often within normal limits, sometimes found little elevation cell count, protein or glucose levels.
- Cerebrospinal fluid examination: Colors are clear pleocytosis ranges from 50 to 2000 cells. Where lymphocyte cells are the dominant cell, the protein rather increased, whereas glucose within normal limits.
- EEG: Shows a diffuse inflammatory process "Bilateral" with low activity.
- Other signs and symptoms that often arise are: Nuchal rigidity, Kernig's signs, Ataxia, Muscle weakness, Diplopia, Confusion, Irritability, Coma.
Complications
- Encephalitis can also occur as a complication of measles, mumps or chickenpox.
- Complications include encephalitis beginning of the cardiovascular system, respiratory and neurologic usually the brain stem.
- Encephalitis can cause residual neurologic defects after recovery.
Assessment for Encephalitis
Symptoms may occur gradually, but may also occur in acute
- Headaches.
- High temperature.
- Ridgiditas nuchal.
- Kernig's signs.
- Ataxia.
- Muscle weakness.
- Paralysis.
- Diplopia.
- Confusion.
- Irritability.
- Lethargy.
- Coma.
Nursing Diagnosis and Interventions for Encephalitis
1. Ineffective Cerebral Tissue Perfusion related to inflammatory processes, increased ICP.
Intervention:
- Observation level of consciousness.
- Check the status of neurology every 1-2 hours and if necessary until a stable state.
- Monitor the signs of the rise of ICT (elevated BP, peurunan pulse, irregular breath, anxiety, changes in pupil).
- Elevate head of bed 30 °.
- Keep the neck and head straight to improve venous return.
- Teach children to avoid the Valsalva manuever (coughing, sneezing).
- Monitor signs / symptoms of septic shock (hypotension, increased temperature, increased RR, confusion, disorientation, peripheral vasoconstriction).
2. Risk for injury related to disorientation, seizures, and the unfamiliar environment.
Intervention:
- Observation level of consciousness.
- Check the status of neurology every 1-2 hours and if necessary until a stable state.
- Maintain a calm and comfortable environment.
- Limit the number of visitors.
- Teach ROM exercises (passive, active) as recommended and regularly.
- Collaboration of anticonvulsants.
3. Altered thought processes related to changes in the level of consciousness
Intervention:
- Observation level of consciousness.
- Check the status of neurology every 1-2 hours and if necessary until a stable state.
- Monitor the signs of the rise of ICT.
- Speak slowly and clearly.
- Maintain a calm and comfortable environment.
- Limit the number of visitors.
4. Imbalanced Nutrition: Less Than Body Requirements related to anorexia, fatigue, nausea, and vomiting
Intervention:
- Ask the patient's favorite food.
- Provide the recommended diet.
- Serve food in small portions but frequently.
- Encourage to eat slowly.
- Allow families to provide food for children.
- Monitor body weight per day.
- Create a pleasant environment.
- Encourage family members to accompany the child during meals.
- Limit fluid intake during meals.
- Give good oral care.
5. Acute pain related to irritation encephalon
Intervention:
- Assess the level of pain.
- Evaluation indicators of pain (facial expression, crying), location, duration, spread, intensity, and precipitating factors.
- Take action to support comfort (change position, imagination, distraction, massage, cold compresses).
- Instruct child to menghindarigerakan that can improve ICT (coughing, sneezing, bending, straining).
- Limit visitors.
- Collaboration of analgesics.