Encephalitis is inflammation of the brain. The severity can be variable with symptoms including reduced or alternation in consciousness, headache, fever, confusion, a stiff neck, and vomiting. Complications may include seizures, hallucinations, trouble speaking, memory problems, and problems with hearing.
Causes of encephalitis include viruses such as herpes simplex virus and rabies as well as bacteria, fungi, or parasites. Other causes include autoimmune diseases and certain medications. In many cases the cause remains unknown. Risk factors include a weak immune system. Diagnosis is typically based on symptoms and supported by blood tests, medical imaging, and analysis of cerebrospinal fluid.
Ineffective Tissue perfusion
Ineffective Tissue perfusion (specify type): cerebral, renal, cardiopulmonary, GI, peripheral
Definition :
Decrease in oxygen resulting in failure to nourish tissues at the capillary level
Defining Characteristics:
Renal
- Altered blood pressure outside of acceptable parameters;
- hematuria;
- oliguria or anuria;
- elevation in BUN/creatinine ratio
Gastrointestinal
- Hypoactive or absent bowel sounds;
- nausea;
- abdominal distention;
- abdominal pain or tenderness
Peripheral
- Edema;
- positive Hoeman's sign;
- altered skin characteristics (hair, nails, moisture);
- weak or absent pulses;
- skin discolorations;
- skin temperature changes;
- altered sensations;
- diminished arterial pulsations;
- skin color pale on elevation, color does not return on lowering the leg;
- slow healing of lesions; cold extremities;
- dependent, blue, or purple skin color
Cerebral
- Speech abnormalities;
- changes in pupillary reactions;
- extremity weakness or paralysis; altered mental status;
- difficult in swallowing;
- changes in motor response;
- behavioral changes
Cardiopulmonary
- Altered respiratory rate outside of acceptable parameters;
- use of accessory muscles;
- capillary refill >3 seconds;
- abnormal arterial blood gases;
- chest pain;
- sense of "impending doom";
- bronchospasms;
- dyspnea;
- dysrhythmias;
- nasal flaring;
- chest retraction
Nursing Diagnosis :
Impaired tissue perfusion : cerebral related to increased intracranial pressure.
Goals:
- The patient returns to the state of the neurological status before the illness.
- Increased awareness and sensory function.
Outcomes :
- Vital signs within normal limits.
- Headaches are reduced.
- Awareness increases.
- Absence or disappearance of signs of raised intracranial pressure.
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Nursing Interventions
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Rationale |
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Total bed rest with a supine sleeping position without a pillow.
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Changes in intracranial pressure will be able to cause a risk for brain herniation.
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Monitor for signs of neurological status with GCS.
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May reduce further brain damage.
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Monitor vital signs; such as BP, pulse, temperature, respiration and caution in systolic hypertension.
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Under normal conditions, autoregulation maintains a state of fluctuating systemic blood pressure. Failure of autoregulation will cause cerebral vascular damage which can be manifested by an increase in systolic and followed by a decrease in diastolic pressure. While the increase in temperature can describe the course of infection.
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Monitor
intake dan output
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Hyperthermia can cause an increase in IWL and increase the risk of dehydration, especially in unconscious patients and nausea which reduces oral intake.
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Help the patient to limit vomiting, coughing. Instruct the patient to exhale when moving or turning in bed.
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The activity of vomiting or coughing can increase intracranial and intra-abdominal pressure. Exhaling while moving or changing positions can protect the patient from the effects of Valsalva.
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