Ineffective Cerebral Tissue Perfusion related to Encephalitis

Nursing Care Plan for Encephalitis

Nursing Diagnosis : Ineffective Cerebral Tissue Perfusion related to increased intracranial pressure.

Goal :

• Neurologic status returned to the state before the illness.
• Increased awareness and sensory function.

Outcomes :

• Vital signs within normal limits.
• Headache is reduced.
• Increased awareness.
• No signs or loss of increased intracranial pressure.

Interventions :
1. Total bed rest with supine sleeping position without a pillow.
Rationale : Changes in intracranial pressure will be able to mislead the risk for brain herniation.

2. Monitor the status of neurological signs with GCS.
Rationale : Can reduce further brain damage.

3. Monitor vital signs such as BP, pulse, temperature, respiration and caution in systolic hypertension.
Rationale : In normal circumstances autoregulation maintains a state of altered systemic blood pressure to fluctuate. Failure of autoregulation, will lead to cerebral vascular damage that can be manifested by an increase in systolic and diastolic pressure followed by a decrease. While the increase in temperature can describe the course of infection.

4. Monitor intake and output.
Rationale : Hyperthermia can lead to increased IWL and increase the risk of dehydration, especially in patients who are not aware, and nausea were lower intake orally.

5. Help the patient to limit vomiting, coughing. Instruct the patient to exhale when moving or turning in bed.
Rationale : Activity vomiting or coughing can increase intracranial pressure and intra-abdominal. Exhale when moving or changing position can protect themselves from the effects of valsalva's.

Collaboration :

6. Arterial blood gas analysis monitor when needed oxygen administration.
Rationale : The possibility of acidosis is accompanied by the release of oxygen at the cellular level may lead to the occurrence of cerebral ischemic.

7. Give appropriate therapy doctors advice.
Rationale : Given therapy can decrease capillary permeability. Lowering of cerebral edema. Lowering metabolic cells / consumption and seizures.