About
Inflammation of the brain tissue and the cerebrum, cerebellum, and the brain stem, often causing increased intracranial pressure and lack of oxygen to areas of the brain. Can be fatal.
Assess
Lethargy, changes in level of consciousness, abnormal motor function, visual changes, fatigue, muscle spasms, seizures, tremors, fever, nausea, vomiting, headache, dizziness, complete neuro assessment.
Complications
Permanent brain damage; death; seizures
Diagnosis
- Pain related to infectious process and cerebral edema
- Risk for falls related to altered level of consciousness
- Excess fluid volume related to increased intracranial pressure
Goals
- The client will be free from complications.
- The client will verbalize understanding of treatment plan.
Interventions
- Monitor vital signs, neurological status, and circulation to extremities.
- Maintain a patent airway.
- Reposition client every two hours.
- Encourage coughing and deep breathing.
- Initiate seizure precautions.
- Keep in a quiet, darkened room to manage for photophobia.
- Administer medications ( antivirals, osmotic diuretics, etc.) as ordered.
- Maintain standard precautions as indicated by agency protocol.
- Maintain head of bed up 30-45 degrees and monitor for s/s of increased intracranial pressure.
- Monitor for signs/ symptoms of complications.
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