IDENTIFICATION DATA:

Name: Mr. Mukesh

Age: 27 years

Sex: Male

Date of admission: 10-2 -20

Bed no. - 14

Cr no. 22045

Education graduation

Occupation private job

Religion Hindu

Address: V.P.O Churah Teh. & Distt chamba H.P

Diagnosis: Encephalitis

HISTORY

CHIEF COMPLAINTS:
Patient is admitted with the chief complaints of :

- Mental confusion X 5 days.

- Convulsions X 4days

-Irritability X 1 day
Medical History:

Present Medical History: patient is suffering from convulsions, irritability.

Past Medical History: There is no any past history.

No History of diabetes mellitus

No history of Hypertension

Surgical History:

Present Surgical History: Patient has not undergone any surgery.

Past surgical History: Patient did not undergo any past surgical history.
.

PERSONAL HISTORY:

Hygiene: Patient hygiene is good+ patient is well groomed

Sleep Pattern: Sleep pattern is disturbed

Diet Pattern: Patient’s Diet pattern is inadequate

Elimination: Patient elimination pattern is inadequate.

FAMILY HISTORY:
Type of family: Nuclear Family.
Family Tree:

Roshan lal (62 yrs) Jeeto devi (59 yrs)

mukesh(27 yrs) Aruna (35 yrs)

Key Terms:

Male

Female

Patient

Family Illness History: No History of Jaundice

No History of Tuberculosis

History of Diabetes Mellitus(father)

FAMILY COMPOSITION:

S.No. Name of Relation with Age/sex Education Occupation Income Health

family patient status status per status
members month
1 Roshan lal Father 62 yrs 10th pass Private 15,000 Healthy
2 Jeeto devi Mother 59 yrs 5th pass Housewife Nil Healthy
3 Aruna devi Sister 35yrs 12th pass Housewife Nil Healthy
4. Mukesh Self 27 yrs Graduate Private job 10,000 Patient

SOCIOECONOMIC STATUS :

Socio-Economic Status: Patient belongs to middle class family .His father works in private company & Mother is
housewife.

Total income: 25,000

Per capita income: 2,40,000

HISTORY OF ANY DISEASE: No history

PERSONAL HISTORY
• Diet- soft diet
• Number of meals per day: loss of appetite
• Food allergies, food preferences: soft diet. No food allergies.
• Bowel & Bladder habit- regular
• Frequency of Micturition: 5-6 time per day
• Frequency of defecation: diarrhea
• Sleep pattern: disturbed due to hospitalization and disease.
• Smoking: non-smoker
• Alcohol Consumption: non-alcoholic
• Tobacco chewing: not significant
Psychosocial history:
• Languages spoken: Hindi
• Social support systems present.
• Any psychological stressors present: anxiety related to associated disease.
PHYSICAL EXAMINATION
GENERAL APPEARANCE AND BEHAVIOUR
• Body build- Thin
• Hygiene & grooming – well groomed
• Mobility status- mobile
• Activity level- dull
• Pallor: yes
• Jaundice: absent
• Consciousness-not oriented to time, place and person
ANTROPOMENTRIC MEASUREMENT
• Height: 160 cm
• Weight: 60kg
• BMI= WEIGHT IN KG/ (height in meters)2= 2.56kg/m2

SKIN: -

Inspection
• Color – dark.
• Lesion – no Primary, Skin lesions, secondary skin lesions
• Vascularity: - no Ecchymosis, Petechiae
Palpation
• Moisture: dry
• Texture: - rough
• Turgor: - normal
• Temperature: - warm
HAIR AND SCALP: -
Hair
• Color: - black
• Texture: - rough
• Distribution: - normal
SCALP
Dryness- Present.
Lumps -No Lumps,
 Lesions- Present
Pediculosi- Presents
Dandruff - Present.
HEAD
No head injuries
NAILS
• Nail bed color: - pale
• Shape of nail plate: - flat
• Tissues surrounding nails: - intact
• Blanch test of capillary refill: - intact
• Blanch test of capillary refill: - 4 sec
SKULL: norm cephalic
FACE
• Color: fair
• Symmetry: symmetrical
• Edema: - not present
• Involuntary movements: -not present
•Examination of Trigeminal nerve: sensory: he was not able to distinguish between sharp and soft touch.
Motor: bilateral equal tension.
•Examination of facial nerve: sensory: corneal reflex present.
Motor: symmetrical facial expressions.
EYES & VISION: -
External structures
• Eye brows: present
• Hair distribution: equal
• Scaling & Flakiness of skin: not present
• Alignment & movement of eyebrows: symmetrical
• Iris/ pupil: normal
• Eye lashes: - no sty and other infection
• Eye lids: - no ptosis/ectropion/entropion.
• Conjunctiva: - pink
• Sclera: - White
• Cornea: soft
Pupils: -
• Reaction to light: pupils constriction to light
• Coronal reflex: - present
• Exophthalmos: not present
• Ptosis: absent
• Examination of optic nerve: Bilateral pupillary constriction to light
• Visual acuity: - 6/6 (both right and left eye).
EARS:
Auricles
• Color: - normal
• Alignment: - symmetrical
• Elasticity: -pinna recoils after it is folded
• Tenderness: - non-tender
External ears
No redness and discharge.
Dry cerumen present
Hearing acuity:
• Weber test: - sound is heard in both ears. Equal laterization of sound.
• Rinne’s test: - AC>BC
NOSE AND SINUS:
• Nasal septum: - deviated
• Facial sinuses (maxillary, frontal): - no tenderness
• Smell (examination of olfactory nerve): - Normal
• Any other problem: no discharge, no tender, no lesions
MOUTH AND OROPHARYNX
1. LIPS
• Color: - darkening
• Texture: - dry
• Angular stomatitis: not present
2. BUCCAL MUCOSA
• Color- reddish dark
• Texture-Moist
• Presence of lesions: not present
3. GUM
• Color- dark complex
• Texture- Moist firm
• Gums bleeding/Gingivitis: not present
4. TEETH: dental carries
5. TONGUE
• Position-Central
• Color and texture-Pink Color, moist, smooth lateral margins, no lesions.
• Tongue base- smooth tongue base with prominent veins
• Mobility- Moves freely
6. FLOOR OF MOUTH: Smooth with no nodule
7. TONSIL: not enlarged
8. PALATE
• Light Pink & smooth soft palate
• Light pink hard palate,
9. UVULA: Midline in position
10. OROPHARYNX
• Taste: normal
• Odor of mouth: no foul odor
• Gag reflex: present
• Swallowing reflex: present
NECK: -
Muscle
• Size: Equal and Head centered
• Head movement: - Coordinated smooth movements with no discomfort
• ROM: rotation, extension, flexion is possible.
• Lymph node: not enlarged
• Trachea: midline
• Thyroid gland: not enlarged
• Jugular veins: not distended
CHEST
Thorax and lungs
Posterior thorax
• Shape and symmetry: - normal shape
• Movement of chest: equal
• Percussion: -resonant sound
• Auscultation: -– bilateral normal breath sound present
Anterior Thorax
Inspection
• Shape &symmetry: - normal
• Movement of chest: Equal
• Any deformity- absent
• Dyspnea on rest- absent
• Dyspnea on expansion- absent
Palpation:
• Symmetrical chest expansion- symmetrical
• Any tenderness- no
• Lump or mass- No
• Skin Temp – warm
• Moisture- dry
Percussion: - resonant sound
Auscultation: - bronchial sound
BREATHING PATTERN-
• Regular
• Respiration rate- 24 breath/min
• Breathing via oxygen mask- no
• Breathing via ET tube- No
• Breathing via F piece- No
• On ventilator- No
CIRCULATORY SYSTEM:
• Pain: not present
• Numbness: not present
• Syncope: absent
• Dizziness: absent
HEART:
• Heart sounds: - S1& S2
• Chest pain- not present
• Any other heart disease or any problem- no history of hypertension.
CHEST AND AXILLAE
• Symmetry: symmetrical
• Lymph nodes: not enlarged
• No gyneocomastia.
ABDOMEN:
• Position of umbilicus: central
Inspection
• Contour of the abdomen: mild distension.
• Shape of abdomen: flat and symmetrical.
• Umbilical hernia: not present.
• Umbilicus: clean
Percussion: - mass
• Bowel sounds: present,
• Inguinal hernia: not present
• Appetite: decreased
Palpation:
• No Hepato splenomegaly
BACK
• Presence of decubitus ulcer: not present.
NUTRITIONAL:
• Appetite: decreased
• Nausea: present
• Vomiting: present
• Pain related to eating: absent
• Dysphagia: absent

NEUROLOGICAL:
• Confusion: absent
• Convulsions: absent
• Loss of strength: yes
• Weakness: present
• Pain: present
• In-coordination: absent
• Changes in sensation: no
• Tingling /pricking: absent
• Level of consciousness: conscious, orientated

REFLEXES
Superficial reflexes
 Superficial abdominal reflex: physiological absent.
Deep reflexes
 Biceps reflex: reactive
 Triceps reflex: reactive
 Patellar reflex: reactive
 Achilles reflex: reactive
INTEGUMENTARY SYSTEM:
• Skin color: dark complex
• Texture: dry
• Skin turgor: decreased
• Hydration: dehydrated
• Discoloration: not present
• Pigmentation: not present
• Lesions /masses: absent
ENDOCRINE SYSTEM-
No goiter
No thyroid tenderness
No tremors and weakness.
HEMATOLOGIC SYSTEM –
Abnormalities of blood cells: no
MUSCULOSKELETAL SYSTEM:
• Postural curve: kyphosis
• Muscle tone: normal
• Muscle strength: week
Upper extremities:
• Inspection: - symmetrical, no deformity, and swelling.
• Palpation: - no edema, tenderness, crepitus, nodule
• ROM: adduction, abduction, extension, flexion possible.
• Finger nails: capillary refill 2-3 seconds
• Peripheral pulses: Radial: - 78 beats per minute
• Triceps: reactive
• Edema/swelling: absent
• Cyanosis: absent
• Joint: absent

Lower extremities:
Muscle
• Symmetry: symmetrical
• Contractures/tremors/atrophy/hypertrophy/asymmetry: No
• Muscle tone: normal
• Toe nails: capillary refill 3 seconds
• Range of motion: possible
• Reflexes: patellar – reactive
• Edema/swelling: not present
• Cyanosis: absent
• Joint: no pain
• Deformity: absent
• Other signs /symptoms: loss of sensation in lower limb.
GENITOURINARY SYSTEM –
• No history of STD
• Incontinence
• Catheterized.
 RECTUM&ANUS:
• Perineal skin integrity: intact
• Bowel elimination pattern: diarrhea

Vital signs:

S.NO CHARACTERISTICS PATIENT NORMAL REMARKS

. VALUE VALUE
1 Temperature 102.20F 98.6oF Fever
2 Respiration 30b/min 16-24b/min Tachypnea
3 Pulse 130b/min 60-100b/min Tachycardia

Lab Invetigation:

S.NO. Lab Test Patient Value Normal Value Remarks

1 Hb 9 gm/dl 12-14gm/dl Anemia
2 WBC 12,000/cumm 5000- Leukocytosis
10,000cumm
3 CSF analysis 18mg/dl 10-15mg/dl Increased
ICP
 4 Platelet count 3,00000/cumm 2,00000- Normal
4.500000/cum
m

Medication:

S.NO. Medication Dose Route Frequency Action

1 Inj. 10mg IV B.D Corticosteroid
Dexamethasone
2 Inj acyclovir 10mg/kg I.V B.D Antiviral

3 Syrup Pcm 15mg/kg Orally B.D Antipyretic

4 Inj phenytoin 5mg/kg I.V O.D anticonvulscent

 DISEASE DISCRIPTION –ENCEPHALITIS

ENCEPHALITIS

Encephalitis is inflammation of the brain. There are several causes, but the most common is viral infection.

Encephalitis often causes only mild flu-like signs and symptoms — such as a fever or headache — or no symptoms at all. Sometimes
the flu-like symptoms are more severe. Encephalitis can also cause confused thinking, seizures, or problems with senses or movement.

Rarely, encephalitis can be life-threatening. Timely diagnosis and treatment are important because it's difficult to predict how
encephalitis will affect each individual.

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.[2] 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.

Certain types are preventable with vaccines. Treatment may include antiviral medications (such as acyclovir), anticonvulsants, and
corticosteroids. Treatment generally takes place in hospital. Some people require artificial respiration.[1] Once the immediate problem
is under control, rehabilitation may be required. In 2015, encephalitis was estimated to have affected 4.3 million people and resulted in
150,000 deaths worldwide.

DEFINITION

Inflammation of the brain that is caused especially by infection with a virus (such as herpes simplex or West Nile virus) or less
commonly by bacterial or fungal infection or autoimmune reaction

ETILOGY:

S.No. In BOOK IN PATIENT

1 Genetic factor -
CLINICAL
2 Arbo virus Arbo virus MANIFESTATION:

3S.NO. Childhood IN
virusBOOK - IN PATIENT
41 Confusion, agitation
Hemorrhagic fever or hallucinations -Confusion, agitation or hallucinations

2 Seizures Seizures

3 Loss of sensation or paralysis in certain -

areas of the face or body
4 Muscle weakness Muscle weakness

5 Fever Fever

6 Headache Headache

DIAGNOSTIC EVALUATION:

S.NO. IN BOOK IN PATIENT

1 Initial Assessment includes: History & Initial Assessment includes: History &
Physical Examination Physical Examination

2 Hb level Hb level

3 Spinal tap and lumber punture -

4 CSF analysis CSF analysis

5 CT scan with MRI CT scan with MRI

COMPLICATION:

S.NO. IN BOOK IN PATIENT

1 Paralysis -

2 Speech impairments -

3 Memory problems Memory problems

4 Personality changes -

MANAGEMENT:

S.NO IN BOOK IN PATIENT

.

1 Corticosteroids Corticosteroids

2 Anticonvulsants Anticonvulsants

3 Sedatives Sedatives

4 Fluids Fluids

NURSING MANAGEMENT:

NURSING ASSESSMENT:
 1. Detailed history of different aspects to be collected
2. Check vital signs
3. Monitor Lab values
4. Monitor intake and output

NURSING DIGNOSIS:
1. Ineffective tissue perfusion related to cerebral infarction as evidenced by necrosis.
2. Impaired thermoregulation related to infectious process as evidenced by rise temperature.
3. Impaired nutritional status less than body requirement related to adequate intake of food as evidenced by weight loss.
4. Risk of injury related to cerebral as evidenced by seizures.
5. Ineffective therapeutic regimen related to knowledge deficit as evidenced by frequent questioning by parents.

GOALS:

Short term Goals:

1. To maintain the tissue perfusion.
2. To maintain thermoregulation.
3. To maintain the nutritional status.
4. To prevent from injury.
5. To improve the knowledge level.

Long term Goals:

1. To provide education to the family members regarding the encephilitis.
2. To maintain the fluid electrolyte level & feeding pattern.
3. To prevent the reoccurrence of the disease condition

Assessment Diagnosis Expected Planning Rational Implementaion Evaluation

outcome
Subjective Ineffective To maintain Assess oxygen To get base line Oxygen saturation level Tissue perfusion is
Data: tissue effective saturation level of data is assessed ie;80%. maintained up-to
Patient is perfusion tissue the patient. some extent.
complaining related to perfusion
about skin cerebral
color changes . infarction as
evidenced by Oxygen therapy is
Objective necrosis and Administer To mainatain given with the help of
Data: cynosis. oxygen with the the saturation of nasal cannula .
help of nasal the patient.
I observed
cannula .
that patient
have fever
ie;102.20F Well ventilated room
and bluish is provided to the
discoloratio patient
Provide well To improve the
n of skin.
ventilated room breathing
to the patient. pattern of the
patient

Assessment Diagnosis Expected Planning Rationale Implementation Evaluation

Outcomes
Subjective Impaired To maintain Assess the To get the General condition of Temperature is
Data: thermoregulation the body general base line the child is assessed reduced upto
Patient is related to temperature condition of data of by intake output. some extent.
complaining infectious process . the patient to patient
about increased as evidenced by get the
body rise in baseline data. Cool and calm
temperature. temperature. environment is
Provide cool and To provided to the
calm maintain patient.
Objective Data: environment to
the body
the patient.
I observed that temperature Cold sponging is
patient have Give cold To reduce done.
fever ie; sponging to the the body
102.20F. patient. temperature Antipyretics are
given as prescribed
Administer
To lower by the physician
antipyretics as
prescribed by the the body
physician. temperature
To
Administer IV maintain
fluids as the
prescribed hydration
of the
patient

Assessment Diagnosis Expected Planning& Rational Implementation Evaluation

outcome Rationale
Subjective Impaired To improve Assess the To get the base Nutritional status is Nutritional status is
Data: Nutritional the Nutritional nutritional status line data assessed by monitoring improved up-to some
Patient is status less status of patient to get weight of the child. extent.as child gain
complaining about than body baseline data. weight.
anorexia. requirement
related to Encourage the To improve the Encourage the child to
Objective Data: less intake of child to eat nutritional eat healthy diet.
food feeding healthy diet. pattern of the
I observed that
as evidenced patient
patient loose his by weakness.
weight by A diet plan is
measuring the Maintain a diet To improve the maintained for the
body weight of plan for the eating habit of child.
the child. child. the patient

Administer IV fluids to
Administer IV To maintain the the child.
fluids to the hydration
child.

Assessment Diagnosis Expected Planning Rational Implementation Evaluation

outcome &Rationale
 Subjective Data: Risk of injury To prevent Assess the To get the base line Check the fever of Risk of injury upto
related to the injury general data the patient i.e 100oF. some extent.
Patient is cerebral condition of the
complaining about edema as patient to get
recurrent attacks of evidence by the baseline
seizures. seizures. data.

Objective Data: Provide safe and

Provide safe
quite environment to
and quite To prevent from
I observe that the child.
environment. injury
patient is
unconscious with
the help of
Glasgow coma
scale.

Administer the
Administer the
medication as
medication as
prescribed by the
prescribed by To prevent from
physician
the physician seizures

Assessment Diagnosis Expected Planning & Rational Implementatio Evaluation

 outcome Rationale n
Subjective Data: Ineffective To improve Assess the general To get the General condition Effective treatment
Patient’s mother is therapeutic regimen the condition of base line is assessed by is given improved
complaining about related to treatment therapeutic patient.to collect data of the physical up to some extent.
treatment by asking of disease condition regimen the baseline data client examination.
questioning. as evidenced by of the client.
frequent questioning
by the parent & Treatment
family members. regimen are
Check the To give the checked by
treatment regimen information checking the
given to the about the medication given
patient.to knows treatment to patient`
Objective Data: I about
observed that management.
patient’s members
having question Queries of the
regarding disease Clear the queries To clear the family members
management. of the family doubt regarding care
members and disease
condition are
cleared.

PROGNOSIS NOTES
DAY 1-patiient is having impaired fluid and electrolyte balance and fluid is restricted to him .Patient is well oriented to time, place
and person. Patient suffering from anorexia. Diuretics are given to patient

DAY 2-The fluid and electrolyte balance is maintained upto some extend

DAY 3- Patient nutritional status is improved upto some level by giving frequent meal to patient and maintaining the diet pattern.
HEALTH EDUCATION

I educate the mother and family members regarding:

1. Diet: Provide proper breast feeding

I.V Fluids

2 Medication: Give medication at particular time.

Give medication as prescribed by physician.

3.Hygiene: Maintain hygiene by baby.

Wear claen clothes to baby.

4 Follow up care: Family members are encouraged for follow up care and
routine check up to prevent from further complications.

BIBLIOGRAPHY
 Marcdante J. Karen ,Kuegman H Robert,Jenson B. Lal,Behrman E. RichaNelson. Essentials of pediatrics.6 th Edition.Sounders
Elsevier. 245-67.
 Datta Parul. Pediatric Nursing .2nd Edition. Jaypee Brothers Medical Publishers.210-235
 Kyle Terri, Essential of Pediatric Nursing,Published by wolters kluwer(India) pvt.Ltd,New Delhi 111-115
 Wilson Hockenberry, Kline Winkelstein, Nursing care of Infants and children , 7 th Edition Published by Elsevier 815-823.