NURSING CARE MANAGEMENT 0121 RLE

Second Semester, Academic Year 2021-2022

CASE BACKGROUND

NURSING CARE MANAGEMENT OF A CLIENT WITH

MENINGOENCEPHALITIS

As a 4th-year Nursing student, you are assigned for your clinical exposure at the
Pediatric Ward of a tertiary hospital in Pampanga.

For this rotation’s clinical exposure, your Clinical Instructor

assigned you to John Wright

Case Background:

On February 22, 2022 at 6am, you received the

patient handover from the outgoing night shift nurse. You
were assigned to the same patient for today’s clinical
rotation. Patient John Wright.

Upon review of the chart, the following information were obtained:

ANGELES UNIVERSITY FOUNDATION – COLLEGE
OF NURSING
HEALTH INSTITUTE

Laboratories
Name John Wright Hospital No. 438882
Age/Sex 3/M Admission No. 198003 Test Requested 02/22/2022 9:00 AM
Room 1 CS No. C1294461L Sample 02/22/2022 9:30 AM
Submitted
Physician Juan Dela Cruz Results Finished 02/22/2022 10:00
AM
Method Flow Cytometry Specimen Whole Blood Results Verified 02/22/2022 10:30
AM

BLOOD SERUM CULTURE AND SENSITIVITY

Result
No microbial growth noted after 2 days of incubation
Impression:
Negative blood infection

COMPUTERIZED TOMOGRAPHY SCAN

Impression:
● Constellation of findings is compatible with encephalitis, probably herpes
simplex in etiology, involving the right temporal lobe and partly the adjacent
basal frontal lobe.
● Leftward subfalcine herniation without causing hydrocephalus
● No evidence of hyrocephalus.
● Focal acute ischemia in the left parahippocampal gyrus and left corona
radiate/external capsule. This finding could be due to vasospasm possible
from meningeal irritation (meningitis)

Vital Signs Monitoring Sheet

 Date Time T P R O2 Sat BP
2/22/2022 3 AM 37.7 110 26 95 90/60
4 AM 37.8 112 32 92 90/60
5 AM 38 111 35 89 90/60
6 AM

Nurses Progress Notes

Date and Focus Data
Time Actions
Reactions
02/21/2022 General Survey D- Received patient awake. With on-going IVF of
10PM #2 D5 IMB 1L x 60cc/hr infusing well, without
signs of phlebitis or infiltration. With oral airway,
and O2 via nasal cannula @ 2LPM inserted at the
airway of the client. Patient is irritable, with current
GCS score of
11---------------------------------------LOP------
02/22/2022 Difficulty of breathing D – SPO2 = 89%, with visible secretions in the
5AM oral cavity, observed labored breathing. Patient is
lethargic and wakes up upon calling his name.
unable to keep alertness, still without verbal
response, patient is able to obey command--------
A – assessed patient’s general condition, secured
placement of oral airway, suctioned secretion as
needed, prepared materials for emergency
intubation, contacted the respiratory department
about possibility of mechanical ventilator use-------
R – Informed Dr. Dela Cruz via phone call,
ordered to stand by intubation set and mechanical
ventilator. Patient's SPO2 went up to 93% post
management. Endorsed to next shift NOD----LOP-

Intravenous Fluid Monitoring Sheet

Bottle Type of Drug Date/Time Signature Date/Time Signature Remarks

No. Solution/ Incorporated Started Consumed/
Blood & Discontinue
Serial No. d
1 D5IMB None 02/21/2022 J. Solis 02/21/2022 L. Puno Consumed
1000cc 7:00 AM 11:00 PM
2 D5IMB None 02/21/2022 L.Puno
1000cc 11:00PM
Medication Order Sheet

Date 2/21 2/22

Medication-Dosage-Frequenc
Date Shift Time Sig Time Sig Time Sig Time Sig Time Sig Time Sig
y
02/21/ Ceftriaxone
2022 (Rocephin) 1g/IV + 10-6
20cc PNSS via
soluset/IV side drip 6-2 8 JS
to infuse for 30
minutes Q12 2-10
8 CA

02/21/ Paracetamol 200

2022 mg/IV Q4 for 10-6
temperature >37.8oC
6-2 8/12 JS

2-10 4/8 CA
02/21/ Acyclovir (Zovirax)
2022 Acyclovir (Zovirax) 1 10-6 12 LP
gm + 20cc IV diluent
via soluset for 30 6-2 12 JS
minutes
2-10

6-2

2-10

10-6

6-2

2-10

10-6

STAT Medications
Medication Dosage and Route Date and Time Signature
Phenobarbital 100 mg/IV 2/21/2022 9AM J. Solis
 After reviewing the patient’s medical record and morning laboratory results, you went to
the patient’s room to perform your assessment and you have noted the following findings:

General Survey
The patient is wearing white sando with a medium body built and has a GCS of
10 points Eye Opening of 4 (opens to voice), Verbal response of 1 (no verbal response),
and Motor response of 5 (localized pain). The patient has difficulty moving because he
has a posturing-flexor problem in upper extremities (decorticate position and transient
leg paralysis.
.
A. Integumentary
● Skin = skin is brown complexion
● Hair = evenly distributed with uncombed hair, smooth and black in color
● Nails = nails and fingernails are pinkish in color, dirty, with dirt in between the
fingers since the hands are always closed due to posturing-flexor problems /
spasticity problems.
● Observed a reddened area at the sacral region due to prolonged pronation.
B. Head and Scalp
● Scalp = there is minimal dandruff noted, but with no lesions and lacerations
● Skull = skull is rounded and smooth, with symmetrical facial features
● Neck = the patient has no head control; head lag is noted when being lifted; pain
and rigidity was noted during extension or flexion of the neck. There are no
palpable masses. There are no jugular distension and the trachea is in midline
position
● Thyroid = smooth, non-tender
● Patient was observed to always unconsciously hold his head particularly his
temple accompanied by visible grimace (Headache)
C. Eyes
● Eyelids = there is no edema noted
● Eyeball = there is no exophthalmos noted
● Conjunctiva = with pale palpebral conjunctiva
● Sclera = anicteric sclerae
● Pupils = with (+) PERRLA (Pupils equally round and reactive to light
accommodation). Pupils constrict sluggishly in direct response to light and 4-5
mm on both eyes. Pupillary accommodation causes constriction in response to
objects that are near and dilation occurs to accommodate distant vision.
● Eye movement = with flat affect, no eye movements to any stimulus like calling
out the patient.

D. Ears
● General = symmetrical in size and shape, with upper part of pinna at the level of
the lateral canthus of the eye and extends slightly outward from the skull
● External- firm and smooth, free from lesions; with soft waxy brown cerumen

E. Nose
● Symmetrical, located in the midline of the face just below the eyes, there is no
swelling, bleeding, lesion or masses. Mucosa is pink and without swelling; with
whitish nasal discharges minimal in amount and non-tender sinuses.
● With minimal nasal flaring noted

F. Face
No facial asymmetry or facial deviation, no edema noted. There is no tenderness
upon palpation. Patient has a normal range of motion of the temporo-mandibular
joint (three finger breath) and no difficulty in swallowing. All facial expression and
mastication are performed normally, teeth are incomplete.

G. Mouth And Throat

● General = the patient has absence of bulbar functions; client was unable to
cooperate in opening the mouth; also had an oral airway inserted, (taped with
Leucoplast) to maintain the mouth open for easy access during suctioning, due to
moderate amount of thick, white, oral secretions, produced by the client.
● Lips = cracked, with untidy Leukoplast tape
● Pharynx = midline, symmetrical without swelling
H. Neck
No lateral deviation of the neck and has normal range of motion actively done pain
free. With a normal palpable carotid pulse. With palpable swelling of the cervical
lymph nodes that are non-tender. Scratches and scaling were noted on the cervical
area circumferentially.

I. Chest And Lungs

● Chest wall is symmetric, bilateral, and coordinated during breathing and chest
rises during inspiration. posterior thorax is free from tenderness and lesion
● Resonant sound upon percussion
● There is crackles noted during auscultation on both lung fields

J. Heart
● There is an absence of visible pulsation. Patient has a regular rhythm.
● Regular rate and rhythm of heartbeat was heard upon auscultation.
● Bilateral equality and symmetry of peripheral pulses
● Patient has a normal capillary refill time of less than 2 seconds after blanching
the peripheral site.
 K. Breast And Axillae
Skin is intact and uniform in color. No mass and lesions noted upon palpation and
inspection of the breast and of the area of the axilla.

L. Abdomen
● Abdomen rises with respiration and falls with expiration.
● Flabby and soft, with normal abdominal bowel sounds heard every 5 to 15
seconds.
● There were no mass palpated and non-tender.

M. Muscles
● Spine has cervical concavity, thoracic convexity and lumbar concavity.
● The patient has a posturing flexor problem, a spasticity problem in which
the upper extremities are always flexed with locked closed hands, and have
resistance while extending upper extremities.
● Both lower extremities have poor muscle strength

N. Vital Signs at 6AM 02/22/2022

Temperature 37.5oC
Heart Rate 108 bpm
Respiratory Rate 35 cpm
Blood Pressure 100/70
Oxygen Saturation 92%

O. Cranial Nerve Assessment

CRANIAL NERVE FINDINGS
CRANIAL NERVE I Actual findings:
(Olfactory) The patient’s ability to identify various aromas was not assessed for the patient
had no verbal response.
CRANIAL NERVE II Actual Findings:
(Optic) The patient’s ability to read was not assessed for the patient had no verbal
 response.

CRANIAL NERVE IIIActual Findings:

(Oculomotor) The patient has spontaneous eye opening, though the patient has a GCS of 10.
With (+) PERRLA (Pupils equally round and reactive to light accommodation).
Pupils are sluggish and have size of 4-5 mm. .
CRANIAL NERVE IV Actual Findings:
(Trochlear) The patient cannot obey commands, and does not respond to any of the
questions.

CRANIAL NERVE V Actual Findings:

(Trigeminal) Patient does not obey commands, and cannot masticate, as evidenced by the
presence of an oral airway and he is being fed through the NGT. However,
there is the presence of the blinking reflex. Does with the used of a cotton ball
placed towards the side of the eye,
CRANIAL NERVE VI Actual Findings:
(Abducens) Patients could not respond to commands hence, assessing lateral rectus
muscle and movement of the eye is hard achieved.
CRANIAL NERVE Actual Findings:
VII The patient could not respond to commands, for that reason, assessing
(Facial) muscles for facial expression could not be achieved. Although during
suctioning the patient showed facial grimaces, especially when the patient felt
discomfort.
CRANIAL NERVE Actual findings:
VIII The patient could not verbally respond; hence the hearing function could Into
(Acoustic) be assessed. The gait could not be assessed due to abnormal posturing-flexor
and spastic upper extremities and poor muscle strength of lower extremities.
CRANIAL NERVE IX Actual findings:
(Glossopharyngeal) There is the absence of the gag reflex due to the presence of an oral airway
and the patient’s ability to assess various tastes was not performed since the
patient could not verbally respond.
CRANIAL NERVE X Actual findings:
(Vagus) The patient was unable to speak. The patient could not obey commands and
so the ability of John to swallow could not be assessed. The mouth was closed
with an oral airway.
CRANIAL NERVE XI Actual findings:
(Accessory) The patient was unable to shrug shoulders and turn head from side to side
against resistance due to uncontrolled muscle movement and the presence of
head lag when lifting his body.
CRANIAL NERVE Actual findings:
XII The patient had an oral airway and was not properly secured with an untidy
(Hypoglossal) Leucoplast.
After endorsement, upon initial nurse visit (around 7AM), the following data was observed:
● Patient was lying on the bed
● With oral airway plastered using a leucoplast on the oral cavity
● Patient was lethargic, and only opens eyes when asked to (not able to maintain
alertness during the entire conversation
● IVF infusing well without signs and symptoms of infection
● Visible discharge in the oral cavity

During the initial visit, the mother of the client verbalized extreme concern that the client
hasn’t taken anything per oral since the day of admission. She even added that prior to being
admitted in the current institution, the patient was not able to tolerate eating and started to vomit
every now and then. “Sobrang laki nang pinayat niya simula ng madala siya sa hospital. Wala
naman problema sa pagkain niya. Tapos hanggang nung nakakapagsalita pa siya, ang palagi
niyang reklamo ay ang sakit na nararamdaman niya sa kanyan ulo'' was stated by Mary. In a
timely manner, Dr. Dela Cruz arrived at the room to conduct his daily rounds. Few moments
upon entering the room, the patient suddenly displayed a grand-mal seizure. As the nurse in the
area, you have secured the patient’s safety while the seizure episode is happening. After the
seizure episode, you have observed that the patient’s O2 saturation significantly dropped to
87%. Due to the incident, the doctor ordered the following:

Doctor’s Order Sheet

TIME/
C A R E D REMARKS/
SIGNATURE
S/P seizure episode
- Administer valium 0.6 ml/IV
- May administer Valium ) 0.6 mL/IV if with active
seizure episode C/O pedia resident on duty
Desaturation; O2 Saturation = 87% accompanied by
decrease in GCS score, GCS = 10
- Inserted ET tube
- Hook to mechanical ventilator with the following
settings:
● FiO2 = 95%
● RR = 30
● PIP = 25
 ● PEEP = 6
● TV = 100
- Continue monitoring patient vital signs via cardiac
monitor
Keep on NPO
Turn patient side to side Q2
Facilitate CT Scan; refer results ASAP
Follow-up results for Blood C/S
Continue all other medications
Refer laboratories STAT
Refer accordingly

Promptly requesting laboratory procedures ordered, results for the said tests arrived
(Around 9:30 AM). Via phone call, the nurse updated Dr. Dela Cruz about the results of the
examination. The following orders were made after the referral.

DAY 2 of Confinement. Post-Labs

Doctor’s Order Sheet

TIME/
C A R E D REMARKS/
SIGNATURE
T.O.
Received patient Laboratory Results
Diagnostics:
- Facilitate EEG this PM
- Facilitate Lumbar Tap. For schedule in the OR c/o
Dr. Medina - Anesthesiologist
Medications:
- Mannitol 60 mL Q4 (defer if SBP < 80mmHg)
- Start Meropenem IV 780mg + 20cc diluent to run
for 30 minutes Q12
- Start Mucosolvan 2.5mL via nebulization Q8
- Start Mupiricin Ointment, apply in the sacral
region thinly OD
Insert Foley catheter and quantify output every shift
Refer Accordingly
 Prescribing Physician:
Juan Dela Cruz, MD
Lic #076589

Your group has decided to have an in depth interview about the patient’s case.
You have noted the following details during the interview.

Socio-Economic and Cultural Factors

Daniel, the client’s father, is the primary earner of the family. He is currently
employed in a private company earning approximately 18,000.00 pesos per month. In
addition to that, Mary has been a small business manager, and according to her, she
usually earns 12,000 – 13,000 per month. Combined, the Wright family’s total monthly
income is approximately 30,000 – 31,000 pesos which according to NEDA is enough to
live a comfortable life. This however, according to Mary, is not as correct as it may
seem. They still find the monthly family income insufficient. Expressed in the table below
is the breakdown of the usual expenses of the Wright family:

EXPENSES AMOUNT PER MONTH

Electricity Bill PHP 3000.00
Water Bill PHP 700.00
Food PHP 10,000.00
Other (Groceries and Toiletries) PHP 10,000.00
Total PHP 23,700.00

John’s father said that they save the excess money whenever there is. Also, they
want to save for the education of all their children because he will be starting to study in
the following school year. In times of shortage, they usually borrow money from relatives
or neighbors.

Educational Attainment
John currently is enrolled in a local elementary school and is currently at 3rd
Grade. Both of John’s parents believe that education is vital to make their children
future, and for that reason they try to save as much as they can to prepare for their
children’s education.”Alam ko na magagaling ang mga anak ko, kaya pagsusumikapan
kong mapagtapos silang lahat sa ano mang kursong gusto nila” added by Mary.

Religious Affiliation
Both parents of John are bonafide members of the Catholic Church. However,
during the pandemic, they decided not to attend masses or other religious gatherings for
they perceive it as a risk for contracting COVID-19. On the other hand, according to the
parents, they still regularly pray at night because they still believe that God is still in
control of their life’s situation.

Health Seeking Behaviors

Mary stated that for primary health concerns, they usually go to their barangay’s
rural health unit which is located just several blocks away from their house. This was
evident during the prenatal period of Mary, when he was pregnant with John During the
interview, they also stated that at times, they seek consultation to traditional healers
such as herbolarios and hilots. Self-medicating for experience of cough and colds,
body pains and fever has also been an evident behavior for the Wright Family..
According to her, the health center also provides basic check-ups, vitamins and other
maintenance medication for free.

Asynchronous Learning Task: Focus Charting

Appropriate, comprehensive, and accurate

documentation is essential to nursing. To further
improve on how well you document, for your
asynchronous learning activity, you are tasked to make
a Focus Charting (F-DAR) on the case scenario provided
above. Make sure that all data, findings, and events will reflect on your documentation. 

● This is an individual Activity. 

● Formulate a FDAR Charting based on the given case scenario.
● The submission will be on the 2nd RLE day of Week 2 at 8am.
● FDAR’s Critical Appraisal Rubric will be used for grading and feedback.
● Submission Format: PNG format, Hand written using the Nurses Progress Notes
Template

Asynchronous Learning Task: Focus Charting Review

● This is an individual Activity. 

● You need to Peer Review an FDAR Charting of your groupmate.
● The submission will be on the 2nd RLE day of Week 2 at 5pm.
● FDAR’s Review Critical Appraisal Rubric will be used for grading and feedback.
● Submission Format: PNG format, Hand written using the Nurses Progress Notes
Template

Asynchronous Learning Task: Drug Study

This is an individual activity. One of the medications given to the patient will be assigned to you
for your drug study to be accomplished in a Google Worksheet. Screenshots of the
accomplished Google worksheet should be submitted as a file upload on the third day of the
2nd week of RLE at 8am. Your clinical instructor will utilize the Drug study’s Critical Appraisal
Rubric for grading and feedback.
Synchronous Learning Task: Drug Study Conference

You will present your drug study individually in your group. Your clinical instructor will utilize the
Drug Study Conference’s Critical Appraisal Rubric for grading and feedback.

Asynchronous Learning Task: Case Study

● This is a Group Activity. 

● The submission will be on the 1st RLE day of Week 3 at 5pm.
● Case Study’s Critical Appraisal Rubric will be used for grading and feedback.
● Submission Format: Google Drive link, PDF format, Arial 11

Synchronous Learning Task: Case Study Presentation

You will present your Case study in your class. Your clinical instructor will utilize theOral
Presentation Rubric for grading and feedback.

Prepared by:

Jonas Kirby R. Solis, RN, MN

NCM 0121 Instructor

Peer Evaluators:

Warlito S. Reyes, RN, MAN

NCM 0121 Instructors
Reviewed by:

Angela P. Apostol, RN, MN

Level IV RLE Coordinator