Japanese Encephalitis is identified as a leading form of viral encephalitis that is known to be spreading globally. Belonging to the genus Flavivirus and the family of Flaviviridae, Japanese encephalitis exists in a zoonotic cycle that occurs in mosquito and vertebrate hosts, such as water birds and pigs. Epidemiological patterns of Japenese encephalitis have been discovered in both epidemic and endemic regions. Shlim and Solomon's (2002) research found: In northern temperate areas (Japan, Taiwan, China, Korea, northern Vietnam, northern Thailand, Nepal, and northern India), large epidemics occur during the summer months (roughly, May to October). In Southern tropical areas (southern Vietnam, southern Thailand, Indonesia, Malaysia, Philippines, Sri Lanka, and southern India), JE tends to be endemic; here, cases occur sporadically throughout the year, with a peak after the start of the rainy season. (p. 184)
Japanese encephalitis has been more commonly seen in children or in visitors to areas of the endemic region than in resident adults. In endemic countries, adults acquire immunity through natural infection. Solomon's (2004) research found: In rural Asia, where exposure to infected mosquitos is unavoidable, serologic surverys show that almost everyone is exposed to Japanese encephalitis virus during childhood. However, fever develops in only a small proportion (about 1 in 300) of those exposed, and neurologic disease develops in even fewer persons. Thus, Japanese encephalitis does not often occur in adults because, in most cases, they are already immune to the virus. (p. 371) Transmission of Japanese encephalitis begins at the lifecycle between mosquito transmission and the affected vertebrates. Kumar's (2014) stated: JEV is transmitted in nature between the vector (mosquito) and the vertebrate host. The main vector in most southeast Asia is the mosquito Culex tritaeniorrhynchus , a rice field breeding mosquito, but other vectors (C. vishnui, C. pseudovishnui, C. gelidus) also play a role. Birds of the family Ardeidae are thought to be important in maintaining, amplifying, and spreading the infection. Apart from birds, the pig is an important amplyifying and "bridging" host as pigs are often kept close to human dwellings. (p. 100)
Culex mosquitoes is known primarily as bird biting mosquitos, but also targets other animals and humans. According to Shlim and Solomon (2002), "It feeds at night, seeks blood meals mainly outdoors, feeds repeatedly during a brief life span, and disperses widely after a blood meal" (p. 184). Humans become infected with the Flavivirus through a bite of an infected mosquito. Man is known as an incidental deadend host in the lifecycle due to the short life of the virus in which is not efficient to spread the infection (Kumar, 2014, p. 100). Once a human has become biten from an infected mosquito, the virus begins to replicate and becomes transported to local lymph nodes in which are responsible for filtering foreign bodies. Tiwari, Singh, and Dhole's (2012) research found: During primary viremia, viral particles are seeded in the extraneural tissues. Major extraneural sites of replication include connective tissue, skeletal muscle, myocardium, smooth muscle, lymphoreticular tissues, and endocrine and exocrine glands. From the blood, the virus penetrates into the CNS. (p. 4)
Throughout the many changes that occur in result of the infection, such as changes in the lungs, myocradium, and reticuloendothelial system, the brain is what primarly becomes the target. Once the virus reaches the brain tissue, reproduction begins in which results in the inflammtory response. According to Ignatavicius and Workman, the inflammation that occurs spreads over the cerbral cortex, the white matter, and the meninges, resulting in the break down of the cortex neurons. This response leads to the demyelination of axons which leads to damage such as hemorrhage, edema, necrosis, and the formation of hollow cavities within the cerebral hemispheres (Ignatavicius & Workman, 2013, p. 940). Like many other viral encephalitis, Japanese encephalitis may be life threatning or may result in neurological sequelae. Japanese encephalitis may present as asymptomatic, or display vivid signs and symptoms of an acute undifferentiated illness or encephalitis. Kumar (2014) states, "When the course is one of the encephalitis, the illness can be divided into three stages-prodromal, acute encephalitic, and a convalescent stage" (p. 101). According to Kumar, the prodromal stage begins abruptly with symptoms that include a high fever accompanied by a headache, nausea, vomitting, and diarrhea. Within hours to a few days after the prodromal stage, the acute stage begins while displaying symptoms such as changes in level of consciousness, generalized tonic spasms, following a coma. The third late stage known as convalescent presents symptoms such as extrapyramidal features, focal deficits, severe dystonia, and abnormal movements that include head nodding, lip smacking, facial grimacing, pill-rolling movements, or choreoathetosis (Kumar, 2014, p. 101). Neurological deficits have been discovered in patients following potential recovery. Tiwari, Singh, and Dhole's (2012) research stated: Fatality is observed in 20-30% of the cases, with signs of acute cerebral edema or severe respiratory distress from pulmonary edema. Recovery usually leaves serious behavioral and neurological sequelae, most notably persistently altered sensorium, extrapyramidal syndrome, epileptic seizures, and severe mental retardation in children. (p. 5) The diagnosis of Japanese encephalitis can become a challange due to vivid symptoms and the mimicking of other illnesses. Kumar (2014) states, "A clinical diagnosis of JE is usually made on the basis of clinical features consistent with encephalitis occurring in the context of an epidemic or outbreak in rural areas in monsoon and post-monsoon season in an endemic area" (p. 102). Confirmation through laboratory studies is therefore essential for accurately diagnosing Japanese encephalitis. Serological tests that may be performed for the diagnosis of Japanese encephalitis include the neutrilization test, agar gel diffusion test, single radial hemolysis, complement fixation test, and the hemagglutination inhibition test. Contraversery on behalf of obtaining samples for diagnosis through isolation has been shown. Soloman (2004) states, "Attempts to isolate virus from the blood of patients with flavivirus encephalitis are usually unsucessful because viremia is transient and titers are low" (p. 374). Immunoglobin M (IgM) capture enzyme-linked immunosorbent assay (ELISA) test in serum or CSF has been successfuly used as a method of diagnosis through detecting Japanese encephalitis virus antibodies. Kumar's (2014) research found: Sensitivity as well as specificity of the test is higher in CSF making it the preferred sample. Detection of IgM in CSF is about 70% in the first week and about 95% after 10 days from onset of illness. If the initial sample (especially serum) was taken very early in the illness and tested negative for JEV IgM, it should be preferably be repeated in serum after an interval of 7-10 days if the diagnostic suspicion is strong. (p. 102)
The step of the nursing process begins with assessment. A nurse's assessment skills is vital when planning care for a patient. The assessment must begin with obtaining subjective and objective data, using a systemic and ongoing process, cluttering the data, as well as recording the data. When caring for a patient with any type of encephalitis, the nurse must assess for common encephalitis symptoms which include fever, nausea, vomitting, changes in level of consciousness, motor dysfunction, focal neurologic deficits, headache, joint pain, fatigue, as well as photophobia and phonophobia. The Glasgow Coma Scale is a helpful tool during a nurse's assessment to help identify the patient's mental status. Ignatavicius and Workman (2013) state, "Mental status changes are more extensive in the patient with encephalitis than with menengitis. Changes include acute confusion, irritability, and personality and behavior changes" (p. 940). In addition to assessing the client's mental status, it is also imperative for the nurse to assess for signs of intracranial pressure such as a widened pulse pressure, bradycardia, irregular respirations, and dilated pupils. Ignatavicius and Workman (2013) state, "Left untreated, increased ICP leads to herniation of the brain tissue and possibly death" (p. 941). Earily identification of increased intracranial pressure allows the nurse to prioritize her interventions and plan care accordingly. Developing a care plan to meet the needs of a patient diagnosed with Japanese encephalitis requires proper nursing diagnosis related to the patients subjective and objective data. Nursing diagnoses that apply to Japanese encephalitis include decreased intracranial adaptive capacity, deficient fluid volume, risk for electrolyte imbalance, nausea, diarrhea, acute/chronic pain, hyperthermia, ineffective thermoregulation, risk for infection, impaired swallowing, risk for aspiration, risk for acute confusion, risk for falls, risk for injury, impaired physical mobility, activity intolerance, risk for impaired skin integrity, imbalanced nutrition: less than body requirements, delayed growth and development, disturbed sensory perception: auditory, disturbed sensory perception: visual, and fatigue. Psychosocial nursing diagnoses that apply to Japanese encephalitis may include anxiety, fear, ineffective coping, and powerlessness. Furthermore, educational nursing diagnoses include may include deficient knowledge.

Prioritizing care for a patient with Japanese encephalitis may impose as a challenge due to the pathology and risks of the illness, as well as the many symptoms that may arrise. According to Solomon, seizures occur in approximately 85% of children with J***phalitis (Solomon, 2004, p. 373). Seizures propose an increase risk for injury and trauma to a patient if precautions are not implemented. Therefore, a priority nursing diagnosis should include:
· Risk for injury related to seizures, as evidenced by pathophysiology of Japanese Encephalitis. The nurse's outcome should consist of patient will remain free of traumatic injury as evidenced by no presented signs and symptoms of trauma/injury following the completion of seizures during shift. A nurse's long term goal or outcome may include patient will remain free of injury during a seizure in the home setting,as evidenced by family members verbalizing homecare considerations for seizure precautions.
1. Inspect patient's enviornment for potential safety hazards. Pad side rails, keep bed in lowest position, and place patient in a side lying position when possible. (Rationale - These actions may protect the patient from injury sustained by striking head or body on furniture or equipment).
2. Position patient safely. If standing or sitting, guide patient to floor and protect the patient's head by cradling in nurse's lap or placing a pad under head. Do not lift patient from floor to bed while seizure is in progress. Clear surrounding area of furniture. If patient is in bed, remove pillows and raise side rails. (Rationale - These measures prevent traumatic injury. Suffocation will possibly occur with use of pillow).
3. Never force apart a patient's clenched teeth. Do not place any objects into patient's mouth such as fingers, medicine, tongue depressor, or airway when teeth are clenched. (Rationale - Avoiding to do so prevents injury to mouth and possible aspiration).
4. Maintain the patient's airway, and suction as needed (during seizure rest periods). Check patient's level of consciousness and oxygen saturation. Check vital signs. Provide oxygen by nasal cannuala or mask if ordered. (Rationale - This prevents hypoxia from occuring during seizure activity).
5. Stay with patient, observing sequence and timing of seizure activity. Note the following: type of seizure; parts of body affected; if there was a loss of consciousness; presence of autonomic signs of lip smacking, mastication, or grimacing; rolling of eyes; presence of incontinence or diaphoresis; presence of apnea. (Rationale - Continues observation assists in documentation, diagnosis, and treatment of seizure disorder).

In addition to the risk for injury that Japanese Encephalitis may impose on a patient, an increase in intracranial pressure may also occur. Solomon (2004), "Approximately 50 percent of patients with Japanese have elevated cerebrospinal fluid opening pressures" (p. 374). Although raised intracranial pressure occurs in the more cases of Japanese Encephalitis, nursing priority must be aimed at this diagnosis to prevent further complications such as brain tissue herniation and possibly death. With this in mind, the second nursing diagnosis should include:
· Decreased intracranial adaptive capacity related to cerebral edema, as evidenced by inflammation of brain that occurs upon the pathophysiology of Japanese encephalitis. The nurses's expected outcome should contain that the patient maintains optimal cerebral tissue perfusion, as evidenced by stable neurological status, ICP less than 10 mm Hg, and cerebral perfusion pressure (CPP) from 60 to 90 mm Hg.
1. Assess the patient's neurological status, including level of consciousness (LOC); pupil size, symmetry, and reaction to light; extraocular movement; gaze preference; motor function abnormal Babinski relex; and postural rigidity. (Rationale - A decreased LOC is the first sign of ICP. Changes in pupil size, symmetry, and reactivity to light will occur with increased ICP. Postural changes such as flexion (decorticate) or extension (decerebrate) may occur. As ICP increases the patient will exhibit fanning of the toes with dorsiflexion of the great toe when testing the Babinski reflex).
2. Monitor vital signs. (Rationale - As compensatory mechanisms fail to regulate ICP, the patient may exhibit a full, bounding pulse, with a gradually slow rate. A widening pulse pressure is shown in the blood pressure. The respiratory rate begins to slow and the patient may develop breathing patterns such as Cheyne-Stokes breathing. Body temperature may present as unstable due to ICP exerting pressure on the hypothalamus).
3. Assess for headache and vomiting. (Rationale - Pressures on brain tissue and blood vessels with increasing ICP causes pain. Vomitting, may occur suddenly without nausea as increased ICP places pressure on the medulla oblongata).
4. Elevate the head of the bed 30 degrees, and keep the head in a neutral alignment. (Rationale - Elevation allows for venous outflow and contributes to a decrease in cerebral blood volume, as well as ICP. Maintaining the head in a neutral position prevents venous obstruction).
5. Educate the the patient and family on behalf of the causes, treatment, and expected outcome. Offer the family frequent feedback regarding the patient's status. (Rationale - Having knowledge on the diagnosis can decrease anxieties, calm the patient, and potentially help decrease ICP).

Pain is known as an unpleasant sensory and emotional experience that is highly subjective. A nurse must prioritize and plan her care around a patient's subjective data related to pain due to the physiological manifestions that arrise from the body's response to this stressor. Pain is a common and expected symptom that presents in Japanese encephalitis. Tiwari, Singh, and Dhole (2012) state, "It usually starts with a fever above 38 degrees celcius, chills, muscle pain, and meningitis-type headaches accompanied by vomitting" (p. 5). Treating the many sources of pain, primarily the headache that occurs in Japanese encephalitis helps drecrease anxiety and promotes a positive outcome. Thus, applying the nursing diagnosis of acute pain in the patient's care plan should be a priority when working with Japanese Encephalitis.
· acute Pain related to inflammation of the brain and cerebral edema, evidenced by verbal reports of headache, photophobia, restlessness, and changes in vital signs. The nurse's expected outcome should be directed at the patient exhibiting increased comfort such as baseline levels for pulse, blood pressure, respirations, and a relaxed muscle tone.
1. Assess pain characteristics such as the precipitating or relieving factors, the quality of the pain (sharp, dull, burning, shooting), whether or not the pain radiates to another location of the body, the severity of the pain while using a numeric scale or an appropriate pain scale for the patient, as well as the timing of the pain such as when the pain began, whether the pain is intermittent or continuous, and how long the pain lasts. (Rationale - Completing a pain assessment is the first step in planning pain management strategies. The patient is the most reliable source of information in regards to their pain).
2. Assess for signs and symptoms associated with pain. (Rationale - Gulanick and Myers (2014) state, "The patient in acute pain may have an elevated BP, HR, and temperature. The patient's skin may be pale and cool to touch. The patient may be restlessness and have difficulty concentrating" (p. 145).
3. Administer appropriate pain medication as ordered. (Rationale - Weaver states, "Nonnarcotic medications are preferred because they do not alter the level of consciousness. If these are not effective, codeine preparations, which have minimal effect on LOC, may be prescribed" (p.1139).
4. Weaver (2011) recommends to "Provide alternative comfort measures such as dim lights, a quiet enviornment, and positioning for comfort" (p. 1139). (Rationale - These measures are geared toward calming the patient and facilitating rest).
5. Gulanick and Meyers (2014) recommends to "Provide anticipatory instruction on pain causes, appropriate preventions, and relief measures" (p. 147). (Rationale - Having knowledge on the cause of the pain and what is expected allows the patient and family to develop strategies to manage the pain).

Fluid imblance is common in Japanese Encephalitis due to some of the initial symptoms that present such as fever, vomiting, and diarrhea. The deficiency and imbalance can result in the loss of electrolytes which affect a variety of functions in the body. Therefore, the nurse must implement the nursing diagnosis of deficient fluid volume as a second priority in her plan of care.
· Deficient fluid volume related to active fluid loss (vomitting and/or diarrhea) and increased metabolic rate, as evidenced by decreased skin turgor, dry mucous membranes, weakness, and changes in mental state. The nurse's expected outcome should indicate that the patient is normovolemic as evidenced by systolic blood pressure measuring at patient's baseline, absence of orthostasis, HR 60 to 100 beats/min, and normal skin turger.
1. Monitor vital signs and document. Consciously monitor heart rate and blood pressure. (Rationale - Gulanick and Meyers (2014) state, "Reduction in circulating blood volume can cause hypotension and tachycardia. Usually the pulse is weak and may be irregular if electrolyte imbalance also occurs. Hypotension is evident in hypovolemia" (p. 77).
2. Monitor fluid loss from vomitting and diarrhea while maintaining and documenting input and output. (Rationale -These actions allow for accurate measurement of possible decreased fluid volume which can result in dehydration).
3. Gulanick and Meyers (2014) state, "Insert an IV cathetor to maintain IV access" (pg. 78). (Rationale - Accessing an IV site not only allows for emergency access, but offers a route for parenteral fluid replacement to prevent or treat complications such as hypovolemic shock).
4. Gulanick and Meyers (2014) recommend to, "Institute measures to control excessive electrolyte loss (e.g., resting the gastrointestinal tract, administering antipyretics, as ordered). For hypovolemia resulting from severe diarrhea or vomiting, administer antidiarrheal or antiemetic medications as prescribed, in addition to IV fluids" (p. 78). (Rationale - These actions will allow the prevention of additional fluid loss).
5. Gulanick and Meyers (2014) state, "If patients are to receive IV fluids at home, instruct the caregiver in managing IV equipment. Allow sufficient time for return demonstration" (p. 78). (Rationale - This offers the opportunity for caregivers to enhance their skills for maintaining the venous access, and ask questions while decreasing their anxiety from this responsibility).