36671085 Tetanus Case Study

TETANUS

INTRODUCTION TETANUS 1

Comes from the Greek word “tetanus” meaning taut and “teiteim” which means to stretch. It is also called lockjaw. It is a serious infectious disease of the nervous system in which toxin causes severe muscle spasm. It is a medical condition characterized by a prolonged contraction of skeletal muscle fibers. It is caused by a bacterium Clostridium tetani. Infection generally occurs through wound contamination and often involves a cut or deep punctured wound. Tetanus is often associated with rust, but this concept is somewhat misleading. The C.Tetani is an Anaerobic bacteria which survives in an environment that lacks oxygen, thus with or without rust a person may have a tetanus once C. Tetani enters the wound. Contaminated wounds are the site where tetanus bacteria multiply. Deep wounds or those with distallized tissue are particularly prone to tetanus infection. The tetanus toxin affects the site of interaction between the nerve and the muscle that it stimulates, this region is called the neuromuscular junction. The tetanus toxin amplifies the chemical signals from the nerve to the muscles to tighten up in a continuous contraction or spasm. This results in either localized or generalized muscle spasm. The incubation period ranges from 3 to 21 days, usually about 8 days. In general the further the injury site is from the central nervous system, the longer the incubation period. The shorter the incubation period, the higher the chance of death. In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days. On the basis of clinical findings, three different forms of tetanus have been described. Local tetanus is an uncommon form of the disease, in which patients have persistent contraction of muscles in the same anatomic area as the injury. These contractions may persist for many weeks before gradually subsiding. Local tetanus may precede the onset of generalized tetanus but is generally milder. Only about 1% of cases are fatal. Tetanus can be prevented by vaccination with tetanus toxoid. A booster is needed every 10 years after primary immunization. In the Philippines the incidence rate of tetanus is 12 out of 86, 241,627. Objectives General objectives: 2

This case study is designed for the student nurses to become practiced, well-informed and mannered in delivering holistic care for patients diagnosed with Tetanus.

Specific Objectives: Skills •

Imply appropriate medical nursing management for Tetanus.

Knowledge •

Discuss the anatomy and physiology of the Nervous system.

•

Define Tetanus. Learn about major etiologic its causes, identify its

clinical manifestations and risk factors. •

Be familiar with the pathophysiology of Tetanus.

•

Be acquainted with the different drugs, its actions, and perform

obligatory nursing responses for each. •

Plan for a suitable nursing care

Attitude •

Establish a nurse-patient interaction through exchanging of

thoughts and information •

Institute bond between the nurse and the patient.

ANATOMY AND PHYSIOLOGY

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Nervous System

The nervous system is an organ system containing a network of specialized cells called neurons that coordinate the actions and transmit signals between different parts of its body. The nervous system consists of two parts, central and peripheral. The central nervous system contains the brain, and spinal cord. The peripheral nervous system consists of sensory neurons, clusters of neurons called ganglia, and nerves connecting them to each other and to the central nervous system. These regions are all interconnected by means of complex neural pathways. The enteric nervous system, a subsystem of the peripheral nervous system, has the capacity, even when severed from the rest of the nervous system through its primary connection by the vagus nerve, to function independently in controlling the gastrointestinal system.

The Central Nervous System is the body’s information headquarters, ultimately regulating nearly all body functions. The CNS includes: The Brain – Processes incoming information from within the body, and outside the body by way of the sensory nerves of sight, touch, smell, sound, and taste. Commands are then sent back throughout the body. The brain also stores and processes language, communication, emotions, thoughts, dreams, and memories. In other words, the brain is where all thinking and decision-making takes place. •

The Spinal Cord – Is the main pathway for information connecting the brain and peripheral nervous system. It extends from the brain about 18 inches down the bony spinal column, which serves as its protection. The spinal cord is a tube •

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made up of nerve fibers. Electrical impulses travel through the nerves and allow the brain to communicate with the rest of the body. The Peripheral Nervous System is responsible for the remainder of the body. It includes cranial nerves (nerves emerging from the brain), spinal nerves (nerves emerging from the spinal cord) and all the major sense organs. The PNS includes: The Somatic Nervous System (SNS) – Responsible for all muscular activities that we consider voluntary or that are within our conscious control. •

The Autonomic Nervous System (ANS) – Responsible for all activities that occur automatically and involuntarily, such as breathing, muscle contractions within the digestive system, and heartbeat. The components of the ANS work together to create a balanced response to outside stimuli1. The ANS includes: •

The Sympathetic System – Stimulates cell and organ function. The sympathetic system is activated by a perceived danger or threat, very strong emotions such as fear, anger or excitement, by intense exercise, or when under large amounts of stress. Basically, anything the body perceives as an emergency will trigger a protective response. Once initiated, it speeds up heart rate, increases the activity of the sweat and adrenal glands, slows down the digestive system and sends blood to the skin and muscles; all of which prepare the body for a “fight or flight” response. o

The Parasympathetic System – Inhibits cell and organ function. The parasympathetic system slows down heart rate, resumes digestion, and increases relaxation throughout the body. This “rest and digest” response counteracts the “fight or flight” response and helps the body recuperate after a crisis is over. A person's normal resting heart rate is determined by the parasympathetic system. If blood pressure is too high or blood carbon dioxide levels are too low, this system slows the heart down and lowers its output. o

NEUROMUSCULAR SYSTEM The combination of the nervous system and the muscles, working together to permit movement, is known as the neuromuscular system. Neuromuscular disorders include motor neuron diseases, neuropathies and muscular dystrophies. The brain controls the movements of skeletal (voluntary) muscles via specialised nerves. Neurons send signals to other cells as electrochemical waves travelling along thin fibres called axons, which cause chemicals called neurotransmitters to be released at junctions called synapses. A cell that receives a synaptic signal may be excited, inhibited, or otherwise modulated. Sensory neurons are activated by physical stimuli impinging on them, and send signals that inform the central nervous system of the state of the body and the external environment. Motor neurons, situated either in the central nervous system or in peripheral ganglia, connect the nervous system to muscles or other effector organs. Central neurons, which in vertebrates greatly outnumber the other types, make all of their input and output connections with other neurons. The interactions of all these types of 5

neurons form neural circuits that generate an organism's perception of the world and determine its behavior. Along with neurons, the nervous system contains other specialized cells called glial cells (or simply glia), which provide structural and metabolic support.

If you want to move part of your body, a message is sent to particular neurons (nerve cells), called upper motor neurons. Upper motor neurons have long tails (axons) that go into and through the brain, and into the spinal cord, where they connect with lower motor neurons. At the spinal cord, the lower motor neurons in the spinal cord send their axons via nerves in the arms and legs directly to the muscle they control.

A typical muscle is serviced by anywhere between 50 and 200 (or more) lower motor neurons. Each lower motor neuron is subdivided into many tiny branches. The tip of each branch is called a presynaptic terminal. This connection between the tip of the nerve and the muscle is also called the neuromuscular junction. The electrical signal from the brain travels down the nerves and prompts the release of the chemical acetylcholine from the presynaptic terminals. This chemical is picked up by special sensors (receptors) in the muscle tissue. If enough receptors are stimulated by acetylcholine, your muscles will contract.

-Vital InformationName: Mr. E.D. Age: 44 6

Sex: Male Address: Lavezares, n. Samar Civil Status: Married Religion: Roman Catholic Occupation: Coconut Farmer Date and Time Admitted: October 15, 2011; 03:50 pm Ward: ISO ward Chief Complaint: inability to open the mouth Final Diagnosis: Tetanus Attending Physician: Dr. ATD

CLINICAL ASSESSMENT

Nursing History Two days prior to admission, the patient was unable to open his mouth widely. The following day, the family ecided to seek for further medical help, they decided to bring the patient to the hospital. The patient ws on their coocnut farm when suddenly, he noticed that his jaw was hard to control and he can’t move it to open his mouth. Past Health Problem Mr. E.D. has no history of past hospitalization. Sometimes he experienced mild fever, coughs, and cold but manageable and treated with over the counter drugs like paracetamol and solmux. He has no known allergies to food, drugs and animals.

Family History His father died because of old age and his mother died of pulmonary infection. On the other hand, their family has a history of hepertension.

Patterns of Functioning Pattern

Home

Hospitalization

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Breathing Pattern

No respiratory problems. Has Respiratory rates became never complained of any rapid, shallow breaths are breathing difficulty. noted. Difficulty of breathing is always claimed.

Circulation

Claimed to never been had a BP check-up before hospitalization.

Sleeping Pattern

Usually sleeps at 9 pm and Disturbed sleep is usually wakes up at 5 am. 8-10 hour complained whenever sleep duration. excessive stimuli is observed.

Drinking Pattern

Usually drinks 8-10 glasses of water a day.

Cannot tolerate to drink water because of lock jaw.

Eating Pattern

Eats three times a day. He eats more carbohydrate, vegetables and adequate protein. Mr. E.D. isn’t fond of using eating utensils since he is staying on his pond, he eats using his bare hands.

Cannot tolerate to feed nor for parenteral feeding because of the inability to open his mouth.

Elimination Patterns

Defecates once daily in Not yet defecated. adequate amount, golden brown in color.

a. Bowel b. Urination

Personal hygiene

The average BP is 160/110 mmHg during hospital stay.

Urinates normally With urinary incontinence, a approximately 3-5x a day in week after his first an adequate amount. admission, he only passes 40 cc of urine. He was then inserted with foley catheter attached to urobag with an adequate amount, yellowish in color. His daily job as a coconut farmer requires a dirty and heavy tasks. Takes a bath daily but isn’t fond of brushing his teeth.

Not able to do daily hygiene because of present condition. It tends to decreased stimuli. S.O. does the bed bath.

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Recreational and Exercise

His walks from house to the farm which took almost 30 mins. is what they considered to be his daily exercise. He drinks alcohol with his friends.

No recreational activities. Cannot tolerate to stand or sit. Passive ROM exercises done.

Brief Social, Cultural and Religious Background

a. Educational Background Mr. E.D. was a fourth grade in his elementary education when he decided to stop and manage his self to help his parents to their work. He never had the chance to continue his study in highschool and college because of financial constraints. b. Occupation He is a fulltimecoconut farmer, who manages their family’s farm. He spends most of his time on his farm which was 30 mins. away from their residence. c. Religious Practice Mr. E.D. is a Roman Catholic. He does not attend Sunday mass regularly since he is usually at his fishpond, but his family claims that he always pray. d. Economic Status Mr. E.D. belongs to a middle class group, he has no fix economic income for they only had a quarterly harvest. But they claim that it was enough to support the whole family

Clinical Inspection 1. Vital signs T=38.2oC

CR= 104 bpm

BP= 160/110 mmHg

RR= 30 bpm

2. Height = 5’3 3. Weight= 88 kg

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PHYSICAL ASSESSMENT

General Appearance

Mr. E.D.., 44 year-old male, with poor posture and gait. He is lying on bed on a semi- fowlers position. He is lethargic and irritable. He cannot respond to questions well and is not well oriented. Mainline IVF: PNSS 1L is attached at the left basilic vein running at 20 cc/hr. Urinary catheter is well attached in the urethra with urobag in place. O2 at 4 LPM via nasal cannula is in place. No edema noted.

Skin

Skin is brown in complexion, warm, and dry with poor skin turgor. No pallor and edema.

Hair

Has a short black hair mixed with gray ones, well distributed. No presence of flakes, lice or lesions noted.

Nails Head

Face Eyes

Nails are short and clean. Are pink in color and slightly curved with smooth and rounded edges. No clubbing of fingers noted. Head is normocephalic, no palpable nodules or masses noted. lesions are not noted. Face is wrinkled due to old age. (+) Facial grimace and locking of jaw noted. Anicteric sclerae with pupils round and black in color which constricts from 4mm-2mm. Has brisk reaction to light. No cataract noted. Slightly pale conjunctiva noted.

Ears

Top of pinna is aligned with the outer corners of both eyes; size is normal and equal; similar in color to face; (-) discharges and swelling, with poor acuity to whisper voice. Cerumen not noted.

Nose

With presence of cilia. Has no discharges nor sinusitis. Nasal cannula attached to both nostrils at 4LPM. NGT is attached (L).

Mouth

Neck Breast Upper Extremities Chest Respiratory System

Lips are dry with cracking and slightly pale oral mucosa was noted. With no inflammation of tonsils. Has poor dention, with bleeding gum and halitosis. Distention of jugular vein noted. Breast are firm. No mass palpated. Both arms are weak. Can perform passive movements only. Respiratory rate of 24-34 breaths/min, shallow breaths in uniform rhythm. Occasional cough noted with whitish sputum. With supplemental O2 @ 4LPM. Crackles is usually heard. 10

Cardiovascular System Gastrointestinal System Genito-urinary System

Apical pulse at the left midclavicular line averaging at 86 bpm. Skip beats not noted upon auscultation. Abdominal pain noted. With several attempts of bowel movements. Urinary catheter (French 14) intact on urethra and attached to urobag. Passes yellow colored urine in minimal amounts.

Musculoskeletal System

Restless at few times. Have been on seizure attacks. Movements are weak. Cannot tolerate standing. Able to sit on wheelchair. With weak handgrip.

GENERAL APPRAISAL Speech

Language

Speaks in native language. He presently can not talk due to illness. Can speak waray-waray when he was still able to talk.

Hearing

Has poor acuity to whispered voice.

Mental status

He is lethargic and irritable.

Emotional Status

Unable to express emotions.

LABORATORY RESULTS

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October 15, 2011 Hematology Test Hematocrit

Results 0.40

Normal Values

Significance of Abnormal Result Normal

0.40-– 0.48 vol%

Hemoglobin

132

140-180 grms/L

White Blood Cell Count

10.6 x 10^9/L

5 – 10 x 10^9/L

Eosinophils

0.02

0.02 – 0.05

Lymphocytes

0.10

0.25 – 0.35

Neutrophils

0.88

0.57-0.65

A decreased value of hemoglobin can be caused by low red blood cell count, by a lack of hemoglobin in the erythrocytes, which also indicates fluid retention. An elevated WBC count indicates infection due to traumatized tissue. Normal A decreased value occurs with impaired lymphatic drainage.

June 16, 2010 Urinalysis Test

Results

Color

yellow

Transparency Glucose pH Sp. Gravity Albumin Pus cells Epithelial Cells Bacteria Mucous threads

Hazclear Negative pH 6.0 1.025 Rare 0.2/hpf few rare moderate

Normal Values Straw to dark yellow clear None 4.5 – 8.0 1.003 – 1.030 None None None None None

Significance of Abnormal Result Normal

Normal Normal

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MEDICATIONS

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES

1.

Nausea

2.

Vomiting

3.

Sweating

of neuralgia,

4.

Constipation

Acute intoxication with alcohol hypnotics, analgesics or psychotropic, narcotic withdrawal treatment.

including trigeminal

5.

Drowsiness

1. Do not take more medication as a single dose or take more doses per day than prescribed by the doctor.

NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

Diclofenac Na

Treats moderate to

Treatment of acute to chronic pain.

75mg q12 TIV

ACTION

Analgesic Non-Steroidal AntiInflammatory Drugs

moderately severe pain and most types

neuralgia.

6. Respiratory depression

2. Store this medicine at room temperature, away from heat and light.

3. Do not stop taking without talking to the doctor

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NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

Pen G

Inhibits enzymes

Penicillin G is reserved for severe infections.

5 mullion q4 ANST TIV

responsible for cell wall synthesis of susceptible

Brand Name: Pen G

organisms. This

2. Vomiting 3. Diarrhea 4. Abdominal pain 5. Colitis

creates an osmotically

7. Hypersensitivity

that swells and bursts from osmotic

Antibiotic

1. Nausea

6. Anorexia

unstable cell wall ACTION

SIDE EFFECTS

pressure.

8. Neurotoxicity 9.

Urticaria, Superinfection

CONTRAINDICATIONS

NURSING RESPONSIBILITIES

Patients with known allergies to penicillin and hypersensitivity to cephalosporins

1. Have a antibiotic skin test done before giving dose to ensure hypersensitivity reactions. 2. Give by IM route only. 3. Continue therapy for at least 2 days after infection has disappeared, usually 710 days. 4. Use the smallest dose possible for IM injection to avoid pain and discomfort.

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NAME OF DRUG and DOSE

Diazepam 5mg q8 TIV

ACTION

Antiepileptic; Anxiolytic Skeletal muscle relaxant (centrally acting)

MECHANISM OF ACTION

INDICATION

*Muscle relaxant: Acts mainly at the Adjunct for relief limbic system and of reflex skeletal reticular formation; muscle spasm mat act in spinal cord due to local to produce skeletal pathology or muscle relaxation; secondary to potentiates the trauma; effects of GABA, an spasticity caused inhibitory by upper neurotransmitter. motoneuron disorders *Parenteral: Treatment of tetanus

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES

1. Drowsiness

Contraindicated with hypersensitivity to benzodiazepines; psychoses, acute narrowangle glaucoma, shock, coma, acute alcoholic intoxication.

1. Monitor heart rate before giving drug.

2. Dizziness 3. GI upset 4. bradychardia

2. Closely monitor BP.

Use cautiously with elderly or debilitated patients; impaired liver or renal function; and in patients with history of substance abuse.

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NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

Ranitidine

It blocks the production of acid by acid-producing cells in the stomach. It belongs to a class of drugs called H2 (histamine-2) blockers.

Short-term treatment of active duodenal ulcer; maintenance therapy for duodenal ulcer patient after healing of acute ulcer; treatment of gastroesophageal reflux disease; short-term treatment of active, benign gastric ulcer; treatment of pathologic GI hypersecretory conditions

1. constipation

1. hypersensitive to

50 mg q8 TIV

ACTION

H2 (histamine-2) blockers

2. diarrhea 3. fatigue 4. headache 5. insomnia 6. muscle pain 7. nausea, and vomiting

the drug

2. acid indigestion 3. dyspepsia 4. patients who has renal diseases

NURSING RESPONSIBILITIES

• Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. • Inform patient that increased fluid and fiber intake may minimize constipation. • Inform patient that medication may temporarily cause stools and tongue to appear gray black.

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NAME OF DRUG and DOSE

MECHANISM OF ACTION

ATS 10, 000 TIV now ANST

Anti-tetanus serum is a preparation of tetanus antibodies administered for the prevention and treatment of tetanus, also known as lockjaw, a serious bacterial infection. In patients with tetanus, bacteria in the body produce a compound known as tetanus toxoid, leading to muscle spasms and decreased muscle control. The condition can be fatal once the airway is involved and the patient is having trouble breathing. It is preventable withantitetanus serum.

ATS 10,000 IU IM now ANST

ACTION

Antibodies

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

1. Redness or hard lump at place of injection.

a hypersensitivity reaction to a test dose

2. Chills 3.

fever

NURSING RESPONSIBILITIES

any condition that may contraindicate intramuscular injection such as thrombocytopenia

.

4. irritability, or unusual tiredness 5. pain, 6. tenderness,

7. itching

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TEXTBOOK DISCUSSION PATHOPHYSIOLOGY TETANUS

Tetanus is an acute, often fatal disease caused by an exotoxin produced in a wound

disinfectants,

and

by Clostridium tetani. Clostridium tetani is a gram-positive, nonencapsulated, motile, obligatively anaerobic bacillus. It exists in vegetative and sporulated forms. Spores are highly resistant to disinfections by chemical or heat, but vegetative forms are susceptible to the bactericidal effect of heat, chemical a number of antibiotics.

Clostridium tetani is a noninvasive organism. It is found in soil and in the intestine and feces of horses, sheep, cattle, dogs, cats, rats, guinea pigs and chicken. Manure-treated soil may contain large numbers of spores too. Tetanus occurs after spores or vegetative bacteria gain access to tissues and produce toxin locally. The usual mode of entry is trough a puncture wound or laceration. Tetanus may also follow elective surgery, burn wounds, otitis media, dental infection, abortion and pregnancy. Neonatal tetanus usually follows infection of the umbilical stump. In the presence of anaerobic conditions, the spores germinate. Toxins,including tetanolysin (which potentiates infection) and tetanospasmin (a potent neurotoxin) are produced. Tetanospasmin, often referred to as tetanus toxin, causes clinical tetanus. The toxin produced is disseminated through the bloodstream and lymphatic system. However, it does not enter the central nervous system through this route, as it cannot cross the blood brain barrier except at the fourth ventricle. The toxin is exclusively taken up by the neuromuscular junction, where it migrates retrograde transynaptically at the rate 75-250mm/day, a process which takes 3-14 days, protected from neutralizing antitoxin, predominantly to inhibitory synapses to prevent the release of acetylcholine.

The toxin acts after the incubation period (3-14) days) at several sites within the central nervous system, including peripheral motor end plates, spinal cord, brain and sympathetic nervous system. The typical clinical manifestations of tetanus are caused when tetanus toxin interferes with release of neurotrasmitters, blocking inhibitor impulses. 18

Blockade of spinal inhibition is produced when the toxin acts at the synapse of interneurons of inhibitory pathways and motor neurons. General muscle rigidity arises from uninhibited afferent stimuli entering the central nervous system from the periphery. The effect of the toxin on the brain is controversial; direct inoculation can cause seizures. One of the many complications from tetanus is respiratory failure secondary to spasms, obstruction by secretions, exhaustion and pulmonary aspiration. Cardiovascular complications thought to be due to hyperactivity of the sympathetic nervous system include tachycardia, with heart rates over 180 beats per minute, severe vasoconstriction and hypertension. Autonomic dysfunction is seen as increased basal sympathetic activity and episodes of sympathetic over activity.

Tetanus Symptoms

In generalized tetanus, the initial complaints may include any of the following: Irritability, muscle cramps, sore muscles, weakness, or difficulty swallowing are commonly seen. • Facial muscles are often affected first. Trismus or lockjaw is most common. This condition results from spasms of the jaw muscles that are responsible for chewing. A sardonicsmile -medically termed risussardonicus -- is a characteristic feature that results from facial muscle spasms. • Muscle spasms are progressive and may include a characteristic arching of the back known as opisthotonus. Muscle spasms may be intense enough to cause bones to break and joints to dislocate. • Severe cases can involve spasms of the vocal cords or muscles involved in breathing. If this happens, death is likely, unless medical help (mechanical ventilation with a respirator) is readily available. •

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Signs and textbook

symptoms

in

the

Signs and symptoms manifested by the patient

Irritability/ Restlessness



muscle cramps



Weakness



difficulty swallowing



Lockjaw



Stiffness



Reflex spasms



↑Blood pressure



↑temperature



Irregular heart beat Sweating



Seizure



Complications of Tetanus In cases of severe tetanus infection, a number of possible complications can develop Fractures The repeated muscle spasms and convulsions that are caused by a tetanus infection may lead to fractures in the vertebrae (bones in the back), as well as in other bones. Bone fractures can sometimes result in a condition called myositis ossificans circumscripta, which is where bone begins to form in the soft tissues, often around a joint. 20

Aspiration pneumonia If you have a tetanus infection, muscle rigidity (stiffness) can make coughing and swallowing difficult. This can cause aspiration pneumonia to develop. Aspiration pneumonia occurs as a result of inhaling the secretions, or contents, of the stomach, which can lead to a lower respiratory tract infection. Laryngospasm Laryngospasm is where the larynx (voicebox) goes into a brief, temporary spasm that usually lasts for between 30-60 seconds. Laryngospasm prevents oxygen from reaching your lungs, making breathing difficult. Tetanic seizures Tetanic seizures are convulsions (fits) that are similar to epileptic fits. They can occur in severe cases of tetanus where the infection has spread to the brain. Someone with a severe tetanus infection may experience severe and frequent tetanic seizures. Pulmonary embolism A pulmonary embolism is a serious and potentially life-threatening condition. It is caused by a blockage in a blood vessel in the lungs that can affect breathing and circulation. It is therefore vital that treatment is given immediately in the form of anti-clotting medication and, if required, oxygen therapy.

Acute renal failure The severe muscle spasms that are associated with a tetanus infection can cause a condition that is known as rhabdomyolysis. Rhabdomyolysis is where the skeletal muscles are rapidly destroyed, resulting in myoglobin (a muscle protein) leaking into the urine. This can lead to acute (severe) renal failure (kidney failure). Preventing tetanus Immunisation is the best way to prevent a tetanus infection from occurring. The complete course of the tetanus vaccination consists of five doses. The vaccine enables your body to create antibodies against the tetanus toxin (tetanospasmin), providing protection from the illness should you be exposed to the Clostridium tetani bacterium in the future.

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Lifestyle Dental infection

Age Sex

Clostridium tetani enters body through a wound

Pathophysiology Anaerobic conditions allow germination of spores andTETANUS production of toxins

[Patient centered] via blood and Toxins are produced and disseminated lymphatics

Tetanospasmin enters the nervous system peripherally at the myeoneural junction and is transported centripetally into neurons of CNS

Interfers with neurotransmitter release to block inhibitors

Leads to unopposed muscle contraction and spasm

Lockjaw Stiffness Neck rigidity Dysphagia Restlessness

↑BP ↑temperature sweating SEIZURE causing opisthotonos

Reflex spasms

22 Aspiration Pneumonia Hypertension

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CONCEPT MAP

2 Ineffective airway clearance r/t retained and excessive secretions

1

Acute pain r/t muscle rigidity 2o unopposed muscle contraction

8

3

Ineffective breathing pattern r/t impaired lung muscle contraction

4

Cc: Difficulty of swallowing

Impaired physical mobility r/t neuromuscular impairment

Dx: Tetanus

stage 3 7

Disturbed sleep pattern r/t excessive environmental stimuli

5 6

Urinary incontinence r/t bladder outlet obstruction

Impaired swallowing r/t pharyngeal muscle spasm

Altered thermoregulation: Hyperthermia r/t tissue trauma 2o presence of C. tetani 24

NURSING CARE PLAN

25

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

Subjective “Nag-tig-a la kalit eya lawas” as verbalized by the S.O. Objectives: • • • • • • • • •

RR= 30bpm BP= 140/100 mmHg (+) Facial grimace (+) Guarding (+) diaphoresis (+) lockjaw (+)muscle spasm (+)periodontal infection (+)hyperextension of head

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION

Independent:

Acute pain r/t muscle rigidity 2o unopposed muscle contraction

After nursing interventions, will demonstrate a reduction in pain behaviors such as absence of facial grimace and guarding.

1. Handled the To promote client’s body safety and gently while allows doing nursing experience less activity. pain during care activity.

2. Minimize movement dimmed provided.

To promote rest and and avoid light excitation of neurons leading to muscle contractions.

3. Maintained side rail up.

Depedent: 1. Diazepam 5mg intravenously given as ordered.

To ensure safety when seizure and muscle rigidity occurs.

It is a muscle relaxant. That helps reduce muscle contractions causing pain.

Lydia Hall’s Care, Core, Cure

Goal was met. (-) guarding behavior

Florence Nightingale’s Environment Theory

Florence Nightingale’s Environment Theory

Ernestine Weidenbach’s Prescriptive Theory

26 2. Tetanus Immune Prophylaxis against tetanus Globulin

Ernestine Weidenbach’s Prescriptive

27

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

Objectives: •

RR=30 bpm

•

AR=120bpm

•

(+) crackles

•

(+)productive cough

•

(+)restlessness

•

(+) drooling

•

(+) impaired swallowing

•

X-ray results shows Bilateral pneumonia and bronchiectasis

RATIONALE

NURSING THEORY

EVALUATION

Independent:

Subjective: “Ginabudlayan siya mag ginhawa” as verbalized by the folks.

INTERVENTION

Ineffective airway clearance r/t retained and excessive secretions

To maintain a patent airway be able to demonstrate effective coughing and clear breath sounds.

1. Suctioned secretions needed.

To maintain as patent airway and prevent aspiration.

take 2. Elevated head of To advantage of the bed/ change gravity position every decreasing 2hours pressure on the diaphragm and enhancing drainage. 3. Kept

the

Precipitators of allergic type allergen free like respiratory dust. reactions that can trigger onset of acute episodes. environment

To promote oxygenation and and maximize effort.

4. Encouraged deep breathing coughing exercise. 5. Position midline flexion.

Depedent:

head To

open or with maintain open airway.

Virginia Henderson’s Basic Care Component Florence Nightingale’s

Goal was partially met. RR decreased to 24 bpm but still with crackles.

Environment Theory

Florence Nightingale’s Environment Theory

Virginia Henderson’s Basic Care Component

Florence Nightingale’s Environment Theory

28

29

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

Subjective: “Nakuri-an sya pagginhawa” as verbalized by the S.O.

Objectives: •

RR=30 bpm

•

AR=120bpm

•

(+) Labored breathing

•

(+)restlessness

•

(+) drooling

•

(+) impaired swallowing

•

(+) nasal flaring

•

X-ray results shows Bilateral pneumonia and bronchiectasis

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION

Lydia Hall’s Care, Core, Cure

Goal was partially met.

Independent:

Ineffective breathing pattern r/t impaired lung muscle contraction

To demonstate ability to breathe comfortably as evidienced by normal respiratory rate of 16-20 bpm.

1. Suctioned secretions needed.

To maintain patent as airway and prevent aspiration.

2. Elevate head of bed/ placed on high back rest.

Elevation of head may decrease dyspneic episodes. An upright position facilitates lung expansion.

3. Assisted in It can be a helpful taking control of technique in maximizing breathing respiratory function

Dependent: 1. Administered oxygen at 4Lpm as ordered.

Oxygen therapy helps decreased dyspnea.

Collaborative: 2. Combivent nebulization done by pulmoaide.

Acts as bronchodilator to promote effective airway passage .

RR lowered down to 24 bpm. Florence Nightingale’s Environment Theory Dorothea Orem’s Self-care Deficit

Ernestine Weidenbach’s Prescriptive Theory

Ernestine Weidenbach’s Prescriptive Theory

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ASSESSMENT

NURSING DIAGNOSIS

PLANNING

Subjective: “Dire sya maka-tulon o kaon” as verbalized by the folks.

Objectives: •

(+)lockjaw

•

(+)restlessness

• •

(+) drooling (+) impaired swallowing (+)hyperextesion of head (+)gum bleeding

• •

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION

Lydia Hall’s Care, Core, Cure

Goal was partially met.

Dependent:

Impaired swallowing related to pharyngeal muscle spasm

After nursing intervention patient will demonstrate effective swallowing without muscle straining.

1. Nasogastric tube inserted by ROD

Independent: 2. Provided meals in a quiet environment away from excessive stimuli.

To provide parenteral feeding in adequate amount.

Able to open his mouth.

The client can achieve a more effective swallow by focusing on chewing and moving foods/fluids to the back of the mouth where the swallowing reflex is triggered.

3. Have suction equipment available during feeding.

For aspiration precaution.

4. Kept with an upright position for 15mins to an hour after meal.

This position uses gravity to aid in the flow of foods/fluids through the esophagus.

5. Instructed family how to monitor and detect aspiration after eating.

For the family to be aware for any situation so that we can avoid aspiration even when nurses are not in their room

Florence Nightingale’s Environment Theory

Virginia Henderson’s Basic Care Component

Florence Nightingale’s Environment Theory

Lydia Hall’s Care, Core, Cure 32

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ASSESSMENT

NURSING DIAGNOSIS

PLANNING

Subjective: “Gina lagnat siya” as verbalized by the folks.

Objectives: •

T=38.2oC

•

(+) body weakness

•

(+)flushed and warm skin

•

(+) sweating

•

(+) shivering

•

(+) periodontal trauma

•

WBC=11.9 x 10^9/L

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION

Lydia Hall’s Care, Core, Cure

Goal was met.

Independent:

Altered thermoregulation: Hyperthermia r/t tissue trauma 2o presence of C. tetani

To lower down body temperature to 37.5oC after 2 hours of nursing interventions.

1. Tepid sponge bath done.

It lower down body temperature.

2. Room’s temperature cooled down.

A consistent temperature limits environmental effects on thermoregulation

3. Provided thick-wool blanket to prevent further chills.

4. Dimmed the light and provided a peaceful environment for rest. Minimized stimulus. Depedent: 4. Paracetamol 500 mg, 1 tab given orally as ordered. 5. Administered Metronidazole 500 mg

This will help maintain a normal body temperature and prevents shivering.

Promotes rest and relaxation , and prevents from disturbances.

Antipyretic that treats fever, by lowering down body temp. An antibiotic used to treat infection caused by anaerobic C. tetani.

Florence Nightingale’s

Body temp. is 37.3oC. (-) Shivering

Environment Theory Florence Nightingale’s Environment Theory

Florence Nightingale’s Environment Theory

Ernestine Weidenbach’s Prescriptive Theory

Ernestine Weidenbach’s Prescriptive Theory

34

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ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION

Dependent: Objectives: •

Urine volume/fluid output= 40 cc within 8 hours.

•

(+) body weakness

•

(+) muscle rigidity

•

Creatinine= HI 161.8 umol/L

•

TPSA=7.31mg/ml

Urinary incontinence r/t bladder outlet obstruction

After nursing interventions, will void urine volume of at least 30 cc every hour.

1. Foley Catheter inserted as ordered.

2. Administered Tamsulosin 20cc intravenously as prescribed.

3. Solfenacin 5mg 1tab given via NGT as ordered.

To promote adequate urine elimination.

Virginia Henderson’s Basic Component

Helps to manage urethral stones and improves the flow of urine

Ernestine Weidenbach’s Prescriptive Theory

Smoothen urethral muscle and relieved symptoms of urge urinary incontinence

Ernestine Weidenbach’s Prescriptive Theory

Goal was met. Urine output=300 cc after 8 hours

Independent: 1. Implement measures to ensure the patency (e.g. keep tubing free of kinks, keep collection bag below bladder level)

Maintaining patency of the indwelling catheter prevents urinary incontinence

2. Encourage fluid intake in small amount frequently.

Drinking a large amount of fluid at one time results in rapid filling of the bladder which increases pressure in the bladder and the subsequent risk of incontinence

3. Provide an environment that

Environmental factors may contribute to

Florence Nightingale’s Environmental Theory

Lydia Hall’s Care, Core, Cure

36 Florence Nightingale’s

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ASSESSMENT

NURSING DIAGNOSIS

PLANNING

Subjective: “Madali siya makibot sa gasulod, ga tiskog naman siya, hindi siya katulog ” as verbalized by the folks. Objectives: •

(+) too much visitors

•

(+) disturbed sleep

•

(+) Weakness

•

(+) Lethargic

•

(+) Irritable

•

(+) hyperextension of head (+) body stiffness

•

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION

Independent:

Disturbed sleep pattern r/t excessive environmental stimuli

After nursing interventions, will able to have undisturbed sleep with long intervals.

1. Keep environment quiet for sleeping, eliminate noise.

Provides more relaxing and comfortable environment for sleeping.

2. Perform nursing procedures all at the same time if possible before patient to go to sleep.

Reduces disturbances in sleeping.

3. Adjusted lighting by dimming the lights.

Light may alter or disturb patient’s sleep.

Florence Nightingale’s Environmental Theory

Goal was met. Slept at long intervals undisturbed.

Virginia Henderson’s Basic Component

Florence Nightingale’s Environmental Theory

Dependent: 1. Administered Diazepam 50mg intravenously

Acts as muscle relaxant and an anxiolytic.

Ernestine Weidenbach’s Prescriptive Theory

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Discharge Planning Mr. E.D.’s family decided to go home even though he was not in good ASSESSMENT

NURSING DIAGNOSIS

PLANNI NG

Subjective:

Objectives: •

(+) body weakness

•

(+)Reluctan ce to attempt movement. (+)Limited range of motion. Decreased muscle strength.

•

NURSING THEORY

EVALUATI ON

Virginia Level of activity or exercise Henderson’ s depends on Basic progression and Componen resolution t

Goal was not met.

RATIONALE

Independent:

“Di na siya kahulag mayad indi parehas sadto ” as verbalized by the folks.

•

INTERVENTION

After 16 Impaired hours (2 physical days 6-2 mobility shift) of nursing r/t interventio neuromusc ns, the patient will ular or impairment maintain increase . strength

1. Evaluate or continuously monitor degree of pain. 2. Maintain bed rest or chair rest when Indicated. Schedule activities providing frequent rest periods and uninterrupted night time sleep.

and function of affected or compensat ory body part.

3. Assist with active or passive range of motion. 4. Encourage patient to maintain upright and erect posture when sitting, standing, or walking.

Systemic rest during cute attacks and important throughout all phases of disease to reduce fatigue and improve strength Maintains or improves joint function, muscle strength, and general stamina. Maximizes joint function, maintains mobility that can precipitate acute attack.

Florence Nightingale’ s Environmen tal Theory

Hildegard Peplau’s Interperso nal Theory of Nursing Florence Nightingale’ s Environmen tal Theory

condition, and they decided to transfer the patient to a higher center per request. MEDICATIONS The following medications are discontinue since the patient’s IV therapy was terminated: •

Benzyl Penicillin 5 M q4 TIV ANST

•

Diazepam 5mg q8 TIV

•

Diclofenac Na 75 mg q12 TIV

•

Ranitidine 50 mg q8 TIV 39

(+) body weakness

EXERCISE AND ACTIVITY • • • •

-Advise folks to assist the patient in doing passive range of motion -Instructed folks to avoid stressful activities for patient -Let the folks provide healthy hygiene to the patient -Encourage to seek psychological support and social group therapy

TREATMENT Nebulization treatment must be resume upon discharge and continuous Oxygen therapy is needed by Mr. E.D. HOME TEACHINGS • • •

-Educate the folks about what is Tetanus and on how to take the prescribed medication of the patient -Advice the folks to let the patient sleep in long intervals and avoid to much stressor to the patient -Teach the folks on what are the possible side effects and effects of the medication to the patient

OUT PATIENT FOLLOW-UP Mr. E.D.’s condition requires thorough medical attention, he shall have a recommended return visit at the hospital. He was encouraged to comply patient follow-up. DIET Mr. E.D. was discharged. SPIRITUALITY Advise folks to seek spiritual help from priests, nuns any religious organization member they know in the society for spiritual counseling

BIBLIOGRAPHY

•

Smeltzer, S., Bare, B., Hinkle, J. & Cheever, K. (2008). Brunner &

Suddarth’s Textbook of Medical-Surgical Nursing, 11th Ed. Lippincott Williams & Wilkins. •

Seeley, R., Stephens, T. & Tate, P. (2007). Essentials of Anatomy &

Physiology, 6th Ed. McGraw-Hill. •

Bickley, L. (2007). Bates’ Pocket Guide to Physical Assessment &

History Taking, 5th Ed. Lippincott Williams & Wilkins •

Karch, A. (2009). 2009 Lippincott’s Nursing Drug Guide. Lippincott

Williams & Wilkins.

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•

Octaviano, E. & Balita, C. (2008). Theoretical Foundations of Nursing:

The Philippine Perspective. Ultimate Learning Series •

www.wikipedia.org

•

www.doh.gov.ph

•

www.eMedicine.com

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