What is Tetanus?
Tetanus, or lockjaw, is a preventable but often fatal disorder that is caused by the bacterium Clostridium tetani, a spore-forming anaerobe. The bacterium exists in spore form in an aerobic environment until it is exposed to an anaerobic environment. The organism then changes to the vegetative form, multiplies, and produces neurotoxins.
Symptoms of Tetanus
Nursing Assessment for Tetanus Client
History of present illness: a severe injury, burns and inadequate immunization.
Respiratory System: dyspnea, cyanosis and asphyxia due to respiratory muscle contraction.
Cardiovascular System : dysrhythmias, tachycardia, hypertension and bleeding, initially the body temperature 38-40 ° C or febrile up to the terminal 43-44 ° C.
Neurologic System: irritability (early), weakness, convulsions (late), paralysis of one or several nerves of the brain.
Urinary System l: urinary retention (bladder distension and urine output does not exist / oliguria)
Digestive System: constipation due to no bowel movements.
Integument and muskuloskletal System: pain, tingling at the site of injury, sweating, initially trismus, muscle spasms face with increasing contraction eyebrows, risus sardonicus, stiff muscles and difficulty swallowing.
If this continues there will be the status of general convulsions and seizures.
Nursing Diagnosis for Tetanus
http://www.nursingcare101.com/tetanus
http://nursing-careplans.blogspot.com/2011/04/nursing-care-plan-for-tetanus.html
http://www.mayoclinic.com/health/tetanus/DS00227/DSECTION=symptoms
Tetanus, or lockjaw, is a preventable but often fatal disorder that is caused by the bacterium Clostridium tetani, a spore-forming anaerobe. The bacterium exists in spore form in an aerobic environment until it is exposed to an anaerobic environment. The organism then changes to the vegetative form, multiplies, and produces neurotoxins.
Symptoms of Tetanus
- Stiffness of your abdominal muscles
- Painful body spasms
- Fever
- Sweating
- Spasms and stiffness in your jaw muscles
- Stiffness of your neck muscles
- Difficulty swallowing
- Elevated blood pressure
- Rapid heart rate
Nursing Assessment for Tetanus Client
History of present illness: a severe injury, burns and inadequate immunization.
Respiratory System: dyspnea, cyanosis and asphyxia due to respiratory muscle contraction.
Cardiovascular System : dysrhythmias, tachycardia, hypertension and bleeding, initially the body temperature 38-40 ° C or febrile up to the terminal 43-44 ° C.
Neurologic System: irritability (early), weakness, convulsions (late), paralysis of one or several nerves of the brain.
Urinary System l: urinary retention (bladder distension and urine output does not exist / oliguria)
Digestive System: constipation due to no bowel movements.
Integument and muskuloskletal System: pain, tingling at the site of injury, sweating, initially trismus, muscle spasms face with increasing contraction eyebrows, risus sardonicus, stiff muscles and difficulty swallowing.
If this continues there will be the status of general convulsions and seizures.
Nursing Diagnosis for Tetanus
- Increased body temperature (hyperthermia) related to the effects of toxins (bacteremia)
- Changes in nutrition, less than body requirements related to the mastication muscle stiffness
- Disturbed interpersonal relationships related to speech difficulties
- Impaired daily needs related to the condition of weak and frequent seizures
- The risk of fluid and electrolyte imbalances related to intake of less and oliguria
- Risk of injury related to frequent seizures
- Ineffective airway clearance related to the accumulation of sputum in the trachea and respiratory muscle spasms.
- Lack of rest requirements related to frequent seizures.
- Breathing pattern disorders related to impaired airway due to spasm of respiratory muscles
- Lack of knowledge of the client and family about tetanus disease related to lack of information.
- Protect the client from injury.
- Provide comfort measures.
- Monitor client for signs of arrythmias.
- Prevent client from having spasms by:
- Controlling the environment
- Avoiding stress, pain, coughing, or flatus to occur to the patient
- Avoid touching, turning, and jarring the bed of the client
- The nurse should organize the activity of the client. Provision of cluster care is a must. cluster care is doing all nursing measures in one setting. Gentle nursing care is also required. The nurse should also turn the client to prevent respiratory problems.
- Maintain adequate airway and ventilation.
- Maintain an intravenous line.
http://www.nursingcare101.com/tetanus
http://nursing-careplans.blogspot.com/2011/04/nursing-care-plan-for-tetanus.html
http://www.mayoclinic.com/health/tetanus/DS00227/DSECTION=symptoms
