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SAINT FRANCIS OF ASSISI COLLEGE

#045 Admiral Village, Talon III Las Piñas City

Tetanus(A CASE STUDY IN INFECTIOUS WARD)

BSN – 4 GROUP 2B

Submitted By:

Dacles, Katrina L.

Daniel, Hannah D.

De Ocampo, Mc Reemon C.

Dolleton, Kristian Joy B.

Fernandez, Albie Lou

Francisco, Isidro D.

Hernandez, Michelle B.

Garong, Khristian Nickole

Layugan, Cindys

Submitted To :

Mr. Albert Yumul, RN MSN

Clinical Instructor

San Lazaro Hospital

July 2011



ACKNOWLEDGEMENT

This grand case presentation, for us, is one of the major hurdles necessary for us to learn angrow in our chosen field. Because of this activity we learned to bond with the group and share ideas stimulating our mind to learn and understand more on the case that we are presenting. The success o presentation would not be possible without the following people:

To EK, for giving us the permission to have her as the subject for this case presentation. Wevery thankful for her cooperation and generosity to us. We promise to have her privacy in the higregard.

To the institution of San Lazaro Hospital and to its staff, we are very thankful for generositywell. For letting us conduct our study in their institution and helping us in finding a suitable patienstudy, we are grateful for their assistance.

To our school, St. Francis of Assisi College for being the vehicle of our learning, our cliniinstructor for being the drivers and guides to our pursuit in acquiring the skills and knowledge in theof nursing.

To our parents, we would not be here without them. We offer them our dedication to our studas a taken for their hard work.

And lastly, to the Lord Almighty, to Jesus Christ our Lord and Savior, for guiding us in oeveryday lives. We offer this work as well in His honor and glory.



I. INTRODUCTION

Tetanus is an acute, often fatal disease caused by an exotoxin produced by the bacteriuClostridium Tetani but prevented by immunization with tetanus toxoid. It is characterized by generalizrigidity and convulsive spasms of skeletal muscles.

Tetanus results in severe, uncontrollable muscle spasms. The jaw is "locked" by muscle spascausing the disease to sometimes be called "lockjaw." In severe cases, the muscles used to breathespasm, causing a lack of oxygen to the brain and other organs that may possibly lead to death.

General Objective

The general objective of this study is to enhance the knowledge, skills and abilities of us, nurstudents, regarding the case we are presenting.

Specific Objectives

• To know the possible signs and symptoms of tetanus

• To know how Tetanus is transmitted to humans

• To know how or what I can do, as a nurse, in managing Tetanus infected patients

II. PERSONAL DATA

Name: E. K.

Address: Iba, Zambales

Sex: Female

Age: 6 y/o

Nationality: Filipino

Religion: Roman Catholic

Admitted: July 5, 2011

Chief Complaint: Chest pain and Muscle Spasms

Admitting Diagnosis: Tetanus; Grade III



III. HISTORY OF PRESENT ILLNESS

• June 27, 2011 - client complained of chest pain and difficulty of breathing and is manifestedchild putting a clenched fist over her chest. Mother ignored the complaint of the client.

• June 29, 2011 - client had occurrence of muscle spasm, persistent occasional chest pain waccompanying difficulty of breathing. Mother became worried and thought that the clienhaving a cardiac problem.

• June 30, 2011 - client is observed by the mother to have difficulty of opening her moudifficulty of swallowing and with occasional spasms. The mother decided to bring the client rural hospital for consultation and was only prescribed Amoxicillin and Ibuprofen. Client wthen advised to be admitted but the mother refused.

• July 1, 2011 – persistence of symptoms occurred and the client was brought again to the hospand was admitted. Attending physician suspected on the signs and symptoms and ordered following medications: Pen G, Ceftriaxone, Amikacin, Metronidazole and ATS.

IV. PAST PERSONAL HISTORY

Patient E. K. first hospitalization was in one rural hospital in their area. She was discharged a diagnosis of CNS infection and UTI. Prior to this, there were no other past hospitalization, operatmedications taken and noted allergic reactions. History of immunization is as follows:

ImmunizationsBCG (infant) CompleteDPT 1, 2, 3 Missed DPT 3Polio CompleteMeasles CompleteBCG (school age) Complete

Tetanus Toxoid (during pregnancy of the mother) Complete

V. NURSING HISTORY

Client is a six year old female with four siblings. The father works as a construction worker the mother is a plain housewife who just delivered their 5th child four months ago. The family lives

construction site with two rooms and they are 11 occupants. The source of water is from a newconstructed deep well water line and with poor garbage disposal. The child is fond of noodles, fifoods and junk foods. The mother who is accompanying the client in the hospital believed that the wmight be the source of the disease because she claimed that they do not boil the water for drinking anuse. She also claimed that the signs and symptoms occurred after the client had bleeding gums du brushing of the teeth.



Throat:

( √ ) swallowing difficulty ( ) frequent sore throats

( ) speech problems Other:Mouth:

( √ ) cavities ( ) tongue problems ( ) canker sores

( ) dentures Other: difficulty in opening

Neck:

( ) swollen glands ( ) thyroid problems Other:

Chest:

( √ ) chest pain ( ) asthma ( √) shortness of breath

( ) cough ( ) TB Other: Pneumonia bilateral (July 5,2011)

Heart:

( ) murmurs ( ) palpitations ( ) valve problems

( ) mitral valve prolapsed ( ) angina Other:

Intestinal:

( ) colitis ( )ulcer gastritis ( ) Barrett’s esophagus

( ) polyps ( √ )constipation Other:

Urinary:

( ) urinary problems ( ) urinary frequency ( ) burning

( ) kidney stones Other:

Genital:

( )infection ( ) warts ( ) herpes

( ) impotence ( )sexual difficulty Other:

Upper Extremity:

( ) pain in arm ( )Carpal Tunnel ( ) shoulder pain



( ) elbow pain ( ) wrist pain Other:

Lower Extremity:

( ) pain in legs ( ) knee pain ( ) pelvic pain

( ) ankle pain ( ) tingling Other:Spine:

( ) low back pain ( ) neck pain ( ) mid back pain

( ) scoliosis ( ) herniated disc ( ) sciatica

Other: difficulty in twisting the body, arching of the back

Systemic:

( √) weight loss ( √ ) fever (√) night sweats

( √ ) trouble sleeping ( ) loss of energy ( ) arthritis

Other: profused sweating throughout the day

smoke: _____________ per day. drink ________________ alcohol per week

Allergies to Medications: (State drugs and their reactions)

None.

Surgeries: (list type of surgery, year performed or your age at the time of surgery)

None.



VII. ANATOMY & PHYSIOLOGY

Nervous System

Tetanus came from the Greek Word“Tetanos” meaning, to contract.” The causative bacterium Clostridium Tetani is a hardyorganism capable of living many years in the soilin a form called a spore. The bacterium was firstisolated in 1899 by S. Kitasato while he wasworking with R. Koch in Germany. Kitasato alsofound the toxin responsible for tetanus anddeveloped the first protective vaccine against thedisease.

Tetanus occurs when a wound becomes contaminated with bacterial spores. Infection followhen spores become activated and develop into gram-positive bacteria that multiply and produce a

powerful toxin (poison) that affects the muscles. Tetanus spores are found throughout the environmusually in soil, dust, and animal waste. The usual locations for the bacteria to enter the body are punwounds, such as those caused by rusty nails, splinters, or insect bites. Burns, any break in the skin, andrug access sites are also potential entryways for the bacteria Tetanus is acquired through contact wenvironment;it is not transmitted from person to person.

Tetanus results in severe, uncontrollable muscle spasms. The jaw is "locked" by muscle spascausing the disease to sometimes be called"lockjaw." In severe cases, the muscles used to breathe canspasm, causing a lack of oxygen to the brain and other organs that may possibly lead to death.

CLOSTRIDIUM TETANI

It is a slender gram-positive, anaerobic rod that may develop a terminal spore giving idrumstick appearance. It is sensitive to heat and cannot survive in the presence of oxygen.

It produces two exotoxins:

1. Tetanolysin - its function of is not known with certainty.



2. Tetanospasmin - is a neurotoxin and causes the clinical manifestations of tetanus. EstimaHuman lethal dose is 2.5 ng/kg (a nanogram is one billionth of a gram).

EPIDEMIOLOGY

Tetanus remains a major public health problem in the developing world and is still encounterethe developed worlds. There are about 800 000: 1 million deaths due to Tetanus each year. 80% of tdeaths occur in Africa and South East Asia and it remains endemic in 90 countries worldwide. Tetanan infectious disease caused by contamination of wounds from bacteria that live in the soil.

• Occurrence: Tetanus occurs worldwide but is most frequently encountered in densely populatregions in hot, damp climates with soil rich in organic matter.

• Reservoir: Organisms are found primarily in the soil and intestinal tracts of animals and human

•

Mode of Transmission: Contaminated wounds, Tissue injury (surgery, burns, deep puncturewounds, crush wounds, Otitis media, dental infection, animal bites, abortion, and pregnancy).

• Host Factors:

o Age: It is the disease of active age (5-40 years), New born baby, female during deliveor abortion

o Sex: males > females

o Occupation: Agricultural workers are at higher risk

o Area: Rural > Urban areaso Immunity: Herd immunity (community immunity) does not protect the individual

o Environmental and social factors: Unhygienic custom habits, Unhygienic delivery practices

PATHOGENESIS

Clostridium Tetani usually enters the body through a wound. In the presence of anaero

conditions, the spores germinate and start to produce toxin and disseminated via blood and lymphToxin reaches the CNS by passing along the motor nerves to the anterior horn cells of the spinal cThe shortest peripheral nerves are the first to deliver the toxin to the CNS, which leads to the early

symptoms of facial distortion and back and neck stiffness.

Toxins act at several sites within the central nervous system, including:

• Peripheral motor end plates



• Spinal cord

• Brain

• Sympathetic nervous system

How Tetanospasmin Reaches the CNS

Tetanospasmin is taken up by motor neurons in the

peripheral nerve endings through endocytosis. It then travels along

the axons until it reaches the motor neuron cell bodies in the spinal

cord, by fast retrograde transport.

The typical clinical manifestations of tetanus are

caused when tetanus toxin interferes with release of neurotrans-mitters blocking inhibitory impulses. This leads to unopposed

muscle contraction and spasm. Seizures may occur, and the

autonomic nervous system may also be affected.



CLINICAL FEATURES

Incubation Period

Ranges from3 to 4 weeks

• The further the injury site is from the CNS, the longer the incubation period• The shorter the incubation period, the higher the chance of death

• In neonatal tetanus, symptoms usually appear from3 to 10 days after birth, averaging about 7days.

Types of Tetanus

1. Local tetanus is an uncommon form of the disease, in which patients have persistent contractiof muscles in the same anatomic area of the injury. Local tetanus may precede the onsetgeneralized tetanus but is generally milder. Only about 1%of cases are fatal.

2. Cephalic tetanus is a rare form of the disease; occasionally occurring with otitis media (eainfections) in which C. tetani is present in the flora of the middle ear, or following injuries tohead. There is involvement of the cranial nerves, especially in the facial area.

3. Generalized tetanus is the most common type (about 80%) of reported tetanus. The diseusually presents with a descending pattern. Neonatal tetanus is a form of generalized tetanus.

Sequence of events

Lock Jaw Stiff Neck Difficulty Swallowing Muscle Rigidity Spasms

Clinical Manifestations

NEONATE OLDER CHILDREN & ADULTONSET: bet. 3 – 10 days with feedingdifficulty in sucking & excessive crying,attempts to feed – spasms & cyanosis

ONSET: insidious with muscular spasmsand cramp- like around inoculation

(+) Fever Irritability & restlessness

Jaws becomes too stiff Progressive increase of stiffness – 24- 28hrs.

Spontaneous or provoked tonic or rigidmuscle contraction, spasms(+)/(-) OpisthotonusDTR – exaggerated or no response

Jaw – trismus or lockjaw (last todisappear)Neck & back – opisthotonusFace – risus sardonicus

Trunk – boardlike abdomenExtremitiesLaryngeal spasms*Excitants*

Cry: varies from repeated, short, mildly (-) Fever



hoarse to strangulated soundingvoiceless noise(+) cyanosis or pallor Headache & profuse sweating

(+) flaccidity, anorexia,exhaustion -death

Sensorium: intact or clear(+) apprehension & anxietyEyes partially closed

Complications

Laryngospasm, Fractures, Hypertension, Nosocomial Infections, Pulmonary Embolism,Aspiration Pneumonia, Death.

IX. PATHOPHYSIOLOGY

TETANOSPASMIN TETANOLYSIN

BLOOD STREAM

CENTRAL NERVOUS SYSTEM

SPINAL CORD- LOCKJAW- TRISMUS- RISUS SARDONICUS- OPISTHOTONUS

BRAIN- IRRITABLE- HEADACHE- LARYNGEAL/

PHARYNGEAL SPASM- GENERAL RIGIDITY- CONVULSIONS



X. TREATMENTS / LABORATORY

Laboratory and Diagnostic Procedures:

Labs 04-30-11 05-01-11 5-13-11 REMARKSWBC 8.1 103/mm3 7.0 103/mm3 7.38RBC 4.72

106/mm34.57103/mm3

5.56

HGB 10.3 L g/dl 10.7 L g/dl 11.11HCT 31.4 L % 30.7 L % 35.19PLT 298 103/mm3 312 103/mm3 574

XI. COURSE IN THE WARD / NURSES NOTES

1st Day: Patient was on NPO; 5LPM of oxygen; with orders for CBC. Medications: Diazepam 5mg/ q 8o for spasms, Metronidazole 100mg/ IV q 6o, AntiTetanus Serum (40,000 initial dose; 20,020,000; 18,000 “IU”) (-)ANST/ IM

2nd Day: Patient still with spasm and trismus. Continue medications. Diazepam 4.3mg/I.V. increasedevery 4 hours.

5th Day: Persistence of symptoms. Appearance of whitish tongue. Given Miconazole oral solution qand Pen G 1M q 6o.

6th Day: Strict aspiration precaution was advised due to tongue biting.

7th Day: Benzotonein Cl & Lidocaine HCl given for gargle. IVF of D5IMB 500cc for 45cc/hour. Wfebrile periods.

9th Day: Decrease spasms and trismus, with occasional fever, CBC was requested and Bisacosuppository prescribed.

10th Day: Febrile: 38oC; (+) Phlebitis – reinserted IV cannula.

11th Day: High grade fever, trismus, spastic episodes. Metronidazole, Ceftazidine 500mg/ IV, Amika200mg/ IV, urinalysis was ordered, discontinued PenG.

13th Day: Febrile

14th Day: Febrile, poor appetite



XII. DRUG STUDY

Penicillin G Potassium

ClassificationAvailable

FormsAction

Contraindication

NursingConsiderations

Patient Teaching

• Anti-bacterial Injection:600,000,

1.2million, 2.4million units/dose

Interferes withbacterial cell

wallsynthesisduring activemultiplication,causing cellwalldeath andresultantbactericidalactivity againstsusceptiblebacteria

• Hypersensitivity penicillins,

cephalosporins, orotherallergens.

• History: - Assessfor hypersensitivity

andcontraindicationstothe drug.

• Physical: Weight; T; skin color,lesions;orientation, affect,reflexes, bilateralgrip strength,visualexamination; P,BP; bowel sounds,normal GI output,liver evaluation;normal urinaryoutput; LFTs, renalfunction tests,blood and urineglucose.

• Take this drugexactly as

prescribed. Do notstop taking thisdrug (long-termtherapy,antiepileptictherapy) withoutconsulting yourhealth careprovider.

• Educate aboutside effects of drug.

• Instruct to reportdifficultybreathing, rashes,severe pain atinjection site,mouth sores,unusualbleeding orbruising.



Metronidazole


FormsAction

Contraindication


Patient Teaching

• Anti-bacterial

• Anti-protozoals

• 500MG TABLETS

• 250MG

TABLETS

• 0.75% CREAM45GM

• 375MGCAPSULES

• 0.75% LOTION59ML

• 0.75% GEL45GM

• VAGINAL .75%GEL 70G

Disrupts DNAand proteinsynthesis insusceptible

organisms.Bactericidal, oramebicidalaction

• Hypersensitivity

• History: - Assessfor hypersensitivityandcontraindications

tothe drug.• Physical: Weight; T; skin color,lesions;orientation, affect,reflexes, bilateralgrip strength,visualexamination; P,BP; bowel sounds,normal GI output,liver evaluation;normal urinaryoutput; LFTs, renalfunction tests,blood and urineglucose.

• Administer withfood or milk tominimize GIirritation. Tabletsmay be crushedfor patients withdifficultyswallowing.

• Take this drugexactly asprescribed. Do notstop taking this

drug (long-termtherapy,antiepileptictherapy) withoutconsulting yourhealth careprovider.

• May causedizziness or light-headedness.Caution patient orother activitiesrequiring alertnessuntil response tomedication isknown.

• Inform patientthat medicationmay cause anunpleasantmetallic taste.

• Inform patientthat medicationmay cause urineto turn dark.

• Advise patient toconsult health



care professionalif no improvementin a few days or if signs andsymptoms of superinfection isseen

Doxycycline


FormsAction

Contraindication


Patient Teaching

• Anti-bacterial • 500MG TABLETS

• 250MG TABLETS

• 0.75% CREAM45GM

• 375MGCAPSULES

• 0.75% LOTION59ML

• 0.75% GEL

Doxycyclineinhibits proteinsynthesis bybinding toribosomes. Itinhibits

bacterial cellgrowth.

• Hypersensitivity

• History: - Assessfor hypersensitivityandcontraindicationstothe drug.

• Do not administerintramuscularly orsubcutaneously.

• Store capsules,tablets at roomtemperature.

• Oral suspension isstable for 2 weeksat roomtemperature.

• Give with full glass

• Take this drugexactly asprescribed. Do notstop taking thisdrug (long-termtherapy,

antiepileptictherapy) withoutconsulting yourhealth careprovider.

• Avoidunnecessaryexposure tosunlight.

• Do not take withantacids, iron



45GM

• VAGINAL .75%GEL 70G

of fluid• May take with

food.• Protect IV Infusion

from sunlight. if precipitate forms,discard.

• Infuse for >1-4hours given byintermittent IVinfusions.

• Determine patternof bowel activityand stoolconsistency.

• Assess skin forrash.

• Monitor levels of consciousness dueto potentialincrease inintracranialpressure.

products, anddairy products.

• After applicationof dental gel,avoid brushing theteeth and flossingthe treated areasfor 7 days.

• Advise patient to

consult healthcare professionalif no improvementin a few days or if signs andsymptoms of superinfection isseen.



Diazepam (Valium)


FormsAction Contraindication


Patient Teaching

• Benzodiazepine

• Anxiolytic• Antiepileptic• Skeletal

musclerelaxant(centrallyacting)

• Tablets : 2, 5,10 mg

• SR capsule:15 mg

• oral solution:1 mg/mL, 5mg/5 mL

• rectal pediatric gel:2.5, 5, 10 mg

• rectal adult gel: 10, 15, 20mg

• injection : 5mg/mL

Exactmechanisms of action notunderstood;

acts mainly atthe limbicsystem andreticularformation; mayact in spinalcord and atsupraspinalsites toproduceskeletal musclerelaxation;potentiates theeffects of GABA, aninhibitoryneurotransmitter; anxiolyticeffects occur atdoses wellbelow thosenecessary tocause sedation,ataxia; haslittle effect oncorticalfunction.

• Contraindicatedwithhypersensitivityto

benzodiazepines;psychoses, acutenarrow-angleglaucoma, shock,coma, acutealcoholicintoxication;pregnancy (cleftlip or palate,inguinal hernia,cardiac defects,microcephaly,pyloric stenosiswhen used infirst trimester;neonatalwithdrawalsyndromereported innewborns);lactation.

• Use cautiouslywith elderly ordebilitatedpatients;impaired liver orrenal function;

• History:Hypersensitivitytobenzodiazepines;

psychoses, acutenarrow-angleglaucoma, shock,coma, acutealcoholicintoxication;elderly ordebilitatedpatients;impaired liver orrenal function;pregnancy,lactation

• Physical:Weight; skincolor, lesions;orientation,affect, reflexes,sensory nervefunction,ophthalmologicexamination; P,BP; R,adventitioussounds; bowelsounds, normaloutput, liver



• Use of barriercontraceptives isadvised whileusing this drug; if you become orwish to becomepregnant, consultwith your healthcare provider.

• You mayexperience theseside effects:Drowsiness,dizziness (maylessen; avoiddriving orengaging in otherdangerousactivities); GIupset (take drug



and in patientswith a history of substance abuse.

evaluation;normal output;LFTs, renalfunction tests,CBC

with food);dreams, difficultyconcentrating,fatigue,nervousness,crying (reversible).

• Report severedizziness,weakness,

drowsiness thatpersists, rash orskin lesions,palpitations,swelling of theankles, visual orhearingdisturbances,difficulty voiding.



Baclofen (Apo-Baclofen)


FormsAction

Contraindication


Patient Teaching

• Skeletalmusclerelaxant(centrallyacting)

Available as 10mg and 20 mgtablets for oraladministration

It inhibitsbothmonosynapticand

polysynapticreflexes atspinal level.

• Hypersensitivity.

• Active pepticulcer disease.

• History:Hypersensitivity tobaclofen, skeletalmuscle spasm

resulting fromrheumaticdisorders, stroke,cerebral palsy,Parkinson’sdisease, seizuredisorders,lactation,pregnancy

• Physical: Weight; T; skin color,lesions;orientation, affect,reflexes, bilateralgrip strength,

visualexamination; P,BP; bowel sounds,normal GI output,liver evaluation;normal urinaryoutput; LFTs, renalfunction tests,blood and urineglucose.



• Avoid alcohol,sleep-inducing, orover-the-counterdrugs becausethese could causedangerous effects.

• Do not take thisdrug during

pregnancy.• Report frequent orpainful urination,constipation,nausea, headache,insomnia, orconfusion thatpersists or issevere.



XIII. PRIORITIZATION/NCP

Ineffective Breathing Pattern

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:

Objective:

• Use of accessory muscles

• Altered respiratory rate

• Dyspnea

• Nasal flaring

•

Pursed-lipbreathing

• Irritability

• Restlessness

IneffectiveBreathing Pattern

After few hoursof nursingintervention the

pt will be able to:• remain within

normal limits

• demonstrateadequatebreathingpattern andunlaboredrespiration

• demonstratecorrecttechnique in

pursed-lipbreathing andrelaxationtechnique

• participate inage-appropriateplay activitieswith minimaleffort

• Assessrespiratory rateand depthevery 2 to 4hours, monitorfor nasalflaring, chestretractions andcyanosis.Auscultatebreath soundsevery 2 to 4hours andreport changes

• Administeroxygen, asordered

• Place child inFowler’sposition, raisinghead of bed

• Schedulenecessary careactivities toprovide

• To be able tomonitorchanges on thept’s conditionand serve asbaseline data.

• To assist pt inbreathing andto ensureproperadministrationof oxygen.

• To providecomfort, reducetension, andhelp facilitateproperbreathing.

• Plannedschedules willreduce thestress andpromote rest.

• To ensure that


pt:• Reveals normal

breath sounds

• Respiratorystatus remainswithin normallimits for age

• Demonstratesadequatebreathingpattern andunlabored

respirations• Demonstrates

correcttechnique inpursed-lipbreathing andrelaxationtechnique

• Demonstratecorrect



• family willdemonstratecorrecttechnique touse inmedicationadministration,oxygenadministration

frequent restperiods

• Assist withactivities of daily living asnecessary

• Identify child’s

developmentallevel and selectappropriateteachingmethod.

• Teach childpursed-lipbreathing andrelaxationtechnique

• Help familyplan of care athome. Discussmedicationadministration,

use of assistiveequipment andavailablecommunityresources.

the pt will notexert too mucheffort thatwould lead tostress.

• To ensure thatthe child willunderstand theinstructions

given to her.• To be able to

give the pt asense of controlon hersituation.

• To ensurecorrectcontinuity of care andprevent anyunwantedcomplications.

technique inmedicationadministration,oxygenadministration

• Participates inage-appropriateplay activities



Hyperthermia


Subjective:

Objective:

• Increased body temp

• Flushed, warmskin

• Dyspnea

• Increased respiratory and heart rate

• Pursed-lipbreathing

• Mild to severedehydration

• Possibleseizures

Hyperthermiarelated toinfection


pt will be able to:

• Remain afebrile

• Maintainadequatehydration

• Remain alertand responsiveand won’t showevidence of seizure activityor decreasedlevel of consciousness

• Family willdemonstratecorrecttechnique forassessingtemperature

• Take axillary ororaltemperatureevery 1 to 4hours after

administrationof antipyretics• Administer

antipyreticmedication asordered andrecordeffectiveness

• Use nonpharmacologicmeasures toreduce highfever such asremovingsheets,blankets andmost clothing.And spongingwith tepidwater

• Monitor heartrate andrhythm,respiratoryrate, level of consciousness

• To be able tomonitorchanges in thept’s condition.

• To lower thebodytemperature of the px and noteif changes inmedication isneeded.

• To supplementthe antipyreticgiven to the ptand furtherreduce the pt’sbodytemperature.

• To be able tomonitorchanges andprovidebaseline data.


pt:

• Remainsafebrile

• Maintainadequatehydration

• Remains alertand responsiveand doesn’texhibitevidence of seizure activity

•

Parents willidentify riskfactors forinfection andstate measuresto preventinfection

• Parentsdemonstrate



andresponsivenessevery 1 to 4hours

• Determine thechild’spreferences fororal fluids andencourage child

to drink asmuch aspossible, unlesscontraindicated

• To ensure thatinternalhydration willbe adhered to.

correcttechnique forassessingtemperature

• Parents identifyappropriatemeasures to

reduce feverand preventdehydration



Alteration in Nutrition: Less than Body Requirements


Subjective:

Objective:

• Lack of interest ineating

• Body weight 20% or moreunder idealweight

• Evidence of lack of food

• Lack of information or misinformationabout nutrition

• Paleconjunctivaand mucousmembrane

Alteration inNutrition: Lessthan body requirementsrelated to lack of resources.


pt will be able to:

• Describereasons for notobtainingadequatenutrition

• Gain specifiedamount of weight weekly

• Eatindependentlywithoutconstant

encouragement

• Use communityresources toimprovenutritionalstatus, asneeded

• Encourage pt todiscuss reasonsfor not eating

•

Determine pt’sfoodpreferencesand attempt toobtainpreferredfoods.

• Suggest eathigh-protein,high caloriefoods

• Determine onpt’s resources

• Assess child for

evidence of balancenutritionpatterns. Stressthe importanceof goodnutrition.

• To be able toassess andgather data forplanning on howto give nutrition

to pt.• To ensure that

the pt will eat inaccordance tohis preference.

• To provideenergy andprevent musclewasting.

• To ensure thatthe food planprovided will beadhered to.

•

To check for theeffectiveness of health teachingand nursingintervention andprovideinformation thatcan help themin realizingproper nutrition.


pt:

• Describereasons for notobtainingadequatenutrition

• Gain specifiedamount of weight weekly

• Eatindependentlywithoutconstant

encouragement

• Use communityresources toimprovenutritionalstatus, asneeded



Nursing Prioritization

Nursing Dx. Rank RationaleIneffective Breathing Pattern 1 Following the principle of ABC, Ineffectiv

Breathing Pattern is the most crucial of thegiven diagnosis. If this particular problem isnot given the highest prioritization, seriouscomplications my follow.

Hyperthermia related to infection 2 This diagnosis ranked 2 in prioritization because the problem can be managed quickly.Also, given that the patient has tetanus, itwould give patient a lot of stress which mighttrigger spasms or convulsions.

Alteration in Nutrition: Less than bodyrequirements related to lack of resources.

3 This is given the least priority because theimprovement needs time to manifest or to benoticeable.



XIV. RECOMMENDATION

• Maintain proper hygiene.

• Maintain adequate nutrition.

• Be certain that the mother/ relative receive information in the signs and symptoms so they do overlook the more subtle sign.

• Teach mother/ relative on how to take care of her child.

• Address physical pain and emotional distress.

• Maintain a quite, pleasant environment to promote relaxation.

• Provide clean and comfortable environment.

• Continue home medication.

• Consult doctor for any problem on complication encountered.

• Be sure to limit visits on pt.

• Reduce stimulus that can cause stress on pt.

XV. DISCHARGE PLANNING

TREATMENT

Nebulization treatment must be resume upon discharge and continuous

Oxygen therapy is needed by EK

HOME TEACHINGS

• Educate relatives about what is Tetanus and on how to take the prescribed medication of patient

• Advice relatives to let the patient sleep in long intervals and avoid too much stressor to the pa

• Teach relatives on what are the possible side effects and effects of the medication to the patien

OUT PATIENT FOLLOW-UP

E.K’s condition requires thorough medical attention, he shall have a recommended return visit athospital. He was encouraged to comply patient follow-up.

DIET



Mr. F.B was discharged with NGT attached for his parenteral feeding. An OTF 1600 cal shall be divinto 6 equal feedings

MEDICATIONS

• Doxycycline (Antibiotic)

• Metronidazole

• Diazepam

• Baclofen

XVI. REFERENCES

• NANDA Edition 10 – Marilyn Doenges, Mary Frances Moorhorse, Alice Murr

• Nursing Care Plans by Marilyn E. Doenges

• Nursing 2006 Drug Hand Book – Lippincott, Williams & Wilkins

• Guide to Human Body – Richard Walker

• Wikipedia

• http://www.medindia.net/health_statistics/diseases/tetanusTetanus J J Farrara b, L M Yenc, T Cookd, N Fairweathere, N Binhc, J Parrya b, C M Parrya b

• http://www.who.int/immunization_monitoring/diseases/Tetanus_map_cases.jpg

• Text book of preventive and social medicine 18 th edition by K.PARK

• Text book of community medicine by T. Bhaskar Rao

• Management and Prevention of Tetanus

• Richard F.Edlich,MD PhD,?Lisa G..Hill,?Chandra A..Mahler, ary Jude Cox,MD,?Daniel G..Becker MD,?Jed H..Horowitz,MD 4 Larry S.Nichter MD MS,4 Marcus L.Martin,MD 5&William C.Lineweaver MD6

• www.rxlist.com/cgi/generic/tettoxpi.htm - 22k

• Manson’s Tropical diseases 21 st edition

• www.emedicine.com

• Imbaba hospital web site



• CDC. Web site

• Springhouse: David Longworth

case pre tetanus temp

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