Nursing Care Plan for Tetanus
Tetanus is infection of the nervous system with the potentially deadly bacteria Clostridium tetani (C. tetani).
Tetanus occurs when a wound becomes contaminated with Clostridium tetani bacterial spores. Infection follows when spores become activated and develop into gram-positive bacteria that multiply and produce a very powerful toxin (tetanospasmin) that affects the muscles. Tetanus spores are found throughout the environment, usually in soil, dust, and animal waste. The usual locations for the bacteria to enter the body are puncture wounds, such as those caused by rusty nails, splinters, or insect bites.
Tetanus often begins with mild spasms in the jaw muscles (lockjaw). The spasms can also affect the chest, neck, back, and abdominal muscles. Back muscle spasms often cause arching, called opisthotonos.
Sometimes the spasms affect muscles that help with breathing, which can lead to breathing problems.
Prolonged muscular action causes sudden, powerful, and painful contractions of muscle groups. This is called tetany. These episodes can cause fractures and muscle tears.
Other symptoms include: Drooling, Excessive sweating, Fever, Hand or foot spasms, Irritability, Swallowing difficulty, Uncontrolled urination or defecation.
Treatment may include:
- Antibiotics, including penicillin, clindamycin, erythromycin, or metronidazole (metronidazole has been most successful)
- Bedrest with a nonstimulating environment (dim light, reduced noise, and stable temperature)
- Medicine to reverse the poison (tetanus immune globulin)
- Muscle relaxers such as diazepam
- Sedatives
- Surgery to clean the wound and remove the source of the poison (debridement)
Nursing Diagnosis : Ineffective airway clearance related to the accumulation of sputum in the trachea and respiratory muscle spasm
Goal : Effective airway
Characterized by: Ronchi, cyanosis, dyspnea, cough accompanied by sputum ineffective or lenders, the results of laboratory tests showed: abnormal blood gas analysis (respiratory acidosis)
Expected Outcome :
- Clients are not crowded, no lender or sleam
- Breathing 16-18 times / minute
- No nostril breathing
- No additional respiratory muscle
- The results of laboratory blood gas analysis of blood within normal limits (pH = 7.35 to 7.45; PCO2 = 35-45 mmHg, PO2 = 80-100 mmHg)
Nursing Interventions - Ineffective Airway Clearance related to Tetanus
1. Clear the airway by adjusting the position of head extension.
2. Physical examination by auscultation of breath sounds heard (there Ronchi) every 2-4 hours.
3. Clean the mouth and respiratory tract of mucus with a secret and do section.
4. Oxygenation according to physician instructions.
5. Observation of vital signs every 2 hours.
6. Observation of the onset of respiratory failure / apnea.
7. Collaboration in a secret-thinning medication (mukolotik).
Rational :
1. The anatomy of the head position of the extension is a way to align the respiratory cavity so that the process of respiration is still running smoothly by removing the blockage of the airway.
2. Ronchi show an upper respiratory problems due to fluid or a secret that covered most of the respiratory tract that need to be removed to optimize the airway.
3. Section is an act of assistance to issue a secret, thus simplifying the process of respiration.
4. The provision of adequate oxygen can supply and provide backup oxygen, thus preventing hypoxia.
5. Dyspnea, cyanosis is a sign of breathing disorder which is accompanied by decreased cardiac work arising tacikardi reffil time and capillary length / time.
6. The inability of the body in the respiratory process required critical interventions by using a breathing (mechanical ventilation).
7. Mukolitik drugs can thin the thick secretions so easy to remove and prevent viscosity.
