Tetanus Nursing Care Plan and Tetanus Nursing Diagnosis

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Tetanus Nursing Care Plan and Tetanus Nursing Diagnosis

Tetanus Nursing Care Plan and Tetanus Nursing Diagnosis - Symptoms of tetanus occur when the bacterium Clostridium tetani infects the body. As we know that the bacterium Clostridium tetani tetanus as a cause of contamination of wounds from the attack through the soil, dust, animal feces, and so forth. If there are injuries and is expected to have been contaminated, tetanus symptoms need to be considered whether the person is infected or not.
Characteristic feature of tetanus is a stiffness and muscle spasms. If this happens to someone who is expected to be contaminated (eg a few days ago stepped on a nail) to worry that the person is stricken with symptoms of tetanus. In the general tetanus, early complaints may include irritability, muscle cramps, muscle pain, weakness, or difficulty swallowing are usually seen.

Tetanus Symptoms Seizures In General
In addition to muscle spasms or seizures trismus mouth is also the most common symptoms of tetanus. This condition results from spasms of the jaw muscles responsible for chewing. Smirk (or in medical terms / medicine called sardonicus risus) is a characteristic feature resulting from facial muscle spasms and is a typical tetanus symptoms lockjaw.

Progressive muscle spasm may include a characteristic arching the back known as opisthotonus. Muscle spasms sometimes strong enough to cause bone to break and joints to dislocate. In the more severe cases can involve spasms of the vocal cords or the muscles involved in breathing. If this happens, death without medical assistance (mechanical ventilation with a respirator) is probable. In this condition a medical emergency that needs to be done quickly and accurately.

Cephalic tetanus cases in addition to causing symptoms of lockjaw, weakness of facial muscles at least one other case. In two-thirds of these cases, the general tetanus will develop. At the local tetanus, muscle spasms occur at or near the site of injury. This condition can also develop into general tetanus. Tetanus infection can also be transmitted to the fetus is called neonatal tetanus. Symptoms of neonatal tetanus is identical with the general tetanus. In this case, the neonate has the ability to suck that hard compared to a normal or difficulty swallowing.

Nursing Assessment - Nursing Care Plan for Tetanus

  • 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

  1. Ineffective airway clearance related to the accumulation of sputum in the trachea and respiratory muscle spasms.

  2. Breathing pattern disorders related to impaired airway due to spasm of respiratory muscles

  3. Increased body temperature (hyperthermia) related to the effects of toxins (bacteremia)

  4. Changes in nutrition, less than body requirements related to the mastication muscle stiffness

  5. Disturbed interpersonal relationships related to speech difficulties

  6. Impaired daily needs related to the condition of weak and frequent seizures

  7. The risk of fluid and electrolyte imbalances related to intake of less and oliguria

  8. Risk of injury related to frequent seizures

  9. Lack of knowledge of the client and family about tetanus disease related to lack of information.

  10. Lack of rest requirements related to frequent seizures.

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