Nursing Care Plan For Tetanus

Friday, January 20, 2012 ·
Nursing Care Plan for Tetanus. 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.

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.

Nursing Diagnosis and Nursing Intervention for Neonatal Tetanus

Nursing Diagnosis for Neonatal Tetanus

  1. Ineffective breathing pattern related to respiratory muscle fatigue
  2. Imbalanced nutrition, Less than body requirements related to the baby's sucking reflex is inadequate.

Nursing Intervention for Neonatal Tetanus

Nursing Diagnosis I

Ineffective breathing pattern related to respiratory muscle fatigue

Nursing Intervention:


  • Assess the frequency and pattern of breath
  • Note the presence of apnea, the frequency change of heart, muscle tone and skin color.
  • Perform cardiac and respiratory monitoring continuously.
  • Suction airway as needed.
  • Give the tactile stimulation immediately after apnea.
  • Monitor laboratory tests as indicated.
  • Give oxygenation as indicated.
  • Give medications as indicated.

Nursing Diagnosis II

Imbalanced nutrition, Less than body requirements related to the baby's sucking reflex is inadequate.

Nursing Intervention:

  • Assess the maturity of the reflex with respect to feeding, sucking, swallowing and coughing.
  • Auscultation bowel sounds.
  • Review the signs of hypoglycemia.
  • Give appropriate medication electrolyte supplements.
  • Give parenteral nutrition.
  • Monitor laboratory tests as indicated.
  • Make provision of drinking according to tolerance.

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