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
- Ineffective airway clearance related to the accumulation of sputum in the trachea and respiratory muscle spasms.
- Breathing pattern disorders related to impaired airway due to spasm of respiratory muscles
- 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
- Lack of knowledge of the client and family about tetanus disease related to lack of information.
- Lack of rest requirements related to frequent seizures.
Nursing Diagnosis and Nursing Intervention for Neonatal Tetanus
Nursing Diagnosis for Neonatal Tetanus- Ineffective breathing pattern related to respiratory muscle fatigue
- Imbalanced nutrition, Less than body requirements related to the baby's sucking reflex is inadequate.
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.
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.
