Professional Documents
Culture Documents
Tetanus
Prepared by: Ivan Manolo Randolf Quia III A.
Paguio RN
I. Introduction
A. Rationale for choosing the case
I prefer to use tetanus as my diagnosis for my case study to use
universal evidence based protocol for treating tetanus with any
type of hospital set up. In addition, this is an excellent case study to
utilize my clinical acumen and analyzed the treatment modalities that
should be implemented.
B. Learning Objectives
General objectives:
-This case study is designed for the nurses to become
practiced, well-informed and mannered in delivering holistic care
for patients
diagnosed with Tetanus
Specific objectives:
-Imply appropriate medical nursing management for Tetanus
-Be familiar with the pathophysiology of Tetanus
-Plan for a suitable nursing care
2013
2012
2011
2010
Diphtheria
107
24
181
2'920
1'536
6'538
6'368
23
62
254
100
926
77
131
166
126
1'069
1'537
1'140
Japanese encephalitis
Measles
Mumps
Pertussis
Polio
Rubella
Rubella (CRS)
Tetanus (neonatal)
Tetanus (total)
Yellow fever
B. Chief Complaint
Difficulty in opening mouth ( Trismus )
F. Familial History
Genogram
ARMAN
Grandfath
er
ATHENA
Grandmoth
er
JUAN
Grandfath
er
DOROTHY
Grandmoth
er
ERLIND
ERLIND
A
A
Mother
Mother
DM
DM &
&
HYPERTE
HYPERTE
NSION
NSION
DOMINADO
R
Father
HYPERTENSI
ON
LENCIO
LENCIO
41y/o
41y/o
HYPERTENSI
HYPERTENSI
ON
ON
RAMIL
40 y/o
RUSTIC
O
38y/o
HYPERTENSI
HYPERTENSI
ON
ON
RAYMO
ND
32y/o
ERWIN
25y/o
I. Physical Assessment
Finding
s
Value
Analysis
BMI 20.7
5.7HT
132
Lbs
BMI 18.3
116
Lbs
Actual Finding
Analysis and
interpretation (with
reference)
Skin
No significant findings
Mouth
Cause by tetanospasmin
Lips
Dry lips
Due to medication of
(metronidazole)
Abdomen
Cause by tetanospasmin
Upper
Extremities
No significant findings
Lower
Extremities
J. Patterns of
Functioning/Activities of
Daily Living
BEFORE HOSPITALIZATION
DURING HOSPITALIZATION
ANALYSIS &
INTERPRETATION
13 he is on
but more on NPO but may order
carbohydrate.
sip of water
Drinking
Pattern:
Patient always
drink alot of
water but when
he was admitted
he is on NPO as
attending
physicians
order.
Bowel
Defecates once
daily in
adequate
amount, golden
brown in color
urinates 5x daily.
Exercis
e and
activity
bago ako
magkasakit mga
once lang ako
dumudumi pero
ngayon wala na
As verbalized by
the client.
The patient
frequently urinates
approximately
1700ml to 2200ml.
The patient
doesnt have any
exercise nor
activities from the
date he was
admitted. He only
stand and walk a
little when he feels
to urinate.
Npo doctors
order
Due to present
condition.
No significant
changes.
REST
/SLEEP
HYGIENE
Usually sleeps at
9 pm and wakes
up at 5 am. 8-10
hours of sleep
duration. Uses
two pillow and
comforter
patient have
long hours of
sleep due to
q4 medication
(diazepam)
but sometimes
complained of
disturbed
sleep due to
excessive
noise.
Relative also
perform sponge
bath.
client have
scheduled
diazepam that
will cause him
to fell asleep for
more than
required hours
of sleep needed.
Occasional
spasm due to
present
condition.
K. Laboratory Findings
CHEMISTRY
Result
Reference
Range
Result
Referen
ce
Blood Urea
Nitrogen
4.82mmol/L
2.50 6.43
13.50
mg/dL
7.0 -18.0
Creatinine
83.92 umol/L
53 115
0.95 mg/dL
0.6 1.3
Sodium
146.40
mmol/L
139 149
146.40
mEq/L
139
149
Potassium
3.06 mmol/L
3.5 5.5
3.06 mEq/L
3.5 5.5
Chloride
108.70
mmol/L
98 108
108.70
mEq/L
98 108
SGPT/AST
34.00 U/L
12 78
34.00 U/L
12 78
HEMATOLOGY
Result
UNIT
Reference
WBC
6.81
10^9/L
4.8 10.8
RBC
4.28
10^12/L
4.7 6.1
Hemoglobin
138
g/l
140 180
Hematocrit
0.420
MCU
96.8
Fl
82 98
MCH
32.3
Pg
28 33
MCHC
33.4
g/l
33 36
Platelet Count
301
10^9L
150 400
RDW
12.70
11.4 14.0
Neutrophil
45.80
40 - 70
Lymphocyte
38.00
19 - 48
Eosinophil
8.30
2-8
Monocyte
7.40
0 - 15
Basophils
0.50
0-5
0.42 0.52
Nursing
Action
Medication Laboratory
Day 1
05-05-15
Assessment
done with
difficulty
open mouth
-Tetanus
Toxoid 0.5ml
IM
-ATS 20,000
IV (- ) ANST
Metronidazo
le 500mg
TIV ( ) ANST
Q8
-Diazepam
1amp TIV at
4hrs
Paracetamol
300mg T>
37.5*c
Cant open
mouth
Trismus
-Blood
Chemistry
Hematology
report
Assessmen Progress
t
note
Nursing
Action
Medication Laborato
ry
Day 2
05-06-15
Assessing
patient needs;
continuity of
care
-Continue
medication
-HGT q12
Assessmen Progress
t
note
Nursing
Action
Medication Laborat
ory
Day 3
05-07-15
As per doctor
-Continue
order give
medication
medication and -HGT q12
monitor patient
Occasional
spasm
Occasional
abdominal
rigidity
Assessmen Progress
t
note
Nursing
Action
Medication
Day 4
05-08-15
As per
doctor order
give
medication
and monitor
patient
-Continue
medication
-Potassium 1
tab TID x2days
-Diazepam drip
q8
-may sips of
Occasional
abdominal
rigidity
Laborat
ory
Assessmen Progress
t
note
Nursing
Action
Medicine
Laboratory
Day 5
05-09-15
Perform
Tepid
sponge bath
the patient;
Take VS
Temp of
38.7c and
recorded.
-Continue
medication
-Diazepam
drip q24
-Start
Baclofen
10mg / tab
q12
-may sips of
water
Medicine
Laboratory
Afebrile
Assessmen Progress
t
note
Nursing
Action
Day 6
05-10-15
Told the
patient to
deep inhale
and exhale;
promote
safety of
patient
Abdominal
rigidity
-Continue
present
medication
Assessm
ent
Progr
ess
note
Nursing
Action
Medicine
Day 7
05-11-15
Occasi
onal
spasm
-Continuity
of care
-Diazepam q24
60+250cc
-IVF D5LR 1L to
D5NSS
-Lactulose 30 cc HS
if no bowel
movement > 3days
Assessm
ent
Progr
ess
note
Nursing
Action
Medicine
Day8
05-12-15
Afebril
e
Perform tepid
sponge bath
Vs: temp
38.7c and
recorded.
-Diazepam bolus
10mg IV
-Complete
Metronidazole ( 7
days )
-IVF rate to 60cc/hr
Laborator
y
Laborato
ry
Anatomy:
Basal Ganglia where the substancia nigra and globus pallidus
secretes GABA and acetylcholine primarily found in the
nucleusbasalis of Meynert(in the basal forebrain) to the
forebrain neocortex and associated limbic structures.
Physiology:
GABA is the chief inhibitoryneurotransmitterin
themammaliancentral nervous system. It plays the principal
role in reducingneuronalexcitability throughout thenervous
system. In humans, GABA is also directly responsible for the
regulation ofmuscle tone.
TETANOSPAS
MIN
blocks the release
of GABA
(gamma
aminobutyric
acid) which
increases ACHs
& causes
contraction of
muscle-causes
increasing
excitability of
spinal cord
neurons and
muscle spasm
TETANOLYSI
N
Lockjaw (Actual)
Nuchal or neck
rigidity (Actual)
Dysphasia
Restlessness
Increases
temperature
(Actual)
eosinophils 8.3%
(Actual)
Increased : sign
of chronic
imflamation due
to
tetanospasmin
Seizure
Nursing
problem
Ran
k
Justification
Subjective:
Yung na tabig ako nagulat ako
tapos biglang sumakit dibdib ko
nanigas tyan at muscle ng legs
ko sumakit mga 6 /10 as
stated by patient.
Acute pain
Facial grimace
and protective
gesture
(holding chest)
Indication that
patient was in
pain.
Objective:
He appears restless and
complaining of abdominal pain
(+)Facial grimace
(+)Protective gesture (holding
chest)
(+)Irritability
Cues
Nursing
Problem
Subjective:
Potential Risk
pasulpot
for injury
sulpot yung
paninigas ng
muscles ko sa
tyan at legs as
stated by client.
Objective:
-Muscles are
tight to touch.
-Patient unable
to move
-irritable facial
expression
-seen at edge of
bed
Rank
Justification
Occasional
muscle spasm
due to present
condition
Diagnosi Planning
s
Subjective:
Yung na tabig ako
nagulat ako tapos
biglang sumakit
dibdib ko nanigas
tyan at muscle ng
legs ko sumakit
mga 6 /10 as
stated by patient ;
Administered
diazepam 10mg QID
as ordered by the
attending physician.
Acute
pain
related to
involunta
ry muscle
contractio
n due to
environm
ental
stimuli
Objective:
He appears restless
and complaining of
abdominal pain
(+)Facial grimace
Short
term:
Implementat Evaluati
ion
on
-Placed on
moderate
high back
After 1hr
rest.
nursing
-Encouraged
interventio deep
n the
breathing
patient
exercises.
relief from -Advice
pain
relative
to
avoid
excessive or
unnecessary
noise.
Hindi na
sya
ganon ka
sakit mga
2 out of
10
nalang
as stated
by the
client.
Implementati
on
Subjective:
pasulpot
sulpot yung
paninigas
ng muscles
ko sa tyan
at leg as
stated by
client.
-Ensure the
clients position
on the center
of the bed
-Maintained
side rails up
-Advised the
clients relative
to look after or
assist the client
every time he
moves or stand
out of bed.
-Educated the
client also the
relative about
the possible
injuries that
may cause by
muscle spasm
Objective:
-Muscles are
tight to
touch.
-Patient
unable to
move
-(+) Facial
grimace
-Seen at
edge of bed
Potential Short:
risk for
injury
-After 1hr of
nursing
intervention
the client
will be free
from injury
Evaluation
Patient
safely and
comfortable
on bed.
Data
Action
Response
05-08- Acute
15
pain
7:45am
Assessment done
;position patient on a
comfortable
positioned;
encouraged deep
breathing exercises;
advice relative to
avoid excessive or
unnecessary noises;
administered
diazepam bolus 10mg
QID as ordered by
doctor.
From
moderate
pain
changed to
mild pain
of 2 out of
10
9:30am Potential
risk for
injury
pasulpot sulpot
yung paninigas ng
muscle ko sa tyan
at legs as stated
by patient; muscle
Placed on center of
bed on a comfortable
position; maintained
side rails up;
executed health
Patient
safe and
comfortabl
e on bed.
Side
Effects
Nursing
Considerations
Metroni
dazole /
Flagyl
-Fever
-Headache
-Abdominal
cramping or
pain
-Dry mouth
-Dark urine
-Polyuria
-Administer with
food or milk to
minimize GI
irritation.
500mg
Q6
Intraveno
us
For
bacterial
infection
caused by
anaerobic
microorgani
sm
-May cause
dizziness or lightheadedness.
Caution patient or
other activities.
- Inform patient
that medication
may cause urine to
turn dark.
Generic/
Brand
name
Dosage,
Mechanism
Frequenc of Actions
y & Route
Side Effects
Nursing
Considerations
Diazepa
m/
Valium
10 mg
Q4
Intravenou
s
-Drowsiness
-Fatigue
-confusion
headache
-Constipation
-Monitor BP,
PR,RR prior to
periodically
throughout
therapy and
frequently during
IV therapy
For CNS
depressant
Muscle
relaxant Anti
anxiety and
anticonvulsa
nt
-Assess IV site
frequently during
administration,
diazepam may
cause phlebitis
and venous
thrombosis
-Advise patient
to notify doctor
immediately if
they have
abdominal pain
Generic/ Dosage;
brand
frequency
name
& Route
Mechanisom
of action
Gephulac 30 cc
Promotes
/
Night time if peristalsis
Lactulose no BM for
movement and
>3days
decrease
ammonia,
probably as a
result of
bacterial
degradation.
Side
Effectes
Nursing
Considerat
ion
-Abdominal
cramps
-Gaseous
distention
-Flatulence
-Nausea
-Vomiting
-Inform
patient
about side
effects and
tell him to
notify if
reaction
becomes
stronger.
Generic/bran
d name
Dosage;
frequency &
Route
Mechanisom
of action
Side Effectes
Nursing
Consideration
Baclofen
(Lioresal)
10mg
1 tab Q12
Per Orem
Decreased
frequency of
muscle
spasms
-Drowsiness
-Dizziness
-Tiredness
-Headache
-Nausea
-Avoid
vigorous
activity and
sudden
movements
-Eat frequent
small meals
-Effects
reversible;
will go away
when the
drug is
discontinued
Gene
ric/Br
and
name
Dosage,
Frequen
cy &
Route
Mechanism of
Actions
Side Effects
Nursing
Considerations
Omep
razole
/
Prilos
ec
40mg
OD
Intraveno
us
Suppress gastric
acid secretion by
specific inhibition
of
the hydrogenPotassium
enzyme system
at the
secretory surface
of
the gastric
parietal
cells; blocks the
final
step of acid
Production.
-Headache
-Abdominal
pain
- Nausea
- Vomiting
- Dry mouth
- Diarrhea
-Give medication
before meals,
preferably in the
morning for oncedaily dosing. If
necessary, also give
an antacid, as
prescribed
-Encourage patient
to avoid alcohol,
aspirin products,
ibuprofen, and foods
that may increase
gastric secretions
-Advise patient to
notify doctor
immediately if they
have abdominal pain
Generic/Br
and name
Dosage,
Frequency
& Route
Mechanism
of Actions
Side
Effects
Nursing
Considerations
Paracetamol
300mg
Q4
Intravenous
For
symptomatic
relief of pain
and fever.
-Decrease
Glucose
level
-Decrease
hemoglobin
-Decrease
hematocrit
- Advise patient
that drug is only
for short term
use and to
consult the
physician if
giving to children
for longer than 5
days or adults
for longer than
10 days.
- Warn patient
that high doses
or unsupervised
long term use
can cause liver
damage.
Generic/
Brand
name
Dosage,
Frequen
cy &
Route
Mechanis
m of
Actions
Side
Effects
Nursing
Considerations
KCL /
Potassiu
m
Chloride
1 tablet
BID
Pre Orem
Potassium
is
necessary
for the
conduction
of nerve
impulses in
such
specialized
tissues as
the heart,
brain, and
skeletal
muscle
Nausea,
vomiting
diarrhea
-Abdominal
discomfort
GI
obstruction,
GI bleeding
GI
ulceration
or
perforation
II. Exercise
-Advice patient to perform daily active range of motion
-Walking exercise.
III. Treatment
-Advice patient to eat rich potassium and caloric food
-Encourage to eat fruits and vegetables
VI. Diet
-Advice patient to eat dark leafy vegetable, banana, fish,
potato, squash
VII. Spiritual
-Advisetoseek spiritualhelpfrompriests,nunsany religious
organization member they know in the society for spiritual
counseling