I. Introduction

Title: Tetanus

Prepared by: Ivan Manolo Randolf Quia III A. Paguio RNI. IntroductionRationale for choosing the caseI 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 -Establish a nurse-patient interaction through exchanging ofthoughts and informationC. Background of the study 1. World Health Organization (WHO) - Tetanus is a serious illness caused by bacteria. The bacteria live in soil and dust. They can also be found in saliva and manure. The bacteria can get into the body through a deep cut. Tetanus causes the muscles in the body to tighten. It can cause pain and threaten your life

2. Center for disease Control (CDC)- Tetanus is an acute, often fatal, disease caused by an exotoxin produced by the bacterium Clostridium tetani. It is characterized by generalized rigidity and convulsive spasms of skeletal muscles. The muscle stiffness usually involves the jaw (lockjaw) and neck and then becomes generalized.

3. Epidemiology In 2013 it caused about 59,000 deaths down from 356,000 in 1990. Tetanus in particular, the neonatalform remains a significant public health problem in non-industrialized countries with 59,000 newborns worldwide dying in 2008 as a result of neonatal tetanus. In the United States, from 2000 through 2007 an average of 31 cases were reported per year.

WHO vaccine-preventable diseases: monitoring system. 2014 global summaryIncidence time series for Philippines.Diseases2013201220112010Diphtheria6__107Japanese encephalitis24__181Measles2'9201'5366'5386'368Mumps____Pertussis230_62Polio0000Rubella254100926_Rubella (CRS)____Tetanus (neonatal)77131166126Tetanus (total)1'069_1'5371'140Yellow fever____

II. Clinical StudyGeneral Data

Name of Patient: EGPAddress: Brg. Calero City Malolos ( Capital ) BulacanAge: 25Religion: CatholicCivil Status: SingleNationality: FilipinoDate of Birth: December 29, 1989Date and Time of Admission: May 05,2015 10:05pmWard / Room: Adult Dept. (PAV 6) 244 - 1Attending Physician: Dr. Rhonamarie A. Fulgar M.DFinal Diagnosis: Tetanus Stage IIB. Chief Complaint Difficulty in opening mouth ( Trismus )

C. History of present illness2weeks prior to admission patient had pricked a nail at planter left foot consulted at clinic and diagnosed with Tetanus and transferred at Provincial Hospital then giving tetanus toxoid then referred to San Lazaro hospital

D. Past Medical History(-) Allergy no known allergy(-) HPN, Lung disease, Kidney disease, asthma

ARMANGrandfather JUANGrandfather

DOROTHYGrandmotherATHENAGrandmother

DOMINADORFatherHYPERTENSIONLENCIO 41y/oHYPERTENSIONRAMIL40 y/o

RUSTICO38y/oHYPERTENSION

RAYMOND32y/o

ERWIN25y/o

ERLINDAMotherDM & HYPERTENSIONF. Familial HistoryGenogram

I. Physical AssessmentFindingsValueAnalysisMay 05, 2015 Measurement: (HT,Wt)

May 14, 2015BMI 20.7

BMI 18.3 5.7HT132 Lbs

116 LbsNormal BMI is 18.5 kg for males (Lancet Magazine 2004; 363:157-64)

Under weight below 18.5 kgNpo doctors orderActual FindingAnalysis and interpretation (with reference)SkinLight to deep brown, no edema present; birthmarks; no abrasion No significant findingsMouth Cannot fully open mouth Cause by tetanospasmin LipsDry lipsDue to medication of (metronidazole)AbdomenAbdominal muscle spasms and rigidity Cause by tetanospasmin Upper ExtremitiesSymmetrical in size and length, no abnormalities, fine hair equally distributedNo significant findingsLower Extremities

Symmetrical in size and length, no abnormalities, fine hair equally distributed , wound (L)plantarBreak in the skin due to nail prick J. Patterns of Functioning/Activities of Daily Living

BEFORE HOSPITALIZATIONDURING HOSPITALIZATIONANALYSIS & INTERPRETATIONEating Pattern:Eat three times a day but more on carbohydrate.From May 05-13 he is on NPO but may sip of waterWeight loss due to npo doctors orderDrinking Pattern:Drink more than 8glass of water. Hindi na ako nakakainom ng tubig kasi naka lock itong jaw ko as stated by patient.Patient always drink alot of water but when he was admitted he is on NPO as attending physicians order.BowelDefecates once daily in adequate amount, golden brown in color bago ako magkasakit mga once lang ako dumudumi pero ngayon wala na As verbalized by the client.Npo doctors orderDue to present condition.UrinationAccording to the patient he urinates 5x daily.The patient frequently urinates approximately 1700ml to 2200ml.No significant changes.Exercise and activityThe patient way of exercise is walking from work.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.The client have less movement compare to his usual due to he experienced muscle contraction.REST /SLEEPUsually sleeps at 9 pm and wakes up at 5 am. 8-10 hours of sleep duration. Uses two pillow and comforterpatient have long hours of sleep due to q4 medication (diazepam) but sometimes complained of disturbed sleep due to excessive noise.client have scheduled diazepam that will cause him to fell asleep for more than required hours of sleep needed.HYGIENEThe patient usually take a bath and brushed his teeth twice daily.Relative also perform sponge bath.Occasional spasm due to present condition.K. Laboratory FindingsCHEMISTRYResultReference RangeResultReferenceBlood Urea Nitrogen4.82mmol/L2.50 6.4313.50 mg/dL7.0 -18.0Creatinine83.92 umol/L53 1150.95 mg/dL0.6 1.3Sodium146.40 mmol/L139 149146.40 mEq/L139 149Potassium3.06 mmol/L3.5 5.53.06 mEq/L3.5 5.5Chloride108.70 mmol/L98 108108.70 mEq/L98 108SGPT/AST34.00 U/L12 7834.00 U/L12 78 HEMATOLOGYResultUNITReferenceWBC6.8110^9/L4.8 10.8RBC4.2810^12/L4.7 6.1Hemoglobin138g/l140 180Hematocrit0.4200.42 0.52MCU96.8Fl82 98MCH32.3Pg28 33MCHC33.4g/l33 36Platelet Count30110^9L150 400RDW12.70%11.4 14.0Neutrophil45.80%40 - 70Lymphocyte38.00%19 - 48Eosinophil8.30%2 - 8Monocyte7.40%0 - 15Basophils0.50%0 - 5L. Course in the wardAssessmentProgress noteNursing ActionMedicationLaboratoryDay 105-05-15

Cant open mouthTrismusAssessment done with difficulty open mouth-Tetanus Toxoid 0.5ml IM-ATS 20,000 IV (- ) ANST-Metronidazole 500mg TIV ( ) ANST Q8-Diazepam 1amp TIV at 4hrs-Paracetamol 300mg T> 37.5*c-Omeprazole 40mg TIV OD while on NPO-Blood Chemistry-Hematology reportAssessmentProgress noteNursing ActionMedicationLaboratoryDay 305-07-15Occasional abdominal rigidityAs per doctor order give medication and monitor patient-Continue medication-HGT q12 AssessmentProgress noteNursing ActionMedicationLaboratoryDay 205-06-15

Occasional spasmAssessing patient needs; continuity of care-Continue medication-HGT q12

AssessmentProgress noteNursing ActionMedicationLaboratoryDay 405-08-15Occasional abdominal rigidityAs per doctor order give medication and monitor patient-Continue medication-Potassium 1 tab TID x2days-Diazepam drip q8-may sips of waterAssessmentProgress noteNursing ActionMedicineLaboratoryDay 505-09-15AfebrilePerform 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 waterAssessmentProgress noteNursing ActionMedicineLaboratoryDay 605-10-15Abdominal rigidityTold the patient to deep inhale and exhale; promote safety of patient-Continue present medicationAssessmentProgress noteNursing ActionMedicineLaboratoryDay 705-11-15Occasional spasm -Continuity of care-Diazepam q24 60+250cc-IVF D5LR 1L to D5NSS-Lactulose 30 cc HS if no bowel movement > 3daysAssessmentProgress noteNursing ActionMedicineLaboratoryDay805-12-15AfebrilePerform tepid sponge bath Vs: temp 38.7c and recorded.-Diazepam bolus 10mg IV-Complete Metronidazole ( 7 days )-IVF rate to 60cc/hrIII. Clinical Discussion of the Disease

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. Penetrating injury (punctured wound)Rusty or dirty nailClostridium Tetani enters the body through a woundDecreased oxygen in the tissues transforms two type of toxinsTETANOSPASMINTETANOLYSINCauses lysis of rbc hemolytic toxin and potentiates infection but does not cause disease process. Actual laboratory result low rbc 4.28 (Actual)and hemoglobin 138 (Actual)Lockjaw (Actual)Nuchal or neck rigidity (Actual)DysphasiaRestlessnessIncreases temperature (Actual)eosinophils 8.3% (Actual) Increased : sign of chronic imflamation due to tetanospasmin Seizure

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

IV. Nursing Problem and Prioritization Cues Nursing problemRankJustificationSubjective: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.

Objective:He appears restless and complaining of abdominal pain(+)Facial grimace(+)Protective gesture (holding chest)(+)Irritability Acute pain 1Facial grimace and protective gesture (holding chest)Indication that patient was in pain.CuesNursing ProblemRankJustificationSubjective:pasulpot 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

Potential Risk for injury2Occasional muscle spasm due to present conditionV. Nursing Care Plan 1AssessmentDiagnosisPlanningImplementationEvaluationSubjective: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.

Objective:He appears restless and complaining of abdominal pain(+)Facial grimace(+)Protective gesture (holding chest)(+)Irritability Acute pain related to involuntary muscle contraction due to environmental stimuli Short term:

After 1hr nursing intervention the patient relief from pain

-Placed on moderate high back rest.-Encouraged deep breathing exercises.-Advice relative to avoid excessive or unnecessary noise.

Hindi na sya ganon ka sakit mga 2 out of 10 nalang as stated by the client.AssessmentDiagnosisPlanningImplementation EvaluationSubjective:pasulpot sulpot yung paninigas ng muscles ko sa tyan at leg as stated by client.

Objective:-Muscles are tight to touch. -Patient unable to move-(+) Facial grimace-Seen at edge of bedPotential risk for injury Short:

-After 1hr of nursing intervention the client will be free from injury -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 spasmPatient safely and comfortable on bed.

VI. Nursing Care Plan 2 (FDAR Method)Date & TimeFocusDataActionResponse05-08-157:45amAcute painYung na tabig ako nagulat tapos bilang sumakit dibdib ko at nanigas tyan legs ko mga 6 out of 10 as stated by patient; vital sign of bp 130/80; pr 108; IVF of diazepam drip 60mg+250cc.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 109:30amPotential risk for injurypasulpot sulpot yung paninigas ng muscle ko sa tyan at legs as stated by patient; muscle are tight to touch ; unable to move due to rigidity; shows irritated facial expression; seen at edge of bed.Placed on center of bed on a comfortable position; maintained side rails up; executed health teaching about possible injuries; seen at intervals.Patient safe and comfortable on bed.VII. Drug StudyGeneric/Brand nameDosage, Frequency & RouteMechanism of ActionsSide EffectsNursing ConsiderationsMetronidazole / Flagyl500mgQ6IntravenousFor bacterial infection caused by anaerobic microorganism-Fever-Headache-Abdominal cramping or pain-Dry mouth-Dark urine-Polyuria-Administer with food or milk to minimize GI irritation.

-May cause dizziness or light-headedness. Caution patient or other activities.

- Inform patient that medication may cause urine to turn dark.

Generic/Brand nameDosage, Frequency & RouteMechanism of ActionsSide EffectsNursing ConsiderationsDiazepam / Valium10 mg Q4Intravenous For CNS depressantMuscle relaxant Anti anxiety and anticonvulsant -Drowsiness-Fatigue-confusion headache -Constipation -Monitor BP, PR,RR prior to periodically throughout therapy and frequently during IV therapy

-Assess IV site frequently during administration, diazepam may cause phlebitis and venous thrombosis

-Advise patient to notify doctor immediately if they have abdominal pain or diarrhea

Generic/brand nameDosage; frequency & RouteMechanisom of actionSide EffectesNursing ConsiderationGephulac / Lactulose30 ccNight time if no BM for >3daysPromotes peristalsis movement and decrease ammonia, probably as a result of bacterial degradation.-Abdominal cramps-Gaseous distention-Flatulence-Nausea-Vomiting-Inform patient about side effects and tell him to notify if reaction becomes stronger.Generic/brand nameDosage; frequency & RouteMechanisom of actionSide EffectesNursing ConsiderationBaclofen (Lioresal) 10mg1 tab Q12Per OremDecreased 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

Generic/Brand nameDosage, Frequency & RouteMechanism of ActionsSide EffectsNursing ConsiderationsOmeprazole / Prilosec40mg ODIntravenous Suppress gastricacid secretion byspecific inhibition ofthe hydrogen-Potassium enzyme system at thesecretory surface ofthe gastric parietalcells; blocks the finalstep of acidProduction.-Headache-Abdominal pain- Nausea VomitingDry mouthDiarrhea -Give medication before meals, preferably in the morning for once-daily 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 or diarrhea

Generic/Brand nameDosage, Frequency & RouteMechanism of ActionsSide EffectsNursing ConsiderationsParacetamol 300mgQ4IntravenousFor 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 nameDosage, Frequency & RouteMechanism of ActionsSide EffectsNursing ConsiderationsKCL / Potassium Chloride1 tabletBIDPre OremPotassium is necessary for the conduction of nerve impulses in such specialized tissues as the heart, brain, and skeletal muscleNausea, vomiting diarrhea -Abdominal discomfortGI obstruction, GI bleeding GI ulceration or perforation- Monitor I&O ratio and pattern in patients receiving the parenteral drug. If oliguria occurs, stop infusion promptly and notify physician

- Be alert for potassium intoxication may result from any therapeutic dosage, and the patient may be asymptomatic

-Monitor patients receiving parenteral potassium closely with cardiac monitor. Irregular heartbeat is usually the earliest clinical indication of hyperkalemia.

VII. Discharge PlanningI. Medication-Multivitamin 1x day for 30daysII. 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 IV. Health teaching-Educate about what is Tetanus and on how to take the prescribed medication of the patient-Advice to let the patient sleep in long intervals and avoid to much stressor to the patient-Teach on what are the possible side effects and effects of the medication to the patientInstruct a healthy hygiene to the patient

V. Out patient follow up-Patient shallhavea recommended return visit at the hospital. He was encouraged to comply patient follow-up.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 counselingIX. REFERENCES / SOURSE1. Sparkys & Taylors Nursing Diagnosis Reference Manual 7th Edition 2. Lancet Magazine 20043. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/tetanus.pdf3. Sauders 5th Edition 2011.4. Preasons