OME ELC W !

A CASE PRESENTATION On

February 24, 2009

Presented by:

NPC- SACR

Objectives

General Objectives:

After our exposure in the clinical setting, the student nurses will develop knowledge and skills in giving proper nursing care to the patient and explore the issue of accountability. We will reflect on whether our everyday nursing practice demonstrates a commitment to ensuring the human well-being of those in our care. Individual patterns of responding to human needs and responsible caring

Specific Objectives:

To enhance our knowledge in determining how the disease (Tetanus) occurred and to what extent will the disease be progressed. To identify the disease that the patient is experiencing and conduct a nursing care that will be implemented. Assess the patients health status and make nursing diagnosis. Make nursing care plan and implement them to the patient with Tetanus.

Specific Objectives:

To develop our nursing capabilities and enhance the knowledge we have that may fully import it to our patient for further learnings about health and awareness of disease. To render proper nursing care within our limits. To establish rapport with our patient or with the folks and gain their trust that we may be able to deliver proper nursing care and services and implement our plan of actions. To demonstrate how words and touch can be used to harm or benefit the patient. To give and nurture the needs of the patient.

Introduction

Tetanus, also called lockjaw, is a medical condition characterized by a prolonged contraction of skeletal muscle fibers. The primary symptoms are caused by tetanospasmin, a neurotoxin produced by the Gram-positive, obligate anaerobic bacterium Clostridium tetani. Clostridium tetani is a noninvasive organism. It is found in soil and in the intestine and feces of horses, sheep, cattle, dogs, cats, rats, guinea pigs and chicken. Manure-treated soil may contain large numbers of spores too.

Tetanus is a global health problem, as C.tetani spores are ubiquitous. The disease occurs almost exclusively in persons who are unvaccinated or inadequately immunized. Tetanus occurs worldwide but is more common in hot, damp climates with soil rich in organic matter. This is particularly true with manuretreated soils, as the spores are widely distributed in the intestines and feces of many non-human animals such as horses, sheep, cattle, dogs, cats, rats, guinea pigs, and chickens. In agricultural areas, a significant number of human adults may harbor the organism. The spores can also be found on skin surfaces and in contaminated heroin.

T US K? R C TA AT

Tetanus is often associated with rust, especially rusty nails, but this concept is somewhat misleading. Objects that accumulate rust are often found outdoors, or in places that harbour anaerobic bacteria, but the rust itself does not cause tetanus nor does it contain more C.tetani bacteria.

T US K? R C TA AT

The rough surface of rusty metal merely provides a prime habitat for a C.tetani endospore to reside, and the nail affords a means to puncture skin and deliver endospore into the wound. An endospore is a nonmetabolising survival structure that begins to metabolise and cause infection once in an adequate environment.

T US K? R C TA AT

Because C.tetani is an anaerobic bacterium, it and its endospores will thrive in an environment that lacks oxygen. Hence, stepping on a nail (rusty or not) may result in a tetanus infection, as the low-oxygen (anaerobic) environment of a puncture wound provides the bacteria with an ideal breeding ground

Name: A. C. Age: 57 yrs. Old Sex: Male I. AL TReligion: Roman Catholic IT V A CivilStatus: Married RM Address: Phase I, Milibili Heights, FOION Roxas, City IN DateandTimeofAdmission: Oct., 31, 2008 @ 6:40 pm ChiefComplaints: lockjaw AdmittingDiagnosis: Severe Tetanus; Gouty Arthritis; Pneumonia AttendingPhysicians: Dr. M. O. / Dr. J. B.

1.HistoryofPresentIllness: One week before admission, A. g the left sin ent patient sustained aItwound at small that foot, second digit. was too ur m N they did not mind having consultation. ess ss Five days after acquiring the A wound, patient complained of difficulty in opening his mouth and difficulty in swallowing foods. Symptoms persisted. Patients family was alarmed to symptoms thus prompted admission in Oct. 27, 2008 @ 6:40 pm. Vital signs upon admission include: BP- 180/90 mmHg, CR- 84 bpm, RR- 24 breaths/min; and T-37o C. Dyspnea, nausea, vomiting and signs of urinary and bowel problems noted.

2.PastMedicalHistory: Year 2001, patient was diagnosed with Chronic Tenalacious Gout. He had a maintenance medication of Colchicine. He is allergic to foods that contain food colorings. 3.FamilyHistory: His mother died of hypertension and old age.

C.C.Alcoholi c

S. C.HTN

C.

A. C.68

L. C.65

F.C.60BA; Arthritis

R. C.59

N

C.C. Jr.

A.C.57Tetanus; Gouty Arthiris

4. Patterns of FunctioningPattern of Funtioniong Breathing Home Hospital

RR: 16-25 breaths per minuteThe patient breathes through a tracheostomy tube attached to mechanical ventilator with settings of Mode- AC Fi02- 60%TV400 PFR- 50BUR- 14

4. Patterns of FunctioningPattern of Funtioniong Home Hospital Elevation in BP not noted except upon admission (180/90mmHg). He is attached to cardiac monitor and pulse oximeter with oxygen saturation of 96-100 %. His BP ranges from 110-140 mmHg systolic / 70-90 mmHg diastolic. With IVF D5 NSS 1L + 20 mEq KCl x 80 cc/hr. @ cephalic vein. The patient usually sleeps at 8 pm and wakes up at 2 oclock in the morning to attend to his ducks. The patient sleeps at intervals, usually in semi-Fowlers position, provided with one pillow on his head and one to support his extremities.

Circulation

Sleeping

4. Patterns of FunctioningPattern of Funtioniong Home Hospital

Drinking

The patient is not used The patient can not open his to drinking water. His mouth total fluid intake amounts to 1050 cc a day including tea and coffee. He drinks alcoholic beverages occasionally.The The patient eats 3 meals and some snacks a day. He eats various kinds of foods only avoiding beans, organ meats, and nonscaly fish NGT is attached. OTF amounting to 250 cc is given at 10am, 2pm and 6pm.

Eating.

4. Patterns of FunctioningPattern of Funtioniong Home Hospital

Elimination: Urinary elimination Bowel eliminationPatient voids whenever he feels the urge. He voids 3-4 times daily. Patient defecates every morning without straining. A Foley catheter is attached to the patient with adequate hourly urine output. Patient experiences no bowel movement for 3 days. He is given Lactulose or Dulcolax suppository based on need.

4. Patterns of FunctioningPattern of Funtioniong

Home Patient takes a bathe everyday .

HospitalImmobility disables the patient to take hygienic measures. Morning care is done every 5 oclock in the morning. Oral care is done with the use of tongue depressor. Suctioning of the mouth is done when needed.

Personal hygiene

Recreation and Exercise

Patient does not have a He has no any form of regular pattern of recreation exercise. He wakes up early and feeds his ducks. His basic form of exercise is walking around their backyard. He likes to listen to AM radio and watches TV at times, but generally sleeps early.

5.BriefSocial,CulturalandReligious background

Educational Background

A.C finished his elementary education in Lonoy Elementary school and his secondary education in Colegio Dela Purisima Conception and was an active varsity player of volleyball. He then took his tertiary education in Calinog Central School as a Commerce Accounting student still as a varsity player.

Occupational

He manages his own family poultry business.

Religious Practices

He attends mass occasionally.

Economic Status

His family belongs to a middle class group. He was able to send his children to college through graduation. His wife is a teacher. They have a business of growing ducks.

B. Clinical Inspection1.VitalSigns

Temperature:37C BloodPressure:100-130/70-90mmHg PulseRate:70-80beatsperminute CardiacRate:75-85beatsperminute RespirationRate:16-25breathsperminute54 57 kgs.

2. Height: Weight:

3.PhysicalAssessment

General AppearancePatient is lying on bed at high or semi Fowlers position. He is weak minimal white hair and has a brown complexion. He has tracheostomy tube attached to mechanical ventilator.. Cardiac monitor with pulse oximetry is attached. NGT and Foley catheters are also attached. With IVF @ right arm; Lockjaw is apparent. Subcutaneous emphysema is marked.

Skin, ir and ha nails

Skin: brown complexions, dry, rough, and cool to touch has slight poor skin turgor. Hair: Minimal white hairs combined to black curly hair, equally distributed, presence of dandruff, no lice. Nails: untrimmed, clean, (+) pallor.

d, ea H e, fac nd a ha mp ly tic

Head: large in size, symmetrical, scalp is intact and moves freely over skull. Face: Pale, (+) subcutaneous emphysema Lymphatic: unremarkable

yes, E ears, ose, n outh m and roat th

Eyes: anicteric sclerae; upper and lower lids completely approximated when closed, eyelashes are evenly distributed, globes are aligned, pinkish conjunctiva, pupils are black in color and 2.5 mm in size. Ears: top pinna is below to the outer corner of the eyes with equal alignment, large in size and equal, skin is intact, similar in color to face. Nose: (-) discharges, (-) sinusitis, same color with the face Mouth: lockjaw; Lips are dry; with slight odor Throat: nonremarkable

and eck N per up ties emi extr

Neck: Symmetrical but shortened; proportional to head and shoulders, there are palpable soft muscles, there is a marked pulsation in the carotid pulse; trachea is in the midline; (+) tracheostomy tube attached to mechanical ventilator Upper Extremities: Symmetrical; consistent brown in color; With IVF D5 NSS 1L + 20 mEq KCl x 80 cc/hr. @ cephalic vein.

tand Ches : Chest: (+) hair, brown in Axilla complexion;

Axilla: (+) hair, (+) palpable lymph nodes; non-odorous

ato spir Re y r With a respiration rate m: 16-25 breaths per ste ranging Patient breathes Sy minute.

through tracheostomy tube attached to mechanical ventilator; (+) wheezes on left lung field

Cardiovascular

There is a palpable pulsation, heart rate ranges 75-85 bpm with a regular rhythm, apical pulse is close to its pulse rate of 70-80 bpm.

GastrointestinalSystemHis abdomen has a consistent color with the rest of the part of the body; soft, nontender; with hypoactive bowel sounds

GenitoUrinarySystem

Black pubic hair, with Foley catheter; urine output is adequate.

Musculoskeletal(+) Generalized weakness; opens lips but not whole mouth; difficulty turning to sides alone. (+) bouttonniere deformity on both hands; (+) rigidity; (+)neck stiffness

4. General appraisal

Speech

(-) verbal output due to lockjaw Known language according to folks are in the native dialect, Filipino, and English. Hears normally; responds to verbal commands. conscious, coherent; GCS-11

Language

Hearing

Mental status

admitted @ Rendu ward under the service of DR. O. and Dr. B. Pen-G 4 million units IV drip Q4 ANST (10-2-6) given as ordered Moxifloxacin 400mg 1 tab OD; Colchicine 1 tab TID pc given as starting dose 11/3/08 Patient has undergone Tracheostomy. was noted with inability to sleep, so he was given with Diazepam 2.5 mg IV STAT as ordere Mobic 15 mg/I tab OD was started as ordered as he complained of mild knee pain. Facial Subcutaneous emphysema was noted, was known already by Dr. M.O. Patient was seen by Dr. B. and removed sutures along incision site. Patient was noted with no urine output and bladder distention. Foley Catheter was inserted as ordered. Furosemide 20mg IV STAT was given as ordered. GCS-11-no verbal response (-) BM 11/4/08- restlessness noted - tracheostomy tube attached to MV with set-up: Mode AC TV-400 FiO2 PFR-50 BUR- 14 GCS-11 (-) BM 11/5/08 GCS-11 limited ROM

CHEMISTRYEXAMINATION RESULT

11/01/08

NORMAL VALUES 4.10-5.90

SIGNIFICANCE Elevated level suggest infection, stress.Indicates alcoholism and stress.

Glucose

6.74 mmol/L

Cholesterol

6.41 mmol/L

0.00-5.20

Triglycerides

3.41 mmol/L

0.00-1.69

Elevated levels are found alcoholism

EXAMINATION

RESULT66.4 umol/L

NORMAL VALUES71.0 133.0

SIGNIFICANCEDecrease level are found with debilitation and decrease muscle mass.

Creatinine

Uric acid

532.2 umol/L

208.0-506.0

Elevated level indicates gout and infection.

Direct HDL

0.80 mmol/L

1.00-1.60

Indicates Malabsorption and malnutrition.

EXAMINATION

RESULT 1.56-mmol/L

NORMAL VALUES 0.00-1.03

SIGNIFICANCE Elevated levels are correlated with alcohol consumption.

VLDL

Sodium

135.3 mmol/L

137-145

Low serum sodium levels result from inadequate sodium, deficient dietary intake, nasogastric aspiration, profuse sweating, GI suctioning, and diuretic therapy.

EXAMINATION

RESULT

NORMAL VALUES

SIGNIFICANCE

Potassium

3.34 mmol/L 3.5-510

Indicates gastric suctioning and diuretic therapy.

ABG

Result

Normalrange

Interpretation:

pH 7.469 7.35-7.45 pCO2 37.5 mmhg 35-45 mmHg pO2 153.0 mmhg 80-100 mmHg HCO3 27.2 mmol/L 22-26 mmol/L O2 Sat. 99% 97-100%

The patient has uncompensated metabolic alkalosis indicates tetany.

HEMATOLOGYEXAMINATION RESULT Hi 12.4 10 x 12/L NORMAL VALUES 4.5 11.0 x 10 12/L SIGNIFICANCE An elevated WBC count commonly signals infection. A depressed count may indicate chronic infection. Low Hgb concentration may indicate hemorrhage, hemolysis of red blood cells.

WBC

RBC Hemoglobin

Lo 4.20 x 10 9/L Lo 120 g/L

4.6 6.2 x 10 9/L

135-180 g/L

EXAMINATION

RESULT Lo 0.36 vol.fr.

NORMAL VALUES 0.40 0.54 vol.fr

SIGNIFICANCE Low HCT indicates acute blood loss, vitamin deficiency.

Hematocrit

Neutrophils.

Hi 78.0 %

50-70 %

Elevated level indicates Physical or emotional stress, acute suppurative infection, inflammatory disease (Gout, pneumonia), trauma

Lymphocytes.

Lo 9.0 %

20 45%

Decreased by severe debilitating illness, drug Adrenocorticosteroid

EXAMINATION

RESULT

NORMAL VALUES

SIGNIFICANCE

Eosinophils Hi 4.0 %

0-3 %

Infection

Monocytes

Hi 9.0 %

0-8

Decrease level indicates chronic inflammatory disease, viral infection.

URINALYSISResult Macroscopic:Transparency: Microscopic: RBCs/hpf Cloudy Numerous to count Clear 0 2 hpf It indicates bacteria. Signifies trauma. An elevated WBC count indicates pyuria and presence of urinary tract infection. Indicates presence of bacteria.

Normal value

Significance of Abnormal Results

WBCs/hpf

Hi 6-12

0 5 hpf

Bacteria:

Few

Negative

RADIOLOGY10/31/08 Chest PA X-ray impression: (L) Basal pneumonia 11/13/08 Chest AP X-ray Impression: (L) Basal pneumonia with regression S/p (L) Tracheotomy Tube insertion The tip of the

ECG INTREPRETATION:

Nonspecific intraventricular delay. Occasional single premature atrial contracture. Nonspecific S-T waves changes at the inferior leads probably due to ischemia or electrical shifts.

Anatomy and Physiology

Case Discussion:

TETANUS

Tetanus occurs after spores or vegetative bacteria gain access to tissues and produce toxin locally. The usual mode of entry is trough a puncture wound or laceration. Tetanus may also follow elective surgery, burn wounds, otitis media, dental infection, abortion and pregnancy. Neonatal tetanus usually follows infection of the umbilical stump.

In the presence of anaerobic conditions, the spores germinate. Toxins,including tetanolysin (which potentiates infection) and tetanospasmin (a potent neurotoxin) are produced. Tetanospasmin, often referred to as tetanus toxin, causes clinical tetanus. The toxin produced is disseminated through the bloodstream and lymphatic system. However, it does not enter the central nervous system through this route, as it cannot cross the blood brain barrier except at the fourth ventricle. The toxin is exclusively taken up by the neuromuscular junction, where it migrates retrograde transynaptically at the rate 75250mm/day, a process which takes 3-14 days, protected from neutralizing antitoxin, predominantly to inhibitory synapses to prevent the release of acetylcholine.

The toxin acts after the incubation period (3-14) days) at several sites within the central nervous system, including peripheral motor end plates, spinal cord, brain and sympathetic nervous system. The typical clinical manifestations of tetanus are caused when tetanus toxin interferes with release of neurotrasmitters, blocking inhibitor impulses. Blockade of spinal inhibition is produced when the toxin acts at the synapse of interneurons of inhibitory pathways and motor neurons. General muscle rigidity arises from uninhibited afferent stimuli entering the central nervous system from the periphery. The effect of the toxin on the brain is controversial; direct inoculation can cause seizures.

One of the many complications from tetanus is respiratory failure secondary to spasms, obstruction by secretions, exhaustion and pulmonary aspiration. Cardiovascular complications thought to be due to hyperactivity of the sympathetic nervous system include tachycardia, with heart rates over 180 beats per minute, severe vasoconstriction and hypertension. Autonomic dysfunction is seen as increased basal sympathetic activity and episodes of sympathetic over activity. (SOA).

FrequencyUnitedStates Incidence has declined with the advent of active immunization. Reports indicate that 560 cases occurred in 1947; 101 cases occurred in 1974; 60-80 cases occurred each year during the 1980s; and 47 cases occurred in California in 1997. Almost all cases occur in persons who are partially immunized or nonimmunized. The incidence of patients who contract tetanus despite full immunization is extremely rare (ie, ~4 per 100 million persons who are immunocompetent and vaccinated).

International Reports show up to 1 million cases annually, mostly in underdeveloped countries. Neonatal tetanus accounts for 50% of the tetanus-related deaths in developing countries. Mortality/Morbidity

Tetanus results in approximately 5 deaths per year in the United States. Mortality in the United States resulting from generalized tetanus is 30% overall, 52% in patients older than 60 years, and 13% in patients younger than 60 years. Residual neurologic sequelae are uncommon. Mortality usually results from autonomic dysfunction (ie, extremes in blood pressure, dysrhythmia, cardiac arrest).

Age In the United States, 59% of cases and 75% of deaths occur in persons aged 60 years or older.

History Most cases in the United States occur in patients with a history of only partial immunization. Persons who inject drugs also constitute a high-risk group. Symptoms usually begin 8 days after the infection, but onset may range from 3 days to 3 weeks. Patients may report a sore throat with dysphagia (early sign). Localized tetanus causes muscle rigidity at the site of spore inoculation. The initial manifestation may be local tetanus, in which the rigidity affects only 1 limb or area of the body where the clostridium-containing wound is located.

Signs and symptoms

The incubation period ranges from 2 to 50 days (average, 5 to 10 days). Tetanus affects skeletal muscle , a type of striated muscle. The other type of striated muscle, cardiac or heart muscle cannot be tetanized, because of its intrinsic electrical properties. In recent years, approximately 11% of reported tetanus cases have been fatal. The highest mortality rates are in unvaccinated persons and persons over 60 years of age. C. tetani, the bacterium that causes tetanus, is recovered from the initial wound in only about 30% of cases, and can be found in patients who do not have tetanus.

According to the Manifested by the textbook patient Lockjaw / trismus Difficulty swallowing Restlessness Irritability Neck stiffness Headache Fever Sore throat Chills Risus sardonicus

Rigidity Opisthotonus Urinary retention Constipation Moderate Leukocytosis Hypertension Tachycardia Difficulty breathing

Diagnosis

A history of a recent wound in a patient with muscle stiffness or spasms is a clue. Tetanus can be confused with meningoencephalitis of bacterial or viral origin, but the combination of an intact sensorium, normal CSF, and muscle spasms suggests tetanus. Trismus must be distinguished from peritonsillar or retropharyngeal abscess or another local cause. Phenothiazines can induce tetanus-like rigidity. C. tetani can sometimes be cultured from the wound, but culture is not sensitive.

Treatment

The wound must be cleaned. Dead and infected tissue should be removed by surgical debridement. Metronidazole treatment decreases the number of bacteria but has no effect on the bacterial toxin. Penicillin was once used to treat tetanus, but is no longer the treatment of choice, owing to a theoretical risk of increased spasms. However, its use is recommended if metronidazole is not available. Passive immunization with human anti-tetanospasmin immunoglobulin or tetanus immune globulin is crucial. If specific anti-tetanospasmin immunoglobulin is not available, then normal human immunoglobulin may be given instead. All tetanus victims should be vaccinated against the disease or offered a booster shot.

Mild tetanus

Mild cases of tetanus can be treated with: Tetanus immune globulin IV or IM metronidazole IV for 10 days diazepam tetanus vaccination

Severe tetanus

Severe cases will require admission to intensive care. In addition to the measures listed above for mild tetanus: human tetanus immunoglobulin injected intrathecally (increases clinical improvement from 4% to 35%) tracheostomy and mechanical ventilation for 3 to 4 weeks, magnesium, as an intravenous (IV) infusion, to prevent muscle spasm, diazepam (known under the common name Valium) as a continuous IV infusion, the autonomic effects of tetanus can be difficult to manage (alternating hyper- and hypotension, hyperpyrexia/ hypothermia) and may require IV labetalol, magnesium, clonidine, or nifedipine.

Drugs such as diazepam or other muscle relaxants can be given to control the muscle spasms. In extreme cases it may be necessary to paralyze the patient with curare-like drugs and use a mechanical ventilator. In order to survive a tetanus infection, the maintenance of an airway and proper nutrition are required. An intake of 3500-4000 Calories, and at least 150g of protein per day, is often given in liquid form through a tube directly into the stomach, or through a drip into a vein. This highcaloric diet maintenance is required because of the increased metabolic strain brought on by the increased muscle activity.

Prevention

A series of 4 primary immunizations against tetanus, followed by boosters q 10 yr, with the adsorbed (for primary immunization) or fluid (for boosters) toxoid is superior to giving antitoxin at the time of injury. Tetanus toxoid comes by itself, mixed with diphtheria in both adult (Td) and child strengths (DT), and combined with both diphtheria and pertussis (DTP). Routine diphtheria, tetanus, and pertussis immunization and booster recommendations are discussed in Immunization. Adults need to maintain immunity with regular boosters q 10 yr. Immunization in an unimmunized or inadequately immunized pregnant woman produces both active and passive immunity in the fetus and should be given at a gestational age of 5 to 6 mo with a booster at 8 mo. Passive immunity develops with maternal toxoid given before a gestational age of 6 mo.