Tetanus Case Study

St. Anthony College of Roxas CitySan Roque Extension, Roxas City

5800 Capiz, Philippines

Bachelor of Science in Nursing 4C- 2011

TETANUSSubmitted by:

Xy-Za Roy Marie D. AlbañaGlorie Anne D. AniscoKhris John V. Balbuena

Charmaine Cheryl Iris V. BellosilloJoanna Keith D. Batuigas

April Rose D. BenitezKaren Kay D. BulanShiehon A. Ferraris

Marie Ann B. MagbanuaFree Van Roy Paclibar

Submitted to:Ms. Wila C. Valles, RN

Clinical Instructor

INTRODUCTION

1

TETANUS

Comes from the Greek word “tetanus” meaning taut and “teiteim” which means to stretch. It is also called lockjaw. It is a serious infectious disease of the nervous system in which toxin causes severe muscle spasm. It is a medical condition characterized by a prolonged contraction of skeletal muscle fibers.

It is caused by a bacterium Clostridium tetani. Infection generally occurs through wound contamination and often involves a cut or deep punctured wound. Tetanus is often associated with rust, but this concept is somewhat misleading. The C.Tetani is an Anaerobic bacteria which survives in an environment that lacks oxygen, thus with or without rust a person may have a tetanus once C. Tetani enters the wound. Contaminated wounds are the site where tetanus bacteria multiply. Deep wounds or those with distallized tissue are particularly prone to tetanus infection. The tetanus toxin affects the site of interaction between the nerve and the muscle that it stimulates, this region is called the neuromuscular junction. The tetanus toxin amplifies the chemical signals from the nerve to the muscles to tighten up in a continuous contraction or spasm. This results in either localized or generalized muscle spasm.

The incubation period ranges from 3 to 21 days, usually about 8 days. In general the further the injury site is from the central nervous system, the longer the incubation period. The shorter the incubation period, the higher the chance of death. In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days. On the basis of clinical findings, three different forms of tetanus have been described. Local tetanus is an uncommon form of the disease, in which patients have persistent contraction of muscles in the same anatomic area as the injury. These contractions may persist for many weeks before gradually subsiding. Local tetanus may precede the onset of generalized tetanus but is generally milder. Only about 1% of cases are fatal.

Tetanus can be prevented by vaccination with tetanus toxoid. A booster is needed every 10 years after primary immunization.

In the Philippines the incidence rate of tetanus is 12 out of 86, 241,627.

Objectives

General objectives:

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This case study is designed for the student nurses to become

practiced, well-informed and mannered in delivering holistic care for patients

diagnosed with Tetanus.

Specific Objectives:

Skills

To demonstrate the vision/mission of the school which is service

oriented, research motivated, technology enable and Vincentian

inspired.

Imply appropriate medical nursing management for Tetanus.

Knowledge

Discuss the anatomy and physiology of the Nervous system.

Define Tetanus. Learn about major etiologic its causes, identify its

clinical manifestations and risk factors.

Be familiar with the pathophysiology of Tetanus.

Be acquainted with the different drugs, its actions, and perform

obligatory nursing responses for each.

Plan for a suitable nursing care

Attitude

Establish a nurse-patient interaction through exchanging of thoughts

and information

Institute bond between the student nurse and the patient.

ANATOMY AND PHYSIOLOGY

3

Nervous System

The nervous system is an organ system containing a network of specialized cells called neurons that coordinate the actions and transmit signals between different parts of its body. The nervous system consists of two parts, central and peripheral. The central nervous system contains the brain, and spinal cord. The peripheral nervous system consists of sensory neurons, clusters of neurons called ganglia, and nerves connecting them to each other and to the central nervous system. These regions are all interconnected by means of complex neural pathways. The enteric nervous system, a subsystem of the peripheral nervous system, has the capacity, even when severed from the rest of the nervous system through its primary connection by the vagus nerve, to function independently in controlling the gastrointestinal system.

The Central Nervous System is the body’s information headquarters, ultimately regulating nearly all body functions. The CNS includes:

The Brain – Processes incoming information from within the body, and outside the body by way of the sensory nerves of sight, touch, smell, sound, and taste. Commands are then sent back throughout the body. The brain also stores and processes language, communication, emotions, thoughts, dreams, and memories. In other words, the brain is where all thinking and decision-making takes place.

The Spinal Cord – Is the main pathway for information connecting the brain and peripheral nervous system. It extends from the brain about 18 inches down the bony spinal column, which serves as its protection. The spinal cord is a tube made up of nerve fibers. Electrical impulses travel through the nerves and allow the brain to communicate with the rest of the body.

4

http://en.wikipedia.org/wiki/Vagus_nerve

http://en.wikipedia.org/wiki/Enteric_nervous_system

http://en.wikipedia.org/wiki/Nerves

http://en.wikipedia.org/wiki/Ganglia

http://en.wikipedia.org/wiki/Peripheral_nervous_system

http://en.wikipedia.org/wiki/Spinal_cord

http://en.wikipedia.org/wiki/Brain

http://en.wikipedia.org/wiki/Central_nervous_system

http://en.wikipedia.org/wiki/Neuron

http://en.wikipedia.org/wiki/Neural_network

http://en.wikipedia.org/wiki/Organ_system

http://en.wikipedia.org/wiki/File:TE-Nervous_system_diagram.svg%00%E5%A1%B9%EF%92%81%E1%B4%BB%E4%A1%BF%E2%B2%AF%E5%B6%82%E8%97%84%E6%8C%A7%00%00%EA%AE%A5

The Peripheral Nervous System is responsible for the remainder of the body. It includes cranial nerves (nerves emerging from the brain), spinal nerves (nerves emerging from the spinal cord) and all the major sense organs. The PNS includes:

The Somatic Nervous System (SNS) – Responsible for all muscular activities that we consider voluntary or that are within our conscious control.

The Autonomic Nervous System (ANS) – Responsible for all activities that occur automatically and involuntarily, such as breathing, muscle contractions within the digestive system, and heartbeat. The components of the ANS work together to create a balanced response to outside stimuli1. The ANS includes:

o The Sympathetic System – Stimulates cell and organ function. The sympathetic system is activated by a perceived danger or threat, very strong emotions such as fear, anger or excitement, by intense exercise, or when under large amounts of stress. Basically, anything the body perceives as an emergency will trigger a protective response. Once initiated, it speeds up heart rate, increases the activity of the sweat and adrenal glands, slows down the digestive system and sends blood to the skin and muscles; all of which prepare the body for a “fight or flight” response.

o The Parasympathetic System – Inhibits cell and organ function. The parasympathetic system slows down heart rate, resumes digestion, and increases relaxation throughout the body. This “rest and digest” response counteracts the “fight or flight” response and helps the body recuperate after a crisis is over. A person's normal resting heart rate is determined by the parasympathetic system. If blood pressure is too high or blood carbon dioxide levels are too low, this system slows the heart down and lowers its output.

NEUROMUSCULAR SYSTEM

The combination of the nervous system and the muscles, working together to permit movement, is known as the neuromuscular system. Neuromuscular disorders include motor neuron diseases, neuropathies and muscular dystrophies.

The brain controls the movements of skeletal (voluntary) muscles via specialised nerves.

Neurons send signals to other cells as electrochemical waves travelling along thin fibres called axons, which cause chemicals called neurotransmitters to be released at junctions called synapses. A cell that receives a synaptic signal may be excited, inhibited, or otherwise modulated. Sensory neurons are activated by physical stimuli impinging on them, and send signals that inform the central nervous system of the state of the body and the external environment. Motor neurons, situated either in the central nervous system or in peripheral ganglia, connect the nervous system to muscles or other effector organs. Central neurons, which in vertebrates greatly outnumber the other types, make all of their input and output connections with other neurons. The interactions of all these types of neurons form neural circuits that generate an organism's perception of the world and determine its behavior. Along with neurons, the nervous system contains other specialized cells called glial cells (or simply glia), which provide structural and metabolic support.

5

http://en.wikipedia.org/wiki/Glial_cells

http://en.wikipedia.org/wiki/Synapse

http://en.wikipedia.org/wiki/Neurotransmitter

http://en.wikipedia.org/wiki/Axon

If you want to move part of your body, a message is sent to particular neurons (nerve cells), called upper motor neurons. Upper motor neurons have long tails (axons) that go into and through the brain, and into the spinal cord, where they connect with lower motor neurons. At the spinal cord, the lower motor neurons in the spinal cord send their axons via nerves in the arms and legs directly to the muscle they control.

A typical muscle is serviced by anywhere between 50 and 200 (or more) lower motor neurons. Each lower motor neuron is subdivided into many tiny branches. The tip of each branch is called a presynaptic terminal. This connection between the tip of the nerve and the muscle is also called the neuromuscular junction.

The electrical signal from the brain travels down the nerves and prompts the release of the chemical acetylcholine from the presynaptic terminals. This chemical is picked up by special sensors (receptors) in the muscle tissue. If enough receptors are stimulated by acetylcholine, your muscles will contract.

-Vital Information-

Name: Mr. F.B.

Age: 78

Sex: Male

Address: Dulangan Pilar, Capiz

Civil Status: Married

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Religion: Roman Catholic

Occupation: Fishpond operator

Date and Time Admitted: June 5, 2010; 11:50 am

Ward: SCL 328

Chief Complaint: Difficulty of swallowing

Final Diagnosis: Tetanus Stage 3;Aspiration Pneumonia, HPN Stage I

Attending Physician: Dr. R. H

CLINICAL ASSESSMENT

Nursing History

One week before admission, patient experience a massive toothache and was relief by pain relievers. He did not bother to ask for consultation because he believes that it will subsides in due time. 4 days after acquiring the dental problem, he complained of difficulty in swallowing foods. The patient and family disregard to seek consultation not until they thought that Mr. FB was having a mild stroke. He was very weak and was unable to open his mouth. He can no longer eat foods, and his family are scared for his health thus they prompted for admission in June 7, 2010.

Past Health Problem Mr. F.B. has no history of past hospitalization. Sometimes he

experienced mild fever, coughs, and cold but manageable and treated with over the counter drugs like paracetamol and solmux. He has no known allergies to food, drugs and animals.

Family History

His father died because of old age and his mother died of pulmonary infection. On the other hand, his elder sister is known to be hypertensive and the second sibling has goiter.

FAMILY GENOGRAM

M

7

F.B.

Old age

A.B.

Pulmonary

infection

C.B.85

HPN

L.B.80

Goiter

F.B.

Tetanus

Legends

Female Male Patient Death

Patterns of Functioning

Pattern Home Hospitalization

Breathing Pattern No respiratory problems. Has never complained of any breathing difficulty.

Respiratory rates became rapid, shallow breaths are noted. Difficulty of breathing is always claimed.

Circulation Claimed to never been had a BP check-up before hospitalization.

The average BP is 140/100 mmHg during hospital stay.

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Sleeping Pattern Usually sleeps at 9 pm and wakes up at 5 am. 8-10 hour sleep duration. Uses two pillow and comforter

Sleeps at 10 pm and wakes up at 6 am. Uses one pillow and blanket. Disturbed sleep is usually complained whenever excessive stimuli is observed.

Drinking Pattern Usually drinks 8-10 glasses of water a day.

With NGT, cannot tolerate to drink water because of lock jaw.

Eating Pattern Eats three times a day. He eats more carbohydrate, vegetables and adequate protein. Mr. F.B isn’t fond of using eating utensils since he is staying on his pond, he eats using his bare hands.

He was been on parenteral feeding and has NGT upon admission. An OTF 1600 calories is divided into 6 equal feedings everyday.

Elimination Patterns

a. Bowel

Defecates once daily in adequate amount, golden brown in color.

Defecates for about 2-3 times a week.

b. Urination Urinates normally approximately 3-5x a day in an adequate amount.

With urinary incontinence, a week after his first admission, he only passes 40 cc of urine. He was then inserted with foley catheter attached to urobag with an adequate amount, yellowish in color.

Personal hygiene

His daily job as a pond operator requires a dirty and heavy tasks. Takes a bath daily but isn’t fond of brushing his teeth.

Morning care done with oral care of bactedol. Using cotton and tongue depressor.

Recreational and Exercise

His walks from house to the fish pond which took almost 30 mins. is what they considered to be his daily exercise. He drinks alcohol and play ”tong-its” with his friends.

No recreational activities. Cannot tolerate to stand or sit. Passive ROM exercises done.

Brief Social, Cultural and Religious Background

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a. Educational Background

F.B. finishes his elementary education in Dulangan Elementary School and his secondary education reaches up to 3rd year in Dulangan National High School. He never had the chance to study in college because of financial constraints.

b. Occupation

He is a fulltime fishpond operator, who manages their own family’s fishpond. He spends most of his time on his pond which was 20 mins. away from their residence.

c. Religious Practice

Mr. F.B is a Roman Catholic. He does not attend Sunday mass regularly since he is usually at his fishpond, but his family claims that he always pray.

d. Economic Status

Mr. F.B belongs to a middle class group, he has no fix economic income for they only had a quarterly harvest. But they claim that it was enough to support the whole family. His two daughters are also working abroad which also helps them financially.

Clinical Inspection

1. Vital signs

T=38.2oC CR= 104 bpm

BP= 140/100 mmHg RR= 30 bpm

2. Height = 6’1

3. Weight= 88 kg

PHYSICAL ASSESSMENT

General Appearance

Mr. F.B., 76 year-old male, with poor posture and gait. He is lying on bed on a semi- fowlers position. He is lethargic and irritable. He cannot respond to questions well and is not well oriented. Mainline IVF: PNSS 1L is attached at the left basilic vein running at 20 cc/hr. Urinary catheter is well attached in the urethra with urobag in place. O2 at 4 LPM via nasal cannula is in place. No edema noted.

Skin

Hair

Skin is brown in complexion, warm, and dry with poor skin turgor. No pallor and edema.

Has a short black hair mixed with gray ones, well distributed. No presence of flakes, lice or lesions noted.

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NailsNails are short and clean. Are pink in color and slightly curved with smooth and rounded edges. No clubbing of fingers noted.

Head

Face

Head is normocephalic, no palpable nodules or masses noted. lesions are not noted.

Face is wrinkled due to old age. (+) Facial grimace and locking of jaw noted.

Eyes

Ears

Nose

Mouth

Anicteric sclerae with pupils round and black in color which constricts from 4mm-2mm. Has brisk reaction to light. No cataract noted. Slightly pale conjunctiva noted.

Top of pinna is aligned with the outer corners of both eyes; size is normal and equal; similar in color to face; (-) discharges and swelling, with poor acuity to whisper voice. Cerumen not noted.

With presence of cilia. Has no discharges nor sinusitis. Nasal cannula attached to both nostrils at 4LPM. NGT is attached (L).

Lips are dry with cracking and slightly pale oral mucosa was noted. With no inflammation of tonsils. Has poor dention, with bleeding gum and halitosis.

Neck

Breast

Upper Extremities

Distention of jugular vein noted.

Breast are firm. No mass palpated.

Both arms are weak. Can perform passive movements only.

Chest Respiratory rate of 24-34 breaths/min, shallow breaths in uniform rhythm.

Respiratory System Occasional cough noted with whitish sputum.With supplemental O2 @ 4LPM. Well tolerated with O2

saturation ranging from 97-99%.Crackles is usually heard.

Cardiovascular System

Apical pulse at the left midclavicular line averaging at 86 bpm. Skip beats not noted upon auscultation.

Gastrointestinal System

Abdominal pain noted. With several attempts of bowel movements.

Genito-urinary System

Urinary catheter (French 14) intact on urethra and attached to urobag.Passes yellow colored urine in minimal amounts.

Musculoskeletal System

Restless at few times. Have been on seizure attacks. Movements are weak. Cannot tolerate standing. Able to sit on wheelchair. With weak handgrip.

GENERAL APPRAISAL

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LABORATORY RESULTS

June 05, 2010

Protein Metabolites and Electrolytes

Test Results Normal ValuesSignificance of

Abnormal Result

Creatinine HI 161.8 umol/L71.0 – 133.0

umol/LMay be due to dehydration.

Sodium LO 134.5 mmol/L 137.0 – 145.0 mmol/L

Hyponatremia may result from

inadequate sodium intake or excessive sodium loss due to profuse sweating.

June 06, 2010

Lipids and lipoproteins

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Speech Speaks in native language. He presently can not talk due to illness.

Language Can speak only Hiligaynon when he was still able to talk.

Hearing Has poor acuity to whispered voice.

Mental status He is lethargic and irritable.

Emotional Status

Unable to express emotions.


Abnormal Result

Cholesterol HI 5.21 mmol/L 0.00 – 5.20 mmol/L

Indicates Hypercholesterolemi

a leading to Hypertension

Direct HDLC LO 0.86 mmol/L1.00 – 1.60

mmol/L

June 16, 2010

Hematology

TestResults

Normal Values

Significance of Abnormal Result

Hematocrit LO 0.31 vol. (fr)0.42 – 0.52

Low Hct suggest anemia, or hemodilution

Hemoglobin LO 103 g/L 130.0

A decreased value of hemoglobin can be caused by low red blood cell count, by a lack of hemoglobin in

the erythrocytes, which also indicates fluid

retention.Red Blood Cell

CountLO 3.61 x 10^12/L

4.2 – 5.4 x 10^12/L

Indicates fluid overload.

White Blood Cell Count

HI 11.9 x 10^9/L 4 – 10 x 10^9/L

An elevated WBC count indicates infection due to

traumatized tissue.

Segmenters HI 0.86 0.50 – 0.65An elevated value

(neutrophilia) occurs in response to bacterial

infection.Eosinophils 0.01 0.01 – 0.04 Normal

Lymphocytes LO 0.07 0.25 – 0.30A decreased value occurs with impaired lymphatic

drainage.

Monocytes HI 0.06 0.02 – 0.05 An elevated value occurs in response to infection.

Platelet 380 x 10^9/L 140 – 400 x 10^9/L

Normal

June 16, 2010

Urinalysis


Abnormal Result

Color Pale straw Straw to dark yellow Normal

Transparency Hazy clearReaction pH 6.0 4.5 – 8.0

Sp. Gravity 1.020 1.003 – 1.030Protein trace negative Protein in the urine

(proteinuria) may indicate

hypertension.Glucose negative negative

NormalAmorph. U/P few

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RBC / hpf HI 11 – 20 / hpf 0 – 3 / hpf Indicates bleedingWBC / hpf 2 -7 / hpf 0 – 5 / hpf

NormalEpithelial Cells Occassional NoneBacteria Moderate None

Yeast cells many None

June 8,2010

TPSA(mini-VIDAS)

VIDAS TPSA is intended for use with a VIDAS (VITEK ImmunoDiagnostic Assay System) instrument as an automated enzyme-linked fluorescent immunoassay (ELFA) for the quantitative measurement of total prostate specific antigen in human serum. The VIDAS TPSA assay is indicated as an aid in the management of patients with prostate cancer and as an aid in the detection of prostate cancer in conjunction with digital rectal examination (DRE) in men age 50 years or older. Prostate biopsy is required for diagnosis of prostate cancer.

June 7,2010

CT SCAN Cranial Plaw

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TestResults Normal Values

Significance of Abnormal

Result

TPSA 7.31mg/ml normal:

0-3.72mg/ml

Increased result shows

prostatic impairment

Test Impression

Neurocranium

Plain axial tomography section of the head shows no definite focal parendrymal lesions or any abnormal hyperdense collection.

The midline structures are undisplaced with the interhemispheric fissure centered on the midline.

The cerebrum shows slightly widened cortical sulcation.

The cerebral ventricles are prominent.

There are no signs of increased intracranial pressure.

The posterior fossa, brainstem and sellar region appear normal.

The petromastoids, bony calvanium and included orbits or paranasal sinuses are unremarkable.

INTERPRETATION:

Cerebral Atrophic Changes.

June 17,2010

CHEST X-RAY

Impression

Bilateral pneumonia with progression in the left.

Left pleural effusion.

Bronchiectasis right lung base.

Atheromatous and tortuous aorta.

Dextroscoliosis, thoracic spine.

15

MEDICATIONS

NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION SIDE EFFECTS CONTRAINDICATIONS NURSING RESPONSIBILITIES

Omeprazole

20mg 1 tab BID

Brand Name:Prosec

Suppresses gastric acid secretion by

specific inhibition of the hydrogen-

potassium ATPase enzyme system at the secretory surface of the gastric parietal

cells; blocks the final step of acid production.

GERD, frequent heartburn.

1. Headache

2. Nausea

3. Vomiting

4. Diarrhea

5. Constipation

6. Abdominal Pain

7. Flatulence

8. Dry mouth

Hypersensitivity to omeprazole and its

components.

1.Administer drug before

meal is serve.

2.Monitor for any urinary

elimination such as pain

or discomfort

associated with

urination.

3. If severe diarrhea is

observed, drug may

need to be

discontinued.

ACTION

Antisecretory drug

Proton Pump Inhibitor

16


MECHANISM OF ACTION


Moxifloxacin

400mg 1tab OD

Brand Name:Avelox

Bactericidal; interferes with DNA replication, repair, transcription, and recombination in susceptible gram-

negative and gram- positive bacteria, preventing cell

reproduction and leading to cell death.

Treatment ofInfection caused

by anaerobic bacteria.

1. Headache

2. Insomnia

3. Nausea

4. Diarrhea

Contraindicated with allergy to

fluoroquinolones, prolonged QT interval,

hypokalemia.

1. Continue therapy as

indicated for condition

being treated.

2. Administer oral drug 4

hr before or at least 8

hr after antacids or

other anion-containing

drugs.

3. Do not change dosage when switching from IV to oral dose.

ACTION

Antibiotic

Fluoroquinolone

17


MECHANISM OF ACTION


Solfenacin

5mg 1tab

Brand Name:VESIcare

Counteracts smooth muscle spasm of the

urinary tract by relaxing the detrusor

and other smooth muscle through the

action at the muscarinic

parasympathetic receptors.

Treatment of overactive

bladder with symptoms of urge urinary incontinence, urgency, and

urinary frequency.

1. Dry mouth

2. Constipation

3. Urinary retention

Contraindicated with allergy to drug or any

component of the drug, severe hepatic

impairment, urine retention, gastric

retention, uncontrolled narrow-angle glaucoma.

1. Provide frequent

small meals if GI

upset occurs.

2. Establish bowel

program if

constipation is a

problem.

3. Establish precautions

if CNS effects occur.

4. Measure post-void

residual urine

volume if patient

has difficulty in

voiding.

ACTION

Muscarinic receptor

entagonist

Urinary antispasmodic

18


MECHANISM OF ACTION


Tamsulosin

250 mg

BID

Brand Name:Harnal

Blocks the smooth muscle alpha1-

adrenergic receptors in the prostate,

prostatic capsule, prostatic urethra,

bladder neck, leading to relaxation, of the

bladder, and prostate, and

improving the flow of urine in cases of BPH.

Adjunct in managing

urethral stones.

1. Somnolence

2. Insomnia

3. Orthostatic

hypotension

4. Abnormal

ejaculation

5. Decreased libido

Hypersensitivity to tamsulosin, prostate cancer, pregnancy.

1. Administer once a day,

30 minutes after the

same meal each day.

2. Monitor patient carefully

for orthostatic

hypotension; dizziness,

and syncope is high with

the first dose. Establish

safety precautions as

appropriate.ACTION

Alpha adrenergic blocker (peripheral

acting)

19


MECHANISM OF ACTION


Lactulose

20cc until BM occurs q8hours

Brand Name:Lactulose

The drug passes unchanged into colon where bacteria break

it down to organic acids that increase

the osmotic pressure in the colon and

slightly acidify the colonic contents,

resulting in an increase in stool

water content, stool softening, and

laxative action. This also results in

migration of blood ammonia into the

colon contents with subsequent trapping and expulsion of the

feces.

Treatment of constipation.

1. Transient

flatulence

2. Distention

3. Intestinal cramps

4. Belching

5. Diarrhea

6. Nausea

Contraindicated with allergy to lactulose, low-

galactose diet.

1. Do not administer other

laxative while using

lactulose.

2. Monitor serum

ammonia levels.

3. Carefully monitor blood

glucose levels in diabetic

patients.

ACTION

Ammonia reaction

drug

Laxative


MECHANISM OF ACTION


1. Do not administer to 20

Tetanus Immune Globulin

250/amp 4amps deep IM (stat)

Brand Name:Tetanus immune

globulin

Supplies passive immunity to those

individuals who have low or no immunity to the toxin produced by

the tetanus organism, Clostridium tetani. The antibodies act to neutralize the

free form of the powerful exotoxin produced by this

bacterium

Is indicated for prophylaxis

against tetanus following injury

in patients whose

immunization is incomplete or uncertain. It is also indicated,

although evidence of

effectiveness is limited, in the

regimen of treatment of

active cases of tetanus.

1. Tenderness

2. Muscle stiffness

at injection site

3. Urticaria

4. Angioedema

5. Fever

6. Chills

7. Chest tightness

8. Precipitous fall

in BP

Contraindicated to

patients with a history of

prior systemic allergic

reactions following the

administration of human

immunoglobulin

preparations, and

severe

thrombocytopenia or

any coagulation disorder

that would

contraindicate

intramuscular injections.

patients with history of

allergy to gamma

globulin or anti

immunoglobulin A

antibodies.

2. Administer 2 weeks

before or 3 months after

immune globulin

administration because

antibodies in the

globulin preparation

may interfere with the

immune response to the

vaccination.

3. Do not mix globulin

with any other

medications.

4. Monitor patient’s vital

signs continuously and

observe for any

symptoms during IM

ACTION

Immune globulin

21

administration.

5. Provide comfort

measures or teach

patient to provide

comfort measures to

help patient to cope with

the discomforts of drug

therapy.


MECHANISM OF ACTION


22

Tramadol

50mg IV q8 PRN for severe pain

Brand Name:Tramal

Treats moderate to

moderately severe

pain and most types

of neuralgia,

including trigeminal

neuralgia.

Treatment of acute to chronic

pain.

1. Nausea

2. Vomiting

3. Sweating

4. Constipation

5. Drowsiness

6. Respiratory depression

Acute intoxication with alcohol hypnotics,

analgesics or psychotropic, narcotic withdrawal treatment.

1. Do not take more medication as a single dose or take more doses per day than prescribed by the doctor.

2. Store this medicine at room temperature, away from heat and light.

3. Do not stop taking Tramadol without talking to the doctor

ACTION

Analgesic

u-opiod

receptor antagonist


MECHANISM OF ACTION


23

http://en.wikipedia.org/wiki/Trigeminal_neuralgia

http://en.wikipedia.org/wiki/Trigeminal_neuralgia

http://en.wikipedia.org/wiki/Neuralgia

Pen G

4 mullion q6 ANST via soluset (8-2)

Brand Name:Pen G

Inhibits enzymes

responsible for cell

wall synthesis of

susceptible

organisms. This

creates an

osmotically

unstable cell wall

that swells and

bursts from osmotic

pressure.

Penicillin G is reserved for

severe infections.

1. Nausea

2. Vomiting

3. Diarrhea

4. Abdominal pain

5. Colitis

6. Anorexia

7. Hypersensitivity

8. Neurotoxicity

9. Urticaria,

Superinfection

Patients with known allergies to penicillin and

hypersensitivity to cephalosporins

1. Have a antibiotic skin test done before giving dose to ensure hypersensitivity reactions.

2. Give by IM route only.

3. Continue therapy for at least 2 days after infection has disappeared, usually 7-10 days.

4. Use the smallest dose possible for IM injection to avoid pain and discomfort.

ACTION

Antibiotic

24

http://en.wikipedia.org/wiki/Superinfection

http://en.wikipedia.org/wiki/Urticaria

http://en.wikipedia.org/wiki/Neurotoxicity

http://en.wikipedia.org/wiki/Hypersensitivity


MECHANISM OF ACTION


Metronidazole, 500mg , IV q8 hrs.

Brand Name:Flagyl

Bactericidal: inhibits DNA synthesis in

specific anaerobes, causing cell death.

Treatment of bacterial infection

(a drug of choice for Tetanus)

1. Headache

2. Dizziness

3. Ataxia

4. Vertigo

5. Insomnia

6. Fatigue

7. Incontinence

8. GI upset

Contraindicated with hypersensitivity to metronidazole; use cautiously with CNS

disease, hepatic disease, candidiasis,

blood dyscrasias.

1. Avoid use unless needed. Metronidazole may be carcinogenic.

2. Reduce dosage in hepatic disease.

ACTION

Antiprotozoal

25


MECHANISM OF ACTION


Telmisartan40mg/12.5, I tab OD

Brand Name:Micardis

Selectively blocks the binding of

angiotensin II to specific tissue

receptors found in the vascular smooth

muscle and adrenal gland.

Treatment of hypertension,

alone or in combination with

other hypertensives.

1. Dizziness

2. Headache

3. nausea

4. vomiting

5. diarrhea

Contraindicated with hypersensitivity to

telmisartan.

Use cautiously with hepatic or biliary impairment,

hypovolemia.

1. Monitor heart rate below normal level before giving drug.

2. Check effectivity of the drug. Closely monitor BP and heart rate.

ACTION

Angiotensin II receptor antagonist

Antihypertensive

NURSING

26


MECHANISM OF ACTION

INDICATION SIDE EFFECTS CONTRAINDICATIONS RESPONSIBILITIES

Diazepam

5mg IV q8

Acts mainly at the limbic system and reticular formation;

mat act in spinal cord to produce skeletal muscle relaxation;

potentiates the effects of GABA, an

inhibitory neurotransmitter.

*Muscle relaxant: Adjunct for relief of reflex skeletal muscle spasm

due to local pathology or secondary to

trauma; spasticity caused

by upper motoneuron

disorders

*Parenteral: Treatment of

tetanus

1. Drowsiness

2. Dizziness

3. GI upset

4. bradychardia

Contraindicated with hypersensitivity to benzodiazepines;

psychoses, acute narrow-angle glaucoma, shock, coma, acute alcoholic

intoxication.

Use cautiously with elderly or debilitated patients; impaired liver or renal

function; and in patients with history of substance

abuse.

1. Monitor heart rate before giving drug.

2. Closely monitor BP.

ACTION

Antiepileptic; Anxiolytic

Skeletal muscle relaxant (centrally

acting)

27


MECHANISM OF ACTION


Acetylcysteine

600g/1 tab in 50 diluent OD

Brand Name:Fluimucil

Mucolytic activity: Splits links in the

mucoproteins contained in

respiratory mucus secretions,

decreasing the viscosity of the

mucus.

Mucolytic adjuvant therapy

for abnormal, viscid, or

inspissated mucus secretions in

acute and chronic bronchopulmonar

y disease.

1. Increase productivity of cough

2. Nausea

3. GI upset.

Contraindicated with hypersensitivity to acetylcysteine; use

caution and discontinue immediately if

bronchospasm occurs.

1. Ensure proper dilution of tablet.

2. Monitor heart rate before giving the drug.

3. Monitor urine output.

ACTION

Mucolytic

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MECHANISM OF ACTION


Bisacodyl

Suppository 1 stick per

rectum

Brand Name:Dulcolax

The drug passes unchanged into the

colon where bacteria breaks it down to organic acid that

increase the osmotic pressure in the colon and slightly acidify

the colonic contents, resulting in an

increase in stool water content, stool softening, laxative

action.

Short term relief of constipation

1. Sweating

2. Flushing

3. muscle cramps

4. excessive thirst

Contraindicated in cases of allergy to these

drugs; acute abdominal pain.

1. Do not give drug within 1 hour of any other drugs.

2. Report sweating, flushing, muscle cramps and excessive thirst.

ACTION

Laxative

29


MECHANISM OF ACTION


Paracetamol

500mg 1tab q4 PRN

Reduces fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation

and sweating which helps disspates heat.

Relief of mild to moderately

severe pain and treatment for

fever

1. Nausea

2. GI upset

3. Dizziness

Contraindicated to patients hypersensitive

to Paracetamol

1. Give drug with food if GI upset occurs.

2. Discontinue drug if hypersensitivity reactions occur.

3. Check for body temperature.

ACTION

Antipyretic

NURSING

30


MECHANISM OF ACTION

INDICATION SIDE EFFECTS CONTRAINDICATIONS RESPONSIBILITIES

Furosemide

5mg IV now

Inhibits reabsorption of the sodium and chloride from the

proximal and distal tubules oral

ascending limb of the loop of Henle leading to Sodium –

rich dieresis.

Treatment for fluid retention.

1. Dizziness

2. Vertigo

3. Weakness

4. Headache

5. Drowsiness

6. Fatigue

7. Orthostatic Hypotension

8. Cardiac Arrhytmias

Allergy to drug, Anuria, Severe Renal Failure

1. Monitor Blood pressure for sudden Hypotension

2. Monitor the Intake and Output.

ACTION

Loop Diuretic

31


MECHANISM OF ACTION


Digoxin

0.251 tab OD (7am)

Increase intra cellular calcium and allows

more calcium to enter myocardial cell

during depolarization

via sodium – potassium pump

mechanism.

Indicated for arrhythmias,

abnormal heart contractility.

1. Arrhythmias

2. Headache

3. Weakness

4. Drowsiness

Allergy to Digitalis preparation. Ventricular Tachycardia, Ventricular

Fibrilation, Heart Block, Sick Sinus

Syndrome, Acute MI

3. Monitor heart rate below normal level before giving drug.

4. Check effectivity of the drug. Closely monitor BP and heart rate.ACTION

Cardiac Glycoside

32

TEXTBOOK DISCUSSION

PATHOPHYSIOLOGY

TETANUS

Tetanus is an acute, often fatal disease caused by an exotoxin produced in a wound

by Clostridium tetani. Clostridium tetani is a gram-positive, nonencapsulated, motile, obligatively anaerobic bacillus. It exists in vegetative and sporulated forms. Spores are highly resistant to disinfections by chemical or heat, but vegetative forms are susceptible to the bactericidal effect of heat, chemical

disinfectants, and a number of antibiotics.

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 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 75-250mm/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.

33

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.

Tetanus Symptoms

In generalized tetanus, the initial complaints may include any of the following:

Irritability, muscle cramps, sore muscles, weakness, or difficulty swallowing are commonly seen. Facial muscles are often affected first. Trismus or lockjaw is most common. This condition results from spasms of the jaw muscles that are responsible for chewing. A sardonicsmile -- medically termed risussardonicus -- is a characteristic feature that results from facial muscle spasms.

Muscle spasms are progressive and may include a characteristic arching of the back known as opisthotonus. Muscle spasms may be intense enough to cause bones to break and joints to dislocate.

Severe cases can involve spasms of the vocal cords or muscles involved in breathing. If this happens, death is likely, unless medical help (mechanical ventilation with a respirator) is readily available.

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http://www.emedicinehealth.com/script/main/art.asp?articlekey=23925

http://www.emedicinehealth.com/script/main/art.asp?articlekey=40739

Complications of Tetanus

In cases of severe tetanus infection, a number of possible complications can develop

Fractures

The repeated muscle spasms and convulsions that are caused by a tetanus infection may lead to fractures in the vertebrae (bones in the back), as well as in other bones. Bone fractures can sometimes result in a condition called myositis ossificans circumscripta, which is where bone begins to form in the soft tissues, often around a joint.

Aspiration pneumonia

If you have a tetanus infection, muscle rigidity (stiffness) can make coughing and swallowing difficult. This can cause aspiration pneumonia to develop. Aspiration pneumonia occurs as a result of inhaling the secretions, or contents, of the stomach, which can lead to a lower respiratory tract infection.

Laryngospasm

Laryngospasm is where the larynx (voicebox) goes into a brief, temporary spasm that usually lasts for between 30-60 seconds. Laryngospasm prevents oxygen from reaching your lungs, making breathing difficult.

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Signs and symptoms in the textbook

Signs and symptoms manifested by the

patientIrritability/ Restlessness muscle cramps

Weakness

difficulty swallowing

Lockjaw

Stiffness

Reflex spasms

↑Blood pressure

↑temperature

Irregular heart beatSweating

Seizure

Tetanic seizures

Tetanic seizures are convulsions (fits) that are similar to epileptic fits. They can occur in severe cases of tetanus where the infection has spread to the brain. Someone with a severe tetanus infection may experience severe and frequent tetanic seizures.

Pulmonary embolism

A pulmonary embolism is a serious and potentially life-threatening condition. It is caused by a blockage in a blood vessel in the lungs that can affect breathing and circulation. It is therefore vital that treatment is given immediately in the form of anti-clotting medication and, if required, oxygen therapy.

Acute renal failure

The severe muscle spasms that are associated with a tetanus infection can cause a condition that is known as rhabdomyolysis. Rhabdomyolysis is where the skeletal muscles are rapidly destroyed, resulting in myoglobin (a muscle protein) leaking into the urine. This can lead to acute (severe) renal failure (kidney failure).

Preventing tetanus

Immunisation is the best way to prevent a tetanus infection from occurring. The complete course of the tetanus vaccination consists of five doses. The vaccine enables your body to create antibodies against the tetanus toxin (tetanospasmin), providing protection from the illness should you be exposed to the Clostridium tetani bacterium in the future.

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Pathophysiology

[Patient centered]

37

TETANUS

Clostridium tetani enters body through a wound

Anaerobic conditions allow germination of sporesand production of toxins

Toxins are produced and disseminated via blood and lymphatics

Tetanospasmin enters the nervous system peripherally at the myeoneural junction and is transported centripetally into neurons of CNS

Interfers with neurotransmitter release to block inhibitors

Leads to unopposed muscle contraction and spasm

Lockjaw ↑BPStiffness ↑temperatureNeck rigidity sweatingDysphagia SEIZURE causingRestlessness opisthotonosReflex spasms

Lockjaw ↑BPStiffness ↑temperatureNeck rigidity sweatingDysphagia SEIZURE causingRestlessness opisthotonosReflex spasms

AgeSex

LifestyleDental infection

Aspiration Pneumonia

Hypertension

Aspiration Pneumonia

Hypertension

CONCEPT MAP

39

Impaired physical mobility r/t

neuromuscular impairment

88

Disturbed sleep pattern r/t excessive

environmental stimuli

77

Urinary incontinence r/t bladder outlet

obstruction

66Altered thermoregulation:

Hyperthermia r/t tissue trauma 2o presence of C.

tetani

55

Impaired swallowing r/t pharyngeal muscle

spasm

44

Acute pain r/t muscle rigidity 2o unopposed muscle contraction

11Ineffective breathing

pattern r/t impaired lung muscle contraction

33Ineffective airway clearance r/t retained

and excessive secretions

22

Cc: Difficulty of swallowing

Dx: Tetanus stage 3

Cc: Difficulty of swallowing

Dx: Tetanus stage 3

NURSING CARE PLAN

ASSESSMENT NURSING

DIAGNOSIS PLANNING INTERVENTION RATIONALE

NURSING THEORY

EVALUATION

Subjective

“Gatiskog naman siya kung makibot o masilawan” as verbalized.

Objectives:

RR= 30bpm BP= 140/100

mmHg (+) Facial grimace (+) Guarding (+) diaphoresis (+) lockjaw (+)muscle spasm (+)periodontal

infection (+)hyperextension

of head

Acute pain r/t muscle rigidity 2o

unopposed muscle

contraction

After nursing interventions, will

demonstrate a reduction in pain behaviors such as absence of facial

grimace and guarding.

Independent:

1. Handled the client’s body gently while doing nursing activity.

2. Minimize movement and dimmed light provided.

3. Maintained side rail up.

Depedent :

To promote safety and allows experience less pain during care activity.

To promote rest and avoid excitation of neurons leading to muscle contractions.

To ensure safety when seizure and muscle rigidity occurs.

Treats moderate

Lydia Hall’s Care, Core,

Cure

Florence Nightingale’s

Environment Theory


Environment Theory

Goal was met.

(-) guarding behavior

40

1. Administered Tramadol 50 mg

IV as ordered

2. Diazepam 5mg intravenously given as ordered.

3. Metronidazole, 500mg , given intravelnously as prescribed.

4. Tetanus Immune Globulin 250/amp 4amps deep IM given as ordered

to moderately severe pain

It is a muscle relaxant. That helps reduce muscle contractions causing pain.

Treatment of bacterial infection caused C. tetani

Prophylaxis against tetanus

Ernestine Weidenbach’s Prescriptive

Theory


Theory


Theory


Theory

41

ASSESSMENT NURSING


NURSING THEORY

EVALUATION

Subjective:

“Ginabudlayan siya mag ginhawa” as verbalized by the folks.

Objectives:

RR=30 bpm AR=120bpm (+) crackles (+)productive

cough (+)restlessness (+) drooling (+) impaired

swallowing X-ray results

shows Bilateral pneumonia and bronchiectasis

Ineffective airway clearance r/t retained and

excessive secretions

To maintain a patent airway

be able to demonstrate

effective coughing and clear breath

sounds.

Independent: 1. Suctioned

secretions as needed.

2. Elevated head of

the bed/ change

position every

2hours

3. Kept the

environment

allergen free like

dust.

4. Encouraged deep

breathing and

coughing

exercise.

5. Position head

To maintain patent airway and prevent aspiration.

To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage.

Precipitators of allergic type respiratory reactions that can trigger onset of acute episodes.

To promote oxygenation and maximize effort.

Virginia Henderson’sBasic Care Component


Environment Theory


Environment Theory

Virginia Henderson’sBasic Care Component

Goal was partially met.

RR decreased to 24 bpm but still with

crackles.

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midline with

flexion.

Depedent :

1. Administered Fluimucil 600 g/tab in 50 cc diluents as prescribed.

Collaborative:

1. Combivent nebulization done by pulmo-aide.

To open or maintain open airway.

Is a mucolytic that helps for easy expectoration.

Acts as bronchodilator to promote effective airway passage.


Environment Theory


Theory


Theory

ASSESSMENT NURSING


NURSING THEORY

EVALUATION

43

Subjective:

“Ginabudlayan siya mag ginhawa” as verbalized by the folks.

Objectives:

RR=30 bpm AR=120bpm (+) Labored

breathing (+)restlessness (+) drooling (+) impaired

swallowing (+) nasal flaring X-ray results

shows Bilateral pneumonia and bronchiectasis

Ineffective breathing pattern r/t

impaired lung muscle

contraction

To demonstate ability to breathe

comfortably as evidienced by

normal respiratory rate of 16-20 bpm.

Independent:

1. Suctioned secretions as needed.

2. Elevate head of bed/ placed on high back rest.

3. Assisted in taking control of breathing

Dependent:

1. Administered oxygen at 4Lpm as ordered.

Collaborative:

2. Combivent nebulization done by pulmo-

To maintain patent airway and prevent aspiration.

Elevation of head may decrease dyspneic episodes. An upright position facilitates lung expansion.

It can be a helpful technique in maximizing respiratory function

Oxygen therapy helps decreased dyspnea.

Acts as bronchodilator to


Cure


Environment Theory

Dorothea Orem’s

Self-care Deficit


Theory


Goal was partially

met.RR lowered down to 24

bpm.

44

aide. promote effective airway passage .

Theory

ASSESSMENT NURSING


NURSING THEORY

EVALUATION

Subjective:

“ Nabudlayan siya magtulon ” as verbalized by the folks.

Objectives:

(+)lockjaw (+)restlessness (+) drooling (+) impaired

swallowing (+)hyperextesion of

head (+)gum bleeding

Impaired swallowing related to

pharyngeal muscle spasm

After nursing intervention patient will

demonstrate effective

swallowing without muscle straining.

Dependent:

1. Nasogastric tube inserted by ROD

Independent:

2. Provided meals in a quiet environment away from excessive stimuli.

To provide parenteral feeding in adequate amount.

The client can achieve a more effective swallow by focusing on chewing and moving foods/fluids to the back of the mouth where the swallowing reflex is triggered.


Cure


Environment Theory

Virginia Henderson’s

Goal was partially

met.Able to open

his mouth.

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3. Have suction equipment available during feeding.

4. Kept with an upright position for 15mins to an hour after meal.

5. Instructed family how to monitor and detect aspiration after eating.

For aspiration precaution.

This position uses gravity to aid in the flow of foods/fluids through the esophagus.

For the family to be aware for any situation so that we can avoid aspiration even when nurses are not in their room

Basic Care Component


Environment Theory


Cure

46

ASSESSMENT NURSING


NURSING THEORY

EVALUATION

Subjective:

“Gina lagnat siya” as verbalized by the folks.

Objectives:

T=38.2oC (+) body

weakness (+)flushed and

warm skin (+) sweating (+) shivering (+) periodontal

trauma WBC=11.9 x

10^9/L

Altered thermoregulation: Hyperthermia r/t tissue trauma 2o

presence of

C. tetani

To lower down body

temperature to 37.5oC after 2

hours of nursing interventions.

Independent:

1. Tepid sponge bath done.

2. Room’s temperature cooled down.

3. Provided thick-wool blanket to prevent further chills.

4. Dimmed the light and provided a peaceful environment for rest. Minimized stimulus.

Depedent :

4. Paracetamol 500

It lower down body temperature.

A consistent temperature limits environmental effects on thermoregulation

This will help maintain a normal body temperature and prevents shivering.

Promotes rest and relaxation , and prevents from disturbances.

Antipyretic that treats fever, by


Cure


Environment Theory


Environment Theory


Environment Theory

Ernestine

Goal was met.

Body temp. is 37.3oC.

(-) Shivering

47

mg, 1 tab given orally as ordered.

5. Administered Metronidazole 500 mg intravenously as ordered.

lowering down body temp.

An antibiotic used to treat infection caused by anaerobic C. tetani.

Weidenbach’s Prescriptive

Theory


Theory

ASSESSMENT NURSING


NURSING THEORY

EVALUATION

48

Objectives:

Urine volume/fluid output= 40 cc within 8 hours.

(+) body weakness (+) muscle rigidity Creatinine= HI

161.8 umol/L TPSA=7.31mg/ml

Urinary incontinence r/t bladder

outlet obstruction

After nursing interventions, will void urine volume of at least 30 cc every hour.

Dependent:

1. Foley Catheter inserted as ordered.

2. Administered Tamsulosin 20cc intravenously as prescribed.

3. Solfenacin 5mg 1tab given via NGT as ordered.

Independent:

1. Implement measures to ensure the patency (e.g. keep tubing free of kinks, keep collection bag below bladder level)

2. Encourage fluid intake in small amount frequently.

To promote adequate urine elimination.

Helps to manage urethral stones and improves the flow of urine

Smoothen urethral muscle and relieved symptoms of urge urinary incontinence

Maintaining patency of the indwelling catheter prevents urinary incontinence

Drinking a large amount of fluid at one time results in rapid filling of the bladder which increases


Basic Component


Theory


Theory


Environmental Theory


Cure

Goal was met.Urine

output=300 cc after 8 hours

49

3. Provide an environment that encourages toileting.

pressure in the bladder and the subsequent risk of incontinence

Environmental factors may contribute to functional incontinence.



ASSESSMENT NURSING


NURSING THEORY

EVALUATION

50

Subjective:

“Madali siya makibot sa gasulod, ga tiskog naman siya, hindi siya katulog ” as verbalized by the folks.

Objectives:

(+) too much visitors

(+) disturbed sleep

(+) Weakness (+) Lethargic (+) Irritable (+)

hyperextension of head

(+) body stiffness

Disturbed sleep pattern r/t excessive

environmental stimuli

After nursing interventions,

will able to have undisturbed

sleep with long intervals.

Independent:

1. Keep environment quiet for sleeping, eliminate noise.

2. Perform nursing procedures all at the same time if possible before patient to go to sleep.

3. Adjusted lighting by dimming the lights.

Dependent:

1. Administered Diazepam 50mg intravenously

Provides more relaxing and comfortable environment for sleeping.

Reduces disturbances in sleeping.

Light may alter or disturb patient’s sleep.

Acts as muscle relaxant and an anxiolytic.




Basic Component




Theory

Goal was met.

Slept at long intervals

undisturbed.

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ASSESSMENT NURSING


NURSING THEORY

EVALUATION

Subjective:

“Di na siya kahulag mayad indi parehas sadto ” as verbalized by the folks.

Objectives:

(+) body weakness

(+)Reluctance to attempt movement.

(+)Limited range of motion.

Decreased muscle strength.

Impairedphysicalmobility

r/t neuromuscular

impairment.

After 16 hours (2 days 6-2

shift)of nursing

interventions, the

patient willmaintain or

increasestrength andfunction ofaffected or

compensatory

body part.

Independent:

1. Evaluate or continuouslymonitor degree ofpain.

2. Maintain bed rest or chair rest when Indicated. Schedule activities providing frequent rest periods and uninterrupted night time sleep.

Assist with active or passive range of motion.

4. Encourage patient tomaintain uprightand erect posturewhen sitting,standing, or walking.

Level of activity or exercise depends onprogression and resolution

Systemic rest during cuteattacks and important throughout all phases ofdisease to reduce fatigueand improve strength

Maintains or improves joint function, musclestrength, and generalstamina.

Maximizes joint function,maintains mobility that can precipitate acute attack.


Basic Component



Hildegard Peplau’s

Interpersonal Theory of Nursing



Goal was not met.

(+) body weakness

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Discharge Planning

Mr. F.B’s family decided to go home even though he was not in good condition, and they have signed a DAMA- Discharged Against Medical Advice. Nevertheless the following discharge planning was formulated:

MEDICATIONS

The following medications must be comply:

-Metronidazole 500mg 1 tab q8 (10am – 6pm – 2am) -Acetylcysteine (Fluimucil)) 600g / 1 tab in 50cc OD -Telmisartan (Micardis) 40mg 1 tab OD -Tramadol 50mg 1 tab q4 PRN for sever pain -Omeparazol (Prosec) 20mg / 1 tab BID -Digoxin 0.25g 1 tab OD (7am) -Moxiflacin (Avelox) 400mg 1 tab OD

EXERCISE AND ACTIVITY

-Advise folks to assist the patient in doing passive range of motion -Instructed folks to avoid stressful activities for patient -Let the folks provide healthy hygiene to the patient -Encourage to seek psychological support and social group therapy

TREATMENT

Nebulization treatment must be resume upon discharge and continuous Oxygen therapy is needed by Mr. F.B

HOME TEACHINGS

-Educate the folks about what is Tetanus and on how to take the prescribed medication of the patient

-Advice the folks to let the patient sleep in long intervals and avoid to much stressor to the patient

-Teach the folks on what are the possible side effects and effects of the medication to the patient

OUT PATIENT FOLLOW-UP

Mr. F.B’s condition requires thorough medical attention, he shall have a recommended return visit at the hospital. He was encouraged to comply patient follow-up.

DIET

Mr. F.B was discharged with NGT attached for his parenteral feeding. An OTF 1600 cal shall be divided into 6 equal feedings

SPIRITUALITY

Advise folks to seek spiritual help from priests, nuns any religious organization member they know in the society for spiritual counseling

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BIBLIOGRAPHY

Smeltzer, S., Bare, B., Hinkle, J. & Cheever, K. (2008). Brunner &

Suddarth’s Textbook of Medical-Surgical Nursing, 11th Ed. Lippincott

Williams & Wilkins.

Seeley, R., Stephens, T. & Tate, P. (2007). Essentials of Anatomy &

Physiology, 6th Ed. McGraw-Hill.

Bickley, L. (2007). Bates’ Pocket Guide to Physical Assessment & History

Taking, 5th Ed. Lippincott Williams & Wilkins

Karch, A. (2009). 2009 Lippincott’s Nursing Drug Guide. Lippincott

Williams & Wilkins.

Octaviano, E. & Balita, C. (2008). Theoretical Foundations of Nursing: The

Philippine Perspective. Ultimate Learning Series

www.wikipedia.org

www.doh.gov.ph

www.eMedicine.com

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Tetanus Case Study

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