Nursing Care Plan for Tetanus

History of present illness: a severe injury, burns and inadequate immunization.

*Respiratory System: dyspnea, cyanosis and asphyxia due to respiratory muscle contraction.

Cardiovascular System : dysrhythmias, tachycardia, hypertension and bleeding, initially the body temperature 38-40 ° C or febrile up to the terminal 43-44 ° C.

Neurologic System: irritability (early), weakness, convulsions (late), paralysis of one or several nerves of the brain.

Urinary System l: urinary retention (bladder distension and urine output does not exist / oliguria)

Digestive System: constipation due to no bowel movements.

Integument and muskuloskletal System: pain, tingling at the site of injury, sweating, initially trismus, muscle spasms face with increasing contraction eyebrows, risus sardonicus, stiff muscles and difficulty swallowing.

If this continues there will be the status of general convulsions and seizures.

Nursing Diagnosis for Tetanus

Ineffective airway clearance related to the accumulation of sputum in the trachea and respiratory muscle spasms.

Breathing pattern disorders related to impaired airway due to spasm of respiratory muscles

Increased body temperature (hyperthermia) related to the effects of toxins (bacteremia)

Changes in nutrition, less than body requirements related to the mastication muscle stiffness

Disturbed interpersonal relationships related to speech difficulties

Impaired daily needs related to the condition of weak and frequent seizures

The risk of fluid and electrolyte imbalances related to intake of less and oliguria

Risk of injury related to frequent seizures

Lack of knowledge of the client and family about tetanus disease related to lack of information.

Lack of rest requirements related to frequent seizures.

Hope so it may help you.

Thank you.