Student Nurses Community

ASSESSMENT

DIAGNOSIS

INFERENCE

SUBJECTIVE:
Im finding it
hard to breathe,
as verbalized by
the patient
OBJECTIVE:
>Cough with
sputum
> Dyspnea
> RR 30 br/min
>Ronchi
> Abnormal ABG
result
(respiratory
acidosis)

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

Clostridium tetani
enters the body
through wound

Spores release
bacteria that
spread in the body

Tetanospasmin is
produced

NURSING CARE PLAN Tetanus

PLANNING
After 24 hours of
nursing
intervention, the
patient should be
able to
experience
effective airway
as indicated by:
RR: 16-20 br/min
No nostril
breathing
Normal ABG
result

INTERVENTIONS
Independent:

nerve signals are

blocked from
spinal cord to
muscles causing
spasm (including
respiratory muscle
spasm)

Position the
patient; adjust the
position of head
extension.
Auscultate breath
sounds (assess for
Ronchi) every 2-4
hours.
Suction secretions
via mouth or
respiratory tract
Oxygenate
according to
doctors orders.
Monitor vital signs
every hour.
Watch out for the
onset of
respiratory
failure / apnea.
Dependent
Administer
secretion-thinning

RATIONALE

EVALUATION

The anatomy of the

head position of
the extension is a
way to align the
respiratory cavity
so that the process
of respiration is still
running smoothly
by removing the
blockage of the
airway. (clears the
airway)

After 24 hours
of nursing
intervention,
goal met.
Patients RR
lowered to 10
br/min; no
nostril
breathing was
noted and
ABG/laboratory
results
revealed
normal.

Ronchi shows an
upper respiratory
problem due to
fluid or respiratory
secretions that
covered most of
the respiratory
tract that need to
be removed to
optimize the
airway.

diaphragm and
laryngeal muscles
are affected +
profuse amounts
of secretions

unsecured airway

medication
(mucolytics) as
ordered

When you suction,

you provide
assistance in
clearing the airway
of secretions and
then simplify the
process of
respiration.
The provision of
adequate oxygen
can supply and
provide backup
oxygen, thus
preventing
hypoxia.
Dyspnea, cyanosis
is a sign of
breathing disorder
which is
accompanied by
decreased cardiac
work arising
tachycardic refill
time and capillary
length / time.
The inability of the
body in the
respiratory process

requires immediate
and critical
interventions by
using a breathing
support
(mechanical
ventilation).
These drugs can
thin the thick
secretions making
it easy to remove
and prevent
viscosity.