St.

Anthony College of Roxas City
San Roque Extension, Roxas City 5800 Capiz, Philippines

Bachelor of Science in Nursing 4C- 2011

TETANUS
Xy-Za Roy Marie D. Albaña Glorie Anne D. Anisco Khris John V. Balbuena Charmaine Cheryl Iris V. Bellosillo Joanna Keith D. Batuigas April Rose D. Benitez Karen Kay D. Bulan Shiehon A. Ferraris Marie Ann B. Magbanua Free Van Roy Paclibar
Submitted by:

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 2

General objectives: 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 Be familiar with the pathophysiology of Tetanus. Be acquainted with the different drugs, its actions, and perform Plan for a suitable nursing care

clinical manifestations and risk factors.

obligatory nursing responses for each.

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

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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. 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: 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.
o

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 5

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.

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 InformationName: Mr. F.B. 6

Age: 78 Sex: Male Address: Dulangan Pilar, Capiz Civil Status: Married 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 A.B. experienced mild fever, coughs, and cold but manageable and treated with F.B. over the counter drugs like paracetamol and solmux. Pulmon He has no known ary allergies to food, drugs and animals. infectio Old age n 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

C.B. 85 HPN

L.B. 80 Goiter

F.B. Tetanus

7

M

Legends

Female

Male

Patient

Death

Patterns of Functioning Pattern Home Hospitalization
8

Breathing Pattern

No respiratory problems. Has Respiratory rates became never complained of any rapid, shallow breaths are breathing difficulty. noted. Difficulty of breathing is always claimed. Claimed to never been had a BP check-up before hospitalization. Usually sleeps at 9 pm and wakes up at 5 am. 8-10 hour sleep duration. Uses two pillow and comforter The average BP is 140/100 mmHg during hospital stay.

Circulation

Sleeping Pattern

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. With NGT, cannot tolerate to drink water because of lock jaw. He was been on parenteral feeding and has NGT upon admission. An OTF 1600 calories is divided into 6 equal feedings everyday.

Drinking Pattern

Usually drinks 8-10 glasses of water a day.

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.

Elimination Patterns a. Bowel b. Urination

Defecates once daily in Defecates for adequate amount, golden times a week. brown in color.

about

2-3

Urinates normally With urinary incontinence, a approximately 3-5x a day in week after his first an adequate amount. 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. 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.

Personal hygiene

9

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

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 BP= 140/100 mmHg 2. Height = 6’1 3. Weight= 88 kg CR= 104 bpm RR= 30 bpm

PHYSICAL ASSESSMENT
10

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 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. Nails are short and clean. Are pink in color and slightly curved with smooth and rounded edges. No clubbing of fingers noted. 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. 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. Distention of jugular vein noted. Breast are firm. No mass palpated. Both arms are weak. Can perform passive movements only. Respiratory rate of 24-34 breaths/min, shallow breaths in uniform rhythm. Occasional cough noted with whitish sputum. With supplemental O2 @ 4LPM. Well tolerated with O2 saturation ranging from 97-99%. Crackles is usually heard. Apical pulse at the left midclavicular line averaging at 86 11

Skin

Hair

Nails Head

Face Eyes

Ears

Nose

Mouth

Neck Breast Upper Extremities Chest Respiratory System

Cardiovascular

System Gastrointestinal System Genito-urinary System Musculoskeletal System

bpm. Skip beats not noted upon auscultation. Abdominal pain noted. With several attempts of bowel movements. Urinary catheter (French 14) intact on urethra and attached to urobag. Passes yellow colored urine in minimal amounts. 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 Speech Speaks in native language. He presently can not talk due to illness. Can speak only Hiligaynon when he was still able to talk. Has poor acuity to whispered voice. He is lethargic and irritable. Unable to express emotions.

Language

Hearing Mental status Emotional Status

LABORATORY RESULTS

June 05, 2010 12

Protein Metabolites and Electrolytes Test Creatinine Results HI 161.8 umol/L Normal Values 71.0 – 133.0 umol/L 137.0 – 145.0 mmol/L Significance of Abnormal Result May be due to dehydration. Hyponatremia may result from inadequate sodium intake or excessive sodium loss due to profuse sweating.

Sodium

LO 134.5 mmol/L

June 06, 2010 Lipids and lipoproteins Test Cholesterol Direct HDLC Results HI 5.21 mmol/L LO 0.86 mmol/L Normal Values 0.00 – 5.20 mmol/L 1.00 – 1.60 mmol/L Significance of Abnormal Result Indicates Hypercholesterolemia leading to Hypertension

June 16, 2010 Hematology Test Hematocrit Results LO 0.31 vol. (fr) Normal Values 0.42 – 0.52 Significance of Abnormal Result Low Hct suggest anemia, or hemodilution 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. Indicates fluid overload. An elevated WBC count indicates infection due to traumatized tissue. An elevated value (neutrophilia) occurs in response to bacterial infection. Normal A decreased value occurs with impaired lymphatic drainage. An elevated value occurs in response to infection. Normal 13

Hemoglobin

LO 103 g/L

130.0

Red Blood Cell Count White Blood Cell Count Segmenters Eosinophils Lymphocytes Monocytes Platelet

LO 3.61 x 10^12/L HI 11.9 x 10^9/L HI 0.86 0.01 LO 0.07 HI 0.06 380 x 10^9/L

4.2 – 5.4 x 10^12/L 4 – 10 x 10^9/L 0.50 – 0.65 0.01 – 0.04 0.25 – 0.30 0.02 – 0.05 140 – 400 x

10^9/L June 16, 2010 Urinalysis Test Color Transparency Reaction Sp. Gravity Protein Results Pale straw Hazy pH 6.0 1.020 trace Normal Values Straw to dark yellow clear 4.5 – 8.0 1.003 – 1.030 negative Significance of Abnormal Result Normal

Protein in the urine (proteinuria) may indicate hypertension. Normal Indicates bleeding Normal

Glucose Amorph. U/P RBC / hpf WBC / hpf Epithelial Cells Bacteria Yeast cells

negative few HI 11 – 20 / hpf 2 -7 / hpf Occassional Moderate many

negative 0 – 3 / hpf 0 – 5 / hpf None None 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.

Test

Results 7.31mg/ml

Normal Values normal: 03.72mg/ml

Significance of Abnormal Result Increased result shows prostatic impairment

TPSA

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June 7,2010 CT SCAN Cranial Plaw

Test

Impression 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.

Neurocranium

15

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.

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MEDICATIONS

NAME OF DRUG and DOSE Omeprazole 20mg 1 tab BID Brand Name: Prosec

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES

ACTION

Antisecretory drug Proton Pump Inhibitor

Suppresses gastric acid secretion by specific inhibition of the hydrogenpotassium 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 drug to is be observed, need may

discontinued.

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NAME OF DRUG and DOSE Moxifloxacin 400mg 1tab OD

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES

Brand Name: Avelox ACTION

Bactericidal; interferes with DNA replication, repair, transcription, and recombination in susceptible gramnegative and grampositive bacteria, preventing cell reproduction and leading to cell death.

Treatment of Infection 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 drugs. anion-containing

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

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NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES

Solfenacin 5mg 1tab

Brand Name: VESIcare

ACTION

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.

Muscarinic receptor entagonist Urinary antispasmodic

19

NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES 1. Administer once a day,

Tamsulosin 250 mg BID

Brand Name: Harnal

ACTION

Blocks the smooth muscle alpha1adrenergic 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.

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.

Alpha adrenergic blocker (peripheral acting)

20

NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES

Lactulose 20cc until BM occurs q8hours

Brand Name: Lactulose

ACTION

Ammonia reaction drug Laxative

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. MECHANISM OF ACTION

Treatment of constipation.

1. Transient flatulence 2. Distention 3. Intestinal cramps 4. Belching 5. Diarrhea 6. Nausea

Contraindicated with allergy to lactulose, lowgalactose diet.

1. Do not administer other laxative lactulose. 2. Monitor serum ammonia levels. while using

3. Carefully monitor blood glucose levels in diabetic patients.

NAME OF DRUG and DOSE

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES

21

1. Do not administer to Tetanus Immune Globulin 250/amp 4amps deep IM (stat) 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. 2. Administer 2 weeks before or 3 months after immune administration antibodies interfere vaccination. 3. Do not mix globulin with any other medications. 4. Monitor patient’s vital signs continuously and observe symptoms for during any IM 22 in with globulin because the the patients with history of allergy globulin antibodies. to or gamma anti A

immunoglobulin

Brand Name: Tetanus immune globulin

ACTION

globulin preparation may immune response to the

Immune globulin

administration. 5. Provide or to comfort teach provide to

measures patient comfort

measures

help patient to cope with the discomforts of drug therapy.

NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES 23

Tramadol 50mg IV q8 PRN for severe pain Brand Name: Tramal ACTION

Treats moderate to moderately severe pain and most types of neuralgia, including trigeminal neuralgia.

Treatment of acute to chronic pain.

1. 2. 3. 4. 5.

Nausea Vomiting Sweating Constipation 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.

Analgesic u-opiod receptor antagonist 3. Do not stop taking Tramadol without talking to the doctor

NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES

24

Pen G 4 mullion q6 ANST via soluset (8-2)

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

Brand Name: Pen G

ACTION

Antibiotic

NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES 25

Metronidazole, 500mg , IV q8 hrs.

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

Brand Name: Flagyl ACTION

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.

6. Fatigue 7. Incontinence 8. GI upset

Antiprotozoal

NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES

26

Telmisartan 40mg/12.5, I tab OD Brand Name: Micardis ACTION

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.

Angiotensin II receptor antagonist Antihypertensive

NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES

27

Diazepam 5mg IV q8

ACTION

Antiepileptic; Anxiolytic Skeletal muscle relaxant (centrally acting)

*Muscle relaxant: Acts mainly at the Adjunct for relief limbic system and of reflex skeletal reticular formation; muscle spasm mat act in spinal cord due to local to produce skeletal pathology or muscle relaxation; secondary to potentiates the trauma; effects of GABA, an spasticity caused inhibitory by upper neurotransmitter. motoneuron disorders *Parenteral: Treatment of tetanus

1. Drowsiness 2. Dizziness 3. GI upset 4. bradychardia

Contraindicated with hypersensitivity to benzodiazepines; psychoses, acute narrowangle 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.

NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES

28

Acetylcysteine 600g/1 tab in 50 diluent OD

Brand Name:
Fluimucil ACTION

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 bronchopulmonary 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.

Mucolytic

NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES 29

Bisacodyl Suppository 1 stick per rectum

Brand Name: Dulcolax ACTION

Laxative

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.

NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES

30

Paracetamol 500mg 1tab q4 PRN

Reduces fever by acting directly on the hypothalamic heatregulating 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 hypersensitivity reactions occur. 3. Check for temperature. if

body

ACTION

Antipyretic

NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES

31

Furosemide 5mg IV now

ACTION

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 and Output. Intake

Loop Diuretic

NAME OF DRUG and DOSE

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES 32

Digoxin 0.251 tab OD (7am)

ACTION

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.

Cardiac Glycoside

33

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 a number of antibiotics.

disinfectants,

and

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. 34

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.

35

Signs and textbook

symptoms

in

the

Signs and symptoms manifested by the patient         

Irritability/ Restlessness muscle cramps Weakness difficulty swallowing Lockjaw Stiffness Reflex spasms ↑Blood pressure ↑temperature Irregular heart beat Sweating Seizure

 

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. 36

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. 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.

37

Age Sex

Lifestyle Dental infection

Clostridium tetani enters body through a wound

Pathophysiology
Anaerobic conditions allow germination of spores andTETANUS toxins production of

[Patient centered] 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 Stiffness Neck rigidity Dysphagia Restlessness Reflex spasms

↑BP ↑temperature sweating SEIZURE causing opisthotonos

38 Aspiration Pneumonia Hypertension

39

CONCEPT MAP

2 Ineffective airway
clearance r/t retained and excessive secretions

1

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

3

Ineffective breathing pattern r/t impaired lung muscle contraction

8

Impaired physical mobility r/t neuromuscular impairment

Cc: Difficulty of swallowing Dx: Tetanus

4

stage 3
7 Disturbed sleep pattern r/t excessive environmental stimuli 5 6

Impaired swallowing r/t pharyngeal muscle spasm

Urinary incontinence r/t bladder outlet obstruction

Altered thermoregulation: Hyperthermia r/t tissue trauma 2o presence of C. tetani
40

NURSING CARE PLAN

41

ASSESSMENT 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

NURSING DIAGNOSIS

PLANNING

INTERVENTION Independent:

RATIONALE

NURSING THEORY

EVALUATION

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.

1. Handled client’s gently doing activity.

the To promote body safety and while allows nursing experience less pain during care activity.

Lydia Hall’s Care, Core, Cure

Goal was met.
(-) guarding behavior

2. Minimize movement dimmed provided.

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

Florence Nightingale’s Environment Theory

3. Maintained side rail up.

To ensure safety when seizure and muscle rigidity occurs.

Florence Nightingale’s Environment Theory

Depedent: 1. Administered Tramadol 50 mg IV as ordered 2. Diazepam 5mg intravenously given as ordered.

Treats moderate to moderately severe pain It is a muscle relaxant. That helps reduce muscle contractions causing pain. Treatment bacterial of

Ernestine Weidenbach’s Prescriptive Theory Ernestine Weidenbach’s Prescriptive Theory Ernestine

42

3. Metronidazole,

43

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

NURSING DIAGNOSIS

PLANNING

INTERVENTION Independent:

RATIONALE

NURSING THEORY Virginia Henderson’s Basic Care Component Florence Nightingale’s Environment Theory

EVALUATION

Ineffective airway clearance r/t retained and excessive secretions

Objectives: • • • • • • • • RR=30 bpm AR=120bpm (+) crackles (+)productive cough (+)restlessness (+) drooling (+) impaired swallowing X-ray results shows Bilateral pneumonia and bronchiectasis

To maintain a patent airway be able to demonstrate effective coughing and clear breath sounds.

1. Suctioned secretions needed.

To maintain as patent airway and prevent aspiration.

Goal was partially met.
RR decreased to 24 bpm but still with crackles.

take 2. Elevated head of To advantage of the bed/ change gravity position every decreasing 2hours pressure on the diaphragm and enhancing drainage. 3. Kept Precipitators of allergic type allergen free like respiratory dust. reactions that can trigger onset of acute episodes. environment To promote oxygenation and and maximize effort. the

Florence Nightingale’s Environment Theory

4. Encouraged deep breathing coughing exercise. 5. Position midline flexion.

Virginia Henderson’s Basic Care Component

head To

open or with maintain open airway.

Florence Nightingale’s Environment Theory 44

Depedent:

45

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

NURSING DIAGNOSIS

PLANNING

INTERVENTION Independent:

RATIONALE

NURSING THEORY Lydia Hall’s Care, Core, Cure

EVALUATION

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.

1. Suctioned secretions needed.

To maintain patent as airway and prevent aspiration.

Goal was partially met.
RR lowered down to 24 bpm.

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

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

Florence Nightingale’s Environment Theory Dorothea Orem’s Self-care Deficit

3. Assisted in It can be a helpful taking control of technique in maximizing breathing respiratory function

Dependent: 1. Administered oxygen at 4Lpm as ordered.

Oxygen therapy helps decreased dyspnea.

Ernestine Weidenbach’s Prescriptive Theory

Collaborative: 2. Combivent nebulization done by pulmoaide. Acts as bronchodilator to promote effective airway passage .

Ernestine Weidenbach’s Prescriptive Theory

46

47

ASSESSMENT Subjective: “ Nabudlayan siya magtulon ” as verbalized by the folks.

NURSING DIAGNOSIS

PLANNING

INTERVENTION Dependent:

RATIONALE

NURSING THEORY Lydia Hall’s Care, Core, Cure

EVALUATION

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.

1. Nasogastric tube inserted by ROD

To provide parenteral feeding in adequate amount.

Goal was partially met.
Able to open his mouth.

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

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. For aspiration precaution.

Florence Nightingale’s Environment Theory

3. Have suction equipment available during feeding. 4. Kept with an upright position for 15mins to an hour after meal.

Virginia Henderson’s Basic Care Component

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

Florence Nightingale’s Environment Theory

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

Lydia Hall’s Care, Core, Cure 48

49

ASSESSMENT Subjective: “Gina lagnat siya” as verbalized by the folks.

NURSING DIAGNOSIS

PLANNING

INTERVENTION Independent:

RATIONALE

NURSING THEORY Lydia Hall’s Care, Core, Cure Florence Nightingale’s Environment Theory Florence Nightingale’s Environment Theory

EVALUATION

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.

1. Tepid sponge bath done. 2. Room’s temperature cooled down.

It lower down body temperature. A consistent temperature limits environmental effects on thermoregulation

Goal was met.
Body temp. is 37.3oC. (-) Shivering

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

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

4. Dimmed the light and provided a peaceful environment for rest. Minimized stimulus. Depedent: 4. Paracetamol 500 mg, 1 tab given orally as ordered. 5. Administered Metronidazole 500 mg

Promotes rest and relaxation , and prevents from disturbances.

Florence Nightingale’s Environment Theory

Antipyretic that treats fever, by lowering down body temp. An antibiotic used to treat infection caused by anaerobic C. tetani.

Ernestine Weidenbach’s Prescriptive Theory

Ernestine Weidenbach’s Prescriptive Theory

50

51

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION Dependent:

RATIONALE

NURSING THEORY Virginia Henderson’s Basic Component Ernestine Weidenbach’s Prescriptive Theory Ernestine Weidenbach’s Prescriptive Theory

EVALUATION

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.

1. Foley Catheter inserted as ordered.

To promote adequate urine elimination.

Goal was met.
Urine output=300 cc after 8 hours

2. Administered Tamsulosin 20cc intravenously as prescribed.

Helps to manage urethral stones and improves the flow of urine Smoothen urethral muscle and relieved symptoms of urge urinary incontinence

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. Maintaining patency of the indwelling catheter prevents urinary incontinence

Florence Nightingale’s Environmental Theory

Drinking a large amount of fluid at one time results in rapid filling of the bladder which increases pressure in the bladder and the subsequent risk of incontinence Environmental factors may contribute to

Lydia Hall’s Care, Core, Cure

52 Florence Nightingale’s

3. Provide an environment that

53

ASSESSMENT 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

NURSING DIAGNOSIS

PLANNING

INTERVENTION Independent:

RATIONALE

NURSING THEORY

EVALUATION

Disturbed sleep pattern r/t excessive environmental stimuli

After nursing interventions, will able to have undisturbed sleep with long intervals.

1. Keep environment quiet for sleeping, eliminate noise.

Provides more relaxing and comfortable environment for sleeping. Reduces disturbances in sleeping.

Florence Nightingale’s Environmental Theory

Goal was met.
Slept at long intervals undisturbed.

2. Perform nursing procedures all at the same time if possible before patient to go to sleep. 3. Adjusted lighting by dimming the lights.

Virginia Henderson’s Basic Component

Light may alter or disturb patient’s sleep.

Florence Nightingale’s Environmental Theory

Dependent: 1. Administered Diazepam 50mg intravenously Acts as muscle relaxant and an anxiolytic. Ernestine Weidenbach’s Prescriptive Theory

54

Discharge Planning
Mr. F.B’s family decided to go home even though he was not in good ASSESSMENT Subjective: “Di na siya kahulag mayad indi parehas sadto ” as verbalized by the folks. Objectives: • • (+) body weakness (+)Reluctan ce to attempt movement. (+)Limited range of motion. Decreased muscle strength. After 16 Impaired hours (2 physical days 6-2 mobility shift) of nursing r/t interventio neuromusc ns, the patient will ular impairment maintain or increase . strength and function of affected or compensat ory body part. NURSING DIAGNOSIS PLANNI NG INTERVENTION Independent: 1. Evaluate or continuously monitor degree of pain. 2. Maintain bed rest or chair rest when Indicated. Schedule activities providing frequent rest periods and uninterrupted night time sleep. 3. Assist with active or passive range of motion. 4. Encourage patient to maintain upright and erect posture when sitting, standing, or walking. Virginia Level of activity or exercise Henderson’ s depends on Basic progression and Componen resolution t Systemic rest during cute attacks and important throughout all phases of disease to reduce fatigue and improve strength Maintains or improves joint function, muscle strength, and general stamina. Maximizes joint function, maintains mobility that can precipitate acute attack. Florence Nightingale’ s Environmen tal Theory RATIONALE NURSING THEORY EVALUATI ON

Goal was not met.
(+) body weakness

• •

Hildegard Peplau’s Interperso nal Theory of Nursing Florence Nightingale’ s Environmen tal Theory

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 55

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

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 & Bickley, L. (2007). Bates’ Pocket Guide to Physical Assessment & Physiology, 6th Ed. McGraw-Hill. History Taking, 5th Ed. Lippincott Williams & Wilkins

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• • • • •

Karch, A. (2009). 2009 Lippincott’s Nursing Drug Guide. Lippincott Octaviano, E. & Balita, C. (2008). Theoretical Foundations of Nursing: www.wikipedia.org www.doh.gov.ph www.eMedicine.com

Williams & Wilkins. The Philippine Perspective. Ultimate Learning Series

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