ACTIVITY 2: Communicable Disease

ACTIVITY #2: CASE STUDY

Tetanus

CASE
A 54-year-old Caucasian boy presented with one-week history of general malaise, mild fever, indolence
and anorexia. He subsequently developed dysphagia, sialorrhoea, difficulties opening the mouth and
eventually dehydration. Due to parental concerns about the boy’s refusal of fluids, a pediatrician was
consulted. At that time of presentation, he shows signs of trismus and muscle rigidity. Together with the
lack of immunization and a toe nail infection, this leads to the suspicion of a generalized tetanus infection
(Generalized tetanus in a 4-years old boy presenting with dysphagia and trismus: a case report, Rudolf,
et.al.).
After sedation, endotracheal intubation and ventilation, passive immunization and initiation of
antimicrobial treatment, he was immediately transferred to a pediatric intensive care unit (PICU) for
further treatment. The frequency and severity of paroxysmal muscle spasms increased progressively
during his PICU stay, despite high doses of sedatives. Not before two weeks after admittance, extubation
and careful weaning off sedatives was achieved.

RELEVANT FACTS
Tetanus infection is caused by the bacteria Clostridium Tetani, which releases toxin after
invading the body. This type of bacteria is commonly found in soil, especially with manure fertilized,
animal feces, human feces, dust, plaster of paris, unsterile sutures, pins, rusty materials, or scissors. In the
case scenario, the 4-year-old boy acquired the infection through a possibility of stepping on a rusty nail
which penetrated with the skin of his toe. Moreover, in newborn victims of this infection, usually acquire
the bacteria through improper performing of aseptic technique to newborn’s umbilical cord after birth,
promoting the bacteria to enter the baby’s body. In adults and children, it primarily causes a person to
experience locking of neck ang jaw muscles, thus also known as “lock jaw” disease.
As the patient in the case scenario experienced, the signs and symptoms of this infection includes
body malaise, mild fever, indolence and anorexia. Moreover, he also developed dysphagia, siallorhoea or
excessive salivation or drooling, difficulties in opening the mouth and dehydration. Thus, the said
symptoms, correlates with the effects brought by the infection which causes trismus or spasms and
rigidity to the muscle of the jaw and neck. The inability to move their mouth and inability to swallow will
then cause the dehydration of the patient. In addition, other symptoms may occur or may be expected to
occur to the patient such as:

 Risus Sardonicus – having grinning expressions which is considered as the primary or

pathognomonic sign of tetanus infection;
 Tachycardic;
 Profuse sweating (also cause patient’s dehydration);
 Abdominal rigidity;
 Laceration of the tongue and buccal mucosa due to severe dehydration and toxins; and
 Septicemia – blood poisoning caused by bacteria.

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ACTIVITY 2: Communicable Disease
Other symptoms may also occur when the infection was not timely managed and reached the
severe stage such as:

 Intermittent convulsions for several minutes which commonly results for a patient to become
cyanotic and experience asphyxiation into death;
 Laryngospasms (spams to the larynx) causing the blockage to the airway due to increased
accumulations of secretions in lower airways or hypoxia, and atelectasis (collapse of the lungs);
 Coma and death caused by fracture in the vertebrae; and
 Death after 10 days (fatal cases).

KEY PROBLEMS
1. Lack of Immunization: Tetanus vaccines is important and is highly recommended to every child
to receive immunization against tetanus after birth. In the case of the 4 years old boy infected
with tetanus, he may receive DTaP or DT vaccines.
2. During the first one week of the infection, the boy experienced general malaise, mild fever and
anorexia.
3. After the first week, there is a development of dysphagia, sore throat and sialorrhoea, difficulties
of opening the mouth causing dehydration. During this time of signs and symptoms, the parent
may also consider to have consultation with an otorhinolaryngologist which may consider a
peritonsillar abscess for the boy’s condition. Certain examinations will be performed and will not
show and provide any clues for the boy’s condition as it is caused by the tetanus.
4. During the assessment with the physician, it is found that the boy had already developed trismus
and muscle rigidity. Trismus and muscle rigidity means that the boy is currently experiencing
spasms to the muscle of his jaw causing it to lock, and causing other facial and neck muscles to
become immovable.
5. The presence of toe nail infection. This may become a sign where the suspected tetanus infection
has started and where the bacteria had entered into the boy’s body.

POSSIBLE SOLUTIONS

 Prevention and Control

As tetanus can be easily acquired from different sources such as soil, rust dust and others, vaccines
are administered to lower and diminish the possible serious signs and symptoms that the bacteria may
cause to an infected person. There are four kinds of vaccines that are used today for the protection against
the tetanus infection such that:
o Diptheria and tetanus (DT) vaccines
o Diptheria, tetanus and pertussis (DTaP) vaccines
o Tetanus and diptheria vaccines (Td) vaccines
o Tetanus, diptheria, and pertussis (Tdap) vaccines

To the case of the boy, DTaP or DT vaccines can be given, while Tdap and TD vaccines are
given to individual 8 years old and above.

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ACTIVITY 2: Communicable Disease
 Treatment
Two types of treatment can be given to the patient with tetanus infection.
1. Specific
a. Tetanus Antitoxin (ATS) as prophylaxis for the risk of infected wounds, or Tetanus
Immune Globulin (TIG) to help in removal of unbound tetanus toxins.
b. Tetanus toxoid – also use for prevention for it is also a vaccine used to provide
immunity against tetanus.
c. Pen G Na (Penicillin G Sodium) - works in stopping the growth of Clostridium
tetani.
d. Muscle relaxant controls such as:
i. Valium (Diazepam) – a sedative that is usually used for anxiety, but is also
commonly used for tetanus infection for relaxing of muscles
ii. Thorazine – a tranquilizer reducing muscle spasms
2. Non-Specific
a. Oxygen inhalation – Clostridium tetani bacteria cannot grow in the presence of
oxygen for it is an anaerobic bacterium.
b. NGT feeding – it helps to provide food for the patient through tubing for he cannot
be able to chew and swallow foods and waters.
c. Tracheostomy (if needed)
d. Adequate fluid, electrolyte and caloric intake

 Nursing Management
Nursing Assessment
1. Assess for the present of current symptoms of the patient.
2. Assess patient for physical examination including the Respiratory, Cardiovascular, Neurologic,
Urinary, Digestive, Integumentary and Muscular System.
3. Assess for history of present illness including severe injuries such as burns and inadequate
immunization.
4. Assess for the possible general convulsions and seizures of the kid.
Nursing Plan
1. To induce the symptoms of tetanus and treat the infection.
2. To ensure understanding of the client and support persons with the prevention techniques of
tetanus infection.
Nursing Interventions
1. Monitor baseline and current vital signs.
2. Assess for the frequency and pattern of breathing.
3. Note if there is a presence of apnea, change in heart rate, muscle and skin color.
4. Maintain adequate airway.
5. Provide cardiac monitoring
6. Maintain IV line to treat dehydration.
7. Provide wound care in the toe nail.
8. WOF urinary retention
9. Provide optimal comfort measures.
10. Provide health teachings to the mother.
a. Discuss the importance of avoiding stimulation of muscles
b. Discuss the necessity for the avoiding of contractures and pressure sores.

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ACTIVITY 2: Communicable Disease
c. Discuss the importance of given immunization and why is it necessary to be given
after birth.
11. Give appropriate medication electrolyte supplements.
12. Monitor laboratory tests as indicated.
13. Give oxygenation as indicated.
14. Give medications as indicated.

REHABILITATION
Tetanus infection is a severe complication to one’s health. It can be a life-threatening disease,
especially to children who do not yet have complete developed antibodies and immunity to fight with the
infection. There is no cure for the tetanus. Nurses and physician focuses on the management of symptoms
and complications of the infection and focusing on subsiding it until the toxin from the bacteria was
resolve.
As part of the rehabilitation or recovery process a patient, especially with the child patient, it is
important to keep in tract with the monitoring of the important parameters or signs and symptoms, and
ensure that there will be no second occurrence of these symptoms. To do this, it is important to follow the
regimen prescribed by the physician, follow the health teachings given by the nurses, and remember
important concepts and techniques to prevent infections with other individuals at home. As support
persons, it is important to understand these necessary concepts such that having aseptic or sterilization
techniques at home, and providing children with necessary immunizations (some immunization or
vaccines, including DPT vaccines for children, can be acquired free through EPI program of the DOH).
On the other hand, as the nurse responsible, it is important to keep in tract the condition of the
patient, acquire every baseline data gathered every assessment and to be used to the following assessment
to monitor changes to prevent if any complications may occur.

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ACTIVITY 2: Communicable Disease
References:
Tetanus Vaccination | CDC
Serum Institute Of India - Tetanus Antitoxin (ATS)
What is the role of tetanus immune globulin (TIG) in the treatment of tetanus (lockjaw)? (medscape.com)
https://nurses-nanda.blogspot.com/2012/01/nursing-care-plan-for-tetanus.html
Tetanus - Symptoms and causes - Mayo Clinic

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