Title:

Tetanus
Prepared by: Ivan Manolo Randolf Quia III A.
Paguio RN

I. Introduction
A. Rationale for choosing the case
I prefer to use tetanus as my diagnosis for my case study to use
universal evidence based protocol for treating tetanus with any
type of hospital set up. In addition, this is an excellent case study to
utilize my clinical acumen and analyzed the treatment modalities that
should be implemented.

B. Learning Objectives
General objectives:
-This case study is designed for the nurses to become
practiced, well-informed and mannered in delivering holistic care
for patients
diagnosed with Tetanus
Specific objectives:
-Imply appropriate medical nursing management for Tetanus
-Be familiar with the pathophysiology of Tetanus
-Plan for a suitable nursing care

C. Background of the study

1. World Health Organization (WHO)
- Tetanus is a serious illness caused by bacteria. The bacteria live in
soil
and dust. They can also be found in saliva and manure.
The bacteria can get into the body through a deep cut. Tetanus causes the
muscles in the body to tighten. It can cause pain and threaten your life
2. Center for disease Control (CDC)
- Tetanus is an acute, often fatal, disease caused by an exotoxin
produced by the bacterium Clostridium tetani. It is characterized by
generalized rigidity and convulsive spasms of skeletal muscles. The
muscle stiffness usually involves the jaw (lockjaw) and neck and then
becomes generalized.
3. Epidemiology
In 2013 it caused about 59,000 deaths down from 356,000 in 1990.
Tetanus in particular, the neonatalform remains a significant public
health problem in non-industrialized countries with 59,000 newborns
worldwide dying in 2008 as a result of neonatal tetanus. In the United
States, from 2000 through 2007 an average of 31 cases were reported per
year.

WHO vaccine-preventable diseases: monitoring system.

2014 global summary
Incidence time series for Philippines.
Diseases

2013

2012

2011

2010

Diphtheria

107

24

181

2'920

1'536

6'538

6'368

23

62

254

100

926

77

131

166

126

1'069

1'537

1'140

Japanese encephalitis
Measles
Mumps
Pertussis
Polio
Rubella
Rubella (CRS)
Tetanus (neonatal)
Tetanus (total)
Yellow fever

II. Clinical Study

A. General Data
Name of Patient: EGP
Address: Brg. Calero City Malolos ( Capital ) Bulacan
Age: 25
Religion: Catholic
Civil Status: Single
Nationality: Filipino
Date of Birth: December 29, 1989
Date and Time of Admission: May 05,2015 10:05pm
Ward / Room: Adult Dept. (PAV 6) 244 - 1
Attending Physician: Dr. Rhonamarie A. Fulgar M.D
Final Diagnosis: Tetanus Stage II

B. Chief Complaint
Difficulty in opening mouth ( Trismus )

C. History of present illness

2weeks prior to admission patient had pricked a nail at planter
left foot consulted at clinic and diagnosed with Tetanus and
transferred at Provincial Hospital then giving tetanus toxoid then
referred to San Lazaro hospital

D. Past Medical History

(-) Allergy no known allergy
(-) HPN, Lung disease, Kidney disease, asthma

F. Familial History
Genogram

ARMAN
Grandfath
er

ATHENA
Grandmoth
er

JUAN
Grandfath
er
DOROTHY
Grandmoth
er

ERLIND
ERLIND
A
A
Mother
Mother
DM
DM &
&
HYPERTE
HYPERTE
NSION
NSION

DOMINADO
R
Father
HYPERTENSI
ON

LENCIO
LENCIO
41y/o
41y/o

HYPERTENSI
HYPERTENSI
ON
ON

RAMIL
40 y/o

RUSTIC
O
38y/o

HYPERTENSI
HYPERTENSI
ON
ON

RAYMO
ND
32y/o

ERWIN
25y/o

I. Physical Assessment
Finding
s

Value

Analysis

May 05, 2015

Measurement:
(HT,Wt)

BMI 20.7

5.7HT
132
Lbs

Normal BMI is 18.5 kg for males

(Lancet Magazine 2004;
363:157-64)

May 14, 2015

BMI 18.3
116
Lbs

Under weight below 18.5 kg

Npo doctors order

Actual Finding

Analysis and
interpretation (with
reference)

Skin

Light to deep brown, no

edema present;
birthmarks; no abrasion

No significant findings

Mouth

Cannot fully open mouth

Cause by tetanospasmin

Lips

Dry lips

Due to medication of
(metronidazole)

Abdomen

Abdominal muscle spasms

and rigidity

Cause by tetanospasmin

Upper
Extremities

Symmetrical in size and

length, no abnormalities,
fine hair equally
distributed

No significant findings

Lower
Extremities

Symmetrical in size and

length, no abnormalities,
fine hair equally
distributed , wound
(L)plantar

Break in the skin due to

nail prick

J. Patterns of
Functioning/Activities of
Daily Living

BEFORE HOSPITALIZATION

DURING HOSPITALIZATION

ANALYSIS &
INTERPRETATION

Eating Pattern: Eat

three From May 05- Weight loss due
to npo doctors
times a day

13 he is on
but more on NPO but may order

carbohydrate.

sip of water

Drinking
Pattern:

Drink more than Hindi na ako

8glass of water. nakakainom ng
tubig kasi naka
lock itong jaw
ko as stated by
patient.

Patient always
drink alot of
water but when
he was admitted
he is on NPO as
attending
physicians
order.

Bowel

Defecates once
daily in
adequate
amount, golden
brown in color

Urinatio According to the

patient he
n

urinates 5x daily.

Exercis
e and
activity

The patient way

of exercise is
walking from
work.

bago ako
magkasakit mga
once lang ako
dumudumi pero
ngayon wala na
As verbalized by
the client.
The patient
frequently urinates
approximately
1700ml to 2200ml.

The patient
doesnt have any
exercise nor
activities from the
date he was
admitted. He only
stand and walk a
little when he feels
to urinate.

Npo doctors
order
Due to present
condition.

No significant
changes.

The client have less

movement
compare to his
usual due to he
experienced
muscle contraction.

REST
/SLEEP

HYGIENE

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

The patient usually

take a bath and
brushed his teeth
twice daily.

patient have
long hours of
sleep due to
q4 medication
(diazepam)
but sometimes
complained of
disturbed
sleep due to
excessive
noise.
Relative also
perform sponge
bath.

client have
scheduled
diazepam that
will cause him
to fell asleep for
more than
required hours
of sleep needed.

Occasional
spasm due to
present
condition.

K. Laboratory Findings
CHEMISTRY

Result

Reference
Range

Result

Referen
ce

Blood Urea
Nitrogen

4.82mmol/L

2.50 6.43

13.50
mg/dL

7.0 -18.0

Creatinine

83.92 umol/L

53 115

0.95 mg/dL

0.6 1.3

Sodium

146.40
mmol/L

139 149

146.40
mEq/L

139
149

Potassium

3.06 mmol/L

3.5 5.5

3.06 mEq/L

3.5 5.5

Chloride

108.70
mmol/L

98 108

108.70
mEq/L

98 108

SGPT/AST

34.00 U/L

12 78

34.00 U/L

12 78

HEMATOLOGY

Result

UNIT

Reference

WBC

6.81

10^9/L

4.8 10.8

RBC

4.28

10^12/L

4.7 6.1

Hemoglobin

138

g/l

140 180

Hematocrit

0.420

MCU

96.8

Fl

82 98

MCH

32.3

Pg

28 33

MCHC

33.4

g/l

33 36

Platelet Count

301

10^9L

150 400

RDW

12.70

11.4 14.0

Neutrophil

45.80

40 - 70

Lymphocyte

38.00

19 - 48

Eosinophil

8.30

2-8

Monocyte

7.40

0 - 15

Basophils

0.50

0-5

0.42 0.52

L. Course in the ward

Assessmen Progress
t
note

Nursing
Action

Medication Laboratory

Day 1
05-05-15

Assessment
done with
difficulty
open mouth

-Tetanus
Toxoid 0.5ml
IM
-ATS 20,000
IV (- ) ANST
Metronidazo
le 500mg
TIV ( ) ANST
Q8
-Diazepam
1amp TIV at
4hrs
Paracetamol
300mg T>
37.5*c

Cant open
mouth

Trismus

-Blood
Chemistry
Hematology
report

Assessmen Progress
t
note

Nursing
Action

Medication Laborato
ry

Day 2
05-06-15

Assessing
patient needs;
continuity of
care

-Continue
medication
-HGT q12

Assessmen Progress
t
note

Nursing
Action

Medication Laborat
ory

Day 3
05-07-15

As per doctor
-Continue
order give
medication
medication and -HGT q12
monitor patient

Occasional
spasm

Occasional
abdominal
rigidity

Assessmen Progress
t
note

Nursing
Action

Medication

Day 4
05-08-15

As per
doctor order
give
medication
and monitor
patient

-Continue
medication
-Potassium 1
tab TID x2days
-Diazepam drip
q8
-may sips of

Occasional
abdominal
rigidity

Laborat
ory

Assessmen Progress
t
note

Nursing
Action

Medicine

Laboratory

Day 5
05-09-15

Perform
Tepid
sponge bath
the patient;
Take VS
Temp of
38.7c and
recorded.

-Continue
medication
-Diazepam
drip q24
-Start
Baclofen
10mg / tab
q12
-may sips of
water
Medicine

Laboratory

Afebrile

Assessmen Progress
t
note

Nursing
Action

Day 6
05-10-15

Told the
patient to
deep inhale
and exhale;
promote
safety of
patient

Abdominal
rigidity

-Continue
present
medication

Assessm
ent

Progr
ess
note

Nursing
Action

Medicine

Day 7
05-11-15

Occasi
onal
spasm

-Continuity
of care

-Diazepam q24
60+250cc
-IVF D5LR 1L to
D5NSS
-Lactulose 30 cc HS
if no bowel
movement > 3days

Assessm
ent

Progr
ess
note

Nursing
Action

Medicine

Day8
05-12-15

Afebril
e

Perform tepid
sponge bath
Vs: temp
38.7c and
recorded.

-Diazepam bolus
10mg IV
-Complete
Metronidazole ( 7
days )
-IVF rate to 60cc/hr

Laborator
y

Laborato
ry

III. Clinical Discussion of the

Disease

Anatomy:
Basal Ganglia where the substancia nigra and globus pallidus
secretes GABA and acetylcholine primarily found in the
nucleusbasalis of Meynert(in the basal forebrain) to the
forebrain neocortex and associated limbic structures.

Physiology:
GABA is the chief inhibitoryneurotransmitterin
themammaliancentral nervous system. It plays the principal
role in reducingneuronalexcitability throughout thenervous
system. In humans, GABA is also directly responsible for the
regulation ofmuscle tone.

Rusty or dirty nail

Penetrating injury (punctured wound)

Clostridium Tetani enters the body through a wound

Decreased oxygen in the tissues transforms two type of

toxins

TETANOSPAS
MIN
blocks the release
of GABA
(gamma
aminobutyric
acid) which
increases ACHs
& causes
contraction of
muscle-causes
increasing
excitability of
spinal cord
neurons and
muscle spasm

TETANOLYSI
N

Lockjaw (Actual)
Nuchal or neck
rigidity (Actual)
Dysphasia
Restlessness
Increases
temperature
(Actual)
eosinophils 8.3%
(Actual)
Increased : sign
of chronic
imflamation due
to
tetanospasmin
Seizure

Causes lysis of rbc

hemolytic toxin and
potentiates infection
but does not cause
disease process.
Actual laboratory
result low rbc 4.28
(Actual)and
hemoglobin 138
(Actual)

IV. Nursing Problem and

Prioritization
Cues

Nursing
problem

Ran
k

Justification

Subjective:
Yung na tabig ako nagulat ako
tapos biglang sumakit dibdib ko
nanigas tyan at muscle ng legs
ko sumakit mga 6 /10 as
stated by patient.

Acute pain

Facial grimace
and protective
gesture
(holding chest)
Indication that
patient was in
pain.

Objective:
He appears restless and
complaining of abdominal pain
(+)Facial grimace
(+)Protective gesture (holding
chest)
(+)Irritability

Cues

Nursing
Problem

Subjective:
Potential Risk
pasulpot
for injury
sulpot yung
paninigas ng
muscles ko sa
tyan at legs as
stated by client.
Objective:
-Muscles are
tight to touch.
-Patient unable
to move
-irritable facial
expression
-seen at edge of
bed

Rank

Justification

Occasional
muscle spasm
due to present
condition

V. Nursing Care Plan 1

Assessment

Diagnosi Planning
s

Subjective:
Yung na tabig ako
nagulat ako tapos
biglang sumakit
dibdib ko nanigas
tyan at muscle ng
legs ko sumakit
mga 6 /10 as
stated by patient ;
Administered
diazepam 10mg QID
as ordered by the
attending physician.

Acute
pain
related to
involunta
ry muscle
contractio
n due to
environm
ental
stimuli

Objective:
He appears restless
and complaining of
abdominal pain
(+)Facial grimace

Short
term:

Implementat Evaluati
ion
on

-Placed on
moderate
high back
After 1hr
rest.
nursing
-Encouraged
interventio deep
n the
breathing
patient
exercises.
relief from -Advice
pain
relative
to
avoid
excessive or
unnecessary
noise.

Hindi na
sya
ganon ka
sakit mga
2 out of
10
nalang
as stated
by the
client.

Assessmen Diagnos Planning

t
is

Implementati
on

Subjective:
pasulpot
sulpot yung
paninigas
ng muscles
ko sa tyan
at leg as
stated by
client.

-Ensure the
clients position
on the center
of the bed
-Maintained
side rails up
-Advised the
clients relative
to look after or
assist the client
every time he
moves or stand
out of bed.
-Educated the
client also the
relative about
the possible
injuries that
may cause by
muscle spasm

Objective:
-Muscles are
tight to
touch.
-Patient
unable to
move
-(+) Facial
grimace
-Seen at
edge of bed

Potential Short:
risk for
injury
-After 1hr of
nursing
intervention
the client
will be free
from injury

Evaluation

Patient
safely and
comfortable
on bed.

VI. Nursing Care Plan 2 (FDAR Method)

Date & Focus
Time

Data

Action

Response

05-08- Acute
15
pain
7:45am

Yung na tabig ako

nagulat tapos
bilang sumakit
dibdib ko at
nanigas tyan legs
ko mga 6 out of
10 as stated by
patient; vital sign
of bp 130/80; pr
108; IVF of
diazepam drip
60mg+250cc.

Assessment done
;position patient on a
comfortable
positioned;
encouraged deep
breathing exercises;
advice relative to
avoid excessive or
unnecessary noises;
administered
diazepam bolus 10mg
QID as ordered by
doctor.

From
moderate
pain
changed to
mild pain
of 2 out of
10

9:30am Potential
risk for
injury

pasulpot sulpot
yung paninigas ng
muscle ko sa tyan
at legs as stated
by patient; muscle

Placed on center of
bed on a comfortable
position; maintained
side rails up;
executed health

Patient
safe and
comfortabl
e on bed.

VII. Drug Study

Generi Dosage,
Mechanis
c/Bran Frequenc m of
d name y &
Actions
Route

Side
Effects

Nursing
Considerations

Metroni
dazole /
Flagyl

-Fever
-Headache
-Abdominal
cramping or
pain
-Dry mouth
-Dark urine
-Polyuria

-Administer with
food or milk to
minimize GI
irritation.

500mg
Q6
Intraveno
us

For
bacterial
infection
caused by
anaerobic
microorgani
sm

-May cause
dizziness or lightheadedness.
Caution patient or
other activities.
- Inform patient
that medication
may cause urine to
turn dark.

Generic/
Brand
name

Dosage,
Mechanism
Frequenc of Actions
y & Route

Side Effects

Nursing
Considerations

Diazepa
m/
Valium

10 mg
Q4
Intravenou
s

-Drowsiness
-Fatigue
-confusion
headache
-Constipation

-Monitor BP,
PR,RR prior to
periodically
throughout
therapy and
frequently during
IV therapy

For CNS
depressant
Muscle
relaxant Anti
anxiety and
anticonvulsa
nt

-Assess IV site
frequently during
administration,
diazepam may
cause phlebitis
and venous
thrombosis
-Advise patient
to notify doctor
immediately if
they have
abdominal pain

Generic/ Dosage;
brand
frequency
name
& Route

Mechanisom
of action

Gephulac 30 cc
Promotes
/
Night time if peristalsis
Lactulose no BM for
movement and
>3days
decrease
ammonia,
probably as a
result of
bacterial
degradation.

Side
Effectes

Nursing
Considerat
ion

-Abdominal
cramps
-Gaseous
distention
-Flatulence
-Nausea
-Vomiting

-Inform
patient
about side
effects and
tell him to
notify if
reaction
becomes
stronger.

Generic/bran
d name

Dosage;
frequency &
Route

Mechanisom
of action

Side Effectes

Nursing
Consideration

Baclofen
(Lioresal)

10mg
1 tab Q12
Per Orem

Decreased
frequency of
muscle
spasms

-Drowsiness
-Dizziness
-Tiredness
-Headache
-Nausea

-Avoid
vigorous
activity and
sudden
movements
-Eat frequent
small meals
-Effects
reversible;
will go away
when the
drug is
discontinued

Gene
ric/Br
and
name

Dosage,
Frequen
cy &
Route

Mechanism of
Actions

Side Effects

Nursing
Considerations

Omep
razole
/
Prilos
ec

40mg
OD
Intraveno
us

Suppress gastric
acid secretion by
specific inhibition
of
the hydrogenPotassium
enzyme system
at the
secretory surface
of
the gastric
parietal
cells; blocks the
final
step of acid
Production.

-Headache
-Abdominal
pain
- Nausea
- Vomiting
- Dry mouth
- Diarrhea

-Give medication
before meals,
preferably in the
morning for oncedaily dosing. If
necessary, also give
an antacid, as
prescribed
-Encourage patient
to avoid alcohol,
aspirin products,
ibuprofen, and foods
that may increase
gastric secretions
-Advise patient to
notify doctor
immediately if they
have abdominal pain

Generic/Br
and name

Dosage,
Frequency
& Route

Mechanism
of Actions

Side
Effects

Nursing
Considerations

Paracetamol

300mg
Q4
Intravenous

For
symptomatic
relief of pain
and fever.

-Decrease
Glucose
level
-Decrease
hemoglobin
-Decrease
hematocrit

- Advise patient
that drug is only
for short term
use and to
consult the
physician if
giving to children
for longer than 5
days or adults
for longer than
10 days.
- Warn patient
that high doses
or unsupervised
long term use
can cause liver
damage.

Generic/
Brand
name

Dosage,
Frequen
cy &
Route

Mechanis
m of
Actions

Side
Effects

Nursing
Considerations

KCL /
Potassiu
m
Chloride

1 tablet
BID
Pre Orem

Potassium
is
necessary
for the
conduction
of nerve
impulses in
such
specialized
tissues as
the heart,
brain, and
skeletal
muscle

Nausea,
vomiting
diarrhea
-Abdominal
discomfort
GI
obstruction,
GI bleeding
GI
ulceration
or
perforation

- Monitor I&O ratio and

pattern in patients
receiving the
parenteral drug. If
oliguria occurs, stop
infusion promptly and
notify physician
- Be alert for potassium
intoxication may result
from any therapeutic
dosage, and the
patient may be
asymptomatic
-Monitor patients
receiving parenteral
potassium closely with
cardiac monitor.
Irregular heartbeat is

VII. Discharge Planning

I. Medication
-Multivitamin 1x day for 30days

II. Exercise
-Advice patient to perform daily active range of motion
-Walking exercise.

III. Treatment
-Advice patient to eat rich potassium and caloric food
-Encourage to eat fruits and vegetables

IV. Health teaching

-Educate about what is Tetanus and on how to take the prescribed
medication of the patient
-Advice to let the patient sleep in long intervals and avoid to much stressor
to the patient
-Teach on what are the possible side effects and effects of the medication to
the patient
-Instruct a healthy hygiene to the patient

V. Out patient follow up

-Patient shallhavea recommended return visit at the hospital.
He was encouraged to comply patient follow-up.

VI. Diet
-Advice patient to eat dark leafy vegetable, banana, fish,
potato, squash

VII. Spiritual
-Advisetoseek spiritualhelpfrompriests,nunsany religious
organization member they know in the society for spiritual
counseling

IX. REFERENCES / SOURSE

1.
2.
3.
3.
4.

Sparkys & Taylors Nursing Diagnosis Reference Manual 7th Edition

Lancet Magazine 2004
http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/tetanus.pdf
Sauders 5th Edition 2011.
Preasons