Nursing Care Plan | NCP Tetanus

Tetanus, or lockjaw, is a preventable but often fatal disorder that is caused by the bacterium Clostridium tetani, a spore-forming anaerobe. The bacterium exists in spore form in an aerobic environment until it is exposed to an anaerobic environment. The organism then changes to the vegetative form, multiplies, and produces neurotoxins.

When the tetanus bacteria enter an open wound, they multiply and produce a potent neurotoxin called tetanospasmin, which enters the bloodstream and acts on the spinal ganglia and central nervous system by interfering with the function of the postsynaptic inhibitory potentials. The anterior horn cells become overstimulated, thus resulting in excessive muscle contraction. Toxins may also act directly on skeletal muscle and cause muscle contraction. Complications include lung disorders such as pneumonia, pulmonary emboli, atelectasis, cardiac dysrhythmias, gastric ulcers, and flexion contractures. Tetanus results in approximately 5 deaths per year in the United States; death usually results from autonomic dysfunction such as extremes in blood pressure, cardiac dysrhythmia, or cardiac arrest.

Because C. tetani is commonly found in soil, tetanus is more common in agricultural regions. Any break in the skin or mucous membrane can result in a tetanus infection, but wounds that are contaminated with soil or those that produce a relatively anaerobic environment are at greater risk. Wounds that produce an anaerobic environment include those with purulent or necrotic tissue, puncture wounds, burns, gunshot wounds, animal bites, and complex fractures. Drug abusers who engage in “skin popping,” or subcutaneous injections, are also at risk for a tetanus infection.

Nursing care plan assessment and physical examination

Classically, patients have a dirty (often soil-contaminated) puncture wound or laceration and describe pain or paresthesia at the puncture site. A history of intravenous drug abuse, dental infection, umbilical stump infection (infants), or penetrating eye infection and inadequate tetanus immunization may also be reported. If the wound has been left untreated, early symptoms include difficulty chewing or swallowing. The patient may have a mild fever or painful muscle contractions or spasms in the affected region. Infants may be unable to suck.

Because most cases of tetanus result in a systemic reaction, inspect the patient for neuromuscular changes. Spasms begin in the facial and jaw muscles and

progress to muscles of the neck, extremities, and respiratory/pharyngeal regions. Muscles ultimately become rigid, with painful spasms in response to any external stimuli. You may note seizures, posturing, and muscle rigidity; during seizure activity, the patient is awake and in severe pain. Autonomic disturbances include diaphoresis, increased heart rate, cardiac dysrhythmias, and blood pressure fluctuations. Spasms of respiratory and pharyngeal muscles may make it difficult to maintain a patent airway. Patients may exhibit increased respiratory rate, increased inspiratory effort, poor lung expansion, and decreased airflow. Late findings include risus sardonicus (a grotesque, grinning expression), trismus (lockjaw), and opisthotonos (rigid somatic muscles that lead to an arched-back posture). With supportive care, signs and symptoms reverse after the toxin has been metabolized in about 6 weeks.

The family may feel guilty if the patient has not been vaccinated. Assess the patient’s and family’s levels of anxiety and their ability to cope. The length of hospitalization and the seriousness of the diagnosis place the patient and family at risk for alterations in growth and development. Assess levels of growth and development using age-appropriate milestones and developmental tasks as guidelines.

Nursing care plan primary nursing diagnosis: Ineffective airway clearance related to muscle spasms and trismus.

Nursing care plan intervention and treatment plan

To prevent tetanus, within 3 days of a puncture wound, patients with no previous tetanus immunization require tetanus immune globulin or tetanus antitoxin for temporary protection. Active immunization with tetanus toxoid is also provided. If the patient had a previous immunization more than 5 years before the injury, a booster injection of tetanus toxoid is warranted at the time of injury. Goals of treatment include neutralizing the toxin, preventing complications, and eliminating the source of the toxin. Human tetanus immune globulin is administered immediately. One-half of the dose is administered by infiltrating the wound, and the remaining half is administered intramuscularly into three limbs. Active immunity is given by administering tetanus toxoid at a site remote from the globulin injections. The affected wound is thoroughly débrided after the antitoxin has been administered. Cultures of the wound may be obtained at that time. Parenteral antibiotics (penicillin in particular if the patient has no allergies to the drug) are administered for 10 days.

Respiratory distress may necessitate intubation or tracheostomy and mechanical ventilation with supplemental oxygen. Nasogastric tubes are inserted to prevent gastric distension. Patients with difficulty swallowing may require nutritional support with total parenteral nutrition or enteral feeding by a nasogastric or nasointestinal tube.

Nursing care focuses on maintaining a patent airway, regular breathing, and adequate circulation and on providing comfort management, protection from injury, and psychosocial support of the patient and family. If muscle spasms or seizure activity places the patient at risk for airway compromise, use the chin lift or jaw thrust to maintain an open airway if possible. Insert an oral or nasal airway before seizures, but if the patient has lockjaw do not attempt to force an airway in place because you may injure the patient and worsen the airway patency. Have intubation and suction equipment immediately available at the bedside should the patient require it. Anchor the endotracheal tube firmly, and document the lip level of the endotracheal tube in the progress notes for continuity.

Institute seizure precautions as soon as the patient is admitted to the unit. Pad the side rails of the bed, and provide immediate access to oxygen, suction, intubation equipment, artificial airways, and a resuscitation bag. Place the patient in a quiet, dark room to reduce environmental stimuli. Position the patient who is unconscious or paralyzed from pharmacologic agents in a side-lying position and turn the patient every 2 hours.

Provide clarification of information about the patient’s diagnosis, prognosis, and treatment to the patient and family. Make sure that the family has adequate time for expression of their feelings each day. Support effective coping mechanisms and provide appropriate referrals to the chaplain, clinical nurse specialist, or counselor if the patient or family demonstrates ineffective coping behaviors.

Nursing care plan discharge and home health care guidelines

Teach the patient and family that tetanus is a preventable disease. Inform them of the appropriate immunization and booster schedule, and encourage them to follow it. Note that the patient may experience pain, tenderness, redness, and muscle stiffness in the limb in which the tetanus injection(s) is (are) given. Explain that the convalescent period following tetanus may be prolonged. The patient may need multidisciplinary rehabilitation and home nursing.