Tetanus Case Study

St.
Anthony College of Roxas City

San Roque Extension, Roxas City
5800 Capiz, Philippines
Bachelor of Science in Nursing

4C- 2011
TETANUS
Submitted by:
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 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
clinical manifestations and risk factors.
• Be familiar with the pathophysiology of Tetanus.
• Be acquainted with the different drugs, its actions, and perform
obligatory nursing responses for each.
• Plan for a suitable nursing care
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
4
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:
o 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.
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 Information-
Name: 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. A.B. Sometimes he
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.
Old age infectio
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
7
C.B. F.B.
L.B.
85
80
HPN Goiter Tetanus
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.
Circulation Claimed to never been had a The average BP is 140/100

BP check-up before mmHg during hospital stay.
hospitalization.
Sleeping Pattern Usually sleeps at 9 pm and Sleeps at 10 pm and wakes

wakes up at 5 am. 8-10 hour up at 6 am. Uses one pillow
sleep duration. Uses two and blanket. Disturbed sleep
pillow and comforter is usually complained
whenever excessive stimuli
is observed.
Drinking Pattern Usually drinks 8-10 glasses With NGT, cannot tolerate to
of water a day. drink water because of lock
jaw.
Eating Pattern Eats three times a day. He He was been on parenteral

eats more carbohydrate, feeding and has NGT upon
vegetables and adequate admission. An OTF 1600
protein. Mr. F.B isn’t fond of calories is divided into 6
using eating utensils since he equal feedings everyday.
is staying on his pond, he
eats using his bare hands.
Elimination Defecates once daily in Defecates for about 2-3

Patterns adequate amount, golden times a week.
brown in color.
a. Bowel
b. Urination 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 Morning care done with oral

operator requires a dirty and care of bactedol. Using
Personal hygiene heavy tasks. Takes a bath cotton and tongue
daily but isn’t fond of depressor.
brushing his teeth.
9
His walks from house to the No recreational activities.
fish pond which took almost Cannot tolerate to stand or
30 mins. is what they sit. Passive ROM exercises
Recreational and considered to be his daily done.
Exercise exercise. He drinks alcohol
and play ”tong-its” with his
friends.
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 CR= 104 bpm
BP= 140/100 mmHg RR= 30 bpm
2. Height = 6’1
3. Weight= 88 kg
PHYSICAL ASSESSMENT
10
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
General Appearance 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 Skin is brown in complexion, warm, and dry with poor
skin turgor. No pallor and edema.
Hair 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
Nails curved with smooth and rounded edges. No clubbing of
fingers noted.
Head is normocephalic, no palpable nodules or masses
Head noted. lesions are not noted.
Face is wrinkled due to old age. (+) Facial grimace and

Face
locking of jaw noted.
Anicteric sclerae with pupils round and black in color
Eyes 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;
Ears
(-) discharges and swelling, with poor acuity to whisper
voice. Cerumen not noted.
With presence of cilia. Has no discharges nor sinusitis.

Nose Nasal cannula attached to both nostrils at 4LPM. NGT is
attached (L).
Mouth 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.
Neck Distention of jugular vein noted.
Breast Breast are firm. No mass palpated.
Both arms are weak. Can perform passive movements

Upper Extremities
only.
Chest Respiratory rate of 24-34 breaths/min, shallow breaths
in uniform rhythm.
Respiratory System Occasional cough noted with whitish sputum.
With supplemental O2 @ 4LPM. Well tolerated with O2
saturation ranging from 97-99%.
Crackles is usually heard.
Cardiovascular Apical pulse at the left midclavicular line averaging at 86
11
System bpm. Skip beats not noted upon auscultation.
Gastrointestinal Abdominal pain noted. With several attempts of bowel
System movements.
Genito-urinary Urinary catheter (French 14) intact on urethra and
System attached to urobag.
Passes yellow colored urine in minimal amounts.
Musculoskeletal Restless at few times. Have been on seizure attacks.

Movements are weak. Cannot tolerate standing. Able to
System
sit on wheelchair. With weak handgrip.
GENERAL APPRAISAL
Speech Speaks in native language.

He presently can not talk
due to illness.
Language Can speak only Hiligaynon

when he was still able to
talk.
Hearing Has poor acuity to

whispered voice.
Mental status He is lethargic and

irritable.
Emotional Unable to express

Status emotions.
LABORATORY RESULTS
June 05, 2010
12
Protein Metabolites and Electrolytes
Significance of
Test Results Normal Values
Abnormal Result
71.0 – 133.0 May be due to
Creatinine HI 161.8 umol/L
umol/L dehydration.
Hyponatremia may
result from
Sodium LO 134.5 mmol/L 137.0 – 145.0 inadequate sodium
mmol/L intake or excessive
sodium loss due to
profuse sweating.
June 06, 2010
Lipids and lipoproteins
Significance of
Abnormal Result
0.00 – 5.20 Indicates
Cholesterol HI 5.21 mmol/L
mmol/L Hypercholesterolemia
1.00 – 1.60 leading to
Direct HDLC LO 0.86 mmol/L
mmol/L Hypertension
June 16, 2010
Hematology
Test Normal Significance of

Results
Values Abnormal Result
Hematocrit LO 0.31 vol. (fr) Low Hct suggest anemia,
0.42 – 0.52 or hemodilution
A decreased value of
hemoglobin can be caused
by low red blood cell count,
Hemoglobin LO 103 g/L 130.0 by a lack of hemoglobin in
the erythrocytes, which
also indicates fluid
retention.
Red Blood Cell LO 3.61 x 4.2 – 5.4 x Indicates fluid overload.
Count 10^12/L 10^12/L
HI 11.9 x 4 – 10 x An elevated WBC count
White Blood Cell
10^9/L 10^9/L indicates infection due to
Count
traumatized tissue.
An elevated value
Segmenters HI 0.86 0.50 – 0.65 (neutrophilia) occurs in
response to bacterial
infection.
Eosinophils 0.01 0.01 – 0.04 Normal
A decreased value occurs
Lymphocytes LO 0.07 0.25 – 0.30 with impaired lymphatic
drainage.
Monocytes HI 0.06 An elevated value occurs in
0.02 – 0.05
response to infection.
Platelet 140 – 400 x Normal
380 x 10^9/L
13
10^9/L
June 16, 2010
Urinalysis
Significance of
Abnormal Result
Straw to dark
Color Pale straw
yellow Normal
Transparency Hazy clear
Reaction pH 6.0 4.5 – 8.0
Sp. Gravity 1.020 1.003 – 1.030
Protein trace negative Protein in the urine
(proteinuria) may
indicate
hypertension.
Glucose negative negative
Normal
Amorph. U/P few
RBC / hpf HI 11 – 20 / hpf 0 – 3 / hpf Indicates bleeding
WBC / hpf 2 -7 / hpf 0 – 5 / hpf
Epithelial Cells Occassional None Normal
Bacteria Moderate None
Yeast cells many 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.
Significance
Test
Results Normal Values of Abnormal
Result
normal: 0- Increased
TPSA 7.31mg/ml
result shows
3.72mg/ml prostatic
impairment
14
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
Neurocranium 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.
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.
16
MEDICATIONS
NAME OF DRUG MECHANISM OF INDICATION SIDE EFFECTS CONTRAINDICATIONS NURSING

and DOSE ACTION RESPONSIBILITIES
Omeprazole 1. Headache 1.Administer drug before

Suppresses gastric GERD, frequent Hypersensitivity to
20mg 1 tab BID acid secretion by heartburn. 2. Nausea omeprazole and its meal is serve.
specific inhibition of 3. Vomiting components. 2. Monitor for any urinary
the hydrogen-
Brand Name: 4. Diarrhea elimination such as pain
potassium ATPase
Prosec enzyme system at the 5. Constipation or discomfort associated
secretory surface of 6. Abdominal Pain with urination.
the gastric parietal
7. Flatulence 3. If severe diarrhea is
ACTION cells; blocks the final
step of acid 8. Dry mouth observed, drug may
production. need to be
Antisecretory drug
discontinued.
Proton Pump
Inhibitor
17
NAME OF DRUG and MECHANISM OF INDICATION SIDE EFFECTS CONTRAINDICATIONS NURSING
DOSE ACTION RESPONSIBILITIES
Moxifloxacin 1. Continue therapy as

Bactericidal; Treatment of 1. Headache Contraindicated with
400mg 1tab OD interferes with DNA 2. Insomnia allergy to indicated for condition
Infection caused
replication, repair, by anaerobic fluoroquinolones, being treated.
3. Nausea
transcription, and bacteria. prolonged QT interval,
recombination in 4. Diarrhea hypokalemia.
Brand Name: susceptible gram- 2. Administer oral drug 4
Avelox negative and gram- hr before or at least 8
positive bacteria,
hr after antacids or
preventing cell
ACTION other anion-containing
reproduction and
leading to cell death. drugs.
Antibiotic
Fluoroquinolone 3. Do not change dosage
when switching from IV
to oral dose.
18
Counteracts smooth Treatment of 1. Dry mouth Contraindicated with 1. Provide frequent

Solfenacin
muscle spasm of the overactive 2. Constipation allergy to drug or any small meals if GI
5mg 1tab urinary tract by bladder with component of the drug, upset occurs.
3. Urinary retention
relaxing the detrusor symptoms of severe hepatic
2. Establish bowel
and other smooth urge urinary impairment, urine
muscle through the incontinence, retention, gastric program if
Brand Name:
action at the urgency, and retention, uncontrolled constipation is a
VESIcare
muscarinic urinary narrow-angle glaucoma.
problem.
parasympathetic frequency.
receptors. 3. Establish precautions
ACTION if CNS effects occur.
4. Measure post-void
Muscarinic receptor residual urine
entagonist volume if patient
Urinary has difficulty in
antispasmodic
voiding.
19
1. Administer once a day,
Blocks the smooth Adjunct in 1. Somnolence Hypersensitivity to 30 minutes after the

Tamsulosin
muscle alpha1- managing 2. Insomnia tamsulosin, prostate same meal each day.
250 mg adrenergic receptors urethral stones. cancer, pregnancy.
3. Orthostatic
in the prostate,
BID hypotension 2. Monitor patient carefully
prostatic capsule,
prostatic urethra, 4. Abnormal for orthostatic
bladder neck, leading hypotension; dizziness,
ejaculation
Brand Name: to relaxation, of the
5. Decreased libido and syncope is high with
Harnal bladder, and
prostate, and the first dose. Establish
improving the flow of safety precautions as
ACTION urine in cases of BPH.
appropriate.
Alpha adrenergic
blocker (peripheral
acting)
20
Lactulose The drug passes Treatment of 1. Transient Contraindicated with 1. Do not administer other
unchanged into colon constipation. flatulence allergy to lactulose, low- laxative while using
20cc until BM occurs where bacteria break galactose diet.
q8hours 2. Distention lactulose.
it down to organic
acids that increase 3. Intestinal cramps
the osmotic pressure 4. Belching 2. Monitor serum ammonia
Brand Name: in the colon and
5. Diarrhea levels.
Lactulose slightly acidify the
colonic contents, 6. Nausea
resulting in an
3. Carefully monitor blood
increase in stool
ACTION glucose levels in diabetic
water content, stool
softening, and patients.
laxative action. This
Ammonia reaction
also results in
drug migration of blood
Laxative ammonia into the
colon contents with
subsequent trapping
and expulsion of the
feces.

21
1. Do not administer to
1. Tenderness patients with history of
Tetanus Immune Supplies passive Is indicated for
2. Muscle stiffness Contraindicated to
Globulin immunity to those prophylaxis allergy to gamma
individuals who have against tetanus at injection site patients with a history of
globulin or anti
250/amp 4amps low or no immunity to following injury prior systemic allergic
3. Urticaria immunoglobulin A
deep IM (stat) the toxin produced by in patients
4. Angioedema reactions following the
the tetanus whose antibodies.
organism, Clostridium immunization is 5. Fever administration of human
tetani. The antibodies incomplete or immunoglobulin 2. Administer 2 weeks
Brand Name: 6. Chills
Tetanus immune act to neutralize the uncertain. It is before or 3 months after
7. Chest tightness preparations, and
globulin free form of the also indicated,
severe immune globulin
powerful exotoxin although 8. Precipitous fall
produced by this evidence of thrombocytopenia or administration because
in BP
bacterium effectiveness is any coagulation disorder antibodies in the
ACTION
limited, in the globulin preparation may
that would
regimen of
contraindicate interfere with the
treatment of
Immune globulin active cases of immune response to the
intramuscular injections.
tetanus. vaccination.
3. Do not mix globulin

with any other
medications.
4. Monitor patient’s vital

signs continuously and
observe for any
symptoms during IM
22
administration.
5. Provide comfort
measures or teach
patient to provide
comfort measures to
help patient to cope with
the discomforts of drug
therapy.

23
Tramadol Treats moderate to Treatment of 1. Nausea Acute intoxication with 1. Do not take more
moderately severe acute to chronic 2. Vomiting alcohol hypnotics, medication as a single
50mg IV q8 PRN for pain. analgesics or dose or take more
severe pain pain and most types 3. Sweating
psychotropic, narcotic doses per day than
of neuralgia, 4. Constipation withdrawal treatment. prescribed by the
including trigeminal 5. Drowsiness doctor.
Brand Name:
Tramal neuralgia. 6. Respiratory
depression 2. Store this medicine at
ACTION room temperature,
away from heat and
light.
Analgesic
u-opiod
3. Do not stop taking
receptor antagonist
Tramadol without
talking to the doctor

24
Pen G Inhibits enzymes Penicillin G is 1. Nausea Patients with known 1. Have a antibiotic
reserved for 2. Vomiting allergies to penicillin and skin test done before
responsible for cell
4 mullion q6 ANST severe hypersensitivity to giving dose to ensure
via soluset (8-2) wall synthesis of 3. Diarrhea
infections. cephalosporins hypersensitivity
susceptible 4. Abdominal pain reactions.
organisms. This 5. Colitis

2. Give by IM route
Brand Name: 6. Anorexia
creates an only.
Pen G
osmotically 7. Hypersensitivity
3. Continue therapy for
unstable cell wall 8. Neurotoxicity at least 2 days after
ACTION 9. Urticaria, infection has
that swells and
disappeared, usually 7-
bursts from osmotic Superinfection
10 days.
pressure.
Antibiotic 4. Use the smallest dose
possible for IM injection
to avoid pain and
discomfort.

25
Metronidazole, Bactericidal: inhibits Treatment of 1. Headache Contraindicated with 1. Avoid use unless
500mg , IV q8 hrs. DNA synthesis in bacterial hypersensitivity to needed.
specific anaerobes, infection 2. Dizziness Metronidazole may be
metronidazole; use
causing cell death. carcinogenic.
(a drug of choice 3. Ataxia cautiously with CNS
Brand Name: for Tetanus) disease, hepatic
4. Vertigo disease, candidiasis, 2. Reduce dosage in
Flagyl
hepatic disease.
blood dyscrasias.
5. Insomnia
ACTION
6. Fatigue
7. Incontinence
Antiprotozoal
8. GI upset

26
Telmisartan Selectively blocks the Treatment of 1. Dizziness Contraindicated with 1. Monitor heart rate
40mg/12.5, I tab OD binding of angiotensin hypertension, hypersensitivity to below normal level
2. Headache
II to specific tissue alone or in telmisartan. before giving drug.
receptors found in the combination with 3. nausea
Brand Name: Use cautiously with hepatic 2. Check effectivity of
vascular smooth other or biliary impairment,
Micardis muscle and adrenal hypertensives.
4. vomiting the drug. Closely
hypovolemia.
gland. monitor BP and heart
5. diarrhea
rate.
ACTION
Angiotensin II
receptor antagonist
Antihypertensive

27
Diazepam Acts mainly at the *Muscle relaxant: 1. Drowsiness Contraindicated with 1. Monitor heart rate
limbic system and Adjunct for relief hypersensitivity to before giving drug.
5mg IV q8 2. Dizziness
reticular formation; of reflex skeletal benzodiazepines;
muscle spasm psychoses, acute narrow- 2. Closely monitor BP.
mat act in spinal cord 3. GI upset
to produce skeletal due to local angle glaucoma, shock,
4. bradychardia
muscle relaxation; pathology or coma, acute alcoholic
potentiates the secondary to intoxication.
effects of GABA, an trauma;
ACTION Use cautiously with elderly
inhibitory spasticity caused
by upper or debilitated patients;
neurotransmitter.
motoneuron impaired liver or renal
Antiepileptic; Anxiolytic function; and in patients
disorders
with history of substance
Skeletal muscle
*Parenteral: abuse.
relaxant (centrally
acting) Treatment of
tetanus

28
Acetylcysteine Mucolytic activity: Mucolytic 1. Increase Contraindicated with 1. Ensure proper
Splits links in the adjuvant therapy productivity of hypersensitivity to dilution of tablet.
600g/1 tab in 50 mucoproteins for abnormal, cough acetylcysteine; use
diluent OD viscid, or caution and discontinue 2. Monitor heart rate
contained in
inspissated mucus 2. Nausea immediately if before giving the
respiratory mucus
secretions in bronchospasm occurs. drug.
secretions, 3. GI upset.
Brand Name: decreasing the acute and chronic 3. Monitor urine
Fluimucil viscosity of the bronchopulmonary output.
mucus. disease.
ACTION
Mucolytic

29
Bisacodyl The drug passes Short term relief 1. Sweating Contraindicated in cases 1. Do not give drug
unchanged into the of constipation of allergy to these within 1 hour of any
colon where bacteria 2. Flushing drugs; acute abdominal other drugs.
Suppository 1 stick per
rectum breaks it down to 3. muscle cramps pain.
organic acid that 2. Report sweating,
increase the osmotic 4. excessive flushing, muscle
pressure in the colon thirst cramps and
Brand Name: and slightly acidify excessive thirst.
Dulcolax the colonic contents,
resulting in an
ACTION increase in stool
water content, stool
softening, laxative
action.
Laxative

30
Paracetamol Reduces fever by Relief of mild to 1. Nausea Contraindicated to 1. Give drug with food if
acting directly on the moderately patients hypersensitive GI upset occurs.
hypothalamic heat- severe pain and 2. GI upset to Paracetamol
500mg 1tab q4 PRN
regulating center to treatment for 2. Discontinue drug if
3. Dizziness hypersensitivity
cause vasodilation fever
and sweating which reactions occur.
helps disspates heat. 3. Check for body
temperature.
ACTION
Antipyretic

31
Inhibits reabsorption Treatment for 1. Dizziness Allergy to drug, Anuria, 1. Monitor Blood
Furosemide
of the sodium and fluid retention. Severe Renal Failure pressure for sudden
5mg IV now chloride from the 2. Vertigo Hypotension
proximal and distal 3. Weakness
tubules oral 2. Monitor the Intake
ascending limb 4. Headache and Output.
ACTION of the loop of Henle

5. Drowsiness
leading to Sodium –
rich dieresis. 6. Fatigue
Loop Diuretic
7. Orthostatic
Hypotension
8. Cardiac
Arrhytmias

32
Increase intra cellular Indicated for 1. Arrhythmias Allergy to Digitalis 3. Monitor heart rate
Digoxin
calcium and allows arrhythmias, preparation. Ventricular below normal level
0.251 tab OD (7am) more calcium to enter 2. Headache Tachycardia, Ventricular before giving drug.
abnormal heart
myocardial cell during contractility. Fibrilation, Heart
3. Weakness 4. Check effectivity of
depolarization Block, Sick Sinus
via sodium – 4. Drowsiness Syndrome, Acute MI the drug. Closely
potassium pump monitor BP and heart
ACTION
mechanism. 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
disinfectants, and a number of antibiotics.
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 symptoms in the Signs and symptoms
textbook 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
Lifestyle
Dental infection
Age
Sex
Clostridium tetani enters body through

a wound
Pathophysiology
Anaerobic conditions allow germination of spores
andTETANUS
production of toxins
[Patient
Toxins are produced centered] via blood and
and disseminated
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 ↑BP
Stiffness ↑temperature
Neck rigidity sweating
Dysphagia SEIZURE causing
Restlessness
opisthotonos
Reflex spasms
38
Aspiration Pneumonia
Hypertension
39
CONCEPT MAP
2 Ineffective airway
1 clearance r/t 3
Acute pain r/t Ineffective
retained and
muscle rigidity 2o excessive breathing pattern r/t
unopposed muscle secretions impaired lung
contraction muscle contraction
Impaired physical Cc: Difficulty of 4

8 Impaired
mobility r/t swallowing swallowing r/t
neuromuscular pharyngeal
impairment Dx: Tetanus muscle spasm
stage 3
7 5
Disturbed sleep Altered
pattern r/t excessive 6 thermoregulation:
environmental Urinary Hyperthermia r/t
stimuli incontinence r/t tissue trauma 2o
bladder outlet presence of C. tetani
obstruction 40
NURSING CARE PLAN
41
NURSING NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS THEORY
Subjective Independent:
“Gatiskog naman siya Acute pain r/t After nursing 1. Handled the To promote Goal was
kung makibot o muscle rigidity 2o interventions, will client’s body safety and Lydia Hall’s met.
masilawan” as demonstrate a gently while allows
unopposed Care, Core,
(-) guarding
doing nursing
verbalized. muscle reduction in pain experience less Cure
activity. behavior
contraction behaviors such as pain during care
absence of facial activity.
Objectives:
grimace and
• RR= 30bpm
guarding.
• BP= 140/100
2. Minimize To promote rest Florence
mmHg
• (+) Facial grimace movement and and avoid Nightingale’s
• (+) Guarding dimmed light Environment
excitation of
• (+) diaphoresis provided.
neurons leading Theory
• (+) lockjaw
to muscle
• (+)muscle spasm
contractions.
• (+)periodontal
infection
• (+)hyperextension
To ensure safety Florence
of head
3. Maintained side Nightingale’s
when seizure
rail up.
and muscle Environment
rigidity occurs. Theory
Depedent:
Treats moderate Ernestine
1. Administered
to moderately Weidenbach’s
Tramadol 50 mg severe pain Prescriptive
IV as ordered
Theory
It is a muscle
2. Diazepam 5mg relaxant. That
intravenously helps reduce Ernestine
given as ordered. muscle Weidenbach’s
contractions Prescriptive 42
causing pain. Theory
Treatment of
3. Metronidazole, bacterial Ernestine
43
NURSING NURSING
DIAGNOSIS THEORY
Subjective: Independent:
“Ginabudlayan To maintain a 1. Suctioned To maintain Virginia Goal was
Ineffective airway
siya mag ginhawa” patent airway Henderson’s
clearance r/t secretions as patent airway and partially met.
as verbalized by be able to needed. prevent Basic Care
the folks. retained and demonstrate Component
aspiration.
excessive effective RR decreased to 24
2. Elevated head of To take bpm but still with
secretions coughing and Florence
clear breath advantage of crackles.
Objectives: the bed/ change Nightingale’s
sounds. gravity
position every Environment
• RR=30 bpm decreasing
2hours Theory
• AR=120bpm pressure on the
• (+) crackles diaphragm and
• (+)productive enhancing
cough drainage.
• (+)restlessness Florence
3. Kept the
• (+) drooling Precipitators of Nightingale’s
• (+) impaired environment
allergic type Environment
swallowing allergen free like respiratory
Theory
• X-ray results dust. reactions that can
shows Bilateral trigger onset of
pneumonia and
acute episodes.
bronchiectasis
To promote Virginia
4. Encouraged deep
oxygenation and Henderson’s
breathing and maximize effort.
Basic Care
coughing
Component
exercise.
5. Position head To open or

Florence
midline with maintain open
Nightingale’s
flexion. airway.
Environment
Theory 44
Depedent:
45
NURSING NURSING
DIAGNOSIS THEORY
“Ginabudlayan siya Ineffective To demonstate 1. Suctioned To maintain patent Lydia Hall’s Goal was
mag ginhawa” as ability to breathe secretions as airway and prevent Care, Core, partially
breathing
verbalized by the comfortably as needed. aspiration. Cure
pattern r/t met.
folks. evidienced by
impaired lung normal respiratory RR lowered
muscle rate of 16-20 down to 24
2. Elevate head of Elevation of head
bpm. bpm.
Objectives: contraction bed/ placed on may decrease
Florence
high back rest. dyspneic episodes.
• RR=30 bpm Nightingale’s
An upright position
• AR=120bpm Environment
facilitates lung
• (+) Labored expansion. Theory
breathing
• (+)restlessness
Dorothea
• (+) drooling
3. Assisted in It can be a helpful Orem’s
• (+) impaired
taking control of technique in Self-care
swallowing maximizing
breathing Deficit
• (+) nasal flaring respiratory function
• X-ray results
shows Bilateral
pneumonia and
bronchiectasis Dependent:
Oxygen therapy Ernestine
1. Administered
helps decreased Weidenbach’s
oxygen at 4Lpm
dyspnea. Prescriptive
as ordered.
Theory
Collaborative:
Ernestine
Acts as
Weidenbach’s 46
bronchodilator to
2. Combivent Prescriptive
promote effective
nebulization Theory
airway passage .
done by pulmo-
aide.
47
NURSING NURSING
DIAGNOSIS THEORY
Subjective: Dependent:
“ Nabudlayan siya After nursing 1. Nasogastric tube To provide Lydia Hall’s Goal was
Impaired
magtulon ” as intervention inserted by ROD parenteral feeding Care, Core, partially
verbalized by the folks. swallowing patient will in adequate Cure
related to met.
demonstrate amount.
pharyngeal effective Able to open
muscle spasm swallowing without his mouth.

Objectives: Independent:
muscle straining. The client can
• (+)lockjaw 2. Provided meals in Florence
achieve a more
• (+)restlessness a quiet effective swallow Nightingale’s
• (+) drooling environment away by focusing on Environment
• (+) impaired from excessive chewing and Theory
swallowing stimuli. moving
• (+)hyperextesion of foods/fluids to the
head back of the mouth
• (+)gum bleeding where the
swallowing reflex
is triggered. Virginia
Henderson’s
3. Have suction For aspiration Basic Care
equipment precaution. Component
available during
feeding.
Florence
4. Kept with an This position uses Nightingale’s
upright position gravity to aid in
for 15mins to an the flow of Environment
hour after meal. foods/fluids Theory
through the
esophagus.
Lydia Hall’s
5. Instructed family For the family to
Care, Core,
how to monitor be aware for any
and detect Cure
situation so that
aspiration after we can avoid 48
eating.
aspiration even
when nurses are
not in their room
49
NURSING NURSING
DIAGNOSIS THEORY
“Gina lagnat siya” Altered To lower down 1. Tepid sponge It lower down body Lydia Hall’s Goal was
as verbalized by thermoregulation: body bath done. temperature. Care, Core, met.
the folks. temperature to Cure
Hyperthermia r/t Body temp. is
37.5oC after 2
tissue trauma 2o 2. Room’s A consistent 37.3oC.
hours of nursing
temperature temperature limits Florence
presence of interventions. (-) Shivering
Objectives: cooled down. environmental Nightingale’s
C. tetani effects on Environment
• T=38.2oC
thermoregulation Theory
• (+) body
weakness
• (+)flushed and 3. Provided Florence
This will help
warm skin thick-wool Nightingale’s
maintain a normal
• (+) sweating blanket to body temperature Environment
• (+) shivering prevent further Theory
and prevents
• (+) chills. shivering.
periodontal
trauma
• WBC=11.9 x Florence
10^9/L Promotes rest and
Nightingale’s
4. Dimmed the relaxation , and
light and Environment
prevents from
provided a Theory
disturbances.
peaceful
environment for
rest. Minimized
Antipyretic that
stimulus.
treats fever, by Ernestine
lowering down body Weidenbach’s
Depedent: temp. Prescriptive
4. Paracetamol 500 Theory
An antibiotic used
mg, 1 tab given
to treat infection
orally as ordered.
caused by anaerobic
C. tetani. Ernestine 50
5. Administered Weidenbach’s
Metronidazole Prescriptive
500 mg Theory
51
NURSING NURSING
DIAGNOSIS THEORY
Dependent:
Objectives: Urinary After nursing 1. Foley Catheter To promote adequate Virginia Goal was
incontinence interventions, inserted as ordered. urine elimination. Henderson’s
• Urine volume/fluid met.
will void urine Basic
output= 40 cc r/t bladder Urine
within 8 hours. volume of at Component
outlet output=300 cc
• (+) body least 30 cc
obstruction 2. Administered Helps to manage Ernestine after 8 hours
weakness every hour.
urethral stones and Weidenbach’s
Tamsulosin 20cc
• (+) muscle rigidity improves the flow of Prescriptive
intravenously as Theory
• Creatinine= HI urine
161.8 umol/L prescribed.
• TPSA=7.31mg/ml
Smoothen urethral Ernestine
3. Solfenacin 5mg muscle and relieved Weidenbach’s
1tab given via NGT symptoms of urge Prescriptive
as ordered. urinary incontinence Theory
Independent:
1. Implement Maintaining patency
measures to ensure of the indwelling
Florence
the patency (e.g. catheter prevents
Nightingale’s
keep tubing free of urinary incontinence
Environmental
kinks, keep
Theory
collection bag below
bladder level)
Drinking a large
2. Encourage fluid Lydia Hall’s
amount of fluid at one
intake in small Care, Core,
time results in rapid
amount frequently. Cure
filling of the bladder
which increases
pressure in the
bladder and the
subsequent risk of 52
incontinence
Environmental factors Florence

3. Provide an
may contribute to Nightingale’s
environment that
53
NURSING NURSING
DIAGNOSIS THEORY
“Madali siya Disturbed sleep After nursing 1. Keep environment Provides more Florence Goal was
makibot sa pattern r/t interventions, quiet for sleeping, relaxing and Nightingale’s met.
gasulod, ga tiskog excessive will able to have eliminate noise. comfortable Environmental
Slept at long
naman siya, hindi environmental undisturbed environment for Theory
intervals
siya katulog ” as stimuli sleep with long sleeping. undisturbed.
verbalized by the intervals.
folks. Virginia
2. Perform nursing Reduces disturbances Henderson’s
procedures all at in sleeping. Basic
Objectives: Component
the same time if
• (+) too much possible before
visitors patient to go to
• (+) disturbed sleep.
sleep Florence
Light may alter or Nightingale’s
• (+) Weakness 3. Adjusted lighting by
disturb patient’s Environmental
• (+) Lethargic dimming the lights. Theory
sleep.
• (+) Irritable
• (+)
hyperextension Dependent:
of head
• (+) body 1. Administered Ernestine
Acts as muscle
stiffness Diazepam 50mg relaxant and an Weidenbach’s
intravenously anxiolytic. Prescriptive
Theory 54
Discharge Planning
Mr. F.B’s family decided to go home even though he was not in good
NURSING PLANNI NURSING EVALUATI
ASSESSMENT INTERVENTION RATIONALE
DIAGNOSIS NG THEORY ON
“Di na siya Impaired After 16 1. Evaluate Level of activity Virginia Goal
kahulag mayad hours (2 or exercise Henderson’
physical or was not
days 6-2 continuously s
indi parehas mobility depends on
shift) monitor progression and Basic met.
sadto ” as
r/t of nursing degree of resolution Componen (+) body
verbalized by interventio pain. t
the folks.
neuromusc ns, the weakness
ular patient will Systemic rest
2. Maintain during cute
impairment maintain or
bed rest or attacks and Florence
Objectives: increase
. chair rest important Nightingale’
strength
• (+) body when throughout all s
and
weakness Indicated. phases of Environmen
function of
• (+)Reluctan affected or Schedule disease to tal Theory
ce to compensat activities reduce fatigue
attempt ory providing and improve
movement. body part. frequent rest strength
• (+)Limited periods and Hildegard
range of uninterrupted Maintains or Peplau’s
motion. night time improves joint Interperso
• Decreased sleep. function, muscle nal Theory
muscle strength, and of Nursing
strength. 3. Assist with general
active or stamina.
passive range Florence
of motion. Maximizes joint Nightingale’
function, s
maintains Environmen
4. Encourage mobility that tal Theory
patient to can precipitate
maintain acute attack.
upright
and erect
posture
when sitting,
standing, or
walking.
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 &
Physiology, 6th Ed. McGraw-Hill.
• Bickley, L. (2007). Bates’ Pocket Guide to Physical Assessment &
History Taking, 5th Ed. Lippincott Williams & Wilkins
56
• Karch, A. (2009). 2009 Lippincott’s Nursing Drug Guide. Lippincott
Williams & Wilkins.
• Octaviano, E. & Balita, C. (2008). Theoretical Foundations of Nursing:
The Philippine Perspective. Ultimate Learning Series
• www.wikipedia.org
• www.doh.gov.ph
• www.eMedicine.com
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St.

Anthony College of Roxas City

Bachelor of Science in Nursing

It is caused by a bacterium Clostridium tetani. Infection generally occurs

The incubation period ranges from 3 to 21 days, usually about 8 days. In

Tetanus can be prevented by vaccination with tetanus toxoid. A booster is

In the Philippines the incidence rate of tetanus is 12 out of 86, 241,627.

• To demonstrate the vision/mission of the school which is service

• Discuss the anatomy and physiology of the Nervous system.

• Establish a nurse-patient interaction through exchanging of

ANATOMY AND PHYSIOLOGY

The nervous system is an organ system containing a network of specialized

The Central Nervous System is the body’s information headquarters, ultimately

• The Somatic Nervous System (SNS) – Responsible for all muscular

The brain controls the movements of skeletal (voluntary) muscles via

Neurons send signals to other cells as electrochemical waves travelling along

If you want to move part of your body, a message is sent to

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

One week before admission, patient experience a massive toothache

Past Health Problem

Female Male Patient Death

Pattern Home Hospitalization

Circulation Claimed to never been had a The average BP is 140/100

Sleeping Pattern Usually sleeps at 9 pm and Sleeps at 10 pm and wakes

Eating Pattern Eats three times a day. He He was been on parenteral

Elimination Defecates once daily in Defecates for about 2-3

b. Urination Urinates normally With urinary incontinence, a

His daily job as a pond Morning care done with oral

Brief Social, Cultural and Religious Background

F.B. finishes his elementary education in Dulangan Elementary School

He is a fulltime fishpond operator, who manages their own family’s

Mr. F.B is a Roman Catholic. He does not attend Sunday mass

Mr. F.B belongs to a middle class group, he has no fix economic

T=38.2oC CR= 104 bpm

BP= 140/100 mmHg RR= 30 bpm

Face is wrinkled due to old age. (+) Facial grimace and

Top of pinna is aligned with the outer corners of both

With presence of cilia. Has no discharges nor sinusitis.

Breast Breast are firm. No mass palpated.

Both arms are weak. Can perform passive movements

Musculoskeletal Restless at few times. Have been on seizure attacks.

Speech Speaks in native language.

Language Can speak only Hiligaynon

Hearing Has poor acuity to

Mental status He is lethargic and

Emotional Unable to express

June 05, 2010

June 06, 2010

Lipids and lipoproteins

June 16, 2010

Test Normal Significance of

June 16, 2010

CT SCAN Cranial Plaw

Plain axial tomography section of the head shows no

The midline structures are undisplaced with the

The cerebrum shows slightly widened cortical