W E L C O M E

!
A CASE PRESENTATION
On

February 24,
2009
NPC- SACR
Presented by:
 Objectives
 General Objectives:

 After our exposure in the clinical

setting, the student nurses will
develop knowledge and skills in
giving proper nursing care to the
patient and explore the issue of
accountability. We will reflect on
whether our everyday nursing
practice demonstrates a
commitment to ensuring the human
well-being of those in our care.
Individual patterns of responding to
human needs and responsible caring
 Specific Objectives:
 To enhance our knowledge in determining
how the disease (Tetanus) occurred and to
what extent will the disease be progressed.

 To identify the disease that the patient is

experiencing and conduct a nursing care
that will be implemented.

 Assess the patient’s health status and

make nursing diagnosis.

 Make nursing care plan and implement

them to the patient with Tetanus.
 Specific Objectives:
 To develop our nursing capabilities and enhance
the knowledge we have that may fully import it to
our patient for further learning’s about health and
awareness of disease.

 To render proper nursing care within our limits.

 To establish rapport with our patient or with the

folks and gain their trust that we may be able to
deliver proper nursing care and services and
implement our plan of actions.

 To demonstrate how words and touch can be used

to harm or benefit the patient.

 To give and nurture the needs of the patient.

 Introduction
 Tetanus, also called lockjaw, is a medical
condition characterized by a prolonged
contraction of skeletal muscle fibers.
The primary symptoms are caused by
tetanospasmin, a neurotoxin produced
by the Gram-positive,
obligate anaerobic bacterium
Clostridium tetani.
 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 is a global health problem, as C. tetani
spores are ubiquitous. The disease occurs
almost exclusively in persons who are
unvaccinated or inadequately immunized.
Tetanus occurs worldwide but is more common
in hot, damp climates with soil rich in organic
matter. This is particularly true with manure-
treated soils, as the spores are widely
distributed in the intestines and feces of many
non-human animals such as horses, sheep,
cattle, dogs, cats, rats, guinea pigs, and
chickens. In agricultural areas, a significant
number of human adults may harbor the
organism. The spores can also be found on skin
surfaces and in contaminated heroin.
  Tetanus is often associated with
T
S ? rust, especially rusty nails, but
U
R CK this concept is somewhat
TA misleading. Objects that
AT accumulate rust are often found
outdoors, or in places that
harbour anaerobic bacteria, but
the rust itself does not cause
tetanus nor does it contain
more C. tetani bacteria.
  The rough surface of rusty
T
S ? metal merely provides a prime
U
R CK habitat for a C. tetani
TA endospore to reside, and the
AT nail affords a means to
puncture skin and deliver
endospore into the wound. An
endospore is a non-
metabolising survival structure
that begins to metabolise and
cause infection once in an
adequate environment.
  Because C. tetani is an
T
S ? anaerobic bacterium, it and its
U
R CK endospores will thrive in an
TA environment that lacks oxygen.
AT Hence, stepping on a nail (rusty
or not) may result in a tetanus
infection, as the low-oxygen
(anaerobic) environment of a
puncture wound provides the
bacteria with an ideal breeding
ground
 Name: A. C.

 Age: 57 yrs. Old

I.  Sex: Male

T A L  Religion: Roman Catholic

VI ATCivil Status: Married
R M  Address: Phase I, Milibili Heights,
FO O N
IN I Roxas, City
 Date and Time of Admission: Oct.,
31, 2008 @
6:40 pm
 Chief Complaints: lockjaw
 Admitting Diagnosis: Severe
Tetanus; Gouty
Arthritis; Pneumonia
 Attending Physicians: Dr. M. O. / Dr.
J. B.
 1. History of Present Illness:
A. g One week before admission,
r s i n t patient sustained a wound at the left
Nu e n foot, second digit. It was too small that
s s m they did not mind having consultation.
s s e
A Five days after acquiring the
wound, patient complained of difficulty
in opening his mouth and difficulty in
swallowing foods.
Symptoms persisted. Patient’s
family was alarmed to symptoms thus
prompted admission in Oct. 27, 2008 @
6:40 pm.
Vital signs upon admission include:
BP- 180/90 mmHg, CR- 84 bpm, RR- 24
breaths/min; and T-37o C. Dyspnea,
nausea, vomiting and signs of urinary
and bowel problems noted.
2. Past Medical History: 
Year 2001, patient was diagnosed with
Chronic Tenalacious Gout. He had a
maintenance medication of Colchicine. He
is allergic to foods that contain food
colorings.

3. Family History: 
His mother died of hypertension and old
age.
 S. C.
C.C. HTN
Alcoholi
c

C. A. C. L. C. F.C. R. C. C.C. A.C.

68 65 59 57
60
N BA; Jr. Tetanus;
Arthritis Gouty
Arthiris
 4. Patterns of Functioning
Pattern of Home Hospital
Funtioniong

Breathing RR: 16-25 breaths per

minuteThe patient breathes
through a tracheostomy tube
attached to mechanical
ventilator with settings of
Mode- AC Fi02- 60%TV-
400 PFR- 50BUR- 14
 4. Patterns of Functioning
Pattern of Home Hospital
Funtioniong
Circulation Elevation in BP not noted except
upon admission (180/90mmHg).
He is attached to cardiac monitor
and pulse oximeter with oxygen
saturation of 96-100 %. His BP
ranges from 110-140 mmHg
systolic / 70-90 mmHg diastolic.
With IVF D5 NSS 1L + 20 mEq KCl
x 80 cc/hr. @ ® cephalic vein.
Sleeping The patient usually The patient sleeps at intervals,
sleeps at 8 pm and usually in semi-Fowler’s position,
wakes up at 2 provided with one pillow on his
o’clock in the head and one to support his
morning to attend extremities.
to his ducks.
 4. Patterns of Functioning
Pattern of Home Hospital
Funtioniong
Drinking The patient is not used The patient can not open his
to drinking water. His mouth
total fluid intake
amounts to 1050 cc a
day including tea and
coffee. He drinks
alcoholic beverages
occasionally.The

Eating. The patient eats 3 NGT is attached. OTF

meals and some amounting to 250 cc is given
snacks a day. He eats at 10am, 2pm and 6pm.
various kinds of foods
only avoiding beans,
organ meats, and
nonscaly fish
 4. Patterns of Functioning
Pattern of Home Hospital
Funtioniong
Elimination:
Urinary Patient voids A Foley catheter is
whenever he feels attached to the patient
elimination the urge. He voids with adequate hourly
3-4 times daily. urine output.

Bowel Patient defecates Patient experiences no

every morning bowel movement for 3
elimination without straining. days. He is given
Lactulose or Dulcolax
suppository based on
need.
 4. Patterns of Functioning
Pattern of Home Hospital
Funtioniong
Personal Patient takes a bathe Immobility disables the patient
everyday . to take hygienic measures.
hygiene Morning care is done every 5
o’clock in the morning. Oral
care is done with the use of
tongue depressor. Suctioning
of the mouth is done when
needed.
Recreation Patient does not have a He has no any form of
and Exercise regular pattern of recreation
exercise. He wakes up
early and feeds his ducks.
His basic form of exercise
is walking around their
backyard. He likes to
listen to AM radio and
watches TV at times, but
generally sleeps early.
5. Brief Social, Cultural and Religious 
background

 Educational Background
 A.C finished his elementary education in Lonoy
Elementary school and his secondary education
in Colegio Dela Purisima Conception and was an
active varsity player of volleyball. He then took
his tertiary education in Calinog Central School
as a Commerce Accounting student still as a
varsity player.

 Occupational
 He manages his own family poultry
business.
 Religious Practices
 He attends mass occasionally.

 Economic Status
 His family belongs to a middle class
group. He was able to send his
children to college through
graduation. His wife is a teacher.
They have a business of growing
ducks.
 B. Clinical Inspection

1.Vital Signs 
 Temperature:  37°C
 Blood Pressure:  100-130/70-90 mmHg
 Pulse Rate:  70-80 beats per minute 
 Cardiac Rate:  75-85 beats per minute
 Respiration Rate:  16-25 breaths per minute

2. Height: 5’4”
Weight: 57 kgs.
3. Physical Assessment
 General Appearance
 Patient is lying on bed at high or
semi Fowlers position. He is
weak ĉ minimal white hair and
has a brown complexion. He has
tracheostomy tube attached to
mechanical ventilator.. Cardiac
monitor with pulse oximetry is
attached. NGT and Foley
catheters are also attached. With
IVF @ right arm; Lockjaw is
apparent. Subcutaneous
emphysema is marked.
 Skin,
i r a n d  Skin: brown complexions, dry,
ha rough, and cool to touch has
nails slight poor skin turgor.
 Hair: Minimal white hairs
combined to black curly hair,
equally distributed, presence of
dandruff, no lice.
 Nails: untrimmed, clean, (+)
pallor.
 ad ,
e
H e,
fac Head: large in size, symmetrical,
a n d 

p h a scalp is intact and moves freely

ly m over skull.
tic  Face: Pale, (+) subcutaneous
emphysema
 Lymphatic: unremarkable
E y es ,  Eyes: anicteric sclerae; upper and
lower lids completely approximated
ears, when closed, eyelashes are evenly
n o se , distributed, globes are aligned,
pinkish conjunctiva, pupils are black
m o u t h in color and 2.5 mm in size.
and  Ears: top pinna is below to the outer
corner of the eyes with equal
th r o a t alignment, large in size and equal,
skin is intact, similar in color to face.
 Nose: (-) discharges, (-) sinusitis,
same color with the face
 Mouth: lockjaw; Lips are dry; with
slight odor
 Throat: nonremarkable
 a n d  Neck: Symmetrical but
N ec k
e r shortened; proportional to head
up p
i ti e s and shoulders, there are
e m
extr palpable soft muscles, there is a
marked pulsation in the carotid
pulse; trachea is in the midline;
(+) tracheostomy tube attached
to mechanical ventilator
 Upper Extremities: Symmetrical;
consistent brown in color; With
IVF D5 NSS 1L + 20 mEq KCl x
80 cc/hr. @ ® cephalic vein.
 t   a n d  
Ches :  Chest: (+) hair, brown in
Axilla complexion;
 Axilla: (+) hair, (+) palpable
lymph nodes; non-odorous
a to
s p ir
Re y
r With a respiration rate
em :
ranging 16-25 breaths per
s t
Sy minute. Patient breathes
through tracheostomy tube
attached to mechanical
ventilator; (+) wheezes on left
lung field
 Cardiovascular 
 There is a palpable pulsation, heart rate
ranges 75-85 bpm with a regular rhythm,
apical pulse is close to its pulse rate of 70-80
bpm.

Gastrointestinal System
His abdomen has a consistent color
with the rest of the part of the body; soft,
nontender; with hypoactive bowel sounds
 Genito – Urinary System

 Black pubic hair, with Foley catheter; urine

output is adequate.

Musculoskeletal
(+) Generalized weakness; opens lips
but not whole mouth; difficulty turning to
sides alone. (+) bouttonniere deformity on
both hands; (+) rigidity; (+)neck stiffness
 4. General appraisal

 Speech
 (-) verbal output due to lockjaw
 Language
 Known language according to folks are in the native
dialect, Filipino, and English.
 Hearing
 Hears normally; responds to verbal commands.
 Mental status
 conscious, coherent; GCS-11
 admitted @ Rendu ward under the service of DR. O. and Dr. B.
Pen-G 4 million units IV drip Q4° ANST (10-2-6) given as ordered
Moxifloxacin 400mg 1 tab OD; Colchicine 1 tab TID pc given as starting dose
11/3/08
Patient has undergone Tracheostomy.
was noted with inability to sleep, so he was given with Diazepam 2.5 mg IV STAT as ordere
Mobic 15 mg/I tab OD was started as ordered as he complained of mild knee pain.
Facial Subcutaneous emphysema was noted, was known already by Dr. M.O.
Patient was seen by Dr. B. and removed sutures along incision site.
Patient was noted with no urine output and bladder distention.
Foley Catheter was inserted as ordered.
Furosemide 20mg IV STAT was given as ordered.
GCS-11-no verbal response
(-) BM
11/4/08- restlessness noted
- tracheostomy tube attached to MV with set-up:
Mode AC
TV-400
FiO2
PFR-50
BUR- 14
GCS-11
(-) BM
11/5/08 – GCS-11
limited ROM
 CHEMISTRY 11/01/08

EXAMINATION RESULT NORMAL SIGNIFICANCE

VALUES
Glucose 6.74 mmol/L 4.10-5.90 Elevated level
suggest
infection,
stress.

Cholesterol 6.41 mmol/L 0.00-5.20 Indicates alcoholism

and stress.

Triglycerides 3.41 mmol/L 0.00-1.69 Elevated levels are

found alcoholism
EXAMINATION RESULT NORMAL SIGNIFICANCE
VALUES
Creatinine 66.4 umol/L 71.0 – 133.0 Decrease level are
found with
debilitation and
decrease muscle
mass.

Uric acid 532.2 umol/L 208.0-506.0 Elevated level

indicates gout and
infection.

Direct HDL 0.80 mmol/L 1.00-1.60 Indicates

Malabsorption and
malnutrition.
EXAMINATION RESULT NORMAL SIGNIFICANCE
VALUES
VLDL 1.56-mmol/L 0.00-1.03 Elevated levels are
correlated with
alcohol
consumption.

Sodium 135.3 mmol/L 137-145 Low serum sodium

levels result from
inadequate sodium,
deficient dietary
intake, nasogastric
aspiration, profuse
sweating, GI
suctioning, and
diuretic therapy.
EXAMINATION RESULT NORMAL SIGNIFICANCE
VALUES
Potassium 3.34 mmol/L 3.5-510 Indicates
gastric
suctioning
and diuretic
therapy.
 ABG
      Result Normal range

 pH 7.469 7.35-7.45
 pCO2 37.5 mmhg 35-45 mmHg
 pO2 153.0 mmhg 80-100 mmHg
 HCO3 27.2 mmol/L 22-26 mmol/L
 O2 Sat. 99% 97-100%
Interpretation:
The patient has uncompensated
metabolic alkalosis indicates tetany.
 HEMATOLOGY

EXAMINATION RESULT NORMAL SIGNIFICANCE

VALUES
WBC Hi 12.4 10 x 4.5 – 11.0 x 10 An elevated WBC count
12/L 12/L commonly signals
infection.

RBC Lo 4.20 x 10 4.6– 6.2 x 10 9/L A depressed count may

9/L indicate chronic
infection.

Hemoglobin Lo 120 g/L 135-180 g/L Low Hgb concentration

may indicate
hemorrhage, hemolysis
of red blood cells.
EXAMINATION RESULT NORMAL SIGNIFICANCE
VALUES

Hematocrit Lo 0.36 0.40 – 0.54 Low HCT indicates acute

vol.fr. vol.fr blood loss, vitamin
deficiency.

Neutrophils. Hi 78.0 % 50-70 % Elevated level indicates

Physical or emotional
stress, acute suppurative
infection, inflammatory
disease (Gout,
pneumonia), trauma

Lymphocytes. Lo 9.0 % 20 – 45% Decreased by severe

debilitating illness, drug
Adrenocorticosteroid
EXAMINATION RESULT NORMAL SIGNIFICANCE
VALUES

Eosinophils Hi 4.0 % 0-3 % Infection

Monocytes Hi 9.0 % 0-8 Decrease level

indicates chronic
inflammatory
disease, viral
infection.
 URINALYSIS
Significance of
Normal
Result Abnormal
value
Results
Macroscopic:
It indicates
Transparency: Cloudy Clear
bacteria.

Microscopic: Numerous to
0 – 2 hpf Signifies trauma.
RBCs/hpf count
An elevated WBC
count indicates
pyuria and
WBCs/hpf Hi 6-12 0 – 5 hpf
presence of
urinary tract
infection.
Indicates presence
Bacteria: Few Negative
of bacteria.
 RADIOLOGY
10/31/08 11/13/08
Chest PA Chest AP
X-ray
X-ray Impression:
impression:
(L) Basal (L) Basal
pneumonia pneumonia with
regression
S/p (L)
Tracheotomy
Tube insertion
The tip of the
 ECG INTREPRETATION:

 Nonspecific intraventricular delay.

 Occasional single premature atrial
contracture.
 Nonspecific S-T waves changes at the
inferior leads probably due to ischemia or
electrical shifts.

Anatomy and Physiology

Case Discussion: TETANUS

 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.

 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. (SOA).
Frequency
United States
 Incidence has declined with the advent of active
immunization. Reports indicate that 560 cases
occurred in 1947; 101 cases occurred in 1974; 60-80
cases occurred each year during the 1980s; and 47
cases occurred in California in 1997. Almost all
cases occur in persons who are partially immunized
or nonimmunized. The incidence of patients who
contract tetanus despite full immunization is
extremely rare (ie, ~4 per 100 million persons who
are immunocompetent and vaccinated).
International
 Reports show up to 1 million cases annually, mostly in
underdeveloped countries. Neonatal tetanus accounts for
50% of the tetanus-related deaths in developing countries.

Mortality/Morbidity
 Tetanus results in approximately 5 deaths per year in the United
States.
 Mortality in the United States resulting from generalized tetanus is
30% overall, 52% in patients older than 60 years, and 13% in
patients younger than 60 years.
 Residual neurologic sequelae are uncommon. Mortality usually
results from autonomic dysfunction (ie, extremes in blood pressure,
dysrhythmia, cardiac arrest).
Age
 In the United States, 59% of cases and 75% of deaths occur in
persons aged 60 years or older.
History
 Most cases in the United States occur in patients
with a history of only partial immunization. Persons
who inject drugs also constitute a high-risk group.
 Symptoms usually begin 8 days after the infection,
but onset may range from 3 days to 3 weeks.
 Patients may report a sore throat with dysphagia
(early sign).
 Localized tetanus causes muscle rigidity at the site
of spore inoculation.
 The initial manifestation may be local tetanus, in
which the rigidity affects only 1 limb or area of the
body where the clostridium-containing wound is
located.
Signs and symptoms

 The incubation period ranges from 2 to 50 days

(average, 5 to 10 days). Tetanus affects skeletal muscle
, a type of striated muscle. The other type of striated
muscle, cardiac or heart muscle cannot be tetanized,
because of its intrinsic electrical properties. In recent
years, approximately 11% of reported tetanus cases
have been fatal. The highest mortality rates are in
unvaccinated persons and persons over 60 years of
age. C. tetani, the bacterium that causes tetanus, is
recovered from the initial wound in only about 30% of
cases, and can be found in patients who do not have
tetanus.
According to the Manifested by the
textbook patient

Lockjaw / trismus √

Difficulty √
swallowing
Restlessness √

Irritability

Neck stiffness √

Headache

Fever √

Sore throat

Chills

Risus sardonicus
Rigidity √
Opisthotonus

Urinary retention √

Constipation √
Moderate √
Leukocytosis
Hypertension √

Tachycardia

Difficulty breathing √
Diagnosis
 A history of a recent wound in a patient with
muscle stiffness or spasms is a clue. Tetanus can
be confused with meningoencephalitis of bacterial
or viral origin, but the combination of an intact
sensorium, normal CSF, and muscle spasms
suggests tetanus. Trismus must be distinguished
from peritonsillar or retropharyngeal abscess or
another local cause. Phenothiazines can induce
tetanus-like rigidity.

 C. tetani can sometimes be cultured from the

wound, but culture is not sensitive.
 Treatment
 The wound must be cleaned. Dead and infected tissue
should be removed by surgical debridement.
Metronidazole treatment decreases the number of
bacteria but has no effect on the bacterial toxin.
Penicillin was once used to treat tetanus, but is no
longer the treatment of choice, owing to a theoretical
risk of increased spasms. However, its use is
recommended if metronidazole is not available.
Passive immunization with human anti-tetanospasmin
immunoglobulin or tetanus immune globulin is crucial.
If specific anti-tetanospasmin immunoglobulin is not
available, then normal human immunoglobulin may be
given instead. All tetanus victims should be vaccinated
against the disease or offered a booster shot.
Mild tetanus
 Mild cases of tetanus can be treated with:
 Tetanus immune globulin IV or IM
 metronidazole IV for 10 days
 diazepam
 tetanus vaccination
 Severe tetanus
 Severe cases will require admission to intensive care. In
addition to the measures listed above for mild tetanus:
 human tetanus immunoglobulin injected intrathecally
(increases clinical improvement from 4% to 35%)
 tracheostomy and mechanical ventilation for 3 to 4 weeks,
 magnesium, as an intravenous (IV) infusion, to prevent
muscle spasm,
 diazepam (known under the common name Valium) as a
continuous IV infusion,
 the autonomic effects of tetanus can be difficult to manage
(alternating hyper- and hypotension, hyperpyrexia/
hypothermia) and may require IV labetalol, magnesium,
clonidine, or nifedipine.
 Drugs such as diazepam or other muscle relaxants
can be given to control the muscle spasms. In
extreme cases it may be necessary to paralyze the
patient with curare-like drugs and use a
mechanical ventilator.
 In order to survive a tetanus infection, the
maintenance of an airway and proper nutrition are
required. An intake of 3500-4000 Calories, and at
least 150g of protein per day, is often given in
liquid form through a tube directly into the
stomach, or through a drip into a vein. This high-
caloric diet maintenance is required because of the
increased metabolic strain brought on by the
increased muscle activity.
 Prevention
 A series of 4 primary immunizations against tetanus,
followed by boosters q 10 yr, with the adsorbed (for primary
immunization) or fluid (for boosters) toxoid is superior to
giving antitoxin at the time of injury. Tetanus toxoid comes
by itself, mixed with diphtheria in both adult (Td) and child
strengths (DT), and combined with both diphtheria and
pertussis (DTP). Routine diphtheria, tetanus, and pertussis
immunization and booster recommendations are discussed
in Immunization. Adults need to maintain immunity with
regular boosters q 10 yr. Immunization in an unimmunized
or inadequately immunized pregnant woman produces both
active and passive immunity in the fetus and should be
given at a gestational age of 5 to 6 mo with a booster at 8
mo. Passive immunity develops with maternal toxoid given
before a gestational age of 6 mo.