Nursing Diagnosis and Interventions for Tetanus
1. Ineffective Airway Clearance related to the accumulation of sputum in the trachea and respiratory muscle spam
Characterized by rhonchi, cyanosis, dyspnea, ineffective cough accompanied by sputum and/or mucus.
Goal: Effective airway
Outcomes :
- No shortness of breath, no mucus or sleam.
- Normal breathing.
- No nostril breathing.
- No additional respiratory muscles.
Intervention and Rationale:
1. Free the airway by adjusting the head extension position.
R / : Anatomically, the extension head position is a way to straighten the respiratory cavity so that the respiratory process remains effective by eliminating airway obstruction.
2. Physical examination by auscultation listening to breath sounds every 2-4 hours.
R / : Ronchi indicates a respiratory disorder due to fluid or secretions that cover part of the respiratory tract, so it needs to be removed to optimize the airway.
3. Clean the mouth and airways of secretions and mucus by suction.
R / : Suction is an action to help remove secretions, thus facilitating the process of respiration.
4. Collaboration of oxygenation.
R/: Adequate oxygen supply can supply and provide oxygen reserves, thereby preventing hypoxia.
5. Observation of vital signs every 2 hours.
R / : Dyspnea, cyanosis is a sign of respiratory problems, accompanied by decreased cardiac work, tachycardia and capillary refill time are prolonged.
6. Observe the onset of respiratory failure.
R / : The body's inability to process respiration requires a critical intervention using a breathing apparatus (mechanical ventilation).
7. Collaboration in the administration of secretion-thinning drugs (mucolytics).
R / : Mucolytic drugs can thin thick secretions, making it easier to excrete and prevent viscosity.
2. Ineffective Breathing Pattern related to disturbed airway due to spasm of the respiratory muscles
Characterized by excitatory spasms, contraction of the respiratory muscles, and accumulation of mucus and secretions.
Goal: Regular and normal breathing pattern
Outcomes :
- Hypoxaemia is resolved, there is an improvement in the fulfillment of oxygen needs.
- No shortness of breath, normal breathing.
- No cyanosis
Interventional and Rational :
1. Monitor respiratory rhythm and respiratory rate.
R / : Indications of irregularities or abnormalities of breathing can be seen from the frequency, type of breathing, ability and rhythm of breathing.
2. Adjust the position to straighten the airway.
R / : The airway is loose and there is no obstruction of the respiratory process
3. Observe for signs and symptoms of cyanosis.
R / : Cyanosis is a sign of inadequate supply of oxygenation to peripheral body tissues.
4. Collaboration of oxygen delivery
R/: Adequate oxygen supply can supply and provide oxygen reserves, thereby preventing hypoxia.
5. Observation of vital signs every 2 hours.
R / : Dyspnea, cyanosis is a sign of respiratory disorders accompanied by decreased heart work, tachycardia and capillary refill time are prolonged.
6. Observe the onset of respiratory failure.
R / : The inability of the body in the process of respiration requires a critical intervention using a breathing apparatus (mechanical ventilation).
7. Collaboration in the examination of blood gas analysis.
R / : The body's compensation for disruption of the process of diffusion and tissue perfusion.
3. Imbalanced Body Temperature (hyperthermia) related to toxin effect (bacteremia)
Characterized by body temperature 38-40 oC, hyperhydration, white blood cells more than 10,000 / mm3.
Goal: Normal body temperature
Outcomes :
- Normal body temperature (36-37oC)
- The laboratory results of white blood cells (leukocytes) are between 5,000-10,000/mm3.
Intervention and Rationale:
1. Set a comfortable ambient temperature.
R/ : Environmental climate can affect the condition and individual body temperature as an adaptation process through evaporation and convection processes.
2. Monitor body temperature every 2 hours.
R / : Identify the development of symptoms towards shock exhaution.
3 . Provide adequate hydration or drink.
R / : Fluid helps to refresh the body and is a compression of the body from within.
4. Perform aseptic and antiseptic techniques in wound care.
R / : Wound treatment eliminates the possibility of toxins that are still around the wound.
5. Implement a program of antibiotic and antipyretic treatment.
R / : Antibacterial drugs can have a broad spectrum to treat gram positive bacteria or gram negative bacteria. Antipyretics work as a thermoregulatory process to anticipate heat.
7. Collaborative in leukocyte laboratory examination.
R / : The results of the examination of leukocytes that increase more than 10,000 / mm3 indicate an infection and or to follow the progress of the treatment programmed.
4. Imbalanced Nutrition: Less Than Body Requirements related to chewing muscle stiffness
Characterized by insufficient intake, food and drinks that enter through the mouth can return again through the nose and decreased body weight accompanied by the results of the examination of protein or albumin less than 3.5 mg%.
Goal: Nutritional needs are met.
Outcomes :
- Optimal weight
- Adequate intake
- Albumin examination results 3.5-5 mg %
Intervention and Rationale:
1. Explain the factors that affect difficulty in eating and the importance of food for the body.
R / : The impact of tetanus is the stiffness of the masticatory muscles so that the client has difficulty swallowing and sometimes reflex back or choking occurs. With an adequate level of knowledge, clients are expected to be participative and cooperative in the diet program.
2. Collaborative:
a. The provision of a high-calorie and high-protein diet is liquid, soft or coarse porridge.
R / : Diet given in accordance with the client's state of the level of opening the mouth and chewing process.
b. Administration of intravenous fluids
R / : Giving intravenous fluids given to clients with the inability to chew or can not eat by mouth so that nutritional needs are met.
c. NGT installation if necessary
R / : NGT can serve as the entry of food as well as to give medicine.
Reference:
Brunner & Suddarth. 2002.
Doengoes, ME .2000
Lynda Juall C, 2003.
Smeltzer, Suzane C. 2002.
Physical Examination for Clients with Nervous System Disorders - Tetanus
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