Bacterium Clostridium tetani.
Contamination of a puncture wound, e.g.: a piercing.
Ear infections as bacteria may enter through ear.
Using unsterile equipment in surgery or other similarly invasive procedures such as tattooing and body piercing.
Ineffective Airway Clearance related to the accumulation of sputum in the trachea and the respiratory muscles spame
Ineffective cough accompanied by sputum or phlegm, lab test results, Abnormal Blood Gas Analysis (respiratory acidosis)
Objective: Airway clearance is effective
- Clients are not congested, mucus, or none sleam
- Respiratory 16 -18 x / minute
- No breathing nostril
- No additional respiratory muscle
- The results of laboratory examination of blood: Blood Gas Analysis in the normal range (pH = 7.35 to 7.45; PCO2 = 35-45 mmHg, pO 2 = 80-100 mmHg)
Nursing Interventions Ineffective Airway Clearance Nursing Care Plan for Tetanus:
1. Clear the airway by adjusting the position of head extension
Rational: The anatomy of the head position of the extension is a way to align the respiratory cavity so that the process of respiration remains smooth to get rid of airway obstruction.
2. Physical examination by auscultation listening to breath sounds (there Ronchi) every 2-4 hours.
Rational: Ronchi indicate a problem caused by upper respiratory fluids or secretions that covered most of the respiratory tract that is necessary to issue, to optimize the airway.
3. Clean the mouth and airways of secretions and mucus by suction
Rational: Suction is an act of assistance to remove secretions, thus simplifying the process of respiration.
Rationale: The provision of oxygen in adequat can supply and provide backup oxygen, thus preventing the occurrence of hypoxia.
5. Observation of vital signs every 2 hours
Rational: Dyspneu, cyanosis is a sign of breathing disorder which is accompanied by decreased cardiac work and capilary tachycardia arising refill time prolonged / long.
6. Observation of the onset of respiratory failure.
Rational: The inability of the body in the process of respiration required critical interventions using tools breathing (mechanical ventilation)
7. Collaboration in drug delivery thinning secretions
Rational: Drug-thinning secretions could dilute the thick secretions that facilitate spending and prevent viscosity.