Nursing Care Plan for Tetanus - Nursing Diagnosis : Hyperthermia and Interventions
Nursing Diagnosis for Tetanus
Definition: The body temperature rises above the normal range.
Characteristics :
- Increase in body temperature above the normal range
- Attacks or convulsions (seizures)
- Skin redness
- Increase respiratory rate
- Tachycardia
- Hands felt warm to the touch
Tetanus is an infectious disease which is caused due Clostridium tetani bacterium.
Tetanus is transmitted through the environment and not from person to person contact. It is also known as lockjaw as it causes spasms that lock the muscles of the jaw. In severe cases, respiratory muscles get locked due to spasm and the person dies due to lack of oxygen to the brain and other parts of the body.
The chief tetanus symptoms generated by the neurotoxins include lockjaw and other contraction of the skeletal muscles of the face and upper body. Highly painful spasms become evident, accompanied by the voluntary muscles becoming increasingly rigid. The limbs and trunk follow, along with an arching of the back that is technically called opisthotonos. As the symptoms progress, so generally do the severity of the spasms, especially the masseter muscle contributing to lockjaw.
Nursing Diagnosis for Tetanus
Hyperthermia related to efeks toxin (bacteremia)
- characterized by :
- body temperature 38-40 ° C,
- hyper-hydration,
- white blood cells more than 10,000 / mm3
Purpose: Normal body temperature
Results Criteria:
- Temperature :36-37 ° C,
- Laboratory results: white blood cells (WBCs) between 5.000-10.000/mm3
Nursing Interventions - Hyperthermia Nursing Care Plan for Tetanus :
1. Set the ambient temperature, which is convenient.
Rational: The climate and environment can affect an individual's body temperature as a process of adaptation through the process of evaporation and convection.
2. Monitor body temperature every 2 hours
Rasioanl: Identify the symptoms progress to the shock.
3. Provide adequate hydration or drinking adequat
Rationale: Fluids help refresh the body and the compression of the body.
4. Take action on aseptic technique and antiseptic treatment of wounds.
Rational: wound care eliminate the possibility of a toxin that is located around the wound.
5. Implement programs and antipieretik antibiotic treatment.
Rational: These drugs may have antibacterial properties to treat a broad spectrum of gram-positive bacteria or gram negative bacteria. Antipyretic worked as a process of thermoregulation, heat anticipation.
6. Collaborative laboratory examination of leukocytes.
Rational: The results of leukocytes increased by more than 10,000 / mm 3 indicates the presence of infection and to keep abreast of the prescribed treatment.
