Case Pres Tetanus Final

E M O C L E W !

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.

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To identify the disease that the patient is experiencing and conduct a nursing care that will be implemented.

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Assess the patient’s health status and make nursing diagnosis.

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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.

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To render proper nursing care within our limits.

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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.

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To demonstrate how words and touch can be used to harm or benefit the patient.

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To give and nurture the needs of the patient.

Introduction 

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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.

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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 manuretreated 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.

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T S ? U R CK A T AT

Tetanus is often associated with rust, especially rusty nails, but this concept is somewhat misleading. Objects that 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.

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T S ? U R CK A T AT

The rough surface of rusty metal merely provides a prime habitat for a C. tetani endospore to reside, and the nail affords a means to puncture skin and deliver endospore into the wound. An endospore is a nonmetabolising survival structure that begins to metabolise and cause infection once in an adequate environment.

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T S ? U R CK A T AT

Because C. tetani is an anaerobic bacterium, it and its endospores will thrive in an environment that lacks oxygen. 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  Sex: Male I.  Religion: Roman Catholic L A T I TCivil Status: Married V A M  Address: Phase I, Milibili Heights, R O N F O 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: One week before admission, A. g patient sustained a wound at the left n i t s r n foot, second digit. It was too small that u e N m s they did not mind having consultation. s e s s Five days after acquiring the A 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.

C.

N

S. C.

C.C.

HTN

Alcoholi c

A. C.

L. C.

68

65

F.C. 60 BA; Arthritis

R. C. 59

C.C. Jr.

A.C. 57 Tetanus; Gouty Arthiris

4. Patterns of Functioning Pattern of Funtioniong Breathing

Home

Hospital

RR: 16-25 breaths per minuteThe patient breathes through a tracheostomy tube attached to mechanical ventilator with settings of Mode- AC Fi02- 60%TV400 PFR- 50BUR- 14

4. Patterns of Functioning Pattern of Funtioniong

Home

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.

Circulation

Sleeping

Hospital

The patient usually sleeps at 8 pm and wakes up at 2 o’clock in the morning to attend to his ducks.

The patient sleeps at intervals, usually in semi-Fowler’s position, provided with one pillow on his head and one to support his extremities.

4. Patterns of Functioning Pattern of Funtioniong

Home

Hospital

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 meals and some snacks a day. He eats various kinds of foods only avoiding beans, organ meats, and nonscaly fish

NGT is attached. OTF amounting to 250 cc is given at 10am, 2pm and 6pm.

4. Patterns of Functioning Pattern of Funtioniong

Home

Hospital

Elimination: Urinary elimination

Patient voids whenever he feels the urge. He voids 3-4 times daily.

A Foley catheter is attached to the patient with adequate hourly urine output.

Bowel elimination

Patient defecates every morning without straining.

Patient experiences no bowel movement for 3 days. He is given Lactulose or Dulcolax suppository based on need.

4. Patterns of Functioning Pattern of Funtioniong

Personal hygiene

Recreation and Exercise

Home Patient takes a bathe everyday .

Hospital Immobility disables the patient to take hygienic measures. 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.

Patient does not have a He has no any form of 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 

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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.

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Religious Practices 

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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: Weight:

5’4” 57 kgs.

3. Physical Assessment General Appearance

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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, d n a r i ha nails

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Skin: brown complexions, dry, rough, and cool to touch has slight poor skin turgor. Hair: Minimal white hairs combined to black curly hair, equally distributed, presence of dandruff, no lice. Nails: untrimmed, clean, (+) pallor.

, d a e H e, fac d n a a h p m ly tic

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Head: large in size, symmetrical, scalp is intact and moves freely over skull. Face: Pale, (+) subcutaneous emphysema Lymphatic: unremarkable

, s e y E ears, , e s o n h t u o m and t a o r th

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Eyes: anicteric sclerae; upper and lower lids completely approximated when closed, eyelashes are evenly distributed, globes are aligned, pinkish conjunctiva, pupils are black in color and 2.5 mm in size. Ears: top pinna is below to the outer corner of the eyes with equal 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

d  n a k c e N r e p up s e i t i m e extr

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Neck: Symmetrical but shortened; proportional to head and shoulders, there are 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.

  d n a   t Ches :  Chest: (+) hair, brown in Axilla complexion; 

Axilla: (+) hair, (+) palpable lymph nodes; non-odorous

o t a ir p s Re y r With a respiration rate : m ranging 16-25 breaths per e t s 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 

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Language 

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Known language according to folks are in the native dialect, Filipino, and English.

Hearing 

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(-) verbal output due to lockjaw

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 VALUES

SIGNIFICANCE

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 VALUES

SIGNIFICANCE

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 VALUES

SIGNIFICANCE

VLDL

1.56-mmol/L

0.00-1.03

Elevated levels are correlated with alcohol consumption.

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.

Sodium

EXAMINATION

RESULT

NORMAL VALUES

Potassium

3.34 mmol/L 3.5-510

SIGNIFICANCE

Indicates gastric suctioning and diuretic therapy.

ABG 

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     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 VALUES

SIGNIFICANCE

WBC

Hi 12.4 10 x 12/L

4.5 – 11.0 x 10 12/L

An elevated WBC count commonly signals infection.

RBC

Lo 4.20 x 10 9/L

4.6– 6.2 x 10 9/L

A depressed count may 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 VALUES

SIGNIFICANCE

Hematocrit

Lo 0.36 vol.fr.

0.40 – 0.54 vol.fr

Low HCT indicates acute 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 VALUES

SIGNIFICANCE

Eosinophils Hi 4.0 %

0-3 %

Infection

Monocytes

0-8

Decrease level indicates chronic inflammatory disease, viral infection.

Hi 9.0 %

URINALYSIS Result

Normal value

Significance of Abnormal Results

It indicates bacteria.

Macroscopic: Transparency:

Cloudy

Clear

Microscopic: RBCs/hpf

Numerous to count

0 – 2 hpf

WBCs/hpf

Hi 6-12

0 – 5 hpf

Bacteria:

Few

Negative

Signifies trauma. An elevated WBC count indicates pyuria and presence of urinary tract infection. Indicates presence of bacteria.

RADIOLOGY 10/31/08 Chest PA X-ray impression: (L) Basal pneumonia

11/13/08 Chest AP X-ray Impression: (L) Basal pneumonia with regression S/p (L) Tracheotomy Tube insertion The tip of the

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ECG INTREPRETATION:  

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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.

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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 75250mm/day, a process which takes 3-14 days, protected from neutralizing antitoxin, predominantly to inhibitory synapses to prevent the release of acetylcholine.

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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.

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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.

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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 

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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

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Difficulty swallowing Restlessness

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Irritability Neck stiffness

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Headache Fever Sore throat Chills Risus sardonicus

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Rigidity

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Opisthotonus Urinary retention

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Constipation

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Moderate Leukocytosis Hypertension

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Tachycardia Difficulty breathing

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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.

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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 

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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.

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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 highcaloric 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.