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Need help with nursing diagnosis


I need help with my nursing diagnosis...I have a patient with tetanus. I chose Risk for Aspiration r/t dysphagia as evidenced by a decrease in the ability to swallow and breath. Does this sound right? Any suggestions? Thanks in advance.

You could go that route, but on an even more basic level, tetanus can cause respiratory muscle spasms, which is a much more immediate threat. Diagnosis would be "inability to sustain spontaneous ventilation."

But yours is good to :)

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

A nursing diagnosis is not the same as a medical diagnosis which is what tetanus is. We treat patients for their nursing problems. Nursing problems are difficulties accomplishing ADLs. You want to assess the patient's response to their medical condition of tetanus. Start by breaking down tetanus into its signs and symptoms:

  • there is usually a recent wound with pain or paresthesia at the site of the injury
  • difficulty chewing or swallowing food
  • muscle spasms
  • increase in muscle tone near the wound where the tetanus entered the body
  • irregular heartbeat/tachycardia
  • muscle hypertonicity
  • hyperactive DTRs
  • profuse sweating
  • low grade fever
  • painful involuntary muscle contractions
  • rigidity of the neck and facial muscles that cause a bizarre grinning expression
  • rigidity of back muscles causing an arched back
  • intermittent tonic seizures

Did you assess the patient? Are any of the above symptoms present? What medications or treatments has the doctor ordered? Is any teaching needed in connection with the treatment ordered by the doctor? Is any teaching needing regarding the disease, its treatment, booster shots, and importance of avoiding external stimulation that would evoke muscle spasms or potential outcomes of treatment? Any positive answers are actual nursing problems for which nursing diagnoses can be found--not "Risk for" diagnoses. "Risk for" diagnoses are used for anticipated problems that haven't even occurred yet.

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