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tetanus

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hi everyone. my pt is diagnosed with tetanus. he is now on a nasogastric tubing. still experiencing with muscle rigidity on the neck leg and abdominal area. He is febrile with temp of 38 degrees. the wound is reddened . pls correct me if im wrong. I'm trying to formulate an appropriate nursing diagnosis.

Nursing dx: elevated by temperature related to release of bacterial toxins secondary to tetanus infection as evidenced by flushed skin and temperature of 38 degrees

Fatigue related to prolonged bedrest

Impaired skin intergrity related to mechanical trauma(puncture)

Disturbed sleep pattern related to recurrent occurence of muscle spasms(not sure with the term spasm im actually referring to the tetany)

thanks evryone i need ur answer as soon as possible

Daytonite, BSN, RN

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

your nursing diagnoses are based on the abnormal data that you collected about the patient. tetanus is a medical diagnosis and there is no nursing diagnosis equivalent. nursing diagnoses will be the patient's responses to the disease.

nursing dx: elevated by temperature related to release of bacterial toxins secondary to tetanus infection as evidenced by flushed skin and temperature of 38 degrees

unless you are required by your instructors to compose your own nursing diagnoses, there is no such nursing diagnosis as
elevated by temperature.
there is already a nanda diagnosis of hyperthermia which you can use:
hyperthermia r/t release of bacterial toxins secondary to tetanus aeb temperature of 38 degrees and flushed skin.

disturbed sleep pattern related to recurrent occurrence of muscle spasms (not sure what the term spasm is actually referring to the tetany)

a spasm is an involuntary muscular contraction due to irritation of the muscle. and, they are usually painful because they are sustained contractions. a charlie horse in the lower legs is one that people commonly know of that will wake them up during the night. people with pinched nerves will also get muscle spasms of the muscles involved. in severe calcium deficiencies, people will get muscle tetany and spasms.

check out for tetanus symptoms and confirm the infection. Then start administering tetanus shots as soon as possible. Fever and muscle spasms are general symptoms of tetanus.

Thanks,

Davis

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