Nursing Interventions for Tetanus

Tetanus 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, rod-shaped, obligate anaerobic bacterium Clostridium tetani. Infection generally occurs through wound contamination and often involves a cut or deep puncture wound. As the infection progresses, muscle spasms develop in the jaw (thus the name "lockjaw") and elsewhere in the body. Infection can be prevented by proper immunization and by post-exposure prophylaxis.


Unlike many infectious diseases, recovery from naturally acquired tetanus does not usually result in immunity to tetanus. This is due to the extreme potency of the tetanospasmin toxin; even a lethal dose of tetanospasmin is insufficient to provoke an immune response.

Tetanus can be prevented by vaccination with tetanus toxoid. The CDC recommends that adults receive a booster vaccine every ten years, and standard care practice in many places is to give the booster to any patient with a puncture wound who is uncertain of when he or she was last vaccinated, or if he or she has had fewer than three lifetime doses of the vaccine. The booster may not prevent a potentially fatal case of tetanus from the current wound, however, as it can take up to two week for tetanus antibodies to form. In children under the age of seven, the tetanus vaccine is often administered as a combined vaccine, DPT/DTaP vaccine, which also includes vaccines against diphtheria and pertussis. For adults and children over seven, the Td vaccine (tetanus and diphtheria) or Tdap (tetanus, diphtheria, and acellular pertussis) is commonly used.

The WHO certifies countries as having eliminated maternal or neonatal tetanus. Certification requires at least two years of rates < 1 case per 1000 live borns. In 1998 in Uganda, 3,433 tetanus cases were recorded in new-born babies; of these, 2,403 died. After a major public health effort Uganda in 2011 was certified as having eliminated tetanus.
Source : wikipedia

Nursing Interventions for Tetanus

Ineffective airway clearance related to the accumulation of sputum in the trachea and respiratory muscle spasm

Characterized by:

Ronchi, cyanosis, dyspnea, cough accompanied by sputum ineffective or lenders, the results of laboratory tests showed: abnormal blood gas analysis (respiratory acidosis)


Effective airway


Clients are not crowded, no lender or sleam
Breathing 16-18 times / minute
No nostril breathing
No additional respiratory muscle
The results of laboratory blood gas analysis of blood within normal limits (pH = 7.35 to 7.45; PCO2 = 35-45 mmHg, PO2 = 80-100 mmHg)

Tetanus Nursing Interventions and Rational:

A. 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 is still running smoothly by removing the blockage of the airway.

2. Physical examination by auscultation of breath sounds heard (there Ronchi) every 2-4 hours.
Rational: Ronchi show an upper respiratory problems due to fluid or a secret that covered most of the respiratory tract that need to be removed to optimize the airway.

3. Clean the mouth and respiratory tract of mucus with a secret and do section.
Rational: section is an act of assistance to issue a secret, thus simplifying the process of respiration.

4. Oxygenation according to physician instructions.
Rational: the provision of adequate oxygen can supply and provide backup oxygen, thus preventing hypoxia.

5. Observation of vital signs every 2 hours.
Rational: dyspnea, cyanosis is a sign of breathing disorder which is accompanied by decreased cardiac work arising tacikardi reffil time and capillary length / time.

6. Observation of the onset of respiratory failure / apnea.
Rational: the inability of the body in the respiratory process required critical interventions by using a breathing (mechanical ventilation)

7. Collaboration in a secret-thinning medication (mukolotik).
Rational: mukolitik drugs can thin the thick secretions so easy to remove and prevent viscosity.

Nursing Assessment for Tetanus

Nursing Diagnosis for Tetanus