Nursing Care Plan for Tetanus


History of present illness: the existence of serious injuries and burns and inadequate immunization.

  • Respiratory System: dyspnea, and cyanosis asphyxia due to contraction of the respiratory bibs.
  • Cardiovascular System: dysrhythmias, tachycardia, hypertension and bleeding, the body temperature initially 38-40 ° C or febrile up to the terminal 43-44 ° C.
  • Neurologic System: irritability (early), weakness, convulsions (late), paralysis of one or several nerves of the brain.
  • Urinary System : urine retention (bladder distention and no urine output / oliguria)
  • Digestive System: constipation due to no bowel movements.
  • Integument and muskuloskletal System: tingling at the site of wound pain, sweating (hyper-hydration), was originally preceded trismus, spasm of the facial muscle contractions to increase the eyebrows, risus sardonicus, stiff muscles and difficulty swallowing.
  • If this continues there will be a status of general convulsions and seizures.

Nursing Diagnosis for Tetanus

Nursing Diagnosis for Tetanus

1. Ineffective airway clearance

2. Ineffective Breathing Pattern

3. Hyperthermia

4. Altered Nutrition: Less than body requirements

5. Risk of fluid and electrolyte imbalance

6. Risk for injury

7. Knowledge deficient

8. Disturbed sleep pattern

Hyperthermia Nursing Care Plan for Tetanus

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