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
1. Ineffective airway clearance
2. Ineffective Breathing Pattern
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