Assessment

HISTORY. Classically, patients have a dirty (often soil-contaminated) puncture wound or laceration and describe pain or paresthesia at the puncture site. A history of intravenous drug abuse, dental infection, umbilical stump infection (infants), or penetrating eye infection and inadequate tetanus immunization may also be reported. If the wound has been left untreated, early symptoms include difficulty chewing or swallowing. The patient may have a mild fever or painful muscle contractions or spasms in the affected region. Infants may be unable to suck.

PHYSICAL EXAMINATION. Because most cases of tetanus result in a systemic reaction, inspect the patient for neuromuscular changes. Spasms begin in the facial and jaw muscles and progress to muscles of the neck, extremities, and respiratory/pharyngeal regions. Muscles ultimately become rigid, with painful spasms in response to any external stimuli. You may note seizures, posturing, and muscle rigidity; during seizure activity, the patient is awake and in severe pain. Autonomic disturbances include diaphoresis, increased heart rate, cardiac dysrhyth-mias, and blood pressure fluctuations. Spasms of respiratory and pharyngeal muscles may make it difficult to maintain a patent airway. Patients may exhibit increased respiratory rate, increased inspiratory effort, poor lung expansion, and decreased airflow. Late findings include risus sar-donicus (a grotesque, grinning expression), trismus (lockjaw), and opisthotonos (rigid somatic muscles that lead to an arched-back posture). With supportive care, signs and symptoms reverse after the toxin has been metabolized in about 6 weeks.

PSYCHOSOCIAL. The family may feel guilty if the patient has not been vaccinated. Assess the patient's and family's levels of anxiety and their ability to cope. The length of hospitalization and the seriousness of the diagnosis place the patient and family at risk for alterations in growth and development. Assess levels of growth and development using age-appropriate milestones and developmental tasks as guidelines.

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