Primary Nursing Diagnosis

Ineffective airway clearance related to muscle spasms and trismus

OUTCOMES. Respiratory status: Gas exchange and ventilation; Symptom control behavior; Treatment behavior: Illness; Comfort level

INTERVENTIONS. Airway management; Airway suctioning; Artificial airway management; Environmental management: Safety; Teaching: Disease process, Prescribed medication; Emotional support

U PLANNING AND IMPLEMENTATION Collaborative

To prevent tetanus, within 3 days of a puncture wound, patients with no previous tetanus immunization require tetanus immune globulin or tetanus antitoxin for temporary protection. Active immunization with tetanus toxoid is also provided. If the patient had a previous immunization more than 5 years before the injury, a booster injection of tetanus toxoid is warranted at the time of injury. Goals of treatment include neutralizing the toxin, preventing complications, and eliminating the source of the toxin. Human tetanus immune globulin is administered immediately. One-half of the dose is administered by infiltrating the wound, and the remaining half is administered intramuscularly into three limbs. Active immunity is given by administering tetanus tox-oid at a site remote from the globulin injections. The affected wound is thoroughly d├ębrided after the antitoxin has been administered. Cultures of the wound may be obtained at that time. Par-enteral antibiotics (penicillin in particular if the patient has no allergies to the drug) are administered for 10 days.

Respiratory distress may necessitate intubation or tracheostomy and mechanical ventilation with supplemental oxygen. Nasogastric tubes are inserted to prevent gastric distension. Patients with difficulty swallowing may require nutritional support with total parenteral nutrition or enteral feeding by a nasogastric or nasointestinal tube.

eee Tetanus

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