ALTERED NUTRITION: LESS THAN BODY REQUIREMENTS ASSESSMENT S: O: The patient manifested: >poor muscle development >poor muscle

e tone >unable to open mouth wide >weakness The pt. may manifest: >hyperactive bowel sounds >underweight >fecal loss of blood >prone to infections >capillary fragility >pale palpebral conjunctiva >pale mucus membrane NURSING DIAGNOSIS Altered Nutrition: less than body requirement r/t inability to open mouth wide and muscle weakness. SCIENTIFIC EXPLANATION Acute disease induced by toxin of tetanus bacillus growing anaerobically in wounds and at site of umbilicus among infants. Characterized by muscular contraction. The client manifested weakness due to severe muscle contraction and due to compensator y mechanism of the body like increase in temperature. The client also OBJECTIVES Short Term: After 4 hours of NI, the patient will verbalize understanding of causative factors when known and necessary interventions. Patients vital signs will decrease/retu rn to normal rate/ranges. Long Term: After 2 days of NI, the patient will demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight and patients vital NURSING RATIONALE INTERVENTIONS > Establish > To gain the rapport trust and cooperation of the pt. and the SO > Monitor and record V/S EXPECTED OUTCOME The patient shall verbalize understanding of causative factors when known and > To gain necessary baseline interventions. data for the Patients vital care and signs shall manageme decrease/retu nt of the rn to normal patient rate/ranges. And the >This will patient shall guide what demonstrate interventions behaviors, to provide lifestyle changes to >To assess regain and/or any maintain abnormalitie appropriate s weight and patients vital signs shall >To maintain to determine normal what rates/ranges. information to provide

>Assess patients condition

>Assess skin turgor and mucous membranes >Ascertain understanding of individual nutritional needs

manifested unable to open mouth wide due to muscle spasm caused by toxins that impaires neurologic functions. Thus, the client is unable to eat resulting to altered nutrition: less than body requirements.

signs will maintain to normal rates/ranges.

>Assess weight, age, body >Provides build, strength, comparativ activity/rest e baseline level, and so forth >Discuss eating >To appeal habits, to clients including food likes/desires preferences, intolerances >Encourage patient to choose foods which are appealing >Emphasize importance of well-balanced, nutritious intake >To stimulate appetite

>To achieve wellness and supply metabolic needs

ACTIVITY INTOLERANCE ASSESSMENT S: O: The patient manifested: > fatigue > weakness > restlessness > increased pulse > abnormal heart rate to activity > low tolerance of activity >with vital signs of: Temperature36.5C Pulse rate104bpm Respiratory rate- 20 cpm The pt. may manifest: > irritability > inability to perform or NURSING DIAGNOSIS Activity Intolerance r/t generalized weakness EXPECTED OUTCOME Short Term: The patient shall Activity After 4 hours of verbalize and intolerance is NI, the patient shall use energy a common will verbalize conservation problem since and will use techniques and physical energy management of activity conservation fatigue with increases the techniques and > Monitor and > To gain increasing demand for management of record V/S baseline data activity level oxygen and for the care and effects of heart rhythm. fatigue with increasing and inactivity shall In tetanus, activity level management have reduced. there is a and effects of of the patient The patients spasm in the inactivity will be vital signs shall muscles due reduced. The > Assess > Provides return to normal to the patients vital temperature, information rates/ranges: spreading of signs will return respirations, about V/S Heart rate in the toxins of and pulse; changes between 60the clostridium to normal rates/ranges: changes in caused by 100bpm. bacteria that Heart rate of 60- behavior hypoxia and causes 100 bpm (irritability, about irritability of lightheadednes behavior synapses of s, short changes the neurons Long Term: attention caused by Long term: making the After 2-3 days of span); if easily reduced The patient shall individuals NI, the patient fatigued, oxygenation demonstrate affected will demonstrate unable to of the brain maintenance of become maintenance of sleep, or weak; energy and physically energy and ability to endurance and weak and endurance tolerate any will be able to SCIENTIFIC EXPLANATION OBJECTIVES NURSING RATIONALE INTERVENTIONS > Establish > To gain the rapport trust and cooperation of the pt. and the SO

begin an activity > exertional discomfort or dyspnea

unable to engage in normal physical activity without experiencing profound fatigue. In very advanced cases this may cause parality of muscles and other evidence of heart failure may appear. Patients may experience activity intolerance because of fatigue, weakness, and poor tissue oxygenation and increased heart rate.

levels and will activity or ADL be able to perform his daily > Assist with activities of life. activities that require exertion and are beyond tolerance and ability > Provide rest periods, plan care and activities around rest/sleep > Provide appropriate quiet activities, and allow interaction with other individuals > Refrain from performing nonessential procedures

perform his daily activities of life. > Minimizes physical exertion, which increases oxygen to tissues > Decreases oxygen expenditure to enhance tissue oxygenation > Promotes diversionary activity and prevents withdrawal

> Patients with limited activity intolerance need to prioritize tasks

> Place patient > To facilitate in semi-Fowler's breathing or sitting position > Replaces blood or blood components depending on type of anemia and need > Provides information to prevent fatigue by minimizing physical activity or exertion, which utilizes more oxygen and less exertion of the heart

> Administer transfusion of blood, packed RBC, platelets as ordered

> Inform patient of measures to take to conserve energy and increase endurance of the client including placing articles within reach, anticipating needs and assisting before client attempts activity, allowing for rest; remain

with patient as needed

> Inform patient to avoid stressful situations > Teach patient to recognize signs of physical overactivity

> Promotes quiet environment for child >This promotes awareness of when to reduce activity

FATIGUE ASSESSMENT

NURSING DIAGNOSIS S: Fatigue r/t muscular O: The weakness and patient spasticity manifested: >decreased performance >weakness >inability to restore energy, even after sleep >tiredness >inability to maintain usual routines >Vital signs taken: Temperature37.5C Pulse rate110 bpm Respiratory rate- 64 cpm The pt. may manifest: >lethargic or listless; drowsy >compromise d

SCIENTIFIC EXPLANATION Decreased The tetanus toxin affects the site of interaction between the nerve and the muscle that it stimulates. This region is called the neuromuscula r junction. The tetanus toxin amplifies the chemical signal from the nerve to the muscle, which causes the muscles to tighten up in a continuous contraction or spasm. This results in either localized or generalized m uscle spasms causing the

EXPECTED OUTCOME Short Term: The patient After 2-3 shall hours of NI, verbalize the patient establishmen will verbalize t of a pattern establishmen of sleep/rest t of a pattern > Monitor and > To gain that of sleep/rest record V/S baseline facilitates that data for the optimal facilitates care and performance optimal managemen of required/ performance t of the desired of required/ >Assess patient activities. desired patients Patients vital activities. condition >This will signs shall Patients vital guide what return to signs will interventions normal return to to provide rates/ranges. normal >Assess current And the rates/ranges. activity level >Fatigue and patient shall exertional achieve Long Term: dyspnea are adequate After 2-3 characteristi activity days of NI, c symptoms tolerance, the patient of anemia AEB ability to will achieve >Assess perform adequate characteristics >Using a activities of activity of fatigue: quantitative daily living tolerance, -severity rating scale and AEB ability to -changes in such as 1 to verbalization perform severity over 10 can help of return to

OBJECTIVES

NURSING RATIONALE INTERVENTIONS > Establish > To gain the rapport trust and cooperation of the pt. and the SO

concentratio n >disinterest in surroundings > increased rest requirements >increased physical complaints

client to be paralyzed and become weakened or fatigued.

activities of daily living and verbalization of return to normal/nearnormal activity levels.

time -aggregating factors -alleviating factors

the patient describe the amount of fatigue experienced. Other rating >Monitor serum scales can electrolytes be and urine developed osmolality and using pictures report or descriptive abnormal words. This values method allows the nurse to compare changes in the patients fatigue level over time. It is important to determine if the patients level of fatigue is constant or if it varies over >Assess time. patients emotional >Anxiety and response to depression fatigue are the more common emotional

normal/nearnormal activity levels.

>Assess the patients expectations for fatigue relief, willingness to participate in strategies to reduce fatigue, and level of family and social support >Evaluate the patients sleep patterns for quality, quantity, time taken to fall asleep, and feeling upon awakening >Assist the patient to

responses associated with fatigue. These emotional states can add to the persons fatigue level and create a vicious cycle >Social support will be necessary to help the patient implement changes to reduce fatigue

>This promotes interest in drinking

develop a schedule for daily activity and rest

>Help the patient to set priorities for desired activities and role responsibilities

>A plan that balances periods of activity with periods of rest can help the patient complete desired activities without adding to levels of fatigue >To conserve energy and this can improve the patients mood and sense of emotional well-being >Bright lighting, noise, visitors, frequent distractions, and clutter in the patients physical

>Minimize environmental stimuli, especially during planned times for rest and sleep

>Teach the patient and family task organization techniques

environment can inhibit relaxation, interrupt rest/sleep, and contribute to fatigue

>Organizatio n can help the patient >Help the build patient endurance develop habits for physical to promote activity effective rest/sleep >Promoting patterns relaxation before sleep and providing for several hours of uninterrupted sleep can contribute to >Provide energy diversional restoration activities >Impaired concentratio n can limit ability to

>Encourage the patient to verbalize feelings about the impact of fatigue

block competing stimuli/ distractions >Fatigue can have a profound negative influence on family processes and social interactions

Impaired swallowing ASSESSMENT NURSING DIAGNOSIS S: Impaired swallowing O: The related to patient nueromascul manifested: ar >poor muscle impairment development >poor muscle tone >unable to open mouth wide >weakness >dysphagia >incomplete lip closure The pt. may manifest: >aspiration >coughing >adventitious breath sounds >productive cough >acidic smelling breath >vomiting >dry mucous

SCIENTIFIC EXPLANATION Acute disease induced by toxin of tetanus bacillus growing anaerobically in wounds and at site of umbilicus among infants. Characterized by mascular contraction. Muscle spasm is caused by toxins because it affects impulses that stimulates muscle contration and rigidity. The client manifested dysphagia due to spasm of muscles in

NURSING RATIONALE INTERVENTIONS Short term: > Establish > To gain the After 3-4 hours rapport trust and of nursing cooperation interventions, of the pt. the client will and the SO be able to pass food and > Monitor and > To gain fluid from record V/S baseline mouth to data for the stomach care and safely manageme nt of the Long term: patient After 2-3 days >Assess of nursing patients >This will interventions, condition guide what the client will interventions be able to to provide maintain desired body >Determine >To assess weight ability to for impaired initiate/sustain ability to effective suck swallow

OBJECTIVES

>Note for >It suggests hyperextension inability to of head complete swallowing process

EXPECTED OUTCOME The patient shall verbalize understanding of causative factors when known and necessary interventions. Patients vital signs shall decrease/retu rn to normal rate/ranges. And the patient shall demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight and patients vital signs shall maintain to normal rates/ranges.

membrane >poor skin turgor

the oral cavity. Neuromascul ar system is afftected that results to severe contraction of muscles. Thus, results to impaired swallowing.

>Auscultate for >to evaluate breath sounds presence of aspiration >Keep Head of >To reduce Bed risk of regurgitation /aspiration

>Suction oral cavity PRN

>To clear secretions and promotes airway safety

>Encourage a rest period before meals

>To minimize fatigue

Risk for aspiration ASSESSMENT NURSING DIAGNOSIS S: Risk for aspiration O: The related to patient impaired manifested: swallowing >poor muscle development >poor muscle tone >unable to open mouth wide >weakness >dysphagia The pt. may manifest: >coughing >adventitious breath sounds >productive cough

SCIENTIFIC EXPLANATION Acute disease induced by toxin of tetanus bacillus growing anaerobically in wounds and at site of umbilicus among infants. Characterized by mascular contraction. Muscle spasm is caused by toxins because it affects impulses that stimulates muscle contration and rigidity. The client manifested dysphagia due to spasm of muscles in

NURSING RATIONALE INTERVENTIONS Short term: > Establish > To gain the After 1-2 hours rapport trust and of nursing cooperation interventions, of the pt. the client will and the SO be able to identify > Monitor and > To gain causative/risk record V/S baseline factor data for the care and manageme Long term: nt of the After 2-3 days patient of nursing >Assess interventions, patients >This will the client will condition guide what be able to interventions demonstrate to provide techniques to prevent and >Assess clients >To correct ability to determine aspiration swallow and presence/eff strength of ectiveness of gag/cough protective reflex mechanisms >Because of potential for regurgitation and or/

OBJECTIVES

EXPECTED OUTCOME Short term: The client shall have identified causative/risk factor Long term: the client shall have demonstrated techniques to prevent and correct aspiration

>Note for administration of enteral

the oral cavity. Thus, resulting to aspiration that may cause complications like aspiration pneumonia.

feedings

misplaceme nt of tube. >because it affect awareness and muscle of gag/swallow .

>Ascertain lifestyle habits such as use of alcohol, tobacco, and other CNS

>Keep wire cutter/scissors with client at all times when jaws are wired/banded >Suction as needed

>To facilitate clearing airway in emergency situations >To clear secretions while reducing potential for aspiration of secretions >To decrease potential risk for aspiration.

>Avoid keeping client in supine position when enteral feedings.

C. diet Type of Diet Date ordered, performed,changed Description Indication/Purpose Specific foods taken Clients response/reaction

DAT with SAP

8/14/11

This type of diet is usually ordered for patients with respiratory problems.

The patient manifests difficulty of swallowing and unable to open mouth wide

Soft foods such as porridge, kamote, mashed potato, soup.

The client has not experienced aspiration. The patient is compliant with regards to the diet ordered.

Before Explain to the patient and the patients relatives the need of the diet. Encourage deep breathing exercises

During Instruct patient to be on high fowlers position while eating or drinking . Instruct patient to eat food that are easy to chew and swallow. Instruct patient to avoid

after Instruct patient to drink water to flush down food Instruct patient to maintain high fowlers position for 10 minutes after eating

certain foods (eg, caffeine, fatty meals, carbonated beverages, peppermint, citrus)