Topics: Pneumonia, Tetanus, Immune system Pages: 7 (1098 words) Published: June 4, 2013

Tetanus is a medical condition characterized by a prolonged contraction of skeletal muscle fibers. The primary symptoms are caused by tetanospasmin, a neurotoxin produced by the Gram-positive, rod-shaped, obligate anaerobic bacterium Clostridium tetani.

Clostridium tetani spores can be found most commonly in soil, dust and manure, but also exist virtually anywhere. If deposited in a wound the neurotoxin interferes with nerves that control muscle movement.

The signs and symptoms of tetanus may include:

▪ Muscle spasms that begin in the jaw and neck
▪ Inability to open the mouth (lockjaw)
▪ Swallowing problems
▪ Breathing difficulties
▪ Painful convulsions
▪ Abnormal heart rhythms.
Tetanus is a life-threatening disease and sometimes, a person dies despite prompt medical attention.

Treatment for tetanus may include:

▪ Antitoxin called tetanus immunoglobulin to neutralise the tetanus toxin ▪ Hospitalisation
▪ Anti-convulsive medications
▪ Antibiotics
▪ Life support – for example, the person may be placed on an artificial respirator if they have severe breathing problems ▪ Vaccination, if the adult hasn’t had a booster shot in the previous five years.

Nursing Diagnosis for Tetanus

1. Ineffective Airway Clearance related to accumulation of secretions result of damage to the muscles of swallowing.

2. Acute Pain related to injury agents (biological).

3. Risk for Aspiration related to loss of consciousness, swallowing disorders.

4. Ineffective Tissue Perfusion related to damage to transport oxygen through the alveolar and capillary membranes.

5. Risk for Injury related to an increase in muscle coordination (convulsions), irritability.

6. Imbalanced Nutrition, Less Than Body Requirements related to decreased swallowing reflexes, less intake.

7. Risk for Infection related to immune primary, invasive procedures.

8. Impaired Swallowing related to neuromuscular damage swallowing muscles.

9. Impaired Urinary Elimination related to damage to sensory motor.

10. Self Care Deficit related to weakness, illness.

11. Knowledge Deficit: about the disease and treatment related to lack of exposure to sources of information.

12. Impaired Verbal Communication related to decreased blood circulation to the brain.

Nursing Care Plan for Pneumonia


Pneumonia is a breathing (respiratory) condition in which there is an infection of the lung.


Pneumonia caused by bacteria tends to be the most serious kind. In adults, bacteria are the most common cause of pneumonia.

▪ The most common pneumonia-causing germ in adults is Streptococcus pneumoniae (pneumococcus). ▪ Atypical pneumonia, often called walking pneumonia, is caused by certain other bacteria. ▪ Pneumocystis jiroveci pneumonia is sometimes seen in people whose immune system is not working well.

Many other bacteria can also cause pneumonia.

Viruses are also a common cause of pneumonia, especially in infants and young children.

Signs and Symptoms

Symptoms of pneumonia caused by bacteria usually come on quickly. They may include:

▪ Cough.
▪ Fever.
▪ Fast breathing and feeling short of breath.
▪ Shaking and "teeth-chattering" chills. You may have this only one time or many times. ▪ Chest pain that often feels worse when you cough or breathe in. ▪ Fast heartbeat.
▪ Feeling very tired or feeling very weak.
▪ Nausea and vomiting.
▪ Diarrhea.


Pathogenesis of pneumonia include interactions between microorganisms (MO) causes that go through various avenues, with patient endurance. Germs reach the alveoli by inhalation, aspiration of oropharyngeal bacteria, hematogenous spread from another focus of infection, or direct spread from the site of infection. At the lower respiratory tract, the bacteria encounter in the form of immune defense system mukosilier, cellular resistance alveolar macrophages, bronchial lymphocytes and neutrophils. Also humoral immune...
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