I. OBJECTIVES

The University of Pangasinan, College of Nursing aims to produce nurses who are competent in the care of people in participation with other care providers in the prevention of disease, promotion and maintenance of health, restoration of well being and alleviation of suffering. With these in mind, we form the following objectives. General objectives:

* This case study is designed for student nurses like us to become practiced, well informed and mannered in delivering holistic care for patients diagnosed with tetanus, as well as to gain knowledge and overview about the disease. Specific objectives:

* To imply appropriate nursing management for tetanus. * To be able to discuss the anatomy and physiology of the nervous system. * To be able to define tetanus and identify its clinical manifestations and risk factors. * To be acquainted with the different drugs for tetanus and their actions. * Plan for a suitable nursing care. * To know the purposes and specific nursing responsibilities before, during, and after some procedure done with the client. * To institute bond between the student nurse and the patient.

II. INTRODUCTION

Tetanus comes from the Greek word “teiteim” which means to stretch. It is also called lockjaw. It is a serious infectious disease of the nervous system in which toxin causes severe muscle spasm. It is a medical condition characterized by a prolonged contraction of skeletal muscle fibers.

It is caused by a bacterium Clostridium tetani. Infection generally occurs through wound contamination and often involves a cut or deep punctured wound. Tetanus is often associated with rust, but this concept is somewhat misleading. The C.Tetani is an Anaerobic bacteria which survives in an environment that lacks oxygen, thus with or without rust a person may have a tetanus once C. Tetani enters the wound. Contaminated wounds are the site where tetanus bacteria multiply. Deep wounds or those with distallized tissue are particularly prone to tetanus infection. The tetanus toxin affects the site of interaction between the nerve and the muscle that it stimulates, this region is called the neuromuscular junction. The tetanus toxin amplifies the chemical signals from the nerve to the muscles to tighten up in a continuous contraction or spasm. This results in either localized or generalized muscle spasm.

The incubation period ranges from 3 to 21 days, usually about 8 days. In general the further the injury site is from the central nervous system, the longer the incubation period. The shorter the incubation period, the higher the chance of death. In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days. On the basis of clinical findings, three different forms of tetanus have been described. Local tetanus is an uncommon form of the disease, in which patients have persistent contraction of muscles in the same anatomic area as the injury. These contractions may persist for many weeks before gradually subsiding. Local tetanus may precede the onset of generalized tetanus but is generally milder. Only about 1% of cases are fatal. Tetanus can be prevented by vaccination with tetanus toxoid. A booster is needed every 10 years after primary immunization.

Some of the common clinical manifestations of Tetanus are as follows:

* Facial muscle spasms * Neck muscle pains * Risus sardonicus- pathognomonic sign * Arrhythmia signs/irregular pulse * Blue lips * Cyanosis * Hypertonicity * Hyperactive Deep Tendon Reflex * Low Grade Fever * Opisthotonus * Intermittent Covulsions * Laryngospasm

III. SIGNIFICANCE OF THE STUDY

* Nursing Education :
Nursing is a field of medicine that constantly requires it’s practitioner’s to increase their knowledge to be able to catch up with the developments in the medical field and to be able to fulfill their role as a nurse educator who educates others and themselves. With this study, the researcher’s will be able to present a detailed information about a disease called tetanus, it’s causes, treatments, managements and latest development regarding this disease, thus helping nurses and other persons concerned with the medical field further understand what tetanus is, which help them become a more educated practitioner of their profession. * Nursing Practice :
This study is significant such that it increases the knowledge of nurses on the causes and risk factors of tetanus which help them further understand the disease which help them establish the right approach and precautions when encountering patients with the mentioned disease. This study includes the surgical and medical management of a tetanus patient therefore making them a more confident and more competent health providers. * Nursing Research :
Researcher’s regarding tetanus have gone a long way, but there are still flaws and missing pieces that need to be solved. With this study, we can provide nursing researcher’s a document where they can analyze and compare a data concerning tetanus patients. This study can as well be use in further improving the established guidelines when it comes to dealing with tetanus patients. Lastly, data in this study can be used as reference for future researches.

IV. DISEASE PROCESS

Tetanus is caused by a bacterium known as Clostridium tetani. It is an anaerobic bacterium that actually develops in environments that do not contain oxygen. Usually the tetanus causing bacterium is present in our environment. It is particularly prevalent in soil, animal feces and other unhygienic conditions. It can lie dormant for years in the form of spores.
When a person gets injured, the wound or the cut becomes an environment that lacks oxygen. If the spores manage to find their way into the wound or the cut, they are able to germinate. After the spores of the bacterium germinate, they release a toxin, which is what causes all the ill-effects of the disease. In the case of our patient, she had a wound on her left breast which became contaminated with Clostridium tetani. She is already succesptible on acquiring the disease from the very beginning since she did not received any immunization in the past.
The toxin attacks the nervous system of the body. The toxin, which is known as tetanospasmin, runs along the spinal cord, the blood stream of the peripheral nervous system and prevents the neuron from releasing the a neurotransmitter that helps the body muscles to relax after a contraction. That is why when a person gets tetanus, he or she suffers from severe spasms and contraction.
Slowly as the bacterium proliferates in the body, more and more toxin is produced and it manages to find its way to different groups of muscles. The toxin particularly affects the jaw muscles, the muscles of the back, arms, legs, neck and abdomen, and the muscles that control the diaphragm and the chest wall.
If a person is suspected of suffering from tetanus, treatment has to be started immediately. There should be no delay. The patient is administered medication to act on the toxin released by the bacterium, and also antibiotics are given. In case the person suffers from respiratory failure, he or she is put on a ventilation machine to facilitate breathing. However, the best treatment against tetanus is prevention. This is done via vaccination, which is usually given as part of the childhood immunization program and thereafter every ten years.

VI. ANATOMY AND PHYSIOLOGY

The nervous system is your body's decision and communication center. The central nervous system (CNS) is made of the brain and the spinal cord and the peripheral nervous system (PNS) is made of nerves. Together they control every part of your daily life, from breathing and blinking to helping you memorize facts for a test. Nerves reach from your brain to your face, ears, eyes, nose, and spinal cord... and from the spinal cord to the rest of your body. Sensory nerves gather information from the environment, send that info to the spinal cord, which then speed the message to the brain. The brain then makes sense of that message and fires off a response. Motor neurons deliver the instructions from the brain to the rest of your body. The spinal cord, made of a bundle of nerves running up and down the spine, is similar to a superhighway, speeding messages to and from the brain at every second.
The brain is made of three main parts: the forebrain, midbrain, and hindbrain. The forebrain consists of the cerebrum, thalamus, and hypothalamus (part of the limbic system). The midbrain consists of the tectum and tegmentum. The hindbrain is made of the cerebellum, pons and medulla. Often the midbrain, pons, and medulla are referred to together as the brainstem.
Cerebrum
The cerebrum is divided into two equal halves called hemispheres and controls our thoughts and actions. It is the largest part of the brain, located in the forebrain, and consists of four lobes. The parietal lobe is responsible for recognition, movement, orientation and perception of stimuli. The temporal lobe controls memory, speech and perception of auditory stimuli. The frontal lobe assists us with problem solving, movement, planning, reasoning, parts of speech and emotions. Last but not least, the occipital lobe controls our sense of sight. The neocortex accounts for the largest part of the cerebrum. This six-layer structure is responsible for higher information processing.
Cerebellum
The cerebellum is part of the hindbrain and, like the cerebrum, has two hemispheres. It contains more than half of the neurons in the brain and is responsible for motor control, sensory perception and coordination. Neural pathways connect the cerebellum with the cerebral motor cortex, which aids muscle movement. Damage to the cerebellum hinders fine motor skills and causes muscle weakness. There are three main arteries that supply blood to this part of the brain: the anterior inferior cerebellar artery, the superior cerebellar artery and the posterior inferior cerebellar artery.
Limbic System
The limbic system is located in the forebrain and consists of the hypothalamus, thalamus, hippocampus and amygdala. It is often referred to as the emotional brain because it controls emotions and memories. The hypothalamus regulates body temperature and controls both emotions and crucial urges. The thalamus relays messages to the cerebral cortex. The hippocampus is responsible for spatial navigation and long-term memory. The amygdala stores memories that are associated with emotional events.
Brain Stem
The brain stem is part of the hindbrain and connects the brain to the spinal cord. It controls various vital functions such as blood pressure, breathing and heart rate. Nerve impulses to and from the cerebellum and the cerebrum must travel through the brain stem. Because of its huge role in life-sustaining bodily functions, damage to the brain stem is very serious and can be life-threatening in certain cases.

VII. PATHOPHYSIOLOGY

Modifiable Risk factors Non-modifiable Risk factor 1. Occupation 1. Age ( too young/too old) 2. Residence 3. Drug Abuse 4. Trauma (eg. Burn) 5. Pregnancy 6. Poverty

Clostridium tetani

Enter to the body causing:
1.Local infection
2.Extensive tissue destruction Released toxins

Absorbed by the bloodstream and lymphatic

Spread in CNS

Inducing hyperexcitality of motor nuerons

Decreased release of inhibitory transmitter

Tissue reflect the effect:
1.asphyxial convulsions,
2. toxic degeneration,
3.inanition,
4.non-specific complications.

Narrative:

After Clostridium Tetani enter the body, it causes local infection and extensive tissue destruction.Local multiplication of microorganism occurs more frequently when the wound is healed. While reproducing, they also release toxins that are absorbed by the bloodstream and the lymphatics or through the peripheral motor nerves. These eventually spread in the central nervous system.The toxins (tetanospasmin) have a great affinity to the central nervous system tissue and spinal motor ganglia, inducing hyper excitability of the motor neurons by the interfering with the release of an inhibitory transmitter.Other tissue reflect the effects of asphyxia convulsions, toxic degeneration, inanition, and non-specific complications.

XI. SURGICAL MANAGEMENT The wound must be cleaned. Dead and infected tissue should be removed by debridement to prevent the entry of pathogenic microorganisms and further exacerbation of the disease.

Debridement is the medical removal of a patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), and by maggot therapy, where certain species of live maggots selectively eat only necrotic tissue.

Purpose
Debridement speeds the healing of pressure ulcers, burns, and other wounds. Wounds that contain non-living (necrotic) tissue take longer to heal. The necrotic tissue may become colonized with bacteria, producing an unpleasant odor. Though the wound is not necessarily infected, the bacteria can cause inflammation and strain the body's ability to fight infection. Necrotic tissue may also hide pockets of pus called abscesses. Abscesses can develop into a general infection that may lead to amputation or death.

Precautions
Not all wounds need debridement. Sometimes it is better to leave a hardened crust of dead tissue, called an eschar, than to remove it and create an open wound, particularly if the crust is stable and the wound is not inflamed. Before performing debridement, the physician will take a medical history with attention to factors that might complicate healing, such as medications being taken and smoking. The physician will also note the cause of the wound and the ways it has been treated. Some ulcers and other wounds occur in places where blood flow is impaired, for example, the foot ulcers that can accompany diabetes mellitus. In such cases, the physician or nurse may decide not to debride the wound because blood flow may be insufficient for proper healing.

Description
In debridement, dead tissue is removed so that the remaining living tissue can adequately heal. Dead tissue exposed to the air will form a hard black crust, called an eschar. Deeper tissue will remain moist and may appear white, or yellow and soft, or flimsy. The four major debridement techniques are surgical, mechanical, chemical, and autolytic.

Types of Debridement

A. Surgical debridement

Surgical debridement (also known as sharp debridement) uses a scalpel, scissors, or other instrument to cut dead tissue from a wound. It is the quickest and most efficient method of debridement. It is the preferred method if there is rapidly developing inflammation of the body's connective tissues (cellulitis) or a more generalized infection (sepsis) that has entered the bloodstream. The physician will begin by flushing the area with a saline (salt water) solution, and then will apply a topical anesthetic gel to the edges of the wound to minimize pain. Using a forceps to grip the dead tissue, the physician will cut it away bit by bit with a scalpel or scissors. Sometimes it is necessary to leave some dead tissue behind rather than disturb living tissue. The physician may repeat the process again at another session.

Advantages * Fast and selective * Can be extremely effective
Disadvantages
* Painful to patient * Costly, especially if an operating room is required * Requires transport of patient if operating room is required
B.Mechanical debridement

In mechanical debridement, a saline-moistened dressing is allowed to dry overnight and adhere to the dead tissue. When the dressing is removed, the dead tissue is pulled away too. This process is one of the oldest methods of debridement. It can be very painful because the dressing can adhere to living as well as nonliving tissue. Because mechanical debridement cannot select between good and bad tissue, it is an unacceptable debridement method for clean wounds where a new layer of healing cells is already developing.

Advantages * Cost of the actual material (ie. gauze) is low

Disadvantages * Non-selective and may traumatize healthy or healing tissue * Time consuming * Can be painful to patient * Hydrotherapy can cause tissue maceration. Also, waterborne pathogens may cause contamination or infection. Disinfecting additives may be cytotoxic.

A. Chemical debridement
Chemical debridement makes use of certain enzymes and other compounds to dissolve necrotic tissue. It is more selective than mechanical debridement. In fact, the body makes its own enzyme, collagenase, to break down collagen, one of the major building blocks of skin. A pharmaceutical version of collagenase is available and is highly effective as a debridement agent. As with other debridement techniques, the area first is flushed with saline. Any crust of dead tissue is etched in a cross-hatched pattern to allow the enzyme to penetrate. A topical antibiotic is also applied to prevent introducing infection into the bloodstream. A moist dressing is then placed over the wound.
Advantages
* Fast acting * Minimal or no damage to healthy tissue with proper application.
Disadvantages
* Expensive * Requires a prescription * Application must be performed carefully only to the necrotic tissue. * May require a specific secondary dressing * Inflammation or discomfort may occur

D. Autolytic debridement
Autolytic debridement takes advantage of the body's own ability to dissolve dead tissue. The key to the technique is keeping the wound moist, which can be accomplished with a variety of dressings. These dressings help to trap wound fluid that contains growth factors, enzymes, and immune cells that promote wound healing. Autolytic debridement is more selective than any other debridement method, but it also takes the longest to work. It is inappropriate for wounds that have become infected.
Advantages
* Very selective, with no damage to surrounding skin. * The process is safe, using the body's own defense mechanisms to clean the wound of necrotic debris. * Effective, versatile and easy to perform * Little to no pain for the patient
Disadvantages
* Not as rapid as surgical debridement * Wound must be monitored closely for signs of infection * May promote anaerobic growth if an occlusive hydrocolloid is used

Preparation
The physician or nurse will begin by assessing the need for debridement. The wound will be examined, frequently by inserting a gloved finger into the wound to estimate the depth of dead tissue and evaluate whether it lies close to other organs, bone, or important body features. The area may be flushed with a saline solution before debridement begins, and a topical anesthetic gel or injection may be applied if surgical or mechanical debridement is being performed.

Aftercare
After surgical debridement, the wound will be packed with a dry dressing for a day to control bleeding. Afterward, moist dressings are applied to promote wound healing. Moist dressings are also used after mechanical, chemical, and autolytic debridement. Many factors contribute to wound healing, which frequently can take considerable time. Debridement may need to be repeated.

Risks
It is possible that underlying tendons, blood vessels or other structures will be damaged during the examination of the wound and during surgical debridement. Surface bacteria may also be introduced deeper into the body, causing infection.

Normal results
Removal of dead tissue from pressure ulcers and other wounds speeds healing. Although these procedures cause some pain, they are generally well tolerated by patients and can be managed more aggressively. It is not uncommon to debride a wound again in a subsequent session.

XII. DISCHARGE PLANNING

* Medications

* Antibiotics
Penicilin 600-1,200mg daily * Neosporin ointment * Polysporin ointment
These ointment antibiotics won't make the wound heal faster, but they can discourage bacterial growth and infection and may allow the wound to heal more efficiently

* Exercise Begin by performing possive to active assisted excercise)..., then as your stamina is restored, increase the level of exercise such as walking around until you achieved the expected outcome with confidence. Above all, don t push yourself beyond your limit. * Front limbs:
Rotate each shoulder 8-10 times, clockwise and counter-clockwise
Flexion and extension of cubital joints, ("front knees") 5-10 times
Flexion and extension of carpal joints, 5-10 times
Flexion and extension of the shoulder, cubital, and carpal joints in combination. * Rear limbs:
Rotate each hip 8-10 times, clockwise and counter-clockwise
Flexion and extension of hock joints, 5-10 times
Flexion and extension of tarsal joints, 5-10 times

* Treatment * Administer medication and apply ointment on precise time. The goal is to halt or prevent further progression of disease and wound infection. Leave unclean wounds open to avoid trapping bacteria in the wound with a bandage. Keep the wound clean * Cover the wound. Exposure to the air may speed healing, but bandages can help keep the wound clean and keep harmful bacteria out.

* Change the dressing. Apply a new dressing at least once a day or whenever the dressing becomes wet or dirty to help prevent infection. If you're allergic to the adhesive used in most bandages, switch to adhesive-free dressings or sterile gauze and paper tape.

* Health Teaching
Have a good hygiene, clean wound sites to prevent further complications. Have a healthy lifestyle and have a regular check up.

* Out-Patient Avoid ‘miracle cures’ drugs that are not prescribed by the physician and other forms of quackery and have a follow up checkup. Report to the physician or clinic immediately as needed. * Diet
Milk, egg albumin, eggnog, nutritious beef, mutton, or chicken broths, malted gruels, wine, brandy, and whisky should be given as frequently as the condition of the patient will admit. If possible, from two to four ounces should be administered every hour. The spasm does not affect the involuntary muscles, so that food is swallowed if it can be placed far back in the pharynx.

* Spiritual and Sexual activities
Don’t lose hope and always have faith in god.. Everything was meant by god by his plan. And you can have your mass by watching it in TV. Pray and ask guidance to our god. It would be difficult for you to have sex because aside from having a lack jaw, your breast was wounded and may cause further complication
ACKNOWLEDGEMENT

We, University of Pangasinan nursing students, warmly express our profound gratitude to the entire management of Pangasinan Provincial Hospital, for the exposure of the client enabled us to learn and increase our knowledge and strengthen our drives to become fulfilled nurses;
Mr. Mario R. Tendero, Head Nurse Medical Ward, for allowing us and welcoming us to gain access to the facilities of the provincial hospital and to gain more knowledge and skills in furthering our nursing profession;
Ms. Aurora Bautista, Chief Nurse, for her full supervision particular in the proper orientation and extend full support to our nursing endeavors;
Mr. Eljohn P. Zulueta, Clinical Instructor, who gives us strict supervision, more reminders, support and encouragement;
Parents, who are unconditional, love and care is always there for us; Our Lord Almighty, source of all good and Giver of life we praise and thank You for everything.