ncps tetany

8/4/2019 ncps tetany

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ALTERED NUTRITION: LESS THAN BODY REQUIREMENTS

ASSESSMENT NURSINGDIAGNOSIS

SCIENTIFICEXPLANATION

OBJECTIVES NURSINGINTERVENTIONS

RATIONALE EXPECTEDOUTCOME

S:

O: The

patient

manifested:

>poor muscledevelopment

>poor muscle

tone

>unable to

open mouthwide

>weakness

The pt. maymanifest:

>hyperactivebowel sounds

>underweight

>fecal loss ofblood

>prone toinfections

>capillaryfragility

>pale

palpebralconjunctiva

>pale mucus

membrane

AlteredNutrition: less

than body

requirement

r/t inability to

open mouthwide and

muscle

weakness.

Acutedisease

induced by

toxin of

tetanus

bacillusgrowing

anaerobically

in wounds

and at site of

umbilicusamong

infants.

Characterized

by muscularcontraction.

The clientmanifested

weakness due

to severemuscle

contractionand due to

compensatory mechanism

of the body

like increasein

temperature.

The client also

Short Term:After 4 hours

of NI, the

patient will

verbalize

understandingof causative

factors when

known and

necessary

interventions.Patients vital

signs will

decrease/retu

rn to normalrate/ranges.

Long Term:

After 2 days of

NI, the patientwill

demonstratebehaviors,

lifestylechanges to

regain and/or

maintainappropriate

weight and

patients vital

> Establishrapport

> Monitor and

record V/S

>Assess

patients

condition

>Assess skinturgor and

mucousmembranes

>Ascertain

understanding

of individualnutritional

needs

> To gain thetrust and

cooperation

of the pt.

and the SO

> To gain

baseline

data for the

care and

management of the

patient

>This willguide what

interventionsto provide

>To assessany

abnormalities

>To

determinewhat

information

to provide

The patientshall verbalize

understanding

of causative

factors when

known andnecessary

interventions.

Patients vital

signs shall

decrease/return to normal

rate/ranges.

And the

patient shalldemonstrate

behaviors,lifestyle

changes to

regain and/ormaintain

appropriateweight and

patients vital

signs shall

maintain to

normalrates/ranges.


2/18

manifested

unable to

open mouthwide due to

muscle spasmcaused by

toxins that

impaires

neurologic

functions.Thus, the

client is

unable to eat

resulting toaltered

nutrition: less

than body

requirements.

signs will

maintain to

normalrates/ranges.

>Assess weight,

age, body

build, strength,activity/rest

level, and soforth

>Discuss eating

habits,

including foodpreferences,

intolerances

>Encouragepatient to

choose foods

which are

appealing

>Emphasize

importance ofwell-balanced,

nutritious intake

>Provides

comparative baseline

>To appeal

to clients

likes/desires

>To stimulateappetite

>To achievewellness and

supplymetabolic

needs


3/18

ACTIVITY INTOLERANCE

ASSESSMENT NURSINGDIAGNOSIS

SCIENTIFICEXPLANATION

OBJECTIVES NURSINGINTERVENTIONS

RATIONALE EXPECTEDOUTCOME

S:

O: The patient

manifested:

> fatigue> weakness

> restlessness

> increased

pulse

> abnormalheart rate to

activity

> low

tolerance ofactivity

>with vitalsigns of:

Temperature-

36.5CPulse rate-

104bpmRespiratory

rate- 20 cpm

The pt. may

manifest:> irritability

> inability to

perform or

ActivityIntolerance

r/t

generalized

weakness

Activity

intolerance isa common

problem since

physical

activity

increases the

demand foroxygen and

heart rhythm.

In tetanus,there is a

spasm in themuscles due

to thespreading of

the toxins of

the clostridiumbacteria that

causes

irritability ofsynapses of

the neurons

making the

individualsaffected

become

physically

weak and

Short Term:After 4 hours of

NI, the patient

will verbalize

and will use

energyconservation

techniques and

management of

fatigue with

increasingactivity level

and effects of

inactivity will be

reduced. Thepatients vital

signs will returnto normal

rates/ranges:

Heart rate of 60-100 bpm

Long Term:After 2-3 days of

NI, the patient

will demonstratemaintenance of

energy and

endurance

> Establishrapport

> Monitor and

record V/S

> Assesstemperature,

respirations,and pulse;

changes in

behavior(irritability,

lightheadedness, short

attentionspan); if easily

fatigued,

unable tosleep, or weak;

ability to

tolerate any

> To gain thetrust and

cooperation

of the pt. and

the SO

> To gain

baseline data

for the care

andmanagement

of the patient

> Providesinformation

about V/Schanges

caused by

hypoxia andabout

behaviorchanges

caused byreduced

oxygenation

of the brain

The patient shallverbalize and

shall use energy

conservation

techniques and

management offatigue with

increasing

activity level

and effects of

inactivity shallhave reduced.

The patients

vital signs shall

return to normalrates/ranges:

Heart rate inbetween 60-

100bpm.

Long term:The patient shall

demonstrate

maintenance ofenergy and

endurance and

will be able to


4/18

begin an

activity

> exertionaldiscomfort or

dyspnea

unable to

engage in

normalphysical

activitywithout

experiencing

profound

fatigue. In very

advancedcases this may

cause parality

of muscles

and otherevidence of

heart failure

may appear.

Patients may

experienceactivity

intolerancebecause of

fatigue,

weakness, andpoor tissue

oxygenationand increased

heart rate.

levels and will

be able to

perform his dailyactivities of life.

activity or ADL

> Assist withactivities that

require exertionand are

beyond

tolerance and

ability

> Provide rest

periods, plan

care and

activitiesaround

rest/sleep

> Provideappropriate

quiet activities,and allow

interaction with

otherindividuals

> Refrain from

performing

nonessential

procedures

> Minimizesphysical

exertion,which

increases

oxygen to

tissues

> Decreases

oxygen

expenditure

to enhancetissue

oxygenation

> Promotesdiversionary

activity andprevents

withdrawal

> Patients

with limited

activity

intoleranceneed to

prioritize tasks

perform his daily

activities of life.


5/18

> Place patient

in semi-Fowler's

or sittingposition

> Administer

transfusion of

blood, packedRBC, platelets

as ordered

> Inform

patient of

measures to

take toconserve

energy andincrease

endurance of

the clientincluding

placing articleswithin reach,

anticipating

needs and

assisting before

client attemptsactivity,

allowing for

rest; remain

> To facilitate

breathing

> Replaces

blood or

blood

componentsdepending

on type of

anemia and

need

> Provides

information to

prevent

fatigue byminimizing

physicalactivity or

exertion,

which utilizesmore oxygen

and lessexertion of

the heart


6/18

with patient as

needed

> Inform

patient to

avoid stressful

situations

> Teach

patient torecognize signs

of physical

overactivity

> Promotes

quiet

environment

for child

>This

promotesawareness of

when to

reduce

activity


7/18

FATIGUE

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS

RATIONALE EXPECTED

OUTCOME

S:

O: The

patient

manifested:

>decreased

performance>weakness

>inability to

restore

energy, even

after sleep>tiredness

>inability to

maintain

usual routines>Vital signs

taken:Temperature-

37.5C

Pulse rate-110 bpm

Respiratoryrate- 64 cpm

The pt. may

manifest:

>lethargic orlistless; drowsy

>compromise

d

Fatigue r/t

muscularweakness and

spasticity

Decreased

The tetanustoxin affects

the site of

interaction

between the

nerve and themuscle that it

stimulates. This

region is

called the

neuromuscular junction. The

tetanus toxin

amplifies the

chemicalsignal from

the nerve tothe muscle,

which causes

the muscles totighten up in

a continuouscontraction or

spasm. Thisresults in

either

localized orgeneralized m

uscle spasms

causing the

Short Term:

After 2-3hours of NI,

the patient

will verbalize

establishmen

t of a patternof sleep/rest

that

facilitates

optimal

performanceof required/

desired

activities.

Patients vital

signs will

return tonormal

rates/ranges.

Long Term:

After 2-3days of NI,

the patientwill achieve

adequate

activitytolerance,

AEB ability to

perform

> Establish

rapport

> Monitor andrecord V/S

>Assess

patients

condition

>Assess current

activity level

>Assess

characteristics

of fatigue:-severity

-changes in

severity over

> To gain the

trust andcooperation

of the pt.

and the SO

> To gainbaseline

data for the

care and

managemen

t of thepatient

>This will

guide whatinterventions

to provide

>Fatigue and

exertionaldyspnea are

characteristic symptoms

of anemia

>Using a

quantitativerating scale

such as 1 to

10 can help

The patient

shallverbalize

establishmen

t of a pattern

of sleep/rest

thatfacilitates

optimal

performance

of required/

desiredactivities.

Patients vital

signs shall

return tonormal

rates/ranges.And the

patient shall

achieveadequate

activitytolerance,

AEB ability toperform

activities of

daily livingand

verbalization

of return to
http://www.medicinenet.com/script/main/art.asp?articlekey=101231http://www.medicinenet.com/script/main/art.asp?articlekey=101231http://www.medicinenet.com/script/main/art.asp?articlekey=101231http://www.medicinenet.com/script/main/art.asp?articlekey=101231


8/18

concentratio

n

>disinterest insurroundings

> increasedrest

requirements

>increased

physical

complaints

client to be

paralyzed

and becomeweakened or

fatigued.

activities of

daily living

andverbalization

of return tonormal/near-

normal

activity

levels.

time

-aggregating

factors-alleviating

factors

>Monitor serum

electrolytes

and urine

osmolality andreport

abnormal

values

>Assess

patients

emotional

response tofatigue

the patient

describe the

amount offatigue

experienced.Other rating

scales can

be

developed

using picturesor descriptive

words. This

method

allows thenurse to

compare

changes in

the patients

fatigue levelover time. It is

important todetermine if

the patients

level offatigue is

constant or ifit varies over

time.

>Anxiety and

depressionare the more

common

emotional

normal/near-

normal

activitylevels.


9/18

>Assess the

patients

expectations

for fatigue

relief,

willingness toparticipate in

strategies to

reduce

fatigue, and

level of familyand 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

emotionalstates can

add to the

persons

fatigue level

and create avicious cycle

>Social

support willbe necessary

to help the

patient

implement

changes toreduce

fatigue

>Thispromotes

interest in

drinking


10/18

develop a

schedule for

daily activityand rest

>Help thepatient to set

priorities for

desired

activities and

roleresponsibilities

>Minimizeenvironmental

stimuli,especially

during planned

times for rest

and sleep

>A plan that

balancesperiods of

activity withperiods of

rest can help

the patient

complete

desiredactivities

without

adding to

levels offatigue

>To conserve

energy and

this canimprove the

patients

mood and

sense of

emotionalwell-being

>Bright

lighting,

noise, visitors,

frequent

distractions,and clutter in

the patients

physical


11/18

>Teach the

patient and

family task

organization

techniques

>Help the

patientdevelop habits

to promote

effective

rest/sleep

patterns

>Provide

diversional

activities

environment

can inhibit

relaxation,interrupt

rest/sleep,and

contribute to

fatigue

>Organization can help

the patient

build

endurancefor physical

activity

>Promoting

relaxationbefore sleep

andproviding for

several hours

ofuninterrupted

sleep cancontribute to

energy

restoration

>Impairedconcentratio

n can limit

ability to


12/18

>Encourage

the patient toverbalize

feelings aboutthe impact of

fatigue

block

competing

stimuli/distractions

>Fatigue can

have a

profound

negative

influence onfamily

processes

and social

interactions


13/18

Impaired swallowing

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS

RATIONALE EXPECTED

OUTCOME

S:

O: The

patient

manifested:

>poor muscle

development>poor muscle

tone

>unable to

open mouth

wide>weakness

>dysphagia

>incomplete

lip closure


>aspiration

>coughing>adventitious

breathsounds

>productivecough

>acidic

smellingbreath

>vomiting

>dry mucous

Impaired

swallowingrelated to

nueromascul

ar

impairment

Acute

diseaseinduced by

toxin of

tetanus

bacillus

growinganaerobically

in wounds

and at site of

umbilicus

amonginfants.

Characterized

by mascular

contraction.Muscle spasm

is caused bytoxins

because it

affectsimpulses that

stimulatesmuscle

contrationand rigidity.

The client

manifesteddysphagia

due to spasm

of muscles in

Short term:

After 3-4 hoursof nursing

interventions,

the client will

be able to

pass food andfluid from

mouth to

stomach

safely

Long term:

After 2-3 days

of nursing

interventions,the client will

be able tomaintain

desired body

weight

> Establish

rapport


>Assess

patients

condition

>Determine

ability toinitiate/sustain

effective suck

>Note for

hyperextensionof head

> To gain the


of the pt.

and the SO

> To gainbaseline

data for the

care and

manageme

nt of thepatient

>This will


to provide

>To assess

for impairedability to

swallow

>It suggests

inability tocomplete

swallowing

process

The patient

shall verbalizeunderstanding

of causative

factors when

known and

necessaryinterventions.

Patients vital

signs shall

decrease/retu

rn to normalrate/ranges.

And the

patient shall

demonstratebehaviors,

lifestylechanges to

regain and/or

maintainappropriate

weight andpatients vital

signs shallmaintain to

normal

rates/ranges.


14/18

membrane

>poor skin

turgor

the oral

cavity.

Neuromascular system is

afftected thatresults to

severe

contraction of

muscles. Thus,

results toimpaired

swallowing.

>Auscultate for

breath sounds

>Keep Head of

Bed

>Suction oral

cavity PRN

>Encourage arest period

before meals

>to evaluate

presence ofaspiration

>To reduce

risk of

regurgitation

/aspiration

>To clear

secretionsand

promotes

airway

safety

>To minimize

fatigue


15/18

Risk for aspiration

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS

RATIONALE EXPECTED

OUTCOME

S:

O: The

patient

manifested:

>poor muscle

development>poor muscle

tone

>unable to

open mouthwide

>weakness

>dysphagia


>coughing>adventitious

breath

sounds>productive

cough

Risk for

aspirationrelated to

impaired

swallowing

Acute

diseaseinduced by

toxin of

tetanus

bacillus

growinganaerobically

in wounds

and at site of

umbilicusamong

infants.

Characterized

by mascular

contraction.Muscle spasm

is caused bytoxins

because it

affectsimpulses that

stimulatesmuscle

contrationand rigidity.

The client

manifesteddysphagia

due to spasm

of muscles in

Short term:

After 1-2 hoursof nursing

interventions,

the client will

be able to

identifycausative/risk

factor

Long term:

After 2-3 days

of nursing

interventions,

the client willbe able to

demonstratetechniques to

prevent and

correctaspiration

> Establish

rapport


>Assess

patients

condition

>Assess clients

ability toswallow and

strength ofgag/cough

reflex

>Note for

administration

of enteral

> To gain the


of the pt.

and the SO

> To gainbaseline

data for the

care and

management of the

patient

>This will


to provide

>To

determinepresence/eff

ectiveness ofprotective

mechanisms

>Because ofpotential for

regurgitation

and or/

Short term:

The client shallhave

identified

causative/risk

factor

Long term:

the client shall

have

demonstratedtechniques to

prevent and

correct

aspiration


16/18

the oral

cavity. Thus,

resulting toaspiration that

may causecomplications

like aspiration

pneumonia.

feedings

>Ascertain

lifestyle habits

such as use of

alcohol,

tobacco, andother CNS

>Keep wire

cutter/scissorswith client at

all times when

jaws arewired/banded

>Suction as

needed

>Avoid

keeping client

in supineposition when

enteral

feedings.

misplaceme

nt of tube.

>because it

affectawareness

and muscle

of

gag/swallow

.

>To facilitateclearing

airway inemergency

situations

>To clearsecretions

while

reducingpotential for

aspiration ofsecretions

>To

decrease

potential riskfor

aspiration.


17/18

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 During after

Explain to the patientand the patients relativesthe need of the diet.

Encourage deepbreathing exercises

Instruct patient to be onhigh fowlers positionwhile eating or drinking .

Instruct patient to eatfood that are easy to

chew and swallow.

Instruct patient to avoid

Instruct patient to drinkwater to flush down food

Instruct patient tomaintain high fowlers

position for 10 minutes

after eating


18/18

certain foods (eg,

caffeine, fatty meals,

carbonated beverages,

peppermint, citrus)

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