Risk for Injury - Nursing Diagnosis for Tetanus

Risk for Injury Definition : At risk for injury as a result of [internal or external] environmental conditions interacting with the individual’s adaptive and defensive resources.

Tetanus is a serious but preventable disease that affects the body's muscles and nerves. Characterized by an acute onset of hypertonia, painful muscular contractions (usually of the muscles of the jaw and neck), and generalized muscle spasms without other apparent medical causes. It typically arises from a skin wound that becomes contaminated by a bacterium called Clostridium tetani, which is often found in soil.

Infection begins when the spores enter the body through an injury or wound. The spores release bacteria that spread and make a poison called tetanospasmin. This poison blocks nerve signals from the spinal cord to the muscles, causing severe muscle spasms. The spasms can be so powerful that they tear the muscles or cause fractures of the spine.

The time between infection and the first sign of symptoms is typically 7 to 21 days. Most cases of tetanus in the United States occur in those who have not been properly vaccinated against the disease.

Early symptoms of tetanus include:
  • Painful muscle spasms that begin in the jaw (lock jaw)
  • Stiff neck, shoulder and back muscles
  • Difficulty swallowing
  • Violent generalized muscle spasms
  • Convulsions
  • Breathing difficulties

  • Immunisation protects against tetanus. Tetanus vaccine is given at 2, 4 and 6 months of age, with boosting doses at 4 years, between 15 to 17 years, and at 50 years of age.
  • Adults who haven't had a booster in the last ten years should get one when they turn 50.
  • Individuals who received a primary course of 3 doses as adults, should receive booster doses 10 and 20 years after the primary course.
  • Adults who have sustained tetanus prone wounds (e.g. open fractures, deep penetrating wounds, contaminated wounds or burns) should disinfect the wound and seek medical attention and receive a boosting dose of tetanus vaccine if more than 5 years have elapsed since their last dose. See Immunisation Handbook
  • If there is doubt about prior vaccination history, tetanus toxoid should be given.

Nursing Diagnosis for Tetanus : Risk for Injury related to improved muscle coordination (convulsions), irritability

  • Increased safety status of physical injury

Expected Outcome :
  • Clients in a safe position and free from injury.
  • Clients do not fall.
  • Patients known method of preventing injury.

Nursing Interventions :

Seizures Management
  • Monitor the position of the head and eyes during a seizure.
  • Use loose clothing.
  • Accompany / stay with the client during the seizure.
  • Maintain airway clearance.
  • Give oxygenation.
  • Monitor neurological status.
  • Monitor vital sign.
  • Record the length and characteristics of seizures (posture, motor activity, procession seizures).
  • Manage medications anticonvulsants.

Environmental Management
  • Identify the client's security needs ..
  • Keep harmful objects for the client
  • Install the side rails.
  • Provide a dedicated space.
  • Limit environmental stimulation (sound, touch, light).
  • Limit visitors.
  • Encourage the family to wait / be close to the client.