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Hyperthermia related to - Tetanus

Nursing Diagnosis for Tetanus : Hyperthermia related to efeks toxin (bacteremia)

Hyperthermia

Definition: The body temperature rises above the normal range.

Characteristics :
  • Increase in body temperature above the normal range
  • Attacks or convulsions (seizures)
  • Skin redness
  • Increase respiratory rate
  • Tachycardia
  • Hands felt warm to the touch
Tetanus is a disease caused by a toxin produced by the bacteria called Clostridium tetani. This toxin can be found in soils heavy in manure or other organic material, particularly in tropical or humid regions of the hemisphere. Once the bacteria enters open wounds or cuts it generates spores, which in turn creates neurotoxins.

The symptoms of tetanus :
  • Lockjaw
  • Stiff neck
  • Seizures or spasms
  • Inability to swallow
  • Fever
  • High blood pressure

Purpose: Normal body temperature

Criteria: 36-37 ° C, the results of laboratory white blood cells (leukocytes) between 5.000-10.000/mm3


Nursing Interventions for Hyperthermia related to - Tetanus

1. Set the temperature a comfortable environment
Rational: the environment can affect the condition and temperature of individual body as a process of adaptation through the process of evaporation and convection.

2. Monitor body temperature every 2 hours
Rational: Identify the symptoms progress toward exhaution shock.

3. Provide adequate hydration or adequate drinking
Rational: Fluids help refresh the body and is a compression body from within.

4. Take action aseptic and antiseptic techniques in wound care.
Rational: Nursing wounds eliminate the possibility of toxins that are still located around the wound.

5. Give cold compress if no seizures occur external stimuli.
Rational: cold compress is one way to lower body temperature by means of conduction process.

6. Implement programs and antipiretic antibiotic treatment
Rational: These drugs can have broad spectrum antibacterial to treat gram-positive or gram negative bacteria. Antipiretic worked as a process of thermoregulation to anticipate an increase in body temperature.

7. Collaborative laboratory examination of leukocytes.
Rational: Test results leukocyte increased by more than 10,000 / mm 3 indicates infection and treatment or to follow the development of the programmed.

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