Capitol University College of Nursing Cagayan de Oro City

A Case Study On

SEVERE TETANUS
In partial fulfillment for the requirements in RLE 50

Submitted to:

Mrs. Marithel Moreno, RN, MN

Clinical Instructor

Submitted by: Agcopra, JUville Ishtar Albaciete, Lindon Amante, Elizabeth Apilan, Mariel Bacarat, Datu Tago II Bangalan, Rhyan Caberte, Kimberly Ann Galleon, Kimberly Hazel Geronemo, Rona Mae Huavas, Kenneth Labuntog, John

BSN-3

August 3, 2012

TABLE OF CONTENTS

TITLE & AUTHORS ABSTRACT

TABLE OF CONTENTS: ACKNOWLEDGEMENT INTRODUCTION SIGNIFICANCE OF THE STUDY TO THE: -Nursing Education -Nursing Practice -Nursing Research OBJECTIVES OF THE STUDY: -General -Specific PATIENTS PROFILE -Nursing Health History -Physical Assessment -Developmental Data(Choose 1 Theory) ANATOMY AND PHYSIOLOGY PATHOPHYSIOLOGY DIAGNOSTIC TESTS MEDICAL AND SURGICAL MANAGEMENT -Drug study NURSING MANAGEMENT -Nursing Care Plan EVALUATION, RESULTS & DISCUSSION

DEFINITION OF TERMS BIBLIOGRAPY

ABSTRACT_____________________________________________________

This is a case study of patient X, 35 years old, male, residing in Sumilao, Bukidnon City. He is a farmer who had been admitted at Northern Mindanao Medical Center for complaints of abdominal spasms and dysphagia. Diagnostic examination revealed him Severe Tetanus. The patient was admitted at Emergency Room in NMMC and has undergone tracheostomy. And it did help patient removed secretions and help him promote enough breathing pattern. Nursing care for the patient focuses on restoring his full independence to take care of himself should he be discharged from the hospital. Nursing care plan was carried out using the fundamental principles of Virginia Hendersons Need Theory. Various health teachings were imparted with emphasis on active rangeof-motion excercises, adequate nutrition and expression of anxiety and fears to help verbalize anxiety and thus establish the patients sense of self-worth.

Acknowledgement ________________________________________________________________

We would like to extend our warmest gratitude to our Almighty God for making this case study possible. And for the people who have been part of doing this case study, without them this could not be possible.

To our Clinical Instructor, Mrs. Marithel Moreno, RN, MN for the corrections, unending support and understanding all throughout this case study. To our PCI thank you for reminding us always to our due responsibilities as a student nurse.

For the staff nurses of Northern Mindanao Medical Center, particularly in Emergency Room for helping us to achieve our goals and for the betterment of this case study through giving their positive approach.

To the client, who has been cooperative during our care in fulfilling this case study. To our family and friends whos been supporting us financially and emotionally all this time and giving their full support and encouragement every time we need them most.

THEORITICAL FRAMEWORK_______________________________________

This study is generally anchored on Virginia Hendersons Need Theory. She postulated the importance of patient independence so the patient will continue to progress after being released from the hospital. Furthermore, she emphasized the role of the nurse as one of the following: substitutive, which is doing something for the patient; supplementary, which is helping the patient to do something; or complementary, which is working with the patient to do something. All of these roles are to help the patient become as independent as possible. This theory helped us assist the patient in performing those activities which will contribute to improve patients health and would be able to help him perform unaided necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible Virginia Henderson emphasized 14 basic needs of the patient that have to be addressed and provided insights for the nurses on how to help patients so that they can care for themselves when they leave the hospital facility.

CONCEPTUAL FRAMEWORK_______________________________________ VIRGINIA HENDERSONS NEED THEORY

LOSS OF LOSS OF APPETITE CONSCIOUSNESSS CONSTIPATION VERTIGO PHYSICAL IMMOBILITY HYPERTENSION ANXIETY R/T FEAR PAIN POOR HYGIENE

NURSING INTERVENTIONS
Eliminate body wastes Communi cate with others

Eat and drink adequatel Avoid danger y

in the environment

Sleep and rest

Move and maintain desirable postures

Sleep and rest Express emotions

Keep body clean and well groomed

IMPROVED HEALTH

SIGNIFICANCE OF THE STUDY_____________________________________ This study is deemed to be of significance to the following areas: Nursing Education. This study can help student nurses understand the biological foundation of illnesses as well as its psychological effects on those confronting a health care crisis. Such knowledge can help students become more effective nurses. An exposure to such kind of disease condition will help improve education in the field of nursing that will provide both student nurses and instructors with exposure to various nursing specialties.

Nursing Practice. This study will provide student nurses overview on hands-on experience on how to interact with the actual patient with such condition under the watchful supervision of a skilled clinical instructor to teach other students how to best practice essential nursing skills as medication administration and patient charting. This can help the nurse hone her skills in a low-stress environment if ones practice is reinforced with comprehensive knowledge.

Nursing Research. As part of a nursing education, many students are required to participate in a specific research study. This may serve as future references and a related literature for future researches that may contribute to their overall body of knowledge to improve efficacy in the clinical setting. Without these research opportunities, the efficiency and quality of nursing care would rarely improve. Not only the students benefit from this research opportunities, through research, teachers are able to find effective methods for educating their students on proper procedure and efficient nursing care. Research is necessary to prove which nursing practices work effectively and which don't. Without research, a nursing education would not be based on concrete evidence.

OBJECTIVES OF THE STUDY______________________________________ General: The general objective of this study is to further enhance the knowledge and understanding of the student nurses about the nature of the patients condition in congruence with the learned concepts from nursing theory classes and incorporate such learning and understanding in knowledge-based practice. Specific: This study seeks to provide relevant information about the disease condition of the client with the following specific objectives: 1. To give a brief overview about the nature of severe tetanus together with its presenting signs and symptoms. 2. To present a theoretical framework that guides the nursing approach that has been integrated to come up with a comprehensive nursing approach to care for a client with a severe tetanus. 3. To present the clients health history using Gordons functional health pattern. 4. To present the abnormal findings during physical assessment and compare it to its normal values. 5. To present the various diagnostic and laboratory tests done and present its significant interpretation. 6. To present a client-centred pathophysiology to help understand the nature of the disease of the client. 7. To discuss the surgical, medical management that was done to the patient. 8. To discuss the action of the drugs that was administered to the patient through a drug analysis. 9. To identify the nursing problems and present the nursing interventions carried out for the patients care. 10. To present a discharge plan that will be used by the patient after discharge from the hospital

NURSING HEALTH HISTORY

PATIENTS PROFILE Name: Address: Age: Sex: Birthdate: Race and religion: Marital Status: Occupation: Room and Bed No.: Date of Admission: Chief complaint: FINAL DIAGNOSIS: Patient X Sumilao, Bukidnon City 35 years old Male March 11, 1977 Filipino/Roman Catholic Married Farmer NMMC- Emergency Room July 24, 2012 Abdominal spasm and dysphagia Severe tetanus

HISTORY OF PRESENT ILLNESS 2 weeks prior to admission patient had onset of abdominal spasm associated with difficulty swallowing. No consultation done and no medications has been taken. 2 days prior to admission patient experienced shortness of breathing thus prompt his family to admit at Northern Mindanao Medical Center. PAST HISTORY Accordingly, patient has had no complete immunization during childhood. According to him, he has not acquired any childhood diseases except for chicken fox and hay fever. He has no known allergies. He has no history of previous hospitalization.

FAMILY HISTORY OF ILLNESS According to the patient, he has known family history of both maternal and paternal side: Hypertension

GORDONS FUNCTIONAL HEALTH PATTERN HEALTH PERCEPTION AND HEALTH MANAGEMENT Patient X is generally like any other typical Filipino about addressing his health concerns. He does not address it until the severity of the symptoms is felt. He does not go to the doctor for consultation and seldom drinks medicines for any condition because he believes medication will only aggravate his symptoms. SLEEP AND REST PATTERN The patient cannot sleep well at night because of preoccupations on the financial problems that his family is into as of the moment. He stated that he cannot sleep thinking where to find the money for his medication since hes the bread winner of the family.

ELIMINATION The patient urinates three to four times a day with 480cc/shift. He has no complains about difficulty or uncontrolled urination. But patient complained on difficulty in defecating. He moved bowel ones a day and his last bowel movement was on July 22, 2012 prior to admission. NUTRITION The patient was on oysteorized feeding. He consumed 1600 ml of oysterized food a day. And he could consume 240 ml of water a day.

ACTIVITY Patient need assistance whenever he change position or stand. He cannot do daily activities such as bathing or dressing alone. RELATIONSHIPS The patient is married for 5 years now. He has 3 childrens and are all close to him. His wife and cousins are who accompany him in hospital stay.

COPING PATTERN The patient is a Roman Catholic, he goes to church seldomly due to workload on their farm. And every time he encounter problems he used to discuss it with his wife and her for any solutions.

PHYSICAL ASSESSMENT Review of systems Assessment Cardiovascular system: Pulse rate (radial) Blood pressure: 85bpm 100/60mmHg 95 bpm 90/60mmHg July 26, 2012 August 2, 2012

Point of maximal Impulse

5th intercostals space 5th intercostals space left midclavicular line left midclavicular line 2-seconds Negative Negative Negative

Capillary refill Clubbing: Jugular vein distention Arrhythmia

2 seconds Negative Negative Negative

Renal system: Fluid intake Urine color Urine Amount Urine pH Urine frequency Urine Characteristics: Specific gravity Urine sugar Urine protein Pus cells RBC: Respiratory system: Respiratory Rate AP:L ratio Chest expansion Adventitious lung sounds Breathing Pattern 30 cpm 1:2 Symmetrical Absent 23 cpm 1:2 Symmetrical absent 1.030 Negative Negative 0-1 Cells Negative 1.030 Negative Negative 0-1 Cells negative 1240 ml Dark yellow 280cc/shift 6.5 4-6 times a day 1600 ml Yellow/amber 480cc/shift 6.5 4-6 times a day

Rhythmic and regular Rhythmic and regular

Tactile fremitus

Symmetrical normal

and Symmetrical normal breath Normal sounds 4cm (normal)

and

Auscultation Diaphragmatic excursion

Normal sounds 3cm (normal)

breath

Abdomen & Digestive system: Shape Symmetry Skin integrity Fluid wave Appetite Pain Bowel sounds Upon percussion Palpation Umbilicus Presence of hemorrhoids Midline None Nervous system: Level of consciousness Orientation Verbal communication Response to stimuli Response to pain Eye response Conscious oriented cannot verbalize alert Good and abrupt Left eye: Positive conscious oriented cannot verbalize alert Good and abrupt Left eye: Positive positive Midline None Flat Symmetrical Firm absent fair negative hypoactive(3-4clicks) Tympanitic Muscle guarding Flat Symmetrical Firm absent fair negative hypoactive(3-4clicks) Tympanitic Muscle guarding

PERRLA, PERRLA, eye opening

positive eye opening

Right eye: no blurring Right eye: no blurring of vision, Reflexes Motor response Cerebellar function Intact Normal balance impaired has of vision Intact Normal been balance impaired has been

Musculoskeletal system Posture Gait Symmetry of: Upper extremity Lower symmetry Strength symmetrical symmetrical symmetrical symmetrical Normal Normal Normal Normal

weak (except in left weak(except in left arm) arm)

Range of motion

Decreased ROM in Decreased ROM in right arm right arm None

Involuntary

Jerky None

movement of the left arm Integumentary system Color Odor Lesions Temperature dusky No unusual odor None Lightly cold temperature Moisture Texture Turgor Nails: Color Shape Texture Capillary refill Hair: Hair distribution Body hair Color Condition Pale and dirty Pitted Smooth and shiny 3 seconds Shaved, bald Evenly and finely distributed none none Pale and dirty Pitted Smooth and shiny 2 seconds Shaved, bald Evenly distributed none none and finely dry Smooth Firm dusky No unusual odor None Lightly cold temperature dry Smooth Firm

HEENT: HEAD: Head size: Head shape Normal Symmetrical ` Normal Symmetrical

Head contour

Symmetrical

Symmetrical

EYES: Shape: Size: Color: Eye lashes Almond 1.5-2cm Black Almond 1.5-2cm Black

Present and curving Present and curving outside outside Decreased Normal Normal Normal Negative poor none pale anicteric Normal Left eye: PERRLA, Positive PERRLA,

Eyelids Visual Acuity Color vision Corneal light reflex Gaze test Eyeball protrusion Conjuntiva Sclera Cornea and lens Accommodation

Decreased Normal Normal Normal negative poor none pale anicteric Normal Left eye: Positive

positive eye opening

positive eye opening

Right eye: no blurring Right eye: no blurring of vision, EARS: Size Shape Symmetry Normal Normal Symmetrical Normal Normal Symmetrical of vision,

NOSE: Mucosa Patency Alar flaring Sinuses Normal Both patent Not present No pain felt Normal Both patent Not present No pain felt

MOUTH: Lips Teeth Oral mucosa Gums Palates Salivary ducts dry Dental carries Pink Pale Intact, smooth, pink dry Dental carries Pink Pale Intact, smooth, pink

Tongue

Not inflamed Slightly pale

Not inflamed Slightly pale Not inflamed

Tonsils

Not inflamed

THROAT: Lymph nodes Symmetry Tenderness Enlargement Symmetrical absent Not enlarged Symmetrical absent Not enlarged

Thyroid: normal normal

The Data above is a comparative assessment for two days dated July 26, 2012 and August 2, 2012 Findings in red font signifies abnormality

ANATOMY AND PHYSIOLOGY___________________________________

The Nervous System

Conditions both within the body and in the environment are constantly changing. The nervous system directs the complex processes of the body's internal environment and also provides a link to the external world. This allows us to respond to changes both from internal sources as well as form external stimuli. The nervous system is broken down into two major part: the central nervous system, which includes the brain and spinal cord, and the peripheral nervous system, which includes all nerves, which carry impulses to and from the brain and spinal cord. These include our sense organs, the eyes, the ears, our sense of taste, smell and touch, as well as our ability to feel pain. Central Nervous System Spinal Cord The spinal cord is a long bundle of neural tissue continuous with the brain that occupies the interior canal of the spinal column and functions as the primary

communication link between the brain and the rest of the body. The spinal cord receives signals from the peripheral senses and relays them to the brain. Brain Stem The brain stem is the part of the brain that connects the cerebrum and diencephalons with the spinal cord. Medulla Oblongata The medulla oblongata is located just above the spinal cord. This part of the brain is responsible for several vital autonomic centers including:

the respiratory center, which regulates breathing. the cardiac center that regulates the rate and force of the heartbeat. the vasomotor center, which regulates the contraction of smooth muscle in the blood vessel, thus controlling blood pressure.

The medulla also controls other reflex actions including vomiting, sneezing, coughing and swallowing. Cerebellum The functions of the cerebellum include the coordination of voluntary muscles, the maintenance of balance when standing, walking and sitting, and the maintenance of muscle tone ensuring that the body can adapt to changes in position quickly. Cerebrum The largest and most prominent part of the brain, the cerebrum governs higher mental processes including intellect, reason, memory and language skills. The cerebrum can be divided into 3 major functions:

Sensory Functions - the cerebrum receives information from a sense organ; i.e., eyes, ears, taste, smell, feelings, and translates this information into a form that can be understood.

Motor Functions - all voluntary movement and some involuntary movement.

Intellectual Functions - responsible for learning, memory and recall.

PATHOPHYSIOLOGY_____________________________________

PREDISPOSING FACTORS

PRECIPITATING FACTORS

Age: 35 years old Sex: Male

Farmer

Clostridium tetani enters body through a wound

Anaerobic conditions allow germination of spores and production of toxins

Toxins are produced and disseminated via blood and lymphatics

Tetanospasmin enters the nervous system peripherally at themyeoneural junction and is transported centripetally into neurons of CNS

Interfers with neurotransmitter release to block inhibitors

Leads to unopposed muscle contraction and spasm

Lockjaw Stiffness Neck rigidity Dysphagia Restlessness Neck spasm

Increase BP Increase temperature Sweating Seizure causing Opisthotonos

Aspiration Pneumonia Hypertension

LEGEND: Predisposing factors Precipitating factors Pathophysiology

LABORATORY

RESULTS

Differential count Lymphocyte 26 % 17.4-48.2% normal

Neutrophil

85.3

43.4-76.2%

Indicate infection

Monocyte

7.6

4.5-10.5%

normal

Eosinophils

0.4

1.0 - 3.0

Indicate infection

Basonophils

0.2

0.0 - 2.0

Normal

Platelet

252

10^3/uL

150 - 400

Normal

COMPLETE BLOOD COUNT TEST RESUL T WBC 10.4 10 ^3/uL UNIT REFEREN CE 5.0-10.0 SIGNIFICAN CE Increase Increase indicates infection, inflammation and trauma. RBC Hemo globin Hema tocrit MCV MCH MCH C RDWCV PDW MPV 9.6 9.2 fL fL 9.0-16-0 8.0-12.0 Normal Normal Normal Normal 14.9 % 12.0-17.0 Normal Normal 83.0 27.0 31.4 fL Pg g/dL 82.0-98.0 27.0-31.0 31.5-31.0 normal Normal normal normal Normal normal 40.6 % 37.0-47.0 normal normal 4.3 14.3 10^6/UL g/dL 4.2-5.4 12.0-16.0 normal normal normal normal DEVIATION

BLOOD CHEMISTRY RESULT

TEST BUN CREATININE K+ Na+ Ca

RESULT 5.5 0.8 3.9 137 7.9

UNITS mgs % mgs% Mmol/L Mmol/L mg/dL

REFERENCE 4.6-23.4 0.6-1.2 3.5-5.3 135-148 8.1-10.4

ASSESSMENT Subjective Gatoskig naman siya kung masilawan as verbalized.

NURSING DIAGNOSIS

PLANNING

INTERVENTION Independent:

RATIONALE

NURSING THEORY

EVALUATION

Pain r/t muscle rigidity 2o unopposed muscle contraction

After nursing interventions, will demonstrate a reduction in pain behaviors such

1. Handled clients gently doing activity.

the To promote body safety and while allows nursing experience less pain during care activity. Lydia Halls Care, Core, Cure

Goal was met. After nursing interventions,patient was demonstrated a reduction in pain behaviors such as absence of facial

Objectives:

as absence of facial grimace 2. Minimize movement dimmed provided.

BP= 90/60 mmHg (+) Facial grimace (+) Guarding (+) diaphoresis (+) lockjaw (+)muscle spasm

and guarding.

To promote rest and and avoid light excitation of neurons leading to muscle contractions. Florence Nightingales Environment Theory

grimace and guarding.

3. Maintained side rail up. To ensure safety when Florence

seizure and Depedent: 1. Diazepam 5mg intravenously given as ordered. It is a muscle relaxant. That helps reduce muscle 2. Metronidazole, 500mg , given intravelnously as prescribed. Treatment bacterial infection caused tetani C. of contractions causing pain. muscle rigidity occurs.

Nightingales Environment Theory

Ernestine Weidenbachs Prescriptive Theory

Ernestine Weidenbachs Prescriptive Theory

ASSESSMENT Subjective: laglum siya mag ginhawa as verbalized by the folks.

NURSING DIAGNOSIS

PLANNING

INTERVENTION Independent:

RATIONALE

NURSING THEORY

EVALUATION

Ineffective airway clearance r/t retained and excessive secretions

To maintain a patent airway be able to demonstrate effective coughing and

1. Suctioned secretions needed.

To maintain patent as airway and prevent aspiration. To take advantage

Virginia Hendersons Basic Care Component

Goal was partially met. Patient was able to maintain a patent airway and was able

2. Elevated head of the bed/ change position 2hours every

of decreasing pressure diaphragm enhancing drainage.

gravity Florence Nightingales Environment Theory

to demonstrate effective coughing and clear breath sounds RR decreased to 24 bpm but still with

Objectives: RR=30 bpm AR=120bpm (+) crackles (+)restlessness (+) drooling (+) impaired swallowing

clear breath sounds.

on

the and

Precipitators allergic 3. Kept environment the respiratory

of type Florence Nightingales Environment of

crackles.

reactions that can onset

allergen free like trigger dust.

acute episodes.

To promote oxygenation and 4. Encouraged deep maximize effort. breathing coughing exercise. and

Theory

Virginia Hendersons Basic Care

Depedent: 1. Administered Fluimucil 600 g/tab in 50 cc diluents as prescribed. . Is a mucolytic that helps for easy expectoration. Ernestine Weidenbachs Prescriptive Theory

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION

Subjective: gakatuk-an siya magtulon as verbalized by the folks. Impaired swallowing related to pharyngeal muscle spasm Objectives: (+)lockjaw (+)restlessness (+) drooling (+) impaired swallowing (+)hyperextesion of head After nursing intervention patient will demonstrate effective swallowing without muscle straining.

Dependent: 1. Nasogastric tube inserted by ROD To provide parenteral feeding in adequate amount. Lydia Halls Care, Core, Cure Goal not met. After nursing intervention patient was demonstrate effective swallowing The Independent: 2. Provided meals in a quiet environment away from excessive stimuli. client a can more Florence Nightingales Environment Theory without muscle straining achieve effective by

swallow on and

focusing

chewing

moving foods/fluids to the back of the mouth where the swallowing reflex is triggered.

Virginia Hendersons

For aspiration precaution.

Basic Care Component

3. Have suction equipment available during feeding. This position uses gravity to aid in the flow of foods/fluids through the 4. Kept with an upright position for 15mins to an hour after meal. For the family to be aware for any situation so that we can avoid aspiration even 5. Instructed family how to monitor and detect aspiration after eating. when nurses are not in their room Lydia Halls Care, Core, Cure esophagus. Florence Nightingales Environment Theory

Evaluations, results and discussion

a. Summary and conclusion As a summary, we were able to have an overview of the patient's health condition and its disease process and identified the priority nursing diagnoses with its corresponding nursing and medical interventions. I reviewed the anatomy and physiology of the systems affected by the illness as well as the pathophysiology of the disease. The list and the individual study on the different drugs of my patient as prescribed by the physician were presented and discussed. The different diagnostic tests undergone by the patient at the time of our assessment were interpreted and were given immediate management. In terms of pain intolerance, the patient was able to demonstrate decrease in physiologic signs of intolerance as evidenced by decrease guarding mechanisms and decrease facial grimace and he was to demonstrate ways that could alleviate pain. Based on the different results and outcomes of care on my top 3 nursing care plans, we therefore conclude that we have done our task well. We did our best to give the most appropriate interventions to attend to the needs of the patient through pharmacologic and non-pharmacologic management.

b. Discharge Plan

NURSING PRIORITIES . Enhance comfort and general well-being. . Prevent/minimize complications. . Promote a positive emotional response. . Provide information regarding the disease condition

DISCHARGE GOALS . Physical/psychological needs being met . Complications prevented/resolving . Patient's Understanding about the condition will widen.

 Medication Instruct patient about the treatment regimen ordered by the doctors must be followed strictly and should not be stopped to prevent the aggravation of the condition. The full course should be followed. Explain the proper drug dosage and time of intake and as much as possible comply with drug regimen. Economy/exercise Encourage patient to have an active and passive ROM because it will promote blood circulation and to improve muscle strength in order to promote total range of motion. Instructed patient to stay in calm and clean environment as much as possible to free patient from stress. Treatment/therapy Instruct patient to consult the physician first if what activities must he avoid or put into limits. Encourage patient to compliance of medication regimen to promote optimal health. Stress the importance of taking medications in a correct dosage, timing, and route. Health teaching/hygiene Importance of personal hygiene to prevent infection. Intake of nutritious foods like vegetables and fruits and intake of foods that is rich in protein such as meat, fish, egg, etc. to promote fast wound healing. Strict compliance of medication regimen to promote wellness. Immediate report to the physician if unusualities occur. Explain to the Significant others about the precautions, patient's diet and S/Sx of the disease. Discouraged patient to participate in strenuous activities that might precipitate stress.

 Instructed Significant others to always remind the patient about his medications to be taken, to his diet and to always be observant about the signs and symptoms of severe tetanus. Instruct patient to come back to the hospital for check-up/ clinic visit (4 to 6 weeks after discharge) to be able to monitor the improvement of the condition. Consultation Return to OPD for further check-up if whether it is improving or not. Also, for early diagnosis of any other underlying conditions. Diet patient was discharged with NGT attached for his parenteral feeding. An OTF 1600 cal shall be divided into 6 equal feedings Sex Encourage to exercise his function as a mother of the family and continue to do thing that is appropriate in his age.

c. Recommendations

Guidelines for the management of patients with severe tetanus have provided recommendations for the choice of management and medication, route of administration, and timing of oral switch therapy and other interventions that is appropriate to clients health condition. These guidelines, largely based on expert opinion, offer a stepwise approach to the decision-making process in the management of severe tetanus, particularly with reference to the interface between the hospital and outpatient environment.

For the patient, we recommend him to follow the instructions given by his attending physician and to follow the prescribed therapeutic regimen to prevent from aggravating of disease. Encourage to observe proper hygiene and sanitation.

For nurses, we recommend them to attend different seminars about severe tetanus for them to know the different trends of treatment that can be used to show the changes made to improve care to clients with severe

tetanus. These will help them to know the appropriate interventions to improve clients condition.

Related learning experience Life is a challenge and as are all challenges, lessons are learned along the way. We sure have gone a long way now. We have come to the second rotation of our clinical exposure at Emergency Room in NMMC. And yet, we realize we have still more to discover and understand in this field that we have chosen. Many people say that if you take up nursing, you will only be making your life stressful and really stressful. True enough, we have been witnesses of how the written requirements, cases to finish, late-night duties, early morning dilemmas plus thick textbooks to memorize by heart can make one truly drained. However, We found that there are two things that we need be skilled of in order to survive the nursing world. First, organize ourselves, and second, think positive. Good personal organization is a basis for having a positive attitude. A positive attitude will then determine the quality of our lives. Its importance cannot be underestimated. Making this possible Our experience in making this case study was not at all different from our previous encounters. We always have a constricted time-schedule and we barely have time to make way for everything since we have a lot to comply. In as much as we wanted to give this our full-time, we cannot. Despite the dire time complexes, We still manage to finish this somehow with our best efforts at heart. Continuing the nursing life If life is a challenge, then we should make the most out of it. After all, what do we have to lose by facing the challenge? Nothing at all. And what do we gain from facing the challenge? Much, much! Much that is of importance. When you select a purpose with which to bring the fulfilment to your life, it is important that you appreciate the significance of what you are doing. You must not see it as just something to pass time.

BIBLIOGRAPHY

Smeltzer, S., Bare, B., Hinkle, J. & Cheever, K. (2008). Brunner & Suddarths Textbook of Medical-Surgical Nursing, 11th Ed. Lippincott Williams & Wilkins.

Seeley, R., Stephens, T. & Tate, P. (2007). Essentials of Anatomy & Physiology, 6th Ed. McGraw-Hill. Bickley, L. (2007). Bates Pocket Guide to Physical Assessment & History Taking, 5th Ed. Lippincott Williams & Wilkins Karch, A. (2009). 2009 Lippincotts Nursing Drug Guide. Lippincott Williams & Wilkins. Octaviano, E. & Balita, C. (2008). Theoretical Foundations of Nursing: The Philippine Perspective. Ultimate Learning Series www.wikipedia.org www.doh.gov.ph www.eMedicine.com

INTRODUCTION_________________________________________

TETANUS

Tetanus is an acute, often fatal disease caused by an exotoxin produced in a wound by Clostridium tetani. Clostridium tetani is a gram-positive, nonencapsulated, motile, obligatively anaerobic bacillus. It exists in vegetative and sporulated forms. Spores are highly resistant to disinfections by chemical or heat, but vegetative forms are susceptible to the bactericidal effect of heat, chemical disinfectants, and a number of antibiotics.

This study is a case of Patient X, a 35-year old male residing in Sumilao, Bukidnon City. We chose this case study as it has gave us a full curiosity why this patient leads to this condition when infact he has no open wound. Furthermore, the case of the patient has become an area of our interest as it has been recorded that slowly the progress of the condition becomes more aggravating that leads to many complications. More so, multidisciplinary approach has been deemed excellent as doctors are still studying well to find the cause of the condition of the patient on why it lead to this way but we could see that despite of the difficult he has, still patient really fighting well to returned his condition to normal functional level. On the researchers end, We are very optimistic that this case study will help us to further enhanced our knowledge on how this disease come- up with this stage and as student nurses skills as we help patients transition to further independence, build strength and mobility and adapt to his situation in order to recover from his medical condition. We had assess our client for three days 26, 27 of July and 2 on August 2012; This study only encompasses the health condition of a 35 year-old patient with Severe Tetanus; His condition is based on lifestyle and disease process of Tetanus therefore should not be used to generalize any patient with the same condition.