Tetanus (Lockjaw)

Please use the book as the primary source sa info as much as possible.

Brief defi and clinical manifestations - zacky

Definition: Tetanus is an infection caused by bacteria called Clostridium tetani. When these
bacteria enter the body, they produce a toxin that causes painful muscle contractions. Another
name for tetanus is “lockjaw”. It often causes a person’s neck and jaw muscles to lock, making it
hard to open the mouth or swallow.
The incubation period ranges from 3 to 21 days, averaging about 8 days. In general, the further
the injury site is from the central nervous system, the longer the incubation period. A shorter
incubation period is associated with more severe disease, complications, and a higher chance
of death. In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging
about 7 days.

There are three clinical forms of tetanus:

● Generalized
○ Generalized tetanus is the most common form, accounting for more than 80% of
cases. The most common initial sign is the spasm of the muscles of the jaw or
“lockjaw”. Other signs may follow “lockjaw.” These can include painful spasms in
other muscle groups in the neck, trunk, and extremities and generalized,
seizure-like activity or convulsions in severe cases. Nervous system
abnormalities, as well as a variety of complications related to severe spasms and
prolonged hospitalization, can accompany generalized tetanus. The clinical
course of generalized tetanus is variable and depends on the
■ Degree of prior immunity
■ Amount of toxin present
■ Age and general health of the patient

Even with modern intensive care, generalized tetanus is associated with death rates of 10% to
20%. Neonatal tetanus is a form of generalized tetanus occurring in newborn infants who lack
the passive protection derived from maternal antibodies.

● Localized
○ Localized tetanus is an unusual form of the disease consisting of muscle spasms
in a confined area close to the site of the injury. Although localized tetanus often
occurs in people with partial immunity and is usually mild, progression to
generalized tetanus can occur.
● Cephalic
○ The rarest form, cephalic tetanus, is associated with lesions of the head or face
and may also be associated with otitis media. The incubation period is short,
 usually 1 to 2 days. Unlike generalized and localized tetanus, cephalic tetanus
results in flaccid cranial nerve palsies rather than spasms. Spasms of the jaw
muscles may also be present. Like localized tetanus, cephalic tetanus can
progress to the generalized form.

Clinical Manifestation: People often call tetanus “lockjaw” because one of the most common
signs of this infection is the tightening of the jaw muscles. Tetanus infection can lead to serious
health problems, including being unable to open the mouth and having trouble swallowing and
breathing.

● Jaw cramping
● Sudden, involuntary muscle spasms — often in the stomach
● Painful muscle stiffness all over the body
● Trouble swallowing
● Seizures (jerking or staring)
● Headache
● Fever and sweating
● Changes in blood pressure and heart rate

Serious health problems that can happen because of tetanus include:

● Laryngospasm (uncontrolled/involuntary tightening of the vocal cords)

● Fractures (broken bones)
● Pulmonary embolism (blockage of the main artery of the lung or one of its branches by a
blood clot that has travelled from elsewhere in the body through the bloodstream)
● Aspiration pneumonia (a lung infection that develops when things like saliva or vomit
accidentally go into the lungs)
● Breathing difficulty
● Hypertension

P&P factors and diagnostic tests - gladys

Predisposing:

● Age. Its occurrence is highest in elderly people. Most reported cases occur in adults.
From 2000–2019, more than 55% of the 579 reported cases were among people 20
through 59 years of age. In addition, more than 30% of those reported cases were
among people 60 years of age or older. The risk of death from tetanus is highest among
people 60 years of age or older. This data shows the vulnerability against tetanus with
age. Tetanus primarily affects older adults because of their higher rate of being
unvaccinated or of being inadequately vaccinated.
● Sex. Tetanus affects both sexes. No overall gender predilection has been reported,
except to the extent that males may have more soil exposure in some cultures. In the
 United States from 1998 to 2000, the incidence of tetanus was 2.8 times higher in males
aged 59 years and younger than in females in the same age range.

Precipitating:

● Unvaccinated or not keeping up with the 10-year booster shots. Tetanus-associated

deaths almost always occur among unvaccinated people, or those with incomplete or
unknown vaccination history.In the United States, most children are vaccinated against
tetanus. In developing countries, it continues to have a high incidence, caused by
infection of an entry point such as the umbilical cord at birth (Bairwa, Rajput, Khanna, et
al., 2012).
● injuries that involve dead skin, such as burns, frostbite, gangrene, or crush
injuries. The spores can get into someone’s body through broken skin, usually through
injuries.
● wounds contaminated with soil, saliva (spit), or feces, especially if not cleaned
well or a foreign body in a wound, such as a nail or splinter. Tetanus bacteria are
more likely to infect certain breaks in the skin.
● An infected umbilical cord when a mother isn't fully vaccinated. Tetanus in newborn
babies is a result of insufficient protection being passed from the mother to her baby
during the pregnancy, together with infection entering into the baby when the umbilical
cord is cut using contaminated instruments.
● Diabetes. Patients who have diabetes and chronic wounds are more prone to tetanus
than the other populations. The infected or ulcerated diabetic foot is a suitable
environment for Clostridium tetani. The prevalence of diabetes among patients
diagnosed with tetanus was 15%, nearly three times the average expected prevalence of
diabetes in the United States.
● Shared and unsanitary needles for illegal drug use. Injecting drugs with unsterilized
needles, particularly needles used by someone else, can introduce bacteria and viruses
into the body. Injecting drug users can develop botulism and tetanus infection through
the injection site.

Diagnostic Tests:

Doctors diagnose tetanus based on a physical exam, medical and vaccination history, recent
history of cuts, scrapes, punctures, and trauma and the signs and symptoms of muscle spasms,
muscle rigidity and pain. There are no hospital lab tests that can confirm tetanus.
But along with symptomatic diagnosis, a spatula test is used to confirm the diagnosis.

Spatula test: It involves inserting a spatula into the back of the throat. In case of no infection,
the spatula will cause a gag reflex and the patient will try to push the spatula out of the mouth.
But if the infection is positive then the spatula will cause the throat muscle to spasm and bite
down onto the spatula.

Disease process - mars & gabby

Clostridium tetani enters the body through an open wound -> Spores germinate under anaerobic
conditions-> C. tetani produces two toxins (-> tetanospasmin & -> tetanolysin) -> Toxin is
transported via axons to the spinal cord and brainstem -> Toxin interferes with neurotransmitter
release -> Unopposed muscle contraction and spasm

Soil is the main reservoir of Clostridium tetani but many animals, both herbivores and
omnivores, carry the bacilli in their intestines and excrete the spores in their faeces. The spores
of C. tetani enter the body through an open wound. Once anaerobic conditions are presented,
such as if the wound is deep and the distal end is shut off from oxygen or when crusting begins,
tetanus bacilli start to germinate. It has an incubation period of 3 days to 3 weeks. C. tetani
produces two toxins as it grows; tetanospasmin and tetanolysin. Tetanolysin is a hemolysin that
does not have a known pathological activity until now. Tetanospasmin is the cause of tetanus
and is sometimes referred to as tetanus neurotoxin (TeNT), as it acts on the central nervous
system. It is responsible for the symptoms of muscular rigidity and spasms that characterize the
disease.

Both the occurrence and severity of tetanus are determined by the amount of toxin
produced and the resistance of the host. The neurotoxic component, tetanospasmin, is one of
the deadliest poisons known. Once tetanospasmin has entered the body, it rapidly travels
through the lymphatic and vascular systems to the central nervous system, where it attacks
motor neurons. Within the neurons, the toxin directly inhibits the activity of neurotransmitters
known as γ-aminobutyric acid (GABA) and glycine. GABA and glycine are inhibitory
neurotransmitters; they serve to dampen neuronal activity. Thus, blockade by tetanospasmin
has an excitatory effect, which makes the neurons overactive.

Tetanospasmin activity causes an excess of impulses to rush through the affected motor
neurons to the muscles, causing them to go into severe convulsive spasm. The most common
spasms occur in the muscle of the jaw, and the first sign of the illness often is stiffness of the
jaw, or trismus. When the widespread convulsive stage of tetanus begins, the muscles of the
mouth are usually affected, pulling the lips out and up over the teeth into a grimace, a mixture of
smile and snarl.

The muscles of the throat can spasm, making swallowing difficult, whereas the larynx or
chest wall muscles can violently spasm, making breathing difficult and life-threatening. If the
tetanus is left untreated, this is a common cause of death, but there are other effects—on the
heart, blood pressure, and vital brain regions—that could result in death later in the course of
the disease.

Nsg diagnosis and HC management - ally

Acute Pain related to uncontrolled muscle spasm as evidenced by jaw cramping

● Monitor skin color and vital signs as these are usually altered in acute pain.
● Administer analgesics, as prescribed, to maintain ‘‘acceptable’’ level of pain.
● Provide or promote non pharmacological pain management: Quiet environment, calm
activities, comfort measures (e.g., back rub, change of position, use of heat or cold
compresses), and Diversional or distraction activities.
● Encourage adequate rest periods to prevent fatigue that can impair ability to manage or
cope with pain.
● Ascertain client’s knowledge of and expectations about pain management. Provides
baseline for interventions and teaching, provides opportunity to allay common fears and
misconceptions.

Hyperthermia related to bacteremia as evidenced by fever, chills, and sweating

● Monitor core temperature by appropriate route. Rectal and tympanic temperatures most
closely approximate core temperature; however, abdominal temperature monitoring may
be done in the premature neonate.
● Promote surface cooling by means of undressing, cool environment and/or fans cool,
tepid sponge baths or immersion or local ice packs, especially in groin and axillae. In
pediatric clients, tepid water is preferred.
● Administer medications, as indicated, to treat underlying cause, such as antibiotics (for
infection)
● Administer replacement fluids and electrolytes to support circulating volume and tissue
perfusion.
● Discuss the importance of adequate fluid intake at all times and ways to improve
hydration status when ill or when under stress to prevent dehydration.

Imbalanced Nutrition, less than body requirements related to mastication muscle stiffness as
evidenced by inability to open mouth

● Assess nutritional needs related to age and growth phase, presence of congenital
anomalies (e.g., tracheoesophageal fistula, cleft lip/palate), or metabolic or
malabsorption problems
● Explore lifestyle factors such as specific eating habits, the meaning of food to clients and
individual food preferences and intolerances/ aversions. Identifies eating practices that
may need to be corrected and provides insight into dietary interventions that may appeal
to clients.
 ● Assess current weight compared to usual weight and norms for age, gender, and body
size. Measure muscle mass or calculate body fat by means of anthropometric
measurements and growth scales to identify deviations from the norm and to establish
baseline parameters.
● Develop individual strategies when the problem is mechanical (e.g., wired jaws or
paralysis following stroke). Consult occupational therapists to identify appropriate
assistive devices or speech therapists to enhance swallowing ability.
● Emphasize the importance of well-balanced, nutritious intake. Provide information
regarding individual nutritional needs and ways to meet these needs within financial
constraints.

Ineffective airway clearance related to aspiration pneumonia as evidenced by dyspnea

● Elevate head of bed, encourage early ambulation, or change client’s position every 2 hr
to take advantage of gravity decreasing pressure on the diaphragm and enhancing
drainage of/ventilation to different lung segments.
● Encourage deep-breathing and coughing exercises or splint chest/incision to maximize
effort.
● Evaluate client’s cough/gag reflex, amount and type of secretions, and swallowing ability
to determine ability to protect their own airway.
● Auscultate breath sounds and assess air movement to ascertain current status and note
effects of treatment in clearing airways.
● Demonstrate/assist client/SO in performing specific airway clearance techniques (e.g.,
forced expiratory breathing [also called huffing] or respiratory muscle strength training,
chest percussion, or use of a vest), as indicated.

Impaired swallowing related to neuromuscular damage swallowing muscles as evidenced by

sudden, involuntary muscle spasms and laryngospasm

● Consult with nutritionists to establish optimum dietary plans considering specific

pathology, nutritional needs, and available resources.
● Note hyperextension of head or arching of neck during or after meals or repetitive
swallowing, suggesting inability to complete the swallowing process.
● Provide a consistency of food and fluid that is most easily swallowed. Risk of choking or
aspiration is reduced when food can be formed into a bolus before swallowing, such as
gelatin desserts or pudding.
● Instruct client to cough and expectorate when secretion management is of concern.
● Massage the laryngopharyngeal musculature (sides of trachea and neck) gently (if
prescribed) to stimulate swallowing.
MAY BE USED AS A GUIDE FOR THE DISEASE PROCESS,
CLINICAL MANIFESTATION & DIAGNOSTIC TEST

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