ASSIGMENT : NURSING ASSESMENT FORMAT

(TETANUS)

Courses : English in nursing I

Lecturer : Framita Rahman, S.Kep., Ns., Msc

Erranged by :

Putri Irawani

1901030

NURSING SCIENCE OF STIKES PANAKKUKANG

MAKASSAR

2022
Surename : Octavia First Name : Weny

Age : 30 years Sex : Women Marital Status : Not merried yet

Accupation : Housewife

Present/Chief Complaint :

Stab wound result in Fever , complaints experienced about 1 week ago and getting worse
lately.

General Condition : Composmentis

EENT :

 Head : The head looks normal, the hair and scalp are clean
 Face : The cheeks look stiff
 Eyes : Conjunctiva not anemic
 Mouth : Jaw looks stiff
RS :
 Out of breath
 Chest : Chest wall retraction
 Abdomen : Symmetrical and looks stiff

CVS : Heart :Heart within normal limits

GIS & NUTRITION :
 Palpation : for symmetry of lung expansion
 Auskultasi : breath sounds, decreased or absent ventilation and the presence of
additional breath sounds.
GUS :

 Genetalia : No abnormalities

CNS : Neurological : Impression within normal limits

 Eye : 4
 Motorik response : 3 = spamsme in muscles
 Verbal response : 5
 Vision : Normal
 Hearing : Normal
 Talk : Normal

MSS & SKIN :

 Skin : No abnormalities
  Extremities : On the legs there are stab wounds
PAIN : spasme in the patient’s muscles
IMMEDIATE PAST HISTORY :
 Past medical story : no history of previous illness
 Family history : no family suffering from tetanus
POINTS OF NOTE : spasm in the muscles, there are stab wounds in the leg area, the body
feels stiff, feels pain when there is contraction of the muscles, shortness of breath.
INVESTIGATIONS :
 Blood lab : not specific, maybe mild leukocytosis, slightly elevated serum CK
 On bacteriological examination, clostridium tetanus was found
 Record EMG : loss of silent period at 50-100 ms after reflex contraction
THERAPY/MEDICATION :
 Oxygenation
 Adjust the position to straighten the airway
 Provide safety around the bed
 Keep dangerous objects away from the patient
 Administration of antitoxin
NURSING DIAGNOSIS :
 Hypethermia related to infection with the bacterium clostridium tetanus
 Impaired physical mobility related to muscle spasm
 Ineffective airway related to respiratory muscle spasm
 Imbalanced nutrition less than body requirements related to inability to digest food
due to spasm in the jaw muscles.
IMPLEMENTATION :
 Teach and motivate to treat wounds adequately
 Prevent the accurrence of new wounds
 If there is an urhent need to health services
 Protect the environment from objects that can injure
 Avoid stress, stay away from the use of non-sterile tools (used syringes, cutting and
care of the umbilical cord)
 If the patients has a seizure, keep the patient away from objects that are dangerous,
and prevent the tongue from being bitten (give a towel to bite).