Nursing Diagnosis and Nursing Interventions

Nursing Diagnosis and Nursing Intervention for Neonatal Tetanus

Neonatal tetanus is a form of generalised tetanus that occurs in newborns. Infants who have not acquired passive immunity from the mother having been immunised are at risk. It usually occurs through infection of the unhealed umbilical stump, particularly when the stump is cut with a non-sterile instrument. Neonatal tetanus mostly occurs in developing countries, particularly those with the least developed health infrastructure. It is rare in developed countries.

In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days. The fatality rate for infants has been estimated as 70% to 100%; death usually occurs by the age of 2 weeks. On the basis of clinical findings, four different forms of tetanus have been described. The time from exposure to symptoms may be up to several months.




Nursing Diagnosis for Neonatal Tetanus
  1. Ineffective breathing pattern related to respiratory muscle fatigue
  2. Imbalanced nutrition, Less than body requirements related to the baby's sucking reflex is inadequate.


Nursing Intervention for Neonatal Tetanus

Nursing Diagnosis I

Ineffective breathing pattern related to respiratory muscle fatigue

Nursing Intervention:

  • Assess the frequency and pattern of breath
  • Note the presence of apnea, the frequency change of heart, muscle tone and skin color.
  • Perform cardiac and respiratory monitoring continuously.
  • Suction airway as needed.
  • Give the tactile stimulation immediately after apnea.
  • Monitor laboratory tests as indicated.
  • Give oxygenation as indicated.
  • Give medications as indicated.


Nursing Diagnosis II

Imbalanced nutrition, Less than body requirements related to the baby's sucking reflex is inadequate.

Nursing Intervention:


  • Assess the maturity of the reflex with respect to feeding, sucking, swallowing and coughing.
  • Auscultation bowel sounds.
  • Review the signs of hypoglycemia.
  • Give appropriate medication electrolyte supplements.
  • Give parenteral nutrition.
  • Monitor laboratory tests as indicated.
  • Make provision of drinking according to tolerance.

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Source : http://nanda-nursing.blogspot.com/2011/04/nursing-diagnosis-and-nursing_20.html

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Nursing Diagnosis - Nursing Interventions

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