22/02/2026
NURSING CARE PLAN FOR NEONATAL TETANUS
1. Nursing Problem: Impaired breathing pattern
Nursing Diagnosis:
Impaired breathing pattern related to chest wall rigidity and muscle spasms secondary to neonatal tetanus as evidenced by irregular respirations and cyanosis.
Goal/Objectives:
The neonate will maintain effective breathing as evidenced by normal respiratory rate and absence of cyanosis within 24–48 hours.
Nursing Interventions and Rationales:
☑️I will monitor respiratory rate, rhythm, and oxygen saturation every 2 hours — to detect early signs of respiratory distress.
☑️I will position the baby in a side-lying position — to promote airway patency and prevent aspiration.
☑️I will administer humidified oxygen as prescribed — to improve oxygenation and prevent hypoxia.
☑️I will minimize handling and environmental stimuli — to prevent triggering spasms that interfere with breathing.
☑️I will prepare emergency resuscitation equipment at the bedside — to ensure prompt intervention in case of respiratory failure.
Evaluation:
The neonate maintained normal respirations and oxygen saturation remained within normal range.
2. Nursing Problem: Ineffective feeding pattern
Nursing Diagnosis:
Ineffective infant feeding pattern related to trismus (lockjaw) and muscle rigidity as evidenced by inability to suck.
Goal/Objectives:
The neonate will maintain adequate nutrition and hydration during hospitalization.
Nursing Interventions and Rationales:
☑️I will assess the neonate’s ability to suck and swallow before feeding — to determine the safest feeding method.
☑️I will administer expressed breast milk via nasogastric tube as prescribed — to ensure adequate nutritional intake.
☑️I will monitor daily weight — to evaluate adequacy of nutrition.
☑️I will monitor intake and output — to assess hydration status.
☑️I will administer intravenous fluids as prescribed — to maintain hydration when oral feeding is not possible.
Evaluation:
The neonate maintained stable weight and adequate urine output.
3. Nursing Problem: Risk for Injury
Nursing Diagnosis:
Risk for injury related to severe muscle spasms and hypertonicity.
Goal/Objectives:
The neonate will remain free from injury throughout hospitalization.
Nursing Interventions and Rationales:
☑️I will place the neonate in a padded cot — to prevent injury during spasms.
☑️I will reduce noise and bright light in the room — to decrease stimuli that trigger spasms.
☑️I will handle the neonate gently and only when necessary — to reduce provocation of muscle contractions.
☑️I will administer prescribed sedatives and muscle relaxants — to control muscle spasms.
☑️I will observe and record frequency and severity of spasms — to evaluate effectiveness of treatment.
Evaluation:
The neonate remained free from injury and spasms reduced in frequency.
4. Nursing Problem: Altered thermoregulation
Nursing Diagnosis:
Altered thermoregulation related to infection and increased muscle activity as evidenced by raised body temperature.
Goal/Objectives:
The neonate will maintain body temperature within normal range (36.5°C–37.5°C).
Nursing Interventions and Rationales:
☑️I will monitor temperature every 4 hours — to identify fever early.
☑️I will remove excess clothing and coverings — to promote heat loss.
☑️I will administer prescribed antipyretics — to reduce elevated temperature.
☑️I will provide tepid sponging if temperature remains high — to assist in lowering body temperature.
☑️I will encourage adequate fluid intake or administer IV fluids as prescribed — to prevent dehydration.
Evaluation:
The neonate’s temperature returned to normal range.
5. Nursing Problem: Impaired skin integrity
Nursing Diagnosis:
Impaired skin integrity related to infected umbilical stump as evidenced by redness and discharge.
Goal/Objectives:
The umbilical stump will heal without further infection within the period of hospitalization.
Nursing Interventions and Rationales:
☑️I will inspect the umbilical stump daily for redness, swelling, or discharge — to monitor progression of infection.
☑️I will perform hand hygiene before and after handling the neonate — to prevent cross-infection.
☑️I will clean the umbilical stump using prescribed antiseptic solution — to reduce bacterial contamination.
☑️I will administer prescribed antibiotics — to eliminate the causative organism.
☑️I will educate the mother on proper cord care — to prevent reinfection after discharge.
Evaluation:
The umbilical stump showed signs of healing with no further signs of infection.
