Maintaining human dignity in caring for children with tetanus

1.  Introduction to tetanus

Tetanus is an acute, frequently deadly, disease as a result of an exotoxin produced by the bacterium Clostridium Tetani. It is characterized by generalized rigidity and convulsive spasms of skeletal muscle tissues. The muscle stiffness commonly starts within the jaw (lockjaw) and neck after which turns into generalized (1-2). 

1.1  Etiology

Clostridium Tetani is anearobic, gram positive, and spore forming motile bacteria which is observed worldwide in soil, dirt and excreta of animals. It lives in two forms. Tetanus spores can survive boiling however no longer autoclaving, while the vegetative cells are killed by antibiotics, heat, and preferred disinfectants. Unlike many clostridia, C. Tetani isn't always a tissue-invasive organism; alternatively it causes illness through toxin (tetanospasmin), more commonly referred to as tetanus toxin (2-3).

1.2   Epidemiology.  

Tetanus takes place global and is endemic in 90 developing countries, however its prevalence varies considerably. The most common form, neonatal (umbilical) tetanus, kills approximately 500,000 infants each year due to the fact the mother became no longer immunized; about 80% of these deaths occur in just 12 tropical Asian and African countries.  Most non-neonatal cases of tetanus are associated with an annoying damage, often a penetrating wound inflicted by way of a dirty item. A family survey in Ethiopia showed incidence rate of 4.3 per 1000 live birth and with mortality rate of 86%. Spores get into the body through wounds which includes penetrating injuries, animal bites, jigger and tooth extraction by neighborhood/local healers. Neonates, born to unimmunized mother, will accumulate it via umbilical stump due to unhygienic cord care, and dressing with herbal remedy or and making use of cow dung on the cord (1, 3-4)

1.3   Pathogenesis

C. tetani typically enters the body through a wound. In the presence of anaerobic conditions, the spores germinate. The vegetative form produces tetanospasmin under anaerobic environment of injured /infected site and disseminated via blood and lymphatics (2-4).

Tetanospasmin, also referred to as tetanus toxin, acts at several sites inside the central nervous system, including peripheral motor end plates, the spinal cord, and the brain, and in the sympathetic nervous system. The usual clinical manifestations of tetanus are caused when tetanus toxin interferes with the discharge of neurotransmitters, blocking inhibitor impulses. This ends in unopposed muscle contraction and spasm (2-4).

1.4  Clinical features

Tetanus can be either generalized or localized. The incubation duration typically is two-fourteen days, however it is able to be as long as months after the injury.

1.4.1  Generalized tetanus

The most (more than eighty% of reported cases) is generalized tetanus. The disease typically manifested with a descending pattern. The first sign is trismus (masseter muscle spasm, or lockjaw) often followed by stiffness, difficulty chewing, dysphagia, and neck muscle spasm. Other symptoms encompass Headache, restlessness, and irritability, risus sardonicus due to intractable spasm of facial and buccal muscles, opisthotonos due to paralysis of abdominal, lumbar, hip, and thigh muscles. Laryngeal and respiratory muscle spasm can lead to airway obstruction and asphyxiation. Dysuria and urinary retention result from bladder sphincter spasm; forced defecation may occur. Notable autonomic effects include tachycardia, arrhythmias, labile hypertension, diaphoresis, and cutaneous vasoconstriction. The tetanic paralysis usually becomes more severe in the 1st wk after onset, stabilizes in the 2nd wk, and ameliorates gradually over the ensuing 1-4 wk (3).  

1.4.2   Neonatal tetanus

Neonatal tetanus (tetanus neonatorum), the infantile form of generalized tetanus, typically manifests within 3-12 days of birth as progressive difficulty in feeding (i.e., sucking and swallowing), with associated hunger and crying. Paralysis or diminished movement, stiffness to the touch, and spasms, with or without opisthotonos, characterize the disease. The umbilical stump may hold remnants of dirt, dung, clotted blood, or serum, or it may appear relatively benign (2-3).   

1.4.3  Localized tetanus

Localized tetanus results in painful spasms of the muscles adjacent to the wound site and may precede generalized tetanus.

1.4.4  Cephalic tetanus

Cephalic tetanus is a rare form of localized tetanus arising from wounds above the neck. Retracted eye lids, trismus, risus sardonicus and spastic paralysis of the tongue and pharyngeal muscle characterize it.

1.5   Diagnosis.  

The diagnosis may be established clinically. The typical setting is an unimmunized patient (and/or mother) who was injured or born within the preceding 2 wk and who presents with trismus, other rigid muscles, and a clear sensorium.  

Routine laboratory studies are usually normal. A peripheral leukocytosis may result from a secondary bacterial infection of the wound or may be stress induced from the sustained tetanic spasms. The cerebrospinal fluid (CSF) is normal, although the intense muscle contractions may raise intracranial pressure (3).

1.6   Management

The ideas of management of tetanus consist of sedation and manage of muscle spasms, neutralization of tetanus toxin, prevention of the production of tetanus toxin by the use of antibiotics to which Clostridium tetani is prone and with the aid of wound debridement, management of complications, such as autonomic dysfunction, and supportive care (5).

1.6.1  Eradication of bacteria

This entails surgical wound excision and debridement after giving TAT and antibiotics. Excision of the umbilical sump isn't recommended. Penicillin 100,000 V/kg/24 divided into four doses should be given for 10 day to eradicate vegetative forms from wound site. For penicillin allergic patients, erythromycin can be used (5).

1.6.2  Neutralization of toxin

Tetanus antitoxic (TAT) is used in a dose of 10,000U, half given intravascular and half intramuscular after a skin test. High dose (50,000- 100,000 U) can be used (5).

1.6.3  Wound management

All wounds should be wiped clean. Necrotic tissue and foreign material should be removed. If tetanic spasms are occurring, supportive care and maintenance of an adequate airway are critical.

Active immunization with tetanus toxoid must begin or preserve as quickly after the individual’s condition has stabilized. Antibiotic prophylaxis towards tetanus is neither practical nor beneficial in dealing with wounds; immunization plays the extra essential function. The need for active immunization, with or without passive immunization, relies upon at the circumstance of the wound and the affected person’s immunization history.  Persons with wounds that are neither clean nor minor, and who have had fewer than 3 prior doses of tetanus toxoid or have an unknown history of prior doses, should receive TIG as well as tetanus toxoid vaccine. This is because early doses of toxoid may high the immune system however now not result in immunity.

1.7     Nursing management

Limit visitation; avoid exposure to exacerbated noise, light sources, and unnecessary tactile stimuli.

Control water intake, monitor airborne noise and intestinal eliminations; evaluate the nutrition offered in relation to the prescribed nutritional content.

Use personal protective equipment; follow aseptic practices when performing procedures.

Monitor for signs of constant muscle spasms; keep beds with elevated heads and cushions.

Keep stretcher protection rails high; lock the stretcher wheels during procedures.

Provide information about preventive methods for infectious diseases.

Perform hydro electrolytic control; nutritional monitoring.

 Plan diet and Nutritional Therapy.

Assess the presence of bladder distention during physical examination; perform rigorous water balance.

Provide alignment of the patient's body; keep the bedding clean, dry, and without wrinkles or folds; perform a decubitus change every two hours (6)

1.8  Complication  

The seizures and the extreme, sustained inflexible paralysis of tetanus predispose the patient to many complications. Aspiration of secretions and pneumonia may started earlier before the first medical attention was received. The seizures may result in lacerations of the mouth or tongue, in intramuscular hematomas or rhabdomyolysis with myoglobinuria and renal failure, or in long bone or spinal fractures. Venous thrombosis, pulmonary embolism, gastric ulceration with or without hemorrhage, paralytic ileus, and decubitus ulceration are constant hazards. Excessive use of muscle relaxants, an integral part of care, may produce iatrogenic apnea. Cardiac arrhythmias, including asystole, unstable blood pressure, and labile temperature regulation reflect disordered autonomic nervous system control that may be aggravated by inattention to maintenance of intravascular volume needs (3).

1.9   Prevention of tetanus

      Tetanus is completely preventable disease.
      Vaccinate all child bearing age group females with TT.
      Primary vaccination of infants and children with DPT.
      Proper wound management (4)

2. Human dignity

The word dignity is derived from a Latin word dignus, which means “equal, of the same price or value” or “that which is fair and/or worthy of respect” (6). According to Merriam Webster English dictionary, dignity is the quality or state of being worthy, honored or esteemed (7). In ethics, it is an intrinsic quality of human nature, the basis of all the person’s rights (8). Dignity is fundamentally a value term which is worth, stature, or value of a particular class of human beings with respect to individuals. Generally the word ‘dignity’ can be a;

Intrinsic dignity is the value that human beings have not by virtue of any other means, but because they are human.

Attributed dignity always involves a choice and is the value that human beings confer upon others by acts of attribution. It is therefore a created value and is a form of conventional value. For example, when we say that extreme poverty creates degrading and undignified living conditions.

Inflorescent dignity is the worth or fee of a system that is conducive to human excellence or fee of a situation by using which a person expresses human excellence. It refer to people who are flourishing as humans or dwelling lives that are steady with and expressive of the intrinsic dignity of the human (9).

Dillon suggests that respect in a care situation recognizes as concurrently as separate and self-synthesizing and as embedded in innumerable networks of private, social and institutional relationships with others in ways that mark our very being as relational and interdependent (10). Kant views dignity as an intrinsic, unconditional and incomparable really worth or worthiness. He states that humans may additionally in no way be used handiest as a method to an end (11). It is quiet impossible to treat all humans as ends all of the time; we all are method to something or a person in some unspecified time in the future. What is immoral is being handled as way without considering that we're beings endowed with dignity” (12). Therefore, having dignity is what distinguishes human beings from substance no longer considered as such.

For human dignity, one of the paramount dimension is privacy and recuperation environments are most of the places in which privacy can be threatened. Maintaining Human dignity creates great emotions in sufferers that must no longer be disrupted via care provision (13).

In reality, it's most essential to maintain patient privateness on the way to set up effective communication among sufferers and care providers, and preserve the former’s peace of thoughts. If that is neglected, results might also include tension, aggression, partial withholding of the facts of the sickness, refusal to undergo bodily examinations, and a well-known decrease within the great of care offerings (14). Some factors that would threaten the distinction/dignity of hospitalized patients are: a loss of capacity to carry out crucial roles in lifestyles, the sensation that existence/life is incomprehensible, loss of guide from friends and the health care provider staff, an experience of uncertainty, and difficulty for the future (15). Furthermore, on every occasion patients’ autonomy is compromised, respect for their dignity decreases (16). It can be stated that preserving HD is one of the ethical aims in clinical care (17). In one of a kind phrases, maintaining HD is the biggest ethical necessities in clinical sciences, specially nursing, so that respect for patients’ HD is extensively emphasised in nursing practice standards (18).

2.1.  Maintaining human dignity in caring for children with tetanus

Respecting human rights and maintaining dignity are also defined as ethical goals of nursing care, which should not differ due to the patient’s race, age, religion, sickness or handicap, gender, or political, social and economic status (19). Research has shown that maintaining dignified patient care includes protecting patients’ privacy, respecting patients, and allowing them to have autonomy (20, 21) and communicating with patients, maintaining their body image, and honoring their privacy (22). Nurses must also realize that respect is an important human necessity, which they can demonstrate by being sensitive to patients’ needs.

2.1.1  Respect: 

Is an important aspect in maintaining human dignity during hospitalization and it includes ‘autonomy’, ‘holistic care’, ‘beliefs and culture’ and ‘informed consent’(23).

2.1.1.1.  Holistic care

Holistic care indicates that nurse’s cared for child as complete individuals. I think the nurse should treat children’s as complete individuals instead of simply focusing on their diseases. A child with tetanus comes to the hospital for treatment, so we should care for him as a complete and independent individual, this honors the child’s dignity. The health care practitioner may neglect this aspect, but the health care provider should remind themselves to pay attention to the patient’s dignity. Even though a child with tetanus can’t express any opinions, the health care provider still respect them and it’s important to treat them as complete individuals.

2.1.1.2.  Autonomy.

Autonomy means that patients can make their own decisions, decide to accept a treatment and participate indecisions about their treatment. In case of children’s because of age matter, communicate with family members and invite the child to join the decision-making.

For me, patients’ dignity means allowing patients instead of family members to make decisions. When child are hospitalized they can decide the kinds of the care they want, and honoring their opinions shows basic respect for them.

2.1.1.3.  Beliefs and culture.

Nurses’ should respect in their nursing care for the child and their family beliefs and cultures. People with some special religions such as Jehovah's Witnesses are not allowed to transfuse blood. In this case the nurse should inquire about their reasons and ask them to sign an agreement and or then report the situation to the doctor. The health care providers should respect the cultural background of the patient they are treating.

2.1.1.4.   Informed consent.

It refers to showing respect by explaining treatment procedures in detail to the child and their parents. It is necessary to explain the situation to patients to inform them of the reasons for the treatment, results, complications, likely consequences, etc. The child or his parents might not totally understand what we say, but at least we respected them by fully explaining the situation.

2.1.2  Protecting privacy

Maintaining patients’ privacy in providing dignity of care is another important aspect in clinical practice and it refer to ‘privacy of the body’, ‘private space’ and ‘privacy of the patient’s condition’ (23).

2.1.2.1.Privacy of the body

Even if the child with tetanus due to the effect of the disease can’t maintain his/her body privacy, it is our obligation to maintain his/her privacy during caring procedure. Although the child with tetanus may not express his/her opinion, they may not like their bodies to be exposed. Thus, it is important to protect the patient’s body by closing the curtain especially in situations such as changing diapers, turning the body over, or administering treatment.

2.1.2.2.Private space

A child with tetanus will be admitted to private, quiet and dark room. It is essential to explain to the child’s family the reason why we are doing so. Once the child discharged from the private room and will be admitted to pediatric ward, there privacy is lacking. Beds should have curtains around them and when the health care providers deal with patients’ problems, they should close the curtains to maintain body privacy.

2.1.2.3. Privacy of the patient’s condition

It is confidentiality about the patient’s condition. When children’s are hospitalized, children’s and their parents have the right to decide whether others know about their condition, nurses should respect them. All of the above show the essential respect for patients.

2.1.3.   Emotional support

Emotional support is part of maintaining dignity of patient care. Communication skills plays a key role in emotional support. Emotional  support include ‘encouraging’, ‘listening’, ‘empathy’, ‘appropriate language’ and ‘spiritual well-being’ (23).

2.1.3.1. Encouraging

It refers to offering positive psychological support to the child and their parents.  It is important to talk with child’s parents about the condition of the child, so that they will not be frustrated by the condition of the child.

2.1.3.2. Listening

When the parents of a child with tetanus express their child condition, it is good to listen to what they say so that they will see that we support them.

2.1.3.3. Empathy

It refers to identifying with the child’s situations: the nurse or other care provider should put themselves in the child’s shoes and thus take care of their privacy.

2.1.3.4. Appropriate language

 It refers to efforts to communicate with the child and his/her parents in their own language or the language they can understand/ they are familiar with. Thus, we can satisfy and properly support them.

2.1.4. Treating all patients alike

A child with tetanus should treated equally regardless of their condition, position in society, or race. Dignity in care is required for patients who are either conscious or unconscious. Those in a coma still need it (23).

2.1.5.   Maintaining body image

Maintaining the patient’s body image is important to dignity in care and the care provider should make their patient neat throughout the caring period (23).

2.2 Challenges to maintain human dignity in caring children with tetanus

2.2.1  Time and insufficient staffing

Time and insufficient staffing are in all likelihood the biggest obstacles nurses face in terms of keeping affected person dignity. When you’re rushed, you could no longer take sufficient time to cope with each affected person as a man or woman. Burnout may additionally abate your efforts to be a powerful affected person propose. It takes career know-how, dedication, and a clean ethical imaginative and prescient to look each and every affected person as any other person, and to attempt to keep that dignity intact

2.2.2  Not preserving the child private life

For teenagers it was important to them not to be separated from their parents because of their illness. For the practitioner the treatment was the focus. Both parties were concerned about their own focus. Neither gave up their own position.

2.2.3  Shattered dignity

Shattered dignity implies that the family members, especially the parents, assumed the practitioners’ moral standards, losing their self-respect in trying to please the practitioners. The children protested with words, tears and deprecating gestures but the practitioners were not sensitive to such expressions. There was a stifling atmosphere and the parents dissociated themselves from their child.

2.2.4  Being violated as a human being

The parents could not protect their child, even though the child cried with anxiety. The practitioners excluded both the children and the parents from a partnership, whereas the parents subjugated themselves to the practitioners. The parents seemed only to want to have the treatment given as fast as possible.

During the physicians’ ward round the parents were quite occupied by themselves. Sometimes up to seven persons would enter the room. The parents listened attentively so as not to miss anything concerning medical decisions. All discussion was between the physicians and the nurses. Nobody paid attention to the children’s distress.

2.2.5 Watching but not touching

When not receiving any help concerning how to perform care activities the parents lost their self-respect and did not ask for more help. Learning by doing is a natural way of being able to perform practical acts but the practitioners did not respond accordingly.

3.  Recommendations

To preserve the patient’s dignity, the nurses should:

1. Lower their voice when asking personal questions or relaying personal information.
2. Be sensitive to the patient’s demographic and special circumstances that the caring process and the outcome of care.
3. Ensure  the child is provided with opportunities and experiences based on interests, strengths and needs
4. Ensure the dignity of the child during personal care routines (such as toileting and nappy changes).
5.  Ensure children are protected from harm at all times and that educators are aware of their roles and responsibilities in relation to child protection

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