A client has a puncture wound caused by a rusty nail. The nurse understands that which of the following should be initiated to prevent tetanus?
A.
Administer antiviral medication.
B.
Provide tetanus antitoxin.
C.
Perform wound debridement.
D.
Apply cold compress to the wound.
The correct answer and Explanation is :
The correct answer is B. Provide tetanus antitoxin.
Explanation:
A puncture wound from a rusty nail is particularly concerning for tetanus, a serious bacterial infection caused by Clostridium tetani. This bacterium is commonly found in soil, dust, and animal feces. When a puncture wound occurs, especially with a rusty nail, it creates an anaerobic (low-oxygen) environment that is ideal for the bacteria to grow and produce toxins.
Tetanus prophylaxis is essential in preventing the disease. The main strategies include administering tetanus vaccines and, in some cases, providing tetanus antitoxin.
- Tetanus Antitoxin (Tetanus Immunoglobulin): This is a form of passive immunity used to provide immediate protection against tetanus toxin. It is administered to individuals who have not been adequately immunized or who have an increased risk due to the nature of their wound. For a puncture wound, especially with a rusty nail, tetanus antitoxin can neutralize the toxin if the infection is suspected or if the wound is deemed high-risk.
- Tetanus Vaccination: The tetanus vaccine (Td or Tdap) is crucial for long-term prevention. It is generally administered every 10 years, or every 5 years if a person has a high-risk injury. For a recent puncture wound, if the patient’s vaccination status is not current, a booster may be given.
- Wound Debridement: While this is an important step in cleaning and managing the wound to reduce infection risk, it does not directly prevent tetanus. It involves removing any foreign material and dead tissue from the wound, which can reduce the risk of infection and support the healing process.
- Cold Compress: Applying a cold compress can help manage pain and swelling, but it does not address the risk of tetanus. It is not a method for preventing tetanus or treating the underlying cause.
In summary, tetanus prophylaxis typically involves both the administration of tetanus antitoxin for immediate protection and the tetanus vaccine for long-term prevention. Ensuring the wound is properly cleaned and debrided is also a critical step in managing the injury.