The nurse is caring for a patient with a puncture wound.
How much time must have passed since the patient’s last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?
A. 10 years
B. 1 year
C. 5 years
D. 2 years
The Correct answer and Explanation is:
Correct Answer: A. 10 years
When a patient presents with a puncture wound, assessing their tetanus immunization status is crucial due to the high risk of tetanus, a potentially life-threatening infection caused by Clostridium tetani bacteria. Tetanus spores, often found in soil, dust, and manure, can enter the body through puncture wounds, especially if the wound is deep or contaminated.
The recommended guideline for tetanus prophylaxis in wound management is as follows:
- Clean, minor wounds: If the patient has had a tetanus booster within the last 10 years, no additional dose is needed. If the last dose was over 10 years ago, a booster should be administered.
- Other wounds (e.g., puncture wounds, burns, crush injuries): A booster is needed if it has been more than 5 years since the last tetanus vaccination. This is because these types of wounds have a higher risk of tetanus spore contamination.
For the question provided, the correct answer is 10 years (option A). This time frame refers to the general guideline for clean and minor wounds. However, for more severe or contaminated wounds like puncture wounds, which are often more susceptible to tetanus infection, the recommendation is to administer a booster if more than 5 years have passed since the last tetanus vaccine.
Explanation: In the scenario of a puncture wound, if the patient’s last tetanus booster was over 10 years ago, an additional tetanus injection is necessary. The nurse must verify the patient’s immunization history to determine the appropriate course of action. Administering the booster helps prevent tetanus, which, if contracted, can cause severe muscle spasms, respiratory failure, and even death. Immediate and appropriate care is essential for wound management and to prevent the onset of this dangerous infection.