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Pott͛s is the tuberculosis of the bone and joints. It is a localized destructive disease caused by Mycobacterium tuberculosis. It is also known as tuberculous
spondylitis. It is usually secondary to an extraspinal source of infection. It can͛t be transmitted to others unless the organisms are exposed and aerosolized by
debridement or surgical manipulation. Most occurs most frequently in spinal column (Pott͛s disease) and in bone and joint structure surrounding the hip and knee.
Most common and dangerous form.
Person with compromised immune system have increased risk because there is depression of natural defense mechanism that normally prevent dissemination of
tuberculosis from primary lesion. Additional risk factors are untreated TB, DM, and ESRD with hemodialysis treatment. Goal for management includes general health
must be improved and deformities must be minimized. Multi-drug approach is generally selecting from Isoniazid, Refampicin, Pyrazinamide, Ethambutol,
Streptomycin or Cyclovirin to prevent development of a bacterial population resistance. Surgical management includes ADSF (Anterior Decompression Spinal Fusion)
which prevents vertebral collapse and neurologic sequelae and to drain any abscess that may have formed, application of knight taylor brace, head halter traction
are used initially to manage the muscle spasm and pain.

cc Ê PAc

Pc 
ame: RCP
Age: 13 years old
Birthday: September 23, 1996
Address: 0497 Lanuza Camp, Barangay Tagpas Binangonan Rizal
Date of Admission: July 20, 2010
Diagnosis: Pott͛s disease

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 ʹ Weakness of both lower extremities

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-Ê Present condition prior to admission, patient experienced upper back pain, non radiating, graded 10/10. Also claimed to have intermittent fever. Patient was
brought to a local hospital in Rizal. Chest x-ray showed PTB.
-Ê During the in term, there was intermittent back pain and episodes of fever.
-Ê 8 months prior to admission persistence of deformity of spine prompted consult of ational Childrens Hospital where thoracolumbar spine x-ray was
requested however patient did not comply because of financial constraints.
 -Ê 1 month PTA, patient experienced numbness and weakness of both lower extremities described as heaviness of both ankles, which gradually progressed to
difficulty in ambulation.
-Ê 1 week PTA, persistence of symptoms prompt consult at CH where patient was diagnosed to have pott͛s disease.
-Ê 1 day PTA, patient sought consult at POC OPD and was advised for admission.

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-Ê Patient was claimed to be born full term via SD at home with assistance of hilot. Patient was apparently born with a loud cry, pink all over and had strong
movements on both upper and lower extremities. Patient and mother are apparently well after delivery.
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-Ê He is the eldest child among 5 siblings. He was in grade VI (primary level). His parents are separated.

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-Ê Patient was independent in all aspects of ADL prior to illness. At present he is independent to eating, grooming, and dressing. However, is much dependent
with activities such as bathing and transferring.

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A.Ê GEERAL SURVEY
1.Ê Overall appearance and grooming- patient is conscious and coherent. He is thin with muscle atrophy noted on lower extremities. Hunching off the
thoracolumbar area was noted. He is wheelchair borne because of immobility.
2.Ê Actual height and weight- his height is 121cm and he weighs 25kg
3.Ê Symptoms of distress- presence of wheelchair
4.Ê Posture , Gait- he has kyphosis, unable to ambulate independently, he uses wheelchair.
5.Ê Relevance and organization of thought- with organize thought and responds to questions correctly
B.Ê VITAL SIGS
Temperature- 36.7 ϶C
Pulse Rate- 84 beats per minute
Respiratory Rate- 28 breaths per minute
C.Ê REGIOAL EXAM
1.Ê Hair, head and face- he has clean and well distributed hair, and with symmetrical face with good musculature.
2.Ê Eyes- he has pale palpebral conjunctivae and unicteric sclerae.
3.Ê ose- no any discharges noted.
 4.Ê Ears- he has symmetrical ears with no discharges and have same color with the skin color of his face
5.Ê Mouth and Throat- He has pink oral mucosa of the mouth without lesions noted and no halitosis
6.Ê eck and Lymph nodes- He had no complains of any tenderness on his neck. He can turn his head side to side, upward and downward and has no palpable
cervical lymph nodes.
7.Ê Skin- He has fair skin complexion with good skin turgor and no pressure sores noted on bony prominences.
8.Ê ails- He has good capillary refill and pinkish nail bed.
9.Ê Thorax and Lungs- He has symmetrical chest wall expansion, with no retractions and with clear breath sounds.
10.ÊCardiovascular- He has a dynamic precordium and normal heart rate. He was noted to have regular heart rhythm and no murmurs upon auscultation.
11.ÊBreasts and axillae- He has no tenderness and lumps on the breasts and axillary area
12.ÊAbdomen- He has flat soft, non tender abdomen with hypoactive bowel sounds noted upon auscultation.
13.ÊExtremities- He has full and equal pulses, no cyanosis , no edema on both upper and lower extremities. However, muscular atrophy was noted only on lower
extremities.
14.Ê Genitals- not assessed
15.Ê Rectum and anus- not assessed
16.Ê Musculoskeletal- he has gibbus formation on his thoracolumbar area. He can perform ROM on both upper extremities fairly but can͛t perform full ROM on
lower extremities because of weakness and muscle atrophy. Muscle strength on upper extremities is graded as 3/5 (fair) and 2/5 (poor) on both lower
extremities according to muscle strength grading scale.

VI.Ê Anatomy And Physiology

The Vertebral Column

The vertebral column (also called the backbone, spine, or spinal column) consists of a series of 33 irregularly shaped bones, called
vertebrae. These 33 bones are divided into five categories depending on where they are located in the backbone. The first seven
vertebrae are called the cervical vertebrae. Located at the top of the spinal column, these bones form a flexible framework for the
neck and support the head. The first cervical vertebrae is called the atlas and the second is called the axis. The atlas' shape allows
the head to nod "yes" and the axis' shape allows the head to shake "no".

The next twelve vertebrae are called the thoracic vertebrae. These bones move with the ribs to form the rear anchor of the rib cage.
Thoracic vertebrae are larger than cervical vertebrae and increase in size from top to bottom.
After the thoracic vertebrae, come the lumbar vertebrae. These five bones are the largest vertebrae in the spinal column. These
vertebrae support most of the body's weight and are attached to many of the back muscles.
 The sacrum is a triangular bone located just below the lumbar vertebrae. It consists of four or five sacral vertebrae in a child, which become fused into
a single bone after age 26. The sacrum forms the back wall of the pelvic girdle and moves with it.

Ê
Ê
The bottom of the spinal column is called the coccyx or tailbone. It consists of 3-5 bones that are fused together in an
adult. Many muscles connect to the coccyx.
These bones compose the vertebral column, resulting in a total of 26 movable parts in an adult. In between the vertebrae
are intervertebral discs made of fibrous cartilage that act as shock absorbers and allow the back to move. As a person
ages, these discs compress and shrink, resulting in a distinct loss of height (generally between 0.5 and 2.0cm) between the
ages of 50 and 55.
When looked at from the side, the spine forms four curves. These curves are called the cervical, thoracic, lumbar, and
pelvic curves. The cervical curve is located at the top of the spine and is composed of cervical vertebrae. ext come the
thoracic and lumbar curves composed of thoracic and lumbar vertebrae respectively. The final curve called the pelvic or sacral curve is formed by the
sacrum and coccyx. These curves allow human beings to stand upright and help to maintain the balance of the upper body. The cervical and lumbar
curves are not present in an infant. The cervical curves forms around the age of 3 months when an infant begins to hold its head up and the lumbar
curve develops when a child begins to walk.
In addition to allowing humans to stand upright and maintain their balance, the vertebral column serves several other important functions. It helps to
support the head and arms, while permitting freedom of movement. It also provides attachment for many muscles, the ribs, and some of the organs
and protects the spinal cord, which controls most bodily functions.

Ê
cc Ê Pathophysiology

Untreated Primary TB

Tubercle Bacilli metastasized to bone via hematogenous

spread and lymphatic transmission

Spinal lesion begins in anterior subchondral bone of single

vertebrae adjacent to the intervertebral discs

Bones destruction starts centrally spreads outwards and

may eventually erode into adjacent joint

If invaded the synovial membrane respond with excessive

secretion, proliferation and thickening

Tuberculosis granulation tissue forms and covers hyaline

articular cartilage and subchondral bone
 Destruction leads to anterior wedging of vertebral bodies

Vertebral collapse Gibbus formation and

kyphotic deformity

Discharge of necrotic material into soft tissues

Impaired Self bathing Activity Disturbed Risk for impaired

physical or hygiene intolerance body skin integrity
mobility deficit image
ccc Ê aboratory
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Platelet Count 0.5-2.0 3.57 Elevated in trauma(surgery
fractures)and TB,severe exercise
Leukocyte 4.5-10x10.9g/L 12.00 Elevated during acute infection and
tissue necrosis, Presence of tubercle
bacilli in the body activates the body͛s
defense system(Leukocytes)to respond
immediately/combat the tubercle bacilli.
Eosinophil 0.00-0.05 0.15 Allergies, parasitic disease ,cancer,
asthma, emphysema, renal dse.
Elevated also if there is an increase in
steroids produce by the adrenal glands
during stress.
Hemoglobin 127-183g/L 126 Decrease in hemoglobin indicates
anemia. A slight decrease in hemoglobin
is not significant.
 c Ê rugtudy

Generic name: Rifampicin

Classification: Anti tuberculosis

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Inhibits DA dependent
polymerase, decreases
replication
Maintenance phase treatment
of all forms of pulmonary and
extra pulmonary tuberculosis
Hypersensitivity, jaundice, severe
hepatic disease
GI disturbance pseudo
membranous colitis, influenza,
like symptoms skin reactions
cosinophilia, transient leukopenia
thrombocytopenia purpura,
shock headache, ataxia, visual
disturbances.
§Ê Assess lung sounds and
character and amount of
sputum periodically
during therapy.
§Ê Assess laboratory and
chest x-ray test,
therapeutic effectiveness
and adverse reaction.
Generic name: Isoniazid

Classification: Antituberculosis

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Inhibits RA synthesis, Pulmonary and extra pulmonary Should not be given to patients Various skin eruptions, fever, ÚÊ Assess lab. Test: sputum,
decreases tubercle bacilli tuberculosis(TB) Lupus vulgaris with drug induced liver disease lymphadenopathy and vasculitis, chest x-ray before
replication hypersensitivity, /V, treatment
gastrointestinal disturbances, ÚÊ Monitor liver and renal
liver dysfunction, peripheral function: ALT, AST,
neuropathy and anemia bilirubin, BU, creatine
output, urinalysis, uric
acid
ÚÊ Asses CS often: affect
mood, behavioural
changes
Generic name: Pyrazinamide

Classification: Antituberculosis

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Mechanism unknown, highly
specific and antibacterial for
mycobacterium tuberculosis
Treatment of active tuberculosis
in adult and selected children
Acute liver disease porphyria,
peripheral renritis, history of
drug-induced hepatitis, acute
gout, hypersensitivity and
pregnancy
Dose related hepatoxicity, /V,
anorexia, thrombocytopenia.
Sicleroblastic anemia with
crythroid hyperplasia,
vacnolation of erythrocytes,
increase serum iron
concentration gout,
ÚÊ Assess pt.s condition
before therapy and
regularly thereafter to
monitor drugs
effectiveness.
ÚÊ Monitor serum uric acid
which may be elevated
and cause gout
symptoms
ÚÊ Regular assess renal
status: input-output
ratio, urinalysis and
specific gravity
ÚÊ Regular assess for
hepatotoxicity:
decreased appetite,
jaundice, dark urine and
fatigue
ÚÊ Assess pt.s and family͛s
knowledge of drug
therapy
Generic name: Ethambutol hydrochloride

Classification: Antituberculosis

MECHAISM OF ACTIO IDICATIO COTRAIDICATIO ADVERSE EFFECT URSIG COSIDERATIO

Inhibits the synthesis of
metabolism in growing
mycobacterium cells, impairing
cell multiplication, and causing
cell death.
Treatment of pulmonary
tuberculosis in conjunction with
at least one other anti-
tuberculotic
-contraindicated with allergy to
ethambutol optic neuritis
-use cautiously with impaired
renal function lactation,
pregnancy, visual problems.
CS: optic neuritis, fever,
malaise, headache, dizziness,
mental confusion, disorientation
hallucination, peripheral neuritis
ÚÊ Administer with food if GI
upset occurs
ÚÊ Administer in sinlge daily
dose, must be used in
combination with the
GIT: anorexia, /V, Abdominal other antituberculosis
pain, transient liver impairment drug
ÚÊ Arrange for follow up of
liver and renal function
test, CBC,
ophthalmologist
examination
Generic name: Streptomycin

Classification: Anti-infective

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Cytotoxic: inhibits DA Metastatic islet cell carcinoma ÚÊ Contraindicated with CS: lethargy, confusion, ÚÊ Obtain baseline
synthesis leading to cell death of the pancreas allergy to streptomycin: depression information before and
partially through the production hematopoietic depression: GI: /V, diarrhea, hepatotoxicity during treatment
of intra stand cross-links in DA pregnancy, lactation
cell cycle non-specific ÚÊ Use cautiously with
impaired renal or hepatic
function
GU: Renal toxicity
Other: infertility, Cancer,
inflammation at injection site
ÚÊ Complete C & S testing
before and after drug
therapy to identify if
correct treatment has
been initiated
ÚÊ Identify urine output: if
decreasing. otify
physician; also increased
BU, creatinine , urine
CrCl< 80 mL/min
ÚÊ Monitor for bleeding;
echymosis bleeding
germs, hematuria, stool
guaiac daily if on long
term therapy.
Ê
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1.Ê Hyperthermia
2.Ê Impaired Physical Mobility
3.Ê Activity Intolerance
4.Ê Disturbed Body Image
5.Ê Self Care Deficit on bathing, toileting and transferring
6.Ê Risk for impaired skin integrity

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S: Impaired Due to ÚÊ During the ÚÊ Identify causative ÚÊ Diagnosis of pain, ÚÊ During the shift
͞Di niya maigalaw physical vertebral shift the contributing factors nutritional status, the patient had
ang kaliwang kamay mobility related collapse, patient that may restricted and perception able to perform
niya at din na to formation of will be movement restricts movements activities within
nakakatayo͟, as musculoskeletal gibbus in the able to his capacity
verbalized by his impairment and vertebrae perform ÚÊ Assess muscle strength ÚÊ To determine safely and able
mother loss of integrity occurs, leading activities adequate functioning to perform
of bone to stiffness, within his of muscles simple ROM
O: structures. alternation of capacity ÚÊ Assess functional ÚÊ Feelings of exercises on the
ÚÊ Limited range motor safely ability by determining frustration may upper
of motion function. Thus, ÚÊ Within the degree of immobility impede attainment extremities.
ÚÊ Absence of impaired shift the emotional, behavioral, of goals
any physical patient response to problems
movement at mobility may will be of immobility.
lower arise. able to
extremities perform ÚÊ Assist with ÚÊ To promote mobility
and weak left simple repositioning on a and circulation even
upper ROM regular schedule when in bed
extremity exercise
 based on ÚÊ Support affected body ÚÊ To maintain position
hand grip. parts using foot of function and
ÚÊ eeds support reduce risk of
assistance presence of ulcers.
with ADL
ÚÊ Muscle
strength of
2/5 on lower
extremities
ÚÊ Muscle
atrophy of
lower
extremity
noted
ÚÊ Mobilized
thru
wheelchair
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S: Hyperthermia Due to invasion of After 1-2 ÚÊ Vital signs taken ÚÊ Serves as baseline data Goal achieved,
͞Mainit ang pakiramdam related to microorganism in hours of and recorded patient͛s temperature
ko͟ infectious and the body it rendering decreased from 39.8϶
inflammatory activates the nursing ÚÊ Remove extra ÚÊ Decrease body to 37.3϶
O: process. inflammatory and care, the clothing temperature through
ÚÊ Weak looking defense patient͛s process of radiation,
ÚÊ Skin warm to mechanism of the body evaporation, and
touch body (leukocytes). temperature ÚÊ Render tepid convection
ÚÊ Flushed skin Leukocytes release will sponge bath
ÚÊ Diaphoretic pyrogens which decrease ÚÊ To help decrease body
ÚÊ eeds assistance elevates body from 39.8϶C temperature through
in performing temperature. to 37.3϶C process of evaporation
ADL ÚÊ Give medication and conduction
ÚÊ Febrile 39.8϶C as ordered like
paracetamol ÚÊ Paracetamol acts on the
heat regulating center,
the hypothalamus which
causes vasodilation and
ÚÊ Encouraged to therefore dissipates
increase fluid heat from the body
intake
ÚÊ To replace lost body
fluids and proper
hydration
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S> ͞ahihirapan Activity intolerance Vertebral collapse After the shift the ÚÊ Assess for muscle ÚÊ To determine After the shift the
akong tumayo ng related to muscle alters the sensory patient will be able strength adequate patient had perform
mag isa dahil weakness on lower and motor function to gradually functioning of activities within his
nanghihina ako͟ extremities of the body resulting perform activities muscles capacity as
to intolerance of within his capacity. ÚÊ Plan care with rest ÚÊ To conserve evidenced by gradual
O> unable to move performing activities. periods between energy range of joint motion
without assistance activities with moderate
> facial grimace assistance.
when moving up ÚÊ Plan for
> body malaise progressive ÚÊ Both activity
> limited ROM increase of activity tolerance and
>Muscle strength level/participation health status
Lower extremities in exercise may improve
2/5 (poor) training, as with progressive
>unable to walk, on tolerated by the training
wheelchair client
> dependent with
bathing, toileting ÚÊ Encourage to eat ÚÊ Protein aids in
and transferring nutritious foods wound healing
such as rich in and cell
proteins and regeneration.
carbohydrates Carbohydrates
yields energy for
ÚÊ Continue physical the body
therapy ÚÊ To improve
muscle strength
and sensory and
motor function
 PAPACIFIC UIVERSITY ORTH PHILIPPIES

Urdaneta City, Pangasinan

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CORPUZ, Charity Mae DE GUZMA, Moises ELASI, Rhea

COVITA, Marjun Rey DIRILO, Lorenz ESPIRITU, Jonjie Marie

DACULA, Juressa Joy DU, Lea FERADEZ, Mary Ann

DE GUZMA, John Jeevy ELASI, Melody FERMO, Catherine

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Ms. Jovelyn ACHETA, R