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Carlos Charmaine MuÑoz
Table of Contents I. II. III. Acknowledgement Introduction Assessment I. Persona l data II. Medical History A. History of present illness B. Past Medical History C. Family Medical History D. Personal and Social history IV. V. VI. Physical as sessment Anatomy and Physiology Pathophysiology VII. Nursing Care Plan VIII. Drug Study IX. Discharge Planning ACKNOWLEDGEMENT
This case study on Pott’s disease would not be possible without those people who continually helped and contributed in the said case study. My heartfelt express ion of appreciation goes out to each and every one of you. First and foremost, I would like to thank the West B staff of EAMC for generously giving me their tim e. To our Professor, Mam Diente,Mam Donnie for patiently supervising and assisti ng us with your knowledge, as we gradually go through the process of doing the c ase study itself, our sincerest thanks. To our patient, for the generous time ex tended for me to explore this case; and for giving me his full cooperation and k indness that helped me complete the needed information for this paper. Also, to our friends and classmates, who, like me, managed to encourage and support each other amidst every discouragement and difficulty, Thank you. To my parents, for supporting me all the way, providing me with everything I need, financially and emotionally. All of those things are genuinely appreciated. Last but not the lea st, to our Almighty Father, for his unceasing guidance and blessings, for consta ntly giving me hope, courage, and patience. Truly, none of this is possible with out you. INTRODUCTION
Tuberculosis (TB) of the spine also known as Potts disease, Pott’s Caries, David s disease, Tuberculosis spondylitis and Pott s curvature, is the most common si te of bone infection in TB. The lower thoracic and upper lumbar vertebrae are th e areas of the spine most often affected. The original name was formed after Per civall Pott, a London surgeon, who first studied the disease. When he died, Patr ick David was the one who continued his work. Pott’s disease results from haemat ogenous spread of tuberculosis (mycobacterium tuberculosis) from other sites. Th e infection then spreads from two adjacent vertebrae into the adjoining disc spa ce. If only one vertebra is affected, the disc is normal,but if two are involved the intervertebral disc, which is avascular, cannot receive nutrients and colla pses. The disc tissue dies and is broken down by caseation, leading to vertebral narrowing and eventually to vertebral collapse and spinal damage. A dry soft ti ssue mass often forms and superinfection is rare. The disease progresses slowly. Signs and symptoms include: back pain, fever, night sweats, anorexia, weight lo ss, and easy fatigability. Diagnosis is based on: blood tests elevated ESR , ski n tests ,radiographs of the spine , bone scan ,CT of the spine , and bone biopsy . Gibbus formation is the pathognomonic sign of this disease.
A person with Pott s disease often develops kyphosis, which results in a hunchba ck. This is often referred to as Pott’s curvature. In some cases, a person with Pott s disease may also develop paralysis, referred to as Pott’s paraplegia, whe n the spinal nerves become affected by the curvature. A person who has been diag nosed with Pott s disease may be treated through a variety of options. He or she may utilize analgesics or antituberculosis drugs to get the infection under con trol. It may also be necessary to immobilize the area of the spine affected by t he disease, or the person may need to undergo surgery in order to drain any absc esses that may have formed or to stabilize the spine. Since Pott s disease is ca used by a bacterial infection, prevention is possible through proper control. Th e best method for preventing the disease is reduce or eliminate the spread of tu berculosis. In addition, testing for tuberculosis is an important preventative m easure, as those who are positive for purified protein derivative (PPD) can take medication to prevent tuberculosis from forming. A tuberculin skin test is the most common method used to screen for tuberculosis, though blood tests, bone sca ns, bone biopsies, and radiographs may also be used to confirm the disease
THEORETICAL FRAMEWORK For the theoretical framework, I used the “21 nursing prob lems” according to Faye Glenn Abdellah. She defined nursing as broadly grouped i nto the 21 nursing problem areas to guide care and promote the use of nursing ju dgement. She also said that nursing is a service that is based on the art and sc ience and aims to help people, sick or well, cope with their health needs. The 2 1 nursing problems are as follows: 1) To maintain good hygiene.
2) To promote optimal activity: exercise, rest, and sleep 3) To promote safety 4 ) To maintain good body mechanics. 5) To facilitate the maintenance of a supply of oxygen 6) To facilitate maintenance of nutrition 7) To facilitate maintenance of elimination 8) To facilitate maintenance of fluid and electrolyte imbalance 9) To recognize the physiologic response of the body to disease conditions 10)To facilitate the maintenance of regulatory mechanisms and functions 11)To facilit ate the maintenance of sensory function 12)To identify and accept positive and n egative expressions, feelings and reactions 13)To identify and accept the interr elatedness of emotions and illness 14)To facilitate the maintenance of effective verbal and non-verbal communication 15)To promote the development of productive interpersonal relationships 16)To facilitate progress towards achievement of pe rsonal spiritual goals 17)To cerate and maintain a therapeutic environment 18)To facilitate awareness of self as an individual with varying needs 19)To accept t he optimum possible goals 20)To use community resources as aid in resolving prob lems
21) To understand the role of social problems as influencing factor ASSESSMENT I. Personal Data: Name: B.P. Address: Novaliches Quezon City Age: 28 years old Sex: Female Civil status: Married Religion: Roman Catholic Birthday: N ovember 19, 1978 Birthplace: Manila Attending Physician: Dr. Adrian Catbagan Adm itting Diagnosis: Spinal cord compression on T/3 level Chief complaint: weakness of lower extremities
II. Medical History A. History of Present Illness: This is a case of B.P., who w as admitted for the first time last September 13,2007 with a chief complaint of weakness of lower extremities. The history of present illness started two months prior to admission, when the patient started to experience weakness of both low er extremities. No other associated signs and symptoms were noted. Few hours pri or to admission, persistence of above symptoms prompted consult. B. Past Medical History: ( - ) HPN ( - ) DM ( - ) asthma ( - ) allergy B. Family Medical Histor y: ( - ) HPN ( - ) DM ( - ) CA ( - ) asthma C. Personal and Social History: ( ) smoker ( - ) alcoholic beverage drinker
The vertebral column provides structural support for the trunk and surrounds and protects the spinal cord. The vertebral column also provides attachment points for the muscles of the back and ribs. The vertebral disks serve as shock absorbe rs during activities such as walking, running, and jumping. They also allow the spine to flex and extend.
MEDICAL/SURGICAL INTERVENTIONS Management of Pott’s disease Drug treatment is ge nerally sufficient for Pott’s disease, with spinal immobilization if required. S urgery is required if there is spinal deformity or neurological signs of spinal cord compression. Standard antituberculosis treatment is required. Duration of a ntituberculosis treatment: If debridement and fusion with bone grafting are perf ormed, treatment can be for six months. If debridement and fusion with bone graf ting are NOT performed a minimum of 12 months’ treatment is required. It may als o be necessary to immobilize the area of the spine affected by the disease, or t he person may need to undergo surgery in order to drain any abscesses that may h ave formed or to stabilize the spine. Other interventions include application of knight/ taylor brace, head halter traction. Surgery includes ADSF ( Anterior de compression Spinal fusion).
Drug Study GENERIC NAME: HRZE (isoniazid+rifampicin+pyrazinamide+ethambutol) Brand name: My rin Dosage: 3 tab 30 min before breakfast Drug Classification:Anti-infective MECHANISM INDICATIONS CONTRAINDICATIONS ADVERSE REACTION NURSING Responsibilitie s
Unknown. Appears to inhibit cellwall biosynthesis by interfering with lipid and DNA synthesis > Actively growing tubercle bacilli >prevention of tubercle bacilli in those exp osed to tuberculosis or those with positive skin test results whose chest x-rays and bacteriologic studies are consistent with nonprogressive tuberculosis Contraindicate d in patients with acute hepatic disease or isoniazidrelated live r damge > peripheral neuropathy, fluid discoloration, optic neuritis, hepatitis >Use cautiously in elderly patients >peripheral neuropathy is more common in pat ients who are slow acetylators or who are malnourished, alcoholic or diabetic, > Monitor hepatic function closely for changes GENERIC NAME: ketorolac tromethamine Brand name:Toradol Dosage: 30 mg Iv q8h Dru g Classification: NSAIDS MECHANISM INDICATIONS CONTRAINDICATIONS ADVERSE REACTION NURSING Responsibilitie s
Unknown. Produces antiinflammatory, analgesic, and antipyretic effects, possibly by inhibiting prostaglandi n synthesis > short-term management of moderately severe, acute pain for single dose treatme nt > Short-term management of moderately sever, acute pain for multiple dose tre atment Contraindicate d in patients hypersensitive to drug and in those with active pep tic ulcer disease , recent GI bleeding or perforation, advanced renal impairment , incomplete homeostasis and with high risk of bleeding. > drowsiness, sedation, edema, hypertension, diarrhea, stomatitis, peptic ulcera tion, rash, diaphoresis > Ketorolac isn’t recommended for children > Use cautiously in patients with hep atic and renal impairment >NSAIDS may mask signs and symptoms of infection becau se of their antipyretic and antiinflammatory actions GENERIC NAME: ciprofloxacin Brand name: Ciprobay Dosage: 500mg/cap BIDx5 days Dr ug Classification: Fluoroquinolones
MECHANISM Inhibits bacterial dna synthesis, mainly by blocking DNA gyrase, bacte ricidal. INDICATIONS > Severe or complicated bone or joint infections >Complicated intraa bdominal infections CONTRAINDICATIONS Contraindicated to patients sensitive to fluoroquinolone s ADVERSE REACTION > headache, retlessness, fatigue, drowsiness, edema, chest pain , nausea, diarrhea, leucopenia, crystalluria NURSING Responsibilities > Use cautiously in patients with CNS disorders, such a s severe cerebral arteriosclerosis or seizure disorders, and in those with risk for seizures. > Monitor patients intake and output and observe for signs of crys talluria >Obtain specimen for culture and sensitivity before giving first-dose PATHOPHYSIOLOGY Pulmonary tuberculosis
Spread of mycobacterium tuberculosis from other Extrapulmomary tuberculosis The infection spreads from two adjacent vertebrae into the adjoining disc space back pain, fever, night sweats, anorexia, weight loss, and easy One vertebra is affected, the disc is normal Two are involved, the avascular int ervertebral disc cannot receive nutrients and collapse Disk tissue dies and brok en down by caseation Vertebral narrowing Vertebral collapse Spinal damage POTT’S DISEASE Kyphosis, paraplegia, bowel and urinary incontinene ce Surgery: evacuation of pus, Anterior decompression spinal fusion GORDON’S PATTERN OF FUNCTIONING
Health-perception/ Healthmanagement pattern Nutritional/ Metabolic pattern Elimi nation pattern Activity/ Exercise pattern Before hospitalization It is her first time to get hospitalized. She usually jus t bears the pain or uses selfmedication. The patient eats all kinds of food. She likes to eat vegetables. The patient defecates regularly at least once a day or sometimes once every two days and urinates frequently. The patient sweats a lot because of the weather. The patient’s form of exercise is doing the household c hores. During hospitalization She hopes that she will get better.. The patient still eats a lot. The patient has urinary and bowel incontinence bec ause of spinal cord injury. Sleep-rest pattern Cognitive/ Perceptual pattern The patient usually sleeps for about 5 hours. The client likes to talk to her ne ighbors after doing all the household chores. Self-perception/ Self-concept pattern The patient has a good self –esteem. She doesn’t have a form of exercise in the hospital because she is bedridden, as a result of spinal cord injury. The patient’ s sleep was still for about 5 hour s. At first the client doesn’t speak much but once you have established rapport with her, you will see that she is a very friendly person. She became open and w as talking more than before. The patient somewhat lost her self-esteem
Role/ Relationship pattern The patient is very friendly and has a good relationship with people around her. WEhen stressed, she usually diverts it by watching television. Coping/ Stresstolerance pattern because she thinks she is useless. The patient is communicative when you talk to her but she will not be the one to open up conversations. When the patient expe riences stress, she just prays to god because there are not other diversional ac tivities she can do in the hospital. Discharge Plan P- atient should be reminded to attend check-ups at the nearest…. O- rthopedic center T- reatment should be taken in a….. T- imely manner S- ight any symptoms other than the usual and report it to the physician
PHYSICAL ASSESSMENT Body part Head Technique used Palpation Inspection Normal fi ndings Absence of masses and nodules Actual findings Head does not appear too la rge or too small. There were no masses and nodules. Anicteric sclera Pink palpeb ral conjunctiva Hair doesn’t look dull. Normal Color is the same as Color is the same as facial skin. Pinna facial skin. No deformities tends to bend easily fou nd. No discharge and recoils easily after bending. Nose Inspection Symmetrical w ith no deformities. Skin Inspection Good or active skin turgor. Absence of Good skin turgor (-) rashes Symmetrical. No deformities found. (-) nasal congestion N ormal Normal Analysis/Interpretation Normal Eyes Inspection Conjunctiva is pink Normal Hair Ears Inspection Inspection Usually black and shiny. Normal
ecchymosis. Mouth Inspection Uniform, pink color of the gums, moist and smooth i n texture Pink-colored gums. Moist buccal mucosa. Normal Nails Inspection Smooth and usually long enough to extend over the fingertips; should be colored pink, convex in shape and with 160o angle between the nails and the n ailbeds. Good capillary refill. Light pink in color, convex in shape. Normal Arms Inspection Should have good muscle contraction. Good flexion and extension. Abse nce of ecchymosis and deformities. Chest is symmetrical, No ecchymosis noted. fu ll and equal pulses. Normal Chest Palpation, Inspection and Auscultation Abnormal Slight DOB (+) gibbus formation
Abdomen Palpation and Inspection rhythmic and breathing pattern is effortless Contour is slightly protuberant. Fl at abdomen. Normoactive bowel sounds. Normal Genitalia Legs and Extremities Inspection N/A Inspection Pinkish in color and intact. Absence of deformities an d good ROM. Absence of edema and ecchymosis. No unusual sounds should be heard; RR should range from normal and effortless respiration. Regular rhythm, no heart murmurs. Adynamic precordium,normal rate,regular rhythm,No murmur Grossly norma l. No edema. No cyanosis. N/A Normal Respiratory system Auscultation Normal Clear breath sounds. No retractions. Cardiovascular Auscultation system Normal
NURSING CARE PLAN Cues Nursing Diagnosis GOAL: After 1 day of nursing interventi on, the patient will recognize and incorporate body image change into selfconcep t in accurate manner without negating self-esteem. EXPECTED OUTCOME: The patient will: 1) Verbalize acceptance of self in situation. 2) Verbalize relief of anxi ety and adaptation to actual/altered body image. 3) Acknowledge self as an indiv idual who has responsibility for self. 1) Determine whether condition is permane nt/ no hope for resolution 2) Evaluate level of clients knowledge of and anxiety related to situation. Observe emotional changes. 3) Have client describe self , noting what is positive and what is negative. Beware of how client believes oth ers see self. 4) Note signs of grieving/indictor s of depression >To assess caus ative/ contributing factors > To assess causative/ contributing factors Planning Implementation Independent: SUBJECTIVE: Disturbed body “Ayoko ng image related to ganito. trauma/ injury to Mahirap. spinal cord as Inaasa nalang evidenced by lahat sa iba.. verbal reports of Wala naman negative feelings din ako about body magawa dahil (feelings of hindi ko naman helplessness and kaya, “ as powerlessn ess) verbalized by the patient. OBJECTIVE: - patient has been bedridden ever sin ce she was hospitalized Evaluate response to interventions, teachings and action s performed. * The patient was able to incorporate body image change into self-c oncept without negating selfesteem. The goal was met. Rationale Evaluation >To asses causative/ contributing factors >To evaluate needs for counseling and
5) Identify previously used coping strategies and its effectiveness. 6) Establis h therapeutic nurse-client relationship conveying an attitude of caring and deve loping a sense of trust. 7) Provide assistance with self care needs/ measures as necessary while promoting individual abilities/indepen dence Collaborative: 8) Refer to appropriate support groups. 9) Talk to SO(s) about ways to help client deal with problem medication >To determine coping skills/capabilities > To assist client/SO(s) to deal with/accept issues of selfconcept related to body image. >To enhance capabi lities >To provide continuity of care >To promote collaboration .
Cues Nursing Diagnosis Planning GOAL: Implementation Independent: Rationale > To identify causative/ contributing factors Evaluation Evaluate responses to interventions, teachings and actions performed. SUBJECTIVE: Self-bathing/ “ Ang hirap ng hygiene deficit ganito, nakahiga relate d to musculona lang lagi, kahit skeletal impairment paligo inaasa sa as evidence d by iba,” as verbalized inability to wash by the patient body or body parts, ob tain or get to OBJECTIVE: water source, get in > patient has been and out of bed ridden ever bathroom. since she was hospitalized because of spinal cord injury 1) Determine existing After 1 day of conditions nursing affecting ability of int ervention, the individual to care patient will for own needs, i.e. perform selfcare spinal cord injury. activities within 2) Determine level of own individual ability strengths of client 3) Note whether EXPECTED deficient is OUTCOME: tempo rary or The patient will: permanent, should 1) Identify decrease or individual i ncrease in time areas of 4) Promote client/ SO weakness/ participation in needs problem 2) Demonstrate identification and techniques/ decision making. lifestyle 5) Develop plan of changes to care appropriate to meet selfindividual care need s situation, 3) Identify scheduling personal activities to resources conform to clients *The client was > To assess able to perform degree of self-care disability activ ities within >To assess degree level of own of disability ability. Goal was met >enhances commitment to plan, optimizing outcomes > to assist in correcting/ dea ling with situation
that can provide assistance normal schedule. 6) Assist with rehab program 7) Allow sufficient time for clien t to accomplish tasks to fullest extent of ability 8) Assist with necessary adap tation to accomplish ADL’s. Begin with familiar, easily accomplished tasks. 9) R eview/modify program periodically to accommodate changes in abilities Dependent: 10)Administer medication regimen Collaborative: 11) Consult with dietitian/nutr itional support team > To enhance capabiities > To enhance capabilities >To encourage client and build on successes. >Assist patient to adhere to plan of care to fullest extent >To provide continui ty of care > To provide continuity of care
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