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INTRODUCTION Pott s 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 can t be transmitted to others unless the organisms are exposed and aerosolized by debridement or surgical manipulation. Most occurs most frequently in spinal column (Pott s 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.

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PATIENT S PROFILE Name: RCP Age: 13 years old Birthday: September 23, 1996 Address: 0497 Lanuza Camp, Barangay Tagpas Binangonan Rizal Date of Admission: July 20, 2010 Diagnosis: Pott s disease CHIEF COMPLAINT Weakness of both lower extremities HISTORY OF PRESENT ILLNESS - 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. - During the in term, there was intermittent back pain and episodes of fever. - 8 months prior to admission persistence of deformity of spine prompted consult of National Childrens Hospital where thoracolumbar spine x-ray was requested however patient did not comply because of financial constraints.

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GENERAL SURVEY 1. he uses wheelchair.he has clean and well distributed hair. 2.Patient was independent in all aspects of ADL prior to illness. patient experienced numbness and weakness of both lower extremities described as heaviness of both ankles. He is wheelchair borne because of immobility. grooming. Gait. FUNCTIONAL HISTORY . head and face. Eyes. REGIONAL EXAM 1. Nose. 1 week PTA. . Symptoms of distress. PAST MEDICAL HISTORY . 2.36.no any discharges noted. PERSONAL SOCIAL AND ENVIRONMENTAL HISTORY . Overall appearance and grooming. Relevance and organization of thought.He is the eldest child among 5 siblings.84 beats per minute Respiratory Rate. V. pink all over and had strong movements on both upper and lower extremities. unable to ambulate independently. However. Hair. is much dependent with activities such as bathing and transferring. Hunching off the thoracolumbar area was noted.with organize thought and responds to questions correctly B.7 C Pulse Rate. persistence of symptoms prompt consult at NCH where patient was diagnosed to have pott s disease. At present he is independent to eating. PHYSICAL ASSESSMENT A. patient sought consult at POC OPD and was advised for admission. Patient was apparently born with a loud cry. His parents are separated.presence of wheelchair 4.patient is conscious and coherent.- 1 month PTA.his height is 121cm and he weighs 25kg 3.Patient was claimed to be born full term via NSD at home with assistance of hilot.28 breaths per minute C. 1 day PTA. Patient and mother are apparently well after delivery. He is thin with muscle atrophy noted on lower extremities. 3. which gradually progressed to difficulty in ambulation.he has kyphosis. VITAL SIGNS Temperature. and dressing. Actual height and weight. 5. He was in grade VI (primary level).he has pale palpebral conjunctivae and unicteric sclerae. and with symmetrical face with good musculature. Posture .

Thorax and Lungs. Ears. Thoracic vertebrae are larger than cervical vertebrae and increase in size from top to bottom. However.He has symmetrical chest wall expansion.He had no complains of any tenderness on his neck. no edema on both upper and lower extremities. non tender abdomen with hypoactive bowel sounds noted upon auscultation. 8. These 33 bones are divided into five categories depending on where they are located in the backbone.4. Neck and Lymph nodes. 14. upward and downward and has no palpable cervical lymph nodes. Nails. 11.He has no tenderness and lumps on the breasts and axillary area 12. The next twelve vertebrae are called the thoracic vertebrae. 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. These vertebrae support most of the body's weight and are attached to many of the back muscles. these bones form a flexible framework for the neck and support the head. Breasts and axillae. muscular atrophy was noted only on lower extremities. Anatomy And Physiology The Vertebral Column The vertebral column (also called the backbone. Genitals. He can turn his head side to side. Rectum and anus. After the thoracic vertebrae.He has pink oral mucosa of the mouth without lesions noted and no halitosis 6. . or spinal column) consists of a series of 33 irregularly shaped bones. VI. 13. 9.He has flat soft. The first cervical vertebrae is called the atlas and the second is called the axis. Musculoskeletal. 10. He was noted to have regular heart rhythm and no murmurs upon auscultation.he has gibbus formation on his thoracolumbar area. Abdomen. come the lumbar vertebrae. called vertebrae. no cyanosis . Cardiovascular. These five bones are the largest vertebrae in the spinal column. Mouth and Throat. Located at the top of the spinal column. These bones move with the ribs to form the rear anchor of the rib cage. The first seven vertebrae are called the cervical vertebrae.he has symmetrical ears with no discharges and have same color with the skin color of his face 5.He has good capillary refill and pinkish nail bed. The atlas' shape allows the head to nod "yes" and the axis' shape allows the head to shake "no". with no retractions and with clear breath sounds.He has full and equal pulses. Extremities. He can perform ROM on both upper extremities fairly but can t perform full ROM on lower extremities because of weakness and muscle atrophy. 7.not assessed 16.He has a dynamic precordium and normal heart rate. Skin.He has fair skin complexion with good skin turgor and no pressure sores noted on bony prominences.not assessed 15. spine.

It consists of 3-5 bones that are fused together in an adult. which become fused into a single bone after age 26. These curves allow human beings to stand upright and help to maintain the balance of the upper body.0cm) between the ages of 50 and 55. The bottom of the spinal column is called the coccyx or tailbone. The final curve called the pelvic or sacral curve is formed by the sacrum and coccyx. thoracic. When looked at from the side. In between the vertebrae are intervertebral discs made of fibrous cartilage that act as shock absorbers and allow the back to move. 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. Next come the thoracic and lumbar curves composed of thoracic and lumbar vertebrae respectively. lumbar. the vertebral column serves several other important functions. resulting in a distinct loss of height (generally between 0.The sacrum is a triangular bone located just below the lumbar vertebrae. resulting in a total of 26 movable parts in an adult. It helps to support the head and arms. and some of the organs and protects the spinal cord. It consists of four or five sacral vertebrae in a child. Many muscles connect to the coccyx. and pelvic curves. It also provides attachment for many muscles.5 and 2. which controls most bodily functions. while permitting freedom of movement. These curves are called the cervical. As a person ages. these discs compress and shrink. The cervical and lumbar curves are not present in an infant. the ribs. The sacrum forms the back wall of the pelvic girdle and moves with it. These bones compose the vertebral column. . In addition to allowing humans to stand upright and maintain their balance. the spine forms four curves. The cervical curve is located at the top of the spine and is composed of cervical vertebrae.

VII. 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 physical mobility Self bathing or hygiene deficit Activity intolerance Disturbed body image Risk for impaired skin integrity .

5-2. Presence of tubercle bacilli in the body activates the body s defense system(Leukocytes)to respond immediately/combat the tubercle bacilli.00 SIGNIFICANCE Elevated in trauma(surgery fractures)and TB. A slight decrease in hemoglobin is not significant.57 12.VIII. Decrease in hemoglobin indicates anemia. Laboratory COMPONENT Platelet Count Leukocyte NORMAL RANGE 0.5-10x10.cancer. Eosinophil 0.05 0.9g/L RESULT 3. Elevated also if there is an increase in steroids produce by the adrenal glands during stress. renal dse.severe exercise Elevated during acute infection and tissue necrosis. asthma.15 Hemoglobin 127-183g/L 126 . emphysema. parasitic disease .00-0.0 4. Allergies.

NURSING CONSIDERATION  Assess lung sounds and character and amount of sputum periodically during therapy. shock headache.IX. influenza. Drug Study Generic name: Rifampicin Classification: Anti tuberculosis MECHANISM OF ACTION Inhibits DNA dependent polymerase. severe hepatic disease ADVERSE REACTION GI disturbance pseudo membranous colitis. jaundice. Assess laboratory and chest x-ray test. visual disturbances. decreases replication INDICATION Maintenance phase treatment of all forms of pulmonary and extra pulmonary tuberculosis CONTRAINDICATION Hypersensitivity. like symptoms skin reactions cosinophilia. therapeutic effectiveness and adverse reaction.  . transient leukopenia thrombocytopenia purpura. ataxia.

chest x-ray before treatment  Monitor liver and renal function: ALT. urinalysis. liver dysfunction. hypersensitivity. behavioural changes . peripheral neuropathy and anemia NURSING CONSIDERATION  Assess lab. Test: sputum. gastrointestinal disturbances. lymphadenopathy and vasculitis. fever. creatine output. N/V. decreases tubercle bacilli replication INDICATION Pulmonary and extra pulmonary tuberculosis(TB) Lupus vulgaris CONTRAINDICATION Should not be given to patients with drug induced liver disease ADVERSE EFFECT Various skin eruptions. bilirubin.Generic name: Isoniazid Classification: Antituberculosis MECHANISM OF ACTION Inhibits RNA synthesis. BUN. uric acid  Asses CNS often: affect mood. AST.

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

malaise. Abdominal pain. ADVERSE EFFECT CNS: optic neuritis. ophthalmologist examination . transient liver impairment NURSING CONSIDERATION  Administer with food if GI upset occurs  Administer in sinlge daily dose. fever. headache. visual problems. INDICATION Treatment of pulmonary tuberculosis in conjunction with at least one other antituberculotic CONTRAINDICATION -contraindicated with allergy to ethambutol optic neuritis -use cautiously with impaired renal function lactation. N/V.Generic name: Ethambutol hydrochloride Classification: Antituberculosis MECHANISM OF ACTION Inhibits the synthesis of metabolism in growing mycobacterium cells. dizziness. peripheral neuritis GIT: anorexia. CBC. mental confusion. disorientation hallucination. and causing cell death. must be used in combination with the other antituberculosis drug  Arrange for follow up of liver and renal function test. pregnancy. impairing cell multiplication.

lactation  Use cautiously with impaired renal or hepatic function ADVERSE EFFECT CNS: lethargy. depression GI: N/V. urine CrCl< 80 mL/min  Monitor for bleeding. also increased BUN. hematuria. echymosis bleeding germs.Generic name: Streptomycin Classification: Anti-infective MECHANISM OF ACTION Cytotoxic: inhibits DNA synthesis leading to cell death partially through the production of intra stand cross-links in DNA cell cycle non-specific INDICATION Metastatic islet cell carcinoma of the pancreas CONTRAINDICATION  Contraindicated with allergy to streptomycin: hematopoietic depression: pregnancy. diarrhea. Notify physician. stool guaiac daily if on long term therapy. inflammation at injection site NURSING CONSIDERATION  Obtain baseline information before and during treatment  Complete C & S testing before and after drug therapy to identify if correct treatment has been initiated  Identify urine output: if decreasing. Cancer. hepatotoxicity GU: Renal toxicity Other: infertility. creatinine . . confusion.

 To promote mobility and circulation even when in bed . leading to stiffness. LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY 1. formation of gibbus in the vertebrae occurs. Impaired Physical Mobility 3. as verbalized by his mother O:  Limited range of motion  Absence of any movement at lower extremities and weak left upper extremity NURSING DIANOSIS Impaired physical mobility related to musculoskeletal impairment and loss of integrity of bone structures. Hyperthermia 2.X. Self Care Deficit on bathing. impaired physical mobility may arise. response to problems of immobility. Thus. behavioral. PLANNING  During the shift the patient will be able to perform activities within his capacity safely  Within the shift the patient will be able to perform simple ROM exercise NURSING INTERVENTION  Identify causative contributing factors that may restricted movement  Assess muscle strength RATIONALE  Diagnosis of pain. SCIENTIFIC EXPLANATION Due to vertebral collapse. toileting and transferring 6. Risk for impaired skin integrity XI. alternation of motor function. NURSING CARE PLAN ASSESSMENT S: Di niya maigalaw ang kaliwang kamay niya at din na nakakatayo . Activity Intolerance 4.  Assist with repositioning on a regular schedule  During the shift the patient had able to perform activities within his capacity safely and able to perform simple ROM exercises on the upper extremities. and perception restricts movements  To determine adequate functioning of muscles  Feelings of frustration may impede attainment of goals EVALUATION  Assess functional ability by determining degree of immobility emotional. nutritional status. Disturbed Body Image 5.

Needs assistance with ADL Muscle strength of 2/5 on lower extremities Muscle atrophy of lower extremity noted Mobilized thru wheelchair  Support affected body parts using foot support  To maintain position of function and reduce risk of presence of ulcers. .    based on hand grip.

the hypothalamus which causes vasodilation and therefore dissipates heat from the body  To replace lost body fluids and proper hydration Goal achieved. SCIENTIFIC EXPLANATION Due to invasion of microorganism in the body it activates the inflammatory and defense mechanism of the body (leukocytes). the clothing patient s body temperature  Render tepid will sponge bath decrease from 39.3  Encouraged to increase fluid intake .8 to 37. Leukocytes release pyrogens which elevates body temperature.8 C to 37.ASSESSMENT S: Mainit ang pakiramdam ko O:  Weak looking  Skin warm to touch  Flushed skin  Diaphoretic  Needs assistance in performing ADL  Febrile 39. patient s temperature decreased from 39. evaporation. and convection  To help decrease body temperature through process of evaporation and conduction  Paracetamol acts on the heat regulating center.3 C  Give medication as ordered like paracetamol  Decrease body temperature through process of radiation.8 C NURSING DIAGNOSIS Hyperthermia related to infectious and inflammatory process. PLANNING INTERVENTION RATIONALE  Serves as baseline data EVALUATION After 1-2  Vital signs taken hours of and recorded rendering nursing  Remove extra care.

INTERVENTION  Assess for muscle strength RATIONALE  To determine adequate functioning of muscles  To conserve energy EVALUATION After the shift the patient had perform activities within his capacity as evidenced by gradual range of joint motion with moderate assistance. toileting and transferring NURSING DIAGNOSIS Activity intolerance related to muscle weakness on lower extremities SCIENTIFIC EXPLANATION Vertebral collapse alters the sensory and motor function of the body resulting to intolerance of performing activities.  Plan care with rest periods between activities  Plan for progressive increase of activity level/participation in exercise training. as tolerated by the client  Encourage to eat nutritious foods such as rich in proteins and carbohydrates  Continue physical therapy  Both activity tolerance and health status may improve with progressive training  Protein aids in wound healing and cell regeneration. Carbohydrates yields energy for the body  To improve muscle strength and sensory and motor function . PLANNING After the shift the patient will be able to gradually perform activities within his capacity. on wheelchair > dependent with bathing.ASSESSMENT S> Nahihirapan akong tumayo ng mag isa dahil nanghihina ako O> unable to move without assistance > facial grimace when moving up > body malaise > limited ROM >Muscle strength Lower extremities 2/5 (poor) >unable to walk.

Rhea ESPIRITU. Charity Mae COVITA. Jovelyn ANCHETA. Lea ELASIN. Moises DIRILO. Mary Ann FERMO. Marjun Rey DACULAN. Melody ELASIN. Catherine CLINICAL INSTRUCTOR Ms. Jonjie Marie FERNANDEZ. Pangasinan A Case Analysis of Pott¶s Disease SUBMITTED BY: GROUP 6 CORPUZ. John Jeevy DE GUZMAN.PANPACIFIC UNIVERSITY NORTH PHILIPPINES Urdaneta City. Juressa Joy DE GUZMAN. Lorenz DU. RN .

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