CASE

PRESENTATION
CLINICAL PRACTICUM 3
PEDIA WARD – WING 2
January 31, 2019
COMPREHENSIVE
HEALTH HISTORY
 BIOGRAPHICAL DATA

Name: J.N
Address: Luna, Ormoc City
Age: 4
Sex: M
Civil Status: Single
Date of Birth: May 27, 2015
Occupation: Student
Type of Service: Inpatient Therapeutic
Source of Information: Mother
 CHIEF COMPLAINT

“Naghilanat siya og sakit iyang bat-ang”

as stated by patient’s mother.
 PAST HEALTH HISTORY

Childhood and Infectious disease: None

Immunization: Complete vaccine
Allergies: None
Medication taken: Rifampicin, Isoniazid, Ethambutol
Major surgeries and previous hospitalization: None
Injuries: None
 HISTORY OF PRESENT ILLNESS

Patient was admitted at EVRMC on January 7, 2020 at 10 pm.

FAMILY HISTORY

Patient
- MALE

- FEMALE

- TUBERCULOSIS
 PSYCHOSOCIAL HISTORY AND LIFESTYLE

Alcohol use: None

Drug use: None
Tobacco use: None
Travel History: From Ormoc to EVRMC
Home Environment: Lived with his mother, father, and 4 siblings.
Hobbies and Leisure Activities: Tv shows and cellphone
Stress: None
Education: Daycare @ Laura Intales Daycare Center
Ethnic Background: Waray-waray
 PHYSICAL
EXAMINATION
 GENERAL SURVEY

Appearance - appears to be of reported age, alert and oriented,

facial features symmetric

Body Structure - body parts equal bilaterally

Behavior - maintains eye contact with appropriate expressions,

comfortable and cooperative, speech is clear.
 VITAL SIGNS

Temperature: 36.9 °C

Pulse rate: 142 bpm

Respiratory rate: 30 bpm

SKIN: Brown skin color, hair pattern is normal, scars are present as
observed.

HEAD: No scars, lumps, rashes, hair loss or other lesions observed.

Facial features are symmetrical, no involuntary movements and
edema observed.
Palpate- No tenderness or deformity

EARS: No tenderness or deformity, no drainage observed

NOSE: No swelling, redness, drainage or deformity noted

MOUTH & THROAT: No white patches or other lesions noted. No
tonsillar enlargement, redness or discharge.

NECK: Symmetrical, no scars or lesions

EYES: No ptosis, lesions, deformities or asymmetry

CHEST & LUNGS: Chest is symmetrical, no deformity. RR- 30 cpm,

normal rate, rhythm and depth, no prolongation of expiration. No
retractions and use of accessory muscles.
Auscultation- No adventitious breath sounds
CARDIOVASCULAR & PERIPHERAL VASCULAR: PR- 142, no
clubbing of nails.

ABDOMEN: No scars, rashes, lesions

MUSCULOSKELETAL: Cannot do full ROM of lower extremities.

NEUROLOGIC: Not able to sit or stand alone.

GENITO-URINARY: Bladder is not full upon palpation.

 ANATOMY AND
PHYSIOLOGY
OF VERTEBRAL
COLUMN
What is Vertebral Column?
• Vertebral Column or backbone, is the
central axis of the skeleton, extending
from the base of the SKULL to
slightly past the end of the PELVIS.

• Consist of 26 individual bones:

*C1-C7 *S (Sacrum)
*T1-T12. *CO (Coccyx)
*L1-L5
The Functions of Vertebral Column
• Supports the weight of the head and trunk

• Protects the spinal cord

• Allows spinal nerves to exit the spinal cord

• Provides a site of muscle attachment

• Permits movement of the head and trunk

VERTEBRA
Intervertebral Disk
*Separtates the vertebral bodies
*Provides additional support
*Prevents vertebral bodies from rubbing against each other
*The disk becomes more compressed with increasing age, so
that the distance between vertebrae—and therefore the overall
height of the individual—decreases. The annulus fibrosus also
becomes weaker with age and more susceptible to herniation.
PATHOPHYSIOLOGY
Pott’s Disease
MEDICATION: Exposure to
Isoniazid Mycobacterium
Pyrazinamide Tuberculosis

- Intermittent
fever
Primary Pulmonary - Upper back pain
Tuberculosis - Night sweats

Hematogenous
spread of M.
Tuberculosis
 Anterior aspect
of vertebral body
is infected

M. tuberculosis spreads to
adjacent intervertebral disc
between two infected vertebrae

Progressive bone
Intermittent
destruction
back pain
 Infected Caseation takes place
intervertebral disc
collapse
Spinal canal
Gibbus deformity narrowed by
Kyphosis
between T4 to T7 abscess and
granulation
tissue

Spinal cord
compression

Neurological effects Numbness Pott’s

and lower motor and weakness paraplegia
deficits of both lower
extremities
LABORATORY RESULTS
Hematology Result

EXAMINATION RESULT NORMAL RANGE SIGNIFICANCE

Hemoglobin 35 g/L 90 – 140 g/L Low. Maybe this is an
indication of anemia
Hematocrit 0.10 L/L 0.44 – 0.72 L/L Low. An indication of
anemia
RBC 1.22 x 1012/L 4.2 – 5.4 x 1012/L Low. This is an
indication of anemia
WBC 1.87 x 109/L 5 – 19.5 x 109/L Low. This is an
indication of anemia
LABORATORY RESULTS
Hematology Result

EXAMINATION RESULT NORMAL RANGE SIGNIFICANCE

Differential Count
Neutrophils 0.07 0.43 – 0.65 Low. Neutropenia
Lymphocytes 0.81 0.20 – 0.45 High. There is an
antigen antibody
reaction
Monocytes 0.11 0.05 – 0.12 Normal
Eosinophils 0.00 0.01 – 0.03 Low. Not real cause of
concern
Basophils 0.01 0.00 – 0.01 Normal
LABORATORY RESULTS
EXAMINATION RESULT NORMAL RANGE SIGNIFICANCE
MCV 29 fL 81 – 99 fL Low. RBC’s are small.
An indication of
microcytic anemia
MCHC 350 g/L 320 – 360 g/L Normal
Platelet 50 x109/L 150 – 400 x109/L Low. An indication of
anemia
Reticulocyte Count 10 1 – 3% High. An indication of
acute bleeding and
hymolytic anemia.
LABORATORY RESULTS
Serology Result
EXAMINATION RESULT NORMAL RANGE SIGNIFICANCE
CRP (quantitative) 99.8 < 3.0 mg/L Positive
ASO Negative There is no
streptococcal infection
Dengue NS1 Antigen Negative
Dengue IgG Negative Dengue negative
Dengue IgM Negative
LABORATORY RESULTS
Chemistry Result
EXAMINATION RESULT NORMAL RANGE SIGNIFICANCE
Sodium 133.31 mEq/L 135 - 145 mEq/L Low. An indication od
Hyponatremia
Potassium 3.39 mEq/L 3.5 - 5.0 mEq/L Low. An indication of
Hypokalemia
Chloride 104.34 mEq/L 96 – 106 mEq/L Normal
SGOT/AST 26 units/L of serum 5 - 40 units/L of serum Normal
SGPT/ALT 11 units/L of serum 7 - 56 units/L of serum Normal
C- Reactive Protein Positive
PHARMACOLOGY
RIFAMPICIN
Generic Name: RIFAMPICIN or RIFAMPIN 

Brand Name: Rifadin, Rimactane

General Action: Antibiotic, Antituberculotic (first line)

Specific Action: Inhibits DNA-dependent RNA polymerase activity in

susceptible bacterial cells.

Stock Dose: Capsules-150,300mg; powder-600mg

Route of Administration: Oral

INDICATIONS OF RIFAMPICIN
• Treatment of Pulmonary TB in conjunction with at least
one other effective antituberculotic.

CONTRAINDICATIONS OF RIFAMPICIN

• Contraindicated with allergy to any rifamycin, acute

hepatic disease, lactation.
 ADVERSE EFFECTS OF RIFAMPICIN
• CNS: headache, drowsiness, fatigue, dizziness, inability to concentrate, mental confusion,
generalized numbness, muscle weakness, visual disturbances.

• Dermatologic: Rash, pruritus, urticaria, flushing, reddish discoloration of body fluids—tears,

saliva, urine, sweat, sputum.

• GI: heartburn, distress, anorexia, vomiting gas, cramps, diarrhea, hepatitis, pancreatitis.

• GU: hemoglobinuria, hematuria, renal insufficiency, acute renal failure, menstrual disturbances.

• Hematologic: eosinophilia, thrombocytopenia, transient leucopenia, hemolytic anemia,

decreased Hgb, hemolysis.

• Other: pain in extremities, osteomalacia, myopathy, fever, flulike symptoms.

 NURSING RESPONSIBILITIES
OF RIFAMPICIN
• Teach client to take drug in a single daily dose. Take on an
empty stomach, 1 hr before or 2 hrs after meals.

• Inform client to take this drug regularly; avoid missing any

doses; do not discontinue this drug without consulting the
health care provider.

• Tell client to have periodic medical checkups, including eye

examinations and blood test, to evaluate the drug effects.
 NURSING RESPONSIBILITIES
OF RIFAMPICIN
• Inform client that he may experience the drug’s side effects
(especially the red colored secretion)

• Instruct client to see his physician if he experience fever, chills,

muscle and bone pain, excessive tiredness or weakness, loss
of appetite, N/V, yellowing of eyes/skin, unusual bleeding or
bruising, skin rash or itching.

• Instruct client to remove contact lenses as they may discolor

ISONIAZID
Generic Name: ISONIAZID

 Brand Name: INH, Isotamine, Nydrazid

General Action: Antibiotic, Antituberculotic (first line)

Specific Action: Inhibits mycobacterial cell wall synthesis and

interferes with metabolism.

Stock Dose: 300mg/day, 15mg/kg

Route of Administration: Oral

INDICATIONS OF ISONIAZID
• First-line therapy of active tuberculosis, in
combination with other agents. Prevention of
tuberculosis in patients exposed to active
disease.
CONTRAINDICATIONS OF ISONIAZID
• Hypersensitivity
• Acute liver disease
• Previous hepatitis from isoniazid.
ADVERSE EFFECTS OF ISONIAZID
CNS: psychosis, seizure

EENT: visual disturbances

GI: drug-induced hepatitis, nausea, vomiting

NEURO: peripheral neuropathy

MISC: fever
NURSING RESPONSIBILITIES
OF ISONIAZID
• Perform mycobacterial studies and susceptibility
tests prior to and periodically during therapy to
detect possible resistance.

• If isoniazid overdosage occurs, treatment with

pyridoxine is instituted.
NURSING RESPONSIBILITIES
OF ISONIAZID
• Advise patient to take medication once daily, as indicated, and not to skip
doses or double up on missed dose.

• Emphasize the importance of continuing therapy even after symptoms have

subsided.

• Caution patient to avoid alcohol during this therapy, as this may increase
the risk of hepatotoxicity.

• Advise patient to notify physician promptly if s/sx of hepatitis or peripheral

neuritis occur.
ETHAMBUTOL
Generic Name: ETHAMBUTOL

Brand Name: Myambutol

Stock Dose: 15–25 mg/kg/day

doses closer to 15 mg/kg/day should be used if the drug is
used for more than 2 months.

Route of Administration: Oral

ETHAMBUTOL
General Action: Antibiotic, Antituberculotic (first line)
Bactericidal only at the high end of the dosing range. At doses used over
long periods of time, ethambutol protects against further development of
resistance.

Specific Action: Ethambutol is bacteriostatic against actively growing TB

bacilli, it works by obstructing the formation of cell wall. Mycolic acids attach
to the 5′-hydroxyl groups of D-arabinose residues of arabinogalactan and
form mycolyl-arabinogalactan-peptidoglycan complex in the cell wall. It
disrupts arabinogalactan synthesis by inhibiting the enzyme arabinosyl
transferase. Disruption of the arabinogalactan synthesis inhibits the
formation of this complex and leads to increased permeability of the cell
wall.
CONTRAINDICATIONS OF ETHAMBUTOL
• Pre-existing optic neuritis
• Visual changes
ADVERSE EFFECTS OF ETHAMBUTOL
• Retrobulbar neuritis
(dose-related—exacerbated during renal failure)
NURSING RESPONSIBILITIES
OF ETHAMBUTOL
• Patients should be counseled to report any changes in
vision. Baseline and monthly visual acuity and color
discrimination monitoring should be performed
(particular attention should be given to individuals on
higher doses or with renal impairment).
NURSING RESPONSIBILITIES
OF ETHAMBUTOL
• Instruct client that it can be
taken with food or on an
empty stomach
• Instruct client to see his
physician if he experience
any problems with his eyes:
vision changes, blurring,
color blindness, trouble
seeing, or eye pain
Instruct client to see his physician if
he experience:
• Swelling of face
• Rash, hives, or trouble breathing
• Numbness, pain, or tingling in hands
or feet
• Joint pain
• Fever or chills
• Nausea, vomiting, poor appetite, or
abdominal pain
• Headache or dizziness
 Nursing
Care Plan 1
Subjective Cues
• “Sakit akong likod” as verbalized by the patient.

Objective Cues
• T- 36.9 °C
• P- 142 bpm
• R- 30 bpm

• Not able to do full range of movement of lower extremities in

sacrum area.
• Not able to sit or stand alone
NURSING DIAGNOSIS
• Impaired physical mobility related to decrease in muscle mass,
control and strength.

Source:
Nurse’s pocket guide
Edition 14, Diagnosis, Prioritized interventions, and rationales
Author: Marilyn E. Doenges, Mary Frances
RATIONALE TO NURSING DIAGNOSIS
• Pott disease manifests as a combination of osteomyelitis and
arthritis that usually involves more than 1 vertebra. The anterior
aspect of the vertebral body adjacent to the subchondral plate
is usually affected. Tuberculosis may spread from that area to
adjacent intervertebral disk. In children, the disk, because it is
vascularized, can be the primary site resulting in impaired
physical mobility of the patient.
 
 
Source: https://www.medscape.com
GOALS AND OBJECTIVES

• After 4 hours of nursing intervention, the patient

will be able to increase strength and function of
affected and/or compensatory body part.
 NURSING INTERVENTION
Independent:
Encourage participation in self-care;
occupational, or recreational activities.
Dependent:
Support body part or joints using pillows,
rolls, foot, foot supports or shoes, gel pads,
foam etc.
Collaborative:
Collaborate with the nurse for the
administration of medication prior to
activity as needed for pain relief as
prescribe by the doctor.
Collaborate with the nurse to collaborate
also with the physical medicine specialist
RATIONALE TO NURSING INTERVENTION
Enhances self-concept and sense of
independence.
 
To maintain position of function and reduce
risk of pressure ulcers.
 
Permit maximal effort and involvement in
activity.
 
 
To develop individual exercise and mobility
program.
EVALUATION
• After 4 hours of nursing intervention, the
patient has increase strength and function of
affected and/or compensatory body part.
• Can sit alone
 Nursing
Care Plan 2
Subjective Cues
• “Tungod sa iyang sakit nagniwang siyag
maayo, unya di pud siya hilig mukaon”
as verbalized by the patient’s mother
Objective Cues
• T- 36.9C
• P- 142bpm
• R- 30 bpm
• Wt-8.5kg

• So skinny, decrease muscle mass

Nursing Diagnosis

Imbalanced Nutrition: less than body

requirement related to biological factors as
evidenced by Pott’s disease

Source: Nurse’s Pocket Guide Edition 14, Diagnosis, Prioritize

Interventions and Rationales Page 578
Author: Marilyn E. Doenges, Mary Frances Moorhouse, Alice C. Murr
Rationale to Nursing Diagnosis
• The infection spreads from two adjacent vertebrae into the
adjoining disc space. If only one vertebra is affected, the disc is
normal; however, if two are involved the disc between them
collapses, as it is avascular and cannot receives nutrients.
Caseation occurs, with vertebral narrowing and eventually
vertebral collapse and spinal damage as one of the causes of
Pott’s disease.

Source: patient.info/doctor/spinal-tuberculosis
Goals and Objectives
After nursing interventions, the patient will be
able to;
• Demonstrate progressive weight gain towards
the goal
• Free from signs of malnutrition
• Demonstrate behaviors, lifestyle changes to
regain and/or maintain appropriate weight
 Nursing Intervention
Independent:
Encourage patient to participate in feeding
programs
Dependent:
 Determine client’s ability to chew, swallow
and taste food. Evaluate teeth and gums
for poor oral health, and note denture
Collaborative:
Collaborate with the nurse to collaborate
with interdisciplinary team and with
Supplemental Assistance Program or other
appropriate assistance program
Rationale to Nursing Intervention
Encourages patient to eat more as he
socializes through feeding programs
 
 All factors that affect ingestion and/or
digestion of nutrients
To set up nutritional goals when client has
specific dietary needs, malnutrition
profound, or long-term feeding exist
Evaluation
After nursing interventions, the patient was able to;
• Demonstrate progressive weight gain towards the
goal
• Free from signs of malnutrition
• Demonstrate behaviors, lifestyle changes to regain
and/or maintain appropriate weight
• Gain weight from 8.5 kg to 13 kg
• Increase eating habits
 Nursing
Care Plan 3
Subjective Cues
• “Dili na siya kadula kay sakit iyang likod” as verbalized by the
patient’s mother

Objective Cues
• T- 36.9 C
• 142 bpm
• R- 30 bpm
• 
• Not able to sit and stand alone
• Not able to do full range of motion of lower extremities in sacrum
area
NURSING DIAGNOSIS
• Activity Intolerance related to immobility as evidenced
Pott’s disease 
 

Source: Nurse’s Pocket Guide Edition 14, Diagnosis, Prioritize Interventions

and Rationales
Author: Marilyn E. Doenges,Mary Frances Moorhouse,Alice C. Murr Page
578
RATIONALE TO NURSING DIAGNOSIS
• Pott disease manifests as a combination of osteomyelitis and
arthritis that usually involves more than 1 vertebra. The
anterior aspect of the vertebral body adjacent to the
subchondral plate is usually affected. Tuberculosis may spread
from that area to adjacent intervertebral disk. In children, the
disk, because it is vascularized, can be the primary site
resulting in impaired physical mobility of the patient.

 
Source: https://www.medscape.com
GOALS AND OBJECTIVES
After nursing interventions, the patient will be
able to;
• Used identified techniques to enhance activity
tolerance
• Report measurable increase in activity
intolerance
• Participate willingly in necessary activities
 NURSING INTERVENTION
Independent:
Encourage patient to participate in
recreation, social activities, and hobbies
appropriate situation
Dependent:
Instruct client in proper performance of
unfamiliar activities and in alternate
ways of doing familiar activities
Collaborative:
Implement a physical therapy/exercise
program in conjunction with the client
and other team members
RATIONALE TO NURSING INTERVENTION
Enhances self-concept and sense
independence
 
 
To conserve energy and promote safety
 
 
 
A collaborative program with short-term
with achievable goals enhances the
likelihood of success and may motivate
the client to adopt a life style of physical
exercise for the enhancement of health
EVALUATION
After nursing interventions, the patient was
able to:
• Used identified techniques to enhance activity
tolerance
• Report measurable increase in activity
intolerance
• Participate willingly in necessary activities
• Can sit alone
PROGNOSIS
Various studies show that 82–95% cases respond to
medical treatment alone in the form of pain relief,
improving neurological deficit, and correction of spinal
deformity. In a recently published study among patients
with neurologic deficit, significant recovery occurred in
92%, with 74% improving from nonambulatory to
ambulatory status.
PROGNOSIS
A total of 116 patients with spinal tuberculosis were
analyzed. Forty-seven patients (35%) had severe symptoms.
Radical surgery was carried out in 84 (62%) patients. Twenty
patients were treated with short-term chemotherapy, while 96
underwent long-term antituberculous treatment. At the end of
chemotherapy, 94 patients had achieved a favorable status
and 22 an unfavorable one.
It is generally good in patients without neurological deficit
and deformity. It is improved by early diagnosis and rapid
intervention.
END By:
Gatella, Jonathan Jr.
Soriano, Nichole Jeae Shaine
Orosco, Vincent Damianne
Gayo, Cristal
Jaudian, Shaira
Picardal, Cristina
Sunico, Ma. Rubelyn
Bautista, Maris