case pres_sci potts
TRANSCRIPT
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General Objective:
This case presentation seeks to enhance the students knowledge with regards to the patients
general health and disease condition, its pathophysiology, possible complications, treatment
plan and medical regimen. It also seeks to assimilate the students skills through application of
several nursing interventions and medical management. Furthermore, this case presentation
intends to improve the students attitude by conveying open-mindedness and utilizing
therapeutic communication all throughout the activity.
Specific Objectives:
Within a week of thorough study of this specific case, the student nurses aim to achieve the
following objectives in this case presentation:
Accurately present a thorough general health assessment of the client which includes physical
assessment and family history taking.
Effectively discuss and elaborate actual signs and symptoms of the specific diagnoses exhibited
by the client.
Thoroughly discuss, explain, and elaborate the nature of disease process.
Effectively provide appropriate and proper nursing diagnoses in line with the clients medical
condition.
To discuss the pathophysiologic mechanism of the disease process of Spinal cord injury
secondary to Potts disease, placing emphasis on how the complications and the disease
etiology relate and sync with each other.
To accurately explain the various laboratory examinations that is required for the detection of
the disease and how significant remarks or findings relate to this disease.
To site various drugs required for the treatment of the disease in giving a client-based analysis
on the said pharmacologic treatment. To evaluate the presenting clinical manifestations based on overall condition with emphasis
placed on the alterations.
Skillfully formulate nursing care plans for the different problems identified.
Appropriately provide nursing interventions according to the standards of nursing practice.
Effectively apply the learned concepts and theories of the disease and the management
Effectively appraise the effectiveness and efficacy of nursing interventions rendered to the
client.
Impart the outcome of the rendered nursing interventions.
Convey the significance of clients response to the rendered nursing interventions.
To be able to give health teachings regarding the prevention and cure of the Spinal cord injury
secondary to Potts disease.
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INTRODUCTION
A. BACKGROUND OF THE STUDYI. Incidence, race, gender, age, ration and proportion
20- 30% of the 172,483 cases in the Philippines has Pott's disease
People who are affected are African American, Hispanic American, Asian American and foreign
born individuals
Most common in males than women
In the Philippines 75% of children are affected
( 2 : 1 ) = Male: Female
II. Rationale for choosing the caseThe group has decided to choose the case of Ms. G with a diagnosis of Acute Spinal Cord
Injury Incomplete SL T4, secondary to pathologic fracture of T11-T12 secondary to Potts disease
because it was the kind of illness that is common among children even in adults in terms of
orthopedic cases and one of the cause why many people became hospitalized and died. It risen
dramatically, and for us its an interesting case.
III.
Significance of the studyThe significance of this study is to enhance the knowledge, to develop skills and the
right attitude of the student nurses in giving care for the patient with spinal cord injury
secondary to Potts disease, its importance and implication. This study will serve as guidelines in
providing nursing care to those who have the same disease.
These are other significance of the study that would support the above statement:
To understand the underlying facts about spinal cord injury secondary to Potts disease
Determine the nursing history: personal data, health history, and physical assessment of the
patient
To illustrate the anatomy, physiology and pathophysiology of the affected organ (vertebral
column)
To discuss and determine manifestation and complication
To develop an effective skill managing a proper care based on the specific signs and symptoms
the patient is experiencing and the results of laboratory examination.
Formulate a drug study on the case
To provide the patient nursing care plan and discharge plan to assure the total wellness
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IV. Scope of limitationThis case study was conducted at Philippine Orthopedic Center, Quezon City Manila in a
12 year old patient with spinal cord injury secondary to Potts disease. The group gathered the data
by conducting interview with the patient and family members. The group also conducted
assessment regarding the patient's health status by observing her especially the vertebral column
and level of functioning of the lower extremities of the patient in order to validate the signs and
symptoms of the disease.
For the duration our study, we started our visit last May 24, 2011 and ended May 27, 2011 for 2
consecutive days. The group wasn't able to acquire more days for observation due to our lack of
time to conduct it.
V. Theoretical FrameworkFor the theoretical framework, we used the 21 nursing problems according to Faye Glenn
Abdellah. She defined nursing as broadly grouped into 21 nursing problem areas to guide care
and promote the use of nursing judgment. She also said that nursing is a service that is based on
the art and science and aims to help people, sick or well, cope with their health needs.
Abdellah's typology was divided into three areas:
(1) The physical, sociological, and emotional needs of the patient;
(2) The types of interpersonal relationships between the nurse and the patient
(3) The common elements of patient care.
Abdellah's Typology of 21 Nursing Problems:
To promote good hygiene and physical comfort
To promote optimal activity, exercise, rest, and sleep
To promote safety through prevention of accidents, injury, or other trauma and
through the prevention of the spread of infection
To maintain good body mechanics and prevent and correct deformities
To facilitate the maintenance of a supply of oxygen to all body cells
To facilitate the maintenance of nutrition of all body cells
To facilitate the maintenance of elimination
To facilitate the maintenance of fluid and electrolyte balance
To recognize the physiologic responses of the body to disease conditions
To facilitate the maintenance of regulatory mechanisms and functions
To facilitate the maintenance of sensory function
To identify and accept positive and negative expressions, feelings, and reactions
To identify and accept the interrelatedness of emotions and organic illness
To facilitate the maintenance of effective verbal and nonverbal communication
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X-ray
CT- scan
MRI
Nursing diagnoses
Acute painDisturbed body image
Self- care deficit
Nursing Intervention
a. Assess pain
b. Assess range of movements in all extremities
c. Promote beds rest
d. Advise and emphasize proper diet
e. Advise increase fluid intake
f. Maintain skin integrity
g. Patients education
Medical management
a. Immobilize the spine
b. Control of the infection
c. Minimize the deformity
d. Build up resistance of the patient through
V-itamins
I-soniazid
P-yrazinamide
E-thambutol
R-ifampicin
S-treptomycin
Surgical Management
Anterior spinal decompression
Spinal fusion
Spinal Cord Injury
Definition
It refers to the injury to the spinal cord that is caused by trauma instead of a disease. Trauma to
the spine can occur at any level button most commonly occurs in the cervical and lower thoracic-upper
lumbar vertebrae.
AKA: Cord Compression, Cord curvature
Classification of SCI
Complete injury no function below the neurological level
Incomplete injury retains some sensation or movement below the level of the injury
Spinal cord injury without radiographic abnormalitydamage inside the column
Spinal cord injury with radiographic abnormalitydamage on both column and cord
Causes:
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a. A motor vehicle accident
b. Acts of violence
c. Falls
d. Sports and recreation injuries
e. Diseases
Risk factors
a. Age
b. Gender
c. Alcohol
d. Drugs
Predisposing factors
a. Trauma
b. Sports activities
Signs and Symptoms
CERVICAL (NECK) INJURIES
When spinal cord injuries occur in the neck area, symptoms can affect the arms, legs, and middle of the
body. The symptoms may occur on one or both sides of the body. Symptoms can include:
Breathing difficulties (from paralysis of the breathing muscles, if the injury is high up in the
neck)
Loss of normal bowel and bladder control (may include constipation, incontinence, bladder
spasms) Numbness
Sensory changes
Spasticity (increased muscle tone)
Pain
Weakness, paralysis
THORACIC (CHEST LEVEL) INJURIES
When spinal injuries occur at chest level, symptoms can affect the legs:
Loss of normal bowel and bladder control (may include constipation, incontinence, bladder
spasms)
Numbness
Sensory changes
Spasticity (increased muscle tone)
Pain
Weakness, paralysis
Injuries to the cervical or high thoracic spinal cord may also result in blood pressure problems, abnormal
sweating, and trouble maintaining normal body temperature.
LUMBAR SACRAL (LOWER BACK) INJURIES
When spinal injuries occur at the lower back level, varying degrees of symptoms can affect one or both
legs, as well as the muscles that control your bowels and bladder:
Loss of normal bowel and bladder control (you may have constipation, leakage, and bladder
spasms)
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Numbness
Pain
Sensory changes
Spasticity (increased muscle tone)
Weakness and paralysis
Complication
Urinary tract problem
Bowel management difficulties
Pressure sores
Deep vein thrombosis
Lung and breathing problems
Autonomic dysreflexia
Spasticity
Pain
Diagnostic test
a. MRI
b. Myelography
c. Somatosensory
d. Spine X-ray
e. Ct-scan
Nursing diagnoses
Risk for injury
Risk for infection
Impaired physical mobility
Nursing intervention
a. Assess airway, breathing, circulation
b. Perform a quick head to toe assessment
c. Immobilize the patient in the position found until help arrive
Acute care
1. Maintain optimum respiratory function
2. Maintain fluid & electrolyte balance and nutrition
3. Maintain immobilization and spine alignment
4. Prevent complications of immobility
5. Maintain urinary elimination
6. Monitor temperature control
7. Prevent infection
8. Perform ROM, exercise to maintain muscle tone
9. Turn the position often to prevent pneumonia, embolism, & skin breakdown
Medical management
a. Pharmacologic therapy
High dose corticosteroids (methylprednisole)
b. Respiratory therapy
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Oxygen administration
Diaphragmatic pacing (electric stimulation of the phrenic nerve
Surgical management
a. Laminectomy excision of the posterior arches and spinous processes of a vertebra
B. CLINICAL SUMMARYI. GENERAL DATA PROFILE
NAME: Patient G
ADDRESS: Blk. 26, Lot 10 Teachers vil. San Jose del Monte, Bulacan
BIRTHDAY: December 10, 1999
BIRTHPLACE: Bataan
SEX: Female
AGE: 12 years old
RELIGION: Roman Catholic
NATIONALITY: Filipino
DATE OF ADMISSION: April 28, 2011
ADMITTING DIAGNOSIS:Potts disease T11-T12 with neurologic
II. CHIEF COMPLAINT:Prior to admission, the patient experience weakness of both lower extremities
III. NURSING HISTORY:
1. History of the Present Illness:
Present condition started 3 months PTA, when accidentally hit her back after tumbling. She
experienced on and off lower back pain described as sharp with pain scale of 9/10, non
radiating, aggravated by supine position and relieved by standing position. This was associated
with on and office fever and chills. There was no numbness or weakness noted. Patient took
Paracetamol500 mg. /tabs every 4 hrs. which provided temporary relief of symptoms. No
consultation done. Patient was able to ambulate independently at this time. Patient had
spontaneous voiding and normal bowel movement.
2. Past Medical History:
a. Childhood Illnesses
-no asthma, no heredofamilial disease
-(+) mumps (2008)
b. Immunizations
-fully immunized (BCG, DPT, OPV, Hepa B, Measles)
c. Allergies
-no known allergies
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D. FAMILY HISTORY
LEGEND:
Male Deceased
Female Deceased
Female ( Alive & Well)
Male ( Alive & Well)
Grandfather
(A&W)
*UTI
Grandmother
(A&W)Grandfather
Grandmother
Uncle A
(A&W)
Uncle B
(A&W)
Father
48y/o
(A&W)
Aunt A
(A&W)
Uncle C
(A&W)
Aunt A
(Unknown)
Mother
46y/o(A&W)
Aunt B
(A&W)
Sister 1
(A&W)
18 /o
Sister 2
(A&W)
16 /o
PATIENT
SCI 2 to
Potts disease
12y/o
Sister 3
(A&W)
10 /o
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E. SOCIAL HISTORY
Psychosocial Theory according to Erik Erikson
STAGE AGE CENTRAL TASK CHARACTERISTICS
School Age 6-12 years old Industry vs. Inferiority >Emerging confidence in
own abilities.
>Taking pleasure in
accomplishments.
PSYCHOSOCIAL THEORY ACCORDING TO ERIK ERIKSON:
According to this theory, school age primary developmental task is one of contributing factor in
competency. When a person makes a contribution during this period, school age children do what is
best for them to accomplish something.
Based on our interview with the client, we found out that the theory of Erikson correlates with
the information weve gathered from the patient. She has her own family and she study hard and go to
school during school hours.
According to Sigmund Freuds Developmental Stage
STAGE AGE CHARACTERISTICS IMPLICATION
Genital 11-13 years old >Energy is directed toward full
sexual maturity and function
and development of skillsneeded to cope with the
environment
>Encourage separation
from parents,
achievement ofindependence and
decision making
According to this theory, the genital stage correlates to her age because she was her own peers with the
same and opposite sex. When it comes to decision making, she ask for his fathers opinion too.
According to Jean Piagets Cognitive Development
STAGE AGE CHARACTERISTICS INTERPRETATION
Concrete Operational 6-12 years old The child begins to
apply logic thinking,
understands spatiality
and reversibility.
The child is increasingly
social and able to apply
rules however thinking
is still concrete.
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According to Sullivans Life Stages
STAGE AGE CHARACTERISTICS INTERPRETATION
Preadolescence 8-12 years old >Move to genuine
intimacy with friend of
the same sex.
>Move away from a
family as a source of
satisfaction in
relationships.
Capacity for
attachment, love and
collaboration emerges
or fails to develop.
F. ENVIRONMENT/LIVING CONDITION
The environment where he lives can be found in Bulacan. The place is clean and suitable for
living. They live in a bungalow with two bedrooms and one toilet outside the house all inaccessible to
wheelchair.
Regarding the hospital environment at Philippine Orthopedic Center where she was confined, it
is a good place to stay on for her safety but the ventilation and lighting interferes with her sleep pattern
and resting period.
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G. PHYSICAL ASSESSMENT
Admission (April 28, 2011)
PARAMETERS ACTUAL FINDINGS INTERPRETATION
General Appearance
Anthropometrics
Skin
HEENT
>Conscious and Coherent
>Not in cardio - respiratory distress
Ht: 37 Wt: 25kg
.
No rashes; with good skin turgor
Pink palpebral conjunctiva, white
sclera, no tonsillopharyngeal
congestion, no nasoaural discharges.
>The patient is wellcooperative.
>The general appearance is
normal.
Normal
The patient is free from
dehydration.
Normal
Chest/Lungs Symmetrical chest expansion, no
retractions, clear breath soundsNormal
Heart Adynamic precordium, normal heart
rate, no murmurs
Normal
Musculo-skeletal (upper and
lower extremities)
Full and equal pulses, no edema, no
cyanosis
Full ROM to both lower extremities,
actively, pain-free
Normal
Back
There is presence of palpable gibbus in
the thoracic area specifically T11 andT12.
Due to hypoplasia or wedging of
one or more lower thoracic orupper thoracic.
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(May 24, 2011)
PARAMETERS NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION
General Appearance
Anthropometrics
Skin
Hair
-Clean in appearance
and well-groomed
-Cooperative
Ht: 37 Wt: 25kg
-With good skin turgor
-Evenly distributed hair
-Thick hair
-Clean in appearance
and well-groomed
-Cooperative
Ht: 37 ; Wt: 23kg
-With fair skin turgor
-Evenly distributed hair
-Thick hair
The patient is well
cooperative.
Loss of appetite- sign of
potts disease.
The patient is slightly
dehydrated.
Normal
Nails -With good capillary refill
of 1-2 seconds
-With pinkish nail beds
-With clean and short
nails
-With good capillary refill
of 1-2 seconds
-With pinkish nail beds
-With clean and short
nails
Normal
Skull and Face -Mouth uniform
consistency; absence of
nodules and masses
-Rounded smooth skull
contour
-Symmetrical facialmovement
-Mouth uniform
consistency; absence of
nodules and masses
-Rounded smooth skull
contour
-Symmetrical facialmovement
Normal
Eyes No eye discharge
With pinkish conjunctiva
(+) blink reflex
No eye discharge
With pinkish conjunctiva
(+) blink reflex Normal
Ears Auricle color same as
acial skin
Auricle are mobile firm
nd not tenderAble to hear on both
ars
No edema and discharge
Auricle color same as
acial skin
Auricle are mobile firm
nd not tenderAble to hear on both
ars
No edema and discharge
Normal
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Mouth
Pinkish lips
With pink gums
No foul odor
With symmetrical
ontour
Pinkish lips
With pink gums
No foul odor
With symmetrical
ontour
Normal
Musculo-skeletal (upper
and lower extremities)
Symmetrical
No atrophy
With full range of
otion
(+) tingling sensation on
both feet and
(+)weakness noted
Lower extremities are
affected due to evident
spinal cord injury and
nerve compression.
Abdomen -No abdominal
distention
-Symmetrical contour
-No abdominal
distention
-Symmetrical contour
Normal
Back Flat
There is presence of
palpable gibbus in the
thoracic area specifically
T11 and T12.
Due to hypoplasia or
wedging of one or more
lower thoracic or upper
thoracic.
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H. Patterns of Functioning
Functional health
pattern
Before hospitalization During hospitalization Interpretation
Health management
pattern
Patients have clean
environment indoors
and some hazardous
materials outside,
which makes it
accident prone.
Patient has a clean
environment.
Patients environment
before hospitalization
is the one that
affected & inflicted
the patients condition
Nutritional/
Metabolic
a. Number of meals a
day.
b. Appetite
c. Glass of water/ day
d. Body built
e. height and weight
Patient usually eats
junk food and drinks
carbonated beveragesoften more than she
drinks water.
Patient prefers eating
junk food than meals
being served in her
house by her mother.
Patient has a low
appetite before
hospitalization.
Patient drinks one
glass of water a day.
Patient is thin
Ectomorph
Patient eats what is
being served, usually
vegetables, meats and
fruits.
Patient eats three
times a day as they are
served.
Patient has normal
appetite.
Patient drinks a glass
of water every meal.
Three glasses a day.
Patient is thin.
Patients diet before
might have an effect
the patientscondition. Have a fair
appetite during
hospitalization.
Her fluid intake is not
sufficient and might
lead to other possible
complications.
Elimination Patient has regular
urination and irregular
bowel movement.Patient defecates once
every 3rdday
Patient urinates twice
day 350 ml and
defecates once a dayHard stool. She has
no difficulty on
passing stool and
urine.
Patient elimination
pattern is not yet
normal because ofdecrease in activity
and effect of the
disease process.
Activity and exercise Patient usually plays
outside and serves as
her daily exercise.
Then eats junk foods
with friends
Patients only exercise
is turning from side to
side and stretching of
limbs. And doing
divisional activities likecoloring.
She doesnt have
enough exercise for
her age to strengthen
her ROM.
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Roles and relationship Patient has good
relationship with all
the family members
and playmates.
Patient has good
relationship with her
family. Her
communication is
lessened due to
unfamiliarity to co-
patients.
Patient has good
relationship to her
mother but has
limited socialization
and communication
with co-patients.
Values and beliefs Patient has good
religious beliefs as a
Roman Catholic and
goes to church
regularly.
Patient has good
religious beliefs and
verbally stated that
she prays at times.
Patient has faith in
God before and during
hospitalization
Self-perception/self-concept
She perceives herselfin a positive way; she
is a good daughter and
a good sister.
She perceives herselfin a positive way; she
is a good daughter and
a good sister.
She still values himselfand views everything
in a positive manner
despite of her
condition.
Self-perception/self-
concept
She perceives herself
in a positive way; she
is a good daughter and
a good sister.
She perceives herself
in a positive way; she
is a good daughter and
a good sister.
She still values himself
and views everything
in a positive manner
despite of her
condition.
I. Course in the Ward4-28-11
Doctor ordered to admit client to ward of choice after consent was secured, to monitor clients I&O
every shift. The ordered medications were isoniazid, rifampicin, and pyrazinamide. Ordered to start to
infuse d5.03 NACl 500 KVO. Placed patient to DAT diet. Admitting diagnosis was SCI inc. secondary to
potts disease T11-T12. The nursing interventions were admitting the client to the children's ward,
turning the client every two hours this was to prevent formations of pressure sore, monitored the I&O
to have baseline data and provided deep breathing, explained the different drug indications and side
effects and coughing exercises to promote lung expansion.
4-30-11/ 5-1-11
Doctor ordered IVF of d5.3 NaCl X KVO. The nursing interventions were to infuse ordered IVF and
regulated it as ordered to inscribe the correct amount of the fluid.
5-2-11Client complained of pain @ lower back, doctor prescribed and ordered Mefenamic 250mg 1tab q8 for
pain. Interventions was to give the medication for pain, at the prescribed time to prevent overdose and
citing the indications to keep the patient informed on the medications that she takes.
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5-3-11/5-4-11
Doctor ordered IVF of d5.3 NaCl x KVO. The nursing interventions were to infuse ordered IVF and
regulated it as ordered to inscribe the correct amount of the fluid.
5-05-11
Doctors order was the patient to be placed with a urinary catheter due to pain in urination and bladder
distention, discontinue IV and medications for further laboratory test, refer to ROM exercises and the
client was to be for SGOT, UA and SGPT. Nursing interventions were to withhold the medications to
observe the proper adherence to medication regimen. Requests were forwarded to the lab and the
purpose of the procedure was explained to keep the client informed. Explained the purpose of
catheterization to the client before doing the procedure. Lastly, patient was instructed to proper ROM
exercises to increase overall physical strength.
5-6-11Doctors order were to follow-up UA result, Flush IFC with NSS OD because of possible infection, give
Mefenamic acid 250mg/1tab q6 for pain due to pain in the catheter insertion site and bladder
distention, instruct patient to Active range of motion exercises to both hips, knee uncle and foot.
Nursing interventions done were flushing of IFC with NSS to prevent clogging of the tube, administered
Mefenamic if client complained of pain to prevent overdose of medication.
5-7-11
Doctors order was to discontinue IFC because of pain in catheterization site, measure I&O every shift
and to watch out for bladder distention. The nursing intervention done was removing of catheter using
the clean method to reduce the risk of infection, measured the I&O to report any changes to the
patient.
5-12-11
Doctor ordered for complete blood count, erythrocyte sedimentation rate and C-Reactive protein. The
nursing interventions are to provide a request to be forwarded to laboratory. Explain to the patient the
importance of the CBC, ESR, and CRP.
5-16-11 Doctor ordered to revised PT orders:
Re-evaluation
General body condition exercises
AROMES to left hip knee & ankle joints with GPS towards ending
MRES to right hip, knee, ankle joints with GPS
Maintenance exercise to both upper extremities
GPS to both Hamstring & Heel cords
5-22-11 Doctor ordered:
Referred service consultant
to secure consent for mobilization once with brace
Will follow up KT brace to PASAF officer
Refer accordingly
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J. LABORATORY/ DIAGNOSTIC EXAM:
April 15, 2011:
COMPLETE BLOOD COUNT
Nursing interventions:
The patient is instructed to increase fluid intake to prevent depletion in hematocrit level
Maintain proper personal hygiene
Importance of hand washing
Advised to eat food high in Vitamins. C to enhance immune system
Advised to have adequate rest and sleep
Strictly adhere to treatment regimen
April 28, 2011
URINALYSIS
Physical Characteristics
COLOR: light yellow
pH Level: 6
Color: Amber Yellow
pH Level: 4.5-8
Pale color indicates diluted urine
Normal
Test Result Unit INTERPRETATION
Sodium (ISE)
Potassium (ISE)
Chloride (ISE)
141 meq/L
4.35 meq/L
103 meq/L
135-148 meq/L
3.70-5 meq/L
98-107 meq/L
Normal
Normal
Normal
Test Result Normal Range Interpretation
Hemoglobin 110 g/L 110-158 g/L Normal
Hematocrit 0.35 g/L 0.36-0.46 g/L Decreased levels are
due to acute blood loss
and dehydration.
Leukocyte count 7.7 5-10 cell/mm3 Normal
Differential Count:
Segmenters
Lymphocytes
Monocytes
Eosinophils
0.58
0.41
0.01
.45-.70%
.18-.45%
.04-.08% Indicate susceptibility of
the client to acquire any
form of infection
Platelet Count 684 150-400x10^q/L Indicates fracture due
to trauma
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SPECIFIC GRAVITY: 1.010 1.005-1.030 Normal
Microscopic Findings:
CELLS:
RBC: 0-1/hpf
Pus Cells: 1-3/hpf
1-2hpf
N/A
Normal
Indicates presence of infection
CRYSTAL:
Amorphous Urates: ++ None
*Presence and accumulation of
crystals in urine indicates
formation of renal stones
CHEMICAL TEST:
Sugar: negative
Protein: negative
Negative
Negative
Normal
Normal
Nursing interventions:
Instructed the patient to increase fluid intake and eat fruits and vegetables high in fluid content
such as watermelons, oranges, green leafy vegetables such as lettuce.
May 02, 2011
COMPLETE BLOOD COUNT
TEST RESULT NORMAL
RANGE
INTERPRETATION
Hemoglobin 104 110-158 g/L Normal
Hematocrit 0.33 0.36-0.46 g/L Normal
Leukocyte Count 15.60 5-10 cell/mm3 Indicates presence of infection
SegmentersLymphocytes
Monocytes
Eosinophils
0.570.31
0.08
0.04
.45-.70%
.18-.45%
.04-.08%
0-.04%
NormalNormal
Normal
Normal
Platelet Count 176 150-400x10^q/L Normal
BLOOD TYPE O+
RH TYPING Positive (+)
CRP: Reactive
SEMI-QUANTITIVE
12 mg/L
Child: Not
usually present
Indicates infection and the
client is high risk for coronary
artery disease and can indicate
inflammation in the arterial
system and coronary arteries.
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Nursing Interventions:
The patient is instructed to increase fluid intake
Maintain proper personal hygiene
Importance of hand washing
Advised to eat food high in Vitamins. C to enhance immune system
Advised to have adequate rest and sleep
Strictly adhere to treatment regimen
TEST RESULT REFERENCE RANGE INTERPRETATION
UREA 29.15 10.22-49.88 Normal
CREATININE 0.71 mg/dl 0.50-1.30 Normal
SGOT 31
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ESR WESTERNGREN METHOD
Children
Result Normal range Interpretation
61 0-10 mm/hr Increased due to
chronic inflammatory
process, infections and
nerve damage due to
physiologic stress and
trauma.
Nursing Interventions:
Monitor daily weight and intake and output.
Monitor dietary habits and serum albumin levels.
Increase fluid intake
Use strict aseptic technique for all invasive procedures.
Provide adequate rest and sleep
Administer prescribed medications
RADIOLOGICS
Chest X-ray:
No infiltrates, intact diaphragm, no rib fracture, diaphragmatic sulci intact
Thoracic spine X-ray:
(+) lytic destruction of T11- T12 vertebral bodies, the rest of the spine shows intact vertebral
body height with intact IV disc spaces.
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II. CLINICAL DISCUSSION OF THE DISEASEa. ANATOMY AND PHYSIOLOGY
Vertebral Column
-Forms the longitudinal axis of the skeleton. It is composed of a series of bones called vertebrae and isapproximately 28 inches long in the adult.
- Humans are born with 33 separate vertebrae. By adulthood, we typically have 24 due to the fusion of
the vertebrae in the sacrum.
The top 7 vertebrae that form the neck are called the cervical spine and are labeled C1-C7.
The upper back, or thoracic spine, has 12 vertebrae, labeled T1-T12.
The lower back, or lumbar spine, has 5 vertebrae, labeled L1-L5. The lumbar spine bears the
most weight relative to other regions of the spine.
The sacrum (S1) and coccyx (tailbone) are made up of 9 vertebrae that are fused together to
form a solid, bony unit.
Elements of the Spine
A. Vertebrae
The vertebrae support the majority of the weight imposed on the spine.
B. Intervertebral Disc
Between the spinal vertebrae is discs, which function as shock absorbers and joints. They are designed
to absorb the stresses carried by the spine while allowing the vertebral bodies to move with respect to
each other. Each disc consists of a strong outer ring of fibers called the annulus fibrosis, and a soft
center called the nucleus pulposus. The outer layer (annulus) helps keep the disc's inner core (nucleus)
intact.
C. Facet Joint
The facet joints connect the bony arches of each of the vertebral bodies. Facet joints connect each
vertebra with those directly above and below it, and are designed to allow the vertebral bodies to rotate
with respect to each other.
D. Neural ForamenThe neural foramen is the opening through which the nerve roots exit the spine and travel to the rest of
the body. The foramen creates a protective passageway for the nerves that carry signals between the
spinal cord and the rest of the body.
E. Spinal Cord and Nerves
Functions of the Spinal column
Movement
Flexibility and mobility
Protection of Major Organs
Spinal cord protection
Shock absorption
Bones for attachment (Ligaments, tendons,
muscles)
Produces red blood cells
Mineral storage
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b. PATHOPHYSIOLOGYBOOK BASE
Non-modifiable
Endemic TB Poor socio-economic
condition
Immunocompromised
Poor nutritional status
Modifiable
Home environment Family history
Nutritional status
History of trauma
Exposure to specific microorganism via droplet
Ingestion of bacteria via nasal cavity
Proliferated to the meniges through the bloodstream reaching the subarachnoid space.
Descending proliferation of infection occurs
Mycobacterium tubercle spread from the anterior aspect of vertebral body
adjacent to the subchondral plate
Infection spread to the adjacent
intervertebral disk
Progressive bone destruction
Narrowing of spinal canal Abscess formation
GIBBUS
Collapse in the anterior spine
Spinal cord compression and neurologic deficits
Signs and Symptoms:
Back Pain
Night Sweats
Weight loss
Loss of appetite
Fatigue and general malaise
Pain and stiffness of the spine
Possible Complications if left untreated:
Absces
Spine deformity/
injury
Paraplegia
Kyphosis
(Potts curvature)
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PATIENT BASE
Non- Modifiable
socio-economic condition
Poor nutritional status
Modifiable
History of trauma
Exposure to specific microorganism via droplet
Ingestion of bacteria via nasal cavity
Proliferated to the meniges through the bloodstream reaching the subarachnoid space.
Descending proliferation of infection occurs
Mycobacterium tubercle spread from the anterior aspect of vertebral body
adjacent to the subchondral plate
Infection spread to the adjacent
intervertebral disk
Progressive bone destruction
Narrowing of spinal canal Abscess formation
(+)GIBBUSformation T11-T12
Collapse in the anterior spine
Spinal cord compression and neurologic deficits
Signs and Symptoms:
Back Pain
Weight loss Fatigue and general malaise
Pain and stiffness of the spine
ComplicationsSpine deformity/
injury
Paraplegia
Kyphosis
(Potts curvature)
Thoracic supine x-ray
revealed (+) lytic
destruction of T11-
T12 vertebral bodies.
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III. Nursing Process
Problem Ranking Rationale
Impaired physical mobility
related to decreased muscle
strength as manifested by
limited ROM and limited ability
to perform gross fine motor skills
1 The patients primary complaint
body malaise and muscle
weakness. We ranked this as first
priority because decreased
mobility can cause different
kinds of complication (bed sores,
decreased ROM)
Self-care deficit related to
musculoskeletal impairment
2 The patient has impaired
physical mobility, as a result she
has self-care deficit. We ranked
this as second priority because
this problem is a result of the
primary problem
Risk for impaired skin integrity
related to physicalimmobilization
3 We ranked this as third priority
because as mentioned, it is onlya risk it is possible threat to the
clients condition. Only
prevention is the needed
intervention
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DISCHARGE PLAN
M-edication:
Encourage significant others to continue medications as prescribed by the physician. With a
strict emphasis on explaining the mechanisms of action of the drugs, the prescribed dosage, side
effects, proper timing of intake of drugs and importance of continuing the medications.
E-nvironment/ E-xrecise
Clients environment must be clean to prevent emergence of other diseases, environmental
factors that includes excessive stress such as emotional stress to the patient must be avoided.
Encourage significant others to have a gradual passive ROM to the patient because it will
promote blood circulation and to improve muscle strength in order to promote total range of
motion.
T-reatment:
Instruct the significant others to consult first the physician in anything that will help the patient
in his conditions like physical activities that she must follow and most especially her diet.
Encourage the significant others to compliance on further treatment for the proper
maintenance and gain of optimal health.
Health teachings:
Importance to maintain proper personal hygiene
Strict adherence to medications to promote wellness.
Increase fluid intake to prevent infection and dehydration importance of proper nutritious food
to maintain healthy body.
Immediate report to the physician for any abnormalities to note any complications.
O-ut-patient
Compliance to medical check-up and therapeutic regimen to reduce or prevent risk of
recurrence of the disease condition. Instruct patient to continue medications as prescribed.
Follow up check-up: a week after discharge.
D-iet
Suggest the significant others to let the patient eat healthy food because it helps the patient feel
better and have more energy. Tell the significant others the importance of following diet and
food restrictions. The patient may also consult to a dietary physician to know what are the
correct dietary intake she must maintain. Increase in high fiber foods such as fruits and green
leafy vegetables to prevent constipation, increase in Vitamin C food to boost immune system
and increase in fluid intake to prevent dehydration.
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Case Presentation
Presented to:
Mrs. Jennifer PalacpacPresented by:
Group 1
Alina, Armi
Alcantara, Keith Austin
Baria, Wilmalyn
Caagbay, Kristine Mae
Enriquez, Shielah Anne Marie
Jabrica, Belenia
Plata, Jerome
Racelis, Kristel Joyce
Rosillas, Bien Jannus
DATE PRESENTED: June 1, 2011
Acute Spinal Cord Injury
Incomplete secondary to
Potts Disease