St.Augustine School of nursing

“A Case Study of Pott’s Disease”

Section 4B

Group 2Douglas Hadriane B. Danao

Miguel Rafael I. CarlosCharmaine MuÑoz

Table of Contents

I. Acknowledgement

II. Introduction

III. Assessment

I. Personal data

II. Medical History

A.History of present illness

B.Past Medical History

C.Family Medical History

D.Personal and Social history

IV. Physical assessment

V. Anatomy and Physiology

VI. 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 expression 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 time.

To our Professor, Mam Diente,Mam Donnie for patiently supervising and assisting us with your knowledge, as we gradually go through the process of doing the case study itself, our sincerest thanks.

To our patient, for the generous time extended for me to explore this case; and for giving me his full cooperation and kindness 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 least, to our Almighty Father, for his unceasing guidance and blessings, for constantly giving me hope, courage, and patience. Truly, none of this is possible without 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 site of bone infection in TB. The lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected. The original name was formed after Percivall Pott, a London surgeon, who first studied the disease. When he died, Patrick David was the one who continued his work.

Pott’s disease results from haematogenous spread of tuberculosis (mycobacterium tuberculosis) from other sites. The infection then spreads from two adjacent vertebrae into the adjoining disc space. 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 collapses. 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 tissue mass often forms and superinfection is rare.

The disease progresses slowly. Signs and symptoms include: back pain, fever, night sweats, anorexia, weight loss, and easy fatigability.

Diagnosis is based on: blood tests - elevated ESR , skin 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 hunchback. 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, when the spinal nerves become affected by the curvature.

A person who has been diagnosed 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 control. It may also be necessary to immobilize the area of the spine affected by the

disease, or the person may need to undergo surgery in order to drain any abscesses that may have formed or to stabilize the spine.

Since Pott's disease is caused by a bacterial infection, prevention is possible through proper control. The best method for preventing the disease is reduce or eliminate the spread of tuberculosis. In addition, testing for tuberculosis is an important preventative measure, 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 scans, bone biopsies, and radiographs may also be used to confirm the disease

THEORETICAL FRAMEWORK

For the theoretical framework, I used the “21 nursing problems” according to Faye Glenn Abdellah. She defined nursing as broadly grouped into the 21 nursing problem areas to guide care and promote the use of nursing judgement. 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.

The 21 nursing problems are as follows:

1) To maintain good hygiene.2) To promote optimal activity: exercise,

rest, and sleep3) To promote safety4) To maintain good body mechanics.5) To facilitate the maintenance of a supply

of oxygen6) To facilitate maintenance of nutrition7) To facilitate maintenance of elimination8) To facilitate maintenance of fluid and

electrolyte imbalance9) To recognize the physiologic response

of the body to disease conditions10) To facilitate the maintenance of

regulatory mechanisms and functions11) To facilitate the maintenance of

sensory function12) To identify and accept positive and

negative expressions, feelings and reactions

13) To identify and accept the interrelatedness 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 personal 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 the optimum possible goals

20) To use community resources as aid in resolving problems

21) To understand the role of social problems as influencing factor

ASSESSMENT

I. Personal Data:

Name: B.P.Address: Novaliches Quezon CityAge: 28 years oldSex: FemaleCivil status: MarriedReligion: Roman CatholicBirthday: November 19, 1978Birthplace: ManilaAttending Physician: Dr. Adrian Catbagan Admitting Diagnosis: Spinal cord compression on T/3 levelChief complaint: weakness of lower extremities

II. Medical History

A.History of Present Illness:This is a case of B.P., who was 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 lower extremities. No other associated signs and symptoms were noted. Few hours prior to admission, persistence of above symptoms prompted consult.

B. Past Medical History:

( - ) HPN( - ) DM( - ) asthma( - ) allergy

B.Family Medical History:( - ) HPN ( - ) DM ( - ) CA ( - ) asthma

C.Personal and Social History:( - ) smoker

( - ) alcoholic beverage drinker

ANATOMY

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 absorbers 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 generally sufficient for Pott’s disease, with spinal immobilization if required. Surgery is required if there is spinal deformity or neurological signs of spinal cord compression.

Standard antituberculosis treatment is required. Duration of antituberculosis treatment: If debridement and fusion with bone grafting are performed, treatment can be for six months. If debridement and fusion with bone grafting are NOT performed a minimum of 12 months’ treatment is required.

It may also be necessary to immobilize the area of the spine affected by the disease, or the person may need to undergo surgery in order to drain any abscesses that may have formed or to stabilize the spine.

Other interventions include application of knight/ taylor brace, head halter traction. Surgery includes ADSF ( Anterior decompression Spinal fusion).

Drug Study

GENERIC NAME: HRZE (isoniazid+rifampicin+pyrazinamide+ethambutol)Brand name: MyrinDosage: 3 tab 30 min before breakfastDrug Classification:Anti-infective

MECHANISM INDICATIONS CONTRA- INDICATIONS

ADVERSE REACTION

NURSINGResponsibilities

Unknown. Appears to inhibit cell-wall biosynthesis by interfering with lipid and DNA synthesis

> Actively growing tubercle bacilli>prevention of tubercle bacilli in those exposed to tuberculosis or those with positive skin test results whose chest x-rays and bacteriologic studies are consistent with non-progressive tuberculosis

- Contraindicated in patients with acute hepatic disease or isoniazid-related liver damge

> peripheral neuropathy, fluid discoloration, optic neuritis, hepatitis

>Usecautiously in elderly patients >peripheral neuropathy is more common in patients who are slow acetylators or who are malnourished, alcoholic or diabetic, >Monitor hepatic function closely for changes

GENERIC NAME: ketorolac tromethamineBrand name:ToradolDosage: 30 mg Iv q8hDrug Classification: NSAIDS

MECHANISM INDICATIONS CONTRA- INDICATIONS

ADVERSE REACTION

NURSINGResponsibilities

Unknown. Produces anti-inflammatory,analgesic, and antipyretic effects, possibly by inhibiting prostaglandin synthesis

> short-term management of moderately severe, acute pain for single dose treatment> Short-term management of moderately sever, acute pain for multiple dose treatment

- Contraindicated in patients hypersensitive to drug and in those with active peptic 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 ulceration, rash, diaphoresis

> Ketorolac isn’t recommended for children> Use cautiously in patients with hepatic and renal impairment>NSAIDS may mask signs and symptoms of infection because of their antipyretic and anti-inflammatory actions

GENERIC NAME: ciprofloxacinBrand name: CiprobayDosage: 500mg/cap BIDx5 daysDrug Classification: Fluoroquinolones

MECHANISM INDICATIONS CONTRA- INDICATIONS

ADVERSE REACTION

NURSINGResponsibilities

Inhibits bacterial dna synthesis, mainly by blocking DNA gyrase, bactericidal.

> Severe or complicated bone or joint infections>Complicated intraabdominal infections

- Contraindicated to patients sensitive to fluoroquinolones

> headache, retlessness, fatigue, drowsiness, edema, chest pain, nausea, diarrhea, leucopenia, crystalluria

> Use cautiously in patients with CNS disorders, such as severe cerebral arteriosclerosis or seizure disorders, and in those with risk for seizures.> Monitor patients intake and output and observe for signs of crystalluria>Obtain specimen for culture and sensitivity before giving first-dose

PATHOPHYSIOLOGY

Spread of mycobacterium tuberculosis from other site

Extrapulmomary tuberculosis

The infection spreads from two adjacent vertebrae into the adjoining disc space

One vertebra is affected, the disc is normalTwo are involved, the avascular intervertebral disc cannot

receive nutrients and collapse

Disk tissue dies and broken down by caseation

Vertebral narrowing

Vertebral collapse

Spinal damage

Kyphosis, paraplegia, bowel and urinary incontinenece

Surgery: evacuation of pus, Anterior decompression spinal fusion

back pain, fever, night sweats, anorexia, weight loss, and easy fatigability.

POTT’S DISEASE

Pulmonary tuberculosis

GORDON’S PATTERN OF FUNCTIONING

Before hospitalization During hospitalizationHealth-perception/ Health-management pattern

It is her first time to get hospitalized. She usually just bears the pain or uses self-medication.

She hopes that she will get better..

Nutritional/ Metabolic pattern The patient eats all kinds of food. She likes to eat vegetables.

The patient still eats a lot.

Elimination pattern 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 has urinary and bowel incontinence because of spinal cord injury.

Activity/ Exercise pattern The patient’s form of exercise is doing the household chores.

She doesn’t have a form of exercise in the hospital because she is bedridden, as a result of spinal cord injury.

Sleep-rest pattern The patient usually sleeps for about 5 hours.

The patient’ s sleep was still for about 5 hours.

Cognitive/ Perceptual pattern The client likes to talk to her neighbors after doing all the household chores.

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 was talking more than before.

Self-perception/ Self-concept pattern

The patient has a good self –esteem.

The patient somewhat lost her self-esteem because she thinks she is useless.

Role/ Relationship pattern The patient is very friendly and has a good relationship with people around her.

The patient is communicative when you talk to her but she will not be the one to open up conversations.

Coping/ Stress-tolerance pattern

WEhen stressed, she usually diverts it by watching television.

When the patient experiences stress, she just prays to god because there are not other diversional activities 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 Technique used Normal findings Actual findings Analysis/Interpretation

Head

Eyes

Hair

Ears

Nose

Skin

PalpationInspection

Inspection

Inspection

Inspection

Inspection

Inspection

Absence of masses and nodules

Conjunctiva is pink

Usually black and shiny.

Color is the same as facial skin. Pinna tends to bend easily and recoils easily after bending.

Symmetrical with no deformities.

Good or active skin

Head does not appear too large or too small. There were no masses and nodules.

Anicteric scleraPink palpebral conjunctiva

Hair doesn’t look dull.

Color is the same as facial skin. No deformities found. No discharge

Symmetrical. No deformities found.(-) nasal congestion

Good skin turgor

Normal

Normal

Normal

Normal

Normal

Normal

Mouth

Nails

Arms

Chest

Inspection

Inspection

Inspection

Palpation, Inspection and

turgor. Absence of ecchymosis.

Uniform, pink color of the gums, moist and smooth in texture

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 nailbeds.

Should have good muscle contraction. Good flexion and extension. Absence of ecchymosis and deformities.

(-) rashes

Pink-colored gums. Moist buccal mucosa.

Good capillary refill.Light pink in color, convex in shape.

No ecchymosis noted. full and equal pulses.

Slight DOB

Normal

Normal

Normal

Abnormal

Abdomen

Genitalia

Legs and Extremities

Respiratory system

Cardiovascular system

Auscultation

Palpation and Inspection

Inspection

Inspection

Auscultation

Auscultation

Chest is symmetrical, rhythmic and breathing pattern is effortless

Contour is slightly protuberant.

Pinkish in color and intact.

Absence of deformities and 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.

(+) gibbus formation

Flat abdomen. Normoactive bowel sounds.

N/A

Grossly normal.No edema.No cyanosis.

Clear breath sounds. No retractions.

Adynamic precordium,normal rate,regular rhythm,No murmur

Normal

N/A

Normal

Normal

Normal

NURSING CARE PLAN

Cues Nursing Diagnosis Planning Implementation Rationale Evaluation

SUBJECTIVE:“Ayoko ng ganito. Mahirap. Inaasa nalang lahat sa iba.. Wala naman din ako magawa dahil hindi ko naman kaya, “ as verbalized by the patient.

OBJECTIVE:- patient has been bedridden ever since she was hospitalized

Disturbed body image related to trauma/ injury to spinal cord as evidenced by verbal reports of negative feelings about body (feelings of helplessness and powerlessness)

GOAL:

After 1 day of nursing intervention, the patient will recognize and incorporate body image change into self-concept in accurate manner without negating self-esteem.

EXPECTED OUTCOME:The patient will:

1) Verbalize acceptance of self in situation.

2) Verbalize relief of anxiety and adaptation to actual/altered body image.

3) Acknowledge self as an individual who has

Independent:

1) Determine whether condition is permanent/ 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 others see self.

4) Note signs of

>To assess causative/ contributing factors

> To assess causative/ contributing factors

>To asses causative/ contributing factors

>To evaluate

Evaluate response to interventions, teachings and actions performed.

* The patient was able to incorporate body image change into self-concept without negating self-esteem. The goal was met.

responsibility for self.

grieving/indictors of depression

5) Identify previously used coping strategies and its effectiveness.

6) Establish therapeutic nurse-client relationship conveying an attitude of caring and developing a sense of trust.

7) Provide assistance with self care needs/ measures as necessary while promoting individual abilities/independence

Collaborative:8) Refer to

appropriate support groups.

9) Talk to SO(s) about ways to

needs for counseling and medication>To determine coping skills/capabilities

> To assist client/SO(s) to deal with/accept issues of self-concept related to body image.

>To enhance capabilities

>To provide continuity of care

>To promote collaboration .

help client deal with problem

Cues Nursing Diagnosis Planning Implementation Rationale Evaluation

SUBJECTIVE:“ Ang hirap ng ganito, nakahiga na lang lagi, kahit paligo inaasa sa iba,” as verbalized by the patient

OBJECTIVE:> patient has been bedridden ever since she was hospitalized because of spinal cord injury

Self-bathing/ hygiene deficit related to musculo-skeletal impairment as evidenced by inability to wash body or body parts, obtain or get to water source, get in and out of bathroom.

GOAL:

After 1 day of nursing intervention, the patient will perform self-care activities within level of own ability

EXPECTED OUTCOME:The patient will:1) Identify

individual areas of weakness/ needs

2) Demonstrate techniques/ lifestyle changes to meet self-care needs

3) Identify

Independent:

1) Determine existing conditions affecting ability of individual to care for own needs, i.e. spinal cord injury.

2) Determine individual strengths of client

3) Note whether deficient is temporary or permanent, should decrease or increase in time

4) Promote client/ SO participation in problem identification and decision making.

5) Develop plan of care appropriate to individual situation, scheduling

> To identify causative/ contributing factors

> To assess degree of disability >To assess degree of disability

>enhances commitment to plan, optimizing outcomes > to assist in correcting/ dealing with situation

Evaluate responses to interventions, teachings and actions performed.

*The client was able to perform self-care activities within level of own ability. Goal was met

personal resources that can provide assistance

activities to conform to clients normal schedule.

6) Assist with rehab program

7) Allow sufficient time for client to accomplish tasks to fullest extent of ability

8) Assist with necessary adaptation to accomplish ADL’s. Begin with familiar, easily accomplished tasks.

9) Review/modify program periodically to accommodate changes in abilities

Dependent:10)Administer

medication regimen

Collaborative:11)Consult with

dietitian/nutritional

> 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 continuity of care

> To provide continuity of care

support team