CASESTUDY Potts Disease

St.Augustine School of nursing

“A Case Study of Pott’s Disease”

Section 4B

Group 2 Douglas Hadriane B. Danao Miguel Rafael I. Carlos Charmaine 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 sleep 3) To promote safety 4) To maintain good body mechanics. 5) To facilitate the maintenance of a supply of oxygen 6) To facilitate maintenance of nutrition 7) To facilitate maintenance of elimination 8) To facilitate maintenance of fluid and electrolyte imbalance 9) To recognize the physiologic response of the body to disease conditions 10) To facilitate the maintenance of regulatory mechanisms and functions 11) To facilitate the maintenance of sensory function 12) 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 City Age: 28 years old Sex: Female Civil status: Married Religion: Roman Catholic Birthday: November 19, 1978 Birthplace: Manila Attending Physician: Dr. Adrian Catbagan Admitting Diagnosis: Spinal cord compression on T/3 level

Chief complaint: weakness of lower extremities II. Medical History A. History of Present Illness: This is a case of B.P., who 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: Myrin Dosage: 3 tab 30 min before breakfast Drug Classification:Anti-infective MECHANISM

INDICATIONS

CONTRAINDICATIONS

ADVERSE REACTION

NURSING Responsibilities

Unknown. Appears to inhibit cellwall 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 nonprogressive tuberculosis

Contraindicate d in patients with acute hepatic disease or isoniazidrelated liver damge

> peripheral neuropathy, fluid discoloration, optic neuritis, hepatitis

>Use cautiously 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 tromethamine Brand name:Toradol Dosage: 30 mg Iv q8h Drug Classification: NSAIDS MECHANISM

INDICATIONS

CONTRAINDICATIONS

ADVERSE REACTION

NURSING Responsibilities

Unknown. Produces antiinflammatory, analgesic, and antipyretic effects, possibly by inhibiting prostaglandi n 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

Contraindicate d 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

GENERIC NAME: ciprofloxacin Brand name: Ciprobay Dosage: 500mg/cap BIDx5 days Drug Classification: Fluoroquinolones

> 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 antiinflammatory actions

MECHANISM

INDICATIONS

CONTRAINDICATIONS

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 fluoroquinolone s

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

PATHOPHYSIOLOGY Pulmonary tuberculosis

NURSING Responsibilities > 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

Spread of mycobacterium tuberculosis from other site Extrapulmomary tuberculosis The infection spreads from two adjacent vertebrae into the adjoining disc space

back pain, fever, night sweats, anorexia, weight loss, and easy fatigability. One vertebra is affected, the disc is normal Two 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 POTT’S DISEASE Kyphosis, paraplegia, bowel and urinary incontinenece Surgery: evacuation of pus, Anterior decompression spinal fusion

GORDON’S PATTERN OF FUNCTIONING

Health-perception/ Healthmanagement pattern Nutritional/ Metabolic pattern Elimination pattern

Activity/ Exercise pattern

Sleep-rest pattern Cognitive/ Perceptual pattern

Self-perception/ Self-concept pattern

Before hospitalization It is her first time to get hospitalized. She usually just bears the pain or uses selfmedication. The patient eats all kinds of food. She likes to eat vegetables. The patient defecates regularly at least once a day or sometimes once every two days and urinates frequently. The patient sweats a lot because of the weather. The patient’s form of exercise is doing the household chores.

The patient usually sleeps for about 5 hours. The client likes to talk to her neighbors after doing all the household chores.

The patient has a good self –esteem.

During hospitalization She hopes that she will get better..

The patient still eats a lot. The patient has urinary and bowel incontinence because of spinal cord injury.

She doesn’t have a form of exercise in the hospital because she is bedridden, as a result of spinal cord injury. The patient’ s sleep was still for about 5 hours. 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. The patient somewhat lost her self-esteem

Role/ Relationship pattern

The patient is very friendly and has a good relationship with people around her.

Coping/ Stresstolerance pattern

WEhen stressed, she usually diverts it by watching television.

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

Technique used Palpation Inspection

Normal findings Absence of masses and nodules

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

Analysis/Interpretation Normal

Eyes

Inspection

Conjunctiva is pink

Anicteric sclera Pink palpebral conjunctiva

Normal

Hair

Inspection

Usually black and shiny.

Ears

Normal Hair doesn’t look dull.

Inspection

Normal Color is the same as Color is the same as facial skin. Pinna facial skin. No deformities tends to bend easily found. No discharge and recoils easily after bending.

Nose

Skin

Inspection

Normal Symmetrical with no deformities.

Symmetrical. No deformities found. (-) nasal congestion

Good or active skin turgor. Absence of

Good skin turgor (-) rashes

Inspection

Normal

ecchymosis. Mouth

Inspection

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

Nails

Inspection

Normal 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.

Arms

Chest

Pink-colored gums. Moist buccal mucosa.

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

Inspection

Palpation, Inspection and Auscultation

Normal Should have good muscle contraction. Good flexion and extension. Absence of ecchymosis and deformities. Chest is symmetrical,

No ecchymosis noted. full and equal pulses.

Abnormal Slight DOB (+) gibbus formation

Abdomen

Palpation and Inspection

rhythmic and breathing pattern is effortless Contour is slightly protuberant.

Genitalia

Inspection

Legs and Extremities

Inspection

Normal Flat abdomen. Normoactive bowel sounds. N/A N/A

Respiratory system

Auscultation

Pinkish in color and intact. Absence of deformities and good ROM. Absence of edema and ecchymosis.

Normal Grossly normal. No edema. No cyanosis. Normal Clear breath sounds. No retractions.

Cardiovascular Auscultation system

No unusual sounds should be heard; RR should range from normal and effortless respiration. Regular rhythm, no heart murmurs.

Normal Adynamic precordium,normal rate,regular rhythm,No murmur

NURSING CARE PLAN Cues

Nursing Diagnosis

Planning

Implementation

Rationale

Evaluation

Independent: SUBJECTIVE: Disturbed body “Ayoko ng image related to ganito. trauma/ injury to Mahirap. spinal cord as Inaasa nalang evidenced by lahat sa iba.. verbal reports of Wala naman negative feelings din ako about body magawa dahil (feelings of hindi ko naman helplessness and kaya, “ as powerlessness) verbalized by the patient. OBJECTIVE: - patient has been bedridden ever since she was hospitalized

GOAL: After 1 day of nursing intervention, the patient will recognize and incorporate body image change into selfconcept 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 responsibility for self.

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 grieving/indictor s of depression

>To assess causative/ contributing factors > To assess causative/ contributing factors

>To asses causative/ contributing factors

>To evaluate needs for counseling and

Evaluate response to interventions, teachings and actions performed. * The patient was able to incorporate body image change into self-concept without negating selfesteem. The goal was met.

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/indepen dence

medication >To determine coping skills/capabilities

Collaborative: 8) Refer to appropriate support groups. 9) Talk to SO(s) about ways to help client deal with problem

>To provide continuity of care

> To assist client/SO(s) to deal with/accept issues of selfconcept related to body image. >To enhance capabilities

>To promote collaboration .

Cues

Nursing Diagnosis

SUBJECTIVE: Self-bathing/ “ Ang hirap ng hygiene deficit ganito, nakahiga related to musculona lang lagi, kahit skeletal impairment paligo inaasa sa as evidenced by iba,” as verbalized inability to wash by the patient body or body parts, obtain or get to OBJECTIVE: water source, get in > patient has been and out of bedridden ever bathroom. since she was hospitalized because of spinal cord injury

Planning

Implementation Independent:

Rationale

GOAL: 1) Determine existing After 1 day of conditions nursing affecting ability of intervention, the individual to care patient will for own needs, i.e. perform self-care spinal cord injury. activities within 2) Determine level of own individual ability strengths of client 3) Note whether EXPECTED deficient is OUTCOME: temporary or The patient will: permanent, should 1) Identify decrease or individual increase in time areas of 4) Promote client/ SO weakness/ participation in needs problem 2) Demonstrate identification and techniques/ decision making. lifestyle 5) Develop plan of changes to care appropriate to meet selfindividual care needs situation, 3) Identify scheduling personal activities to resources conform to clients

> To identify causative/ contributing factors

Evaluation Evaluate responses to interventions, teachings and actions performed.

*The client was > To assess able to perform degree of self-care disability activities within >To assess degreelevel of own of disability ability. Goal was met

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

that can provide assistance

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 support team

> To enhance capabiities > To enhance capabilities

>To encourage client and build on successes.

>Assist patient to adhere to plan of care to fullest extent >To provide continuity of care > To provide continuity of care