Potts Disease Case Study OLGC

Anatomy and Physiology

The spinal cord is the largest nerve in the body, and it is comprised of the nerves which act as the communication system for the body. The nerve fibers within the spinal cord carry messages to and from the brain to other parts of the body. The spinal cord is surrounded by protective bone segments, called the vertebral column. The vertebral column is comprised of seven cervical vertebrae, twelve thoracic vertebrae, five lumbar vertebrae and five sacral vertebrae. The vertebral column also provides attachment points for 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.

Introduction Potts disease  Is a spine infection associated with tuberculosis that is characterized by bone destruction, fracture, and collapse of the vertebrae, resulting in kyphotic deformity.  Is the presentation of the extra-pulmonary tuberculosis arthritis of the intervertebral joints  Also called tuberculosis spondylitis, tuberculous spondyloarthropathy, spinal TB, musculoskeletal tuberculosis  The causative agent is Mycobacterium Tubercule  Particularly the lower thoracic and the upper lumbar regions are affected.  Commonly localized in the thoracic 11 and thoracic 12.  The original name was formed after Percivall Potts a London surgeon.  Patient with BCG has 80% immunity.  Pathognomonic Sign: Gibbus Formation  Signs and Symptoms: Back Pain, Fever, Night Sweating, Anorexia, Weight Loss, Spinal mass, sometimes associated with numbness, tingling, or muscle weakness of the legs  Diagnostic Exam: Blood Test: elevated erythrocyte sedimentation rate, Tuberculin test, Bone Scan, Radiographs of the spine, CT of the spine, Bone biopsy, MRI  Predisposing Factors: Direct contaminant especially in children, Malnutrition, Poor Environmental Condition, Trauma

Nursing History 1. Personal Data

Name: Ms. RB Age: 3y/o Sex: Female Address: Sto. Tomas Santiago, Batangas Occupation: N/A Religion: Roman Catholic Date and Time of admission: March 5, 2009 4:30pm Admitting Physician: Dr. HM

2. Chief Complaint

Fever and Back pain

3. History of Present illness

5 months before hospitalization the patient felled from the stairs. The patient’s mother brought her to a “manghihilot”.

2 weeks before hospitalization the patient’s mother have seen a mass at the patient’s back, the patient had fever and accompanied with back pain. The mother decided to go to the doctor for consultation.

1 day before hospitalization the patient’s mother went to the hospital and was referred to Phil. Orthopedic Center. The patient was admitted at children’s ward and scheduled for CBC and x-ray of the thoracolumbar spine.

4. Past Medical History

The patient’s mother always consults “Manghihilot” when her daughter is sick. The mother has lack of interest in going to health center to seek medical consultation when her daughter is sick.

5. Family Medical History

The mother and father of the patient self-medicates when there are sick, the mother said that there family has never been hospitalized. The father works as a construction worker, smoke cigarettes at least 3-4 sticks a day. The mother stays at home to take care of her 5 children.

Pathophysiology Pulmonary Tuberculosis Spread of Mycobacterium Tubercule in the T7-T9 of the spine Extra-pulmonary Tuberculosis The infection spreads from intervertebral disc Pus formation between the intervertebral disc Back Pain, Fever, Night Sweats, Spinal mass

Disc tissue dies and broken down by Vertebral Vertebral Spinal Potts’ Disease Damage Narrowing Collapse caseation

Laboratory / Diagnostic Examinations March 5, 2009 Blood Chemistry

Normal Value

Result

Findings

Component: -Hemoglobin mass

110-150 g/L(female)

125 g /L

Normal

-Leucocyte count

4.5-10 x 10 g/L

16.90 g/L

May indicate infection

-Segmenters

0.50-0.70

0.45

Normal

-Lymphocyctes

0.20-0.40

0.42

May indicate infection

-Monocytes

0.00-0.07

0.08

May indicate infection

-Eosinophils

0.00-0.05

0.05

Normal

-Platelet count

150-400 x 109/L

532 x 109/L

May indicate inflammatory disease

Differential count:

April 16, 2009 Blood Chemistry

Normal Value

Result

Findings

Component: -Hemoglobin mass

110-150 g/L(female)

129 g/L

Normal

-Hematocrit

0.37-0.54

0.40

Normal

-Leucocyte count

4.5-10 x 10 g/L

13.6 x 10 g/L May indicate infection

-Segmenters

0.50-0.70

0.45

Normal

-Lymphocyctes

0.20-0.40

0.50

May indicate infection

-Monocytes

0.00-0.07

0.01

Normal

-Eosinophils

0.00-0.05

0.04

Normal

-Platelet count

150-400 x 109/L

375 x 109/L

Normal

Differential count:

March 5, 2009 Urinalysis

Normal Value

Result

Findings

Electrolytes: Sodium

135-148 mmol/L

139.7 mmol/L

Normal

Potassium

3.5-5.3 mmol/L

3.98 mmol/L

Normal

Chloride

98-107 mmol/L

101.7 mmol/L

Normal

March 10, 2009 Urinalysis

Normal Value

Result

Findings

Color

Straw to Dark yellow

Light yellow

Normal

Transparency

Slightly Hazy

Hazy

Normal

Specific Gravity

1.002-1.006

1.003

Normal

Reaction

Acidic

March 12, 2009 X-ray of the Thoracolumbar spine Impression: Pneumonitis, both lower lung zone with lyphadenopathies Consolidation vs. Extension of paravertebral abscess, right lower lung zone Potts disease, as described, T6-T11

March 24, 2009 CT scan of the Thoracic spine Impression: Findings as consistent with Potts disease T8-T9 with pulmonary extension as described

Drug Study Classification Generic Name: Rifampicin Brand Name:

Anti-infectives

Dosage 200mg/5ml syrup 6ml OD ac PO

Mechanism of Action Rifampicin inhibits DNAdependent polymerase, decreases replication

Indication

Contraindication

Maintenance phase Hypersensitivity, treatment of all jaundice, severe forms of hepatic disease pulmonary and extra-pulmonary tuberculosis(TB)

Adverse Reaction

Nursing Consideration

GI disturbances, pseudomembranous colitis (rare), abnormalities of liver function, fatalities in those with liver disorders, influenza-like symptoms, skin reactions, eosinophilia, transient leucopenia, thrombocytopenia, purpura, shock, drowsiness, headache, ataxia, visual disturbances, menstrual irregularities. Reddish colored urine and tears. IV: Thrombophloebitis; extravasation following local irritation and inflammation.

>Assess lung sounds and character and amount of sputum periodically during therapy >Assess results of periodic laboratory tests and chest x-ray, therapeutic effectiveness and adverse reactions >Monitor patient compliance with treatment regimen

Classification Generic Name: Isoniazid Brand Name:

Anti-infectives

Dosage

Mechanism of Action

200mg/5ml syrup 6ml OD ac PO

Isoniazid inhibits RNA synthesis, decreases tubercule bacilli replication

Indication Pulmonary and extra-pulmonary tuberculosis(TB)

Contraindication

Adverse Reaction

Nursing Consideration

Acute liver disease or history of hepatic damage during INH therapy; hypersensitivity

Peripheral neuritis, optic neuritis; psychotic reactions, convulsions, nausea, vomiting, fatigue, epigastric distress, visual disturbances, fever, rash, pyridoxine deficiency

>Assess laboratory examinations >Monitor liver/renal function >Assess CNS often >Assess hepatic status >Assess for visual disturbance that may indicate optic neuritis

Classification Generic Name: Paracetamol Brand Name:

Analgesics

Dosage

Mechanism of Action

125mg/5ml syrup 5ml Q4 PRN PO

Paracetamol exhibits analgesic action by peripheral blockage of pain impulse generation. It produces antipyresis by inhibiting the hypothalamic heat-regulating centre. Its weak anti-inflammatory activity is related to inhibition of prostaglandin synthesis in the CNS.

Indication Treatment of fever

Contraindication Hypersensitivity

Adverse Reaction Stimulation, drowsiness, nausea, vomiting, abdominal pain, hepatotoxicity, hepatic seizure, renal failure, luekopenia, neutropenia, hemolytic anemia, thrombocytopenia, pancytopenia, rash, urticaria, hypersensitivity, cyanosis, anemia, neutropenia, jaundice, pancytopenia, CNS stimulation, delirium followed by vascular collapse, convulsions, coma, death

Nursing Consideration >Assess patient’s fever >Assess for allergic reactions >Assess hepatotoxicity >Monitor liver and renal functions

Nursing Care Plan Assessment

Diagnosis

Inference

Planning

Intervention

Rationale

Evaluation

Subjective: “Kulang daw siya sa timbang sabi ng doctor” as verbalized by the mother

Imbalanced Nutrition less than body requirements related to ingest adequate nutrients

Pulmonary Tuberculosis

After 8hrs of Nursing Interventions the patient will demonstrate a behaviors to achieve appropriate weight

-Assess weight, age, body build, strength, activity/rest level

-To provide comparative baseline

-Discuss eating habits, including food preferences to the mother

-To appeal to the patients likes

After 8hrs of Nursing Interventions the patient has demonstrated a behaviors to achieve appropriate weight

Objective: -Under weight -Lack of interest in eating nutritious food

Weakens immune system Generalized weakness Loss of appetite

-Administer Vitamins -To enhance patients as ordered intake -Encourage and provide for frequent rest periods

-To conserve energy, especially in metabolic requirements

-Encourage small, frequent meals with food high in protein and carbohydrates

-To maximize nutrient intake without undue fatigue

-Provide oral care before/after meals at bedtime

-To reduce bad taste left from the medications used in respiratory treatment

Imbalanced Nutrition

Assessment Subjective: “Nilagyan siya ng Taylor Brace” as verbalized by the mother Objective: -Limited range of motion -Difficulty in turning -Presence of Taylor Brace

Diagnosis Impaired Physical Mobility related to therapeutic restrictions of movement

Inference

Planning

Pulmonary Tuberculosis

After 4hrs of Nursing Interventions the patient’s mother will verbalize understanding of the situation and treatment regimen and safety measures

Intervention

Rationale

-Encourage to change position every 2 hours

-To prevent complications

-Schedule activities with adequate res periods

-To reduce fatigue

Extra-pulmonary Tuberculosis

-Provide regular skin care

-To promote good hygiene

Infection spreads from the intervertebral disc

-Provide passive exercises

-To maintain muscle integrity

-Encourage adequate intake nutritious foods

-To maximize energy production

-Explain the use of adjunctive devices such as Taylor Brace

-To promote knowledge and enhances safety

Spread of Mycobacterium Tubercule in the spine

Pus formation between the intervertebral disc Disc tissue dies and broken down by caseation Vertebral Collapse Spinal Damage Impaired Physical Mobility

Evaluation After 4hrs of Nursing Interventions the patient’s mother has verbalized understanding the situation and treatment regimen and safety measures