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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, and
                             Disc tissue dies Night
                             Sweats, Spinal mass
                               broken down by
                              Vertebral Disease
                               VertebralNarrowing
                                Potts’ Damage
                                Spinal 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
Differential count:
-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




                                                                                 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


Differential count:
-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




                                                                                 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       Dosage      Mechanism of       Indication      Contraindication    Adverse Reaction           Nursing
                                                     Action                                                                        Consideration

Generic Name:   Anti-infectives    200mg/5ml      Rifampicin      Maintenance phase Hypersensitivity,    GI disturbances,        >Assess lung
Rifampicin                         syrup          inhibits DNA-   treatment of all  jaundice, severe     pseudomembranous        sounds and
                                   6ml OD ac PO   dependent       forms of          hepatic disease      colitis (rare),         character and
Brand Name:                                       polymerase,     pulmonary and                          abnormalities of        amount of sputum
                                                  decreases       extra-pulmonary                        liver function,         periodically
                                                  replication     tuberculosis(TB)                       fatalities in those     during therapy
                                                                                                         with liver disorders,   >Assess results of
                                                                                                         influenza-like          periodic
                                                                                                         symptoms, skin          laboratory tests
                                                                                                         reactions,              and chest x-ray,
                                                                                                         eosinophilia,           therapeutic
                                                                                                         transient               effectiveness and
                                                                                                         leucopenia,             adverse reactions
                                                                                                         thrombocytopenia,       >Monitor patient
                                                                                                         purpura, shock,         compliance with
                                                                                                         drowsiness,             treatment regimen
                                                                                                         headache, ataxia,
                                                                                                         visual disturbances,
                                                                                                         menstrual
                                                                                                         irregularities.
                                                                                                         Reddish colored
                                                                                                         urine and tears. IV:
                                                                                                         Thrombophloebitis;
                                                                                                         extravasation
                                                                                                         following local
                                                                                                         irritation and
                                                                                                         inflammation.
Classification       Dosage         Mechanism of            Indication      Contraindication     Adverse Reaction          Nursing
                                                        Action                                                                             Consideration

Generic Name:   Anti-infectives    200mg/5ml syrup   Isoniazid inhibits   Pulmonary and      Acute liver disease   Peripheral            >Assess
Isoniazid                          6ml OD ac PO      RNA synthesis,       extra-pulmonary    or history of         neuritis, optic       laboratory
                                                     decreases            tuberculosis(TB)   hepatic damage        neuritis; psychotic   examinations
Brand Name:                                          tubercule bacilli                       during INH            reactions,            >Monitor
                                                     replication                             therapy;              convulsions,          liver/renal
                                                                                             hypersensitivity      nausea, vomiting,     function
                                                                                                                   fatigue, epigastric   >Assess CNS
                                                                                                                   distress, visual      often
                                                                                                                   disturbances,         >Assess hepatic
                                                                                                                   fever, rash,          status
                                                                                                                   pyridoxine            >Assess for visual
                                                                                                                   deficiency            disturbance that
                                                                                                                                         may indicate optic
                                                                                                                                         neuritis
Classification       Dosage          Mechanism of           Indication    Contraindication    Adverse Reaction         Nursing
                                                         Action                                                                        Consideration

Generic Name:   Analgesics         125mg/5ml syrup   Paracetamol           Treatment of    Hypersensitivity    Stimulation,          >Assess patient’s
Paracetamol                        5ml Q4 PRN PO     exhibits analgesic    fever                               drowsiness, nausea,   fever
                                                     action by                                                 vomiting,             >Assess for
Brand Name:                                          peripheral                                                abdominal pain,       allergic reactions
                                                     blockage of pain                                          hepatotoxicity,       >Assess
                                                     impulse                                                   hepatic seizure,      hepatotoxicity
                                                     generation. It                                            renal failure,        >Monitor liver
                                                     produces                                                  luekopenia,           and renal
                                                     antipyresis by                                            neutropenia,          functions
                                                     inhibiting the                                            hemolytic anemia,
                                                     hypothalamic                                              thrombocytopenia,
                                                     heat-regulating                                           pancytopenia, rash,
                                                     centre. Its weak                                          urticaria,
                                                     anti-inflammatory                                         hypersensitivity,
                                                     activity is related                                       cyanosis, anemia,
                                                     to inhibition of                                          neutropenia,
                                                     prostaglandin                                             jaundice,
                                                     synthesis in the                                          pancytopenia, CNS
                                                     CNS.                                                      stimulation,
                                                                                                               delirium followed
                                                                                                               by vascular
                                                                                                               collapse,
                                                                                                               convulsions, coma,
                                                                                                               death
Nursing Care Plan
    Assessment               Diagnosis              Inference              Planning               Intervention             Rationale              Evaluation

Subjective:             Imbalanced Nutrition       Pulmonary          After 8hrs of Nursing   -Assess weight, age,    -To provide             After 8hrs of Nursing
 “Kulang daw siya sa    less than body            Tuberculosis        Interventions the       body build, strength,   comparative baseline    Interventions the
timbang sabi ng         requirements related                          patient will            activity/rest level                             patient has
doctor” as verbalized   to ingest adequate                            demonstrate a                                                           demonstrated a
by the mother           nutrients               Weakens immune        behaviors to achieve    -Discuss eating         -To appeal to the       behaviors to achieve
                                                    system            appropriate weight      habits, including       patients likes          appropriate weight
Objective:                                                                                    food preferences to
-Under weight                                                                                 the mother
-Lack of interest in                               Generalized
eating nutritious                                   weakness                                  -Administer             -To enhance patients
food                                                                                          Vitamins as ordered     intake

                                                 Loss of appetite                             -Encourage and          -To conserve energy,
                                                                                              provide for frequent    especially in
                                                                                              rest periods            metabolic
                                                                                                                      requirements
                                               Imbalanced Nutrition
                                                                                              -Encourage small,       -To maximize
                                                                                              frequent meals with     nutrient intake
                                                                                              food high in protein    without undue
                                                                                              and carbohydrates       fatigue

                                                                                              -Provide oral care      -To reduce bad taste
                                                                                              before/after meals at   left from the
                                                                                              bedtime                 medications used in
                                                                                                                      respiratory treatment
Assessment                Diagnosis            Inference               Planning               Intervention             Rationale            Evaluation

Subjective:              Impaired Physical         Pulmonary          After 4hrs of Nursing   -Encourage to           -To prevent           After 4hrs of Nursing
“Nilagyan siya ng        Mobility related to      Tuberculosis        Interventions the       change position         complications         Interventions the
Taylor Brace” as         therapeutic                                  patient’s mother will   every 2 hours                                 patient’s mother has
verbalized by the        restrictions of          Spread of           verbalize                                                             verbalized
mother                   movement               Mycobacterium         understanding of the    -Schedule activities    -To reduce fatigue    understanding the
                                                Tubercule in the      situation and           with adequate res                             situation and
Objective:                                           spine            treatment regimen       periods                                       treatment regimen
-Limited range of                                                     and safety measures                                                   and safety measures
motion                                          Extra-pulmonary                               -Provide regular skin   -To promote good
-Difficulty in turning                           Tuberculosis                                 care                    hygiene
-Presence of Taylor
Brace                                           Infection spreads                             -Provide passive        -To maintain muscle
                                                    from the                                  exercises               integrity
                                               intervertebral disc
                                                                                              -Encourage adequate     -To maximize energy
                                                 Pus formation                                intake nutritious       production
                                                  between the                                 foods
                                               intervertebral disc
                                                                                              -Explain the use of     -To promote
                                               Disc tissue dies and                           adjunctive devices      knowledge and
                                                broken down by                                such as Taylor Brace    enhances safety
                                                    caseation

                                               Vertebral Collapse

                                                 Spinal Damage

                                               Impaired Physical
                                                   Mobility
Nursing Case study potts disease

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Nursing Case study potts disease

  • 2. 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.
  • 3. 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
  • 4. 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.
  • 5. 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, and Disc tissue dies Night Sweats, Spinal mass broken down by Vertebral Disease VertebralNarrowing Potts’ Damage Spinal Collapse caseation
  • 6. Laboratory / Diagnostic Examinations March 5, 2009 Blood Chemistry Normal Value Result Findings
  • 7. 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 Differential count: -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 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 Differential count: -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 March 5, 2009 Urinalysis Normal Value Result Findings
  • 8. 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
  • 9. Drug Study Classification Dosage Mechanism of Indication Contraindication Adverse Reaction Nursing Action Consideration Generic Name: Anti-infectives 200mg/5ml Rifampicin Maintenance phase Hypersensitivity, GI disturbances, >Assess lung Rifampicin syrup inhibits DNA- treatment of all jaundice, severe pseudomembranous sounds and 6ml OD ac PO dependent forms of hepatic disease colitis (rare), character and Brand Name: polymerase, pulmonary and abnormalities of amount of sputum decreases extra-pulmonary liver function, periodically replication tuberculosis(TB) fatalities in those during therapy with liver disorders, >Assess results of influenza-like periodic symptoms, skin laboratory tests reactions, and chest x-ray, eosinophilia, therapeutic transient effectiveness and leucopenia, adverse reactions thrombocytopenia, >Monitor patient purpura, shock, compliance with drowsiness, treatment regimen headache, ataxia, visual disturbances, menstrual irregularities. Reddish colored urine and tears. IV: Thrombophloebitis; extravasation following local irritation and inflammation.
  • 10.
  • 11. Classification Dosage Mechanism of Indication Contraindication Adverse Reaction Nursing Action Consideration Generic Name: Anti-infectives 200mg/5ml syrup Isoniazid inhibits Pulmonary and Acute liver disease Peripheral >Assess Isoniazid 6ml OD ac PO RNA synthesis, extra-pulmonary or history of neuritis, optic laboratory decreases tuberculosis(TB) hepatic damage neuritis; psychotic examinations Brand Name: tubercule bacilli during INH reactions, >Monitor replication therapy; convulsions, liver/renal hypersensitivity nausea, vomiting, function fatigue, epigastric >Assess CNS distress, visual often disturbances, >Assess hepatic fever, rash, status pyridoxine >Assess for visual deficiency disturbance that may indicate optic neuritis
  • 12. Classification Dosage Mechanism of Indication Contraindication Adverse Reaction Nursing Action Consideration Generic Name: Analgesics 125mg/5ml syrup Paracetamol Treatment of Hypersensitivity Stimulation, >Assess patient’s Paracetamol 5ml Q4 PRN PO exhibits analgesic fever drowsiness, nausea, fever action by vomiting, >Assess for Brand Name: peripheral abdominal pain, allergic reactions blockage of pain hepatotoxicity, >Assess impulse hepatic seizure, hepatotoxicity generation. It renal failure, >Monitor liver produces luekopenia, and renal antipyresis by neutropenia, functions inhibiting the hemolytic anemia, hypothalamic thrombocytopenia, heat-regulating pancytopenia, rash, centre. Its weak urticaria, anti-inflammatory hypersensitivity, activity is related cyanosis, anemia, to inhibition of neutropenia, prostaglandin jaundice, synthesis in the pancytopenia, CNS CNS. stimulation, delirium followed by vascular collapse, convulsions, coma, death
  • 13. Nursing Care Plan Assessment Diagnosis Inference Planning Intervention Rationale Evaluation Subjective: Imbalanced Nutrition Pulmonary After 8hrs of Nursing -Assess weight, age, -To provide After 8hrs of Nursing “Kulang daw siya sa less than body Tuberculosis Interventions the body build, strength, comparative baseline Interventions the timbang sabi ng requirements related patient will activity/rest level patient has doctor” as verbalized to ingest adequate demonstrate a demonstrated a by the mother nutrients Weakens immune behaviors to achieve -Discuss eating -To appeal to the behaviors to achieve system appropriate weight habits, including patients likes appropriate weight Objective: food preferences to -Under weight the mother -Lack of interest in Generalized eating nutritious weakness -Administer -To enhance patients food Vitamins as ordered intake Loss of appetite -Encourage and -To conserve energy, provide for frequent especially in rest periods metabolic requirements Imbalanced Nutrition -Encourage small, -To maximize frequent meals with nutrient intake food high in protein without undue and carbohydrates fatigue -Provide oral care -To reduce bad taste before/after meals at left from the bedtime medications used in respiratory treatment
  • 14. Assessment Diagnosis Inference Planning Intervention Rationale Evaluation Subjective: Impaired Physical Pulmonary After 4hrs of Nursing -Encourage to -To prevent After 4hrs of Nursing “Nilagyan siya ng Mobility related to Tuberculosis Interventions the change position complications Interventions the Taylor Brace” as therapeutic patient’s mother will every 2 hours patient’s mother has verbalized by the restrictions of Spread of verbalize verbalized mother movement Mycobacterium understanding of the -Schedule activities -To reduce fatigue understanding the Tubercule in the situation and with adequate res situation and Objective: spine treatment regimen periods treatment regimen -Limited range of and safety measures and safety measures motion Extra-pulmonary -Provide regular skin -To promote good -Difficulty in turning Tuberculosis care hygiene -Presence of Taylor Brace Infection spreads -Provide passive -To maintain muscle from the exercises integrity intervertebral disc -Encourage adequate -To maximize energy Pus formation intake nutritious production between the foods intervertebral disc -Explain the use of -To promote Disc tissue dies and adjunctive devices knowledge and broken down by such as Taylor Brace enhances safety caseation Vertebral Collapse Spinal Damage Impaired Physical Mobility