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Pott's disease nursing, medical, surgical managements

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Pott's disease nursing, medical, surgical managements

  1. 1. Pott’s Disease MEDICAL MANAGEMENT IDEAL - Non Operative Treatment: - if detected early (before collapse of more than 1-2 vertebral body) treatment consists of antibiotics and immobilization; - even w/ mild kyphosis (but no neurologic deficit), antibiotics & bracing are used; - w/ adequate medical treatment, there may be significant resolution of neurologic symptoms, and there will be a halt in the progression of kyphosis; - in young children, there will often be some resolution in the kyphosis, especially if only one of two vertebrae are involved; - antibiotics for all patients at the outset, reserving surgery for cold abscesses that are palpable posteriorly, as well as for those cases w/ neurological environment that have failed to improve in response to 2-3 months of antiTB therapy and immobilization; - 2 months of pyrazinamide, isoniazid, and rifampin given qd, followed by 4 months of INH and rifampin; - outcomes: - assessment of outcome should include prevalence of symptoms, amount of physical activity, amount of CNS involvement, presence/absence of sinus and/or abscess, and radiographic status of the lesion; Diagnostic Tests  blood tests - elevated erythrocyte sedimentation rate  tuberculin skin test  bone scan  bone biopsy Imaging  Spinal x-ray may not show early disease as 50% of bone mass must be lost for changes to be visible on x-ray. However, plain radiographs can show vertebral destruction and narrowed disc space.  MRI is useful to demonstrate the extent of spinal compression and can show changes at an earlier stage than plain radiographs. Bone elements visible within the swelling, or abscesses, are strongly indicative of Pott’s disease as opposed to malignancy.  CT scans and nuclear bone scans can also be used. Non-drug Immobilization of the spine is usually for 2 or 3 months. Therapy  non-operative - antituberculous drugs 1
  2. 2.  analgesics  immobilization of the spine region by rod (Hull)  Surgery may be necessary, especially to drain spinal abscesses or to stabilize the spine  Richards intramedullary hip screw - facilitating for bone healing  Kuntcher Nail - intramedullary rod  Austin Moore - intrameduallary rod (for Hemiarthroplasty) Microbiology  Needle biopsy of bone or synovial tissue. Numbers of tubercle bacilli present are usually low but are pathognomonic.  Acid-fast stain and culture for Mycobacterium tuberculosis, plus fungi and other pathogens, should be performed. Management of Pott’s disease  Drug treatment is generally sufficient for Pott’s disease, with spinal immobilisation 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. 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
  3. 3. SURGICAL MANAGEMENT IDEAL Surgical  Surgery plays an important part in the management. It confirms the diagnosis, relieves compression if it occurs, permits evacuation of pus, and reduces the degree of deformation and the duration of treatment. Therapy  immobilization of the spine region by rod (Hull)  Surgery may be necessary, especially to drain spinal abscesses or to stabilize the spine  Richards intramedullary hip screw - facilitating for bone healing  Kuntcher Nail - intramedullary rod  Austin Moore - intrameduallary rod (for Hemiarthroplasty) Surgery includes ADSF ( Anterior Decompression Spinal Fusion). - Operative Indications Treatment: - surgery is indicated for cold abscesses that are palpable posteriorly; - with cord compression surgery is required if neurological status deteriorates in spite of chemotherapy and immobilization; - attempt to give non operative treatment 2-3 months before determining the response; - w/ abscess and kyphosis operative intervention is required especially if kyphosis is progressive; - advantages include less progressive kyphosis, earlier healing, and decrease sinus formation; - patients younger than 15 years w/ kyphosis greater than 30 deg are at high risk for progression of kyphosis are also good candidates for surgery; - children aged less than 10 yrs with destruction of vertebral bodies who have partial or no fusion even during the adolescent growth spurt; - surgery may include; - requires anterior abscess drainage; - anterior spinal arthrodesis w/ iliac strut grating; - anterior arthrodesis allows better correction of the kyphosis, whereas debridement alone may actually have worsening of the kyphosis; - posterior spinal arthrodesis (indications unclear) - adjuvant chemotherapy beginning 10 days before surgery is essential;
  4. 4. NURSING MANAGEMENT Nursing diagnoses Ineffective airway clearance Risk for aspiration Ineffective breathing pattern Acute pain Risk for infection Risk for impaired skin integrity Autonomic dysreflexia Deficient fluid volume Risk for disuse syndrome Anxiety Impaired physical mobility Disturbed body image Nursing interventions  As with all spinal injuries, suspect cord damage until proved otherwise. Apply a properly sized cervical collar if cervical injury is suspected.  During the initial assessment and X-rays, immobilize the patient on a firm surface.  Offer the patient comfort and reassurance, talking to him quietly and calmly. Remember, the fear of paralysis will be overwhelming. Allow a family member who isn't too distraught to stay with him.  If the injury necessitates surgery, administer prophylactic antibiotics as ordered. Catheterize the patient, as ordered, to avoid urine retention, and monitor defecation patterns to avoid impaction.  If the patient has a halo or skull tong traction device, clean the pin sites daily and provide analgesics for headaches. During traction, turn the patient often to prevent pneumonia, embolism, and skin breakdown. Perform passive range-of-motion exercises to maintain muscle tone. Use a rotating bed, if available, to facilitate turning and avoid spinal cord injury.  Position the patient properly according to injuries to avoid aspiration.  If necessary, insert a nasogastric tube to prevent gastric distention.  Suggest appropriate diversionary activities to fill the hours of immobility. Offer prism glasses for reading.  Watch closely for neurologic changes. Immediately report changes in skin sensation and loss of muscle strength. Either could point to pressure on the spinal cord, possibly as a result of edema or shifting bone fragments.  When the patient is able to ambulate, request a physical therapy consultation for ambulation and proper application of a back brace.

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