Republic of the Philippines UNIVERSITY OF NORTHERN PHILIPPINES Tamag, Vigan City

COLLEGE OF NURSING

CASE STUDY ON POTTS DISEASE

THEA C. TURQUEZA, RN, MAT Ng, MAN Clinical Instructor ___________________

In Partial Fulfillment Of The Requirements In

NCM 103 Related Learning Experience (RLE) PHILIPPINE ORTHOPEDIC CENTER

___________________

Presented by

JONAS JACO P. TALAMO BSN III-B JESS B. TANGONAN BSN III-D SHERWIN G. ULLERO BSN III-A

SUMMER AFFILATION June 11, 2010

Republic of the Philippines UNIVERSITY OF NORTHERN PHILIPPINES Tamag, Vigan City

COLLEGE OF NURSING

CASE STUDY GRADING SHEET

PARAMETERS Introduction & Objectives Personal Data Nursing History of Past and Present Illness PEARSON Assessment Diagnostic Procedures a. Ideal b. Actual Anatomy & Physiology of Organs Involved Pathophysiology a. Algorithm b. Explanation Management a. Medical b. Surgical c. NCP with Evaluation d. Promotive & Preventive Management Drug Study Discharge Plan Updates ORGANIZATION BIBLIOGRAPHY TOTAL

PERCENTAGE % 5 5 15 5 5 15

ACTUAL GRADE

2.5 2.5 20 5 5 5 5 2.5 2.5 100%

REMARKS: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

____________________________________________ THEA C. TURQUEZA, RN, MAT Ng, MAN Clinical Instructor

Republic of the Philippines UNIVERSITY OF NORTHERN PHILIPPINES Tamag, Vigan City

COLLEGE OF NURSING

TABLE OF CONTENTS

PAGE Title Page Grading Sheet Table of Contents INTRODUCTION Objective of the Study Patients Profile Nursing History of Past & Present Illness PEARSON Assessment Diagnostic Procedures A. Ideal B. Actual Anatomy & Physiology Pathophysiology A. Algorithm B. Explanation Management A. Medical B. Surgical C. NCP with Evaluation D. Promotive & Preventive Management Drug Study Discharge Plan Updates BIBLIOGRAPHY 16 19 21 25 27 29 31 33 13 14 7 9 11 i ii iii 1 3 4 5 6

INTRODUCTION

Marvin Paccial Piangco, 15 years old and a resident of 019 Road 10 Joseph St., Bagumbayan, Taguig City, was admitted last May 22, 2010 at 4:22 in the afternoon at Philippine Orthopedic Center with a chief complaint of nape pain. He was admitted by Dr. Llanes with an admission diagnosis of Potts disease, C5C6 without Neurologics. He was admitted at the Male Traction Ward all throughout his hospitalization. The case study that is to be presented features a patient who has Potts disease. It is a spine infection associated with tuberculosis that is characterized by bone destruction, fracture, and collapse of the vertebrae, resulting in kyphotic deformity or curvature of the spine. It is a grave disorder that produces destruction of the vertebrae.

The source of infection is usually outside the spine. It is most often spread from the lungs via the blood. There is a combination of osteomyelitis and infective arthritis. Usually more than one vertebra is involved. The area most affected is the anterior part of the vertebral body adjacent to the subchondral plate. Tuberculosis may spread from that area to adjacent intervertebral discs. In adults, disc disease is secondary to the spread of infection from the vertebral body but in children it can be a primary site, as the disc is vascular in children.

It is the most common place for tuberculosis to affect the skeletal system although it can affect the hips and knees, too. The usual sites to be involved are the lower thoracic and upper lumbar vertebrae.

The infection 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 disc between them collapses as it is avascular and cannot receive nutrients. Caseation occurs, with vertebral narrowing and eventually vertebral collapse and spinal damage. A dry soft tissue mass often forms and superinfection is rare.

OBJECTIVES

This case study aims to attain the following: 1. Obtain a broader and deeper understanding of Potts disease as to its: 1.1 Cause and precipitating factors, 1.2 Clinical manifestations, 1.3 Diagnostic and laboratory procedures, 1.4 Affectation of the heart and other physiological organs, 1.5 Pathophysiology and disease process.

2. Assess the client as to its: 2.1 Medical or surgical management, 2.2 Promotive and preventive measures against Potts disease, 2.3 Potential complications. 3. Formulate prioritized nursing diagnoses addressing to the clients health care needs as evidenced by the clients presenting cues.

4. Plan appropriate nursing objectives that are specific, measurable, attainable, realistic and time bound. 5. Utilize and render quality health service in the care of the patient who has Potts disease and its complications.

6. Evaluate the efficacy and degree of client-centeredness of the formulated nursing care plans.

7. Integrate the formulated care plans with other health-oriented fields to obtain maximum health nursing care.

8. Study the pharmacologic agents that are used in relieving and treating emphysema, its side effects, contraindications and possible drug-interactions.

PATIENTS PROFILE

PERSONAL DATA NAME: AGE: ADDRESS: SEX: Marvin Paccial Piangco 15 years old 019 Road 10 Joseph St., Bagumbayan, Taguig City Male

DATE OF BIRTH: October 1, 2004 BIRTHPLACE: CIVIL STATUS: RELIGION: NATIONALITY: OCCUPATION: MEDICAL PROFILE ADMISSION DATE: CHIEF COMPLAINT: ADMITTING AGENCY: WARD: HOSPITAL NUMBER: May 22, 2010 Nape pain Philippine Orthopedic Center Male Traction Ward 58-41-29 TIME: 4:22 P.M. Taguig City Single Roman Catholic Filipino None

ADMITTING DIAGNOSIS: Potts disease, C5C6 without Neurologics

HISTORY OF PAST AND PRESENT ILLNESS

PAST ILLNESS

Marvin Paccial Piangco, 15 years old, male, a high school student from Taguig City, has completed his immunization when he was younger. He did not have any allergies and he did not have any history of childhood illness and during his growth years, he just experienced cough, colds, and fever. He had no previous hospitalizations. No family history of major medical illnesses was stated.

PRESENT ILLNESS

The present health history started four months ago prior to admission. Patient Marvin has started to experience neck pain with associated weight loss. According to the mother, the patient had an accident while he was playing basketball with his friends. The patient was noted having left neck mass approximately 1.5 cm in its greatest diameter, soft, movable, and non-tender. No accompanying symptoms were noted such as pain, cough, fever, weight loss and night sweats. The patient sought consult ay Veterans Memorial Medical Center. The impression at that time was tuberculosis and the following were requested: sputum AFB, chest X-ray, and ultrasound of the neck. Due to financial constraints, the patient was only able to undergo ultrasound which showed lymphadenopathies, bilateral. However, the patient was lost to follow-up. Three months prior to admission, persistence of the mass prompted consult with a manghihilot and manipulation was done which brought no improvement. Two months after that, the patient claimed intermittent, pricking, nape pain, graded 6/10 that was localized and it was aggravated by movement. No accompanying symptoms were noted such as bowel and bladder changes, muscle weakness, and sensory deficits. No consult was done at that time and the patient selfmedicated with Mefenamic acid 500mg/tab, 1 tablet three times a day, which afforded temporary relief of symptoms. One month prior to admission, an increase in severity of nape pain prompted consult at Rizal Medical Center and the following was requested: chest X-ray, cervical X-ray, blood examinations, and AFB. However, the patient was then lost to follow-up. Two weeks prior to admission, the patient was able to do laboratory requests at Rizal Medical Center. Chest X-ray and AFB showed negative (-) results. However, cervical spine X-ray revealed changes in C5C6 levels, to consider Potts disease. The patient was advised admission. But due to financial constraints, the patient was referred to Philippine Orthopedic Center for further evaluation and management, hence the admission.

PEARSON ASSESSMENT June 9, 2010 (Hospital) June 10, 2010 (Hospital) Conscious and coherent Answers questions accordingly An upcoming third year high school student Sleeps at times With pale lips With poor interaction

P
(Psycho-social)

Marvin Paccial Piangco, 15 years old from Road 10 Joseph St., Bagumbayan,

Taguig City He was born on October 1, 2004 Psychosocial Crisis: Identity vs. Role Confusion Weak in appearance Conscious and coherent With significant other to attend his needs Uses Tagalog as primary language

E
(Elimination)

With IFC connected to a urine bag No bowel elimination Urine output: light yellow urine in moderate amount Perspired at times

With IFC connected to a urine bag Defecated once Urine output: light yellow urine in moderate amount Bowel pattern: no disturbances in defecating Perspired at times Sleeps at times Had adequate sleep Weak and pale

A/R
(Activity/ Rest)

The patient is lying on bed most of the times In reversed Trendelenburg position Sleeps at intervals Limited movement due to body weakness

Has limited ROM Unable to perform gross and fine motor skills Has continuous sleep Sleeps early at night Weak and pale Medications No known allergies to food and medications
o

S
(Safety)

Medications No known allergies to food and medications Level conscious Skin integrity: dry Temperature: 36.7oC BP: 120/80 mmHg Patient has significant others to attend his needs of consciousness:

Level

of

consciousness:

conscious Skin integrity: dry Temperature: 37.0 C BP: 120/90 mmHg With hot environment Afebrile V/S taken: BP: 120/90 mmHg Temp: 37.0 oC RR: 34 cpm PR: 108 bpm Respiratory distress: (+) Abnormal breath sounds: (-) Differential count: Segmenters: .50 Lymphocytes: .40 Monocytes: .10 Hgb: 122 g/L Platelet count: 360 x 10^9/L known

O
(Oxygenation)

V/S taken: BP: 120/80 mmHg Temp: 36.7 oC RR: 28 cpm PR: 91 bpm Respiratory distress: (-) Abnormal breath sounds: (-) Hgb: 122 g/L Platelet count: 360 x 10^9/L

N
(Nutrition)

Diet as tolerated With good appetite Patient has no

Diet as tolerated With good appetite Patient has no known allergies to any food

allergies to any food

DIAGNOSTIC PROCEDURES

IDEAL LABORATORY STUDIES

Tuberculin skin test (purified protein derivative [PPD]) results are positive in 84-95% of patients with Potts disease who are not infected with HIV.

The erythrocyte sedimentation rate (ESR) may be markedly elevated (>100 mm/h). Microbiology studies are used to confirm diagnosis. Bone tissue or abscess samples are obtained to stain for acid-fast bacilli (AFB), and organisms are isolated for culture and susceptibility. CT-guided procedures can be used to guide percutaneous sampling of affected bone or soft-tissue structures. These study findings are positive in only about 50% of the cases. IMAGING STUDIES

Radiography

Radiographic changes associated with Potts disease present relatively late. The following are radiographic changes characteristic of spinal tuberculosis on plain radiography:

Lytic destruction of anterior portion of vertebral body Increased anterior wedging Collapse of vertebral body Reactive sclerosis on a progressive lytic process Enlarged psoas shadow with or without calcification

Additional radiographic findings may include the following:

Vertebral end plates are osteoporotic. Intervertebral disks may be shrunk or destroyed. Vertebral bodies show variable degrees of destruction. Fusiform paravertebral shadows suggest abscess formation. Bone lesions may occur at more than one level.

CT Scan CT scanning provides much better bony detail of irregular lytic lesions, sclerosis, disk collapse, and disruption of bone circumference. Low-contrast resolution provides a better assessment of soft tissue, particularly in epidural and paraspinal areas.

 CT scanning reveals early lesions and is more effective for defining the shape and calcification of soft-tissue abscesses. In contrast to pyogenic disease, calcification is common in tuberculous lesions. MRI o MRI is the criterion standard for evaluating disk-space infection and osteomyelitis of the spine and is most effective for demonstrating the extension of disease into soft tissues and the spread of tuberculous debris under the anterior and posterior longitudinal ligaments. MRI is also the most effective imaging study for demonstrating neural compression. o MRI findings useful to differentiate tuberculous spondylitis from pyogenic spondylitis include thin and smooth enhancement of the abscess wall and welldefined paraspinal abnormal signal, whereas thick and irregular enhancement of abscess wall and ill-defined paraspinal abnormal signal suggest pyogenic spondylitis. Thus, contrast-enhanced MRI appears to be important in the differentiation of these two types of spondylitis. ACTUAL COMPLETE BLOOD COUNT The complete blood count (CBC) is one of the most commonly ordered blood tests. The complete blood count is the calculation of the cellular (formed elements) of blood. These calculations are generally determined by special machines that analyze the different components of blood in less than a minute. A major portion of the complete blood count is the measure of the concentration of white blood cells, red blood cells, and platelets in the blood. The complete blood count (CBC) test is performed by obtaining a few milliliters (one to two teaspoons) of blood sample directly from the patient. It can be done in many settings including the doctor's office, laboratories, and hospitals. The skin is wiped clean with an alcohol pad, and then a needle is inserted through the area of cleansed skin into to patient's vein (one that can be visualized from the skin.) The blood is then pulled from the needle by a syringe or by a connection to a special vacuumed vial where it is collected. The sample is then taken to the laboratory for analysis.

HEMATOLOGY:
NAME AND PURPOSE OF THE PROCEDURE

NORMAL VALUES

ACTUAL VALUES

NURSING NURSING IMPLICATION REPSONSIBILITES

Complete Blood Count (CBC) - To diagnose and manage numerous diseases such as acute and chronic infection, allergies and problems with clotting. Hemoglobin - To detect and monitor the severity of various kinds of hemolytic anemia. Hematocrit - To determine if patient has signs of anemia, leukemia, diet deficiency, or other medical condition. White Blood Cell - To find out how many WBC the patient has which may rule out infection.

RBC: 3.8-6.5x1012/L

5.45x10 /L

12

Normal

HgB: 140-180g/L

122g/L

Normal

HcT: 0.40-0.54%

0.37%

Normal

WBC: 10-25x109/L Neutrophils: 0.40-0.75 Lymphocytes: 0.20-0.45 Eosinophils: 0.01-0.04 Platelet: 150-450x109/L

10.3 x109/L

Normal

0.63 0.35 0.02 360 x109/L

Normal Normal Normal Normal

Explain the procedure and present the benefits of the test. Inform the patient that the blood be drawn from a vein, usually above the elbow or back of the hand. Wipe the puncture site. Place the bandage around the upper arm to apply pressure and raise the vessel to swell with blood. Insert the needle at the distended vein and aspirate needed blood sample. Apply pressure after the procedure. Observe for bleeding and bruises. Report the results to the physician. Document findings and take proper intervention for every abnormality noted as ordered.

 MANTOUX TEST The Mantoux test (or Mantoux screening test, Tuberculin Sensitivity Test, Pirquet test, or PPD test for Purified Protein Derivative) is a diagnostic tool for tuberculosis. The Mantoux test is used in the United States and is endorsed by the American Thoracic Society and Centers for Disease Control and Prevention (CDC). Multiple puncture tests such as the Tine test are not recommended. The Mantoux test is one of the two major tuberculin skin tests for tuberculosis used in the world. A standard dose of 5 Tuberculin units (0.1 mL) is injected intradermally (into the skin) and read 48 to 72 hours later. A person who has been exposed to the bacteria is expected to mount an immune response in the skin containing the bacterial proteins. The reaction is read by measuring the diameter of induration (palpable raised hardened area) across the forearm (perpendicular to the long axis) in millimeters. No induration should be recorded as "0 mm". Erythema (redness) should not be measured. If a person has had a history of a positive tuberculin skin test, another skin test is not needed. RADIOGRAPHY Radiography is the use of certain types of electromagnetic radiationusually ionizing to view objects. The use of non-ionizing radiations (visible light and ultraviolet light) to view objects should be considered as a normal optical method (e.g., light microscopy). The modification of an object through the use of ionizing radiation is not radiography. Depending on the nature of the object and the intended outcome it can be radiotherapy, food irradiation, or radiation processing.

ANATOMY AND PHYSIOLOGY OF THE ORGANS INVOLVED 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 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.

PATHOPHYSIOLOGY OF POTTS DISEASE A. ALGORITHM Hematogenous spread of TB

Spread of Mycobacterium tubercule in the T7-T9 of the spine

Inflammation of a portion of the vertebral column Pus or lesion formation in the intervertebral disc Back pain, fever, night sweats, and spinal mass Disc tissue dies and breaks down by caesation Vertebral narrowing Vertebral collapse of the anterior spine Kyphosis

Spinal root compression Spinal damage Paraplegia

Potts disease

B. EXPLANATION Potts disease is usually secondary to an extraspinal source of infection. The basic lesion involved in Potts disease is a combination of osteomyelitis and arthritis that usually involves more than one vertebra. The anterior aspect of the vertebral body adjacent to the subchondral plate is area usually affected. Tuberculosis may spread from that area to adjacent intervertebral disks. In adults, disk disease is secondary to the spread of infection from the vertebral body. In children, because the disk is vascularized, it can be a primary site. Progressive bone destruction leads to vertebral collapse and kyphosis. The spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion, leading to spinal cord compression and neurologic deficits. The kyphotic deformity is caused by the collapse in the anterior spine. Lesions in the thoracic spine are more likely to lead to kyphosis than those in the lumbar spine. A cold abscess can occur if the infection extends to adjacent ligaments and soft tissues. Abscesses in the lumbar region may descend down the sheath of the psoas to the femoral trigone region and eventually erode into the skin.

MEDICAL AND SURGICAL MANAGEMENT Drug treatment is generally sufficient for Potts disease, with spinal immobilization if required. Surgery is required if there is spinal deformity or neurological signs of spinal cord compression. Standard anti-tuberculosis treatment is required. Duration of anti-tuberculosis 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 twelve months treatment is required. There have been discussions on whether the treatment of choice should be conservative chemotherapy for 12 months or chemotherapy and surgery combined. Management should be based on the goals of treatment for each individual case. Effective chemotherapy for spinal tuberculosis is the gold standard and mainstay of the treatment and all other methods of treatment are regarded as supplementary. Drug Treatment Regimens The standard triple chemotherapy (isoniazid, rifampin, and pyrazinamide), should be given for at least 12 months, rather than the 6- to 9-month short-term chemotherapy that has been proposed by some authors. Good general supportive care and an effective chemotherapy started at the early stages of the disease are the keys to early and effective eradication and minimizing complications. Surgery Although chemotherapy is the mainstay in the management of tuberculosis spondylitis, surgical procedures still play an important role. Problems arising from bone destruction, paraplegia, and pulmonary insufficiency due to spinal deformity cannot be solved with chemotherapy alone. Indications for surgical treatment include 1) neurological involvement, 2) deformity and/or impending increase in deformity, and 3) the presence of large tuberculosis abscess and/or abundant necrotic tissue. Abscess, tuberculosis lesion, paraplegia, and kyphosis, have been managed surgically by various procedures: Cold Abscess. Aspiration or surgical drainage was carried out for some patients with a large cold abscess because it was thought that evacuation of the abscess improved the patient's general condition, and rapid progression of the abscess along the spine was prevented. Tuberculous destructive lesion. Two surgical methods-focal dbridement and anterior radical surgery-are available to eradicate the lesion. 1. Focal dbridement. Focal dbridement can

effectively remove the diseased tissue and sequestra and also can evacuate the abscess; however, it does not prevent the progression of kyphosis due to the lack of anterior support. Focal dbridement and simple abscess evacuation provide no long-term advantage over ambulant chemotherapy alone and therefore are no longer accepted as a preferred method of treatment. 2. Anterior radical surgery. Anterior radical debridement and arthrodesis with a strut graft and chemotherapy has been the treatment of choice. There is evidence that better results regarding deformity, recurrence, development of paralysis, and resolution are obtained when radical surgery is performed combined with chemotherapy. Paraplegia. During the early phases of the disease with active infection, possible reasons include direct compression of the neural structures by the abscess and/or sequestrated bone fragments, direct dural invasion, vascular compromise due to compression or thrombosis, acute instability, or severe deformity. Direct compression by abscess or necrotic tissue is the most frequent cause of early onset paralysis and generally has a good prognosis and a relatively high probability to resolve with effective treatment. Paraplegia due to vertebral tuberculous lesion is caused by direct impingement of the abscess, ischemia due to altered blood supply, intra dural abscess and kyphosis. It is generally known that the recovery rate from paraplegia is influenced by many factors: the patient's general state, age, and spinal cord condition; the level and the number of involved vertebrae; the severity of spinal deformity; the duration and severity of paraplegia; the time to initiation of treatment; the type of treatment; and drug sensitivity. Paralysis occurring in children generally have a better prognosis compared to adults

Paralysis lasting longer than 6 months is most unlikely to improve, and late paralysis with inactive disease and significant kyphosis is much less responsive to treatment. Paralysis due to vascular insufficiency has a worse prognosis. Several methods have been used for the treatment of patients with paraplegia: 1) chemotherapy alone, 2) laminectomy, 3) costotransversectomy, and 4) radical surgery. In the early stages of the disease, paraplegia caused by abscess can be resolved by effective chemotherapy alone as by decompressive surgery, however, chemotherapy alone is inappropriate management of paraplegia in the patient with advanced tuberculosis and deformity. It is unfair to allow a patient to lie paralyzed for some weeks to months awaiting a cure through conservative care. Decompressive laminectomy will destabilize already hampered spine therefore should not be done. When patients with Pott's paraplegia and severe spinal deformity do not respond to chemotherapy and have worsening neurology, decompressive surgery is indicated to arrest the progress of paralysis and hopefully to restore normal neurology.

Kyphosis / Deformity. Tuberculosis kyphosis is an unstable lesion that tends to progress until there is sound bony fusion anteriorly. Kyphosis has been managed by several surgical

procedures: posterior fusion, anterior radical surgery, and various combined operations such as a one-stage, two-stage, or three-stage procedures. Each patient should be cautioned about the high neurologic risk with corrective surgery of the rigid deformed spine. Until now, the following surgical procedures have been practiced by various surgeons: 1. Flexible Kyphosis: Skeletal traction Posterior fusion Anterior radical surgery Two-stage operation: Posterior instrumentation followed by anterior radical surgery Anterior release and graft, followed by posterior instrumentation Three-stage operation (anterior release followed by posterior instrumentation and delayed anterior radical surgery). 2. Fixed Kyphosis. One-stage operation

Two-stage operation (anterior release, deformity correction and anterior graft, followed by posterior instrumentation) Multi-stage operation (osteotomy, halopelvic device, posterior instrumentation and fusion). Skeletal traction for cervical kyphosis. Posterior fusion for kyphosis. Disproportionate posterior spinal growth has been suspected as a contributing factor in the progression of kyphotic deformity after management of spinal tuberculosis by posterior fusion only. Especially, in children frequently there will be a loss of the initial gain of correction and progression of kyphosis after noninstrumented posterior spinal fusion if anterior fusion is not achieved. Additional instrumentation seems to prevent the progression of kyphosis. Anterior radical surgery for kyphosis. Radical surgery (Hong Kong Operation) was found to give better results than focal dbridement for the correction and prevention of kyphosis. Progression of kyphosis is more observed in multilevel lesions. Posterior closing wedge osteotomy for kyphosis (Galveston one-stage operation). This technique is a very effective one-stage operation. It involves a modified bilateral costotransversectomy approach to the spine, followed by removal of structures in a wedge shape, including the vertebral arch, the disk, and a portion of the centrum. The wedge is closed by posterior compression instrumentation, enabling an angular correction of 30 to 50. Decancellation or corporal eggshell procedure. This posterior close wedge procedure involves transpedicular curettage or evacuation of the cancellous bone of the vertebral body, excision of the posterior elements and posterior wall of the body, and correction of kyphosis by closing the wedge. This is a highly demanding procedure with additional surgical risks.

Two-stage operations. 1. Anterior radical surgery, followed by posterior resection and instrumentation. Yau et al used Luque instrumentation in a two-stage procedure to correct the deformity.

2. Combined posterior instrumentation plus anterior radical surgery for flexible kyphosis (twostage operation). This procedure may be most appropriate for active cases of progressive kyphosis where the curve is stil flexible. Prevention and correction of kyphosis and kyphoscoliosis by posterior instrumentation has three advantages. Posterior stabilization of the spine arrests the disease early, encourages early fusion, and enables correction of the deformity. The procedure is indicated only in those patients who are likely to develop or who have a preexisting deformity. It is suggested that a formula be used to predict the kyphosis that will remain at the end of chemotherapy to determine if prophylactic or corrective spinal instrumentation surgery is indicated.

PREVENTIVE AND PROMOTIVE MANAGEMENT Eat a well-balanced diet that includes plenty of protein foods, fresh fruits, and vegetables to help your skin, urinary tract, and bowel functions healthy. Change your position frequently in a wheelchair and in bed to prevent pressure sores. Exercise to improve respiratory function, increase bone strength, regulate bodily functions, and possibly improve spasticity. Drink water throughout the day to benefit your skin, urinary tract, and bowel functions. Do not smoke. Smoking constricts your vessels making it harder to blood oxygen and nutrients to flow to the body tissues. Smoking also negatively affects respiratory health. Regularly examine your skin and pay special attention to bony areas such as heels, tailbone, and shoulder blades. The patient is best treated initially in the supine position. Occasionally, the patient may have been transported prone by the pre-hospital care providers. Logrolling the patient to the supine position is safe to facilitate diagnostic evaluation and treatment. Use analgesics appropriately and aggressively to maintain the patients comfort if he or she has been lying on a hard backboard for an extended period. Prevent pressure sores. Denervated skin is particularly prone to pressure necrosis. Turn the patient every 1-2 hours. Use of brace. Compliance of medications.

DISCHARGE PLAN M edication Pyrazinamide 500 mg tab two times a day Bisacodyl 10 mg tab once a day Pyridoxine (Vitamin B6) 1 tab two times a day Isoniazid 400 mg 1 tab once a day Rifampicin 450 mg tab once a day Ethambutol 450 mg tab two times a day E xercise Encourage patients relative to perform passive range of motion exercises on patients extremities Encourage the patient to do simple exercises as tolerated such range of motion exercise T reatment Bed rest on the affected part Exposure to air and sunlight Liberal diet: increased protein Increased liquids Massive anti-TB drugs Bone grafting Encourage patient to comply with the medication as ordered by the physician Explain the importance of adhering his treatment regimen

H ealth Teaching Instruct patient to maintain body mechanics Instruct client to avoid contact sports Emphasized the importance of strict compliance to medication Encourage to follow instructions including medications, treatment regimen, dos and donts to be given by the doctor Instruct relatives to assist patient in all activities he does to avoid further complications Tell SO and patient to report immediately to physician if unusual signs happen to the patient O ut Patient/ Follow-up Instruct the patient to follow-up check up if the condition worsens

 Instruct family to return to their attending physician for scheduled check-up and consultation Advise family to report to the physicians any complaints Advice patient to report signs of unusualities that may happen to him D iet Diet as Tolerated but be careful and be selective to the foods. Instruct the patient to eat foods rich in protein Eat meals when their energy levels are at their highest which is usually in the morning. Eat slowly and chewed food thoroughly to avoid becoming breathless while eating and to prevent choking Eat balance nutritious food

S-pecial care: Special attention and precaution is needed for the patient. Advice SO to watch every activity that the patient does and assist him Instruct SO to reposition patient every two hours to avoid pressure ulcers or respiratory complications Assist patient on proper hygiene

UPDATES

BIBLIOGRAPHY BOOKS Burke, Shirley R. Himan Anatomy & Physiology in Health and Diseases, 3rd Ed. Canada: Delmar Publisher Inc., 1992. Doenges, Marilynn E., et al. Nurses pocket Guide: Diagnoses, Interventions, and Rationales, 11th Ed. Philadelphia, Pennsylvania: F.A. DAVIS COMPANY, 2008. Doenges, Marilynn E., et al. Nursing Care Plans: Guidelines for Individualizing Client Care Across the Lifespan, 7th Ed. Philadelphia, Pennsylvania: F.A. DAVIS COMPANY, 2006. Karch, Amy M. Nursing 2007 Lippincotts Nursing Drug Guide, 27th Ed. Philadelphia, Pennsylvania: Lippincott William & Wilkins, 2007. Lippincott Williams & Wilkins. Nursing 2006 Drug Handbook, 26th Ed. Philadelphia, Pennsylvania: Lippincott William & Wilkins, 2006. Merriam-Webster, Merriam-Websters Medical Dictionary, New Ed. Springfield, Massachusetts, USA: Merriam-Webster Incorporated, 2006. Sciarra, Jana L., et al. Medical-Surgical Nursing Made Incredibly Easy, Philadelphia, Pennsylvania: Lippincott William & Wilkins, 2004. Smeltzer, Suzanne C., et al. Brunner & Suddarths Textbook of Medical -Surgical Nursing, Vol 1, 11th Ed. Philadelphia, Pennsylvania: Lippincott Williams & Wilkins, 2008. Springhouse. Nursing 92 Drug Handbook. Springhouse, Pennsylvania: Springhouse Corporation, 1992. Taylor, Carol, et al. Fundamentals of Nursing The Art and Science of Nursing Care, 5th Ed. Philadelphia, Pennsylvania: Lippincott Williams & Wilkins, 2005. WEBSITES http://nursingcrib.com/nursing-care-plan/online-nursing-care-plan-potts-disease/ http://health.hpathy.com/potts-disease-symptoms-treatment-cure.asp/ http://www.ninds.nih.gov/disorders/sci/sci.htm http://www.caspases.org/showabstract.php?pmid=16607070

DRUG STUDY NAME OF DRUG Isoniazid MECHANISM OF ACTION Bactericidal: NURSING RESPONSIBILITIES Observe 10 Rs of administration. Give on an empty stomach, 1 hour

DOSAGE

INDICATIONS

CONTRAINDICATIONS

SIDE EFFECTS

400 mg 1 tab OD

Tuberculosis, in

all Containdicated with allergy CNS: which to isoniazid, isoniazid- neuropathy,

Peripheral seizures,

Interferes with lipid forms and nucleic

acid organisms in susceptible

are associated hepatic injury or toxic encephalopathy, other severe adverse optic neuritis and

biosynthesis actively

growing prophylaxis

in reactions to isoniazid, acute atrophy, impairment, psychosis

memory toxic

before or 2 hours after meals, may be given with food if GI upset occurs. Give in a single daily dose. Decrease foods

tubercle bacilli.

specific patients who hepatic disease. are reactors tuberculin or

GI: Nausea, vomiting, epigastric distress,

household members of recently

bilirubinemia, elevated AST, ALT levels,

diagnosed tubercular or who to are be

jaundice, hepatitis Hematologic: Agranulocytosis, hemolytic and aplastic anemia, thrombocytopenia, eosinophilia,

containing tyramine or histamine in patients diet. Instruct patient not to drink alcohol as muscle as possible.

considered

high risk (patients with HIV, IV drug users.

pyridoxine deficiency, pellagra, hyperglycemia, hypophospphatemia due to altered vitamin D metabolism

 Rifampicin 450 mg tab OD Inhibits dependent DNARNA Treatment of Contraindicated allergy rifampicin, hepatic disease. Use cautiously to with CNS: any drowsiness, acute dizziness, Headache, fatigue, irritability

Observe 10 Ps of administration. Administer on an empty stomach, 1 hour before or 2 hours after meal.

pulmonary TB on conjunction with at least one another effective antituberculotic Unlabeled uses:

polymerase activity in susceptible

to concentrate, mental with confusion, generalized ataxia, weakness, disturbances, been muscle safest exudative conjunctivitis use in Dermatologic: pruritus, Rash, urticaria, of

bacterial cells.

Administer on an single daily dose. Instruct patient that he might experience reddish to orange coloring of body

pregnancy (teratogenic numbness, effects have reported in preclinical visual studies; antituberculosis regimen for

Infections caused by Staphylococcus aureus and

fluids (urine, sweat, sputum, tears, feces, saliva). Instruct client to

Staphylococcus epidermis, usually combination therapy in

pregnancy is associated to be rifampin, and

isoniazid, ethambutol).

flushing, reddish to orange coloring

body fluids GI: epigastric anorexia, vomiting, Heartburn, distress, nausea, cramps,

take drug regularly. Avoid missing any doses; do not

continue this drug without consulting

healthcare provider.

diarrhea, pseudomembranous colitis, elevations pancreatitis, of liver

enzymes, hepatitis GU: Hemoglibinuria, hematuria, insufficiency, renal function Hematologic: Eosinophilia, thrombocytopenia, transient hemolytic decreased hemolysis Other: Pain in leucopenia, anemia, Hgb, renal acute

extremities, osteomalacia, myopathy, fever

Pyridoxine

1 tab BID

Needed protein,

for

fat, Vitamin

B6

CNS: flushing, lethargy

Paresthesia, warmth,

Observe 10 Rs of administration. Monitor pyridoxine levels throughout

deficiency associated with therapy isoniazid

carbohydrates metabolism; enhances glycogen release from liver and muscle tissue needed coenzyme metabolic transformations of a variety of amino acids as for

Integumentary: pain at injury site

the treatment. Assess pyridoxine deficiency; nausea, vomiting, dermatitis, cheilosis, irritability. Instruct patient to swallow the tabs for

whole, do not break, crush or chew. Teach patient to

avoid other vitamin supplements unless directed prescriber. by

Ethambutol

450 mg tab OD Inhibits synthesis metabolites growing mycobacterium

the Treatment of pulmonary in tuberculosis

of Contraindicated in

with CNS: Optic neuritis, malaise, dizziness, confusion, headache, with mental

Assess for allergy to ethambutol: neuritis, impaired function. Administer in a optic and renal

allergy to ethambutol; fever, optic neuritis. cautiously

conjunction with at Use least other

impaired renal function, disorientation, visual problems. hallucination, peripheral neuritis

cells, impairing cell antituberculotics metabolism, correcting multiplication cell and

single daily dose; must be used in

GI: Anorexia, nausea, vomiting, GI upset, abdominal transient impairment Hypersensitivity: Allergic dermatitis, reactions, pruritus, pain, liver

combination other

with

causing cell death.

antituberculotics. Instruct client to

take drug regularly; avoid missing any doses and drug must be used in with

anaphylactoid reaction

combination other

antituberculotics.

Pyrazinamide

500 mg tab BID

Bactericidal interference

Tuberculosis, as an Hypersensitivity,

severe CNS: headache GI: hepatotoxicity, liver

Observe the 10 Rs of administration. Monitor serum uric acid, which may be elevated and cause gout symptoms.

with adjunct when other hepatic damage, acute gout abnormal

lipid; nucleic acid drugs are not feasible. biosynthesis possible is

function tests, peptic ulcer, vomiting, diarrhea GU: difficulty, uric acid HEMATOLOGY: Hemolytic anemia INTEGUMENTARY: photosensitivity, urticaria Urinary increased nausea, anorexia,

Monitor studies weekly.

liver

Give with meals to decrease symptoms. Instruct patient that compliance dosage duration necessary. with GI

schedule, is

Bisacodyl

10 mg tab OD

Acts

directly

on Short term treatment Hypersensitivity, by of constipation, fissures, or rectal vomiting, pain,

rectal CNS: nausea, weakness

muscle

Check I & O to identify fluid loss. Assess rectal cramping, bleeding,

intestine increasing

motor bowel

appendicitis, GI: nausea, vomiting, anorexia, diarrhea, burning Metabolism: losing alkalosis, hypokalemia, tetany, Protein cramps, rectal

activity; thought to preparation irritate intramural

for acute surgical abdomen, ulcerated acute hemorrhoids, hepatitis, fecal

colonic surgery, examination flexes:

nausea, vomiting. If these symptoms

increases water in the colon

impaction, intestinal tract obstruction

occur, drug should be discontinued. Give alone with enteropathy,

water only; do not take within 1 hour of antacid, milk. Administer in AM or PM. Discuss patient with the that

electrolyte and fluid imbalance

adequate fluid and bulk consumption is necessary.

NURSING CARE PLAN NURSING DIAGNOSIS NURSING INTERVENTIONS Investigate report of pain, noting the characteristics, location, intensity (0-10 scale).

CUES June 9, 2010, 8:00 9:00 AM

ANALYSIS

OBJECTIVES

RATIONALE

EVALUATION Goal partially met.

Potts disease is a After an hour of Independent: P: Acute pain E: related form to extrapulmonary tuberculosis of rendering effective nursing that interventions, Helpful determining pain management needs

in The patient was able to incorporate relaxation skills and diversional activities into pain

Subjective: Sumasakit inflammatory ang likod ko by as process

impacts the spine. It patient will be able incorporate skills

verbalized patient.

the S: as evidenced has an effect that is to by:

and control program.

sometimes described relaxation Patients verbalization of pain as being a sort of and arthritis for

effectiveness of the program. firm and

diversional

Objective: Facial mask of pain

the activities into pain Provide mattress small pillows. Soft or sagging mattress large inhibits proper It is patient position alignment. and pillows the body

vertebrae that make control program. up the spinal column. properly as

Self narrowed focus Facial grimace Fatigue Pain scale of 6/10 Weak looking Facial grimace With limited range of motion and 6/10

Pain scale of More known tuberculosis spondylitis.

pale- Discomfort

often experienced as a local phenomenon that begins in the Suggest assume In acute phase, total bed rest

Discomfort V/S follows: T: 37.0oC P: 108 bpm R: 34 cpm BP: 120/90 mmHg taken as

thoracic section of the spinal column. Early signs of the presence of Potts disease generally

of proper comfort while in bed or chair. bed Promote rest as

may necessary limit pain.

be to

indicated.

begin with back pain that may seem to be due to simple muscle strain. Encourage frequent changes of position. Prevents general fatigue and joint stiffness.

Apply warm or moist compress on the affected area several times a day.

Heat muscle

promotes

relaxation mobility, decreases and morning stiffness.

and

pain

relieves

Provide massage.

gentle

Promotes relaxation and

reduces muscle

tension. Encourage use of stress management techniques. Promotes relaxation, provides sense

of control and may coping activities. enhance

Collaborative: Administer non- steroidal inflammatory drugs prescribed. as antiThese drugs

control mild to moderate and inflammation by inhibition prostaglandin synthesis. of pain

Administer antibiotic prescribed. as

To further

prevent

infection.

June 9, 2010, 8:00 P: 9:00 AM

Impaired

physical mobility E: related to pain

Pulmonary Tuberculosis Spread of Mycobacterium Tubercule in the spine Extra-pulmonary Tuberculosis Infection spreads from the intervertebral disc Pus formation between the intervertebral disc Disc tissue dies and broken down by caseation Vertebral Collapse Spinal Damage Impaired Physical Mobility

After 30 minutes of Independent: rendering effective nursing interventions, the patient will perform physical activity by independently changing Encourage and For

Goal met. The patient proper was able to perform physical activity which the is to reposition his body without faster assistance from other of motivation in

facilitate exercises as tolerated. Allow the patient to move or

circulation. Make patients recovery and

Subjective:

S: as evidenced

Hindi ko po maigalaw by: ang katawan ko as Patients verbalized patient.

by

the

verbalization of inability to move

perform activities like changing the position of legs at own rate. Keep side rails up. Turn and

increases people as evidenced by attempting to move by

position

self-esteem patient.

without assistance.

Objective: Inability to move

Limited range of move

To promote safe his own self. environment. To optimize

With limited range Decreased of motion Decreased strength Discomfort V/S follows: T: 36.7oC P: 91 bpm R: 28 cpm BP: 120/80 mmHg taken as

muscle muscle

circulation to all tissues and

strength Reluctant attempt movement Dependence to significant others to

reposition patient. Perform passive

prevent pressure ulcers. To venous promote return,

assistive range of motion exercises to extremities. Teach the patient on the hazards of immobility can lead that to

prevent stiffness, and maintain

muscle strength. To gain

complications like pressure and ulcers

coordination the patient.

of

respiratory

complications.