I. INTRODUCTION

Pott’s is the tuberculosis of the bone and joints. It is a localized destructive disease caused by Mycobacterium tuberculosis. It is also known as tuberculous spondylitis. It is usually secondary to an extraspinal source of infection. It can’t be transmitted to others unless the organisms are exposed and aerosolized by debridement or surgical manipulation. Most occurs most frequently in spinal column (Pott’s disease) and in bone and joint structure surrounding the hip and knee. Most common and dangerous form. Person with compromised immune system have increased risk because there is depression of natural defense mechanism that normally prevent dissemination of tuberculosis from primary lesion. Additional risk factors are untreated TB, DM, and ESRD with hemodialysis treatment. Goal for management includes general health must be improved and deformities must be minimized. Multi-drug approach is generally selecting from Isoniazid, Refampicin, Pyrazinamide, Ethambutol, Streptomycin or Cyclovirin to prevent development of a bacterial population resistance. Surgical management includes ADSF (Anterior Decompression Spinal Fusion) which prevents vertebral collapse and neurologic sequelae and to drain any abscess that may have formed, application of knight taylor brace, head halter traction are used initially to manage the muscle spasm and pain.

II. PATIENT’S PROFILEName: RCPAge: 13 years oldBirthday: September 23, 1996Address: 0497 Lanuza Camp, Barangay Tagpas Binangonan RizalDate of Admission: July 20, 2010 Diagnosis: Pott’s disease

III. CHIEF COMPLAINT – Weakness of both lower extremities

IV. HISTORY OF PRESENT ILLNESS- Present condition prior to admission, patient experienced upper back pain, non radiating, graded 10/10. Also claimed to have intermittent fever. Patient was

brought to a local hospital in Rizal. Chest x-ray showed PTB.- During the in term, there was intermittent back pain and episodes of fever.- 8 months prior to admission persistence of deformity of spine prompted consult of National Childrens Hospital where thoracolumbar spine x-ray was

requested however patient did not comply because of financial constraints.

- 1 month PTA, patient experienced numbness and weakness of both lower extremities described as heaviness of both ankles, which gradually progressed to difficulty in ambulation.

- 1 week PTA, persistence of symptoms prompt consult at NCH where patient was diagnosed to have pott’s disease.- 1 day PTA, patient sought consult at POC OPD and was advised for admission.

PAST MEDICAL HISTORY- Patient was claimed to be born full term via NSD at home with assistance of hilot. Patient was apparently born with a loud cry, pink all over and had strong

movements on both upper and lower extremities. Patient and mother are apparently well after delivery.PERSONAL SOCIAL AND ENVIRONMENTAL HISTORY

- He is the eldest child among 5 siblings. He was in grade VI (primary level). His parents are separated.FUNCTIONAL HISTORY

- Patient was independent in all aspects of ADL prior to illness. At present he is independent to eating, grooming, and dressing. However, is much dependent with activities such as bathing and transferring.

V. PHYSICAL ASSESSMENTA. GENERAL SURVEY

1. Overall appearance and grooming- patient is conscious and coherent. He is thin with muscle atrophy noted on lower extremities. Hunching off the thoracolumbar area was noted. He is wheelchair borne because of immobility.

2. Actual height and weight- his height is 121cm and he weighs 25kg3. Symptoms of distress- presence of wheelchair4. Posture , Gait- he has kyphosis, unable to ambulate independently, he uses wheelchair.5. Relevance and organization of thought- with organize thought and responds to questions correctly

B. VITAL SIGNSTemperature- 36.7 ⁰CPulse Rate- 84 beats per minuteRespiratory Rate- 28 breaths per minute

C. REGIONAL EXAM1. Hair, head and face- he has clean and well distributed hair, and with symmetrical face with good musculature.2. Eyes- he has pale palpebral conjunctivae and unicteric sclerae.3. Nose- no any discharges noted.

4. Ears- he has symmetrical ears with no discharges and have same color with the skin color of his face5. Mouth and Throat- He has pink oral mucosa of the mouth without lesions noted and no halitosis6. Neck and Lymph nodes- He had no complains of any tenderness on his neck. He can turn his head side to side, upward and downward and has no palpable

cervical lymph nodes.7. Skin- He has fair skin complexion with good skin turgor and no pressure sores noted on bony prominences.8. Nails- He has good capillary refill and pinkish nail bed.9. Thorax and Lungs- He has symmetrical chest wall expansion, with no retractions and with clear breath sounds. 10. Cardiovascular- He has a dynamic precordium and normal heart rate. He was noted to have regular heart rhythm and no murmurs upon auscultation.11. Breasts and axillae- He has no tenderness and lumps on the breasts and axillary area12. Abdomen- He has flat soft, non tender abdomen with hypoactive bowel sounds noted upon auscultation.13. Extremities- He has full and equal pulses, no cyanosis , no edema on both upper and lower extremities. However, muscular atrophy was noted only on lower

extremities.14. Genitals- not assessed15. Rectum and anus- not assessed16. Musculoskeletal- he has gibbus formation on his thoracolumbar area. He can perform ROM on both upper extremities fairly but can’t perform full ROM on

lower extremities because of weakness and muscle atrophy. Muscle strength on upper extremities is graded as 3/5 (fair) and 2/5 (poor) on both lower extremities according to muscle strength grading scale.

VI. Anatomy And PhysiologyThe Vertebral Column

The vertebral column (also called the backbone, spine, or spinal column) consists of a series of 33 irregularly shaped bones, called vertebrae. These 33 bones are divided into five categories depending on where they are located in the backbone. The first seven vertebrae are called the cervical vertebrae. Located at the top of the spinal column, these bones form a flexible framework for the neck and support the head. The first cervical vertebrae is called the atlas and the second is called the axis. The atlas' shape allows the head to nod "yes" and the axis' shape allows the head to shake "no".

The next twelve vertebrae are called the thoracic vertebrae. These bones move with the ribs to form the rear anchor of the rib cage. Thoracic vertebrae are larger than cervical vertebrae and increase in size from top to bottom.

After the thoracic vertebrae, come the lumbar vertebrae. These five bones are the largest vertebrae in the spinal column. These vertebrae support most of the body's weight and are attached to many of the back muscles.The sacrum is a triangular bone located just below the lumbar vertebrae. It consists of four or five sacral vertebrae in a child, which become fused into a single bone after age 26. The sacrum forms the back wall of the pelvic girdle and moves with it.

The bottom of the spinal column is called the coccyx or tailbone. It consists of 3-5 bones that are fused together in an adult. Many muscles connect to the coccyx.

These bones compose the vertebral column, resulting in a total of 26 movable parts in an adult. In between the vertebrae are intervertebral discs made of fibrous cartilage that act as shock absorbers and allow the back to move. As a person ages, these discs compress and shrink, resulting in a distinct loss of height (generally between 0.5 and 2.0cm) between the ages of 50 and 55.

When looked at from the side, the spine forms four curves. These curves are called the cervical, thoracic, lumbar, and pelvic curves. The cervical curve is located at the top of the spine and is composed of cervical vertebrae. Next come the thoracic and lumbar curves composed of thoracic and lumbar vertebrae respectively. The final curve called the pelvic or sacral curve is formed by the sacrum and coccyx. These curves allow human beings to stand upright and help to maintain the balance of the upper body. The cervical and lumbar curves are not present in an infant. The cervical curves forms around the age of 3 months when an infant begins to hold its head up and the lumbar curve develops when a child begins to walk.In addition to allowing humans to stand upright and maintain their balance, the vertebral column serves several other important functions. It helps to support the head and arms, while permitting freedom of movement. It also provides attachment for many muscles, the ribs, and some of the organs and protects the spinal cord, which controls most bodily functions.

VII. Pathophysiology

Untreated Primary TB

Tubercle Bacilli metastasized to bone via hematogenous spread and lymphatic transmission

Spinal lesion begins in anterior subchondral bone of single vertebrae adjacent to the intervertebral discs

Bones destruction starts centrally spreads outwards and may eventually erode into adjacent joint

If invaded the synovial membrane respond with excessive secretion, proliferation and thickening

Tuberculosis granulation tissue forms and covers hyaline articular cartilage and subchondral bone

Destruction leads to anterior wedging of vertebral bodies

Vertebral collapse Gibbus formation and kyphotic deformity

Discharge of necrotic material into soft tissues

Impaired physical mobility

Self bathing or hygiene

deficit

Activity intolerance

Disturbed body image

Risk for impaired skin integrity

VIII. Laboratory

COMPONENT NORMAL RANGE RESULT SIGNIFICANCEPlatelet Count 0.5-2.0 3.57 Elevated in trauma(surgery

fractures)and TB,severe exerciseLeukocyte 4.5-10x10.9g/L 12.00 Elevated during acute infection and

tissue necrosis, Presence of tubercle bacilli in the body activates the body’s defense system(Leukocytes)to respond immediately/combat the tubercle bacilli.

Eosinophil 0.00-0.05 0.15 Allergies, parasitic disease ,cancer, asthma, emphysema, renal dse. Elevated also if there is an increase in steroids produce by the adrenal glands during stress.

Hemoglobin 127-183g/L 126 Decrease in hemoglobin indicates anemia. A slight decrease in hemoglobin is not significant.

IX. Drug Study

Generic name: Rifampicin

Classification: Anti tuberculosis

MECHANISM OF ACTION INDICATION CONTRAINDICATION ADVERSE REACTION NURSING CONSIDERATION

Inhibits DNA dependent polymerase, decreases replication

Maintenance phase treatment of all forms of pulmonary and extra pulmonary tuberculosis

Hypersensitivity, jaundice, severe hepatic disease

GI disturbance pseudo membranous colitis, influenza, like symptoms skin reactions cosinophilia, transient leukopenia thrombocytopenia purpura, shock headache, ataxia, visual disturbances.

Assess lung sounds and character and amount of sputum periodically during therapy.

Assess laboratory and chest x-ray test, therapeutic effectiveness and adverse reaction.

Generic name: Isoniazid

Classification: Antituberculosis

MECHANISM OF ACTION INDICATION CONTRAINDICATION ADVERSE EFFECT NURSING CONSIDERATION

Inhibits RNA synthesis, decreases tubercle bacilli replication

Pulmonary and extra pulmonary tuberculosis(TB) Lupus vulgaris

Should not be given to patients with drug induced liver disease

Various skin eruptions, fever, lymphadenopathy and vasculitis, hypersensitivity, N/V, gastrointestinal disturbances, liver dysfunction, peripheral neuropathy and anemia

Assess lab. Test: sputum, chest x-ray before treatment

Monitor liver and renal function: ALT, AST, bilirubin, BUN, creatine output, urinalysis, uric acid

Asses CNS often: affect mood, behavioural changes

Generic name: Pyrazinamide

Classification: Antituberculosis

MECHANISM OF ACTION INDICATION CONTRAINDICATION ADVERSE EFFECT NURSING CONSIDERATIONS

Mechanism unknown, highly specific and antibacterial for mycobacterium tuberculosis

Treatment of active tuberculosis in adult and selected children

Acute liver disease porphyria, peripheral renritis, history of drug-induced hepatitis, acute gout, hypersensitivity and pregnancy

Dose related hepatoxicity, N/V, anorexia, thrombocytopenia. Sicleroblastic anemia with crythroid hyperplasia, vacnolation of erythrocytes, increase serum iron concentration gout,

Assess pt.s condition before therapy and regularly thereafter to monitor drugs effectiveness.

Monitor serum uric acid which may be elevated and cause gout symptoms

Regular assess renal status: input-output ratio, urinalysis and specific gravity

Regular assess for hepatotoxicity: decreased appetite, jaundice, dark urine and fatigue

Assess pt.s and family’s knowledge of drug therapy

Generic name: Ethambutol hydrochloride

Classification: Antituberculosis

MECHANISM OF ACTION INDICATION CONTRAINDICATION ADVERSE EFFECT NURSING CONSIDERATION

Inhibits the synthesis of metabolism in growing mycobacterium cells, impairing cell multiplication, and causing cell death.

Treatment of pulmonary tuberculosis in conjunction with at least one other anti-tuberculotic

-contraindicated with allergy to ethambutol optic neuritis-use cautiously with impaired renal function lactation, pregnancy, visual problems.

CNS: optic neuritis, fever, malaise, headache, dizziness, mental confusion, disorientation hallucination, peripheral neuritis

GIT: anorexia, N/V, Abdominal pain, transient liver impairment

Administer with food if GI upset occurs

Administer in sinlge daily dose, must be used in combination with the other antituberculosis drug

Arrange for follow up of liver and renal function test, CBC, ophthalmologist examination

Generic name: Streptomycin

Classification: Anti-infective

MECHANISM OF ACTION INDICATION CONTRAINDICATION ADVERSE EFFECT NURSING CONSIDERATION

Cytotoxic: inhibits DNA synthesis leading to cell death partially through the production of intra stand cross-links in DNA cell cycle non-specific

Metastatic islet cell carcinoma of the pancreas

Contraindicated with allergy to streptomycin: hematopoietic depression: pregnancy, lactation

Use cautiously with impaired renal or hepatic function

CNS: lethargy, confusion, depressionGI: N/V, diarrhea, hepatotoxicityGU: Renal toxicityOther: infertility, Cancer, inflammation at injection site

Obtain baseline information before and during treatment

Complete C & S testing before and after drug therapy to identify if correct treatment has been initiated

Identify urine output: if decreasing. Notify physician; also increased BUN, creatinine , urine CrCl< 80 mL/min

Monitor for bleeding; echymosis bleeding germs, hematuria, stool guaiac daily if on long term therapy.

X. LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY 1. Hyperthermia2. Impaired Physical Mobility

3. Activity Intolerance4. Disturbed Body Image5. Self Care Deficit on bathing, toileting and transferring6. Risk for impaired skin integrity

XI. NURSING CARE PLAN

ASSESSMENT NURSING DIANOSIS

SCIENTIFIC EXPLANATION

PLANNING NURSING INTERVENTION RATIONALE EVALUATION

S:“Di niya maigalaw ang kaliwang kamay niya at din na nakakatayo”, as verbalized by his mother

O: Limited range

of motion Absence of

any movement at lower extremities and weak left upper extremity based on hand grip.

Needs

Impaired physical mobility related to musculoskeletal impairment and loss of integrity of bone structures.

Due to vertebral collapse, formation of gibbus in the vertebrae occurs, leading to stiffness, alternation of motor function. Thus, impaired physical mobility may arise.

During the shift the patient will be able to perform activities within his capacity safely

Within the shift the patient will be able to perform simple ROM exercise

Identify causative contributing factors that may restricted movement

Assess muscle strength

Assess functional ability by determining degree of immobility emotional, behavioral, response to problems of immobility.

Assist with repositioning on a regular schedule

Support affected body parts using foot support

Diagnosis of pain, nutritional status, and perception restricts movements

To determine adequate functioningof muscles

Feelings of frustration may impede attainment of goals

To promote mobility and circulation even when in bed

To maintain position of function and reduce risk of

During the shift the patient had able to perform activities within his capacity safely and able to perform simple ROM exercises on the upper extremities.

assistance with ADL

Muscle strength of 2/5 on lower extremities

Muscle atrophy of lower extremity noted

Mobilized thru wheelchair

presence of ulcers.

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATIONS:“Mainit ang pakiramdam ko”

O: Weak looking Skin warm to

touch Flushed skin Diaphoretic Needs assistance

in performing ADL

Febrile 39.8⁰C

Hyperthermia related to infectious and inflammatory process.

Due to invasion of microorganism in the body it activates the inflammatory and defense mechanism of the body (leukocytes). Leukocytes release pyrogens which elevates body temperature.

After 1-2 hours of rendering nursing care, the patient’s body temperature will decrease from 39.8⁰C to 37.3⁰C

Vital signs taken and recorded

Remove extra clothing

Render tepid sponge bath

Give medication as ordered like paracetamol

Encouraged to increase fluid intake

Serves as baseline data

Decrease body temperature through process of radiation, evaporation, and convection

To help decrease body temperature through process of evaporation and conduction

Paracetamol acts on the heat regulating center, the hypothalamus which causes vasodilation and therefore dissipates heat from the body

To replace lost body fluids and proper hydration

Goal achieved, patient’s temperature decreased from 39.8⁰ to 37.3⁰

ASSESSMENT NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING INTERVENTION RATIONALE EVALUATION

S> “Nahihirapan akong tumayo ng mag isa dahil nanghihina ako”

O> unable to move without assistance> facial grimace when moving up> body malaise> limited ROM>Muscle strength Lower extremities 2/5 (poor)>unable to walk, on wheelchair> dependent with bathing, toileting and transferring

Activity intolerance related to muscle weakness on lower extremities

Vertebral collapse alters the sensory and motor function of the body resulting to intolerance of performing activities.

After the shift the patient will be able to gradually perform activities within his capacity.

Assess for muscle strength

Plan care with rest periods between activities

Plan for progressive increase of activity level/participation in exercise training, as tolerated by the client

Encourage to eat nutritious foods such as rich in proteins and carbohydrates

Continue physical therapy

To determine adequate functioning of muscles

To conserve energy

Both activity tolerance and health status may improve with progressive training

Protein aids in wound healing and cell regeneration. Carbohydrates yields energy for the body

To improve muscle strength and sensory and motor function

After the shift the patient had perform activities within his capacity as evidenced by gradual range of joint motion with moderate assistance.

PANPACIFIC UNIVERSITY NORTH PHILIPPINES

Urdaneta City, Pangasinan

A Case Analysis of Pott’s Disease

SUBMITTED BY: GROUP 6

CORPUZ, Charity Mae DE GUZMAN, Moises ELASIN, Rhea

COVITA, Marjun Rey DIRILO, Lorenz ESPIRITU, Jonjie Marie

DACULAN, Juressa Joy DU, Lea FERNANDEZ, Mary Ann

DE GUZMAN, John Jeevy ELASIN, Melody FERMO, Catherine

CLINICAL INSTRUCTOR

Ms. Jovelyn ANCHETA, RN

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