Case Pres_sci Potts

8/2/2019 Case Pres_sci Potts

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General Objective:

This case presentation seeks to enhance the students knowledge with regards to the patients

general health and disease condition, its pathophysiology, possible complications, treatment

plan and medical regimen. It also seeks to assimilate the students skills through application of

several nursing interventions and medical management. Furthermore, this case presentation

intends to improve the students attitude by conveying open-mindedness and utilizing

therapeutic communication all throughout the activity.

Specific Objectives:

Within a week of thorough study of this specific case, the student nurses aim to achieve the

following objectives in this case presentation:

Accurately present a thorough general health assessment of the client which includes physical

assessment and family history taking.

Effectively discuss and elaborate actual signs and symptoms of the specific diagnoses exhibited

by the client.

Thoroughly discuss, explain, and elaborate the nature of disease process.

Effectively provide appropriate and proper nursing diagnoses in line with the clients medical

condition.

To discuss the pathophysiologic mechanism of the disease process of Spinal cord injury

secondary to Potts disease, placing emphasis on how the complications and the disease

etiology relate and sync with each other.

To accurately explain the various laboratory examinations that is required for the detection of

the disease and how significant remarks or findings relate to this disease.

To site various drugs required for the treatment of the disease in giving a client-based analysis

on the said pharmacologic treatment. To evaluate the presenting clinical manifestations based on overall condition with emphasis

placed on the alterations.

Skillfully formulate nursing care plans for the different problems identified.

Appropriately provide nursing interventions according to the standards of nursing practice.

Effectively apply the learned concepts and theories of the disease and the management

Effectively appraise the effectiveness and efficacy of nursing interventions rendered to the

client.

Impart the outcome of the rendered nursing interventions.

Convey the significance of clients response to the rendered nursing interventions.

To be able to give health teachings regarding the prevention and cure of the Spinal cord injury

secondary to Potts disease.


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INTRODUCTION

A. BACKGROUND OF THE STUDYI. Incidence, race, gender, age, ration and proportion

20- 30% of the 172,483 cases in the Philippines has Pott's disease

People who are affected are African American, Hispanic American, Asian American and foreign

born individuals

Most common in males than women

In the Philippines 75% of children are affected

( 2 : 1 ) = Male: Female

II. Rationale for choosing the caseThe group has decided to choose the case of Ms. G with a diagnosis of Acute Spinal Cord

Injury Incomplete SL T4, secondary to pathologic fracture of T11-T12 secondary to Potts disease

because it was the kind of illness that is common among children even in adults in terms of

orthopedic cases and one of the cause why many people became hospitalized and died. It risen

dramatically, and for us its an interesting case.

III.

Significance of the studyThe significance of this study is to enhance the knowledge, to develop skills and the

right attitude of the student nurses in giving care for the patient with spinal cord injury

secondary to Potts disease, its importance and implication. This study will serve as guidelines in

providing nursing care to those who have the same disease.

These are other significance of the study that would support the above statement:

To understand the underlying facts about spinal cord injury secondary to Potts disease

Determine the nursing history: personal data, health history, and physical assessment of the

patient

To illustrate the anatomy, physiology and pathophysiology of the affected organ (vertebral

column)

To discuss and determine manifestation and complication

To develop an effective skill managing a proper care based on the specific signs and symptoms

the patient is experiencing and the results of laboratory examination.

Formulate a drug study on the case

To provide the patient nursing care plan and discharge plan to assure the total wellness


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IV. Scope of limitationThis case study was conducted at Philippine Orthopedic Center, Quezon City Manila in a

12 year old patient with spinal cord injury secondary to Potts disease. The group gathered the data

by conducting interview with the patient and family members. The group also conducted

assessment regarding the patient's health status by observing her especially the vertebral column

and level of functioning of the lower extremities of the patient in order to validate the signs and

symptoms of the disease.

For the duration our study, we started our visit last May 24, 2011 and ended May 27, 2011 for 2

consecutive days. The group wasn't able to acquire more days for observation due to our lack of

time to conduct it.

V. Theoretical FrameworkFor the theoretical framework, we used the 21 nursing problems according to Faye Glenn

Abdellah. She defined nursing as broadly grouped into 21 nursing problem areas to guide care

and promote the use of nursing judgment. She also said that nursing is a service that is based on

the art and science and aims to help people, sick or well, cope with their health needs.

Abdellah's typology was divided into three areas:

(1) The physical, sociological, and emotional needs of the patient;

(2) The types of interpersonal relationships between the nurse and the patient

(3) The common elements of patient care.

Abdellah's Typology of 21 Nursing Problems:

To promote good hygiene and physical comfort

To promote optimal activity, exercise, rest, and sleep

To promote safety through prevention of accidents, injury, or other trauma and

through the prevention of the spread of infection

To maintain good body mechanics and prevent and correct deformities

To facilitate the maintenance of a supply of oxygen to all body cells

To facilitate the maintenance of nutrition of all body cells

To facilitate the maintenance of elimination

To facilitate the maintenance of fluid and electrolyte balance

To recognize the physiologic responses of the body to disease conditions

To facilitate the maintenance of regulatory mechanisms and functions

To facilitate the maintenance of sensory function

To identify and accept positive and negative expressions, feelings, and reactions

To identify and accept the interrelatedness of emotions and organic illness

To facilitate the maintenance of effective verbal and nonverbal communication


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X-ray

CT- scan

MRI

Nursing diagnoses

Acute painDisturbed body image

Self- care deficit

Nursing Intervention

a. Assess pain

b. Assess range of movements in all extremities

c. Promote beds rest

d. Advise and emphasize proper diet

e. Advise increase fluid intake

f. Maintain skin integrity

g. Patients education

Medical management

a. Immobilize the spine

b. Control of the infection

c. Minimize the deformity

d. Build up resistance of the patient through

V-itamins

I-soniazid

P-yrazinamide

E-thambutol

R-ifampicin

S-treptomycin

Surgical Management

Anterior spinal decompression

Spinal fusion

Spinal Cord Injury

Definition

It refers to the injury to the spinal cord that is caused by trauma instead of a disease. Trauma to

the spine can occur at any level button most commonly occurs in the cervical and lower thoracic-upper

lumbar vertebrae.

AKA: Cord Compression, Cord curvature

Classification of SCI

Complete injury no function below the neurological level

Incomplete injury retains some sensation or movement below the level of the injury

Spinal cord injury without radiographic abnormalitydamage inside the column

Spinal cord injury with radiographic abnormalitydamage on both column and cord

Causes:


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a. A motor vehicle accident

b. Acts of violence

c. Falls

d. Sports and recreation injuries

e. Diseases

Risk factors

a. Age

b. Gender

c. Alcohol

d. Drugs

Predisposing factors

a. Trauma

b. Sports activities

Signs and Symptoms

CERVICAL (NECK) INJURIES

When spinal cord injuries occur in the neck area, symptoms can affect the arms, legs, and middle of the

body. The symptoms may occur on one or both sides of the body. Symptoms can include:

Breathing difficulties (from paralysis of the breathing muscles, if the injury is high up in the

neck)

Loss of normal bowel and bladder control (may include constipation, incontinence, bladder

spasms) Numbness

Sensory changes

Spasticity (increased muscle tone)

Pain

Weakness, paralysis

THORACIC (CHEST LEVEL) INJURIES

When spinal injuries occur at chest level, symptoms can affect the legs:

Loss of normal bowel and bladder control (may include constipation, incontinence, bladder

spasms)

Numbness

Sensory changes


Pain

Weakness, paralysis

Injuries to the cervical or high thoracic spinal cord may also result in blood pressure problems, abnormal

sweating, and trouble maintaining normal body temperature.

LUMBAR SACRAL (LOWER BACK) INJURIES

When spinal injuries occur at the lower back level, varying degrees of symptoms can affect one or both

legs, as well as the muscles that control your bowels and bladder:

Loss of normal bowel and bladder control (you may have constipation, leakage, and bladder

spasms)


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Numbness

Pain

Sensory changes


Weakness and paralysis

Complication

Urinary tract problem

Bowel management difficulties

Pressure sores

Deep vein thrombosis

Lung and breathing problems

Autonomic dysreflexia

Spasticity

Pain

Diagnostic test

a. MRI

b. Myelography

c. Somatosensory

d. Spine X-ray

e. Ct-scan

Nursing diagnoses

Risk for injury

Risk for infection

Impaired physical mobility

Nursing intervention

a. Assess airway, breathing, circulation

b. Perform a quick head to toe assessment

c. Immobilize the patient in the position found until help arrive

Acute care

1. Maintain optimum respiratory function

2. Maintain fluid & electrolyte balance and nutrition

3. Maintain immobilization and spine alignment

4. Prevent complications of immobility

5. Maintain urinary elimination

6. Monitor temperature control

7. Prevent infection

8. Perform ROM, exercise to maintain muscle tone

9. Turn the position often to prevent pneumonia, embolism, & skin breakdown

Medical management

a. Pharmacologic therapy

High dose corticosteroids (methylprednisole)

b. Respiratory therapy


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Oxygen administration

Diaphragmatic pacing (electric stimulation of the phrenic nerve

Surgical management

a. Laminectomy excision of the posterior arches and spinous processes of a vertebra

B. CLINICAL SUMMARYI. GENERAL DATA PROFILE

NAME: Patient G

ADDRESS: Blk. 26, Lot 10 Teachers vil. San Jose del Monte, Bulacan

BIRTHDAY: December 10, 1999

BIRTHPLACE: Bataan

SEX: Female

AGE: 12 years old

RELIGION: Roman Catholic

NATIONALITY: Filipino

DATE OF ADMISSION: April 28, 2011

ADMITTING DIAGNOSIS:Potts disease T11-T12 with neurologic

II. CHIEF COMPLAINT:Prior to admission, the patient experience weakness of both lower extremities

III. NURSING HISTORY:

1. History of the Present Illness:

Present condition started 3 months PTA, when accidentally hit her back after tumbling. She

experienced on and off lower back pain described as sharp with pain scale of 9/10, non

radiating, aggravated by supine position and relieved by standing position. This was associated

with on and office fever and chills. There was no numbness or weakness noted. Patient took

Paracetamol500 mg. /tabs every 4 hrs. which provided temporary relief of symptoms. No

consultation done. Patient was able to ambulate independently at this time. Patient had

spontaneous voiding and normal bowel movement.

2. Past Medical History:

a. Childhood Illnesses

-no asthma, no heredofamilial disease

-(+) mumps (2008)

b. Immunizations

-fully immunized (BCG, DPT, OPV, Hepa B, Measles)

c. Allergies

-no known allergies


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D. FAMILY HISTORY

LEGEND:

Male Deceased

Female Deceased

Female ( Alive & Well)

Male ( Alive & Well)

Grandfather

(A&W)

*UTI

Grandmother

(A&W)Grandfather

Grandmother

Uncle A

(A&W)

Uncle B

(A&W)

Father

48y/o

(A&W)

Aunt A

(A&W)

Uncle C

(A&W)

Aunt A

(Unknown)

Mother

46y/o(A&W)

Aunt B

(A&W)

Sister 1

(A&W)

18 /o

Sister 2

(A&W)

16 /o

PATIENT

SCI 2 to

Potts disease

12y/o

Sister 3

(A&W)

10 /o


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E. SOCIAL HISTORY

Psychosocial Theory according to Erik Erikson

STAGE AGE CENTRAL TASK CHARACTERISTICS

School Age 6-12 years old Industry vs. Inferiority >Emerging confidence in

own abilities.

>Taking pleasure in

accomplishments.

PSYCHOSOCIAL THEORY ACCORDING TO ERIK ERIKSON:

According to this theory, school age primary developmental task is one of contributing factor in

competency. When a person makes a contribution during this period, school age children do what is

best for them to accomplish something.

Based on our interview with the client, we found out that the theory of Erikson correlates with

the information weve gathered from the patient. She has her own family and she study hard and go to

school during school hours.

According to Sigmund Freuds Developmental Stage

STAGE AGE CHARACTERISTICS IMPLICATION

Genital 11-13 years old >Energy is directed toward full

sexual maturity and function

and development of skillsneeded to cope with the

environment

>Encourage separation

from parents,

achievement ofindependence and

decision making

According to this theory, the genital stage correlates to her age because she was her own peers with the

same and opposite sex. When it comes to decision making, she ask for his fathers opinion too.

According to Jean Piagets Cognitive Development

STAGE AGE CHARACTERISTICS INTERPRETATION

Concrete Operational 6-12 years old The child begins to

apply logic thinking,

understands spatiality

and reversibility.

The child is increasingly

social and able to apply

rules however thinking

is still concrete.


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According to Sullivans Life Stages

STAGE AGE CHARACTERISTICS INTERPRETATION

Preadolescence 8-12 years old >Move to genuine

intimacy with friend of

the same sex.

>Move away from a

family as a source of

satisfaction in

relationships.

Capacity for

attachment, love and

collaboration emerges

or fails to develop.

F. ENVIRONMENT/LIVING CONDITION

The environment where he lives can be found in Bulacan. The place is clean and suitable for

living. They live in a bungalow with two bedrooms and one toilet outside the house all inaccessible to

wheelchair.

Regarding the hospital environment at Philippine Orthopedic Center where she was confined, it

is a good place to stay on for her safety but the ventilation and lighting interferes with her sleep pattern

and resting period.


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G. PHYSICAL ASSESSMENT

Admission (April 28, 2011)

PARAMETERS ACTUAL FINDINGS INTERPRETATION

General Appearance

Anthropometrics

Skin

HEENT

>Conscious and Coherent

>Not in cardio - respiratory distress

Ht: 37 Wt: 25kg

.

No rashes; with good skin turgor

Pink palpebral conjunctiva, white

sclera, no tonsillopharyngeal

congestion, no nasoaural discharges.

>The patient is wellcooperative.

>The general appearance is

normal.

Normal

The patient is free from

dehydration.

Normal

Chest/Lungs Symmetrical chest expansion, no

retractions, clear breath soundsNormal

Heart Adynamic precordium, normal heart

rate, no murmurs

Normal

Musculo-skeletal (upper and

lower extremities)

Full and equal pulses, no edema, no

cyanosis

Full ROM to both lower extremities,

actively, pain-free

Normal

Back

There is presence of palpable gibbus in

the thoracic area specifically T11 andT12.

Due to hypoplasia or wedging of

one or more lower thoracic orupper thoracic.


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(May 24, 2011)

PARAMETERS NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

General Appearance

Anthropometrics

Skin

Hair

-Clean in appearance

and well-groomed

-Cooperative

Ht: 37 Wt: 25kg

-With good skin turgor

-Evenly distributed hair

-Thick hair

-Clean in appearance

and well-groomed

-Cooperative

Ht: 37 ; Wt: 23kg

-With fair skin turgor

-Evenly distributed hair

-Thick hair

The patient is well

cooperative.

Loss of appetite- sign of

potts disease.

The patient is slightly

dehydrated.

Normal

Nails -With good capillary refill

of 1-2 seconds

-With pinkish nail beds

-With clean and short

nails

-With good capillary refill

of 1-2 seconds

-With pinkish nail beds

-With clean and short

nails

Normal

Skull and Face -Mouth uniform

consistency; absence of

nodules and masses

-Rounded smooth skull

contour

-Symmetrical facialmovement

-Mouth uniform

consistency; absence of

nodules and masses

-Rounded smooth skull

contour

-Symmetrical facialmovement

Normal

Eyes No eye discharge

With pinkish conjunctiva

(+) blink reflex

No eye discharge

With pinkish conjunctiva

(+) blink reflex Normal

Ears Auricle color same as

acial skin

Auricle are mobile firm

nd not tenderAble to hear on both

ars

No edema and discharge

Auricle color same as

acial skin

Auricle are mobile firm

nd not tenderAble to hear on both

ars

No edema and discharge

Normal


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Mouth

Pinkish lips

With pink gums

No foul odor

With symmetrical

ontour

Pinkish lips

With pink gums

No foul odor

With symmetrical

ontour

Normal

Musculo-skeletal (upper

and lower extremities)

Symmetrical

No atrophy

With full range of

otion

(+) tingling sensation on

both feet and

(+)weakness noted

Lower extremities are

affected due to evident

spinal cord injury and

nerve compression.

Abdomen -No abdominal

distention

-Symmetrical contour

-No abdominal

distention

-Symmetrical contour

Normal

Back Flat

There is presence of

palpable gibbus in the

thoracic area specifically

T11 and T12.

Due to hypoplasia or

wedging of one or more

lower thoracic or upper

thoracic.


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H. Patterns of Functioning

Functional health

pattern

Before hospitalization During hospitalization Interpretation

Health management

pattern

Patients have clean

environment indoors

and some hazardous

materials outside,

which makes it

accident prone.

Patient has a clean

environment.

Patients environment

before hospitalization

is the one that

affected & inflicted

the patients condition

Nutritional/

Metabolic

a. Number of meals a

day.

b. Appetite

c. Glass of water/ day

d. Body built

e. height and weight

Patient usually eats

junk food and drinks

carbonated beveragesoften more than she

drinks water.

Patient prefers eating

junk food than meals

being served in her

house by her mother.

Patient has a low

appetite before

hospitalization.

Patient drinks one

glass of water a day.

Patient is thin

Ectomorph

Patient eats what is

being served, usually

vegetables, meats and

fruits.

Patient eats three

times a day as they are

served.

Patient has normal

appetite.

Patient drinks a glass

of water every meal.

Three glasses a day.

Patient is thin.

Patients diet before

might have an effect

the patientscondition. Have a fair

appetite during

hospitalization.

Her fluid intake is not

sufficient and might

lead to other possible

complications.

Elimination Patient has regular

urination and irregular

bowel movement.Patient defecates once

every 3rdday

Patient urinates twice

day 350 ml and

defecates once a dayHard stool. She has

no difficulty on

passing stool and

urine.

Patient elimination

pattern is not yet

normal because ofdecrease in activity

and effect of the

disease process.

Activity and exercise Patient usually plays

outside and serves as

her daily exercise.

Then eats junk foods

with friends

Patients only exercise

is turning from side to

side and stretching of

limbs. And doing

divisional activities likecoloring.

She doesnt have

enough exercise for

her age to strengthen

her ROM.


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Roles and relationship Patient has good

relationship with all

the family members

and playmates.

Patient has good

relationship with her

family. Her

communication is

lessened due to

unfamiliarity to co-

patients.

Patient has good

relationship to her

mother but has

limited socialization

and communication

with co-patients.

Values and beliefs Patient has good

religious beliefs as a

Roman Catholic and

goes to church

regularly.

Patient has good

religious beliefs and

verbally stated that

she prays at times.

Patient has faith in

God before and during

hospitalization

Self-perception/self-concept

She perceives herselfin a positive way; she

is a good daughter and

a good sister.

She perceives herselfin a positive way; she


a good sister.

She still values himselfand views everything

in a positive manner

despite of her

condition.

Self-perception/self-

concept

She perceives herself

in a positive way; she


a good sister.

She perceives herself

in a positive way; she


a good sister.

She still values himself

and views everything

in a positive manner

despite of her

condition.

I. Course in the Ward4-28-11

Doctor ordered to admit client to ward of choice after consent was secured, to monitor clients I&O

every shift. The ordered medications were isoniazid, rifampicin, and pyrazinamide. Ordered to start to

infuse d5.03 NACl 500 KVO. Placed patient to DAT diet. Admitting diagnosis was SCI inc. secondary to

potts disease T11-T12. The nursing interventions were admitting the client to the children's ward,

turning the client every two hours this was to prevent formations of pressure sore, monitored the I&O

to have baseline data and provided deep breathing, explained the different drug indications and side

effects and coughing exercises to promote lung expansion.

4-30-11/ 5-1-11

Doctor ordered IVF of d5.3 NaCl X KVO. The nursing interventions were to infuse ordered IVF and

regulated it as ordered to inscribe the correct amount of the fluid.

5-2-11Client complained of pain @ lower back, doctor prescribed and ordered Mefenamic 250mg 1tab q8 for

pain. Interventions was to give the medication for pain, at the prescribed time to prevent overdose and

citing the indications to keep the patient informed on the medications that she takes.


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5-3-11/5-4-11

Doctor ordered IVF of d5.3 NaCl x KVO. The nursing interventions were to infuse ordered IVF and

regulated it as ordered to inscribe the correct amount of the fluid.

5-05-11

Doctors order was the patient to be placed with a urinary catheter due to pain in urination and bladder

distention, discontinue IV and medications for further laboratory test, refer to ROM exercises and the

client was to be for SGOT, UA and SGPT. Nursing interventions were to withhold the medications to

observe the proper adherence to medication regimen. Requests were forwarded to the lab and the

purpose of the procedure was explained to keep the client informed. Explained the purpose of

catheterization to the client before doing the procedure. Lastly, patient was instructed to proper ROM

exercises to increase overall physical strength.

5-6-11Doctors order were to follow-up UA result, Flush IFC with NSS OD because of possible infection, give

Mefenamic acid 250mg/1tab q6 for pain due to pain in the catheter insertion site and bladder

distention, instruct patient to Active range of motion exercises to both hips, knee uncle and foot.

Nursing interventions done were flushing of IFC with NSS to prevent clogging of the tube, administered

Mefenamic if client complained of pain to prevent overdose of medication.

5-7-11

Doctors order was to discontinue IFC because of pain in catheterization site, measure I&O every shift

and to watch out for bladder distention. The nursing intervention done was removing of catheter using

the clean method to reduce the risk of infection, measured the I&O to report any changes to the

patient.

5-12-11

Doctor ordered for complete blood count, erythrocyte sedimentation rate and C-Reactive protein. The

nursing interventions are to provide a request to be forwarded to laboratory. Explain to the patient the

importance of the CBC, ESR, and CRP.

5-16-11 Doctor ordered to revised PT orders:

Re-evaluation

General body condition exercises

AROMES to left hip knee & ankle joints with GPS towards ending

MRES to right hip, knee, ankle joints with GPS

Maintenance exercise to both upper extremities

GPS to both Hamstring & Heel cords

5-22-11 Doctor ordered:

Referred service consultant

to secure consent for mobilization once with brace

Will follow up KT brace to PASAF officer

Refer accordingly


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J. LABORATORY/ DIAGNOSTIC EXAM:

April 15, 2011:

COMPLETE BLOOD COUNT

Nursing interventions:

The patient is instructed to increase fluid intake to prevent depletion in hematocrit level

Maintain proper personal hygiene

Importance of hand washing

Advised to eat food high in Vitamins. C to enhance immune system

Advised to have adequate rest and sleep

Strictly adhere to treatment regimen

April 28, 2011

URINALYSIS

Physical Characteristics

COLOR: light yellow

pH Level: 6

Color: Amber Yellow

pH Level: 4.5-8

Pale color indicates diluted urine

Normal

Test Result Unit INTERPRETATION

Sodium (ISE)

Potassium (ISE)

Chloride (ISE)

141 meq/L

4.35 meq/L

103 meq/L

135-148 meq/L

3.70-5 meq/L

98-107 meq/L

Normal

Normal

Normal

Test Result Normal Range Interpretation

Hemoglobin 110 g/L 110-158 g/L Normal

Hematocrit 0.35 g/L 0.36-0.46 g/L Decreased levels are

due to acute blood loss

and dehydration.

Leukocyte count 7.7 5-10 cell/mm3 Normal

Differential Count:

Segmenters

Lymphocytes

Monocytes

Eosinophils

0.58

0.41

0.01

.45-.70%

.18-.45%

.04-.08% Indicate susceptibility of

the client to acquire any

form of infection

Platelet Count 684 150-400x10^q/L Indicates fracture due

to trauma


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SPECIFIC GRAVITY: 1.010 1.005-1.030 Normal

Microscopic Findings:

CELLS:

RBC: 0-1/hpf

Pus Cells: 1-3/hpf

1-2hpf

N/A

Normal

Indicates presence of infection

CRYSTAL:

Amorphous Urates: ++ None

*Presence and accumulation of

crystals in urine indicates

formation of renal stones

CHEMICAL TEST:

Sugar: negative

Protein: negative

Negative

Negative

Normal

Normal

Nursing interventions:

Instructed the patient to increase fluid intake and eat fruits and vegetables high in fluid content

such as watermelons, oranges, green leafy vegetables such as lettuce.

May 02, 2011

COMPLETE BLOOD COUNT

TEST RESULT NORMAL

RANGE

INTERPRETATION

Hemoglobin 104 110-158 g/L Normal

Hematocrit 0.33 0.36-0.46 g/L Normal

Leukocyte Count 15.60 5-10 cell/mm3 Indicates presence of infection

SegmentersLymphocytes

Monocytes

Eosinophils

0.570.31

0.08

0.04

.45-.70%

.18-.45%

.04-.08%

0-.04%

NormalNormal

Normal

Normal

Platelet Count 176 150-400x10^q/L Normal

BLOOD TYPE O+

RH TYPING Positive (+)

CRP: Reactive

SEMI-QUANTITIVE

12 mg/L

Child: Not

usually present

Indicates infection and the

client is high risk for coronary

artery disease and can indicate

inflammation in the arterial

system and coronary arteries.


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Nursing Interventions:

The patient is instructed to increase fluid intake

Maintain proper personal hygiene

Importance of hand washing

Advised to eat food high in Vitamins. C to enhance immune system

Advised to have adequate rest and sleep

Strictly adhere to treatment regimen

TEST RESULT REFERENCE RANGE INTERPRETATION

UREA 29.15 10.22-49.88 Normal

CREATININE 0.71 mg/dl 0.50-1.30 Normal

SGOT 31


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ESR WESTERNGREN METHOD

Children

Result Normal range Interpretation

61 0-10 mm/hr Increased due to

chronic inflammatory

process, infections and

nerve damage due to

physiologic stress and

trauma.

Nursing Interventions:

Monitor daily weight and intake and output.

Monitor dietary habits and serum albumin levels.

Increase fluid intake

Use strict aseptic technique for all invasive procedures.

Provide adequate rest and sleep

Administer prescribed medications

RADIOLOGICS

Chest X-ray:

No infiltrates, intact diaphragm, no rib fracture, diaphragmatic sulci intact

Thoracic spine X-ray:

(+) lytic destruction of T11- T12 vertebral bodies, the rest of the spine shows intact vertebral

body height with intact IV disc spaces.


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II. CLINICAL DISCUSSION OF THE DISEASEa. ANATOMY AND PHYSIOLOGY

Vertebral Column

-Forms the longitudinal axis of the skeleton. It is composed of a series of bones called vertebrae and isapproximately 28 inches long in the adult.

- Humans are born with 33 separate vertebrae. By adulthood, we typically have 24 due to the fusion of

the vertebrae in the sacrum.

The top 7 vertebrae that form the neck are called the cervical spine and are labeled C1-C7.

The upper back, or thoracic spine, has 12 vertebrae, labeled T1-T12.

The lower back, or lumbar spine, has 5 vertebrae, labeled L1-L5. The lumbar spine bears the

most weight relative to other regions of the spine.

The sacrum (S1) and coccyx (tailbone) are made up of 9 vertebrae that are fused together to

form a solid, bony unit.

Elements of the Spine

A. Vertebrae

The vertebrae support the majority of the weight imposed on the spine.

B. Intervertebral Disc

Between the spinal vertebrae is discs, which function as shock absorbers and joints. They are designed

to absorb the stresses carried by the spine while allowing the vertebral bodies to move with respect to

each other. Each disc consists of a strong outer ring of fibers called the annulus fibrosis, and a soft

center called the nucleus pulposus. The outer layer (annulus) helps keep the disc's inner core (nucleus)

intact.

C. Facet Joint

The facet joints connect the bony arches of each of the vertebral bodies. Facet joints connect each

vertebra with those directly above and below it, and are designed to allow the vertebral bodies to rotate

with respect to each other.

D. Neural ForamenThe neural foramen is the opening through which the nerve roots exit the spine and travel to the rest of

the body. The foramen creates a protective passageway for the nerves that carry signals between the

spinal cord and the rest of the body.

E. Spinal Cord and Nerves

Functions of the Spinal column

Movement

Flexibility and mobility

Protection of Major Organs

Spinal cord protection

Shock absorption

Bones for attachment (Ligaments, tendons,

muscles)

Produces red blood cells

Mineral storage


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b. PATHOPHYSIOLOGYBOOK BASE

Non-modifiable

Endemic TB Poor socio-economic

condition

Immunocompromised

Poor nutritional status

Modifiable

Home environment Family history

Nutritional status

History of trauma

Exposure to specific microorganism via droplet

Ingestion of bacteria via nasal cavity

Proliferated to the meniges through the bloodstream reaching the subarachnoid space.

Descending proliferation of infection occurs

Mycobacterium tubercle spread from the anterior aspect of vertebral body

adjacent to the subchondral plate

Infection spread to the adjacent

intervertebral disk

Progressive bone destruction

Narrowing of spinal canal Abscess formation

GIBBUS

Collapse in the anterior spine

Spinal cord compression and neurologic deficits

Signs and Symptoms:

Back Pain

Night Sweats

Weight loss

Loss of appetite

Fatigue and general malaise

Pain and stiffness of the spine

Possible Complications if left untreated:

Absces

Spine deformity/

injury

Paraplegia

Kyphosis

(Potts curvature)


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PATIENT BASE

Non- Modifiable

socio-economic condition

Poor nutritional status

Modifiable

History of trauma

Exposure to specific microorganism via droplet

Ingestion of bacteria via nasal cavity

Proliferated to the meniges through the bloodstream reaching the subarachnoid space.

Descending proliferation of infection occurs

Mycobacterium tubercle spread from the anterior aspect of vertebral body

adjacent to the subchondral plate

Infection spread to the adjacent

intervertebral disk

Progressive bone destruction

Narrowing of spinal canal Abscess formation

(+)GIBBUSformation T11-T12

Collapse in the anterior spine

Spinal cord compression and neurologic deficits

Signs and Symptoms:

Back Pain

Weight loss Fatigue and general malaise

Pain and stiffness of the spine

ComplicationsSpine deformity/

injury

Paraplegia

Kyphosis

(Potts curvature)

Thoracic supine x-ray

revealed (+) lytic

destruction of T11-

T12 vertebral bodies.


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III. Nursing Process

Problem Ranking Rationale

Impaired physical mobility

related to decreased muscle

strength as manifested by

limited ROM and limited ability

to perform gross fine motor skills

1 The patients primary complaint

body malaise and muscle

weakness. We ranked this as first

priority because decreased

mobility can cause different

kinds of complication (bed sores,

decreased ROM)

Self-care deficit related to

musculoskeletal impairment

2 The patient has impaired

physical mobility, as a result she

has self-care deficit. We ranked

this as second priority because

this problem is a result of the

primary problem

Risk for impaired skin integrity

related to physicalimmobilization

3 We ranked this as third priority

because as mentioned, it is onlya risk it is possible threat to the

clients condition. Only

prevention is the needed

intervention


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DISCHARGE PLAN

M-edication:

Encourage significant others to continue medications as prescribed by the physician. With a

strict emphasis on explaining the mechanisms of action of the drugs, the prescribed dosage, side

effects, proper timing of intake of drugs and importance of continuing the medications.

E-nvironment/ E-xrecise

Clients environment must be clean to prevent emergence of other diseases, environmental

factors that includes excessive stress such as emotional stress to the patient must be avoided.

Encourage significant others to have a gradual passive ROM to the patient because it will

promote blood circulation and to improve muscle strength in order to promote total range of

motion.

T-reatment:

Instruct the significant others to consult first the physician in anything that will help the patient

in his conditions like physical activities that she must follow and most especially her diet.

Encourage the significant others to compliance on further treatment for the proper

maintenance and gain of optimal health.

Health teachings:

Importance to maintain proper personal hygiene

Strict adherence to medications to promote wellness.

Increase fluid intake to prevent infection and dehydration importance of proper nutritious food

to maintain healthy body.

Immediate report to the physician for any abnormalities to note any complications.

O-ut-patient

Compliance to medical check-up and therapeutic regimen to reduce or prevent risk of

recurrence of the disease condition. Instruct patient to continue medications as prescribed.

Follow up check-up: a week after discharge.

D-iet

Suggest the significant others to let the patient eat healthy food because it helps the patient feel

better and have more energy. Tell the significant others the importance of following diet and

food restrictions. The patient may also consult to a dietary physician to know what are the

correct dietary intake she must maintain. Increase in high fiber foods such as fruits and green

leafy vegetables to prevent constipation, increase in Vitamin C food to boost immune system

and increase in fluid intake to prevent dehydration.


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Case Presentation

Presented to:

Mrs. Jennifer PalacpacPresented by:

Group 1

Alina, Armi

Alcantara, Keith Austin

Baria, Wilmalyn

Caagbay, Kristine Mae

Enriquez, Shielah Anne Marie

Jabrica, Belenia

Plata, Jerome

Racelis, Kristel Joyce

Rosillas, Bien Jannus

DATE PRESENTED: June 1, 2011

Acute Spinal Cord Injury

Incomplete secondary to

Potts Disease

Case Pres_sci Potts

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