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Anatomy and Physiology
The spinal cord is the largest nerve in the body, and it is comprised of the nerves which act as the communication system for the body. The nerve fibers within the spinal cord carry messages to and from the brain to other parts of the body. The spinal cord is surrounded by protective bone segments, called the vertebral column. The vertebral column is comprised of seven cervical vertebrae, twelve thoracic vertebrae, five lumbar vertebrae and five sacral vertebrae. The vertebral column also provides attachment points for muscles of the back and ribs. The vertebral disks serve as shock absorbers during activities such as walking, running and jumping, they also allow the spine to flex and extend.
Introduction Potts disease
Is a spine infection associated with tuberculosis that is characterized by bone destruction, fracture, and collapse of the vertebrae, resulting in kyphotic deformity. Is the presentation of the extra-pulmonary tuberculosis arthritis of the intervertebral joints Also called tuberculosis spondylitis, tuberculous spondyloarthropathy, spinal TB, musculoskeletal tuberculosis The causative agent is Mycobacterium Tubercule Particularly the lower thoracic and the upper lumbar regions are affected. Commonly localized in the thoracic 11 and thoracic 12. The original name was formed after Percivall Potts a London surgeon. Patient with BCG has 80% immunity. Pathognomonic Sign: Gibbus Formation Signs and Symptoms: Back Pain, Fever, Night Sweating, Anorexia, Weight Loss, Spinal mass, sometimes associated with numbness, tingling, or muscle weakness of the legs Diagnostic Exam: Blood Test: elevated erythrocyte sedimentation rate, Tuberculin test, Bone Scan, Radiographs of the spine, CT of the spine, Bone biopsy, MRI Predisposing Factors: Direct contaminant especially in children, Malnutrition, Poor Environmental Condition, Trauma
Nursing History
1. Personal Data Name: Ms. RB Age: 3y/o Sex: Female Address: Sto. Tomas Santiago, Batangas Occupation: N/A Religion: Roman Catholic Date and Time of admission: March 5, 2009 4:30pm Admitting Physician: Dr. HM 2. Chief Complaint Fever and Back pain 3. History of Present illness 5 months before hospitalization the patient felled from the stairs. The patient’s mother brought her to a “manghihilot”. 2 weeks before hospitalization the patient’s mother have seen a mass at the patient’s back, the patient had fever and accompanied with back pain. The mother decided to go to the doctor for consultation. 1 day before hospitalization the patient’s mother went to the hospital and was referred to Phil. Orthopedic Center. The patient was admitted at children’s ward and scheduled for CBC and x-ray of the thoracolumbar spine.
4. Past Medical History The patient’s mother always consults “Manghihilot” when her daughter is sick. The mother has lack of interest in going to health center to seek medical consultation when her daughter is sick. 5. Family Medical History The mother and father of the patient self-medicates when there are sick, the mother said that there family has never been hospitalized. The father works as a construction worker, smoke cigarettes at least 3-4 sticks a day. The mother stays at home to take care of her 5 children.
Pathophysiology
Pulmonary Tuberculosis
Spread of Mycobacterium Tubercule in the T7-T9 of the spine
Extra-pulmonary Tuberculosis The infection spreads from intervertebral disc
Pus formation between the intervertebral disc
Back Pain, Fever, Night Sweats, Spinal mass
Disc tissue dies and broken down by caseation
Vertebral Narrowing
Vertebral Collapse
Spinal Damage
Potts’ Disease
Laboratory / Diagnostic Examinations
March 5, 2009 Blood Chemistry Component: -Hemoglobin mass -Leucocyte count Differential count: -Segmenters -Lymphocyctes -Monocytes -Eosinophils -Platelet count 0.50-0.70 0.20-0.40 0.00-0.07 0.00-0.05 150-400 x 109/L 0.45 0.42 0.08 0.05 532 x 109/L Normal May indicate infection May indicate infection Normal May indicate inflammatory disease 110-150 g/L(female) 4.5-10 x 10 g/L 125 g /L 16.90 g/L Normal May indicate infection Normal Value Result Findings
April 16, 2009 Blood Chemistry Component: -Hemoglobin mass -Hematocrit -Leucocyte count 110-150 g/L(female) 0.37-0.54 4.5-10 x 10 g/L 129 g/L 0.40 Normal Normal Normal Value Result Findings
13.6 x 10 g/L May indicate infection
Differential count: -Segmenters -Lymphocyctes -Monocytes -Eosinophils -Platelet count 0.50-0.70 0.20-0.40 0.00-0.07 0.00-0.05 150-400 x 109/L 0.45 0.50 0.01 0.04 375 x 109/L Normal May indicate infection Normal Normal Normal
March 5, 2009 Urinalysis Electrolytes: Sodium Potassium Chloride 135-148 mmol/L 3.5-5.3 mmol/L 98-107 mmol/L 139.7 mmol/L 3.98 mmol/L 101.7 mmol/L Normal Normal Normal Normal Value Result Findings
March 10, 2009 Urinalysis Normal Value Result Findings
Color Transparency Specific Gravity Reaction
Straw to Dark yellow Slightly Hazy 1.002-1.006
Light yellow Hazy 1.003 Acidic
Normal Normal Normal
March 12, 2009 X-ray of the Thoracolumbar spine Impression: Pneumonitis, both lower lung zone with lyphadenopathies Consolidation vs. Extension of paravertebral abscess, right lower lung zone Potts disease, as described, T6-T11
March 24, 2009 CT scan of the Thoracic spine Impression: Findings as consistent with Potts disease T8-T9 with pulmonary extension as described
Drug Study
Classification Dosage Mechanism of Action Rifampicin inhibits DNAdependent polymerase, decreases replication Indication Contraindication Adverse Reaction Nursing Consideration >Assess lung sounds and character and amount of sputum periodically during therapy >Assess results of periodic laboratory tests and chest x-ray, therapeutic effectiveness and adverse reactions >Monitor patient compliance with treatment regimen
Generic Name: Rifampicin Brand Name:
Anti-infectives
200mg/5ml syrup 6ml OD ac PO
Maintenance phase Hypersensitivity, treatment of all jaundice, severe forms of hepatic disease pulmonary and extra-pulmonary tuberculosis(TB)
GI disturbances, pseudomembranous colitis (rare), abnormalities of liver function, fatalities in those with liver disorders, influenza-like symptoms, skin reactions, eosinophilia, transient leucopenia, thrombocytopenia, purpura, shock, drowsiness, headache, ataxia, visual disturbances, menstrual irregularities. Reddish colored urine and tears. IV: Thrombophloebitis; extravasation following local irritation and inflammation.
Classification
Dosage
Mechanism of Action Isoniazid inhibits RNA synthesis, decreases tubercule bacilli replication
Indication
Contraindication
Adverse Reaction
Nursing Consideration >Assess laboratory examinations >Monitor liver/renal function >Assess CNS often >Assess hepatic status >Assess for visual disturbance that may indicate optic neuritis
Generic Name: Isoniazid Brand Name:
Anti-infectives
200mg/5ml syrup 6ml OD ac PO
Pulmonary and extra-pulmonary tuberculosis(TB)
Acute liver disease or history of hepatic damage during INH therapy; hypersensitivity
Peripheral neuritis, optic neuritis; psychotic reactions, convulsions, nausea, vomiting, fatigue, epigastric distress, visual disturbances, fever, rash, pyridoxine deficiency
Classification
Dosage
Mechanism of Action Paracetamol exhibits analgesic action by peripheral blockage of pain impulse generation. It produces antipyresis by inhibiting the hypothalamic heat-regulating centre. Its weak anti-inflammatory activity is related to inhibition of prostaglandin synthesis in the CNS.
Indication
Contraindication
Adverse Reaction
Nursing Consideration >Assess patient’s fever >Assess for allergic reactions >Assess hepatotoxicity >Monitor liver and renal functions
Generic Name: Paracetamol Brand Name:
Analgesics
125mg/5ml syrup 5ml Q4 PRN PO
Treatment of fever
Hypersensitivity
Stimulation, drowsiness, nausea, vomiting, abdominal pain, hepatotoxicity, hepatic seizure, renal failure, luekopenia, neutropenia, hemolytic anemia, thrombocytopenia, pancytopenia, rash, urticaria, hypersensitivity, cyanosis, anemia, neutropenia, jaundice, pancytopenia, CNS stimulation, delirium followed by vascular collapse, convulsions, coma, death
Nursing Care Plan
Assessment Subjective: “Kulang daw siya sa timbang sabi ng doctor” as verbalized by the mother Objective: -Under weight -Lack of interest in eating nutritious food Diagnosis Imbalanced Nutrition less than body requirements related to ingest adequate nutrients Inference Pulmonary Tuberculosis Planning After 8hrs of Nursing Interventions the patient will demonstrate a behaviors to achieve appropriate weight Intervention -Assess weight, age, body build, strength, activity/rest level -Discuss eating habits, including food preferences to the mother -Administer Vitamins as ordered -Encourage and provide for frequent rest periods Rationale -To provide comparative baseline Evaluation After 8hrs of Nursing Interventions the patient has demonstrated a behaviors to achieve appropriate weight
Weakens immune system
-To appeal to the patients likes
Generalized weakness
-To enhance patients intake -To conserve energy, especially in metabolic requirements -To maximize nutrient intake without undue fatigue -To reduce bad taste left from the medications used in respiratory treatment
Loss of appetite
Imbalanced Nutrition -Encourage small, frequent meals with food high in protein and carbohydrates -Provide oral care before/after meals at bedtime
Assessment Subjective: “Nilagyan siya ng Taylor Brace” as verbalized by the mother Objective: -Limited range of motion -Difficulty in turning -Presence of Taylor Brace
Diagnosis Impaired Physical Mobility related to therapeutic restrictions of movement
Inference 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
Planning After 4hrs of Nursing Interventions the patient’s mother will verbalize understanding of the situation and treatment regimen and safety measures
Intervention -Encourage to change position every 2 hours -Schedule activities with adequate res periods -Provide regular skin care -Provide passive exercises -Encourage adequate intake nutritious foods -Explain the use of adjunctive devices such as Taylor Brace
Rationale -To prevent complications
Evaluation After 4hrs of Nursing Interventions the patient’s mother has verbalized understanding the situation and treatment regimen and safety measures
-To reduce fatigue
-To promote good hygiene -To maintain muscle integrity -To maximize energy production
-To promote knowledge and enhances safety