Case Study Agad

8/14/2019 Case Study Agad

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Table of Contents

I. AcknowledgementII. IntroductionIII. AssessmentI. Personal data

II. Medical HistoryA.History of present illnessB.Past Medical HistoryC.Family Medical HistoryD.Personal and Social historyIV. Physical assessmentV. Anatomy and PhysiologyVI. PathophysiologyVII. Nursing Care PlanVIII. Drug StudyIX. Discharge PlanningACKNOWLEDGEMENT


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This case study on Pott s disease would not bepossible without those people who continually helpedand contributed in the saidcase study. My heartfeltexpression of appreciation goes out to each and everyoneof you.

First and foremost, I would like to thank the West Bstaff of EAMC for generously giving me their time.

To our Professor, Mam Diente,Mam Donnie forpatiently supervising and assisting us with yourknowledge, as we gradually gothrough the process ofdoing the case study itself, our sincerest thanks.

To our patient, for the generous time extended forme to explore this case; and forgiving me his fullcooperation and kindness that helped me complete theneededinformation for this paper.

Also, to our friends and classmates, who, like me,managed to encourage and support each other amidstevery discouragement anddifficulty, Thank you.

To my parents, for supporting me all the way,providing me with everything I need, financially andemotionally. All of thosethings are genuinelyappreciated.

Last but not the least, to our Almighty Father, forhis unceasing guidance andblessings, for constantlygiving me hope, courage, and patience. Truly, none ofthisis possible without you.

INTRODUCTION


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Tuberculosis (TB) of the spine also known as

Potts disease, Pott s Caries, David's disease,Tuberculosis spondylitis and Pott's curvature,is the most common site of bone infection inTB. The lower thoracic and upper lumbarvertebrae are the areas of the spine mostoftenaffected. The original name was formed afterPercivall Pott, a London surgeon,

who firststudied the disease. When he died, PatrickDavid was the one who continued his work.

Pott s disease results from haematogenousspread of tuberculosis (mycobacteriumtuberculosis) from other sites. The infectionthen spreads from twoadjacent vertebrae intothe adjoining disc space. If only one vertebrais affected,the disc is normal,but if two areinvolved the intervertebral disc, which isavascular, cannot receive nutrients andcollapses. The disc tissue dies and is brokendown by caseation, leading tovertebralnarrowing and eventually to vertebral collapseand spinal damage. A drysoft tissue massoften forms and superinfection is rare.

The disease progresses slowly. Signs andsymptoms include: back pain, fever,nightsweats, anorexia, weight loss, and easyfatigability.

Diagnosis is based on: blood tests elevatedESR , skin tests ,radiographs of thespine , bone scan ,CT of the spine , andbonebiopsy. Gibbus formation is the pathognomonicsign of this disease.


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A person with Pott's disease oftendevelops kyphosis, which results in ahunchback. This is often referred to as Pott scurvature. In some cases, a person with Pott'sdisease may also develop paralysis,referred toas Pott s paraplegia, when the spinal nervesbecome affected by the curvature.

A person who has been diagnosed withPott's disease may be treated through avariety

of options. He or she may utilizeanalgesics or antituberculosis drugs to gettheinfection under control. It may also benecessary to immobilize the area of thespineaffected by the disease, or the person mayneed to undergo surgery in order todrain anyabscesses that may have formed or to stabilizethe spine.

Since Pott's disease is caused by a bacterialinfection, prevention is possiblethroughproper control. The best method for preventingthe disease is reduce oreliminate the spreadof tuberculosis. In addition, testing fortuberculosis is animportant preventativemeasure, as those who are positive for purifiedproteinderivative (PPD) can take medication toprevent tuberculosis from forming.Atuberculin skin test is the most commonmethod used to screen for tuberculosis, thoughblood tests, bone scans, bonebiopsies, andradiographs may also be used to confirm thedisease


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THEORETICAL FRAMEWORK

For the theoretical framework, I used the 21nursing problems according to Faye Glenn Abdellah.She defined nursing as broadly grouped into the 21nursing problem areas to guidecare and promote theuse of nursing judgement. She also said that nursing isaservice that is based on the art and science and aims

to help people, sick or well, cope with their healthneeds.

The 21 nursing problems are as follows:

1) To maintain good hygiene.


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2) To promote optimal activity: exercise,rest, and sleep

3) To promote safety

4) To maintain good body mechanics.

5) To facilitate the maintenance of a supplyof oxygen

6) To facilitate maintenance of nutrition

7) To facilitate maintenance of elimination

8) To facilitate maintenance of fluid andelectrolyte imbalance

9) To recognize the physiologic responseof the body to disease conditions

10)To facilitate the maintenance ofregulatory mechanisms and functions

11)To facilitate the maintenance of sensoryfunction

12)To identify and accept positive andnegative expressions, feelings andreactions

13)To identify and accept theinterrelatedness of emotions and illness

14)To facilitate the maintenance ofeffective verbal and non-verbalcommunication

15)To promote the development ofproductive interpersonal relationships

16)To facilitate progress towardsachievement of personal spiritual goals

17)To cerate and maintain a therapeuticenvironment

18)To facilitate awareness of self as anindividual with varying needs

19)To accept the optimum possible goals

20)To use community resources as aid inresolving problems


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21)To understand the role of socialproblems as influencing factor

ASSESSMENT

I. Personal Data:

Name: B.P.Address: Novaliches Quezon CityAge: 28 years oldSex: FemaleCivil status: MarriedReligion: Roman CatholicBirthday: November 19, 1978Birthplace: ManilaAttending Physician: Dr. Adrian CatbaganAdmitting Diagnosis: Spinal cord compression on T/3levelChief complaint: weakness of lower extremities


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II. Medical HistoryA.History of Present Illness:This is a case of B.P., who was admittedfor the first time last September 13,2007 with a chiefcomplaint of weakness oflower extremities. Thehistory of present illness started two months priortoadmission, when the patient started to experienceweakness of both lowerextremities. No other

associated signs and symptoms were noted. Fewhours prior to admission, persistenceof abovesymptoms prompted consult.

B. Past Medical History:( - ) HPN( - ) DM( - ) asthma( - ) allergy

B.Family Medical History:( - ) HPN( - ) DM

( - ) CA( - ) asthma

C.Personal and Social History:( - ) smoker( - ) alcoholic beverage drinker


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ANATOMY


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The vertebral column provides structural support for thetrunk and surrounds andprotects the spinal cord. Thevertebral column also provides attachment pointsforthe muscles of the back and ribs. The vertebral disksserve as shock absorbers during activities such aswalking, running, and jumping.They also allow thespine to flex and extend.


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MEDICAL/SURGICAL INTERVENTIONS

Management of Pott s disease

Drug treatment is generally sufficient forPott s disease, with spinal immobilization if

required. Surgery is required if there is spinaldeformity or neurological signs of spinal cordcompression.

Standard antituberculosis treatment isrequired. Duration of antituberculosistreatment: If debridement and fusion withbone grafting are performed, treatment can befor six months. If debridement and fusion withbone grafting are NOT performed a minimum of12 months treatment is required.

It may also be necessary to immobilize the

area of the spine affected by the disease, orthe person may need to undergo surgery inorder to drain any abscesses that may haveformed or to stabilize the spine.

Other interventions include application ofknight/ taylor brace, head halter traction.Surgery includes ADSF ( Anteriordecompression Spinal fusion).


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Drug Study

GENERIC NAME: HRZE(isoniazid+rifampicin+pyrazinamide+ethambutol)Brand name: MyrinDosage: 3 tab 30 min before breakfastDrug Classification:Anti-infective

MECHANISM INDICATIONS CONTRA-INDICATIONSADVERSEREACTIONNURSINGResponsibilities


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Unknown.Appears toinhibit cell-wallbiosynthesisbyinterferingwith lipidand DNAsynthesis> Activelygrowingtubercle bacilli>prevention oftubercle bacilli

in thoseexposed totuberculosisor those withpositive skintest resultswhose chestx-rays andbacteriologicstudies areconsistentwith non-progressivetuberculosis-Contraindicated in patientswith acutehepatic diseaseor isoniazidrelated

liverdamge> peripheralneuropathy,fluiddiscoloration,optic neuritis,hepatitis>Usecautiously inelderlypatients>peripheralneuropathy ismorecommon inpatients whoare slowacetylators orwho are

malnourished,alcoholic ordiabetic,>Monitorhepaticfunctionclosely forchanges

GENERIC NAME: ketorolac tromethamineBrand name:ToradolDosage: 30 mg Iv q8hDrug Classification: NSAIDS

MECHANISM INDICATIONS CONTRAINDICATIONSADVERSE

REACTIONNURSINGResponsibilities


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Unknown. > short-term -> drowsiness, > KetorolacProducesanti-inflammatory,analgesic,andantipyreticeffects,

possibly byinhibitingprostaglandin synthesismanagementof moderatelysevere, acutepain for singledosetreatment> Short-termmanagementof moderatelysever, acutepain formultiple dosetreatmentContraindicated in patientshypersensitiveto drug and inthose with

active pepticulcer disease ,recent GIbleeding orperforation,advanced renalimpairment,incompletehomeostasissedation,edema,hypertension,diarrhea,stomatitis,pepticulceration,rash,

diaphoresisisn trecommendedfor children> Usecautiously inpatients withhepatic andrenalimpairment>NSAIDS maymask signsandsymptoms ofinfectionand with highrisk ofbecause oftheirbleeding. antipyreticand anti-inflammatoryactions

GENERIC NAME: ciprofloxacinBrand name: CiprobayDosage: 500mg/cap BIDx5 daysDrugClassification: Fluoroquinolones


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MECHANISM INDICATIONS CONTRAINDICATIONSADVERSEREACTIONNURSINGResponsibilitiesInhibits > Severe or -> headache, > Usebacterial dna complicatedContraindicated retlessness, cautiously insynthesis,bone

or jointto patientsfatigue,patients withmainly byinfections sensitive todrowsiness, CNS disorders,blocking>Complicatedfluoroquinolone edema, such as severeDNA gyrase,intraabdominal s chest pain, cerebralbactericidal. infections nausea,diarrhea,leucopenia,crystalluriaarteriosclerosisor seizuredisorders, andin those withrisk for

seizures.> Monitorpatients intakeand output andobserve forsigns ofcrystalluria>Obtainspecimen forculture andsensitivitybefore givingfirst-dose

PATHOPHYSIOLOGY

Pulmonary tuberculosis


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Spread of mycobacterium tuberculosis from otherExtrapulmomary tuberculosisThe infection spreads from two adjacent vertebraeinto the adjoining disc spaceOne vertebra is affected, the disc is normalTwo are involved, the avascular intervertebral disc cannotreceive nutrients and collapse

Disk tissue dies and broken down by caseationVertebral narrowingVertebral collapseSpinal damageKyphosis, paraplegia, bowel and urinary incontineneceSurgery: evacuation of pus, Anteriordecompression spinal fusionback pain, fever, night sweats,rexia, eight loss, and eaPOTT S DISEASESpread of mycobacterium tuberculosis from otherExtrapulmomary tuberculosisThe infection spreads from two adjacent vertebrae

into the adjoining disc spaceOne vertebra is affected, the disc is normalTwo are involved, the avascular intervertebral disc cannotreceive nutrients and collapseDisk tissue dies and broken down by caseationVertebral narrowingVertebral collapseSpinal damageKyphosis, paraplegia, bowel and urinary incontineneceSurgery: evacuation of pus, Anteriordecompression spinal fusionback pain, fever, night sweats,rexia, eight loss, and ea

POTT S DISEASEGORDON S PATTERN OF FUNCTIONING


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BeforehospitalizationDuringhospitalizationHealth-perception/Health-managementpattern

It is her first timeto get hospitalized.She usually justbears the pain oruses self-medication.She hopes that shewill get better..Nutritional/The patient eats allThe patient stillMetabolic pattern kinds of food.Shelikes to eatvegetables.eats a lot.Elimination pattern The patientdefecates regularlyat least once a dayor sometimesonce

every two days andurinates frequently.The patient sweatsa lot because of theweather.The patient hasurinary and bowelincontinencebecause of spinalcord injury.Activity/ ExercisepatternThe patient s formof exercise is doingthe householdchores.She doesn t have aform of exercise inthe hospitalbecause she isbedridden, as a

result of spinal cordinjury.Sleep-rest pattern The patient usuallysleeps for about 5hours.The patient s sleepwas still for about 5hours.Cognitive/Perceptual patternThe client likes totalk to herneighbors afterdoing all thehousehold chores.At first the clientdoesn t speak muchbut once you haveestablished rapportwith her, you willsee that she is avery friendlyperson. Shebecame open andwas talking morethan before.

Self-perception/Self-conceptpatternThe patient has agood self esteem.The patientsomewhat lost herself-esteem


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because she thinksshe is useless.Role/ RelationshippatternThe patient is veryfriendly and has agood relationshipwith people aroundher.The patient iscommunicativewhen you talk toher but she will not

be the one to openup conversations.Coping/ Stress-WEhen stressed, When the patienttolerance pattern she usuallydivertsit by watchingtelevision.experiences stress,she just prays togod because thereare not otherdiversionalactivities she cando in the hospital.

Discharge Plan

P- atient should be reminded to attend check-ups at the nearest .

O- rthopedic center

T- reatment should be taken in a ..

T- imely manner

S- ight any symptoms other than the usual and report it to the physician


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PHYSICAL ASSESSMENT

Body part Technique used Normal findings Actual findings Analysis/InterpretationHead PalpationInspectionAbsence of massesand nodules

Head does not appear toolarge or too small. Therewere no masses andnodules.NormalEyesHairEarsNoseSkinInspectionInspectionInspectionInspectionInspection

Conjunctiva is pinkUsually black andshiny.Color is the same asfacial skin. Pinnatends to bend easilyand recoils easily afterbending.Symmetrical with nodeformities.Good or active skinturgor. Absence ofAnicteric scleraPink palpebralconjunctivaHair doesn t look dull.Color is the same asfacial skin. No deformities

found. No dischargeSymmetrical. Nodeformities found.(-) nasal congestionGood skin turgor(-) rashesNormalNormalNormalNormalNormal


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Mouth Inspection

Nails Inspection

Arms Inspection

Chest Palpation,

Inspection andAuscultation

ecchymosis.

Uniform, pink color ofthe gums, moist andsmooth in texture

Smooth and usuallylong enough to extendover the fingertips;should be coloredpink, convex in shapeand with 160o anglebetween the nails andthe nailbeds.

Should have goodmuscle contraction.Good flexion and

extension. Absence ofecchymosis anddeformities.

Chest is symmetrical,

NormalPink-colored gums. Moistbuccal mucosa.

NormalGood capillary refill.Light pink in color,convex in shape.

NormalNo ecchymosis noted. fulland equal pulses.

AbnormalSlight DOB(+) gibbus formation


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Abdomen

Genitalia

Legs andExtremities

Respiratory

system

Cardiovascularsystem

Palpation andInspection

InspectionInspection

Auscultation

Auscultation

rhythmic andbreathing pattern iseffortless

Contour is slightlyprotuberant.

Pinkish in color andintact.

Absence ofdeformities and goodROM. Absence ofedema andecchymosis.

No unusual soundsshould be heard; RRshould rangefrom normaland effortlessrespiration.

Regular rhythm, noheart murmurs.

Flat abdomen.Normoactive bowelsounds.

N/A

Grossly normal.No edema.No cyanosis.

Clear breath sounds. Noretractions.


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Adynamicprecordium,normalrate,regular rhythm,Nomurmur

Normal

N/ANormal

Normal

Normal


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NURSING CARE PLAN

Cues Nursing Diagnosis Planning Implementation Rationale EvaluationSUBJECTIVE:Ayoko ngganito.Mahirap.

Inaasa nalanglahat sa iba..Wala namandin akomagawa dahilhindi ko namankaya, asverbalized bythe patient.OBJECTIVE:- patient hasbeen bedriddenever since shewashospitalizedDisturbed bodyimage related totrauma/ injury tospinal cord asevidenced byverbalreports ofnegative feelingsabout body(feelings ofhelplessness andpowerlessness)GOAL:

After 1 day of nursingintervention, thepatient will recognizeand incorporate bodyimage change into self-concept in accuratemanner withoutnegating self-esteem.EXPECTED OUTCOME:The patient will:1) Verbalizeacceptance ofself in situation.2)Verbalize relief ofanxiety andadaptation toactual/alteredbody image.3) Acknowledgeself as anindividual whohas

responsibility forself.Independent:1) Determinewhethercondition ispermanent/ nohope forresolution2) Evaluate level ofclientsknowledge ofand anxietyrelated tosituation.Observeemotionalchanges.3)Have client

describe self ,noting what ispositive andwhat is negative.Beware of howclient believesothers see self.4) Note signs ofgrieving/indictors of depression>To assesscausative/contributingfactors> To assesscausative/


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contributingfactors>To assescausative/contributingfactors>To evaluateneeds forcounseling andEvaluate

response tointerventions,teachings andactionsperformed.* The patientwas able toincorporatebody imagechange intoself-conceptwithoutnegating self-esteem.The goal wasmet.


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5) Identifypreviously usedcopingstrategies and itseffectiveness.

6) Establishtherapeuticnurse-clientrelationshipconveying anattitude of caringand developing asense of trust.

7) Provideassistance withself care needs/

measures asnecessary whilepromotingindividualabilities/independence

Collaborative:

8) Refer toappropriatesupport groups.

9) Talk to SO(s)about ways tohelp client dealwith problem

medication

>To determinecopingskills/capabilities

> To assistclient/SO(s) todeal with/acceptissues of self-concept related tobody image.

>To enhancecapabilities

>To providecontinuity of care

>To promotecollaboration .


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Cues Nursing Diagnosis Planning Implementation Rationale EvaluationSUBJECTIVE:Ang hirap ngganito, nakahigana lang lagi, kahitpaligo inaasa saiba, as

verbalizedby the patientOBJECTIVE:> patient has beenbedridden ever

since she washospitalizedbecause of spinalcord injurySelf-bathing/hygiene deficitrelated to musculoskeletalimpairmentas evidenced byinability to washbody or body parts,obtain or get towater source, get inand out ofbathroom.GOAL:After 1 day ofnursingintervention, thepatient willperform self-careactivities withinlevel of ownabilityEXPECTED

OUTCOME:The patient will:1) Identifyindividualareas ofweakness/needs2) Demonstratetechniques/lifestylechanges tomeet self-care needs3) IdentifypersonalresourcesIndependent:1)

Determine existingconditionsaffecting ability ofindividual to carefor own needs, i.e.spinal cord injury.2) Determineindividualstrengths of client3) Note whetherdeficient istemporary orpermanent, shoulddecrease orincrease in time4) Promote client/ SOparticipation inproblemidentification anddecision making.5) Develop plan ofcare appropriate toindividualsituation,schedulingactivities to

conform to clients> To identifycausative/contributingfactors> To assessdegree ofdisability>To assess degreeof disability>enhancescommitment toplan, optimizingoutcomes> to assist incorrecting/ dealingwith situation


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Evaluateresponses tointerventions,teachings andactionsperformed.*The client wasable to performself-careactivities withinlevel of own

ability.Goal was met


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that canprovideassistance

normal schedule.

6) Assist with rehabprogram

7) Allow sufficienttime for client toaccomplish tasksto fullest extent ofability

8)Assist withnecessaryadaptation toaccomplish ADL s.Begin with familiar,easilyaccomplishedtasks.

9)Review/modify

programperiodically toaccommodatechanges in abilities

Dependent:

10)Administermedicationregimen

Collaborative:

11)Consult withdietitian/nutritionalsupport team

> To enhancecapabiities> To enhancecapabilities

>To encourageclient and build onsuccesses.

>Assist patient toadhere to plan ofcare to fullestextent

>To providecontinuity of care

> To providecontinuity of care


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Case Study Agad

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