LYCEUM OF THE PHILIPPINES UNIVERSITY

COLLEGE OF NURSING


A
CASE ANALYSIS
ON
POTTS DISEASE





















I. PATIENTS PROFILE
NAME: Patient JA
Age: 8 years old
Date of Birth: December 14, 2006
Status: Child
Educational Attainment: Grade 2
Address: 157 Capino St. Brgy. Silangan, Dolores Quezon
Date Admitted: December 12, 2013
Doctor Incharge: Dr. Callangan, Dr. Garcia/ Palumar
Diagnosis: Potts Disease T
11
-T
12
NAD L
1
- L
2
Chief Complaint: back pain

II. NURSING HISTORY
Past History:
Patient was delivered via Normal Spontaneous Delivery at home, there
were no problems developed during pregnancy. His common illness were cough
, colds, fever and flu. The patient had complete vaccinations. Has no known
allergies to food and drugs.
Three months prior to admission (October 2013) the patient noted pain on
low back area while walking towards their relative house. He stated a non-
radiating, intermittent as described as shearing/ tearing with intensity of 3-5/10. It
was relieved by assuming a supine position and managed by warm compress. It
was aggravated by forward and backward bending as well as running. During this
time the patient was able to ambulate independently and do all activities of daily
living independently. No consultation was done or any medications taken.
Last November 2013 the patient had a same complaint with increasing
intensity of 4-5/10 and a stabbing character. No fever, cough or colds noted. The
patients mother opted to bring the patient for consultation, however, while
walking on the way to clinic the patient noted sudden, continuous, non-radiating
lowback pain and complaint as 8-10 in intensity and he was not able to ambulate
because of pain but there were no weakness or numbness of extremities. He
was seen by a local physician at Quezon and was given unrecalled pain
medication which offered temporary relief. The patient manifested difficulty in
prolonged ambulation but with decreased intensity of pain and he was sent
home. One month prior to admission he still experienced recurrence of low back
pain described as dull aching, non-radiating with intensity of 8/10, accompanied
by numbness of lower extremity. Patient sought consultation at a private clinic
where he was diagnosed with lumbar strain and prescribed unrecalled pain
medications that gave temporary relief. During this time no weakness of both
lower extremities was noted. He was not admitted to a hospital.
Three weeks prior there was still presence of low back pain with same
character and severity and the patient developed numbness of both lower
extremities not accompanied by weakness. No consultation was done but the
father self-medicated for relief of pain Paracetamol 250 mg/5mg. Two weeks
prior, there was persistence intermittent low back pain with same character and
severity and developed numbness and weakness of both lower extremities. They
consulted a local clinic and was prescribed Paracetamol 250mg/5ml 1tbsp every
6 hours. One week prior to admission there was persistence of intermittent low
back pain same character and intensity and progression of weakness of both
lower extremities described as difficulty in rising from bed.
One day prior to admission there were presence of low back pain and weakness
of both lower extremities, patient decided to seek consultation with an
orthopaedic surgeon were series of xrays of spine were done. The parents
claimed that the results were unremarkable, however official results were
unavailable. During this time, patient was told that spinal cord injury was being
considered and advised to have an MRI of lumbosacral spine but due to financial
difficulties it was not done. They were referred to Orthopedic Hospital for further
management.
Present Illness
During our clinical exposure at Philippine Orthopedic Hospital, last
February 4, 2014 I received a patient lying on bed, no contraptions attached, he
was afebrile, no Taylor brace attached. He complaints of pain described as dull-
aching with intensity of 3-4/10. It was relieved by rest he has difficulty in
ambulating but no numbness on extremities due medications given such as
Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol.

FAMILY HISTORY


SOCIAL HISTORY
The patient lives with her parents and siblings. They live in a small, one-
storey apartment. The patients father is a part time Jueteng collector and the
mother is a factory worker. They have harmonious relationship with each other.
The patient is currently a Grade 2 student with average grades and performance.
He is a consistent honor student

BODY
PARTS
METHODS FINDINGS ANALYSIS
Skin Inspection




- Yellow- tinged skin




-due to
increased
bilirubin
concentration
in the blood.




Palpation
-Slightly pallor



-have scar on his right knee about
2-3 inches wide

- Skin is intact and warm to touch
- It easily and immediately return to
its position.
-due to
decrease
oxygen
supply.
-due to
vehicular
accident.
- Normal
- Normal

Scalp Palpation - Free from masses, lumps, scar
nits, dandruff and lesions, no areas
of tenderness.
- Normal


Hair Inspection -black hair. -Normal
Nails Inspection






Palpation
- Nails are unclean



- clubbing of nails seen.


-capillary refill returns slowly
- due to
occupation
(gardener)/po
or hygiene
- due to
oxygen
deficiency
- indicate
decrease
oxygen
supply.


Head Inspection


Palpation
- Head is symmetric and erect. Has
no involuntary movement, still and
upright.
- Hard and smooth without lesions
- Normal


-Normal
Neck Inspection


Auscultation
Palpation
-Neck is symmetric, with head
centered and without bulging
masses or any enlargement.
- No bruits auscultated
- No enlarged and tender lymph
nodes
-Normal.


- Normal.
- Normal.
Eyes Inspection - Parallel and evenly placed,
symmetrical not protruding.





- No presence of redness and
swelling
- Normal.
Indicate
proper
functioning of
muscle
eyebrows.

- Normal

- Cornea is transparent with no
opacities, iris is round, flat and
evenly colored.
- Pupil equally round reactive to
light and accommodation



- Sclera is yellowish in color
- Normal


- Normal.
Indicates
proper
functioning of
oculomotor
-due to
increased
bilirubin
concentration
in the blood
Ears Inspection - Parallel symmetrical proportional
to the size of the head.
- Skin is smooth with no lesions,
lumps or nodules
- Small amount of odorless
cerumen is present.
- Normal

- Normal

- Normal
Mouth Inspection - Lips are smooth and moist without
lesions or swelling.
- Has decayed teeth
- Buccal mucosa appears pink.

- Tongue is pink and moist with
papillae.
- Normal

- Abnormal
due to poor
hygiene.
- Normal
Nose Inspection

Palpation
- Color is the same as the rest of
the face.
- Use of accessory muscles when
breathing.


- Nasal structure is smooth and
symmetric, no tenderness.

- Normal

-Abnormal
due to
difficulty of
breathing.
-Normal
Thoracic Auscultation - Has bronchial breath sound. No
adventitious sounds auscultated
-Observed retraction
- Normal

-Abnormal
due to
difficuly of
breathing
Abdomen Inspection



-Globular in shape and distended



-due to
ascites
probably
secondary to


Inspection














Auscultation





Percussion



Palpation


-umbilical skin tones are similar to
surrounding abdominal skin tone.
-deviated umbilicus




-everted umbilicus is seen


-abdomen is asymmetric




-friction rub heard over the lower
right costal area


-with hypoactive bowel sounds

-dullness



-movement of fluid wave against
the resting hand




-hard to touch

alcoholic liver
disease.
-Normal

-may be
caused from
from a
enlarged
organ or fluid.
-due to
distended
abdomen
-due to
abdominal
distention/acc
umulation of
fluid
-associated
with hepatic
abscess or
metases
-due to
ascites
-suggests
large
amounts of
fluids
-due to
accumulation
of fluid to
interstitial
spaces.

-indicates
liver
enlargement.
Upper
Extremities
Inspection -bilaterally equal
-no lesion seen
-not edematous
-was not able to move

-Normal
-Normal
-Normal
Lower
Extremities
Inspection -scar noted about 3 inches wide on
his right knee

-bipedal edema noted
-due to
vehicular
accident
-due to
accumululatio
n of interstitial
fluid.
Neurologic System
Level of
Consciousn
ess
Inspection Client is awake and eyes open
upon assessment
Normal
Language
Communica
tion
Inspection Has good eye contact, has difficulty
in verbalizing feelings.



Abnormal due
to the
condition
Orientation Inspection Client can be able to recall things
but with disorientation.
Abnormal due
to the
condition.
Memory Inspection Client can recall short and long
term events.
Normal

VI. DIAGNOSTIC LAB RESULT
HEMATOLOGY
Date: July 9,2012

TEST RESULT UNIT REFERENCE ANALYSIS
ERYTHROCYTES 5.04 10^12/L Male: 4.6-6.2
Female: 4.2-5.4
NORMAL
HEMOGLOBIN 143.0 g/l Male: 140-180
Female: 120-
140
NORMAL
HEMATOCRIT 0.462 % Male: 0.40-0.54
Female: 0.38-
0.47
NORMAL
LEUKOCYTE

Neutrophil

Eosinophils(P)


Basophils(P)
Lymphocyte (P)

Monocyte (P)
13.95

0.804

0.009


0.002
0.068

0.117
10^9/L

%

%


%
%

%
4.5-11

40-70%

2-8%


0-5%
19-48%

3-9%
Increase due to
smoking.
Increase due to
anemia
Decrease due to
alcohol
intoxication
Decrease due to
Decrease due to
infection
Increase due to
infection
THROMBOCYTE 228 10^9/L 150-400 NORMAL
MCH 28.36 Pg 27-31 NORMAL
MCV 91.53 F1 80-96 NORMAL
MCHC 0.31 0.32-0.36 Decrease due to
anemia
RDW
Atypical
lymphocyte
Granulocyte
Large immature
cells
11
0.000

0.000
0.000


%



BATANGAS REGIONAL HOPSPITAL
DATE: JULY 09,2012
CHEST PA FINDINGS:
Patchy density is noted in the
periaortic area.
Suggest lateral view for verification.
Heart is not enlarged.
Other chest structures are not
remarkable.














DRUG STUDY
Name of the
drug
Classification
and Mechanism
of Action
Indication Side Effects Contraindication Nursing
Responsibilities
Monitoring
Parameters
Generic Name:
Rifampicin

Brand Name:
Rifadin

Dosage:
Route:
Frequency:
Antituberculolitics

Inhibits DNA-
dependent RNA
polymerase,
which impairs
RNA synthesis;
bactericidal.
-pulomonary
tuberculosis,
with other
antituberculotics
CNS:
headache,
fatigue,
drowsiness,
dizziness
GI: anorexia,
nausea,
vomiting,
abdominal pain,
diarrhea,
flatulence.
MUSCULO:
osteomalacia
SKIN: pruritus,
rash
-Hypersensitivity
to rifampicin
-use cautiously in
patients with liver
disease

-Give drug with
at least one
other
antituberculotic.
-Warn the patient
that he may feel
drowsy and that
drug can turn
body fluids red-
orange.
-Advise patient
or relative to
avoid alcohol
during drug
therapy.

-Monitor hepatic
function,
hematopoietic
studies and uric
acid levels.
Drugs systemic
effects may
asymptomatically
raise liver
function test
results and uric
acid level.



Name of the
drug
Classification
and Mechanism
of Action
Indication Side Effects Contraindication Nursing
Responsibilities
Monitoring
Parameters
Generic Name:
Isoniazid

Brand Name:
Isotamine

Dosage:
Route:
Frequency:
Antituberculolitics

May inhibit cell
wall biosynthesis
by interfering
with lipid and
DNA synthesis;
bactericidal
-Actively
growing
tubercle
bacilli
-To prevent
tubercle
bacilli in
those
exposed to
TB.
CNS:
headache,
fatigue,
drowsiness,
dizziness
GI: epigastric
distress,
nausea,
vomiting,
abdominal
pain,
diarrhea,
flatulence.
METABOLIC:
hyperglycemi
a,
hypocalcemia
.
SKIN:
irritation at
injection site

-Patients with
acute hepatic
disease or
isoniazid-related
liver damage.
-Use cautiously in
elderly patients,
in those with
chronic non-
isoniazid-related
liver disease or
chronic
alcoholism.

-Instruct to take drug
exactly as prescribed;
warn against stopping
drug without
prescribers content.
-Advise to take drug 1
hour before or after
meals.
-Tell patient /relatives
to notify prescriber if
signs and symptoms of
liver impairment occur
such as appetite loss,
fatigue, malaise, yellow
skin or eye
discoloration and dark
urine.
-Instruct to avoid
products containing
tyramine, such as aged
cheese, beer and
chocolate, because
drug has some MAO
inhibitor activity.
- Encourage to comply
fully with treatment,
may take months or
years.
-Monitor hepatic
function,
hematopoietic
studies and uric
acid levels.
Drugs systemic
effects may
asymptomatically
raise liver
function test
results and uric
acid level.


Name of the
drug
Classification
and Mechanism
of Action
Indication Side Effects Contraindication Nursing
Responsibilities
Monitoring
Parameters
Generic Name:
Pyrazinamide

Brand Name:
Etibi

Dosage:
Route:
Frequency:
Antituberculolitics

It is an
antibiotic and
works by
stopping the
growth of
bacteria.
-Adjunctive
treatment
for
pulmonary
tuberculosis
General -
Fever,
porphyria
and painful
urination.
Gastrointes
tinal -
Nausea,
vomiting and
loss of
appetite.
Blood -
Anemia.
Miscellaneo
us - Joint or
muscle pain,
rashes,
hives, and
itching.



Caution should
be exercised in
patients with
history of liver or
kidney disease,
diabetes, gout,
high uric acid
level in the
blood,
alcoholism, who
are taking other
medications,
during
pregnancy and
breastfeeding.
Avoid alcohol
consumption
while taking this
medication.
Avoid live
vaccination
during treatment
period.


-Instruct the patient
that there are no
restrictions on foods,
beverages, or
activities during
treatment with
pyrazinamide unless
the doctor directs
otherwise.
-Ask the patient if
he/she has ever had an
allergic reaction to
pyrazinamide , liver
disease, gout, kidney
disease, diabetes
mellitus.
- Take each dose
with a full glass (8
ounces) of water.
-Stress the importance
of compliance with
drug therapy.
-Advice to report
adverse reactions to
prescriber.
-Monitor hepatic
function,
hematopoietic
studies and uric
acid levels.
Drugs systemic
effects may
asymptomatically
raise liver
function test
results and uric
acid level.
-Monitor ALT
and AST levels
every 3-4 weeks





Name of the
drug
Classification
and Mechanism
of Action
Indication Side Effects Contraindication Nursing
Responsibilities
Monitoring
Parameters
Generic Name:
Ethambutol

Brand Name:
Etibi

Dosage:
Route:
Frequency:
Antituberculolitics

May inhibit
synthesis of one
or more
metabolites of
susceptible
bacteria,
changing cell
metabolism
during cell
division,
bacteriostatic.
-Adjunctive
treatment
for
pulmonary
tuberculosis
CNS:
headache,
fatigue,
drowsiness,
dizziness
GI: abdominal
pain,
anorexia,
nausea,
vomiting,
abdominal
pain,
diarrhea,
flatulence.
METABOLIC:
hyperuricemia
MUSCULO:
joint pain
SKIN:
pruritus, rash
-contraindicated
in children
younger than age
13, patients
hypersensitive to
drug and with
optic neuritis
-use cautiously in
patients with
impaired renal
function,
cataracts,
recurrent eye
inflammation,
gout, diabetic
retinopathy.

-Perform visual acuity
and color
discrimination tests
before and during
therapy.
-Reassure patient that
visual disturbances
usually disappear
several weeks to
months after drug is
stopped. Inflammation
of the optic nerve is
related to dosage and
duration of treatment.
-Ensure that changes
in vision dont result
from underlying
condition.
-Stress the importance
of compliance with
drug therapy.
Advice to report
adverse reactions to
prescriber.
-Monitor hepatic
function,
hematopoietic
studies and uric
acid levels.
Drugs systemic
effects may
asymptomatically
raise liver
function test
results and uric
acid level.
-Monitor ALT
and AST levels
every 3-4 weeks



NURSING CARE PLAN
ASSESSMENT DIAGNOSIS SCIENTIFIC
EXPLANATION
PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE
DATA:
Sumasakit po
ang likod ko
nahihirapan po
ako matulog

C-dull aching
pain
O-three months
ago
L-right lower
back
D-continuous
S- 3-4/10
P- relieved when
resting
Worsen during
trying to transfer
to a wheelchair
A-Taylor brace

OBJECTIVE
DATA:
-guarding
behaviour
-grimace
-sleep
disturbances
Acute pain
related to
inflammatory
process
Potts disease
is a form of
extrapulmonary
tuberculosis
that impacts
the spine. It
has an effect
that is
sometimes
described as
being a sort of
arthritis for the
vertebrae that
make up the
spinal column.
More properly
known as
tuberculosis
spondylitis. It is
often
experienced as
a local
phenomenon
that begins in
the thoracic
section of the
spinal column.
Early signs of
the presence of
Potts disease
After 30 minutes
of nursing
interventions the
patient will be
able to know
ways on how to
relieve the pain.
Independent:
Investigate
report of pain,
noting
characteristics,
location,
intensity (0-10
scale).

Provide firm
mattress and
small pillows.





Suggest
patient assume
position of
proper comfort
while in bed or
chair. Promote
bed rest as
indicated.

Encourage
frequent
changes of
position.

Helpful in
determining
pain
management
needs and
effectiveness
of the program.

Soft or
sagging
mattress and
large pillows
inhibits the
proper body
alignment.

In acute
phase, total
bed rest may
be necessary
to limit pain.




Prevents
general fatigue
and joint
stiffness.
After 30 mins of
nursing
intervention the
patient was able
to know how to
relieve the pain.
generally begin
with back pain
that may seem
to be due to
simple muscle
strain

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



Provide gentle
massage.



Encourage
use of stress
management
techniques.



Collaborative:
Administer
nonsteroidal
anti-
inflammatory
drugs as
prescribed.


Administer
anti-biotic as
prescribed
Heat promotes
muscle
relaxation and
mobility,
decreases pain
and relieves
morning
stiffness.

Promotes
relaxation and
reduces
muscle tension

Promotes
relaxation,
provides sense
of control and
may enhance
coping
activities.

These drugs
control mild to
moderate pain
and
inflammation
by inhibition of
prostaglandin
synthesis.
To prevent
further
infection.
ASSESSMENT DIAGNOSIS SCIENTIFIC
EXPLANATION
PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE
DATA:
Hindi po ako
makalakad o
makatayo

Nilalagyan sya
ng Taylor brace
as verbalized by
the auntie

OBJECTIVE
DATA:
-limited range of
motion
-presence of
Taylor brace
Impaired
physical mobility
related to
therapeutic
restriction of
movement
Potts disease
is a form of
extrapulmonary
tuberculosis
that impacts
the spine.
There is a pus
formation
between the
intervertebral
disc. The disc
tissue dies and
broken down
by cascation
leading to
vertebral
collapse and
spinal damage
causing
impaied
physical
mobility.
After 30 minutes
of nursing
interventions the
patients mother
will be able to
verbalize
understanding of
the situation and
treatment
regimen and
safety
measures.
Independent:
Encouraged to
change
position every
2 hours.

Scheduled
activities with
adequate
period of rest.

Provided
regular skin
care

Provided
passive range
of motion.

Encouraged
adequate
intake of
nutritious foods

Explained the
use of
adjunctive
devices such
as the Taylor
Brace.


To prevent
bed sores.



To reduce
fatigue



To promote
good hygiene


To maintain
muscle
integrity

To maximize
energy
production.


To promote
knowledge and
enhances
safety


After 30 minutes
of nursing
interventions the
patients mother
was able to
verbalize
understanding of
the situation and
treatment
regimen and
safety
measures.