Alsbeth Rey Joyce J.

Arangote

POTT’S DISEASE
(Tuberculosis of the Spine)

Definition:

Pott’s disease is the tuberculosis of the spine. In patient with TB, spine is the common site of
infection. Lower thoracic and the upper vertebrae are the most often affected area in the spine. It is a
disease of childhood and adolescence. The most common level of the lesion is the thoraco- lumbar level.
This is because movement and the stress of weight bearing are maximum at this level. Pott’s disease is
also known as Pott’s syndrome, Pott’s ccurvature, Pott’s caries, angular kyphosis, and David’s disease.

Cause/ etiology:

-mycobacterium tuberculosis is the main cause.

The focus of spine may be found in one of the following sites:

1. Para- discal lesion- a lesion in the subchondral area of the vertebral body. This is the most
common site.
2. Central body lesion- a lesion in the anterior surface of the vertebral.
3. Anterior type- a lesion in the anterior surface of the vertebral.
4. Appendicial lesion- a lesion in the pedicle, lamina, transverse process and spinous process.
5. Articular lesion- a lesion in the posterior intervertebral joint.

Clinical manifestations:

-back pain
-body malaise
-fever and chills
-anorexia
-loss of appetite
-weight loss
-night sweating
-headache
-change in the shape of the back
-spinal mass, sometimes it goes along with numbness, tingling sensation or muscle weakness of legs.

Risk Factors:

-undernutrition
-poor hygiene
-poor socio-economic status
-don’t have BCG
-active TB or history of pulmonary tuberculosis

Complications:

1. Cold abscess- an invariable feature of TB of the spine. It forms in the paravertebral areas and
soon tracks downwards due to gravity and towards the surface following the tracks of nerves and
blood vessels.
 2. Pott’s paraplegia- all parts below the lesion in the spinal cord are affected by the curvature that
results to paralysis. The patient is clinically, radiologically, and hematologically assessed. In
assessing the patient, look for the signs of pressure in the cord, like slight spasticity of the legs
causing unsteady gait, exaggerated knee and ankle jerks and extensor plantar response.
3. Spinal deformities- in the thoracic spine, angular kyphosis is characterized. In the cervical and
lumbar spine, the loss of the normal lordosis occurs first followed by the gibbus. The prominence
of the gibbus depends on the number of the vertebrae involve.
4. Bed sores
5. Meningitis
6. Constipation and impaired urinary elimination
7. Tuberculosis of the hip and knee joint
8. Paresis-muscular weakness
9. Hypostatic pneumonia

Diagnostic tests:

1. Bone scan
Pre-procedure:
-explain the procedure and purpose to the patient
-ensure that the patient knows that an injection of radionuclide will be given 2-3 hours before the
actual scan and the test is painless.
-encourage to increase fluid intake.
-remind the patient to empty the bladder before the procedure starts.
Post-procedure:
-tell and explain to the patient that usual activities can resume after bone scanning.

2. CT scan/ radiography
Pre-procedure:
-patient must sign a consent form
-explain the procedure and purpose to the patient.
-inform who will perform and what time it will start
-obtain the patients history
-instruct the patient to remove all metallic objects.
Post-procedure:
-monitor patient’s status
-assess patient’s general condition
-watch for any reactions

3. Bone Biopsy
Pre- procedure:
-verify doctor’s order
-patient must sign a consent form
-identify the patient and explain the purpose and procedure
-wash and dry hands
-assemble the equipments needed
-ensure privacy
-assist in positioning
-observe the patient during the procedure
Post-procedure:
-apply pressure over the puncture site
-cover the site with plaster or plastic dressing. Tell the patient not to bath or wash the site for 24
hrs.
-provide comfort safety to the patient.
Medical Management:

-immobilization must be used using prolonged bed rest body cast.

-tuberbulous spondylitis of the thoraco- lumbar spine should be treated with combination chemotherapy
for 6-9 months.
-isoniazid and rifampin should be administered during the therapy is the first line anti-tuberculous
medication used in the revention and treatment of ruberculosis. It has no use except in the treatment of
mycobacterium infection.
-Rifampicin- is typically used to treat mycobacterium infection including tuberculosis and leprosy

Surgical Management:

1. Anterior decompression and spinal fusion- through a standard thorocotomy the abscess is
evacuated and debridement done. Fusion is accomplished through the use of bone parts, bone
chips taken from the iliac crest, wire of acrylic glue.
2. Costo- transversectomy- in this operation, the posterior ends of one or two ribs and the
corresponding transverse processes of the vertebrae are excised and the cold abscess evacuated.
3. Antero- lateral decompression- in this operation, in addition to costotransversectomy, the pedicles
and part of the vertebral bodies are excised to achieve decompression.
4. Spinal fusion- to reduce pain.

Postprodedure:

-restrain the patient flat on bed for 1week

-teach the patient on log rolling technique

-protect the patient from infection

Braces: Jewett and Taylor Braces

 NURSING CARE PLAN

Problem #1: Pain

Diagnosis: Acute pain r/t inflammatory process

Rationale: distressing sensations, unpleasant factor maybe experience. Early signs of the presence of
Pott’s disease generally begin with back pain that may seem due to a simple muscle sprain.

Cues:
-back pain
-spinal mass
- headache

Goal:
After 30mins.of nursing intervention the patient will be able to manifest decrease of pain with at least a
scale of 2/10 from 8/10.

Objective:

1. After nursing intervention the pt. will be able cooperate in relaxation skills and diversional
activities into pain control program.

Nursing Interventions:

-Assess pain scale by asking the patient from 0 as the lowest and 10 is the highest. It helps to determine
appropriate intervention and provides basis for comparison and evaluation of therapy. It helps in
determining the pain management needs and effectiveness of the program.

-Encourage use of stress management techniques. Promotes relaxation, provides sense of control and
may enhance coping activities.

-Provide comfort measure such as changing position or massaging. Promotes relaxation and reduces
muscle tension.

-Assess patient’s willingness or ability to explore a range of techniques aimed at controlling pain. Some
patients will feel uncomfortable exploring alternative methods of pain relief. However, patients need to
be informed that there are multiple ways to manage pain.

-Apply warm or moist compress on the affected area several times a day. Heat promotes muscle
relaxation and mobility, decreases pain and relieves morning stiffness.

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

Collaborative:

Administer analgesics as prescribe. To maintain acceptable level of pain. Notify physician if regimen is
inadequate to meet pain control.

Administer non-steroidal anti-inflammatory drugs as prescribed. These drugs control mild to moderate
pain and inflammation by inhibition of prostaglandin synthesis.

Administer antibiotic as prescribed. To prevent further infection.

Problem #2: Immobility

Diagnosis: Impaired physical mobility r/t musculoskeletal impairment secondary to Pott’s paraplegia

Rationale: Commonly, rehabilitation and disease involve some degree of mobility. Restricted movement
affects performance of ADL.

Cues:
-gibbus
-anorexia
-body weakness

Long Term Goal:

After 2weeks of nursing intervention the patient will be able to perform at maximum level of his capacity.

Objectives:

1. The patient will be able to willing participate in passive or active assistive ROM exercises to
all extremities.

Nursing interventions:

-Assess patient ability to perform ADL effectively and safely on a daily basis. Restricted movement
affects the ability to perform most ADLs. Safety with ambulation is an important concern.

-Assess the degree of immobility. To obtain baseline data.

-Inspect skin daily. Observe for pressure areas and provide meticulous care. Altered circulation, loss of
sensation, and paralysis potentiate pressure sore formation.

-Perform passive or active assistive ROM exercises .To promote increased venous return, prevent
stiffness and maintain muscle straight endurance.

-Turn and position patient every 2hrs. To optimize circulation to all tissues and to relieve pressure.

-Position leg at 90-degrees at regular intervals. To prevent frozen shoulder contractures.

Problem #3: Presence of “Hunchback” deformities

Diagnosis: Body Image disturbance r/t injury progressive destruction of the vertebral column secondary
to Pott’s disease.

Rationale: Patient with Pott’s disease has kyphosis which results with negative self-esteem due to injury
of the spinal cord which makes the patient traumatize.

Cues:
-change in the shape of the back
-gibbus

Goal:
After 1 day of nursing intervention the patient will be able to verbalize acceptance in self situation.
Objectives:
 1. The patient will be able to be free from any disturbance regarding will the disease and will be
able to gain self esteem.
2. The patient will be able to verbalize free from anxiety and adaptation to actual body image.

Nursing Interventions:

-Establish therapeutic relationship conveying an attitude of caring and developing a sense of trust. To
assist client to deal with or accept issues of self-concept related to body image.

-Evaluate level of client’s knowledge and anxiety related to situation and observe any emotional changes.
To assess causative or any contributing factors.

-Identify previously used coping strategies and its effectiveness. To determine skills and capabilities.

-Provide assistance with self-care needs. To enhance capabilities.

-Have client describe self, noting what is positive and negative. To assess causative or contributing
factors.

-Note signs of grieving or indications of depression. To evaluate needs for counseling and medication.

-Refer to appropriate support groups. To provide continuity of care.

Problem #4: Presence of Bedsores

Diagnosis: Risk for impaired skin integrity related to immobility secondary to spinal cord injury

Rationale: Immobility which leads to pressure, shear, and friction, is the factor most likely to put an
individual at risk for altered skin integrity.

Goal:
After 8hrs. of nursing intervention, the patient will be able to be free from impaired skin integrity as
manifested by absence of bed sores.

Objectives:

1. The patient will be able to identify individual risk factors about skin integrity.
2. The patient will be able to verbalize understanding of treatment regimen.
3. The patient will be able to demonstrate behaviors to prevent skin breakdown.
4. The patients skin remains intact as evidence by negative redness over bony prominences and
capillary refill <6 seconds over areas of redness.

Nursing Intervention:

-Assess skin surface/ pressure points. To obtain information or baseline data. Healthy skin varies from
individual to individual, but should have good turgor, feel warm and dry to touch, be free from
impairment and have quick capillary refill.

-Observe for reddened/ blanched areas and institute treatment immediately. Reduces likelihood of
progression to skin breakdown.

-Encourage the patient to increase fluid intake. Hydrated skin is less prone to breakdown.

-Turn and position the patient every 2hrs. To optimize circulation to all tissues and to relieve pressure.
-Emphasize importance of adequate fluid intake. To maintain skin turgor.

-Encourage continuation of regular exercise program. To enhance circulation.

Problem #5: No Bowel Movement for 1week

Diagnosis: Constipation r/t immobility secondary to paralysis

Rationale: Too little fluid, too little fiber, inactivity or immobility, and disruption in daily routine can
result in constipation.

Cues:
-pott’s paraplegia
-body weakness
- anorexia

Goal:
After 2 days of nursing intervention the patient will be able no longer at risk for constipation.

Objectives:

1. The patient will be able to maintain usual pattern of bowel functioning.

2. The patient will be able to verbalize understanding of risk factors and appropriate intervention
related to the situation.
3. The patient will be able to increase in fiber and fluid intake.

Nursing Interventions:

-Assess usual pattern of elimination. It is important to ascertain what is normal for each individual.

-Encourage the patient to increase fluid intake including fruit juice that are high in fiber. To promote
moist and soft stool.

-Assess activity level. Prolonged bed rest, lack of exercise and inactivity contribute to constipation.

-Encourage activity or exercise within limits of individual ability. To stimulate construction of the
intestine.

-Evaluate usual dietary habits, eating habits, eating schedule, and liquid intake. Change in mealtime, type
of food, disruption of the usual schedule, and anxiety can lead to constipation.

References:

Nursing Care Plan 6th edition, Meg Gulanick, et atl., 1998.

Nurses Pocket Guide 9th edition, Marilynn E. Doenges, et al., 2004.

Orthopedic Nursing Manual, 2nd edition, Artemio M. Bultre Jr., Bebian M. Alparce, 2006.
http://www.google.com.ph/#hl=tl&source=hp&q=pott
%27s+disease&meta=&aq=0&oq=pott%27s&fp=afdf0b8a3af6d2f3
Natarajans’s Text Book of Orthopaedics and Traumatology 6th edition, 2005.

Lois White, Gena Duncan. Medical Surgical Nursing An Integrated Approach, 1998.

http://www.hpath.com/diseases/potts-disease-symptoms-treatment-cure.asp

http://www.patient.co.uk/showdoc/40001278/

http://nursingcrib.com/online-nursing-care-plan-potts-disease/