CHINESE GENERAL HOSPITAL COLLEGES

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Sumitted By: Paras, Sarah Jane P.
IVB Group 1





Area of Rotation: Philippine Orthopedic Center






REPUBLIC OF THE PHILIPPINES
Department of Health
PHILIPPINE ORTHOPEDIC CENTER
Maria Clara cor Banawe Sts.
Quezon City





NURSING SERVICE TRAINING SECTION
CLINICAL CASE ANALYSIS

NAME: Maria Angela Harina
ADDRESS: Sitio Sampalucan Brgy. San Jose, Antipolo City
DATE ADMITTED: March 10, 2014
DOCTOR INCHARGE:
DIAGNOSIS: T/c Potts Disease T2-T3 with Neurologic Deficits


NURSING HISTORY


According to the relative of the patient, the patient fell on the bike when she was
2 years old. The parents brought the child at the Philippine Orthopedic Center, she was
then examined, the doctors said that she is well and okay. But few years later, this
2014, the child fell on the ground when she was in school. The patient cannot stand and
walk on her own. Her parents decided to bring Ms. Angela to the Emergency Room of
Philippine Orthopedic Center. Hence, she was diagnosed with to consider Potts
Disease T2-T3 with neurologic deficits, further, admitted at the institution.










DIAGNOSTIC PROCEDURE

1. Tuberculin skin test (purified protein derivative [PPD]) - results are positive in
84-95% of patients with Pott disease who are not infected with HIV. A standard
dose of 5 Tuberculin units (0.1 mL)(The standard Mantoux test in the UK consists
of an intradermal injection of 2TU of Statens Serum Institute (SSI) tuberculin
RT23 in 0.1ml solution for injection.) Injected intradermally (between the layers of
dermis) and read 48 to 72 hours later. This intradermal injection is termed the
mantoux technique. A person who has been exposed to the bacteria is expected
to mount an immune response in the skin containing the bacterial proteins. The
reaction is read by measuring the diameter of induration (palpable raised
hardened area) across the forearm (perpendicular to the long axis) in millimeters.
If there is no induration, the result should be recorded as "0 mm". Erythema
(redness) should not be measured. If a person has had a history of a positive
tuberculin skin test, or has not had a recent tuberculin skin test (within one year),
another skin test may be needed.
2. The erythrocyte sedimentation rate (ESR) may be markedly elevated (>100
mm/h).ESR stands for erythrocyte sedimentation rate. It is a test that indirectly
measures how much inflammation is in the body. However, it rarely leads directly
to a specific diagnosis. This test can be used to monitor inflammatory or
cancerous diseases. It is a screening test, which means it cannot be used to
diagnose a specific disorder. However, it is useful in detecting and monitoring
tuberculosis, tissue death, certain forms of arthritis, autoimmune disorders, and
inflammatory diseases that cause vague symptoms.
3. Radiography - radiographic changes associated with Potts disease present
relatively late. The following are radiographic changes characteristic of spinal
tuberculosis on plain radiography: visibly seen curvature of the spine or visible
bone lesions on different levels.
4. CT scanning - CT scanning provides much better bony detail of irregular lytic
lesions, sclerosis, disk collapse, and disruption of bone circumference. Low-
contrast resolution provides a better assessment of soft tissue, particularly in
epidural and paraspinal areas. CT scanning reveals early lesions and is more
effective for defining the shape and calcification of soft-tissue abscesses. In
contrast to pyogenic disease, calcification is common in tuberculous lesions.
5. MRI - MRI is the criterion standard for evaluating disk-space infection and
osteomyelitis of the spine and is most effective for demonstrating the extension
of disease into soft tissues and the spread of tuberculous debris under the
anterior and posterior longitudinal ligaments. MRI is also the most effective
imaging study for demonstrating neural compression. MRI findings useful to
differentiate tuberculous spondylitis from pyogenic spondylitis include thin and
smooth enhancement of the abscess wall and well-defined paraspinal abnormal
signal, whereas thick and irregular enhancement of abscess wall and ill-defined
paraspinal abnormal signal suggest pyogenic spondylitis. Thus, contrast-
enhanced MRI appears to be important in the differentiation of these two types of
spondylitis.
6. Bone biopsy - A bone biopsy is a procedure in which a small sample of bone is
taken from the body and looked at under a microscope for cancer, infection, or
other bone disorders. Confirm the diagnosis of a bone disorder that was found by
another test, such as an X-ray, CT scan, bone scan, or a MRI. Tell the difference
between a noncancerous (benign) bone mass, such as a bone cyst, and bone
cancer, such as multiple myeloma. See what is causing a bone infection
(osteomyelitis) or if an infection is present. Find the cause of ongoing bone pain.
Check bone problems seen on an X-ray.























MEDICAL MANAGEMENT

Since Pott's disease is caused by a bacterial infection, prevention is possible
through proper control. The best method for preventing the disease is reduce or
eliminate the spread of tuberculosis. In addition, testing for tuberculosis is an important
preventative measure, as those who are positive for purified protein derivative (PPD)
can take medication to prevent tuberculosis from forming. A tuberculin skin test is the
most common method used to screen for tuberculosis, though blood tests, bone scans,
bone biopsies, and radiographs may also be used to confirm the disease.
Before the advent of effective anti-tuberculosis chemotherapy, PottS disease
was treated with immobilization using prolonged bed rest or a body cast.
Studies performed by the British Medical Research Council indicate that
tuberculous spondylitis of the thoracolumbar spine should be treated with
combination chemotherapy for 6-9 months.
According to the most recent recommendations issued in 2003 by the US
Centers for Disease Control and Prevention, the Infectious Diseases Society of
America, and the American Thoracic Society, a 4-drug regimen should be used
empirically to treat Pott disease.
Isoniazid and rifampin should be administered during the whole course of
therapy. Additional drugs are administered during the first 2 months of therapy.
These are generally chosen among the first-line drugs, which include
pyrazinamide, ethambutol, and streptomycin. The use of second-line drugs is
indicated in cases of drug resistance.
Opinions differ regarding whether the treatment of choice should be conservative
chemotherapy or a combination of chemotherapy and surgery. The treatment
decision should be individualized for each patient.






SURGICAL MANAGEMENT

Indications for surgical treatment of Potts disease generally include the following:
o Neurologic deficit (acute neurologic deterioration, paraparesis, paraplegia)
o Spinal deformity with instability or pain
o No response to medical therapy (continuing progression of kyphosis or
instability)
o Large paraspinal abscess
o Nondiagnostic percutaneous needle biopsy sample
Resources and experience are key factors in the decision to use a surgical
approach.
The lesion site, extent of vertebral destruction, and presence of cord
compression or spinal deformity determine the specific operative approach
(kyphosis, paraplegia, tuberculous abscess).
In Pott disease that involves the cervical spine, the following factors justify early
surgical intervention:
o High frequency and severity of neurologic deficits
o Severe abscess compression that may induce dysphagia or asphyxia
o Instability of the cervical spine


















NURSING CARE PLAN




Nursing Problems
Identified
Justification
Acute pain related to
inflammatory
process
It is the first priority that needs immediate action and it is included
in the Maslow hierarchy of needs. Clients who are in pain will be
motivated to get these biological needs met before being
interested in learning about their medication, rules for self-care,
and health education. And it is also included in basic survival
needs.
Imbalance nutrition
related to inadequate
food intake
It is the second priority due to Maslows hierarchy of needs
wherein these physiological needs requires immediate
intervention. It is an intake insufficient to meet daily energy
requirements.
Impaired physical
mobility related to
therapeutic
restriction of
movement
It is the third priority and it is also included in Maslows Hierarchy
of Needs under physiological needs. Mobility is the ability to move
freely, easily, rhythmically and purposely in the environment, it is
an essential part of living. People must move to protect
themselves and to meet their basic needs. Mobility is vital to
independence; a fully mobilized person is a vulnerable and
dependent as an infant.
Self bathing
hygiene deficit
related to
musculoskeletal
impairment
It is the fourth priority and it is a health deficit that requires
immediate attention and adequate management. It is also
included in Maslows Hierarchy of Needs under physiological
needs. Bathing produces sense of well-being. It is a refreshing
and relaxing and frequently improves morale, appearance, and
self respect.
Disturbed body
image related to
trauma/injury to
spinal cord
It is the fifth priority and it is included in Maslows Hierarchy of
Needs under Self-esteem. Patients want a positive self regard to
increase their confidence to feel ones own worth.
Risk for infection
related to insufficient
knowledge to avoid
exposure to
pathogens
It is the last priority because if intervention is done on the
condition, future problems can be minimized or totally prevented;
Susceptibility to other diseases and infection can be prevented. It
is a health threat that does not need immediate action.