PANPACIFIC UNIVERSITY NORTH PHILIPPINES

COLLGE OF NURSING

Case Analysis

POTTS DISEASE






























SUBMITED BY: BRIAN D. LIQUIT
PANPACIFIC UNIVERSITY NORTH PHILIPPINES
COLLEGE OF NURSING
CASE ANALYSIS

Name: Evangelista, Jamaica
Address: B19 Quezon blvd.Barangay 919 Sta. Cruz Manila
Date admitted: January 16, 2014
Dr. In charge: Dr. Gian carlo Karlo
Diagnosis: Spinal cord injury incomplete spinal level T11-L1, 2 to pathologic fracture of T12 probably
to pots disease.

Nursing History:
October 2013, patient fall from the bike, thus sustaining injury (+) low back pain noted. No
consult above
December 2013, still with low back pain(+) consult in POC with diagnosis of potts disease T11-
L1, advised for MRI
January 16, 2013, upon follow up in OPD
(+) enlargement of gibus deformity
(+) neurologic deficit noted
It was then admitted for ortho management.

Pathopysiology:


Pulmonary tuberculosis

Spread of mycobacterium tuberculosis from other

The infection spreads from two adjacent vertebrae into adjoining disc space>

Back pain , fever, night sweats.

One vertebrae is affected the disc is normal. Two are involved, the avascular intervertebral disc
cannot receive nutrients and collapse

Disk tissue dies and broken down by caseation

Vertebral narrowing

Vertrebral collapse

Spinal damage

POTTS DISEASE

Kyphosis paraplegia bowel and urinary incontinence







Diagnostic procedure:

MRI OF THE THORACOLUMBAR SPINE

MULTIPLE PLAIN AXIAL, CORONAL AND SAGITAP MR IMAGES OF THE THORACIC AND
LUMBAR SPLINTS WERE OBATAINED AND REVEALED THE FOLLOWING FINDINGS:

THERE ID STRAIGHTENING OF THE THORACIC AND LUMBAR CURVE.

LYTIC DISTRUCTION OF T12 IS NOTED.

T11 AND L1 WELL DEFINED AND NO ABNORMAL MAMARROW SIGNALS SEEN AS WEEL AS
THE REST OF THE VERTEBRAL BODIES

THE T11 L1 INTERVERTEBRAL DISC SHOWS LOSS OF THE NORMAL INCREASED T2 SIGNALS

THE REST OF THE INTERVERTEBRAL SPACES ARE PRESERVED.

A PARAVERTEBRAL SOFT TISSUE MASS IS NOTED AT THE LEVELS OF T11TO L1

SPINAL CORD INPINGEMENT IS NOTED AT THE LEVEL OF T12WITH MILD INCREASED T2
SIGNALS

IMPRESSIONS:
ABOVE FINDINGS MAY SUGGEST INFECTIONS SPONDYLITIS IS TO BONE TUMOR OF
T12
CAUSING SPINAL CORD IMPINGEMENT
SUGGEST TISSUE CORRELATION FOR FURTHER EVALUATION

COMPONENT RESULT NORMAL VALUE
HEMOGLOBIN MASSES 124 120-160
HEMATOCRIT 0.38 0.37-0.57
LEUCOCYTE 7.01 4.8-10.8
DIFFERENTIAL COUNT
SEMENTERS 0.67 0.40-0.74
LYMPHOCYTES 0.34 0.19-0.48
MONOCYTES 0.07 0.03-0.09
EOSINOPHILS 0.02 0.00-0.07
BASOPHILS 0.00 0.00-0.02
PLATELET COUNT 675 150-450
COAGULATION STUDIES
PROTHROMBIN TIME 13.7 11-15
PT% ACTIVITY 96.5
PTINR 1.02
ACTIVATED PTT 35.3 22-45






Generic Name: Tramadol Hydrochloride
Brand Name: Ultram
Classification: Opioid Analgesic
Dosage: 50mg. IVP PRN q8
Indication: For severe pain
































MECHANISM
OF ACTION
SIDE EFFECTS CONTRAINDICATION ADVERSE REACTION NURSING
CONSIDERATION
Unknown. A
centrally acting
synthetic
analgesic
compound not
chemically
related to
opiates.
Thought to
bind to opioid
receptor and
inhibiting
reuptake of nor
epinephrine
and serotonin.
Dizziness


Rash


Diarrhea
Contraindicated in
patients
hypersensitivity to
drug or other opioids.
Respiratory
depression


Vasodilation


Seizures


Confusion


Avoid performing
tasks that require
alertness.


Stop the medication
and report
immediately to the
doctor.

BRAT diet











ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE
sumasakit ang
likod as
verbalized by the
patient with a pain
scale of 5/10

OBJECTIVE
-Facial grimace
-protective
gestures noted

V/S taken as
follows:
BP: 130/80
Temp:36.4
0
C
PR:87 bpm
RR:22 bpm
V
Acute pain related
to tissue damage
After 1-2 hours of
nursing
interventions the
feeling of pain will
be able to decrease
from 4/10 to
1/10pain scale
Use pain
assessment scale to
identify intensity of
pain




Position patient in
unaffected side


Encourage
relaxation technique
(Deep Breathing
Exercise)





Provide music
therapy



Administer
analgesic
(ketorolac) as
ordered.
Provide baseline
for assessing
changes in pain
level and
evaluating
interventions
To prevent further
pressure thus
promoting
comfort.

Skeletal muscle
relaxation is
believed to
reduce pain by
relaxing tense
muscles and
tissues that
contribute to the
pain.
It is an
inexpensive and
effective therapy
for the reduction
of pain.
To relieved pain

Goal met.
The patient
feeling of pain
decreases from
4/10 to 1/10
pain scale