Institute of Nursing

Nicanor Reyes Sr. St., Sampaloc, Manila

Submitted by: Submitted to:

BSN038/Group-152 Ms. Elizabeth Hacinas, RN, MAN
Navarez, Ma. Katrina Rose Clinical Instructor
Pascual, Erolle
Penid, Neshiel
Poreno, Michelle
Rivera, Armie Louer
Sales, Ma. Nora
Torres, Mayden
Urbano, Francis Noel
Valeros, John Mark
Vicedo, Vergel Nazer
Villena, Anthony

LEARNING OBJECTIVES
General Objectives:

This study aims to convey familiarity and to provide an effective nursing care to patient diagnosed with Potts
Disease through understanding the patient’s history, disease process, and management.

 
Specific Objectives:

 To conduct and evaluate thorough assessment, nursing health history, Patterns of Functioning, Activities
of Daily Living, Interpretation and Analysis of Physical Assessment and Laboratory examinations done to
the client.

 To discuss the Pathophysiology, usual Clinical Manifestations and possible Complications of patient’s
condition.

 To have knowledge and be familiar with client’s medications.

 To formulate a workable nursing care plan on the subjective and objectives cues gathered.

 To provide and disseminate important information as teachings to the client and his significant others to
boost the knowledge and understanding of the nature of the present health condition.

 To improve skills and knowledge as health care providers in the clinical area.

INTRODUCTION
BIOGRAPHIC DATA

Name: JRC Age: 5 years old

Address: Harangan San Isidro, Montalban, Rizal Gender: Female
Religion: Roman Catholic Nationality: Filipino
Marital Status: Married
Primary Language Spoken: Tagalog
Birthday: Agust 31, 2004
Room Number: Pedia Ward
Chief Complaint: Deformity of the back
Provisional Diagnosis: T/C Potts Disease T12 with neurologics
Date of Admission: December 8, 2009

NURSING HISTORY

I. Present Health History

Six months prior to admission, patient’s mother noticed mild deformity at mid-back of her daughter with associated
weakness. During those times, the patient can still ambulate and there are no urinary and bowel dysfunctions noted. Her
mother noticed a lump or “bukol” at her back in June 2009. The mass gradually increased in size. “October na nang
napansin ko na malaki na yung bukol niya sa likod.” By November 27 the patient could no longer walk. Due to financial
constraints, she had her check-up and was only admitted on December 8. She was diagnosed with T/C Potts Disease T12
with neurologics.

II. Past Health History

The patient has complete immunizations as stated by her mother. By April 2009, she had a boil. When asked about the
interventions done, her mother said, “Wala naman masyado, tinapalan lang namin nung gumamela, gumaling din naman
kasi.” The client is hospitalized for the fourth time now. She was first hospitalized in Pasig General Hospital because of
diarrhea by which date cannot be recalled. She also took vitamins before but was stopped because it caused her loose
bowel movements.The patienthas no known allergies and does not travel abroad.

III. Developmental Level

A. Physical
 The client weighs 10 kgs and the patient’s height is approximately 85 cm. The client is starting to lose teeth.
B. Motor Skills
Before the client was hospitalized and was still able to walk.
Activities of daily living
ADL Before Hospitalization
Nutrition The mother of the client stated
that the patient don’t eat
chicken but eats vegetables and
usually eat 2 cups of rice per
meal and drink at least 4
glasses of water per day and
loves drinking soft drinks.
Elimination The mother verbalize that her
child urinates five times a day
with no difficulty and has dark
yellow urine. She also added
that he defecated everyday with
no difficulty.
During hospitalization
The mother of the client said
that during hospitalization she
rarely have appetite and
whenever she like to eat she
just usually ate few spoon and
drink 2-3 half full glasses a
day.
During his hospitalization, she
voids 3 to 4 times a day and
defecates every morning since
admitted.
Interpretation & Analysis
Interpretation: The client has
a problem in her nutrition when
she was hospitalized.
Analysis:
Nutrition is the sum of all the
interactions between an
organism and the food it
consumes. People require the
essential nutrients in the food
for growth and maintenance of
all body tissues and the normal
functioning of all body
processes(Fundamentals of
Taylor, et.al; p1171, 1235-
1238)
Interpretation:
The client’s elimination pattern
has changed during
hospitalization especially his
bowel movement.
Analysis:
Normal feces are made of about
75% water and 25% solid

Exercise According to her mother the
patient loves playing such as
running and playing with other
kids usually both girls and boys,
they usually play hide and seek.
Hygiene The mother of the patient said
that she took a bath once a
day, brushes her teeth twice a
day, trim his nails twice a week
and changes his clothes every
day.
She has no form of exercise
when she was hospitalized.
Since she was admitted took a
bath once and brushes her
teeth once a day. She changes
her clothes twice since she was
admitted.
material. Its consistencies are
soft, semisolid and formed.
They are brown in color.
Formed stool is usually about 1
inch in diameter and has the
tubular shape of the colon, but
may be larger or smaller,
depending on the condition of
the colon. (Fundamentals of
Nursing by Taylor et.al; p1346)
Interpretation:
The client’s routine exercises
have been changed when he
was hospitalized because of his
condition as well as the
environment.
Analysis:
Exercise is a type of physical
activity defines as planned,
structured, and repetitive bodily
movement done to improve or
maintain one or more
components of physical fitness.
People participate in exercise
program to decrease risk factors
for cardiovascular disease and
to increase their health and
well-being. (Fundamentals of
Nursing by Kozier et.al; p1065)
Interpretation:
Prior to hospitalization, she
practices proper hygiene, while
during, he does not practice
proper hygiene since he has a
bathroom privileges.

Rest & Sleep The client sleep at night around
7 pm then wakes up at 6am.
She takes a nap at afternoon
for 1 hr. The mother of the
patient said that her child was
She usually sleep at around 8
pm then wakes up at 6 am with
frequent periods of waking up.
At afternoon, she takes 2 hours
nap. The mother said that she
Analysis:
Bathing: an adult or pediatric
client purposes are remove
transient microorganism, body
secretions and excretions, and
dead cell, to stimulate
circulation to the skin, to
produce sense of well-being, to
promote relaxation and comfort
and to prevent or eliminate
unpleasant odors.
Mouth Care: brushing your
teeth at least twice a day, once
in the morning and again before
bed, is recommended. Some
people brush their teeth after
every meal. Brushing for 2-3
minutes each time is
recommended. Toothbrush
should be changed after 2
months.
Apply a small amount of
toothpaste on a toothbrush and
gently brush a few teeth at a
time on all sides in a circular
motion. After brushing, you
should rinse your mouth with
water and spit the water out
into a sink. Do not swallow the
toothpaste. (Fundamentals of
Nursing by Kozier et.al; p706)
Interpretation:
The client has disturbed sleep
pattern due to the change of
environment.
Analysis:
contented with her sleep. was disturbed because of the
other patient.
Rest and sleep are essential for
health. People who are ill
frequently require more rest
and sleep than usual. Stress
affects basic human needs –
altered elimination pattern,
change in appetite, altered
sleep pattern. (Fundamentals of
Nursing    by Kozier et.al;
p1020, 1114)