Pott's Done

1 INTRODUCTION This chapter discusses briefly basic concepts of the medical diagnoses of the patient.
A more lengthy and patient centered discussion can be found on the section on Anatomy and Physiology, and Pathophysiology. Pott's disease, which is also known as Potts caries, David's disease, and Pott's curvature, is a medical condition of the spine. Individuals suffering from Pott's disease typically experience back pain, night sweats, fever, weight loss, and anorexia. They may also develop a spinal mass, which results in tingling, numbness, or a general feeling of weakness in the leg muscles. Often, the pain associated with Pott's disease causes the sufferer to walk in an upright and stiff position. Pott disease most commonly involves the thoracic and lumbosacral spine. However, published series have show some variation. Lower thoracic vertebrae is the most common area of involvement (40-50%), followed closely by the lumbar spine (35-45%). In other series, proportions are similar but favor lumbar spine involvement. Approximately 10% of Pott disease cases involve the cervical spine. Approximately 1-2% of total tuberculosis cases are attributable to Potts disease. In the Netherlands between 1993 and 2001, tuberculosis of the bone and joints accounted for 3.5% of all tuberculosis cases (0.2-1.1% in patients of European origin and 2.3-6.3% in patients of nonEuropean origin). In United States, although the incidence of tuberculosis increased in the late 1980s to early 1990s, the total number of cases has decreased in recent years. The frequency of extrapulmonary tuberculosis has remained stable. Bone and soft-tissue tuberculosis accounts for approximately 10% of extrapulmonary tuberculosis cases and between 1% and 2% of total cases. Tuberculous spondylitis is the most common manifestation of musculoskeletal tuberculosis, accounting for approximately 40-50% of cases.
2 In the Philippines, eighty percent of people afflicted with tuberculosis are in the most economically productive of their lives, and the disease sends many self-sustaining families into poverty. According to World Health Organization, the Philippines ranks fourth in the world for the number of cases of tuberculosis and has the highest number of cases per head in Southeast Asia. Out of all admissions over a ten-year period, 10% of cases were diagnosed to have tuberculosis. Of these cases, 83% had pulmonary tuberculosis and 22.8% had extra-pulmonary tuberculosis. Reasons for Choosing the Case Based on statistics given by the World Health Organization, The Philippines ranks fourth in the world for the number of cases of tuberculosis and has the highest number of cases per head in Southeast Asia. Thru the efforts made by the department of health and the Philippine government, this number are decreasing each year by the use of providing concrete solution to lessen or totally eradicate tuberculosis in the country. But even though pulmonary tuberculosis is prevalent in the country, there are still rare cases of extra-pulmonary tuberculosis. This prompt us to choose the case to be able to understand more deeply how the disease progresses and what measures should be obtained to prevent the disease from spreading. Objectives General: To further study and fully understand the disease process and its complications in order to come out with the appropriate comprehensive Nursing Care Plan and to acquire necessary knowledge, skills and attitude in delivering compassionate care in a patient with Potts disease. Specific: Correlate pathophysiology of [Pott's disease] with its typical clinical manifestations. Discuss the options of medical treatment with regards to [Pott's disease]. Identify the components of appropriate nursing assessment for patients with this kind of disease. Develop strategies for nursing interventions aimed at meeting the defined goals and discuss the rationale for the use of each strategy. Develop patient education guides for patients with this disorder. List evaluation strategies for determining the effectiveness of the nursing care plan.
3 Chapter II ASSESSMENT A. Nursing History: PERSONAL DATA Name: Gender: Age: Height: Weight: Status: Nationality: Occupation: Religion: Date of Admission: Time of Admission: Diagnosis: J.A. Male 26 years old 5 feet & 7 inches 85 kgs. Single Filipino Newspaper Junker Roman Catholic June 29, 2011 5:31 PM Thoracic Compressive Myelopathy secondary to Potts Disease T9-T12 Date of Interview: Informant: Initial Vital Signs: BP: 120/80 mmhg Temp:36.5 C PR: 90 bpm RR:28 cpm July 5, 2011 Patient himself
CHIEF COMPLAINT The client was brought to the hospital due to his complain of difficulty of defecating.
4 HISTORY OF PRESENT ILLNESS Thirteen Months/A year and one month (June, 2009) prior to admission, the patient consulted at Delos Santos Medical Center due to complaint of unrelieved cough and was then diagnosed with Pulmonary Tuberculosis. Treatment was advised and started by taking anti TB medications such as Rifampicin, Isoniazid, Pyrazinamide, ethambutol and streptomycin (RIPES). Three months after the introduction of anti TB medications the client stated relieved from symptoms of pulmonary tuberculosis and did not continue any more the desired schedule of treatment. The treatment was supervised by the DOTS clinic.
Nine months (October, 2010) prior to admission, the patient started to observe a lump in his back and complaint of back pain. The patient took analgesics as verbalized by the client to relieve him from pain.
Seven months (November, 2010) prior to admission the patient started experiencing numbness & weakness of both lower extremities. The patient stated that the symptoms are still bearable and did not bother to continue his work. The patient stated that he planned to have a consultation at DSMC but he was hesitated to consult because he was having problems regarding his insurance.
Four months (February 2011) prior to admission the patient started experiencing difficulty in ambulating together with numbness & weakness on the lower extremities. The patient sought medical management at Delos Santos Medical Center (DSMC) and was recommended to have a MRI at DSMC and was then advised to have a biopsy of mass seen on the thoracic spine. The patient underwent MRI at DSMC. The patient did not respond to the recommendation made by his doctor to have Biopsy at DSMC due to financial insufficiency due to problems on insurances.
Two months (April 2011) prior to admission the patient began experiencing difficulty in defecating. Due to the persistent symptoms the patient was referred to consult at the out-patient department in St. Lukes Medical Center (SLMC). The patient was advised to undergo decompression process by undergoing laminectomy on his spine. The doctor made an impression
5 that the patient is suffering from Potts disease or extra-pulmonary tuberculosis.
3 weeks prior to admission, the patient complain of deterioration of symptoms specifically pain and difficulty of defecating. On the day of admission (June 29, 2011), the patient consulted at the St. Lukes Medical Center and was scheduled to undergo operation of Laminectomy on June 30, 2011. The patient was diagnosed to have Potts disease. The operation was done successful and the patient was attached with a drainage (Hemo Vac) in his spine. PAST HISTORY The patient had mumps when he was 9 years old. He also stated that he had chicken pox when he was 12. The patient was not given any medications to treat his childhood illnesses due to beliefs of treatment using herbs. The patient was treated using malunggay leaves apply to the skin for Chicken Pox and was given aniel (Blue powder used for laundry) apply to the skin to treat Mumps. The patient was diagnosed to have a stone formation in the Gall bladder and inflammation was detected thru laboratory examinations such as X-Ray of the genitor urinary tract and other diagnostic exams. The patient has been hospitalized in De Los Santos Medical Center (DSMC) last April 2009 for the removal of his gallbladder (Cholecystectomy). The operation was done successful. The patient stated that 7 days after the course of treatment, the patient experienced improvement of health. The patient stated that he usually experienced stress by working as a newspaper junker and he submitted to smoking to relieved himself from stress. He also stated that he needed to hold a job in the city to support his family in the province. At age 17, he experienced depression due to financial insufficiency since his family cannot afford to provide his education for college.
6 The patient and the patients mother have no memory of any vaccine given to him since birth. This was due to low socio economic status of his family and poor health management in the province (Bicol Province). The patient cannot recall any major accident or injury happen to him since birth. PERSONAL AND SOCIAL HISTORY The client graduated only high school in Bicol and have been living with his parent in Bicol for 17 years. At the age of 18 he went to Manila (Quezon City) to seek for a job in a city. He stated that he started smoking within this time and he also stated that during this time he can actually consume at least 1 pack per day or 8 pack years at present . We worked as a janitor on a Fast food Chain (Jollibee) for 3 years. Since then upon finishing contract he decided to apply for a new job as a Newspaper Junker of a Newspaper Company (The Philippine Star) also in Quezon City. The company he was working (The Philippine Star) gave their assistance to support the client regarding his financial needs thru insurance (SSS). Due to problems on filing for health insurance, it cause the client not to be diagnosed having Potts disease as early as possible. The Client is currently residing at Cubao, Quezon City. He was living alone in an apartment. The client described his apartment to be small with only one bedroom.
7 B. FAMILIAL HISTORY (Genogram) PATERNAL Grand Mother MATERNAL Grand Mother
Grand Father
Grand Father
Mother Aunt Uncle Father
LEGEND: LIVING Male:
DECEASED
Patient: W/ Diabetes:
Female: Smoking: Patients Parent:
P
Sister
8 PHYSICAL ASSESSMENT Date of Physical Assessment: July 06, 2011 / 6:55pm BMI: 29.411 Height:56 Weight: 85KGS Vital Signs: BP: 120/90mmhg Temperature: 37.3C Pulse rate: 89bpm Respiratory rate: 29cpm Pain Scale: 3 General Observations: The patient was restless, conscious, coherent, oriented to time, person, and place. He has thrombo embolic stockings on both lower extremities and was undergo laminectomy (June 30, 2011) on the thoracic (T9) and therefore completely limited in mobilization. Hemovac at the back was noted and complain for back pain. BODY PARTS Skin METHODS OF ASSESSMENT Inspection NORMAL Color: skin is uniform whitish pink or brown in color. No bleeding and ecchymosis and vascularity Lesions: no skin lesions are present except for birthmarks or moles which may be flat or elevated. No edema present ACTUAL FINDINGS INTERPRETATION
The overall The blood supply appearance of patients particularly at the back skin is light brown area decreased (due to prolong lying in bed). Some elevated Thus insufficient circumscribed fluidamount of oxygen filled less than 1cm in cause skin lesions diameter was noted at (vesicle) and dry skin the back. is an indication of decrease fluids in the body (Fundamentals of nursing, 6th ed page 687).
9 Palpation Moisture in skin folds varies with the environment Skin turgor: when released should return to original contour rapidly and no edema is present. Rounded (normocephalic) and asymmetric with frontal, parietal, temporal, occipital and prominences: Generally dry, warm and equal bilaterally Skin in hands slightly cooler than rest of body Dry skin probably due to environment (Kozier, Skill 30-2 p.579)
Head a. Skull
Inspection
Normocephalic, with prominences in the frontal and occipital area
The head is normocephalic in shape without the presence of mumps or disorientation The shape is gently curve with prominence at the frontal and parietal bones. (Fundamentals of nursing taylor 6th ed. vol.1 page616 ) The scalp is moisten during inspection showing good for a normal scalp (Fundamentals of th nursing taylor 6 ed. vol.1 page614) Client manifests normal findings
b. Scalp
Palpation
Smooth skull contour absence of nodules or masses
The scalp is moist, symmetrical and firm. No lesions and mass noted
c.Hair
Inspection
Color: dark black to blonde; may turn gray or white; may be chemically distribution Face is symmetrical Shape is gently curved with prominences at the frontal and parietal bones
The hair is dark brown in color. The texture was fine, smooth and thin slightly curly hair. Equally distributed and no signs of alopecia and lice. Symmetrical. No involuntary muscle movement
Face
Inspection
Client manifests normal findings
10 Palpation Eyes Inspection Smooth uniform consistency; absence of nodules or masses Should be symmetrical with no dropping infection, tumors or other abnormalities with the visual acuity of 20/20 Sclera: white without exudates, lesions foreign bodies in dark skinned may have brown patches Pupils: deep black,round of equal diameter 2-6mm PEERLA No tearing swelling or discharge in conjunctiva External ear gently no pain, edema, lesions. Earlobes are bean shaped, parallel and symmetrical. Skin is same color as complexion. Ear Canal & the tympanic membrane should be intact, translucent, shy & gray. No redness & discharge. Smooth uniform consistency; absence of nodules or masses Eyebrows equally distributed with dark brown in color. Eyelashes slightly curved upward evenly distributed and color is same with eyebrows Eyelids function normally conjunctiva is moist and pinkish Cornea is smooth and transparent Sclera has no problem Pupil equally round, reactive to light and accommodation with clear visual acuity and moves freely without discomfort. External ear no pain & lesions. Earlobes are bean shaped, parallel to the eye and symmetrical. Ear Canal & the tympanic membrane intact, translucent, shy & gray. No presence of earwax can be notice Can hear sounds when whispered & watch ticked. Client manifests normal findings Client manifests normal findings
Ears
Inspection
11 Assessing hearing sounds one ear at a time can hear whispered voice & ticking watch from distance of 1-2ft. Symmetrical midline of the face. Without swelling, bleeding, lesions or masses and each nostril are patent, no discharges and no nasal flaring; nasal mucosa is pink in color. No pain and discomfort during palpation Breath smells fresh. Lips are pink and moist with no lesions or inflammation tongue is midline, pink moist, rough without lesions Symmetrical: Moves freely gums are paled red strippled surface No swelling or bleeding
Nose
Inspection
It is symmetrical in line, no swelling no bleeding, lesions or masses
Palpation
Mouth
Inspection
There is no pain and upon palpation there is no swelling and tenderness of the paranasal sinuses Lips are dry and no edema noted. The gums are pink, no gum bleeding and no lesions noted. The tongue is in midline that moves freely and no dentures The buccal mucosa is pink and moist. The tongue is in The uvula is in midline pink and not swelling and also the tonsils are pink and not swelling
12 Nails Inspection Color: Have a pink cast in light-skinned brown in dark skinned. Shape and configuration is surface is smooth and slightly rounded or flat. Curved nails are normal. Uniform nails thickness throughout; no splintering or brittle edges Capillary refill present should return to normal 2-3 sec, Symmetrical with head in central position able to move freely without discomfort or noticeable limits Muscles should be symmetrical without palpable and no masses or lumps Light pink in color, Client manifests convex in shape. normal findings
Palpation Neck Inspection
Good capillary refill.
Symmetrical with head Client manifests in central position and normal findings able to move head w/o discomfort
Palpation
No visible masses and lumps noted No tenderness upon palpation and trachea is in the midline Normal ROM Cervical lymph nodes are not palpable and non-tender
13 BODY PARTS Skin METHODS OF ASSESSMENT Inspection NORMAL Color: skin is uniform whitish pink or brown in color. No bleeding and ecchymosis and vascularity Lesions: no skin lesions are present except for birthmarks or moles which may be flat or elevated. No edema present Moisture in skin folds varies with the environment Skin turgor: when released should return to original contour rapidly and no edema is present. Rounded (normocephalic) and asymmetric with frontal, parietal, temporal, occipital and prominences: ACTUAL FINDINGS INTERPRETATION
The overall The blood supply appearance of patients particularly at the back skin is light brown area decreased (due to prolong lying in bed). Some elevated Thus insufficient circumscribed fluidamount of oxygen filled less than 1cm in cause skin lesions diameter was noted at (vesicle) and dry skin the back. is an indication of decrease fluids in the body (Fundamentals of nursing, 6th ed page 687). Dry skin probably due to environment (Kozier, Skill 30-2 p.579)
Palpation
Generally dry, warm and equal bilaterally Skin in hands slightly cooler than rest of body
Head d. kull S
Inspection
Normocephalic, with prominences in the frontal and occipital area
The head is normocephalic in shape without the presence of mumps or disorientation The shape is gently curve with prominence at the frontal and parietal bones. (Fundamentals of nursing taylor 6th ed. vol.1 page616 )
14 e.Scalp Palpation Smooth skull contour absence of nodules or masses The scalp is moist, symmetrical and firm. No lesions and mass noted The scalp is moisten during inspection showing good for a normal scalp (Fundamentals of nursing taylor 6th ed. vol.1 page614) Client manifests normal findings
f. Hair
Inspection
Color: dark black to blonde; may turn gray or white; may be chemically distribution Face is symmetrical Shape is gently curved with prominences at the frontal and parietal bones Smooth uniform consistency; absence of nodules or masses Should be symmetrical with no dropping infection, tumors or other abnormalities with the visual acuity of 20/20 Sclera: white without exudates, lesions foreign bodies in dark skinned may have brown patches Pupils: deep black,round of equal diameter 2-6mm PEERLA
The hair is dark brown in color. The texture was fine, smooth and thin slightly curly hair. Equally distributed and no signs of alopecia and lice. Symmetrical. No involuntary muscle movement
Face
Inspection
Palpation Eyes Inspection
Smooth uniform consistency; absence of nodules or masses Eyebrows equally distributed with dark brown in color. Eyelashes slightly curved upward evenly distributed and color is same with eyebrows Eyelids function normally conjunctiva is moist and pinkish Cornea is smooth and transparent Sclera has no problem Pupil equally round, reactive to light and accommodation with
Client manifests normal findings Client manifests normal findings
15 No tearing swelling or discharge in conjunctiva clear visual acuity and moves freely without discomfort.
Ears
Inspection
External ear gently no pain, edema, lesions. Earlobes are bean shaped, parallel and symmetrical. Skin is same color as complexion. Ear Canal & the tympanic membrane should be intact, translucent, shy & gray. No redness & discharge. Assessing hearing sounds one ear at a time can hear whispered voice & ticking watch from distance of 1-2ft.
External ear no pain & lesions. Earlobes are bean shaped, parallel to the eye and symmetrical. Ear Canal & the tympanic membrane intact, translucent, shy & gray. No presence of earwax can be notice Can heard sounds when whispered & watch ticked.
16 Nose Inspection Symmetrical midline of the face. Without swelling, bleeding, lesions or masses and each nostril are patent, no discharges and no nasal flaring; nasal mucosa is pink in color. No pain and discomfort during palpation Breath smells fresh. Lips are pink and moist with no lesions or inflammation tongue is midline, pink moist, rough without lesions Symmetrical: Moves freely gums are paled red strippled surface No swelling or bleeding It is symmetrical in line, no swelling no bleeding, lesions or masses Client manifests normal findings
Palpation
Mouth
Inspection
There is no pain and upon palpation there is no swelling and tenderness of the paranasal sinuses Lips are dry and no edema noted. The gums are pink, no gum bleeding and no lesions noted. The tongue is in midline that moves freely and no dentures The buccal mucosa is pink and moist. The tongue is in The uvula is in midline pink and not swelling and also the tonsils are pink and not swelling
Nails
Inspection
Color: Have a pink cast in light-skinned brown in dark skinned. Shape and configuration is surface is smooth
Light pink in color, Client manifests convex in shape. normal findings
17 and slightly rounded or flat. Curved nails are normal. Uniform nails thickness throughout; no splintering or brittle edges Capillary refill present should return to normal 2-3 sec, Symmetrical with head in central position able to move freely without discomfort or noticeable limits Muscles should be symmetrical without palpable and no masses or lumps
Palpation Neck Inspection
Good capillary refill.
Symmetrical with head Client manifests in central position and normal findings able to move head w/o discomfort
Palpation
No visible masses and lumps noted No tenderness upon palpation and trachea is in the midline Normal ROM Cervical lymph nodes are not palpable and non-tender
18 Chest Inspection Without lesions; Skin is intact (Kozier, Skill 30-11 p.614) Full and Symmetric chest expansion Notes resonate, except over the scapula, ribs and is lower on the diaphragm Without lesions; with intact skin Client manifests normal findings
Rapid shallow breathing Partial chest expansion upon respiration
Tachypnea is respiratory rate greater than 29bpm . It result from pulmonary irritation and heightened oxygen demand result from pain and anxiety. Often seen in patient with restrictive lung disease and obesity Client manifests normal findings Rales heard upon auscultation indicates pulmonary tuberculosis (Kozier, Skill 30-11 p. 616) Client manifests normal findings Client manifests normal findings Tachypnea is respiratory rate greater than 29bpm . It result from pulmonary irritation and heightened oxygen demand result from pain and anxiety. Often seen in patient with restrictive lung disease and obesity.
Palpation Auscultation
Without nodules Quiet, rhythmic and effortless breathing
Without nodules, no masses Crackles (rales) at the lower lobes of the lungs Marked dullness over dependent portion of lungs Skin intact No tenderness, No masses, Respiratory rate of 29bpm was noted.
Thorax a. Anterior
Inspection Palpation Auscultation
Skin intact No tenderness, No masses, Quiet, rhythmic, and effortless respirations. Bronchovesicular and vesicular breath sounds.
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b. Posterior
Inspection
Anteroposterior to transverse diameter in ratio 1:2; Chest symmetric Spine vertically aligned Skin intact; chest wall intact; uniform temperature; ; no tenderness; no masses Vesicular and bronchovesicular breath
Thoracostomy tube and surgical staples on the left side as well as orthopaedic hardware at the thoracic spine remain in place. Mild thoracic kyphosis was noted. uniform temperature; ; no tenderness; no masses Intermittent nonmusical, brief crackling sounds heard.
The disease(Potts) is characterized by bone destruction and abcess formation. (Pathophysiology 6th edition by Carol Mattson Porth page133) Client manifests normal findings With pulmonary tuberculosis fine crackles occur. Nursing interpreting signs (Wolters Kluwer page 168) Presence of heart murmurs could indicate valve insufficiency (pp.451-469, Health Assessment & Physical Examination Zator Estes) There are no significant problems (pp.552-562, Health Assessment & Physical Examination Zator Estes) Constipation can be caused by certain factors including
Palpation
Auscultation
Heart
Auscultation
There is no lifts and heaves and there is no presence of heart murmurs
There is presence of heart murmurs
Abdomen
Inspection
Abdominal contour is flat or rounded symmetrical and uniform in color.
The clients abdomen is flat and rounded and uniform in color and no scars and no masses or tenderness
Auscultation
Audible bowel sounds Not low-pitched and
Decreased bowel movement 3 cycle in 1 whole minute
20 murmur sounds For bowel sounds, it is high pitched sound occur 5 to 30 times per minute neuromuscular conditions. Clinical manifestations of spinal cord compression include bowel and/or bladder dysfunction. (Textbook on Medical-Surgical Nursing 10th edition page 362) Percussion Tympany over the stomach and gasfilled bowels; dullness especially over the liver and spleen, or a full bladder No tenderness, relaxed abdomen with smooth, consistent tension Bladder and Liver is not palpable Dull percussion note was heard over the liver Client manifests normal findings
Palpation
Abdomenal tenderness and distension upon palpation. Bladder and Liver is not palpable
Constipation may occur with a spinal cord lesion. (Nursing interpreting signs and symptoms by Walters Kluwer page 149) Local muscle flaccidity due pressure on motor nerves (Anatomy and physiology by Anne Waugh 0age 186) The pressure damage initially causes pain there may be loss of sensation and paralysis
Musculos keletal
Inspection
Palpation
Muscles has equal size on both sides of the body, no contractures, no fasciculation, or tremors Bones has no deformities Joints has no swelling Muscles are firm, has smooth coordinated movements Bones has no
Muscle flaccidity particularly on the lower extremities Weak muscle strength were noted at lower extremities
Weak muscle strength were noted at lower extremities Pains were noted on the lower extremeties.
21 tenderness and swelling Joints have no tenderness and swelling, crepitation or nodules. Joints moves smoothly Bilateral symmetry without any presence of deformities, edema and discoloration. Intact. (Anatomy and physiology by Anne Waugh 10th edition page 186)
Extremiti es
Inspection
Hands are steady and no tremor noted. However muscle weakness and numbness with hyperflexion, and positive from joint pains were noted on the lower extremeties.
The most common sensory deficit from spinal nerve root compression are paresthesias and numbness particularly of the leg and foot (Pathophysiology by Carol Matson Porth 7th edition page 1205) Client manifests normal findings
Palpation
Glasgow coma scale is 15 Positive reflexes such as biceps reflex, triceps reflex, brachioradialis reflex, patellar reflex and Achilles reflex
Glasgow coma scale is 15 Positive reflexes such as biceps reflex, triceps reflex, Brachioradialis reflex, patellar reflex and Achilles reflex
Cranial Nerves I Olfactory By asking patient to close his eyes and identify different mild aromas. The nurse will ask the patient to read snellen chart; check Identify different mild aromas such as coffee, vanilla, peanut butter, orange, lime, chocolate Ability to clearly visualize the snellen chart; check visual fields by Able to identify mild aromas such as coffee, vanilla, peanut butter, orange, lime, chocolate Client manifests normal findings
II Optic
Able to clearly visualize the snellen chart; check visual fields by
22 visual fields by confrontation III Oculomot or The nurse will be assessing the six ocular movements and pupil reaction of a patient The nurse will be assessing the six ocular movements of a patient. confrontation Ablility to perform extraocular eye movement (EOM); movement of sphincter of pupil; movement of ciliary muscles of lens Ablity to perform extra eye movements specifically movements of eyeballs downward laterally confrontation Client manifests normal findings
Able to perform extraocular eye movement (EOM); movement of sphincter of pupil; movement of ciliary muscles of lens
IV Trochlear
Client manifests normal findings Able to perform extra eye movements specifically movements of eyeballs downward laterally Patient has presence of blink reflex; can feel the sensation of skin of face and nasal mucosa; able to feel the sensation of anterior oral cavity; mastication of muscles Client manifests normal findings
V Trigemin al
The nurse lightly touches the lateral sclera of the eye while the patient is looking upward. To test light sensation, have the client close eyes, wipe a wisp of cotton over patients forehead and paranasal sinuses. Ask client to clench teeth. The nurse will be assessing the directions of gaze.
Presence of blink reflex; can feel the sensation of skin of face and nasal mucosa; able to feel the sensation of anterior oral cavity; mastication of muscles
VI Abducens
Ability to move eye balls laterally
Able to move eye balls laterally
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VII Facial
The nurse will ask the patient to smile, raise eyebrows, frown, and puff out cheeks, close eyes tightly. Identifying various tastes placed on tip and sides of tongue. The nurse will be assessing the patients ability to hear spoken word and vibrations of tuning fork. The nurse will be applying tastes on posterior tongue for identification. Asking the patient to move tongue from side to side and up and down. The nurse will do palpation on the pharynx and larynx, assessing the gag reflex with the use of tongue depressor and assess the presence of
Ability to perform different facial expressions; able to identify different tastes
Able to perform different facial expressions; able to identify different tastes
VIII Auditory
Ability to clearly hear spoken words and vibrations of tuning fork
Able to clearly hear spoken words and vibrations of tuning fork
IX Glossopha ryngeal
Ablity to move the tongue from side to side and up and down; no difficulty in swallowing;; able to identify different taste on posterior tongue
Able to move the tongue from side to side and up and down; no difficulty in swallowing;; able to identify different taste on posterior tongue
X Vagus
Palpable pharynx and larynx; presence of gag reflex; no presence of hoarseness in the clients speech
Pharynx and larynx are palpable; presence of gag reflex; no presence of hoarseness in the clients speech
Patient has normal findings
24 hoarseness. XI Accessory The nurse will apply pressure on patients shoulders and ask patient to shrug shoulders against resistance and turn head to side against resistance from the nurse hand. By asking patient to protrude tongue at midline and move it side to side and up and down Ablity to shrug shoulders against resistance and able to turn to side against resistance without any difficulty Able to shrug shoulders against resistance and able to turn to side against resistance without any difficulty Patient has normal findings
XII Hypogloss al
Ability to protrude tongue at midline and move up and down and side to side
Able to protrude tongue at midline and move up and down and side to side
Patient has normal findings
25 GORDONS PATTERNS OF FUNCTIONING
Patterns
Prior to Hospitalization
During Hospitalization
Analysis & Interpretation/ Reference 26 I: Clients health perception is altered. A: Because of his condition, he perceived that he has to stop smoking because it is one the major factor why he was first diagnosed of PTB. Reference: Fundamentals of Nursing; The Art and Science of Nursing Care, 6th edition page 70 I: Clients nutrition is altered because of loss of appetite A: Because of his condition, illness, anxiety and medication it can contribute to poor intake or loss of appetite. To hospitalized patient, food and eating may take on much greater meaning. Having high protein diet helps the body to build new tissues that support bones damaged by tuberculosis. Reference: Fundamentals of Nursing; The Art and Science of Nursing Care, 6th edition page 1443 www.livestrong.com
Health Perception/ Health Management
The patient is a 26 years old male. He was diagnosed with Pulmonary tuberculosis and has taken medication for 3 months. According to him, he smokes 1 pack a day but stopped after he was diagnosed. He also drinks about 2-3 glasses of alcoholic beverages during special occasions.
The patient is conscious, coherent and oriented to time, place and person. He stated, Di ko na magawa yung mga ibang bagay na nagagawa ko noon, may lmitasyon na rin sa pagkilos ko.
NutritionalMetabolic
The patient eats three times a day with about 1 cup of rice per serving which usually consist of meat or vegetables. He also stated that he is allergic to seafood and drinks about 5-8 glasses (210ml/glass) of water per day.
The patient is on high protein diet. From time to time he feels loss of appetite in eating but still manage to eat three times a day and still drinks about 5-8 glasses of water per day.
Elimination
Patient has no problem in defecating and urinating. He usually defecates once a day with a consistency of soft to hard and a color
Patients defecation pattern had changed since he can no longer control his bowel. He defecates 1 time every other day. The consistency of his stool is hard and with color of dark
I: Clients bowel pattern is altered. A: One of the effect or complication of T9T12 spinal cord
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ANATOMY AND PHYSIOLOGY Spinal Anatomy The spinal column is one of the most vital parts of the human body, supporting our trunks and making all of our movements possible. Its anatomy is extremely well designed, and serves many functions, including:

Movement Balance Upright posture Spinal cord protection Shock absorption
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All of the elements of the spinal column and vertebrae serve the purpose of protecting the spinal cord, which provides communication to the brain and mobility and sensation in the body through the complex interaction of bones, ligaments and muscle structures of the back and the nerves that surround it. The normal adult spine is balanced over the pelvis, requiring minimal workload on the muscles to maintain an upright posture. Loss of spinal balance can result in strain to the spinal muscles and spinal deformity. When the spine is injured and its function impaired, the consequences may be painful and even disabling. Regions of the Spine Humans are born with 33 separate vertebrae. By adulthood, we typically have 24 due to the fusion of the vertebrae in the sacrum.
The top 7 vertebrae that form the neck are called the cervical spine and are labeled C1C7. The seven vertebrae of the cervical spine are responsible for the normal function and mobility of the neck. They also protect the spinal cord, nerves and arteries that extend from the brain to the rest of the body. The upper back, or thoracic spine, has 12 vertebrae, labeled T1-T12. The lower back, or lumbar spine, has 5 vertebrae, labeled L1-L5. The lumbar spine bears the most weight relative to other regions of the spine, which makes it a common source of back pain.
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The sacrum (S1) and coccyx (tailbone) are made up of 9 vertebrae that are fused together to form a solid, bony unit.
Spinal Curvature When viewed from the front or back, the normal spine is in a straight line, with each vertebra sitting directly on top of the other. Curvature to one side or the other indicates a condition called scoliosis. When viewed from the side, the normal spine has three gradual curves:

The neck has a lordotic curve, meaning that it curves inward. The thoracic spine has a kyphotic curve, meaning it curves outward. The lumbar spine also has a lordotic curve.
These curves help the spine to support the load of the head and upper body, and maintain balance in the upright position. Excessive curvature, however, may result in spinal imbalance. Elements of the Spine The elements of the spine are designed to protect the spinal cord, support the body and facilitate movement. A. Vertebrae The vertebrae support the majority of the weight imposed on the spine. The body of each vertebra is attached to a bony ring consisting of several parts. A bony projection on either side of the vertebral body called the pedicle supports the arch that protects the spinal canal. The laminae are the parts of the vertebrae that form the back of the bony arch that surrounds and covers the spinal canal. There is a transverse process on either side of the arch where some of the muscles of the spinal column attach to the vertebrae. The spinous process is the bony portion of the vertebral body that can be felt as a series of bumps in the center of a person's neck and back. B. Intervertebral Disc Between the spinal vertebrae are discs, which function as shock absorbers and joints. They are designed to absorb the stresses carried by the spine while allowing the vertebral bodies to move with respect to each other. Each disc consists of a strong outer ring of fibers called the annulus fibrosis, and a soft center called the nucleus pulposus. The outer layer (annulus) helps keep the disc's inner core (nucleus) intact. The annulus is made up of very strong fibers that connect each vertebra together. The nucleus of the disc has a very high water content, which helps maintain its flexibility and shock-absorbing properties.
30 C. Facet Joint The facet joints connect the bony arches of each of the vertebral bodies. There are two facet joints between each pair of vertebrae, one on each side. Facet joints connect each vertebra with those directly above and below it, and are designed to allow the vertebral bodies to rotate with respect to each other. D. Neural Foramen The neural foramen is the opening through which the nerve roots exit the spine and travel to the rest of the body. There are two neural foramen located between each pair of vertebrae, one on each side. The foramen creates a protective passageway for the nerves that carry signals between the spinal cord and the rest of the body. E. Spinal Cord and Nerves The spinal cord extends from the base of the brain to the area between the bottom of the first lumbar vertebra and the top of the second lumbar vertebra. The spinal cord ends by diverging into individual nerves that travel out to the lower body and the legs. Because of its appearance, this group of nerves is called the cauda equina - the Latin name for "horse's tail." The nerve groups travel through the spinal canal for a short distance before they exit the neural foramen. The spinal cord is covered by a protective membrane called the dura mater, which forms a watertight sac around the spinal cord and nerves. Inside this sac is spinal fluid, which surrounds the spinal cord. The nerves in each area of the spinal cord are connected to specific parts of the body. Those in the cervical spine, for example, extend to the upper chest and arms; those in the lumbar spine the hips, buttocks and legs. The nerves also carry electrical signals back to the brain, creating sensations. Damage to the nerves, nerve roots or spinal cord may result in symptoms such as pain, tingling, numbness and weakness, both in and around the damaged area and in the extremities. Numbering of Spinal Nerves and Vertebrae* Segmental Level Cervical Number of Level of Exit Nerves From Vertebral Column 8 Nerve C1* (suboccipital nerve) passes above the arch of vertebra C1. Nerves C2-C7 go through foramina above the corresponding vertebrae. Nerve C8 passes through the foramen between the arches of vertebra C7 and vertebra T1. Thoracic, Lumbar Sacral Coccygeal 12 ,5 5 1 Nerves T1 to L5 also pass through foramina below the arches of the corresponding vertebrae. Nerves S1-S4 branch into primary rami within the sacrum, and the rami go through the dorsal and ventral sacral foramina. The fifth sacral and the coccygeal nerves pass through the sacral hiatus.
31
*
The first cervical nerves lack dorsal roots in 50% of people, and the coccygeal nerves may be absent.
SPINAL AND VERTEBRAL LEVELS The dorsal and ventral roots traverse the subarachnoid space and pierce the arachnoid and dura mater. At this point, the dura becomes continuous with the epineurium. After passing through the epidural space, the roots reach the intervertebral foramina, where the dorsal root ganglia are located. The dorsal and ventral roots join immediately distal to the ganglion to form the spinal nerve. The length and obliqueness of the roots increase progressively in a rostrocaudal direction because of the increasing distance between cord segments and the corresponding vertebral segments (see Fig. 5-3). The lumbosacral roots are, therefore, the longest and constitute the cauda equina in the lower part of the subarachnoid space. The cord ends as the conus medullaris, which tapers rather abruptly into a slender filament called the filum terminale. The caudal 3 cm of the spinal cord contains most of the segments that communicate with the lower limb and perineum. Immediately below the conus medullaris are all the segmental nerve roots below L1.
32
Relation of segments of the spinal cord and spinal nerves to the vertebral column. The vertebral bodies are on the right side, and the dorsal spines of the vertebrae on the left. The filum terminale lies in the middle of the cauda equina and has a distinctive bluish color that distinguishes it from the white nerve roots. It consists of pia mater surrounding neuroglial elements and is a vestige of the spinal cord of the embryonic tail. The filum terminale picks up a dural investment opposite the second segment of the sacrum, and the resulting coccygeal
33 ligament attaches to the dorsum of the coccyx. Anatomical and Clinical Correlations Lesions of the spinal cord result from trauma, degenerative and demyelinating disorders, tumors, infections, and impairment of blood supply. The following notes on selected lesions show the necessity of understanding the intrinsic anatomy of the spinal cord to interpret signs and symptoms. CLINICAL EXAMINATION Testing for impairment or loss of cutaneous sensation is an important part of the neurological examination; it is particularly useful in detecting the site of a lesion that involves the spinal cord or nerve roots. The distribution of cutaneous areas (dermatomes) supplied by the spinal nerves is shown in Figure 5-13. Cutaneous areas supplied by adjacent spinal nerves overlap. For example, the upper half of the area supplied by T6 is also supplied by T5, and the lower half by T7. There is, therefore, little or no sensory loss after interruption of a single spinal nerve or dorsal root. The overlapping of dermatomes contrasts with the sharp delineation of the areas supplied by cutaneous nerves, which are formed in the limb plexuses by the mingling of fibers from various segmental nerve roots. Reflex contraction of muscles is also used in testing for the integrity of segments of the cord and of the spinal nerves. The segments involved in four commonly tested stretch or tendon reflexes are as follows: biceps reflex, C5 and C6; triceps reflex, C6 to C8; quadriceps reflex (knee jerk), L2 to L4; and gastrocnemius reflex (ankle jerk), S1 to S2. Before specific pathological conditions are mentioned, it should be noted that a distinction is made between the effects of a lesion involving motor neurons as opposed to those involving descending motor pathways. Destruction or atrophy of lower motor neurons (in the present context, those of the ventral horn) results in flaccid paralysis of the affected muscles, diminished or absent tendon reflexes, and progressive atrophy of the muscles deprived of motor fibers. The term upper motor neuron lesion is regularly used clinically but leaves much to be desired. The lesion may be in the cerebral cortex or in another part of the cerebral hemisphere, in the brain stem, or in the spinal cord. Thus, the term upper motor neuron is a collective term including all the descending pathways that control the activities of the neurons that supply the muscles. The following signs are associated with an upper motor neuron lesion after the acute effects have worn off: varying degrees of voluntary paralysis, which is most severe in the upper limb; a positive Babinski's sign (i.e., upturning of the great toe and spreading of the toes on stroking the sole); and spasticity with exaggerated tendon reflexes.
34
35
Dermatomes - Cutaneous distribution of spinal nerves. A dermatome is an area of skin supplied by sensory neurons that arise from a spinal nerve ganglion.
36 PATHOPHYSIOLOGY
37 LABORATORY AND DIAGNOSTIC RESULTS Name of patient: Patient J.H.A. Date of Request: 6/30/11 Date received: 6/30/11 PROCEDURE Surgical Pathology -Specimen: T8 vertebra abcess -Specimen is received in formalin and labeld as T8 vertebral abscess NORMAL VALUES Age: 26 Time Requested: 10:39am Time received: 16:50 ACTUAL FINDINGS - It consists of a tan red, irregular, soft tissue fragment measuring 1x0.5x0.2cm. Gender: Male
INTERPRETATIONS NURSING RESPONSIBILITY - Diagnosis: Chronic Granulomatous - Monitor vital signs until stable -Assess the site for excess drainage or bleeding -Evaluate discomfort Administer analgesic or sedative as necessary.
Source: Nurses Quick Reference to Common Laboratory and Diagnostic Test (4th Edition) by Frances Fishbach and Marshall Dunning III
38 Patients Initial: JHA Age: 26 Date and time requested: 7/1/2011 PROCEDUR NORMAL ACTUAL E FINDINGS FINDINGS Hemoglobin 14-17g/l 9.6 g/l Gender: Male INTERPRETATIO N -There is a decrease Hgb level may indicate anemia or thalassemia. NURSING RESPONSIBILITITE S -Monitor vital signs -Tracking test sent until results receives -Notification of patient of results -Documentation that notification occurred -Assuring that recommendation follow-up occurred. -Monitor laboratory values. -Report abnormal values to physician -Bed rest. -Immobilization of affected joint by splintage. -Nutritious, high protein diet. Drainage of abscess -Surgical decompression. - Monitor intake and output.
Hematocrit
42-52%
29.8%
-There is a decrease Hct level may indicate anemia and presence patients chronic stage disease.
RBC
4.2-5.4mil/mm3 3.51mil/mm3
WBC
450010500cell/mm3
12,700mm3
-There is a decrease in RBC count that may indicate anemia, acute hemmorhage and chronic infection. -There is an increase in WBC that may indicate acute infection in which the degree of increase of WBCs depends on severity of infection, age, resistance, inflammation &
39 haemorrhage. -Differential Count Neutrophils 40-74% 87% -There is an increase Neutrophils indicates that there is presence os bacterial infection. High level may indicate an active infection one basic cause of high neutrophils count. -There is a decrease Lymphocytes count that indicates immune system dysfunction and presence of debilitating disease of the patient. -There is an increase in Monocytes count thta may indicate overwhelming infection. -The result is within normal range; an increase in Platelet count that may indicate acute infection and inflammatory disease. If Platelet count deceases it is due to toxic effect of many drugs and bone marrow lesions during therapies; allergic condition and viral infection.
Lymphocytes
19-48%
7%
Monocytes
3-9%
6%
Platelet
140,000400,000mil/mm 3
260,000mil/mm 3
40 MCV -The result is within normal range. An increase in MCV occur with iron deficiency, excessive iron requirement, thalassemia, lead poisoning and chronic inflammation Elevated to normal occurs in some anemias: B12 deficiency, and inflammation. MCH 26-34 pg/cell 27 pg/cell -The result is within normal range. MCH decrease in microcyti anemia and thalassemia. MCHC 32-36g/dl 32g/dL -The result is within normal range. MCHC increase indicate spherocytosis. MCHC decrease signify that RBCs contain less hemoglobin that normal as in iron deficiency anemia & thalassemia. Source: Nurses Quick Reference to Common Laboratory and Diagnostic Test (4th Edition) by Frances Fishbach and Marshall Dunning III 82-98 fl 84 fl
41 Patients Initial: JHA Age: 26 Date and time requested: 7/1/2011 Date and Time of exam: 5:26am PROCEDURE NORMAL ACTUAL VALUES FINDINGS -Blood Chemistry 0.800.92 mg/dl Creatinine 1.50mg/dl Gender: Male INTERPRETATION NURSING RESPONSIBILITIES - The result is within normal range of 0.92 mg/dl. It signifies that the client is not having a kidney problem with or without regards to his disease. Increase of values may indicate renal disease. - PRETEST -Assess patient's compliance and knowledge base before explaining the purpose and procedure. -No Calcium supplements should be ingested 8 to 12hours before blood sample. INTRATEST -Accurate test results depend on proper collection, preservation and labeling. POSTTEST -Evaluate the outcome, and monitor the patient for signs and symptoms of excess and deficient electrolytes. - PRETEST -Assess patient's compliance and knowledge base before explaining the purpose and procedure. -No Calcium supplements should be ingested 8 to 12hours before blood sample. INTRATEST -Accurate test results
Chloride
98-107 mmol/L
105 mmol/L
-The result is within normal range of 105 mmol/L. It signifies that the client is not dehydrated and is not having a renal shut down. Increase or decrease of values may indicate severe dehydration, complete renal shutdown and chronic renal failure respectively
42 depend on proper collection, preservation and labeling. POSTTEST Evaluate the outcome, and monitor the patient for signs and symptoms of excess and deficient electrolytes. Ionized 1.00-1.30 1.08 mmol/L -The result is within -Assess patient's Calcium mmol/L normal range of compliance and 1.08mmol/L. knowledge base Increase in values before explaining the may indicate purpose and hyperparathyroidism procedure. and other thyroid -No Calcium associated supplements should conditions. Decrease be ingested 8 to in values may 12hours before blood indicate sample. hypoparathyroidism, INTRATEST Pagets disease of -Accurate test results the bone, multiple depend on proper myeloma, and renal collection, failure. preservation and labeling. POSTTEST -Evaluate the outcome, and monitor the patient for signs and symptoms of excess and deficient electrolytes. Source: Nurses Quick Reference to Common Laboratory and Diagnostic Test (4th Edition) by Frances Fishbach and Marshall Dunning III
Patients Initial: JHA Age: 26 Date and time requested: 7/1/2011 00:24am Date and Time received: 7/1/2011 5:02am
Gender: Male
43 PROCEDURE NORMAL VALUES -Blood Chemistry 135-145 Sodium mmol/L ACTUAL FINDINGS 140 mmol/L INTERPRETATION NURSING RESPONSIBILITIES
- The result is within normal range.It signifies that the client is not dehydrated and is not having a renal shut down. Increase or decrease of values may indicate severe dehydration, complete renal shutdown,diabetes insipidus and chronic renal failure respectively.
Potassium
3.5-5.3 mmol/L
4.2 mmol/L
- PRETEST -Assess patient's compliance and knowledge base before explaining the purpose and procedure. -No Calcium supplements should be ingested 8 to 12hours before blood sample. INTRATEST -Accurate test results depend on proper collection, preservation and labeling. POSTTEST -Evaluate the outcome, and monitor the patient appropriately for signs and symptoms of excess and deficient electrolytes. - The result is within PRETEST normal range.It signifies -Assess patient's that the client is not compliance and dehydrated and is not knowledge base having a renal shut down. before explaining the Increase or decrease of purpose and values may indicate severe procedure. dehydration, complete renal -No Calcium shutdown, cystic fibrosis supplements should and sickle cell anemia be ingested 8 to respectively. 12hours before blood sample. INTRATEST -Accurate test results depend on proper collection,
44 preservation and labeling. POSTTEST -Evaluate the outcome, and monitor the patient appropriately for signs and symptoms of excess and deficient electrolytes. Magnesium 1.81.8mg/dl -The result is within normal PRETEST 2.4mg/dl range.It signifies that the -Assess patient's client is not dehydrated and compliance and is not having a renal shut knowledge base down. Increase or decrease before explaining the of values may indicate purpose and severe dehydration, procedure. complete renal -No Calcium shutdown,chronic supplements should pancreatitis,hypothyroidism be ingested 8 to and hypoparathyroidism 12hours before blood respectively. sample. INTRATEST -Accurate test results depend on proper collection, preservation and labeling. POSTTEST -Evaluate the outcome, and monitor the patient appropriately for signs and symptoms of excess and deficient electrolytes. Source: Nurses Quick Reference to Common Laboratory and Diagnostic Test (4th Edition) by Frances Fishbach and Marshall Dunning III
Patients Initial: JHA Age: 26 Date and time requested: 7/3/2011 15:25 Date and Time of exam: 7/3/2011 16:45
Gender: Male
45 Procedure Chest X-ray Normal Values Normal and appearing and normally positioned chest, bony thorax, soft tissues, mediastinum, lungs, pleura, heart, and aortic arch. ActuaL Findings -The previously noted endotracheal tube is no longer inserted. -Thoracostomy tube and surgical staples on the left and orthopaedic hardware at the thoracic spine remain. -There is increased opacity in the right paracardiac vesicular crowding secondary to elevated right thigh. Interpretation Nursing Responsibilities -s/p endotracheal -Explain the extubation. purpose and procedure of obtaining a chest -s/p x-ray and assure thoracostomy, the patient that chest tube the test is drainage. painless. -No preparation is necessary that -Increased make certain that opacity in the jewerlies and right paracardiac metallic objects area which relate are removed to vascular from the chest crowding area. secondary to -Screen for elevated pregnancy status hemidiagram. and, if positive, Infiltrates or advise the atelectasis at this radiology area be ruled out. department. -Monitor pulmonary and chest disorders, and provide the patient with support and counselling. -Explain the need for repeat chest x-ray films and follow up tests.
-Cardiac silhouette is not enlarged. -Aorta is not tortuous. -There is interval decrease in the subcutaneous supraclavicular region. -The left 9th posterior rib is surgically absent.
-The rest of the findings remain stationary. Source: Nurses Quick Reference to Common Laboratory and Diagnostic Test (4th Edition) pages 188-189 by Frances Fishbach and Marshall Dunning III Patients Initial: JHA Age: 26 Gender: Male Date and time requested: 7/5/2011 PROCEDURE NORMAL ACTUAL INTERPRETATION NURSING
46 VALUES Microbiology Sample Type: Sputum Gram Stain Results: FINDING S S RESPONSIBILIT Y -Assess patient's compliance and knowledge base before explaining the purpose and procedure. -Have patient rinse with water to remove excess oral flora; instruct patient to cough deeply and collect and transport in a sterile container -Accurate test results depend on proper collection, preservation and labeling. -Should be aware of infection control to be use as precaution. When there is occurrence of positive result. -A written report of the examination will be sent to the requesting health -There is presence of care practitioner, Gram (+) cocci in who will discuss short chains. May the results with the indicate patient. Mycobacterium - Recognize Tuberculi, a gram anxiety related to (+) bacteria; that test Results. possibly caused the Discuss the present disease of implications of the patient. abnormal test results on the Patients lifestyle. -There is presence of Provide teaching Gram (+) cocci in and information
Gram (+) cocci in short chains.
-The presence of normal upper respiratory tract flora should be expected. -Tracheal aspirates and bronchoscopy samples can be contaminated with normal flora, but transtracheal aspiration specimens should show nogrowth. -Normal respiratory flora include Neisseria catarrhalis, Candida albicans, diphtheroids, _hemolytic streptococci, and some staphylococci. -The presence of normal flora does not rule out infection. -A normalGram stain of sputum -Few contains polymorphonucle ar leukocytes, alveolar macrophages, and a few squamous epithelial cells.
Gram (+) cocci in clusters
-Negative
-Positive
47 clusters. a grampositive, coagulasepositive coccus that occurs in clusters. This organism expresses receptors for bone matrix components, such as collagen, which help it to attach to and infect bone. -There is presence of Gram (-) bacilli occurring singly that when compared to hematogenous osteomyelitis, continguous-focus infections are more likely to also include gram-negative and anaerobic bacteria. - The presence of greater than25 squamous epithelial cells per low powerfield (lpf ) indicates oral contamination,and the specimen should berejected.- The presence of many polymorphonuclear neutrophils and few squamous epithelial cells indicates thatthe specimen was collected from an area of infection and is satisfactory for further analysis. regarding the clinical implications of the test results, as appropriate. - Reinforce information given by the patients health care provider regarding further testing, treatment, or referral to another health careprovider. -Emphasize the importance of reporting continued signs and symptoms of the infection. Answer any questions or address any concerns voiced by the patient or family. -Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy.
Gram (-) bacilli occurring singly
-Negative
-Few
Polymorphonucle ar cells Squamous epithelial cells
-Negative
>25/LPF
5-10 lpf
Mucus Threads
-Few
-Few
-Evaluate test -The amount of results inrelation Mucus threads in the to the patients
48 sputum sample is normal. symptoms and other tests performed.
Source: Nurses Quick Reference to Common Laboratory and Diagnostic Test (4th Edition) by Frances Fishbach and Marshall Dunning III
Patients Initial: JHA
Age: 26
Gender: Male
49 Date and time requested: 6/30/2011 11:05 Date and Time of exam: 7/1/2011 6:36 Procedure Normal Values ActuaL Findings -Diagnostic Radiology Bedside PA No identifiable cardiothoracic or musculoskeletal abnormality
Interpretation
-Patchy opacities are -Patchy seen in the upper left opacities signify lung field; upon infiltration and auscultation. consolidation in -Progression of the the lungs. previously noted -Opacification opacitites in the right of airspaces lower lobe/ within the lung paracardiac region. parenchyma -A suspicious suggest active INTRATEST curvilinear opacity is tuberculosis. -Accurate test seen in the left upper results depend on lung field. proper -The left 9th posterior collection, rib is surgically preservation and absent. labelling. -An edotracheal tube is seen in place with POST TEST its tip 2.5 cm. -Evaluate the -Left-sided outcome, and thoracostomy tube is monitor the seen with sentinel patient hole within the left appropriately. hemithorax. -Radiolucencies are noted in the soft tissues at the left supraclavicular region. Source: Nurses Quick Reference to Common Laboratory and Diagnostic Test (4th Edition) pages 188-189 by Frances Fishbach and Marshall Dunning III
Nursing Responsibilities -PRETEST -Asses patients compliance and knowledge base before explaining the purpose and procedure.
COURSE IN THE WARD
50
DATE July 5, 2011
July 6, 2011
July 7, 2011
DOCTORS ORDER Sit and dangle legs with assistance for 15 minutes Monitor vital signs Continue medications Provide strengthening exercises Sit and dangle legs with assistance for 15 minutes Monitor vital signs Continue medications Provide strengthening exercises Apply support stockings before discharge Sit and dangle legs with assistance for 15 minutes Monitor vital signs Continue medications Provide strengthening exercises Provide discharge planning Deliver health teaching to patient and significant others
STUDENT NURSE ACTIVITY Student nurse monitored the vital signs of the patient every 4 hours and assisted the physical therapist in facilitating sitting and dangling of the legs of the patient. Student nurse administered medications as prescribed.
OUTCOME The patient responded well and participated in sitting and dangling of his legs. The patient felt relieved every time he was log rolled and repositioned.
Student nurse monitored patients vital signs every 4 hours. Medications were administered on time and log rolling was provided for by the student nurse.
The patient responded well and participated in strengthening exercises. He felt relieved every time he was log rolled and repositioned.
Student nurse monitored the vital signs of the patient every 4 hours, applied support stocking to the patients extremities and assisted the physical therapist in facilitating sitting and dangling of the legs of the patient. Student nurse administered medications as prescribed. Health teaching delivered to patient and his significant others.
The patient and his significant others verbalized understanding on the current situation, the importance of providing strengthening exercises and applying support stockings on the patients lower extremities.
51 Patient JHA, 26 years old was admitted in St Lukes Medical Center last July 29, 2011 with a chief complaint of difficulty of defecating. The patient was diagnosed with Potts disease. He was scheduled for a confinement due to surgical operation for the removal of the mass present in his spine.
Drug Name Isoniazid
Classification Antituberculosis
Dosage/ Route 300 mg/day PO
Drug Name Rifampin Rifampicin
Classification Antibiotic Antituberculotic
Dosage and Route 200 mg/day PO
Action Indication Inhibits DNAtuberculosis dependent RNA polymerase activity in Action Indication susceptible bacterial cells Inhibits DNAdependent RNA Tuberculosis polymerase activity in susceptible bacterial cells.
Side Effects Optic neuritis, psychotic reactions, convulsions, Side Effects nausea, vomiting, epigastric GI disturbances, distress abnormalities of liver function, drowsiness, headache, visual disturbances, reddish colored urine and tears,
52 Nursing Responsibilities Monitor vital signs Monitor input and output Nursing Responsibilities in Contraindicated patients with acute hepatic disease Monitor vital signs Monitor renal/liver Monitor input and function output Assess for visual Give medication disturbance before meals which may indicate optic Monitor renal/liver neuritis function Assess lung sounds and character and Assess lung sounds amount of sputum and character and periodically during amount of sputum course periodically during course Monitor patient compliance with Monitor patient medication regimen compliance with medication regimen
DRUG STUDY
Reference:Lippincotts Nursing Drug Guide 2009
53
Drug Name Pyrazinamide
Classification Anti-infective
Dosage/ Route 1500 mg PO
Action Inhibits DNAdependent RNA polymerase activity in susceptible bacterial cells
Indication tuberculosis
Side Effects Dark urine, difficulty in urination, painful or swollen joints, yellow eyes, nausea and vomitting
Nursing Responsibilities Monitor vital signs Monitor input and output Contraindicated in patients with hepatic disease Take each dose with a full glass of water Monitor patient compliance with medication regimen
54
Drug Name Ethambutol
Classification Anti-infective
Dosage/ Route 400 mg/day PO
Indication Tuberculosis
Side Effects
Nursing Responsibilities Headache, loss Monitor vital of appetite, upset signs stomach, or Monitor input nausea/vomiting, and output visual Contraindicated disturbance, in patients with confusion, hepatic disease nausea and Take each dose vomiting, severe with a full glass abdominal pain, of water easy bleeding or Monitor patient brusing compliance with medication regimen
55
Drug Name Streptomycin
Classification Anti-ineffective
Dosage/ Route 500 mg/daily IM
Side Effects
Nursing Responsibilities
Headache, Monitor vital nausea, vomiting signs and Monitor input disequilibrium and output Contraindicated in patients with hepatic disease When administering medication, inject deep into upper outer quadrant of buttocks Alternate route of administration Monitor patient compliance with medication regimen
56
Drug Name Dolcet
Classification Analgesic
Dosage/ Route 500 mg IM PRN
Action It possesses weak agonist actions at the opioid receptor, releases serotonin, and inhibits the reuptake of norepinephrine
Indication Indicated to moderate to severe pain.
Side Effects
GI disturbances, nausea, Monitor vital dizziness,hot signs flushes, Monitor input constipation, and output diarrhea, dry Contraindicated mouth, increased in patients with sweating, epilepsy, tinnitus history of seizures, increased intracranial pressure or head trauma, patients at risk for respiratory depression, severe hepatic impairment
57
Drug Name Myrin P Forte
Classification Antibiotic
Dosage/ Route 250 mg /day PO
Side Effects
GI disturbances, nausea, Monitor vital dizziness,hot signs flushes, Monitor input constipation, and output diarrhea, dry Medicine mouth, increased should be taken sweating, with an empty tinnitus stomach or with food to relieve GI discomfort Contraindicated in patients with impaired hepatic function, severe renal insufficiency
58 Dosage and Route PRN 15mg PO Nursing Responsibilities Monitor vital signs Monitor input and output Monitor renal/liver function. Monitor bowel frequency. Monitor patient compliance with medication regimen
Drug Name Dulcolax
Classification Laxative
Action It acts directly on the bowels, stimulating the bowel muscles to cause a bowel movement
Indication Short term relief of constipation. Constipation, either chronic or of recent onset, whenever a stimulant laxative Is required.
Side effects
Abdominal cramps.
59
NURSING CARE PLAN
Assessment Subjective: Masakit ang banding gitna ng likod ko as verbalized by the patient. -Aching -Onset is indefinite -Localized in the middle area of the back -Pain goes away for up to 30 minutes at times but recurs again -Pain scale of 6/10, when not
Diagnosis Chronic pain related to thoracic compression as manifested by facial grimace and guarding behavior
Inference Precipitating factors: -Obesity -Work: (junkerheavy lifter) and Predisposing factors: -T8 spinal abscess -Kyphosis T9 spinal compression Alteration of peripheral nervous system impulses (T8T9)
Planning Short term:
Intervention Independent:
Rationale
Evaluation Short term: After an hour of nursing interventions, the patient was able to verbalize that pain is relieved/ controlled as evidenced by pain scale of 3/10 or lower Long term: After 3days of nursing interventions, the patient was able to verbalize nonpharmacologic methods that provide relief and follow
After an hour of nursing -Assess for pain interventions, the tolerance patient will be able to verbalize that pain is relieved/ controlled as evidenced by pain scale of 3/10 or lower -Note cultural Long term: and developmental After 3days of influences nursing affecting pain interventions, the patient will be able to verbalize non-Provide comfort pharmacologic measures, quiet methods that environment,
-To help determine possibility of underlying condition or organ dysfunction requiring treatment -Verbal or behavioral cues may have no direct relationship to the degree of pain perceived -To promote nonpharmacological
60 moved -With pulsation -Pain worsens when repositioning (9/10) Objectives: -Body temperature of 36.8C rose to 37.3C in 4 hours -Facial grimace noted -Observed evidence of pain during repositioning -restlessness -sleep disturbance -Spinal cord (T8) abscess Nociception Transmission and interpretation of pain signal to the brain Localized midposterior pain Guarding behavior; restlessness; irritability The gate control theory of pain is the idea that physical pain is not a direct result of activation of pain receptor neurons, but rather its perception is modulated by interaction between different neurons. provide relief and follow prescribed pharmacological regimen and calm activities -Note when pain occurs -Investigate report of pain, noting characteristics, location, intensity (0-10 scale) -Provide firm mattress and small pillows pain management -To medicate prophylactically, as appropriate -Helpful in determining pain management needs and effectiveness of the program -Soft or sagging mattresses and large pillows inhibit the proper body alignment -In acute phase, total bed rest maybe necessary to limit pain prescribed pharmacological regimen
-Suggest patient to assume position of proper comfort while in bed. Promote bed rest as indicated -Encourage frequent changes of position
-Prevent general fatigue and joint stiffness
61 -Encourage use of stress management techniques -Promotes relaxation, provides sense of control and may enhance coping activities -Increasing/ decreasing dosage, stepped program helps in self-management of pain
-T9 compression via CT Scan -Guarding behavior
-Evaluate/ document patients response to analgesia, and assist in transitioning/ altering drug regimen, based on individual needs Dependent: -Administer/ monitor medication such as analgesics/, as indicated, to maximum dosage, as needed -Administer antibiotic as
-To maintain acceptable level of pain. Notify the physician if regimen is inadequate to meet pain control goal -To prevent further infection
62 prescribed
Collaborative: -For further -Coordinate with diagnostic or medical laboratory technologists, evaluation radiation technologists, nuclear medicine department -To promote -Coordinate with wellness dietician, nutritionist -To provide -Coordinate with financial support charitable institution and HMO -To support -Coordinate with patient and spiritual family spiritually counselor Source: Gate Control Theory of Pain. (n.d.). Science Daily. Retrieved September 30, 2011, from www.sciencedaily.com/articles/g/gate_control_theory_of_pain.htm Doenges, M.E. et.al (2006). Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationale. ed. 10. 392-396
63
Assessment Subjective: Mula pa noong una, nahihirapan na talaga ako dumumi. Sabi ng doctor, dahil sa sakit ko ito. Objective: Change in bowel pattern (0-1x bowel activity every 2 days.) Distended abdomen Hard, dry, lumpy stools Percussed abdominal dullness
Diagnosis Impaired Elimination Pattern r/t damage of defecation reflex secondary to cord compression (T8-T9) as evidenced by decrease bowel movement and decrease bowel sounds.
Inference Cord compression of T8 and T9 Damage of defecation reflex (Dermatome) Relaxation of anal sphincter muscle Frequent attempts to empty bowel and bearing down or manual removal of stool And
Planning Long Term: After 1 week of nursing interventions client will be able to: Identify measures that prevent or treat constipation from 0 as to not knowledgeable to 3 as knowledgeable Short Term: After 3 days of nursing intervention client will be able to:: 1. State relief from discomfort of constipation from 0 as to very discomforting to 3 as very comfortable 2. Maintain passage of
Intervention Independent: Assess pattern of defecation including time of day, amount and frequency of stool.
Rationale
Evaluation
Assess clients current medications, food and fluid intake.
Palpate for abdominal distention, percuss for dullness, and
Goal met: To provide a After 1 week of nursing baseline interventions client data and was able to: history about the Identify measures clients that prevent or treat defecation constipation from 0 habits and as to not patterns. knowledgeable to 3 as knowledgeable To determine After 3 days of effects of medications nursing intervention client is be able to:: that may 1. State relief possibly from contribute to discomfort the clients of condition constipation from 0 as to very To have an discomfortin accurate g to 3 as data that the very client is
64 Noted decrease frequency of stool (bowel sounds 4cpm). Irritable/ Restless stools, formed stool every day as possible without straining. auscultate for bowel sounds. constipated. Constipated client has a distended abdomen with abdominal rigidity and tenderness. Bowel sounds are present. To significantly increase the frequency of stools. To encourage client to defecate with ease To establish a sense of control for the client. comfortable 2. Maintain passage of stools, formed stool every day as possible without straining.
Generalized body weakness Impaired physical mobility Decreased peristaltic activity Impaired elimination pattern
Encourage increase in fluid and fiber-rich foods. Provide privacy for defecation
Initiate a regular schedule for bowel elimination.
65 Offer hot coffee or lemon if not contraindicate d. Explain what valsalva maneuver is and the reason it should be avoided.
To promote vasodilation thereby stimulating peristaltic activity. Valsalva maneuver could cause bradycardia and would be less helpful for the client. To establish a trust and rapport with patient.
Respond quickly to clients call help in toileting. Collaborative: Provide high fiber diet. (dietitian/nutr itionist) Administer laxatives as prescribed Provide enema as prescribed
Doenges, M.E. et.al (2006). Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationale. ed. 10. 137-140
66
Assessment Subjective: Nahihirapan akong kumilos, kaya hindi ako masyadong makagalaw Objective: -Difficulty moving lower extremities -anxious -muscle loss in the legs -restraints on pt. noted -pt. grimaces when lower extremities is moved
Diagnosis Impaired Physical Mobility r/t neuromuscular impairment as manifested by inability to move without assistance.
Inference Spinal Cord compression Numbness/ tingling of lower extremity Generalized body malaise Impaired physical mobility of lower extremity
Planning Long Term: After 1 week of nursing interventions client will be to: Maintain position of function from presence of 0 as to presence of contractures to 3 as to absence of contractures. Short Term: After 3 days of nursing intervention client will be able to:: 3. Increase strength and function of the affected part
Intervention Independent: Assess clients ability to comply with the procedure
Rationale To determine clients readiness about the situation. To enhance healing and builds muscle strength and endurance and promotes independe nce and sense of control To strengthen abdominal
Evaluation Goal met: After 1 week of nursing interventions client is able to: Maintain position of function from presence of 0 as to presence of contractures to 3 as to absence of contractures. After 3 days of nursing intervention client is be able to:: 1. Increase strength and function of the affected part .
Schedule activity with rest periods. Encourage participation in ADLs within individual limitations.
Provide/assist with passive and active ROM exercises depending on
67 surgical procedures. muscle and flexors of spine and promotes good body mechanics Until healing occurs, acivity is limited and advanced slowly according to individual tolerance.
Assists with activity/progressive ambulation
Doenges, M.E. et.al (2006). Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationale. ed. 10. 271-276
68 DISCHARGE PLAN M.E.T.H.O.D.S MEDICINE o Take home medications as directed by the physician o Analgsesics o Standard antituberculosis treatment is required.
-
Duration of antituberculosis treatment: If debridement and fusion with bone grafting are performed, treatment can be for six months If debridement and fusion with bone grafting are NOT performed a minimum of 12 months treatment is required.
EXERCISE o Types of Exercises Recommended exercises for Pott's disease rehabilitation include stretching and a group of exercises involving the use of proprioceptive neuromuscular facilitation -- techniques. These exercises usually progress in difficulty you do them. Your health care provider will carry out checks to determine what level of exercise is safe for you and then gradually build you up from there. The presence of other diseases that might negate treatment, such as osteoporosis, is also ruled out before your exercise regimen begins
Isometric Exercises Pott's disease usually leads to several neurological symptoms that could be made worse by unsupervised exercise. It is therefore important to progress with caution. Physical therapists usually start with isometric exercises. The goal of such exercises is to develop muscle strength through contractions without movement. This way, muscle strength is
69 gradually built up while minimizing the risk of further damage. After gaining enough strength and dexterity with these non-movement exercises, you are ready for the next stage. o Stretching Exercises Use extreme care when performing stretching exercises with Pott's disease. As a general rule, only gentle stretching exercises are permissible. In fact, before implementing this stage of exercises, assisted passive movements should first be perfected. Gentle stretching of your extremities is introduced only once the physical therapist confirms that it is safe. It is also important that you maintain spinal stability while performing these gentle stretching exercises. TREATMENT o Patient must strictly comply with physicians orders. Failure to comply may lead to perseverance and worsening of the patients condition. HEALTH TEACHING o Inform patient regarding follow-up check up and take home medications o Educate the family members of the cause of the patients illness. Inform them that dengue mosquito breeds primarily in man-made containers like earthenware jars, metal drums and concrete jugs used for domestic water storage, as well as discarded plastic food containers, used automobile tyres and other items that collect rainwater. o Encourage significant others to take part in protecting the child and the family from future illness. OUTPATIENT o Contact caregiver if: There is increased body temperature or fever
70 Blood in stool The body temperature is elevated The incision is swollen, red or has pus coming from it. This may seem that there is an infection The incision comes off.
DIET o Diet as tolerated o Fluid intake should be increased o Diet should include foods that are high in protein, to build new tissues that support bones damaged by the disease o Vitamin D intake should be increased. It aids in calcium absorption which helps the bones o Avoid foods that are high in sodium, especially processed foods, along with sauces
SPIRITUAL/SOCIAL o Seek home visits from the family priest or pastor once capable o Ask for family members to visit every now and then, but do warn of the diseases high risk of transmission o As much as possible, limit activities outside the house to prevent possible complications with the patient and to minimize the risk of transmitting the disease
71
EVALUATION
After having our duty in St. Lukes Medical Center our group really had a great time having our duty in charity ward, second floor and considering the condition of the patient is a toxic one. With these in mind, we strived to know and understand the disease; studied how to detect and deal with it and its victims like Patient JA. But it never became a hindrance for us to deliver a good quality nursing care in spite of all the lockage within ourselves. Our group had utilized each and every information that we know for us to be oriented by this disease. We give priority even with the tiniest problem that we need to address. The essence of unity had been developed thru our collaboration with each other. We had formulated a nursing diagnosis and interventions in which at the end we were able to imply to the patient and the patient was able also to respond easily with our interventions. In over all evaluation the outcome of our intervention together with the collaboration of the staff nurses was good. Day by day as our rotation progress the condition of the patient was getting good. Thus reflecting on our interventions it was an effective one. And at the end there was only one thing that matters to us that we had let that person felt that someone cares for him. And the essence of being a real globalian had been developed in each and every one of us.

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1 INTRODUCTION This chapter discusses briefly basic concepts of the medical diagnoses of the patient.

5 that the patient is suffering from Potts disease or extra-pulmonary tuberculosis.

7 B. FAMILIAL HISTORY (Genogram) PATERNAL Grand Mother MATERNAL Grand Mother

Mother Aunt Uncle Father

LEGEND: LIVING Male:

Female: Smoking: Patients Parent:

Normocephalic, with prominences in the frontal and occipital area

Smooth skull contour absence of nodules or masses

Client manifests normal findings

Client manifests normal findings

It is symmetrical in line, no swelling no bleeding, lesions or masses

Client manifests normal findings

Client manifests normal findings

Client manifests normal findings

Palpation Neck Inspection

Good capillary refill.

Client manifests normal findings

Client manifests normal findings

Normocephalic, with prominences in the frontal and occipital area

Client manifests normal findings

Palpation Eyes Inspection

Client manifests normal findings Client manifests normal findings

Client manifests normal findings

Client manifests normal findings

Client manifests normal findings

Light pink in color, Client manifests convex in shape. normal findings

Palpation Neck Inspection

Good capillary refill.

Client manifests normal findings

Client manifests normal findings

Rapid shallow breathing Partial chest expansion upon respiration

Without nodules Quiet, rhythmic and effortless breathing

Inspection Palpation Auscultation

There is no lifts and heaves and there is no presence of heart murmurs

There is presence of heart murmurs

Abdominal contour is flat or rounded symmetrical and uniform in color.

Audible bowel sounds Not low-pitched and

Decreased bowel movement 3 cycle in 1 whole minute

Able to clearly visualize the snellen chart; check visual fields by

Client manifests normal findings

Ability to move eye balls laterally

Able to move eye balls laterally

Client manifests normal findings

Ability to perform different facial expressions; able to identify different tastes

Able to perform different facial expressions; able to identify different tastes

Client manifests normal findings

Ability to clearly hear spoken words and vibrations of tuning fork

Able to clearly hear spoken words and vibrations of tuning fork

Client manifests normal findings

Client manifests normal findings

Patient has normal findings

Patient has normal findings

25 GORDONS PATTERNS OF FUNCTIONING

Health Perception/ Health Management

Movement Balance Upright posture Spinal cord protection Shock absorption

Gram (+) cocci in short chains.

Gram (+) cocci in clusters

Gram (-) bacilli occurring singly

Polymorphonucle ar cells Squamous epithelial cells

48 sputum sample is normal. symptoms and other tests performed.

Patients Initial: JHA

COURSE IN THE WARD