Potts Disease case analysis

8/12/2019 Potts Disease case analysis

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PANPACIFIC UNIVERSITY NORTH PHILIPPINES

COLLGE OF NURSING

Case Analysis

POTTS DISEASE

SUBMITED BY: BRIAN D. LIQUIT


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PANPACIFIC UNIVERSITY NORTH PHILIPPINESCOLLEGE OF NURSING

CASE ANALYSIS

Name: Evangelista, JamaicaAddress: B19 Quezon blvd.Barangay 919 Sta. Cruz ManilaDate admitted: January 16, 2014

Dr. In charge: Dr. Gian carlo KarloDiagnosis: Spinal cord injury incomplete spinal level T11-L1, 2 to pathologic fracture of T12 probablyto 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 disccannot 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


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Diagnostic procedure:

MRI OF THE THORACOLUMBAR SPINE

MULTIPLE PLAIN AXIAL, CORONAL AND SAGITAP MR IMAGES OF THE THORACIC ANDLUMBAR 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 ASTHE 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 T2SIGNALS

IMPRESSIONS: ABOVE FINDINGS MAY SUGGEST INFECTIONS SPONDYLITIS IS TO BONE TUMOR OF

T12CAUSING SPINAL CORD IMPINGEMENT

SUGGEST TISSUE CORRELATION FOR FURTHER EVALUATION

COMPONENT RESULT NORMAL VALUE

HEMOGLOBIN MASSES 124 120-160

HEMATOCRIT 0.38 0.37-0.57LEUCOCYTE 7.01 4.8-10.8DIFFERENTIAL COUNT

SEMENTERS 0.67 0.40-0.74LYMPHOCYTES 0.34 0.19-0.48

MONOCYTES 0.07 0.03-0.09

EOSINOPHILS 0.02 0.00-0.07BASOPHILS 0.00 0.00-0.02

PLATELET COUNT 675 150-450COAGULATION STUDIES

PROTHROMBIN TIME 13.7 11-15

PT% ACTIVITY 96.5

PTINR 1.02

ACTIVATED PTT 35.3 22-45


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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. Acentrally actingsyntheticanalgesiccompound notchemicallyrelated toopiates.Thought tobind to opioidreceptor andinhibitingreuptake of norepinephrineand serotonin.

Dizziness

Rash

Diarrhea

Contraindicated inpatientshypersensitivity todrug or other opioids.

Respiratorydepression

Vasodilation

Seizures

Confusion

Avoid performingtasks that requirealertness.

Stop the medicationand reportimmediately to thedoctor.

BRAT diet


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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE

sumasakit ang

likod as

verbalized by thepatient with a pain

scale of 5/10

OBJECTIVE

-Facial grimace

-protective

gestures noted

V/S taken asfollows:BP: 130/80Temp:36.4

0C

PR:87 bpmRR:22 bpm

V

Acute pain relatedto tissue damage

After 1-2 hours ofnursinginterventions thefeeling of pain willbe able to decreasefrom 4/10 to1/10pain scale

Use pain

assessment scale to

identify intensity of

pain

Position patient in

unaffected side

Encourage

relaxation technique

(Deep Breathing

Exercise)

Provide music

therapy

Administeranalgesic(ketorolac) asordered.

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 tensemuscles 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 patientfeeling of paindecreases fro4/10 to 1/10pain scale

Documents

Potts Disease case analysis