Вы находитесь на странице: 1из 68

VISION MISSION

A premier inclusive of choice The Our Lady of Fatima


aspiring to improve man as man by University, together with Fatima
developing individuals through a Medical Science Foundation, Inc. is
legacy of excellent education and dedicated to the improvement of man
compassionate value formation as man through the holistic formation
of individuals imbued with knowlegde,

UNIVERSITY MISSION

College of Nursing Cavite State University shall


1st Semester AY: 2019-2020 provide excellent equitable and
relevant educational
opportunities in the arts, science
and technology through quality
instruction and responsive
research and development
activities. It shall produce
NURSING CARE OF CLIENT WITH POTT’S DISEASE professional, skilled and morally
upright individuals for global

A Case Study Presented to the Faculty


Of OLFU College of Nursing

In Partial Fulfillment of the Requirement in NCM 104 for the Degree,


Bachelor of Science in Nursing

Presented by:

GROUP 3B

Presented to:

Elenita Manrique-Arreglo, MD, RN


Panel Member

Nelia R. Capulong MAN, RN, RM


Dean, College of Nursing

October 2019

1|P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


TABLE OF CONTENTS

Chapter 1: INTRODUCTION
Background of the Study

Nature and Extent of Clinical Condition…...………………….…………………………………………………………….4

Purpose of the Study


Specific Objectives

Cognitive.............................................................................................................................Error! Bookmark not defined.


Psychomotor........................................................................................................................Error! Bookmark not defined.
Affective..............................................................................................................................Error! Bookmark not defined.
Significance of the Study......................................................................................................................................................5

Chapter 2: REVIEW OF RELEVANT PATIENT RECORDS AND HISTORY

I. DEMOGRAPHIC DATA..............................................................................................................................................6
II. REASON FOR SEEKING HEALTH CARE...................................................................................................................6
III. Past Medical History......................................................................................................................................................7
IV. Heredo-Familial History................................................................................................................................................7
V. SOCIO-ECONOMIC HISTORY....................................................................................................................................9
VI. .Developmental History.................................................................................................................................................9
A. E. Erikson’s Psychosocial Development.........................................................................................................................9
B. L. Kholberg’s Moral Development................................................................................................................................10
VII. Gordon’s 11 Functional Health Patterns.....................................................................................................................10

2|P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Chapter 3: RESULTS DISCUSSION: ANALYSIS AND INTERPRETATION
WITH CLINICAL IMPLICATION AND SIGNIFICANCE\

I. Comprehensive Physical Examination...........................................................................................................................15


II. Diagnostic Test.............................................................................................................................................................. 35
III. Review of System.........................................................................................................................................................47

Chapter 4: SYNTHESIZING FRAMEWORKS, INFERENCE, ACTION PLANS AND CASE REFLECTIONS

I. Pathophysiologic Framework..........................................................................................................................................49
II. Case Management..........................................................................................................................................................51
A. Medical Management....................................................................................................................................................51
1. Pharmacologic Intervention............................................................................................................................................51
III. Plans for Nursing Actions.............................................................................................................................................63
A. Nursing Care Plan.........................................................................................................................................................63
B. Discharge Plan............................................................................................................................................................... 68
References:......................................................................................................................................................................... 69

3|P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


CHAPTER 1: INTRODUCTION

A. Objectives:

 General objectives:

To be able to acquire reliable information about Pott’s disease in order for us students to become
knowledgeable; be able to demonstrate competent nursing care that will address our patient’s condition; and to
demonstrate right attitude as member of the health care team.

 Specific objectives:

o To obtain pertinent information about the patient’s demographic and socio-economic profile.
o To be well informed on the client’s history including the past and present illness.
o To be familiar with the structures and normal function of the body organs involved.
o To gain knowledge about the underlying causes and factors of the client’s diagnosis.
o To be able to formulate and establish appropriate nursing care plan that will help improve our client’s
condition.
o To be familiar with some of the client’s medications which includes both therapeutic and the adverse
effects.

B. Background of the Study

Pott's disease is a form of tuberculosis that occurs outside the lungs whereby the disease is seen in the
vertebrae. (Covington, Richard, 2016) It is the most common as well as one of the most dangerous forms of
skeletal tuberculosis and accounts for 50% of all cases of skeletal tuberculosis. (Jain AK, 2015).

In 2014, among all 6 million notified cases of tuberculosis (TB), 0.8 million (14%) were new cases of
extrapulmonary tuberculosis. Tuberculous spondylitis, also called Pott’s disease, accounts for 1–5% of TB cases
and represents about 50% of all bone and joint TB.Despite the successful achievement in decreasing global
pulmonary TB incidence in the last decades, the proportion of extrapulmonary tuberculosis seems to be
increasing in developed countries, mainly as a consequence of higher immigration rates and human
immunodeficiency virus (HIV) infection. (WHO,2015).

Despite all technological advances, the diagnosis of Pott’s disease tends to be delayed because of a
nonspecific initial early manifestations and/or low degree of suspicion. The diagnostic approach needs to be
based on chronic pain or deformity, epidemiological considerations, imaging, and adequate procedures to obtain
samples for bacteriological, pathological, or molecular confirmation. Treatment requires several months of
medical therapy according to current recommendations and consideration for surgical procedures, when
indicated.

4|P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Purpose of the Study

 Specific
o Cognitive
-Provide important information relevant to the client situation and within the level of the client
ability to understand the course of disease
-Exclude any negative information that the client have acquired and might affect the client’s
perspective regarding the disease.

o Psychomotor

-Implement nursing interventions for the client’s care.


-Identify other problems that may interfere with the ability to care for self
-Perform physical assessment with special attention on the system focus
-Provide important as teachings to the client and the significant others to boost their
knowledge and understanding of the client’s health condition.
-To use the nursing process to identify nursing problems of the client and provide the
appropriate nursing care plan.

o Affective
- Develop therapeutic relationship with client
- Increase understanding of patient feelings or emotions to the situation
- Facilitate client developing trust in own unique strengths

Significance of the Study

o Patient

-This case study will help the patient understand all the changes that she may undergo during
and after the course of the treatment.

-This will allow the patient to have a better understanding ofher situation which will help the
patient to have a positive outlook in life despite the presence of the illness and for the client to
better understand the significant things regarding her health condition.

-This study will help encourage the patient undergo treatments for her to get better and be stronger.

o Family

-This study will help the family of the patient to understand the importance of family support
to the client during the course of the illness and its treatment.

-This will help them in learning ways to participate in the treatment and recovery of the patient
from the disease.

-This will help the patient's family to help the client to cop e up with her illness and will be
there for her.
5|P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
o Students

-This case study will give important details and knowledge about Pott's disease.

-This study will help the students understand the different factors, implications and nursing practice that
need to be understood and rendered to a patient suffering from Pott's disease.

-This study will help the students have a better understanding of the illness and therefore will have a
better understanding of the skills that they can use in managing patients with Pott's Disease.

o Society

-This study will raise awareness about the risk factors of Pott's disease treatment and the course of the
illness.

-This study will help the society know more about Pott's disease.

-This study will make the society be knowledgeable about Pott's disease and would make prevention and
awareness about this illness.

Chapter 2: REVIEW OF RELEVANT PATIENT RECORDS AND HISTORY

I. DEMOGRAPHIC DATA
A. Initials of Clients’ Name: P.J.P.D
B. Address: 868 Santo Domingo St. Fatima 2 Area E Sapang palay San Jose city, Bulacan
C. Age: 21 years old
D. Birth Date: February 25, 1998
E. Birth Place: Fabella Santa Cruz, Manila
F. Gender: Female
G. Civil Status: Single
H. Religion: Christian
I. Highest Educational Attainment: College Graduate
J. Occupation: None
K. Monthly Income / Budget: N/A
L. Date of Interview: September 3, 2019
M. Primary Informant: Patient P.J.P.D
N: Secondary Informant: Mother
O. Other Data Sources: Chart of the Patient

II. REASON FOR SEEKING HEALTH CARE

The client sought for consultation due to persistent symptoms of pain and mass formation on left flank.

III. Past Medical History

Back on October 2018, the patient started experiencing pain on the right side of her body after a child
accidentally fell down while she was on side lying position. She just ignored it even she was in severe pain. She
continued on her daily routine such as going to work in a private school as an educator and attending to her church
6|P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
activities. Two weeks after, patient sought for medical assistance at a local hospital in Sapang Palay because she
can no longer tolerate the pain. She experienced fever and noticed swelling on the right ribs. She found out that her
ribs got fractured.

In November 2018, patient underwent minor surgery at Sapang palay to remove the broken ribs and to
prevent further infection. After a week, patient continue on her work even she was not fully recovered.

In December 2018, patient noticed a small red spot on her left flank that was painful at the same time.
Because of this symptom, patient decided to resign to her work. The spot became bigger as months passed by but
patient didn’t seek consultation on a 6 months period.

In June 26, 2019, on Outpatient basis, patient together with her mother went to Tala hospital to ask for
medical consultation regarding the mass on her left flank. She underwent CT scan on the same day.

In July 11, 2019, the patient and her mother came back to Tala hospital for follow up check up. CT scan
result revealed the patient diagnosis as Psoas abscess secondary to Potts disease. The attending physician ordered
to admit the patient for proper treatment regimen.

IV. Heredo-Familial History

A. Genogram

Health implication:

This heredo-familial history shows that the common hereditary diseases that the family has inherited are hypertension and
metabolic diseases such as diabetes, hypokalemia and hyperthyroidism. There is no noted history of infectious disease on
her family as verbalized by the patient.

7|P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


B. Family APGAR

Evaluation Questions Almost Some of the Hardy


Constructs Always (2) Time (1) Ever
(0)
Adaptation I am satisfied with the help that I receive from 
my family when something is troubling me.
Partnership I am satisfied with the way my family discusses 
items of common interest and shares problem-
solving with me
Growth I find that my family accepts my wishes to take 
on new activities or make changes in my
lifestyle.
Affection I am satisfied with the way my family 
expresses affection and responds to my feelings
such as anger, sorrow and love.
Resolve I am satisfied with the way my family and I 
spend time together.

TOTAL 9

0-3 = Low 4-7 = Moderate 8-10= High

Health Implication:

The result of her family APGAR is 9. This shows that despite the presence of an illness to the patient, this didn’t affect
her adaptation, growth, affection and the way she spent time with her family. On the part of partnership, patient feels that
her family some time didn’t want her to be involved on problem solving maybe because they didn’t want her to feel
stress.

V. SOCIO-ECONOMIC HISTORY

Patient P.J.P.D is the youngest of 3 children. She is a registered and licensed professional teacher. She was an
educator in a private school at San Jose Del Monte Bulacan from August 2018 to December 2018 where she handled
elementary and secondary students in different subjects. Her marital status is single and she is living with her family in a
bungalow house in Bulacan. She and her sister helped each other for financial matter but at the moment, her sister was the
only one who was working and providing for their family needs with 20, 000 php monthly salaries (with permission from
the client).

As per her daily diet, she mentioned that she is eating various types of foods but her favorite is Bitter melon. She
neither smokes nor drinks alcoholic beverages. She always slept late in the evening to finish her lesson plans and woke up
at 4am for preparation to work. Her daily sleeping pattern was 4-5 hours prior to her condition but it was changed when
she was admitted.

The patient’s favorite hobby is reading books. She loves learning new information and she believed that it will be
learned from the books. She was also an active member of their religious society. She was able to attend the Sunday
activity on the church and she was a leader for bible lessons.

8|P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


VI.. DEVELOPMENTAL HISTORY

A. Erick Erikson’s Psychosocial Development

Stage & Functional Age Task Evidences of Milestone Achievement

Intimacy vs. Isolation (Ages  Strong and deep - Patient P.J.P.D. currently lives
18yrs. To 40 yrs.) romantic with their parents
relationships - Had friends and relatives visit
 Close relationships and take care of her during her
with friends and time in the hospital.
family

Health Implication:

This shows that though patient P.J.P.D. is unmarried or she has no romantic relationship but she has a strong
relationship with both her friends and her family members. This shows that she is in the Intimacy side of Erik
Erikson’s stage six of development.

B. L. Kholberg’s Moral Development

Stage & Functional Age Task Evidences of Milestone Achievement

Post Conventional In stage 5, the world is -Patient P.J.P.D. believed that everything was
(Social Contract viewed as holding different made by a certain reason. She keeps her faith
Orientation) opinions, rights, and with God in order to continue her life.
values. Such perspectives
should be mutually
respected as unique to each
person or community.
Laws are regarded as social
contracts rather than rigid
edicts. Those that do not
promote the general
welfare should be changed
when necessary to meet the
greatest good for the
greatest number of people.
This is achieved through
majority decision and
inevitable compromise.
Democratic government is
theoretically based on stage
five reasoning.

9|P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Health Implication:

These shows that patient P.J.P.D. has a positive outlook in life despite her condition. She believes that God has
reason why this is happening to her.

VII. Gordon’s 11 Functional Health Patterns

A. Health Perception – Health Management

Before Hospitalization During Hospitalization

 For patient P.J.P.D, she wasn’t able to prioritize


her health. All she wanted was to do her work as  During the interview, Patient P.J.P.D. believed that
an educator even sometimes she was feeling she should increase her appetite to stay healthy. She
fatigue. gave emphasis on taking good care of the bones for
most of the time.
When an accident happened in October 2018, she
just ignored it even she was in severe pain. She still  She learned to be conscious on her health in such a
went to work and continued on teaching her way that she should not ignore symptoms even how
students. She then sought consultation when she simple it is.
cannot tolerate anymore the pain on her right ribs.
 She was able to follow doctor and nurse suggestion
After her minor operation in November 2018, she go by adherence to her medication, limiting her
back to work even she was not fully recovered. After activities and repositioning to her bed.
a month, she experienced persistent attack of pain
that became the reason for her to resign to her job.

In January 2019, she noticed to her left flank a small Other information are noted:
red mass but ignored it until it became bigger for the
succeeding months. In June 2019, the patient and her  She neither smoke nor drink alcoholic beverages
mother sought for medical consultation.  She usually performed breast self-examinations and
no lumps noted.
 She had no colds during her hospital stay.
Other information is noted:
 She neither smoke nor drink alcoholic beverages
 She usually performed breast self-examinations
and no lumps noted.
 She had no colds for a year.

Health Implications: At a very young age and being diagnosed with this kind of Illness, this shows that the
patient never loses hope. Of all things that were mentioned, she did everything she can to improve her
health by simply following all the doctor's and nurse’s orders. According to her, this will help on her fast
recovery.

B. Nutritional – Metabolic
Before Hospitalization During Hospitalization

 Patient P.J.P.D. had no appetite on eating  Patient P.J.P.D had no restrictions on her diet.
foods. Sometimes she forgets to eat Her physician encouraged her to increase her
breakfast before going to work. This was food intake. She always had at least one
reflected to her weight of 40 kilos before vegetable per serving like her favorite is
hospital. But then she managed to drink an ampalaya guisado. Patient also had no difficulty
10 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
average of 8 glasses of fluid per day. in swallowing. Her weight improved from 40 kgs
to 43 kgs (weight dated: 09-03-2019). The
patient’s daily fluid intake was an average of 4
glasses this is due to her medications.

Health Implication: This signifies that patient P.J.P.D. became more concern about the foods she eats after
being diagnosed with Pott’s disease. She also followed her doctor’s advice to increase her appetite and
understood that this has a big factor in her health condition.

C. Elimination

Before Hospitalization During Hospitalization


 Patient P.J.P.D defecates once a day and  Patient P.J.P.D trained herself to defecate during her
urinates 6-8 times a day. bath time which is every other day. She had no
discomfort or problem and does not use laxative.
According to the patient, she perspires
excessively during late afternoon even she is not According to patient, she voids an average of 8-10
doing anything. times per day and there is no problem on the bladder.
The characteristic of her urine is color orange and no
excess perspiration was reported.

Health Implication: This signifies that though her elimination was not as exactly the same as before diagnosed,
her body is still able to function and eliminates the toxic wastes in her body

D. Activity – Exercise

Before Hospitalization During Hospitalization


 According to the patient, she has enough  As stated by the patient, she has enough energy to do
energy to do task in school and to do simple task. She has no exercise routine as prohibited
household chores. The only exercise she had by the doctor Instead, she was advised to timely
was walking for about 200 meters a day on move her extremities and change position more
going to work. But prior to admission, this often. Her only leisure activity was watching videos
was changed because of the mass forming on her phone.
on her left flank that limits herself to move.
 There was no absent of body part, No difficulty on
Before client’s hospitalization, patient had a moving body parts for range of motion, can easily
straight body figure and slowly developing pick or grip anything, respiration and blood pressure
to kyphosis. was normal.
 She was admitted with kyphosis but due to medical
and surgical management, her posture had
improvement.

Health Implication: This signifies that even though the doctor restricted her on daily exercises, patient was
able to follow the doctor's order to timely move her extremities and change in position more often. Patient
knew that by following her doctor can improve her health and quality of life and helps her to recover fast.

*Katz Index of Independence in Activities of Daily Living

Activities Independence = 1 point Dependence = 0 point


Points (1 or 0) No supervision, direction or personal With supervision, direction or personal
11 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
assistance needed assistance or total care
Bathing 
Dressing 
Toileting 
Transferring 
Continence 
Feeding 
TOTAL POINTS: 0

Health Implication: With the scoring of Katz Index of Independence in ADL shown above, this simply
shows that the patient needs supervision and direct assistance of care including in bathing, dressing,
toileting, feeding and etc.

E Sleep – Rest

Before Hospitalization During Hospitalization


• Patient P.J.P.D. reported that she has no enough • Patient usually sleeps at 11pm and wake up at 7am.
sleep because of her work. According to her, (8hrs of sleep per day) Then after lunch, she takes a
she sleeps late at night by doing her lesson plan. nap. For her, she has enough sleep for entire day.
She sleeps at 12 in the midnight and wakes up 4
in the morning to start preparing to go to work. According to patient, she usually had dreams. She had
She has an average of 4 hours of sleep every no difficulty on sleeping.
day. According to patient she sometimes had a
dream and a nightmare was very rare to happen.

Health Implication: This implies that the patient had more sleeping hours during her hospitalization. She also
verbalized that she needs to sleep and rest more often for her faster recovery.

F. Cognitive – Perceptual

Before Hospitalization During Hospitalization


 Patient P.J.P.D participates in decision  . When it comes in decision making, her family
making with her family. She also shares doesn’t want her to involve on other issues to
her idea and thoughts when there was avoid her being stress.
certain activity in the school.
 Patient P.J.P.D. was assessed for any changes in
 She had no problem with recalling recent memory, and she stated that when she started
memories. taking DOTS, she can't recall the names of her
church mates. It happened on the same day that
 She had no hearing and vision problem. they donated blood and visited her.
Even the surroundings is too noisy, she can
concentrates on her teaching.  She had no hearing and vision problem. She
immediately loses her focus as she was easily
distracted by environmental noises. She can
quickly learn things by reading.

Health Implication: According to statement above, this shows that there are changes with patient’s cognitive
perception which is forgetfulness and easy distractibility that never happened before her hospitalization. But
patient had no problem with her senses.

G. Self-Perception – Self-Concept

12 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Before Hospitalization During Hospitalization
 For patient P.J.P.D., her role to her family,  The patient did not answer and only smiled when
friends and community was very important she asked about how she describes herself. When
to her. she asked if she still feels good about herself, she
agreed and still feels happy despite her situation. 

 Despite losing hope and finding out her


condition in July 2019, she is neither anxious nor
depressed. She can control her emotions and
nothing annoys her, but she gets angry only
when she cannot do what she wants.

 Based on our observation, the patient has good


eye contact with a calm voice and proper speech
and she was relaxed while doing the interview.

Health Implication: This implies that Patient P.J.P.D. knows her role as a person and she is an optimistic despite
her illness. Even sometimes she feels angry of incapable of doing things; still she was able to look the situation in
a positive way.

H. Role-Relationship

Before Hospitalization During Hospitalization


 Patient P.J.P.D lives with her family. She was  Her family is very supportive, which made her
the youngest daughter and able to help with manage her condition and keep being strong. Her
their basic needs. mother always by her side and helps her on
 She was an educator in a private school where performing activities of daily living.
she performs very well but she felt very stress
at work.
 She's also a member of a social group in
church and organization at school.

Health Implication: This signifies that Patient P.J.P.D has a strong support system and has a very loving family
that’s very essential on her fast recovery. They are always there for each other and that’s the key in every
challenge in life.

I. Sexuality Reproductive

Before Hospitalization During Hospitalization


 Patient menstrual cycle is regular and  The patient menstruation is regular and begins
reported no menstrual problem. every 3rd week of the month. The last menstrual
period was July 22, 2019. No menstrual problem
stated by the patient.

Health Implication: This implies that there are no changes in patient’s menstrual cycle before and during
her hospitalization. This shows that her menstrual cycle is regular and she does not feel any discomfort.

J. Coping- Stress

Before Hospitalization During Hospitalization


13 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
 Patient P.J.P.D. has no major problem  The big changes in the patient’s life are her
before her condition started. October 2018, inability to do the normal activities of daily
an accident happened that limit her on doing living. With the faith in God and the help from
things. her family, she can able to handle the situation
very well.
 During the interview, the patient was relaxed and
she doesn’t need any medication for relaxation. 

 Whenever there are problems in her life, she let


things happened because she believes that it has
an ending. She trusts God with her condition.
She believes that there’s a reason for all of the
things happening to her life. And for her, that’s
an effective way to cope with the situation.

Health Implication: According the patient statement, this shows that there is a big change in patient’s life
after what happened to her. She wasn’t able to do simple daily activity but despite that, her faith and support
system helps her a lot to cope with the situation.

K. Value-Belief Pattern

Before Hospitalization During Hospitalization

 Patient P.J.P.D mentioned that her  The patient wanted to continue her profession as a
family are very religious and always teacher.
pray together and attend to church
every Sunday.
 Her faith and religion are important to her as these
helped her cope with her disease, especially now at
the most difficult stage of her life.

 She has a strong faith in God.

Health Implication: This implies that patient is very eager to recovery to her illness and wants to continue her
passion with teaching. Her condition doesn’t affect her faith in God and made it even stronger.

Chapter 3: RESULTS DISCUSSION: ANALYSIS AND INTERPRETATION


WITH CLINICAL IMPLICATION AND SIGNIFICANCE

I. Comprehensive Physical Examination

A. Vital Signs Date / Time of Exam: 9/3/19


T = 36OC
PR = 78bpm
RR = 19cpm
14 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
BP = 120/70mmHg
O2SAT= 99%

B. Anthropometric Data (only those applicable)

Height 155 cm
Weight 43 kg
BMI 17.9

Health Implication:
This represents that the patient belongs to category of mild thinness which signifies that the patient is under
weight

C. General Appearance

Body build and height – weight proportionality Underweight

Posture and Gait Can stand with assistance


Over-all hygiene and grooming Clean and neat
Body and breath odor No body odor, No breath odor
Obvious signs of distress / illness No obvious signs of distress / illness
Mental status Conscious
Attitude Cooperative
Affect/mood; appropriateness of responses Appropriate to situation
Quantity and quality of speech Understandable, have association of thoughts
Relevance and organization of thoughts Logical sequence
Health Implication:
This signifies that most of the patient general appearance are normal but cannot stand without an assistance due
to knee stiffness.

Focused Assessment

Pre -OP

Body Part Examined Actual Finding Normal Finding Clinical Significance


INTEGUMENTARY

Skin
I: color, uniformity, Brown in appearance, No lesion ABNORMAL
edema, lesions (-) edema, scar below Skin color is brown Scar cause by her previous incision
P: moisture, temp. breast, wound at left Soft and warm to
15 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
Turgor lower back, skin goes touch
back <3 sec when When skin is pinched,
pinched it goes back to normal
state immediately
Hair
I: evenness of growth Hair is evenly Evenly distributed NORMAL
thickness, texture, distributed , patient Fine to course
oiliness, infection report no hair loss,
or infestation, body dull and brittle, slight
hair oily when palpated,
P: smoothness no infection and
smooth when
touched.
HEAD
Skull and Face Head is normally hard No masses NORMAL
I: size, shape, and smooth without No lesions.
symmetry lession, nodules, Symmetrical, round
: facial features masses and non uniform consistency:
: eyes for edema tender; face is absence of nodules and
and hollowness symmetry with oval masses; head is non-
P: nodules, masses, in appearance and no tender; Symmetrical
Depressions abnormal movements facial movements
noted
Nail
I: plate shape, texture, Pink tones, clean Nail bed is pink NORMAL
bed color, nails with no Concave shape
surrounding tissues abnormalities

P: Blanch test Capillary refill goes Capillary refill backs NORMAL


back <3 seconds, within 1-3 seconds.
smooth when touched Smooth to touch
Eyes and Vision
I: eyebrows for Eyes are symmetry, Symmetrically NORMAL
distribution & brows are aligned aligned and equally
alignment, quality & and equally distributed
Movement distributed

: eyelashes for lashes are evenly and Evenly and equally NORMAL
evenness of equally distributed distributed
distribution &
direction of curl

: eyelids for surface Eyelids has no No discharge, no NORMAL


characteristics, position in discharged or any discoloration of
relation to cornea, ability to discoloration, patient eyelids; when eyelids
blink & frequency can normally blink are closed, sclera is not
with no visible sclera
visible. Sclera is
when eyes are close
and white sclera is white.
noted

: bulbar & palpebral Conjunctiva appears NORMAL


Pink conjunctiva. No
conjunctiva for color, pink with no
texture, and lesion discharge discharge.

16 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


I/P: (-) edema, non No edema or
lacrimalglandsac,nasola tenderness over tenderness over NORMAL
crimalductfor edema, lacrimal and lacrimal and
tenderness / tearing nasolacrimal duct nasolacrimal duct.

I: corneafor clarity, texture Transparent cornea, Translucent, shiny and NORMAL


& sensitivity iris are visible with smooth details of the
shiny and smooth iris are visible.
details

I: pupilsfor color, shape, Black in appearance, Black in color; equal NORMAL


symmetry of size, direct size are equal, round in size; round smooth
and consensual reaction to and smooth, flat iris border, iris flat and
light, & accommodation and normal reaction
round. Pupils constrict
to any light is noted.
and dilate as a reaction
to light.

Ears and Hearing Auricle is same color Color same as facial NORMAL
I: auriclesfor color, as face, both are skin; symmetrical;
symmetry and position symmetry and aligned auricles aligned with
with outer canthus of the outer canthus of
the both eyes
the eye

: externalcanalfor No discharges during NORMAL


Absence of lesions
cerumen, lesions, pus or inspection
blood

P: auriclesfor texture, Auricles are firm and Firm and not tender. NORMAL
elasticity and areas of non tender
tenderness

* Gross Hearing Acuity No difficulty or any Normal voices are NORMAL


Tests: normal voice tone abnormalities in audible
and whispered voice hearing senses

Nose and Sinuses

I: nose deviation in shape Nose are symmetry, Symmetrical; no NORMAL


size, color, flaring, no discharge, (-) nasal discharge. Absence of
discharge; flaring, non redness, nasal flaring
: nasal mucosafor redness, non swelling
swelling, growth or
discharge
No tenderness and
Pa: tenderness, masses, Non tenderness, (-) lesions. Pink Mucosa.
displacements; lesion, mucosa is Nasal septum intact NORMAL
: nasalpatency pink, intact septum
and in midline
17 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
and in midline.
: maxillaryand
frontalsinuses for Non tender in sinuses NORMAL
tenderness
Pe: the above sinuses for Sinuses are not tender.
tenderness

Mouth / Oropharynx Soft, moist, no Uniform pink color; NORMAL


I: lipsfor symmetry of lesions but pale in soft moist, smooth
contour, color, texture, appearance texture; symmetry of
moisture, lesion contour.

32 permanent teeth;
: teeth for alignment, loss, No dentures, no NORMAL
smooth, white and
dental filings and caries; decay and complete
white healthy teeth shiny tooth enamel.

Pink gums; moist firm


: gums for bleeding, color, Gums are pink, moist, NORMAL
retraction, lesions, no lesions texture gums; no
swelling retraction of gums

: tongue for position, color Moderate size, moist, NORMAL


& texture; movement, as and pink in color, can Pink, Moist and
well as the base of the move tongue with no slightly rough with
tongue, mouth floor and difficulty moderate size.
frenulum

: salivary gland ducts for No swelling or any NORMAL


swelling, redness redness No swelling

: palates for color, shape, Soft and hard palate NORMAL


texture, presence of bony are in pink color Light pink in soft and
prominences hard palate.

Positioned in the
: uvula for position & Uvula are in normal midline of soft palate NORMAL
mobility position and mobility
Pink; smooth and no
: oropharynx for color & Pink and smooth with discharge NORMAL
texture (-) discharge

Palatine tonsils are


: tonsils for color, pink, no discharge
discharge, and size and moderate in size

18 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


NECK Generally uniform in
Neck Muscles Uniform in color, color. Symmetrical. NORMAL
I: abnormal swelling or symmetry, no lesion, No masses and
masses, head movement, no swelling, no
swelling
and muscle strength masses and any
difficulty in
movement is not seen
during inspection

No palpable lymph
Lymph Nodes No enlargement of nodes NORMAL
P: enlargement lymph nodes

Trachea No visible mass.


P: lateral deviation (-) Mass, no pain Painless and rise freely NORMAL
Thyroid Gland reported by patient with swallowing.
I: symmetry and visible and can rise freely
masses, rise during with swallowing
swallowing
P: smoothness

THORAX & LUNGS


Posterior Thorax
I: shape & symmetry from Spine is not Spine vertically ABNORMAL
posterior-lateral views; symmetrical aligned; spinal column Due to kyphosis
spinal alignment for is straight . No
deformities tenderness. No masses.
Pa: temperature, bulges, Warm, patient report Bilateral Symmetry of
tenderness, abnormal slight tenderness NORMAL
vocal fremitus. No
movements, when touch, no
respiratoryexcursion, abnormal vocal pain during respiration
vocal fremitus resonance

Full symmetric chest


Pe: for symmetry of Patient have full expansion NORMAL
resonance; symmetric chest
diaphragmatic expansion when
excursion asked to breath; resonant
A: breath sounds (-) wheezes, (-)
crackles, and clear NORMAL
breath sounds
No lift or heaves.
Symmetrical.
Anterior Thorax
I: breathing pattern, coastal No forceful cardiac NORMAL
and costovertebral angle contraction No weak vibrations
upon tactile palpation.

19 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Pa: respiratory excursion, (-) weak vibration
tactile fremitus upon palpation NORMAL
Symmetrical
Pe: symmetry of resonance
excursion, tactilef remitus Symmetrical NORMAL

Resonant
Pe: symmetry of resonance Breath sounds are NORMAL
A: breath sounds resonant

Heart
I: precordium for
pulsations & lifts or
heaves
A: heart sounds (S1, S2, (-) Murmur, normal Dull Sound (S1, S2) NORMAL
etc.) rate, regular rhythm

Central Vessels: Pulses are record with Symmetric pulse


Carotid Arteries normal findings , no volume; full pulsation NORMAL
P: volume, quality jugular distention No distention of
A: bruit jugular veins
Jugular Veins
I: distention

Peripheral Vessels Veins not visible.


I: presence or appearance Veins are not visible Immediate return of NORMAL
of superficial veins, signs color.
of phlebitis
*Buerger’s Test
*Capillary Refill

Breast & Axillae Moderate breast size, Skin is smooth and NORMAL
I: breast for size, symmetry, smooth, uniform in color.
symmetry, contour or uniform in color, non
shape, discoloration, tenderness No tenderness.
retraction, hyper
vascularity, swelling,
edema

: areola for size, shape, Size is normal as Symmetric contour. NORMAL


symmetry, color, surface patient reported, No No palpable masses or
characteristics, masses, masses, tenderness, or nodules.
lesions lesions
Patient seen with
scar below breast

: nipples for size, shape, Patient report normal No secretion. Brown NORMAL
position, color, discharge, size of nipples, shape in color
lesion and no discharge is
noted

20 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


P: lymph nodes, breast, Skin color is brown, Brown skin in color. NORMAL
areola & nipples for no tenderness, no Symmetric contour.
tenderness, masses, masses, no nodules No lesion or
nodules, discharge and no discharge tenderness.

ABDOMEN Round abdomen, no Rounded or NORMAL


I: skin integrity, contour & lesions and no protuberant abdomen.
symmetry, hernia, tenderness during Absence of lesion and
distention (girth), palpation tenderness
movements associated w/
respiration, peristalsis &
aortic pulsations
Normal bowel sounds
A: bowel, vascular, & Normal bowel sounds NORMAL
occur irregularly every
peritoneal friction rub
sounds 5-15 seconds

(-) tympani and


Pe: all quadrants / regions No tympani during NORMAL
for tympany and deviations auscultation deviation sound.

Pa: light to deep palpations No pain reported by


Liver and bladder not
ALL quadrants from least patient during NORMAL
palpable.
painful to most painful palpation.
for masses, tenderness,
muscle guarding; liver
(bimanual) and bladder
palpation

MUSCULOSKELETAL Smooth coordinated Smooth coordinated


Muscles movement is movements. No ABNORMAL due to prolong lying on
I: size, contractures, observed, no tremors, tenderness and bed
fasciculation, tremors tenderness at site of swelling. No tremors,
P: tonicity, flaccidity, abscess extraction,
spasticity, smoothness of but non swelling and no palpable nodules.
movement, strength no palpable nodules
Patient also report
tingling sensation at
both knee
Bones
I: structure, deformity Patient have kyphosis No deformities. No ABNORMAL
P: edema, tenderness but (-) in edema and tenderness and
swelling swelling. Smoothness
of movement.

Joints
I: swelling (-) joint swelling, (-) No tenderness and
P: tenderness, smoothness tenderness but not swelling. Able to NORMAL
of movement, swelling, able to perform some perform activities of
crepitation, nodules activity due daily living.
hospitalization

21 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


NEUROLOGIC
Mental Status
- Language Patient observed with Able to talk oriented to NORMAL
- Orientation no abnormalities in time, place and person.
- Memory mental status No lapses in memory.
- Attention Span / Able to concentrate.
Calculation Eye opening converse
normally.

Consciousness Level Obeys to verbal


command

Cranial Nerves
I to XII: Can identify what CN I: Able to identify NORMAL
(OOOTTAFAGVSH) kind of aromas different smells

CN II: Visual fields


No abnormality in intact
eye sight NORMAL

The patient’s eyes CN III: PERRLA,


response to light convergence NORMAL
accommodation is
normal

The movement of the CN IV: Inward and


eye both inward and Downward eye NORMAL
downward are normal movement

CN V: Clenching of
Patient can clench her teeth, symmetric jaw NORMAL
teeth, jaw movement
movement, face, scalp,
is symmetrical, can
sense light touch and nasal mucous
pain on the face, membrane and cornea
scalp, nasal mucous
membrane.

CN VI: Lateral eye


Lateral eye NORMAL
movement is normal movement

Patient can perform CN VII: Able to make NORMAL


all the facial facial expressions

22 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


expression

CN VIII: Hearing
Patient hearing acuity acuity within normal NORMAL
is within normal range
range

CN IX: Able to
Patient can swallow swallow; phonation of NORMAL
without a problem pharyngeal muscles
and the vibration of
the pharyngeal

CN X: Able to
swallow and has
NORMAL
talking muscles of the
Patient gag reflex is
intact palate, pharynx and
larynx

CN XI: neck turn /


The trapezius muscles shoulder shrug
is strong contraction NORMAL
and symmetrical in
size
CN XII: tongue
The tongue can movement
strongly resist to NORMAL
force applied to
tongue depressor

Has (+) biceps, triceps,


Reflexes N/A brachioradialis,
- Deep, superficial & patellar, Achilles and
pathologic no plantar reflex

Can repeatedly and


Fine Motor Patient can perform rhythmically touch the
- Upper Extremities: finger to nose test nose
* Finger-Nose Test with smooth accurate
movement.

Can alternately supine


* Alternate Supination & The patient able to and prorate hands with
Pronation of hands on perform supination accuracy and rapidity
knees and pronation

23 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


without any problem

Can perform Finger-


Nose and to RN finger
* Finger to Nose & to RN Patient can perform
finger finger to nose to RN
smoothly
Can perform Finger to
Finger test
Patient able to
* Fingers-to-fingers perform finger to
finger test
Can perform Finger to
Thumb test
Able to perform
* Fingers-to-thumb finger to thumb test
without a problem

Light ticking or
touching sensation
Sensory Function The patient was able
* Light/Deep Touch to identify the
difference within
light an deep touch Able to determine
sharp and dull
sensation
* Pain Sensation Can identify the sharp
and dull sensation Able to determine hot
and cold
Patient able to
* Temperature identify whether hot
or cold put in skin Able to determine
position of fingers and
toes
*Position / Kinesthetic The patient is aware
to the position and
movement of the
body parts

Recognize common
object
* Tactile Discrimination steriognosis;patient Able to identify
able to identify the numbers/ letters
object given to her written on palm
Graphesthesia; patient
able to identify what
numbers or letters
written on her palm.

GENITALS N/A

24 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


* For females:
I: pubic hairdistribution,
amount, characteristics;
its areas for parasites,
inflammation, swelling,
lesions
: clitoris, urethral and UNABLE TO
vaginal orifices for ASSESS
inflammation or
discharge
P: Bartholin’s glands,
lymph nodes for
enlargement, tenderness,
swelling
* Internal Exam for OB
clients for cervical dilation,
effacement and AP pelvic
diameter
RECTUM & ANUS UNABLE TO
I: anus and surrounding ASSESS
tissue for color, integrity,
lesions
P: anal sphincter tonicity,
nodules, masses and
tenderness

I. Comprehensive Physical Examination


A. Vital Signs Date / Time of Exam: 9/9/19
T = 36.4OC
PR = 103bpm
RR = 24cpm
BP = 100/70mmHg

B. General Appearance

Body build and height – weight proportionality

Posture and Gait Difficulty to stand


Over-all hygiene and grooming Clean and neat
Body and breath odor No body odor, No breath odor
Obvious signs of distress / illness Patient looks restlessness
Mental status Conscious
Attitude Cooperative
Affect/mood; appropriateness of responses Appropriate to situation
Quantity and quality of speech Understandable, have association of thoughts
Relevance and organization of thoughts Logical sequence
Health Implication:
This signifies that the patient has normal general appearance except for posture and gait related too her recent
spinal surgery.

Focused Assessment
25 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
Pre-OP

Body Part Examined Actual Finding Normal Finding Clinical Significance


INTEGUMENTARY

Skin Brown in appearance, (-) No lesion


I: color, uniformity, edema, edema, scar below Skin color is brown ABNORMAL
lesions breast, wound at left Soft and warm to touch Scar cause by her previous
P: moisture, temp. lower back and entire When skin is pinched, it incision and recent surgery at
Turgor vertebral area goes back to normal state back
immediately

Hair
I: evenness of growth Evenly distributed NORMAL
thickness, texture, Hair is evenly Fine to course
oiliness, infection distributed , patient
or infestation, body report no hair loss, dull
hair and brittle,slight oily
P: smoothness when palpated, no
infection and smooth
when touched.
HEAD
Skull and Face Head is normally hard No masses
I: size, shape, and smooth without No lesions. Symmetrical, NORMAL
symmetry lesion, nodules, masses round uniform consistency:
: facial features and non tender; face absence of nodules and
: eyes for edema restlessness, with oval in masses; head is non-tender;
and hollowness appearance and no Symmetrical facial
P: nodules, masses, abnormal movements movements
Depressions noted

Nail
I: plate shape, texture, Pink nail bed Nail bed is pink
bed color, Concave shape
surrounding tissues
NORMAL
Capillary refill goes Capillary refill backs within
back <3 seconds, smooth 1-3 seconds. Smooth to
P: Blanch test when touched touch

Eyes and Vision


I: eyebrows for Eyes are symmetry, Symmetrically
distribution & brows are aligned and aligned and equally NORMAL
alignment, quality & equally distributed distributed
Movement

: eyelashes for NORMAL


evenness of lashes are evenly and Evenly and equally
distribution & equally distributed distributed
direction of curl

: eyelids for surface Eyelids has no No discharge, no


discharged or any NORMAL
characteristics, position in discoloration of eyelids;
discoloration, patient
26 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
relation to cornea, ability to can normally blink with when eyelids are closed,
blink & frequency no visible sclera when sclera is not visible. Sclera is
eyes are close and white white
sclera is noted

: bulbar & palpebral Pink conjunctiva, No


conjunctiva for color, Conjunctiva appears NORMAL
discharge
texture, and lesion pink with no discharge

I/P: lacrimal gland No edema or tenderness NORMAL


(-) edema, non
sac,nasolacrimal duct for over lacrimal and
tenderness over lacrimal
edema, tenderness / nasolacrimal duct.
and nasolacrimal duct
tearing
Translucent, shiny and NORMAL
Transparent cornea, iris
I: cornea for clarity, texture are visible with shiny smooth details of the iris are
& sensitivity and smooth details visible.

I: pupils for color, shape, Black in appearance, Black in color; equal in size; NORMAL
symmetry of size, direct and size are equal, round and round smooth border, iris
consensual reaction to light, smooth, flat iris and flat and round. Pupils
& accommodation normal reaction to any constrict and dilate as a
light is noted.
reaction to light.

Ears and Hearing Auricle is same color as Color same as facial skin; NORMAL
I: auriclesfor color, face, both are symmetry symmetrical; auricles
symmetry and position and aligned with outer aligned with the outer
canthus of the both eyes canthus of the eye

: externalcanalfor cerumen, Absence of lesions NORMAL


No discharges during
lesions, pus or blood inspection

P: auriclesfor texture,
Firm and not tender. NORMAL
elasticity and areas of Auricles are firm a nd
tenderness non tender

* Gross Hearing Acuity Normal voices are audible


Tests: normal voice tone No difficulty or any
NORMAL
and whispered voice abnormalities in hearing
senses
Nose and Sinuses Nose are symmetry, no Symmetrical; no discharge. NORMAL
I: nose deviation in shape discharge, (-) nasal Absence of nasal flaring
size, color, flaring, flaring, non redness, non

27 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


discharge; sweling
: nasal mucosa for redness,
swelling, growth or No tenderness and lesions.
discharge Pink Mucosa. Nasal septum
Non tenderness, (-) intact and in midline. NORMAL
Pa: tenderness, masses, lesion, mucosa is pink,
displacements; intact septum and in
: nasalpatency midline
Sinuses are not tender.

: maxillary and frontal NORMAL


sinuses for tenderness Non tender in sinuses
Pe: the above sinuses for
tenderness
Mouth / Oropharynx Soft, moist, no lesions Uniform pink color; soft NORMAL
I: lips for symmetry of but pale in appearance moist, smooth texture;
contour, color, texture, symmetry of contour.
moisture, lesion

: teeth for alignment, loss, No dentures, no decay 32 permanent teeth; smooth,


dental filings and caries; and complete white white and shiny tooth NORMAL
healthy teeth enamel.

: gums for bleeding, color, Gums are pink, moist,


retraction, lesions, no lesions Pink gums; moist firm
texture gums; no retraction NORMAL
swelling
of gums
: tongue for position, color Moderate size, moist,
and pink in color, can Pink, Moist and slightly NORMAL
& texture; movement, as rough with moderate size.
well as the base of the move tongue with no
tongue, mouth floor and difficulty
frenulum

: salivary gland ducts for


No swelling or any NORMAL
swelling, redness
redness
No swelling
: palates for color, shape,
texture, presence of bony
Soft and hard palate are NORMAL
prominences Light pink in soft and hard
in pink color
palate.

: uvula for position &


Uvula are in normal Positioned in the midline of NORMAL
mobility
position and mobility soft palate

: oropharynx for color &


Pink and smooth with (-) NORMAL
texture Pink; smooth and no
discharge
discharge

28 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


: tonsils for color, discharge, Palatine tonsils are pink,
and size no discharge and
moderate in size

NECK
Neck Muscles Uniform in color, Generally uniform in color. NORMAL
I: abnormal swelling or symmetry, no lesion, no Symmetrical. No masses and
masses, head movement, swelling, no masses and swelling
and muscle strength any difficulty in
movement is not seen
during inspection

No enlargement of
Lymph Nodes lymph nodes No palpable lymph nodes NORMAL
P: enlargement

Trachea

P: lateral deviation
Thyroid Gland (-) Mass, no pain No visible mass. Painless NORMAL
I: symmetry and visible reported by patient and and rise freely with
masses, rise during can rise freely with swallowing.
swallowing swallowing
P: smoothness

THORAX & LUNGS Spine is not symmetrical Spine vertically aligned; ABNORMAL
Posterior Thorax spinal column is straight . Due to kyphosis
I: shape & symmetry from No tenderness. No masses.
posterior-lateral views;
spinal alignment for
deformities

Warm, patient report Bilateral Symmetry of vocal


Pa: temperature, bulges, fremitus. No pain during
slight tenderness when
tenderness, abnormal
touch, no abnormal respiration NORMAL
movements,
vocal resonance
respiratoryexcursion,
vocal fremitus

Pe: for symmetry of Patient have full Full symmetric chest


resonance; diaphragmatic symmetric chest expansion
excursion expansion when asked
NORMAL
to breath;
A: breath sounds resonant
(-) wheezes, (-)
crackles, and clear
breath sounds
Anterior Thorax
I: breathing pattern, coastal No lift or heaves.
29 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
and costovertebral angle Symmetrical. ABNORMAL
Increase respiratory rate Cause by pain due to her
recent operation
Pa: respiratory excursion, No weak vibrations upon
tactile fremitus tactile palpation.
(-) weak vibration upon
palpation NORMAL
Pe: symmetry of resonance Symmetrical
excursion, tactile fremitus
Symmetrical NORMAL

Pe: symmetry of resonance Resonant


A: breath sounds
Breath sounds are NORMAL
resonant
Heart
I: precordium for pulsations
& lifts or heaves
A: heart sounds (S1, S2, (-) Murmur, normal rate, NORMAL
etc.) regular rhythm Dull Sound (S1, S2)
Central Vessels:
Carotid Arteries
P: volume, quality
Symmetric pulse volume;
A: bruit Increase pulse rate full pulsation
Jugular Veins noted, no jugular NORMAL
No distention of jugular
I: distention distention veins

Peripheral Vessels
I: presence or appearance of
superficial veins, signs of
phlebitis Veins not visible. Immediate
*Buerger’s Test Veins are not visible
return of color. NORMAL
*Capillary Refill

Breast & Axillae Moderate breast size, Skin is smooth and uniform NORMAL
I: breast for size, symmetry, symmetry, smooth, in color.
contour or shape, uniform in color, non
discoloration, retraction, tenderness No tenderness.
hyper vascularity,
swelling, edema

: areola for size, shape,


Size is normal as patient Symmetric contour. No NORMAL
symmetry, color, surface
characteristics, masses, reported, No masses, palpable masses or nodules.
lesions tenderness, or lesions
Patient seen with scar
below breast

: nipples for size, shape,


position, color, discharge, Patient report normal No secretion. Brown in color NORMAL
lesion size of nipples, shape
and no discharge is
noted
30 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
P: lymph nodes, breast, Brown skin in color.
areola & nipples for Symmetric contour. No
tenderness, masses, nodules, lesion or tenderness.
discharge Skin color is brown, no
tenderness, no masses, NORMAL
no nodules and no
discharge
ABDOMEN
I: skin integrity, contour &
symmetry, hernia, Round abdomen, no Rounded or protuberant NORMAL
distention (girth), lesions and no abdomen. Absence of lesion
movements associated w/ tenderness during and tenderness
respiration, peristalsis & palpation
aortic pulsations
NORMAL
A: bowel, vascular, & Normal bowel sounds occur
peritoneal friction rub irregularly every 5-15
sounds Normal bowel sounds
seconds

(-) tympani and deviation


Pe: all quadrants / regions NORMAL
No tympani during sound.
for tympany and deviations
auscultation

NORMAL
Pa: light to deep palpations
Liver and bladder not
ALL quadrants from least
No pain reported by palpable.
painful to most painful for
patient during palpation.
masses, tenderness,
muscle guarding; liver
(bimanual) and bladder
palpation

MUSCULOSKELETAL
Muscles
I: size, contractures, Tenderness both Smooth coordinated ABNORMAL related to
fasciculation, tremors shoulder, no swelling, no movements. No tenderness previous surgery
P: tonicity, flaccidity, tremors, no palpable and swelling. No tremors, no
spasticity, smoothness of nodules
palpable nodules.
movement, strength

Bones
I: structure, deformity With deformities at the No deformities. No ABNORMAL
P: edema, tenderness back, (-) in edema and tenderness and swelling. Patient develop kyphosis
swelling Smoothness of movement. related to vertebral fracture

Joints No tenderness and swelling.


I: swelling (-) joint swelling, (-) Able to perform activities of NORMAL
P: tenderness, smoothness of tenderness but unable to
movement, swelling, perform daily activities NORMAL
31 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
crepitation, nodules of daily living.

NEUROLOGIC Able to talk oriented to time,


Mental Status place and person. No lapses
- Language Patient observed with no in memory. Able to NORMAL
- Orientation abnormalities in mental concentrate. Eye opening
- Memory status converse normally.
- Attention Span / Obeys to verbal command
Calculation
Consciousness Level

Cranial Nerves NORMAL


I to XII: CN I: Able to identify
Can identify the aromas
(OOOTTAFAGVSH) different smells

No abnormality in eye CN II: Visual fields intact NORMAL


sight

The patient’s eyes


CN III: PERRLA,
response to light
convergence NORMAL
accommodation is
normal

The movement of the


CN IV: Inward and
eye both inward and NORMAL
downward are normal Downward eye movement

Patient can clench her


CN V: Clenching of teeth,
teeth, jaw movement is NORMAL
symmetrical, can sense symmetric jaw movement,
light touch and pain on face, scalp, nasal mucous
the face, scalp, nasal membrane and cornea
mucous membrane

Can move eye laterally CN VI: Lateral eye


NORMAL
movement

Patient was able to make CN VII: Able to make facial


facial expressions NORMAL
expressions

Hearing acuity is in
CN VIII: Hearing acuity ABNORMAL
normal range
due to surgical wound

32 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


within normal range

Able to swallow with no


difficulty
CN IX: Able to swallow;
phonation of pharyngeal
muscles

Can swallow and talk


with muscle of palate, NORMAL
CN X: Able to swallow and
pharynx, and larynx
has talking muscles of the
palate, pharynx and larynx

Can turn the neck with


no pain and pain at
shoulder even without CN XI: neck turn / shoulder
palpation. shrug

The tongue can


strongly resist to force
applied to tongue
depressor
N/A CN XII: tongue movement

Reflexes Has (+) biceps, triceps,


- Deep, superficial & brachioradialis, patellar,
pathologic Achilles and no plantar
reflex
Patient can perform
finger to nose test with
Fine Motor smooth accurate
- Upper Extremities: Can repeatedly and
movement
* Finger-Nose Test rhythmically touch the nose

The patient able to


perform pronation and
Can alternately spine and
supination without any
* Alternate Supination & problem prorate hands with accuracy
Pronation of hands on and rapidity
knees
Patient can perform
finger to nose to RN
* Finger to Nose & to RN smoothly Can perform Finger-Nose
finger and to RN finger

Patient able to perform


finger to finger test
* Fingers-to-fingers Can perform Finger to
Finger test

Able to perform finger


to thumb test without a
* Fingers-to-thumb problem Can perform Finger to

33 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Thumb test

The patient was able to


identify the difference
Sensory Function within light an deep Light ticking or touching
* Light/Deep Touch touch sensation

Can identify the sharp


and dull sensation
Able to determine sharp and
* Pain Sensation
dull sensation
Patient able to identify
whether hot or cold put
in skin
* Temperature Able to determine hot and
cold
The patient is aware to
the position and
*Position / Kinesthetic movement of the body
parts Able to determine position
of fingers and toes
steriognosis;patient able
to identify the object
* Tactile Discrimination given to her
Recognize common object
Graphesthesia; patient
able to identify what
Able to identify numbers/
numbers or letters
letters written on palm
written on her palm.

GENITALS N/A
* For females:
I: pubic hairdistribution,
amount, characteristics; its
areas for parasites,
inflammation, swelling,
N/A
lesions
: clitoris, urethral and
vaginal orifices for
inflammation or discharge
P: Bartholin’s glands,
lymph nodes for
enlargement, tenderness,
swelling
* Internal Exam for OB
clients for cervical dilation,
effacement and AP pelvic
diameter
RECTUM & ANUS N/A
I: anus and surrounding
tissue for color, integrity,
lesions

34 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


P: anal sphincter tonicity,
nodules, masses and
tenderness

II. Diagnostic Test

HEMATOLOGY RESULT

September 5, 2019

Time Collected: 4:30 PM

Time Released: 6:41 PM

Complete Blood Result Unit Reference Values Interpretation Analysis


Count

Red Blood Cells 4.94 X10^12/L 3.60-4.69 HIGH Dehydration

Hemoglobin 13.14 g/dL 10.80-14.20 Normal

Hematocrit 40.5 % 37.7-53.7 Normal

MCV 82.0 fL 81.1-96.0 Normal

MCH 26.6 pg 27.00-31.20 LOW Malnutrition.

MCHC 32.4 g/dL 31.80-35.40 Normal

RDW 12.1 % 11.5-14.5 Normal

White Blood Cell 6.75 X10^9/L 3.70-10.1 Normal

Differential
Count

Neutrophil 57.01 % 39.3-73.7 Normal

Lymphocytes 26.30 % 18.0-48.3 Normal

35 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Monocytes 10.32 % 4.40-12.7 Normal

Eosinophil 5.38 % 0.60-7.30 Normal

Basophil 1.00 % 0.00-1.70 Normal

Platelet count 341 X10^9/L 155-366 Normal

MPV 5.35 fL 9.4–12.3 LOW Inflammation

July 26, 2019

Time Collected: 4:35

Time Released: 6:21

Complete Result Units Reference Interpretation Analysis


Blood Values
Count

Red 4.77 X10^12/L 3.60-4.69 HIGH Dehydration


Blood
Cell

Hemoglob 12.24 g/dL 10.80-14.20 Normal


in

Hematocri 38.1 % 37.7-53.7 Normal


t

MCV 79.9 fL 81.1-96.0 Normal

MCH 25.7 pg 27.00-31.20 Normal

MCHC 32.1 g/dL 31.80-35.40 Normal

RDW 13.1 % 11.5-14.5 Normal

White 12.11 X10^9/L 3.70-10.1 HIGH Due to infection

36 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Blood
Cell

Differenti
al Count

Neutroph 76.77 % 39.3-73.7 HIGH Due to infection


il

Lymphoc 10.96 % 18.0-48.3 LOW Due to infection


ytes

Monocyte 7.47 % 4.40-12.7 Normal

Eosinophil 4.22 % 0.60-7.30 Normal

Basophil 0.59 % 0.00-1.70 Normal

Platelet 451 X10^9/L 155-366 HIGH Infection is present.


Count

MPV 5.09 fL 9.4–12.3 LOW Inflammation

July 21, 2019

Time Collected: 11:58

Time Released: 14:04

Complete Result Unit Reference Values Interpretation Analysis


Blood Count

Red Blood 4.41 x10^12/L 3.60-4.69 Normal


Cells

Hemoglobin 11.22 g/dL 10.80-14.20 Normal

Hematocrit 35.0 % 37.7-53.7 Normal

MCV 79.4 fL 81.1-96.0 LOW Small RBCs

37 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


MCH 25.5 pg 27.00-31.20 LOW Malnutrition.

MCHC 32.1 g/dL 31.80-35.40 Normal

RDW 13.0 % 11.5-14.5 Normal

White Blood 6.22 x10^9/L 3.70-10.1 Normal


Cells

Differential
Count

Neutrophil 62.72 % 39.3-73.7 Normal

25.30 % 18.0-48.3 Normal


Lymphocytes

Monocytes 7.73 % 4.40-12.7 Normal

Eosinophil 4.04 % 0.60-7.30 Normal

Basophil 0.21 % 0.00-1.70 Normal

Platelet 510 x10^9/L 155-366 HIGH Due to infection.


Count

MPV 4.74 fL 9.4–12.3 LOW Inflammation

July 11, 2019

Date Collected: 20:42

Date Released: 21:40

Complete Reference
Result Unit Interpretation Analysis
Blood Count Value
Red Blood
4.8 x10^12/dl 3.60-4.69 HIGH Patient is dehydrated
Cells
Hemoglobin 11.35 g/dl 10.80-14.20 NORMAL
Hematocrit 35.3 % 37.7-53.7 LOW Due to infection

38 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


MCV 78.7 FL 81.1-96.0 LOW RBC are smaller
MCH 25.3 pg 27.00-31.20 LOW Malnutrition.
MCHC 32.2 g/dl 31.80-35.40 NORMAL
RDW 12.6 % 11.5-14.5 NORMAL

WBC 11.39 x10^9/L 3.70-10.1 HIGH Due to infection

Differential
Count
Neutrophil 75.09 % 39.3-73.7 HIGH Infection
Infection ; Patient is
Lymphocytes 14.89 % 18.0-48.3 LOW
underweight.
Monocytes 7.39 % 4.40-12.7 NORMAL
Eosinophil 2.04 % 0.60-7.30 NORMAL
Basophil 0.59 % 0.00-1.70 NORMAL
Platelet Count 606 X10^9/L 155-366 HIGH Due to infection.
MPV 5.08 fL 9.4–12.3 LOW Inflammation.

Coagulation Test

July 11, 2019

Date Received: 21:28

Date Reported: 22:02

Coagulation Result Unit Reference Range Interpretation Analysis


Test

Prothrombin
Time

PT Patient: 14.7 sec. 10-15 sec Normal

PT Control: 13.9 sec.

% Activity 88.5 % Normal

INR: 1.073 0.85-1.15 Normal

39 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Partial
Thromboplastin
Time

PTT Patient: 33.3 sec. 25-36 sec Normal

PTT Control: 29.7 sec.

CLINICAL CHEMISTRY REPORT

July 11, 2019

Time Collected: 8:30 PM

Time Reported: 11:21 PM

Electrolytes Result Unit Reference Range Interpretation

Sodium 140.6 mmol/L 135-145 mmol/L Normal

Potassium 4.53 mmol/L 3.5-5.5 mmol/L Normal

Chloride 105.3 mmol/L 98- 108 mmol/L Normal

July 21, 2019

Time Collected: 8:35 AM

Time Reported: 12:18 PM

ELECTROLYTES RESULT UNITS REFERENSE Interpretatio Analysis


RANGE n

Sodium 143.2 mmol/L 135-145 mmol/L Normal

Potassium 4.29 mmol/L 3.5-5.5 mmol/L Normal

Chloride 109.1 mmol/L 98-108 mmol/L HIGH Dehydration

URINALYSIS

40 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


July 21, 2019

Time collected: 10:03 AM

Time Reported: 11:09 AM

Macroscopic Result Interpretation Analysis

Color Pale Yellow Normal

Transparency Slightly Hazy Normal

Specific Gravity 1.020 Normal

Protein Negative Normal

Glucose Negative Normal

pH 6.0 Normal

Leukocyte Negative Normal

Blood Negative Normal

Ketone Negative Normal

Bilirubin Negative Normal

Nitrite Negative Normal

Urobilinogen Normal Normal

Microscopic Result Interpretation Analysis

Isomorphic RBC 0-2/hpf Normal

Pus Cell 0-2/hpf Normal

41 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Squamous Epithelial Cell Many Normal

Amorphous Urate

Amorphous Phosphate

Mucus Thread Rare Normal

Bacteria

Crystal

Cast

Yeast Cell Few Normal

July 22, 2019 Time out: 4:55 PM

Test Result Normal Values Units Interpretation Analysis

UREA UV 2.10 2.10-7.10 mmol/l Normal

CREATININE PAP TEST

July 12, 2019

Time Collected: 8:42 PM

Time Released: 2:15 AM

TEST Result Normal Values Units Interpretation Analysis

Creatinine PAP 48.18 49.00-90.00 umol/l LOW Muscle weakness

July 21, 2019

Time In: 8:35 AM

Time Out: 11:32 AM

42 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Test Result Normal Value Unit Interpretatio Analysis
n

Creatinine PAP 37.54 49.00-90.00 umol/l LOW Muscle weakness

Radiologic/Sonographic Findings

CHEST X-RAY

July 11, 2019

19:16

Clinical Data: T/C Psoas Abscess

Comparison: No previous films available for comparison

Findings:

Lungs shown no active parenchymal opacities.


Heart is not large.
Aorta is unremarkable.
Diaphragm and sulci are intact.
Bony thorax is unremarkable.
Impression: NORMAL CHEST

CT SCAN
June 26, 2019

8:31 AM

43 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Results Interpretation

Gallbladder and biliary tree Adequately distended Normal

Wall is not thickened

There are no intraluminal densities noted. No biliary ectasia.

Pancreas Normal in size and configuration. No focal mass lesions seen. Normal
Pancreatic and common bile ducts are not dilated

Spleen Normal in size and configuration with an index of 308. No focal Normal
mass lesion seen.

Adrenal glands Unremarkable Normal

Kidney Right:normal in size with good parenchymal opacification Normal


measuring 9.2x 3.7 x 4.8cm CC x T X AP. No evident calculi, mass
or ectasia noted

Left: normal in size and configuration with good parenchymal


opacification measuring 10.3 x 4.1 x 4.1 cm CC x T x AP. No
evident calculi, mass or ectasia noted

Uterus Retroverted and normal in size measuring 5.5 x 3.1 x 4.4cm CC x T Normal
x AP. The endometrium is not thickened measuring 1.2cm with
fluid collection noted. No focal lesion seen. Both adnexal regions
are unremarkable. No pelvic mass lesion or fluid collection fluid.

Gastrointestinal tract Stomach and included bowel loops are non-dilated,with no evidence Normal
of wall thickening

Retroperitoneum Aorta is normal in caliber. No enlarged retroperitoneal lymph Normal


nodes.

Peritoneum No ascites or free air is present Normal

44 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Lower hemithoraces Fibrotic densities or free air is present Normal

IMPRESSION:

1. Consider Pott’s disease of the T11 to L1 vertebrae, a more malignant process is not ruled out,with extension into the psoas
muscle resulting to psoas abscess with mass effect and extra-abdominal extension as described.
2. Lytic change in the angle of the seventh rib on the right, nay be infectious vs neoplastic.

CT SCAN

June 26, 2019

8:31 AM

Findings:

Bones and soft tissues: Lytic changes replaced by soft tissue and fluid collection are seen in the T12 vertebral body predominantly on
its left side on the T11 and L1 vertebral bodies. Immediately adjacent to the vertebral lesionis a peripherally enhancing well
delineated fluid collectionmeasuring 10.6x10.0x20.2 cm (APxTxCC), approximate volume of 1,120cc occupying the left psoas
muscle breaching the overlying posterior abdominal wall and extends to the subcutaneous region of the left side of the back partially
encasing the left paravertebral muscle. Calcifications are seen in the inferior region of the lesion, at the level of the iliacus. Minimal
surrounding fat stranding is appreciated both in the subcutaneous and mesenteric regions.

The aforementioned left psoas muscle lesion has displaced the left kidney supero-anterolaterally, rotating it in a counter-clockwise
direction. The bowel loops in the left hemi-abdomen are displaced medially.

A dotted hypodense lesion measuring 0.9x 0.9x 0.9 cm (AP x T x CC) is seen in the right side of the T11 vertebral body.

Liver: Normal in size and configuration, with smooth contours and homogenous tissue attenuation. No calcifications or mass lesion
seen. The intra hepatic ducts and vessels are not dilated.

III. Review of System

Anatomy of the Spine

45 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


The spinal column or vertebrae, also known as the spine or backbone is a part of our skeletal system that protects the
delicate nerve tissue of the spinal cord. More than two dozen bones stacked upon one another to form the spine. The
bone closest to the head is called the atlas because it carries the weight of the skull.Individual bones are grouped together and
include seven neck bones or cervical, 12 chest-level bones or thoracic, 5 lower back bones or lumbar, four fused bones forming
the sacrum and the tailbone with is called the coccyx.

Our spine is composed of many units ofbones called a vertebra or vertebrae for the plural form of the word.A vertebra
is made up of the body and the arch. The arch aligns and forms the spinal canal when the vertebrae are stacked.There is
“cushions” or disk between each vertebra. These intervertebral disks are made up of cartilage, collagen fibers, and water.
Ligaments hold the vertebrae and the intervertebral disks together.

There three main functions of the spine these are:

 To protect the spinal cord nerve roots and several of the body's internal organs.
 To also provide structural support.
 To maintain balance and an upright posture.

46 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


The adult vertebral column does not form a straight line, but instead has four curvatures along its length are cervical,
thoracic, lumbar, pelvic (sacrum/coccyx) .These curves increase the vertebral column's strength, flexibility, and ability to
absorb shock. The thoracic vertebrae is the longest segment of the vertebral column and the lumbar vertebrae is the largest
vertebrae.

Anatomy of the Bony Thorax

The thorax is the superior part of the trunk between the neck and the abdomen. It is formed by the 12 pairs of ribs, the
sternum (breast bone), costal cartilages, and the 12 thoracic vertebrae. These bony and cartilaginous structures form the
thoracic cage or rib cage which surrounds the thoracic cavity and supports the shoulder girdle. The thoracic cavity contains the
heart, the lungs, and some abdominal organs. The thoracic cage provides attachments for muscles of the neck, thorax, upper
limbs, abdomen, and back. The thorax moves up and down to allow breathing, so it is one of the most dynamic regions of the
body.

There are three primary components of the thoracic cage, these are the sternum, thoracic vertebrae and their
intervertebral discs and the ribs and costal cartilages. The sternum, or breast bone, is the flat, elongated bone that forms the
midline of the anterior thoracic cage. It has 3 parts which are the manubrium, the body, and the xiphoid process.The 12
thoracic vertebrae have the same bony components as the lumbar vertebrae. They also have several additional special features
like the costal facets, a flat spots for attachments on the body of the vertebrae for articulation with the ribs.

Another part of the bony thorax is the ribs. They are elongated, flattened, and twisted bones. They are very lightweight
and resilient. Our ribs composed of 3 types. These are the true ribs (ribs 1-7). These are attached directly to the sternum
through their own costal cartilages. We also have the false ribs(ribs 8-10). Their costal cartilages are joined to the rib just

47 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


above them so their attachment to the sternum is indirect. Lastly we have the floating Ribs (ribs 11-12). These ribs are attached
to the vertebrae, but not to the sternum so they float on one end and so is called the “floating ribs”.

The functions of the thoracic cage or bony thorax are:

 To protect vital internal organs such as the heart and the lungs.
 Supports muscles on the back and attaches muscles on the back, shoulder and chest.
 Aids in breathing.

CHAPTER 4: SYNTHESIZING FRAMEWORKS, INFERENCE,


ACTION PLANS AND CASE REFLECTIONS

I. Pathophysiologic Framework

A. Theory-based Pathophysiology
ETIOLOGY: Mycobacterium Tuberculosis

RISK FACTORS:
PREDISPOSING (Poverty, Overcrowding, iliteracy, malnutrition, alcoholism,drug abuse, DM)

Mycobacterium Alveolar macrophage Mycobacterium in


tuberculosis infection phagocytise the phagosome proliferates
mycobacterium and multiplies

48 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


FEVER

Cell-mediated
Immune system
immunity forming
compromised
Memory t cells release cytokines granuloma

Caseous necrosis Tuberculosis disseminates to vascular system


cavitates
Tuberculosis affects lumbar vertebrae

Inflammation Back pain Kyphosis Visible Crackling Temporary


of joints bulges sounds on immobility
joints

B. Client-based Pathophysiology
Etiology: Mycobacterium Tuberculosis
Risk Factors:
MODIFIABLE NON-MODIFIABLE
 LOW BODY WEIGHT (BMI: 17.5) - AGE (21 years old)
 ENVIRONMENTAL FACTORS
 FINANCIAL PROBLEM

Granuloma spreads to
Unaware contact with infected person (TB)
upper lobes of the lungs
Extra pulmonary TB

Hematogenous dissemination of
MTB
Bacteria gradually build up in
the vertebrae of the) bacteria in the vertebrae
(T11-L1
Proliferation
Fracture of the ribs

Bacteria lodge to the vertebrae

Infection leading to POTT’S DISEASE

Progressive bacteria will damage the cells Granulomatous inflammation

Lymphocytes activated
Vasodilation of the blood vessels erosion of margins of the FEVER
↑ WBC production vertebrae

Necrosis Disk degeneration


49 | P a g e N U R↑ SBlood C A R E↑ Capillary
I N Gflow O F C Lpermeability
IENT WITH POTTS DISEASE BSN 3A
Pus collection
Progressive bone destruction
(+) watery discharges REDNESS Localized edema
(+) pus discharges
weakening of the trabeculae
PSOAS ABCESS LOCALIZED, DULL PAIN
(+) MASS collapse of the vertebrae
Extra abdominal
extension
bone wedging

Loss of Appetite affecting the L para vertebral


Nutrition Compromised PARESIS KYPHOSIS
Deviation of the vertebrae to
Weight loss the RIGHT

malnutrition DEXTROSCLEROSIS

II. Case Management


A. Medical Management
Pharmacologic Intervention
Drug Labels Contraindications Mechanism of Adverse Effects Nursing Responsibilities
Action
-Drug Name: hypersensitivity to May contribute No adverse effect
PREGABALIN the to analgesic and seen of patient  Educate patientthat this
(Lyrica) activesubstances anticonvulsant drug may make her feel
effects by dizzy or drowsy so avoid
binding to sites strenuous activities.
-Dosage/Route:
75 mg P.O q8 hours
in CNS
 Educate patient not to
drink alcohol while taking
-Classifications: this medication because it
anticonvulsant will add drowsiness.

-Indications:  Instruct patient not to


Management for neuropathic take a double dose to make
pain up for a missed one.

-In Relation to the Patient:  explained to patient that


controlling acute side effects of this
postoperative pain medication includes ataxia,
dizziness, peripheral
Date ordered: edema, tremors, and
Sept 6,2019 at 1:06pm weight gain. 

Drug Labels Contraindications Mechanism Adverse Effects Nursing Responsibilities


of Action

50 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


-Drug Name: Hypersensitivit Binds to No adverse  Asses type, location, and
TRAMADOL y; Cross sensitivity mu-opiod effect seen on intensity of pain before and 2-3
with opiods may receptor. patient hour. (peak) after administration
-Dosage/Route: Inhibits
occur
50mg SIVP q6 PRN reuptake of  Assess previous analgesic
pain score 4/10-7/10 serotonin and history. This is not
norepinephren recommended for patients
-Classifications: e in the CNS. dependent on opioid for more
Analgesics (Centrally than 1 week; may cause opioid
acting) withdrawal symptoms

-Indications:  Advise patient to change


Moderate to moderately position slowly to minimize
severe pain orthostatic hypotension

-In Relation to the Patient:  Instruct patient on how and


post operative analgesic when to ask for pain medication

Date ordered:  Advice patient to notify health


Sept 5, 2019 2:20 pm care professional before taking other
prescription,over the counter or
herbal products concurrently

Drug Labels Contraindications Mechanism of Adverse Effects Nursing Responsibilities


Action
-Drug Name:  Contraindicat  Decreases No adverse effect  Monitor intake and output
HYDROCORTISONE ed in patients inflammation, seen on patient  Monitor patient’s weight,
SODIUM SUCCINATE hypersensitivi mainly by blood pressureand
ty to drug or stabilizing electrolyte level.
-Dosage/Route:
its leukocytelysosoma
100 mg, IV q 8
hourstimes 6 doses
ingredients. l membranes
 Caution patient to avoid
vaccinations without first
-Classifications:  Use consulting health professional
Corticosteriods cautiously in
patient with
-Indications: tuberculosis  Explain need for continued
Severe inflammation
medical follow-up to
-In Relation to the
assess effectiveness and
Patient: possible side effects of
used as post operative medication
corticosteriods  Inspect patient’s skin for
petechiae.
Date order:
Sept 5, 2019 at 10:45am  Unless contraindicated
give a low sodium diet
that’s high in potassium
and protein.

Drug Labels Contraindication Mechanism of Adverse Effects Nursing Responsibilities


s Action

51 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


-Drug Name:
TRANEXAMIC ACID Contraindicated in  Inhibits action No adverse effect  Do skin testing
of plasminogen (via seen on patient
patients
binding to the kringle  Tell patient to inform the
-Dosage/Route: hypersensitivity to domain ), thereby healthcare provider if color
1 g IV q 8 hours drug or its reducing conversion blind, have history of stroke,
times 3 doses ingredients. of plasminogen to and blood clot, or bleeding in
plasmin, an enzyme your brain
-Classifications: that degrades fibrin
Antifibrinolytic clots, fibrinogen, and  Caution patient to avoid
other plasma protien products containing aspirin
-Indications: and NSAIDs
Treatment of excessive
bleeding resulting from  Store medication at room
systemic or local temperature away from
hyperfibrinolysis moisture and heat

-In Relation to the


Patient:
Used to prevent
perioperative blood loss.

Date order:
Sept 5, 2019 at 11:15am

Drug Labels Contraindication Mechanism of Adverse Effects Nursing Responsibilities


s Action
-Drug Name: Contraindicated in  May There is no adverse  Monitor BP, heart rate
MIDAZOLAM patients potentiate the effect seen on patient. and rhythm, respiration,
HYDROCHLORIDE hypersensitive to effects of GABA, airway integrity, and
drug. depress the CNS, pulse oximetry during
-Dosage/Route:
and suppress the procedure.
1mg IV
spread of seizure  Have oxygen and
-Classifications: activity resuscitation equipment
Benzodiazepines available in case of
severe respiratory
s-Indications: depression.
Preoperative sedation  Administer I.V. dose
slowly to prevent
respiratory depression.
In Relation to the
Patient:  Because drug
diminishes patient’s
used to induce recall of events around
sleepiness or the time of surgery,
drowsiness and Provide written
relieve information, family
apprehension member instructions,
and follow-up contact
Date ordered:
Sept 5, 2019 at
8:35am

Drug Labels Contraindication Mechanism of Adverse Effects Nursing Responsibilities


s Action
52 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
-Drug Name: Contraindicated in Rapid acting IV No adverse effect  continuously monitor vital
PROPOFOL patients sedative-hypnotic seen on the patient. signs.
(DIPRIVAN) hypersensitive to
drug or its  Monitor patient at risk for
-Dosage/Route: hyperlipidemia for elevated
components(includ
50mg IV triglyceride levels.
ing egg lecithi,
-Classifications: soybean oil and  Watch for apnea during
Phenol derivatives glycerol.) induction; may persist for
longer than 60 seconds.
-Indications: Ventilatory support may be
Pre op. drug needed.
For anesthesia
induction.  reassure patient that she will be
monitor during drug
-In Relation to the administration.
Patient:
Used for sedation  Advice patient that
performance of activities
Date ordered: requiring mental alertness may
Sept 5,2019 8:35pm be impaired for some time after
drug use.

Drug Labels Contraindications Mechanism of Adverse Effects Nursing


Action Responsibilities
-Drug Name: Calcium There is no adverse effect Give calcium
CALCIUM GLUCONATE gluconate is used to seen on patient gluconate I.V. only.
prevent or treat
-Dosage/Route: negative calcium Monitor ECG
1 gramSIVP (Slow balance. It also when giving calcium
Intravenous Push) helps facilitate gluconate I.V. Give
nerve and muscle slowly at a rate that
-Classifications: performance as well
should not exceeds
Calcium salts as normal cardiac
function.
to 200 mg/minute.
-Indications:
During exchange blood Monitor serum
transfusion calcium levels.

-In Relation to the Patient:


Used as peri-operative drugto
prevent hypocalcemia.

Date ordered:
Sept5, 2019 at 1:40 pm

53 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Drug Labels Contraindications Mechanism of Adverse Effects Nursing Responsibilities
Action

-Drug name: Hypersensitivity to -Rifampicin inhibits No adverse effect  -Educate patient that tablet
Fixed dose drug and to its DNA- seen on patient should be taken 1 hour before
Combination component dependent RNA or 2 hours after meal to
tabs polymerase facilitate absorption.
(FIXCOM 4) activity in
-Dosage/Route: susceptible
 Rifampicin 150 cells.
 -Monitor patient’s liver
mg function test before and every
 Isoniazid 75 -Isoniazid kills 2 or 4 weeks during therapy.
mg actively Immediately report for
 Pyrazinamide growing abnormalities.
400 mg tubercle bacilli
 Ethambutol Hcl by inhibiting  -Educate patient to expect skin
275 mg the biosynthesis and body fluids discoloration
of mycolic of reddish-orange to reddish-
-Classifications: acids which are brown. Due to Rifampicin side
Antibacterial major
effect.
(antimycobacterial) components of
the cell wall of
-Indications: M. tuberculosis.  -Educate the patient not to
 Treatment of double the dose to make up for
pulmonary and -Pyrazinamide the missed dose.
extra inhibits the
pulmonary growth of M.  -Educate patient about lose of
tuberculosis tuberculosis appetite due to drug effect.
organism is
-In relation to the unknown
patients:
Used as anti -Ethambutol diffuses
Tuberculosis into actively
drugs growing
Tuberculosis
-Date ordered: such as tubercle

54 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


July 12,2019 at bacilli.
10:00am

Drug Labels Contraindicat Mechanism of Adverse Effects Nursing Responsibilities


ions Action

-Drug Name:  Assess pain ( note type, location,


KETOROLAC Hypersens Inhibits No adverse effect and intensity) prior to and 1-2
itivity; cross- prostaglandin seen on patient hours following administration
-Dosage/Route: sensitivity with synthesis, producing
30 mg. IV q6 peripherally  Advise patient to maintain
other NSAIDs
hoursround the clock mediated analgesia. adequate fluid intake.
times 8 doses
may exist Also has antipyretic
and anti  teach patient signs and symptoms
-Classifications: inflammatory of GI bleeding , including blood
NSAIDs properties. in vomit ,urine or stool,
.
-Indications:  Warn patient not to take ketorolac
Short-term management with other NSAIDs
of moderately severe,
acute pain for multiple
dose.

-In Relation to the


Patient:
used as analgesic

Date order:
Sept 5, 2019
12:55 pm

55 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Drug Labels Contraindications Mechanism of Adverse Nursing Responsibilities
Action Effects
-Drug Name: Contraindicated in Inhibits No adverse  Tell patient to report
CLINDAMYCIN PHOSPHATE patients bacterial effect to discomfort at IV insertion
hypersensitive to protein patient. site.
-Dosage/Route: the antibiotic synthesis by  Monitor renal, hepatic,
600mg TIV q8 hours
congener binding to the and
-Classifications:
lincomycin 50S subunit of hematopoieticfunctions
Antibiotic the ribosome. during prolonged therapy.
 Observe patient for signs and
symptomsof superinfection
-Indications:
 .Instruct patient to report
Used to treat acute infection adverse effects, especially
caused by sensitive aerobic diarrhea. Warn patient not to
and anaerobic organisms self-treat diarrhea.

-In Relation to the Patient:


Used to treat acute infection

Date ordered:
July 11,2019 at 3:50pm

Drug Labels Contraindications Mechanism Adverse Nursing Responsibilities


of Action Effects
-Drug Name: Contraindicated in Inhibits cell- No adverse  Tell patient to report a rash,
patients hypersensitive wall synthesis effect seen on fever, or chills. A rash is
AMPICILLIN-SULBACTAM to drug or other during patient the most frequent allergic
penicillin. bacteriamultip reaction.
-Dosage/Route:
lication
1.5 gram TIV q8 hours  Advise patient to report
discomfort at insertion site.
-Classifications:

56 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Antibiotics.  Monitor liver function test

-Indications:
 educate patient that this drug
may increase alkaline
For skin-structure infections phosphate, bilirubin, BUN,
caused bysusceptible strains creatinine, and LDH level.

-In Relation to the patient:  educate patient that this drug


may decrease hemoglobin
used to treatinfections level.
caused by mycobacterium
tuberculi

Date ordered:
July 11, 2019 at 3:50 pm

Drug Labels Contraindications Mechanism of Action Adverse Effects Nursing Responsibilities


DrugName: Hrpersensitivity Prevents acetylcholine No adverse effect  Monitor respirations and
ATRACURIUM from binding seen on patient vital signsclosely until
BESYLATE toreceptors on motor patient has fully
(Tracruim) end plate, thus recoveredfrom
blockingneuromuscula neuromuscular
Dosage/Route:
25mg IV
r transmission blockade, as indicatedby
tests of muscle strength
Classifications: (hand grip, headlift, and
Skeletal muscle ability to cough)
relaxant  Assess for electrolytes
imbalances
Indications:

Adjunct to general
anesthesia to  Monitor input and Output
facilitate
endotrachial
intubation and to
relaxskeletal
muscles during
surgery or
mechanical
ventilaton.

-In Relation to the


Patient:
Used as general
endotracheal
anesthesia

Date ordered:
Sept 4, 2019 at
2:10pm

57 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Drug Labels Contraindications Mechanism of Adverse Effects Nursing Responsibilities
Action
Drug Name: Contraindicate reduces pain No adverse effect  Monitor blood pressure
ISOFLUCANE d to patient with sensitivity seen on patient and temperature to
(FORANE) known sensitivity (analgesia) and detect residual
to isoflucane or relaxes muscles. hypotention and
Dosage/Route:
other halogenated possibility of malignant
Induction:
2% with the 9L/min
anesthetics It potentiates hyperthermia.
oxygen. inhalation glycine receptor
activity, which
Maintenance: decreases motor
1.8 % with 2 L/min function.
oxygen inhalation
It activates calcium
Classifications: ATPase by
Inhaled General increasing
Anesthetics membrane fluidity
Indications:
used for induction and
maitenance of general
anesthesia.

In Relation to the
Patient:
Used as general
anesthesia

Date ordered:
Sept 5,2019 8:32 am

58 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Drug Labels Contraindications Mechanism of Adverse Nursing Responsibilities
Action Effects
Drug Name:
FENTANYL Hypersensitivity to  Binds to No adverse effect  Repeated intraoperative
fentanyl or its opiate receptors in seen on patient doses can cause respiratory
Dosage/Route: components, the CNS, altering depression to persist into
50 mcg IV intermittent pain. the response to and the postoperative period.
perception of pain.
Classifications:  monitor patient closely for
Opioid agonist respiratory distress

Indications:  Monitor patient for signs


Analgesic action of short and symptoms of
duration during anesthesia constipation.
and immediate postoperative
period.  Assess patient for
withdrawal symptoms after
Analgesic supplement in dosage reduction or
general or regional anesthesia. conversion to another
opioid analgesic.
In Relation to the Patient:
Used as post-operative  Instruct patient on correct
analgesic application and disposal of
patches.
Date ordered:
September 5, 2019 at 9:15 am

59 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Drug Labels Contraindications Mechanism of Adverse Effects Nursing Responsibilities
Action
-Drug Name: Hypersentivity Unknown,bin No adverse effect  Monitor bowel an bladder
NALBUPHINE ds with opiate seen on patient function
HYDROCHLORID receptors in the
E CNS, altering  Carefully monitor vital
(NUBAIN) signs,pain level, respiratory
perception of and
emotional status and sedation level to
Dosage/Route: prevent respiratory
8 mg IV q6 hours as response to pain.
depression .
needed

Classifications:
opioid agonist-
antagonist- opioid
partial agoinist

-Indications:
relief of moderate to
severe pain post-
operative

-In Relation to the


Patient:
Post operative pain
reliever

Date ordered:
Sept 5,2019 at
2:00pm

60 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Drug Labels Contraindications Mechanism of Adverse Effects Nursing Responsibilities
Action
-Drug Name: Hypersensitity to Sterile, non No adverse effect Moinotr patient
Plain Normal Saline the solution pyrogenic seen on patient frequently:
Solution solution for Sign of infiltration or
(0.9% NaCl Solution) fluid and sluggish flow.
electrolytes
-Dosage/Route: Sign of plebitis or
1L run for 8 hours IV
replenishment. infection.
(42 gtts/min)
Condition of catheter
-Classifications: dressing
ISOTONIC
Check the level of IVF:
-Indications: Correct
Replace Extracellular Fluid solution,medication and
. volume.
-In Relation to the Patient:
Used for diluting drugs and Check and regulate
packed RBC. proper drop factor

Date ordered: Change the IV solution if


July 11,2019 at 3:50pm needed.

Drug Labels Contraindications Mechanism of Action Adverse Effects Nursing Responsibilities


DrugName: Hypersensitity to  Hypertonic No adverse effect  Do not administer
D5LR(5% Dextrose the solution solution are those that seen on patient unless solution is clean
in lactated Ringers have an effective and container is
solution) osmolality greater than undamaged
the body fluids. This
Dosage/Route:
pulls the the fluid into  Caution must be exercised
1 literrun for 8
vascular by osmosis in the administration of
hours(42 gtts/min)at
resulting to imcrease parenteral fluids especially
left arm
vascular volume. It sodium ions to patient
once NPO
receiving corticosteroids.
(11:00pm) raises the intravascular
pressure and provide
Classifications: fluid, electrolyte and
Hypertonic Solution calories for
emergency.
Indications:
Treatment for
persons needing
extra calories who
cannot tolerate fluid
61 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
overload

-In Relation to the


Patient:
For preoperative
body fluid
maintenance

Dated ordered:
Sept 4,2019 at
2:10pm

III. Plans for Nursing Actions

A. NURSING CARE PLAN

Name of the Patient: P.J.P.D. Date: September 03, 2019 Medical Diagnosis: Psoas
Abscess, left VS Pott’s Disease

Nursing Diagnosis:Imbalanced Nutrition: Less Than Body Requirements

Assessment Diagnosis Planning Implementation Evaluation

Subjective: LTG: Rationale: LTG:

- “Wala akong Imbalanced -Patient will 1. Look for physical -The patient - Patient
gana kumain Nutrition: Less demonstrate signs of poor nutritional encountering demonstrates lifestyle
Than Body behaviours, lifestyle intake. nutritional changes however her
pero pinipilit
Requirements changes to recover deficiencies may weight didn’t
kong related to and obtain the improved instead it
kumaen”, as resemble to be
decreased desire appropriate weight. decreases from 43
verbalized by to eat
sluggish and fatigued. kgs to 42 kgs (based
the client -Patient will maintain Other manifestations on weight last
a normal BMI of include pale and dry September 5, 2019)
18.6-24.9 skin, poor muscle Goal was partially
Objective: tone, dull and brittle met.
hair.
(+) poor
muscle tone STG: 2. Determine client’s -All factors that can STG:
ability to chew, affect ingestion or
-After 2 hours of swallow, and taste food. digestion of nutrients. - Goal was met. After
Weight: 43kgs nursing intervention Evaluate teeth and 2 hours of nursing
Height: 155cm the client will: gums for poor oral intervention, the
BMI: 17.9 health. client identified the
- understand significance of
importance of 3. Assess weight and nutrition to the
Vital Signs: nutrition to healing calculate for body mass -to establish baseline general health of a
process and general indez. Ascertain healthy parameters person.
Temp: 36⁰C health. body weight for age and
PR: 78bpm height(47.85kg for - The client also
- identify behaviours, 155cm female). identified ways to
RR: 19
lifestyle changes to change her lifestyle
BP: 120/70 recover and/or reach to have the
02 Sat: 99% - Various
the appropriate 4. Note the patient’s appropriate weight.
weight. perspective and feeling
psychological,
psychosocial,
62 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
toward eating and food. religious, and cultural
factors determine the
type, amount, and
appropriateness of
food utilized.

-that may be affecting


5. Assess drug appetite, food intake
interactions and disease or absorption
effects

6. Consider six small - Eating small,


nutrient-dense meals frequent meals lessens
instead of three larger the feeling of fullness.
meals daily to lessen the
feeling of fullness.

7. Discourage - These beverages will


caffeinated or decrease hunger and
carbonated beverages. lead to early satiety.

8. Prevent or minimize -May have a negative


unpleasant odors or effect on appetite and
sights. eating.

9. Provide
- Attention to the
companionship during
mealtime.
social perspectives of
eating is important in
both hospital and
home settings.

10. Encourage client to -to stimulate appetite


choose foods or have
family member bring
foods that seem
appealing.

63 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Nursing Care Plan
Name of the Patient: P.J.P.D. Date: September 03, 2019 Medical Diagnosis: Psoas
Abscess, left VS Pott’s Disease

Nursing Diagnosis: Ineffective Coping related to Progression of Disease evidenced by Inability To Meet Role Performance

Assessment Diagnosis Planning Implementation Evaluation

Subjective: LTG: Rationale:


LTG:
- “Gusto ko ulit Ineffective - Client will have a 1. Determine individual - Obtaining insight - Client was able to
makapagturo pero Coping related positive attitude stressors. allows the patient to maintain a positive
di ko magawa dahil to Progression about her situation reevaluate the threat or attitude about her
sa sakit ko”, as of Disease identify new ways to situation but still
verbalized by the evidenced by - Client will maintain deal with it. Because a wasn’t able to
client Inability To a desired level of role patient has an altered maintain desired
Meet Role function. health status does not level of role function.
Performance mean the coping Goal was partially
Objective: difficulties she exhibits met.
are only related to that.
-Client’s affect was STG: Persistent stressors such
observed to be as the may exhaust the
bothered about not - After 2 hours of patient’s ability to
being able to teach. nursing intervention: maintain effective STG:
coping.
- Inadequate -Client will be able to - Goal was met:
confidence describe and initiate - Patients may have -Client was able to
effective coping 2. Evaluate resources support in a single describe and initiate
Vital Signs: strategies. and support systems setting, such as during effective coping
Temp: 36⁰C available to the patient. hospitalization, yet lack strategies
PR: 78bpm -Client will develop sufficient support in the
RR:19 ability to reassure self home setting. -Client was able to
BP: 120/70 develop ability to
O2 Sat: 99% - Client will identify 3. Assist patient set -Involving patients in reassure self
her personal strengths realistic goals and decision making helps
and ways to use them identify personal skills her move toward - Client was able
to maintain a desired and knowledge. independence. to identify her own
level of role function personal strengths
4. Call client by name. -Using client’s name and ways to use them
Ascertain how client enhances sense of self to maintain a desired
prefers to be addressed. and promotes level of role function
individuality and self –
esteem.

5. Consider the patient’s - Acknowledgment of


use of coping strategies the patient’s feelings
that the patient has validates the feelings
found effective in the and communicates
past. acceptance of those
feelings. This enhances
64 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A
the patient’s confidence
and mastery of the
situation.

- Acknowledging and
6. Use empathetic empathizing creates a
communication. supportive environment
that enhances coping.

7. Convey feelings of -An honest relationship


acceptance and facilitates problem-
understanding. Avoid solving and successful
false reassurances. coping. False
reassurances are never
helpful to the patient and
only may serve to relieve
the discomfort of the
care provider

8. Encourage the patient - During crises, patients


to recognize her own may not be able to
strengths and abilities. recognize their strengths.

9. Encourage use of - Relaxation can help


cognitive behavioral patients cope and
relaxation like listening increase their sense of
to music control.

10. Explain disease -May help client to


process, procedures and express emotions, grasp
events in a simple situation and feel more
concise manner. Devote in control.
time for listening.

65 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


Nursing Care Plan
Name of the Patient: P.J.P.D. Date: September 9, 2019 Medical Diagnosis: Psoas
Abscess, left VS Pott’s Disease

Nursing Diagnosis: Impaired Physical Mobility related to Post-Spinal Surgery

Assessment Diagnosis Planning Implementation Evaluation

Subjective: LTG: Rationale:


LTG:
- “Nahihirapan Impaired - Client will not 1. Note factors affecting - surgery restrict the
akong tumayo at Physical Mobility manifest any signs current situation patient’s movement The client was able
maglakad” as related to Post- of muscle atrophy. to show an increase
verbalized by the Spinal Surgery strength and function.
patient -Client will show Client was free from
increase strength on 2. Assess degree of - To determine if pain signs of muscle
both lower pain; listen to client’s management can atrophy
extremities description about pain. improve mobility. -The goal was met.
Objective:

(+) discomfort STG: 3. Assist in range of - Enhances circulation, STG:


when moving motion exercises restores and maintains
- After 4 hours of muscle tone and joint -After 4 hours of
(+) assistance by nursing mobility, and prevents nursing intervention
her mother when intervention: muscle atrophy. the client was able to
standing and verbalize
walking -Client will be able understanding of the
to verbalize her 4. Reposition -Reduces pressure areas situation and
Vital Signs: understanding periodically even when and promotes peripheral individual treatment
regarding her sitting in chair. Teach circulation regimen and safety
Temp: 37 C situation and safety patient how to use measures.
PR: 84 bpm measures that must weight-shifting -The goal was met.
RR: 20 cpm be observed. techniques
BP: 120/80 mmHg
O2 sat: 98% -Client will be able
to perform range of 5. Instruct in use of - To help the client for
motion exercises. side-rails, walker or position changes,
cane transfers and ambulation

6. Provide safe and - To promote safety


unhurried environment measures and reduce
risk for injury.

66 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


B. Discharge Plan

Client with Pott’s disease is instructed to take the following plan for discharge.

M-edications should be taken regularly as prescribed like paracetamol and tramadol 325 + 37.5 mg/tab and pregabalin 75
mg/cap 3x a day in 14 days on exact dosage, time and frequency. Make sure that the purpose of medications is fully
disclosed by the health care provider.

E-xercise should be promoted in a way by stretching hand and feet every morning. Encourage the patient to keep active
to adhere to exercise program and to remain as self sufficient as possible. Advised the family to avoid, if possible,
exposing the patient in doing heavy work or activity. Make sure that the patient will have a safe and comfortable bed to
take a rest. Instruct the guardian to provide clean surroundings for the client.

T-reatment after discharge is expected. Instruct the patient to take her prescribed medicine at right dosage and at the right
time. Inform the patient to have a follow-up check-up.

H-ealth teaching about the importance of proper hygiene and hand washing to prevent infection should be emphasized.
Encourage the patient to have a plenty of rest for recovery. Teach the patient to observe the wound and report to the
physician any swelling, redness, drainage, odor. Notify the physician if fever is present.

O-ut patient consultation such as regular follow-up check-ups should be greatly encouraged to clients with Pott’s disease
as ordered by the physician to ensure the containing management and treatment.

D- iet for TB patient includes yellow-orange fruits and vegetables such as orange, mango, papaya, sweet pumpkin, and
carrots which are rich in Vitamin A, while Vitamin C is found in fresh fruits like guava, orange, tomato, sweet lime and
lemon. Encourage the patient to avoid junk foods and preservative foods.

S-piritual activity like praying and attending to church activity can help improve the patient’s condition. Encourage the
patient to enjoy company with family, friends and relatives.

67 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A


References:

(n.d.). Retrieved from https://courses.vcu.edu/DANC291-003/unit_4.htm

Catarina Lacerda, R. L. (2017). Hindawe. Retrieved September 30, 2019, from Hindawe.com:
https://www.hindawi.com/journals/crim/2017/4165301/

Cheever, J. L. (2018). Brunner and Suddarth's Textbook of Medical Surgical Nursing. Quezon City: Lippincott Williams and Wilkins .

Herdman, T. (2012). NANDA International Nursing diagnoses: Definitions and classification 2012-14. Chichester, U.K: Ames, lowa:
Wiley-Blackwell.

Hidalgo, J. A. (2019, August 8). emedicine.medscape. Retrieved September 30, 2019, from emedicine.medscape.com:
https://emedicine.medscape.com/article/226141-overview

Hinkle, J. L. (2014). Brunner & Suddarth's textbook of medical-surgical nursing (Edition 13). Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins.

John Hawks Net. (2011, September 18). Retrieved September 9, 2019, from John Hawks Net:
http://johnhawks.net/explainer/laboratory/types-of-vertebrae.html

Karch, A. M. (2016). Pocket Drug Guide for Nurses. USA: Lippincott.

Kelly, J. R. (2014). Health Assessment in Nursing 5th Edition. Quezon City: C and E Publishing Inc.

Kluwer, W. (2017). Nursing 2017 Drug Handbook. USA: Lippincott.

Lumen Learning. (n.d.). Retrieved Occtober 1, 2019, from Lumen Learning Teacher Education:
https://courses.lumenlearning.com/teachereducationx92x1/chapter/kohlbergs-stages-of-moral-development/

Mcleod, S. (2018). Simply Psychology. Retrieved October 1, 2019, from Simply Psychology.Org:
https://www.simplypsychology.org/Erik-Erikson.html

Sanoski, A. H. (2017). Davis's Drug Guide for Nurses 16 Edition. USA: Davis.

UPMC. (2019). Retrieved September 17, 2019, from upmc.com: https://www.upmc.com/services/rehab/rehab-


institute/conditions/spinal-cord-injury/basics/anatomy

Videbeck, S. P. (2018). Psychiatric Mental Health Nursing 7th Edition. USA: Paperback. Barnes & Nobles.

Wikipedia. (2019). Retrieved September 15, 2019, from Wikipedia.com:


http://en.wikipedia.rog/wiki/Gordon's_functional_health_patterns

68 | P a g e NURSING CARE OF CLIENT WITH POTTS DISEASE BSN 3A