FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING

POTTs DISEASE
(A CASE PRESENTATION)
BY: GROUP 83 (BSN 221)
LABRADOR, Precious Mary LIANG, Zhennie MAGBOJOS, John Rafael MANGALINDAN, Jemimah MARABE, James Francis MENDIOLA, Robby PANGAN, Kimely Anne POLICARPIO, Charmaine RECIBE, Cheemnee Wayne RED, Kathryn Jenn

PRESENTED TO:
Maam Mary Jeannie Patrimonio Clinical Instructor

P O T T S

DISEASE

POTTs DISEASE
Definition
Potts disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints. It is named after Percivall Pott (1714-1788), a London surgeon who trained at Barts. Scientifically, it is called tuberculous spondylitis and it is most commonly localized in the thoracic portion of the spine. AKA: Pott's syndrome, Pott's caries, Pott's curvature, angular kyphosis, kyphosis secondary to tuberculosis, tuberculosis of the spine, tuberculous spondylitis and David's disease

POTTS DISEASE

POTTs DISEASE
Etiology
Potts disease is caused when the vertebrae become soft and collapse as the result of caries or osteitis. Typically, this is caused by mycobacterium tuberculosis. As a result, a person with Pott'sdisease often develops kyphosis, which results in a hunchback.

POTTS DISEASE

POTTs DISEASE
Epidemiology
Approximately 1-2% of total tuberculosis cases are attributable to Potts disease. The incidence rate here in the Philippines is approximately 20-30% of the entire patient diagnosed to have Tuberculosis. Most of the cases of the Pott's disease in the Philippines are caused by the non-compliance of the treatment regimen of TB. Tuberculosis worldwide accounts for 1.7 billion infections, and 2 million deaths per year. Over 90% of TB occurs in poorer countries, but a global resurgence is affecting richer ones. The disease affects males more than females in a ratio of between 1.5 and 2:1. In the USA it affects mostly adults but in the countries where it is commonest it affects mostly children.
POTTS DISEASE

POTTs DISEASE
Risk Factors
Tuberculosis/Endemic TB Poor socioeconomic conditions Diabetes Steroid Use Chronic Disease Immunosuppression IV drug Abuse Rheumatoid Arthritis
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POTTs DISEASE
Signs and Symptoms
Localized back pain Paravertebral swelling Systematic signs and symptoms of TB Neurological signs may occur leading to paraplegia Spinal mass, sometimes associated with numbness, tingling, or muscle weakness of the leg

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POTTS DISEASE

POTTS DISEASE

POTTS DISEASE

PHYSICAL ASSESSMENT
Body Parts Height Actual Findings Change of shape of back Weight loss Analysis kyphosis

Weight

Anorexia

Vital signs Temperature

Normal Findings 36.5-37.5 degrees Celsius

Actual Findings Increase in temperature

Analysis

Febrile

General Survey
Body built Overall hygiene and grooming Normal Findings mesomorph clean and neat Actual Findings Ectomorph Self bathing hygiene deficit Analysis Deviation from Normal Deviation from Normal

POTTS DISEASE

PHYSICAL ASSESSMENT
Assessment of the Skin
Normal Findings Actual Findings Analysis

Skin color

Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive -Fundamentals of Nursing 8th edition Kozier and Erbs page 579

redness

erythema

No edema Presence of edema -Fundamentals of Nursing 8th edition Kozier and Erbs page 579 with edema edema

Uniform: within normal range Skin temperature -Fundamentals of Nursing 8th edition Kozier and Erbs page 579 Warm skin temperature

Febrile Deviation from Normal

POTTS DISEASE

PHYSICAL ASSESSMENT
Assessment of the Nose

Palpate the maxiliary and frontal sinuses for tenderness

Not tender

Tenderness in one or more sinuses

Deviation from normal

Assessment of the Thorax

Posterior Thorax Normal Findings Spine is vertically aligned. Spinal column is straight, right and left shoulder and hips are at the same height. - Fundamentals of Nursing 8th edition Kozier and Erbs page 614 No tenderness, no masses Actual Findings Analysis

Inspect the spinal alignment for deformities.

Exaggerated spinal curvatures

Kyphosis due to gibbous formation

Palpate the posterior thorax

Pain with palpation over the spine

Deviation from normal

POTTS DISEASE

PHYSICAL ASSESSMENT
Assessment of the Musculoskeletal System
Normal Findings Equal in size on both body parts. Inspect the muscle for size. - Fundamentals of Nursing 8th edition Kozier and Erbs page 640 Equal strength on each body sides ( sternocleidomastoid, trapezius, deltoid, biceps, triceps, wrist and finger, grip strength, hip and hamstring. - Fundamentals of Nursing 8th edition Kozier and Erbs page 640 Varries in accordance to a person genetic make-up Fundamentals of Decrease range of motion. Pain in Nursing 8th edition Kozier and Erbs movement page 641 Muscle atrophy Deviation from Normal Actual Findings Analysis

Test muscle strength.

Weakness

Deviation from Normal

Assess range of motion

Deviation from Normal

Bones
Inspect the skeleton for structure No deformities Bones misaligned Presence of tenderness or swelling Deviation from normal Deviation from normal

Palpate the bones to locate any No tenderness or swelling areas of edema or tenderness

Joints
Inspect the swelling. Palpate each joint for tenderness, smoothness of movement, swelling, crepitation, and presence of nodules. No swelling No tenderness, crepitation or nodules Swelling joints Deviation from Normal

Assess joint range of motion

Joints move smoothly Varies to some degree in accordance with persons genetic Decreased range of motion make-up and degree of physical POTTS DISEASE activity

Deviation from normal

DIAGNOSTICS

DIAGNOSTIC PROCEDURE
Blood Test- elevated ESR Tuberculine Test Radiographs of the spine Bone Scan CT of the Spine Bone biopsy

MICROBIOLOGY
Needle biopsy Acid-fast strain and culture

POTTS DISEASE

DIAGNOSTIC PROCEDURE
Imaging Studies
CT scanning
CT scanning provides much better bony detail of irregular lytic lesions, sclerosis, disk collapse, and disruption of bone circumference. Low-contrast resolution provides a better assessment of soft tissue, particularly in epidural and paraspinal areas.

MRI
MRI is the criterion standard for evaluating disk-space infection and osteomyelitis of the spine and is most effective for demonstrating the extension of disease into soft tissues and the spread of tuberculous debris under the anterior and posterior longitudinal ligaments. MRI is also the most effective imaging study for demonstrating neural compression.
POTTS DISEASE

LABORATORY RESULTS:
Laboratory Studies
Tuberculin skin test (purified protein derivative [PPD])Results are positive in 84- 95% of patients with Pott disease who are not infected with HIV

The erythrocyte sedimentation rate (ESR)

May be markedly elevated (>100mm/h).

Microbiology studies
Are used to confirm diagnosis. Bone tissue or abscess samples are obtained to stain for acid-fast bacilli (AFB), and organisms are isolated for culture and susceptibility. CTguided procedures can be used to guide percutaneous sampling of affected bone or soft-tissue structures. These study findings are positive in only about 50% of the cases.
POTTS DISEASE

LABORATORY RESULTS Aspirate from joint space & abscess

Transparency: turbid. Colour: creamy. Consistency: cheesy. Fibrin clot: large. Mucin clot: poor. WBC: 25000/cc.mm.

POTTS DISEASE

LABORATORY RESULTS
Imaging Studies
Radiography
Radiographic changes associated with Pott disease present relatively late. The following are radiographic changes characteristic of spinal tuberculosis on plain radiography: Lytic destruction of anterior portion of vertebral body Increased anterior wedging Collapse of vertebral body Reactive sclerosis on a progressive lytic process Enlarged psoas shadow with or without calcification

Additional radiographic findings may include the following:

Vertebral end plates are osteoporotic. Intervertebral disks may be shrunk or destroyed. Vertebral bodies show variable degrees of destruction. Fusiform paravertebral shadows suggest abscess formation. Bone lesions may occur at more than one level.

POTTS DISEASE

LABORATORY RESULTS
Imaging Studies
X-Ray spine
Early: Narrowed joint space. Diffuse vertebral osteoporosis adjacent to joint. Erosion of bone. Fusiform paraspinal shadow of abscess in soft tissue. Late: Destruction of bone. Wedge-shaped deformity (collapse of vertebrae anteriorly). Bony ankylosis.
POTTS DISEASE

LABORATORY RESULTS
Imaging Studies
CT SCAN
CT scanning reveals early lesions and is more effective for defining the shape and calcification of soft-tissue abscesses. In contrast to pyogenic disease, calcification is common in tuberculous lesions.

MRI
MRI findings useful to differentiate tuberculous spondylitis from pyogenic spondylitis include thin and smooth enhancement of the abscess wall and welldefined paraspinal abnormal signal, whereas thick and irregular enhancement of abscess wall and ill-defined paraspinal abnormal signal suggest pyogenic spondylitis. Thus, contrast-enhanced MRI appears to be important in the differentiation of these two types of spondylitis.
POTTS DISEASE

LABORATORY RESULTS Complications Vertebral collapse resulting in kyphosis.

Spinal cord compression. Sinus formation. Paraplegia (so called Pott's paraplegia).

POTTS DISEASE

PATHOPHYSIOLOGY
PREDISPOSING FACTORS Gender Age
Extreme vascularity Immune system

PRECIPITATING FACTORS Diet Environment

crowded and poor living condition Human immunodeficiency Epidemic

M. Tuberculosis transmitted from primary T.B or via open wound through blood and lymphatic drainage Infection spread into the vertebrae and joints Adjacent disc collapse resulting to Gibbus formation Further colonization of M. Tuberculosis would cause shortening of the spine and destruction of the vertebral column

Symptoms include:

back pain,
immobility, leukocytosis severe weakness of lower extremities, fever, night sweats, lack of appetite and weight loss occur. *The person may experience tingling, numbness; and weakness in the legs. If left untreated will result to: Bone deformities Neurologic deficit

If treated with: Antimicrobial therapy:

Reduced progression of bone deformities

Surgery:

POTTS DISEASE

Correct bone

ECOLOGIC MODEL
Ecologic Model
Hypothesis:

Potts disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints. The main agent is the M. tuberculosis which is also the major agent for PTB. In the case of Potts disease patients, the TB harbored in the vertebrae and it could cause more serious problems.
Predesposing Factors:

Host:
>10 and <60 yrs old Male HIV positive patients History of TB

Agent:
Mycobacterium Tuberculae

Environment:
Crowded and poor living condtion Epidemic zone Low economic level Tropical countrie

POTTS DISEASE

ECOLOGIC MODEL
Environment: -Crowded and poor living condition -Epidemic zone -Low economic level

Host: ->10 and <60 yrs old -Male -HIV positive patients -History of TB

-Tropical countries

Analysis: The agent-host-environment model is primarily use in predicting illness rather than promoting wellness, although identification of risk factors that result from the interactions of agent, host, and environment are helpful in promoting and maintaining health. Because each of the agent-host-environment factors constantly interacts with others, health is an ever changing state. Health is seen when all three elements are in balance while illness is seen when one, two, or all three elements are not in balance (Fundamentals of Nursing by Kozier 2004 Conclusion: We therefore conclude that the patient is suffering from Potts disease because of the environmental factors that attributed against the host. The factors developing the disease can be prevented and take as a process to eliminate the disease.

POTTS DISEASE

Prioritized List of Nursing Problems

Nursing Problems Identified Acute pain related to inflammatory process Justification It is the first priority that needs immediate action and it is included in the Maslow hierarchy of needs. Clients who are in pain will be motivated to get these biological needs met before being interested in learning about their medication, rules for self-care, and health education. And it is also included in basic survival needs. It is the second priority due to Maslows hierarchy of needs wherein these physiological needs requires immediate intervention. It is an intake insufficient to meet daily energy requirements. It is the third priority and it is also included in Maslows Hierarchy of Needs under physiological needs. Mobility is the ability to move freely, easily, rhythmically and purposely in the environment, it is an essential part of living. People must move to protect themselves and to meet their basic needs. Mobility is vital to independence; a fully mobilized person is a vulnerable and dependent as an infant. It is the fourth priority and it is a health deficit that requires immediate attention and adequate management. It is also included in Maslows Hierarchy of Needs under physiological needs. Bathing produces sense of well-being. It is a refreshing and relaxing and frequently improves morale, appearance, and self respect. It is the fifth priority and it is included in Maslows Hierarchy of Needs under Selfesteem. Patients want a positive self regard to increase their confidence to feel ones own worth. It is the last priority because if intervention is done on the condition, future problems can be minimized or totally prevented; Susceptibility to other diseases and infection can be prevented. It is a health threat that does not need immediate action.

Imbalance nutrition related to inadequate food intake Impaired physical mobility related to therapeutic restriction of movement

Self bathing hygiene deficit related to musculoskeletal impairment

Disturbed body image related to trauma/injury to spinal cord Risk for infection related to insufficient knowledge to avoid exposure to pathogens

POTTS DISEASE

NURSING CARE PLAN

CUES Subjective: Reports of pain/disco mfort. Sumasakit na ang likod ko. Objective: -Facial mask of pain. -Narrowed focus. -Distraction behaviors -Fatigue. V/S taken as follows: T: 37.4 P: 83 R: 18 Bp: 120/80 NURSING DIAGNOSIS ANALYSIS GOALS AND OBJECTIVE
GOALS: In 8 hours of duty, after the selected nursing interventions the client would be able to alleviate or reduce the pain that is accepted by the client. OBJECTIVE: 1.After 30 minutes of discussion, the importance in following prescribed pharmacological regimen. 2.After 30 minutes of demonstration, the client would be able to identify at least three (3) relaxation techniques and diversional activities in controlling pain. 3. After 30 minutes of discussion, the client would be able to verbalize thoughts about hher current health status

NURSING INTERVENTION Investigate reports of pain, noting location and intensity (scale of 0-10). Note precipitating factors and nonverbal cues. Monitor Vital Signs Place/monitor use of pillows, sandbags, trochanter rolls, splints, braces. Encourage use of stress management techniques, e.g., progressive relaxation, biofeedback, visualization, guided imagery, selfhypnosis, and controlled breathing. Provided Therapeutic Touch. Involve client in diversional activities appropriate for individual situation. Administer prescribed analgesics and observe for pain relief, side effects. Provide an opportunity for clients to express their own words how they view the pain and the situation.

RATIONALE
Helpful in determining pain management needs and effectiveness of program. (Nursing Care Plans page 725) To obtain Baseline Data Rests painful joints and maintains neutral position. Note: Use of splints can decrease pain and may reduce damage; however, prolonged inactivity can result in loss of joint mobility/function. (Nursing Care Plans page 725) Promotes relaxation, provides sense of control, and may enhance coping capabilities. (Nursing Care Plans page 725) Refocuses attention, provides stimulation, and enhances self-esteem and feelings of general well-being. (Nursing Care Plans page 725) The nurses assess the patients response to each medication. As the acute pain subsides, medications are reduced as prescribed (Medical-Surgical Nursing 8th Edition Volume II by Suzanne Smeltzer page1882) This will help the nurse understand what the pain means to the client and how the client is coping with it. (Fundamentals of Nursing 8th Edition Volume II page 1197 by Erbs)

EVALUATION

Acute pain related to Inflammatory responses as manifested by verbalization of pain over the spine of the client.

Because of Inflammation and necrosis from the infection, exudates and Necrotic material lead to increased pressure within the bone with eventual abscess formation. The abscess can eventually drain from the tract and drain through the skin. (Ortopedic Nursing Secrets by Michael E. Zychowics page 83)

Was the client able to identify the importance of following the prescribed pharmacologic al regimen? _Yes _No Was the able to demonstrate at least 3 relaxation and diversional activities in controlling pain? _Yes _No Was the client able to verbalize his/her current health status? _Yes _No

POTTS DISEASE

MANAGEMENT OF POTTS DISEASE Nursing intervention:

Monitor vital signs Provide comfort measure Inspect skin for presence of cold abscess Increased fluid intake Check traction setup Promote deep breathing and coughing exercise Keep skin clean and dry Note emotional and behavioural responses to problem of immobility Encourage patient to express feelings Assist with physical therapy Administered multivitamins as indicated Provide a balanced diet of complex carbohydrates and ordered amount of high quality protein and essential amino acids. Increase resistance of diet trough proper nutrition Proper immobilization by bracing Adequate rest Close monitoring regarding response to therapy Observe for possibility of antimicrobial drug resistance POTTS DISEASE

MANAGEMENT OF POTTS DISEASE

Medical management:
Non-operative antituberculous drug Analgesic Chemotherapy for 9-12 months Vitamin b complex Pharmacologic management

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MANAGEMENT OF POTTS DISEASE

Surgical management:
Surgery may be necessary, especially to drain spinal abscesses or to stabilized the spine Anterior decompression and/ or fussion of the spine Richards intramedullary hip screw- facilitating for bone healing Kuntcher nail- intramedullary rod Austin moore- intramedullary rod(for hemiarthroplasty) Taylor brace
POTTS DISEASE

DISCHARGE PLAN
DISCHARGE PLAN
MEDICATION   Encourage the patient to have a strict compliance with regards to the medication to attain therapeutic effects. Give adequate instructions to the significant others about the importance of the following medications and dietary regimens so that the patients condition can remain stable as soon as possible.  Continue home medications. Home medications: Iosoniazid Pyrazinamide Ethambutol Rifampicin Streptomycin

EXERCISE TREATMENT

Encourage the client to have an exercise like back extension exercises at least 5-10 min 3-4 times Instruct the client to take all the medication as prescribed by the physician and participate in continuous treatment. Practice good hygiene. Comply with medication. Bed rest Drainage of abscess Proper nutrition Instruct the patient and family to return to their attending physician for scheduled follow up visit. Immobilization using body cast External bracing Instruct the patient to continue taking the medication as prescribed Advise patient and the family to report to the physician if any recurrence or severity of symptoms, any adverse effects to the medication, and any development of complications.

HEALTH TEACHING       ORTHOPEDIC    

Advice the client to have proper nutrition; take foods that high in protein to increase resistance of client DIET SPIRITUALITY   Encourage the client to pray to God always, ask for guidance and pray for the healing and restoration of health. Always seek spiritual advice and go on Sunday masses

POTTS DISEASE