Patients Name: Anthony de Guzman Age: 13 / Address: Marikina City

Medical Diagnosis: Pottss Disease T9-T10 Date Admitted: September 18, 2006

ASSESSMENT
Subjective: The patient verbalized, Kasalanan kasi to nung mga kalaro ko. Kund di nila ko niluksuhan hindi sana ako nagkaganito. Baka tuloy tuksuhin nila ako dahil ditto. Objectives: - 13 y.o. boy - Noted Gibbus formation in his back - Unsteady and irregular gait. - Needs assistance during ambulation or mobility. - Wear skeletal brace (Taylor brace)

DIAGNOSIS

RATIONALE
Potts disease is a disease characterized by softening and collapse of the vertebrae, often resulting in a hunchback deformity. Change in body image is often accompanied by depersonalization. Threats to self-concept are enormous as patients face the realization of illness and possible disability. Priorities and values change when body image is threatened. Reference: Medical Surgical Nursing (Brunner and Suddarths)

PLAN
Goal: After 4 hours of nursing intervention, the patient will be able to verbalize realistic view and acceptance of self in situation.

INTERVENTION
1. Encourage verbalization of feelings, accepting what is said. 2. Observe nonverbal communication, e.g., body posture and movements, eye contact, gestures, use of touch

RATIONALE
1 Helps patient begin to adapt to change and reduces anxiety about altered function. 2. Contains large percentage of communication and therefore is extremely important. How the person uses touch provides information about how it is used for communication and how comfortable the individual is with being touched. 3. Information must be validated by the patient as assumptions may be inaccurate. 4. More important than
age and maybe useful in

EVALUATION
After the nursing intervention, the patient was able to verbalized realistic view and acceptance of self in his present condition.

Self-concept disturbance related to changes in body image secondary to musculoskeletal impairment (Potts disease)

3. Reflect back to the patient what has been said, for clarification and verification. 3. Raise bedside rails whenever the client is sleeping or left alone. 4. Identify
developmental level

5. Discuss patients view of body image and how this illness might affect it.

anticipating and identifying some needs. Some degree of regression occurs during illness, dependent on many factors such as the coping skills of the individual and severity of the illness. 5. The patients perception of a change in body image may occur over a period of time or suddenly or be a continuous subtle process. Awareness can alert the nurse to the need for appropriate interventions tailored to the individual need 6. Provides opportunity to begin incorporating actual changes in an accepting and hopeful atmosphere. 7. Provides success for experiences, reaffirming capabilities and enhancing self-esteem

6. Encourage discussion of physical changes in simple, direct and factual manner. Give realistic feedback and discuss options, e.g. rehabilitation services, therapy. 7. Introduce tasks at patients level of functioning, progressing to more complex activities as tolerated.