POTT’s DISEASE

FAR EASTERN UNIVERSITY U NIVERSITY INSTITUTE OF NURSING

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

PRESENTED TO: Ma¶am Mary Jeannie Patrimonio Clinical Instructor

P O T T µS

DISEASE

P O T T µS

DISEASE

POTT¶s DISEASE Definition Pott¶s disease is a presentation presentation of of extrapulmonary extrapulmonary tuberculosis tuber culosis that affects affects the spine, spine, a kind of tuberculo tuberculous us arthritis arthr itis of the interver intervertebra tebrall joints joints.. It is named after Perciv Percivall all Pott (1714 (1714-1788) -1788),, a London surgeon who trained at Barts. Scientifically,, it is called Scientifically called tuberculo tuberculous us spondy spondylitis litis and it is most commonly localized in the thoracic portion of the spine. AKA: Pot AKA: Pott' t's s sy synd ndro rome, me, Pott' Pott's s ca cari ries es,, Pot Pott' t's s cu curv rvat atur ure, e, angularr kyphosis, angula kyphosis, kyphosis second secondary ary to tuberculosis, tuberculosis, tuberculosis tuber culosis of the spine, tuberc tuberculous ulous spondy spondylitis litis and David's disease

POTT¶S DISEASE

POTT¶s DISEASE Etiology Pott¶s 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.

POTT¶S DISEASE

POTT¶s DISEASE Epidemiology Approximately 1-2% of total tuberculosis cases are attributable to Pott¶s 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. POTT¶S DISEASE

POTT¶s DISEASE Risk Factors Tuberculosis/Endemic TB Poor socioeconomic conditions Diabetes Steroid Use Chronic Disease Immunosuppression IV drug Abuse Rheumatoid Arthritis POTT¶S DISEASE

POTT¶s 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

POTT¶S DISEASE

POTT¶S DISEASE

POTT¶S DISEASE

POTT¶S DISEASE

PHYSICAL ASSESSMENT Body Parts

Actual Findings

Height

Change of shape of back

kyphosis

Weight

Weight loss

Anorexia

Vital signs Temperature

Analysis

Normal Findings

Actual Findings

Analysis

36.5-37.5 degrees Celsius

Increase in temperature

Febrile

General Survey Body built Overall hygiene and grooming

Normal Findings mesomorph

Actual Findings Ectomorph

clean and neat

Self bathing hygiene deficit

POTT¶S DISEASE

Analysis Deviation from Normal Deviation from Normal

PHYSICAL ASSESSMENT Assessment of the Skin Normal Findings

Skin color

Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive

Actual Findings

Analysis

redness

erythema

-Fundamentals of Nursing 8 th edition Kozier and Erb¶s page 579

No edema Presence of edema


with edema

Uniform: within normal range Skin temperature


edema

Febrile Warm skin temperature

POTT¶S DISEASE

Deviation from Normal

PHYSICAL ASSESSMENT Assessment of the Nose

Tenderness in one or more sinuses

Palpate the maxiliary Not tender and frontal sinuses for tenderness

Deviation from normal

Assessment of the Thorax Posterior Thorax

Inspect the spinal alignment for deformities.

Palpate the 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 Erb¶s page 614 No tenderness, no masses

Actual Findings

Analysis

Exaggerated spinal curvatures

Kyphosis due to gibbous formation

Pain with palpation over the spine


POTT¶S DISEASE

PHYSICAL ASSESSMENT Assessment of the Musculoskeletal System Normal Findings

Actual Findings

Analysis

Muscle atrophy


Weakness


Equal in size on both body parts. Inspect the muscle for size.

- Fundamentals of Nursing 8th edition Kozier and Erb¶s page 640 Equal strength on each body sides

Test muscle strength.

( sternocleidomastoid, trapezius, deltoid, biceps, triceps, wrist and finger, grip strength, hip and hamstring. - Fundamentals of Nursing 8th edition Kozier and Erb¶s page 640

Assess range of motion

Varries in accordance to a person genetic make-up Fundamentals of Decrease range of motion. Pain in Nursing 8th edition Kozier and Erb¶s movement page 641


Bones Inspect the skeleton for structure

No deformities

Palpate the bones to locate any No te ndern ess or swel ling areas of edema or tenderness

Bones misaligned


Prese nce of tenderness or swel ling

Devi ation f rom normal

Swelling joints


Joints Inspect the swelling. Palpate each joint for tenderness, smoothness of movement, swelling, crepitation, and presence of nodules.

Assess joint range of motion

No swelling No tenderness, crepitation or nodules

Joints move smoothly Varies to some degree in accordance with person¶s genetic Decreased range of motion make-up and degree of physical POTT¶S DISEASE activity


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

POTT¶S 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. POTT¶S 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. POTT¶S DISEASE

LABORATORY RESULTS Aspirate from joint space & abscess  Transparency: turbid.  Colour: creamy.  Consistency: cheesy.  Fibrin clot: large.  Mucin clot: poor.  WBC: 25000/cc.mm.

POTT¶S 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.

POTT¶S 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. POTT¶S 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. POTT¶S DISEASE

LABORATORY RESULTS Complications  Vertebral collapse resulting in kyphosis.  Spinal cord compression.  Sinus formation.  Paraplegia (so called Pott's paraplegia).

POTT¶S DISEASE

PATHOPHYSIOLOGY

PRECIPITATING FACTORS Diet Environment

PREDISPOSING FACTORS Gender Age

crowded and poor living condition Human immunodeficiency Epidemic

Extreme vascularity Immune system

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 treated with:

Antimicrobial therapy:

If left untreated will result to:

Reduced progression of bone deformities

Bone deformities Neurologic deficit

Surgery:

POTT¶S DISEASE

Correct bone

ECOLOGIC MODEL Ecologic Model Hypothesis:

Pott¶s 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 i s also the major agent for PTB. In the case of Pott¶s 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

POTT¶S DISEASE

ECOLOGIC MODEL Environment: -Crowded

and poor living

condition -Epidemic -Low

Host:

economic level

-Tropical

->10

zone

countries

and <60 yrs old

-Male -HIV

positive patients

-History

of TB

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 Pott¶s disease because of the environmental factors that attributed against the host. The factors developing the disease can be prev ented and take as a process to eliminate the disease.

POTT¶S DISEASE

Prioritized List of Nursing Problems Nursing Problems Identified Acute pain related to inflammatory process

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

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 Maslow¶s 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 Maslow¶s 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 Maslow¶s 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 Maslow¶s Hierarchy of Needs under Selfesteem. Patients want a positive self regard to increase their confidence to feel one¶s 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.

POTT¶S DISEASE

NURSING CARE PLAN CUES Subjective: Reports of pain/disco mfort. ´Sumasakit na ang likod ko.µ 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

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

ANALYSIS

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)

GOALS AND OBJECTIVE

NURSING INTERVENTION

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.

Investigate reports of pain, noting location and intensity (scale of 0-10). Note precipitating factors and nonverbal cues.

OBJECTIVE:

Place/monitor use of pillows, sandbags, trochanter rolls, splints, braces.

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

POTT¶S DISEASE

Monitor Vital Signs

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, provid es stimulation, and enhances self-esteem and feelings of general well-being. (Nursing Care Plans page 725) The nurses assess the patient·s 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 8 th Edition Volume II page 1197 by Erbs)

EVALUATION

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

MANAGEMENT OF POTT¶S 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 POTT¶S DISEASE

MANAGEMENT OF POTT¶S DISEASE

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

POTT¶S DISEASE

MANAGEMENT OF POTT¶S 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 POTT¶S DISEASE

POTT’s DISEASE

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