POTT’s 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:Ma’am Mary Jeannie Patrimonio

Clinical Instructor

FAR EASTERN UNIVERSITYINSTITUTE OF NURSING

P O T T ‘S D I S E A S E

POTT’s DISEASE

DefinitionPott’s 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

POTT’S DISEASE

POTT’s DISEASE

EtiologyPott’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

EpidemiologyApproximately 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 itaffects mostly children.

POTT’S DISEASE

POTT’s DISEASE

Risk FactorsTuberculosis/Endemic TB

Poor socioeconomic conditions

Diabetes

Steroid Use

Chronic Disease

Immunosuppression

IV drug Abuse

Rheumatoid Arthritis

POTT’S DISEASE

POTT’s DISEASE

Signs and SymptomsLocalized 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

POTT’S DISEASE

Body Parts Actual Findings Analysis

Height Change of shape of back

kyphosis

Weight Weight loss Anorexia

Vital signs Normal Findings Actual Findings Analysis

Temperature 36.5-37.5 degrees Celsius

Increase in temperature Febrile

General SurveyNormal Findings Actual Findings Analysis

Body built mesomorph Ectomorph Deviation from Normal

Overall hygiene and grooming

clean and neat Self bathing hygiene deficit

Deviation from Normal

PHYSICAL ASSESSMENT

POTT’S DISEASE

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 Erb’s

page 579

redness erythema

Presence of edema

No edema

-Fundamentals of Nursing 8th edition Kozier and Erb’s

page 579

with edema edema

Skin temperature

Uniform: within normal range

-Fundamentals of Nursing 8th edition Kozier and Erb’s

page 579

Warm skin temperatureFebrile

Deviation from Normal

PHYSICAL ASSESSMENT

POTT’S DISEASE

Assessment of the Nose

Palpate the maxiliary and frontal sinuses for tenderness

Not tenderTenderness in one or more sinuses

Deviation from normal

Assessment of the Thorax

Posterior Thorax Normal Findings Actual Findings Analysis

Inspect the spinal alignment for deformities.

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

Exaggerated spinal curvatures

Kyphosis due to gibbous formation

Palpate the posterior thorax

No tenderness, no masses

Pain with palpation over the spine

Deviation from normal

PHYSICAL ASSESSMENT

POTT’S DISEASE

Assessment of the Musculoskeletal System

Normal Findings Actual Findings Analysis

Inspect the muscle for size.

Equal in size on both body parts.

- Fundamentals of Nursing 8th edition Kozier and Erb’s page 640

Muscle atrophy Deviation from Normal

Test muscle strength.

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 Erb’s page 640

Weakness Deviation from Normal

Assess range of motion

Varries in accordance to a person genetic make-up Fundamentals of Nursing 8th edition Kozier and Erb’s

page 641

Decrease range of motion. Pain in movement

Deviation from Normal

BonesInspect the skeleton for

structureNo deformities Bones misaligned Deviation from normal

Palpate the bones to locate any areas of edema or tenderness

No tenderness or swelling Presence of tenderness or swelling Deviation from normal

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

Joints move smoothly

Swelling joints Deviation from Normal

Assess joint range of motion

Varies to some degree in accordance with person’s genetic make-up and degree of physical activity

Decreased range of motion Deviation from normal

DIAGNOSTICS

DIAGNOSTIC PROCEDURE

Blood Test- elevated ESRTuberculine TestRadiographs of the spineBone ScanCT of the SpineBone biopsy

MICROBIOLOGYNeedle biopsyAcid-fast strain and culture

POTT’S DISEASE

DIAGNOSTIC PROCEDURE

Imaging Studies

CT scanningCT 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.

MRIMRI 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. CT-guided 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 StudiesRadiography

•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 SCANCT 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.

MRIMRI findings useful to differentiate tuberculous spondylitis from pyogenic spondylitis include thin and smooth enhancement of the abscess wall and well-defined 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

POTT’S DISEASE

PATHOPHYSIOLOGYPREDISPOSING 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:

•Correct bone

ECOLOGIC MODELEcologic ModelHypothesis:

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 is 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

POTT’S DISEASE

Host:

->10 and <60 yrs old

-Male

-HIV positive patients

-History of TB

Environment:

-Crowded and poor living condition

-Epidemic zone

-Low economic level

-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 Pott’s 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.

Prioritized List of Nursing Problems

POTT’S DISEASE

Nursing Problems Identified Justification

Acute pain related to inflammatory

process

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.

Imbalance nutrition related to inadequate

food intake

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.

Impaired physical mobility related to

therapeutic restriction of movement

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.

Self – bathing hygiene deficit related to

musculoskeletal impairment

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.

Disturbed body image related to

trauma/injury to spinal cord

It is the fifth priority and it is included in Maslow’s Hierarchy of Needs under Self-esteem. Patients want a positive self regard to increase their confidence to feel one’s own worth.

Risk for infection related to insufficient knowledge to avoid exposure to pathogens

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.

NURSING CARE PLAN

POTT’S DISEASE

CUESNURSING

DIAGNOSISANALYSIS

GOALS AND OBJECTIVE

NURSINGINTERVENTION

RATIONALE EVALUATION

Subjective:Reports of

pain/discomfort.

“Sumasakit na ang likod ko.”

Objective:-Facial mask of pain. -Narrowed focus. -Distraction

behaviors -Fatigue. V/S taken as follows: T: 37.4

P: 83R: 18Bp: 120/80

Acute painrelated toInflammatoryresponses asmanifested

byverbalization

ofpain over thespine of theclient.

Because ofInflammationand necrosisfrom theinfection,exudates andNecroticmaterial lead toincreased 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: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

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, self-hypnosis, 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.

Helpful in determining pain management needs and effectiveness of program. (Nursing Care Plans page 725)

To obtain Baseline DataRests 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 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 8th Edition Volume II page 1197 by Erbs)

Was the client able to identify the importance of following the prescribed pharmacological 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

DISCHARGE PLAN

POTT’S DISEASE

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 patient’s condition can remain stable as soon as possible.Continue home medications.Home medications:IosoniazidPyrazinamideEthambutolRifampicinStreptomycin

EXERCISE Encourage the client to have an exercise like back extension exercises at least 5-10 min 3-4 times

TREATMENT Instruct the client to take all the medication as prescribed by the physician and participate in continuous treatment.

HEALTH TEACHING Practice good hygiene.Comply with medication.Bed restDrainage of abscessProper nutrition

ORTHOPEDIC 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.

DIETAdvice the client to have proper nutrition; take foods that high in protein to increase resistance of client

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