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POTTS DISEASE

DEFINITION
PREVALENCE

DEMOGRAPHIC
PROFILE

FAMILY MEDICAL HISTORY PAST MEDICAL HISTORY HISTORY OF PRESENT ILLNESS

GORDONS PHYSICAL

Assessment

PHYSICAL
ASSESSMENT

DIAGNOSTIC TESTS

ANATOMY & PHYSIOLOGY

PATHOPHYSIOLOGY

DIAGRAM

NURSING CARE

PLAN

Problem #1: Pain Subjective Cue: Madalas talagang sumasakit ang likod ko as verbalized by the patient. Pain scale of 6 out of 10 Objective Cues: - Facial mask of pain - Narrowed focus - Losss of appetitee - T: 36.9 C - Pr: 85 bmp - RR: 22 bmp - BP: 120/80 mm/Hg Nursing Diagnosis: Acute pain r/t to bone trauma secondary to Potts Disease. Rationale: Potts disease generally begins with back pain that may seem to be due to simple muscle strain (Doenges, Moorhouse, and Murr)

NOC: Pain Control Short-Term Goal: After 30 min of NI the patient will be able to incorporate relaxation skills and activities into pain control such as deep breathing exercises, relaxation techniques and diversional activities. NIC: Pain Management Nursing Interventions: 1) Investigated report of pain, noting characteristics, location, and intensity (0 -10 scale) - Helpful in determining pain management needs and effectiveness of the program (Doenges, Moorhouse, and Murr). 2) Provide firm mattress and small pillow - Provides support and reduces spinal flexion, decreasing spasm. (Doenges, Moorhouse, and Murr) 3) Suggest patient assume position of proper comfort while in bed. - In acute phase, total bed rest may be necessary to limit pain (doenges, Moorhouse, and Murr)

4) Encouraged frequent changes of position. - Prevents general fatigue and joint stiffness (Doenges, Moorhouse, and Murr) 5) Applied warm or moist compress on the affected area several times a day. - Heat promotes muscle relaxation and mobility, decreases pain and relieves morning stiffness (Doenges, Moorhouse, and Murr) 6) Provided gentle massage. - Promotes relaxation, provides sense of control and may enhance coping activities (Doenges, Moorhouse, and Murr) 7) Encouraged use of stress management techniques. - Promotes relaxation, provides sense of control and may enhance coping activities (Doenges, Moorhouse, and Murr) 8) Administered non-steroidal anti-inflammatory drugs as prescribed. - These drugs control mild to moderate pain and inflammation by inhibition of prostaglandin synthesis (Doenges, Moorhouse, and Murr)

EVALUATION
Short-Term Goal Met: After 30 min of NI the patient was able to incorporate relaxation skills and activities into pain control such as deep breathing exercises, relaxation techniques and diversional activities.

Problem # 2: Risk for impaired skin integrity Subjective Cue: Inabot na akong ng ilang lingo dito na buong araw lang akong nakahiga. Objective Cues: - Complete bed rest - Loss of motor function of lower extremities (paraplegic) - Presence of edema - Kyphosis Nursing Diagnosis: Risk for impaired skin integrity R/T immobility secondary to spinal cord injury. Rationale: Immobility which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity (Doenges, Moorhouse, and Murr, 2008: 278)

NOC: Risk Control Short-Term Goal: After 15 min of NI the patient will be able to participate to level of ability to prevent skin breakdown and to understand the importance of turning every 2 hours. NIC: Skin Surveillance Nursing Interventions: 1) Inspected all skin areas, noting capillary blanching/refill, redness, and swelling. Pay particular attention to back/side of head and folds where skin continuously touches. - Skin is especially prone to breakdown because of changes in peripheral circulation, inability to sense pressure, immobility, altered temperature regulation. (Doenges, Moorhouse, and Murr) 2) Encouraged the patient to increase fluid intake - Hydrated skin is less prone to breakdown (Doenges, Moorhouse, and Murr)

3) Turned and positioned the patient every 2 hours - To optimize circulation to all tissues and relieve pressure (Doenges, Moorhouse, and Murr) 4) Emphasized the importance of adequate fluid intake. - To maintain skin turgor (Doenges, Moorhouse, and Murr) 5) Elevated lower extremities periodically, if tolerated. - Enhances venous return. Reduces edema formation. (Doenges, Moorhouse, and Murr)

EVALUATION
Short-Term Goal Met: After 15 min of NI the patient was able to participate to level of ability to prevent skin breakdown and understood the importance of turning every 2 hours as evidenced by patients verbalization pinag aalarm ko yung asawa ko sa cellphone para hindi nya makalimutan na alalayan ako sa paglilipat ng posisyon ko

Problem # 3: Immobility Subjective Cue: Heto ako ngaun hindi ko na maigalaw ang aking mga binti as verbalized by the patient. Objective Cues: - Inability to purposefully move; Potts paraplegia -Limited range of motion - Decreased muscle strength Nursing Diagnosis: Impaired physical mobility R/T musculoskeletal impairment secondary to Potts paraplegia. Rationale: Commonly rehabilitation and disease involves some degree of mobility. Restricted movement affects performance of ADLs. (Doenges, Moorhouse, and Murr)

NOC: Mobility Level Short-Term Goal: After 1 hour of NI the patient will maintain or increase strength and function of unaffected and/or compensatory body part. NIC: Bed Rest Care Nursing Interventions: 1) Continually assessed motor function. - Continuous motor function helps determine appropriate interventions for a specific motor impairment (Doenges, Moorhouse, and Murr) 2) Performed/assisted with passive and active ROM exercises - Strength abdominal muscles and flexors of spine; promotes good body mechanics. (Doenges, Moorhouse, and Murr) 3) Encouraged use of relaxation techniques - Relaxation techniques reduce muscle tension and fatigue and may help limit pain of muscle spasm and spasticity (Doenges, Moorhouse, and Murr)

4) Inspected skin daily. Observe for pressure areas. - Altered circulation loss of sensation and paralysis potentiate pressure sore formation (Doenges, Moorhouse, and Murr) 5) Health teaching about the importance of preventing complications per system such as for: Pneumonia-bronchial tapping, deep breathing and coughing exercises. -Bedsores- Good perineal care, proper skin care, turning every 2 hours. - Urinary and Kidney Problem- Good perineal care, increase fluid intake -Constipation- Provide privacy, increase fluid intake -Deformity- Contracted knee, atrophy of muscles, foot drop, and joint contractures. - To prevent complications due to immobility (Doenges, Moorhouse, and Murr)

EVALUATION
Short-Term Goal Partially Met: After 1 hour of NI the patient was able to maintain but not totally increase strength and function of unaffected and/or compensatory body parts.

Problem # 4: Self Care Deficit; Bathing/Hygiene Subjective Cue: Itong misis ko lage nandito yan, sya na din ang nagaaligo saakin ngaun dahil sa kondisyon ko. as verbalized by the patient. Objective Cues: -Bed rest -Frustration -Potts Paraplegic -Inability to perform tasks of self-care Nursing Diagnosis: Self bathing/hygiene deficit R/T musculoskeletal impairment secondary to Potts paraplegia. Rationale: Musculoskeletal damage impairs individuals activity of daily living such as bathing, personal hygiene, walking (Doenges, Moorhouse, and Murr)

NOC: Self Care: Activities of Daily Living (ADLs) Short-Term Goal: After 30 min of NI the patient will be able to perform self-care activities within level of own ability. NIC: Self-Care Assistance Nursing Interventions: 1) Determine existing conditions affecting ability of individual to care for own needs, i.e. spinal cord injury. - To identify causative/contributing factors (Doenges, Moorhouse, and Murr) 2) Determine individual strengths of client - To assess degree of disability (Doenges, Moorhouse, and Murr) 3) Note whether deficient is temporary or permanent, should decrease or increase in time. - To assess degree of disability (Doenges, Moorhouse, and Murr)

4) Promote client/SO participation in problem identification and decision making. - To enhance commitment to plan, optimizing outcomes (Doenges, Moorhouse, and Murr) 5) Develop plan of care appropriate to individual situation, scheduling activities to conform to clients normal schedule. - To assist in correcting/dealing with situation (Doenges, Moorhouse, and Murr) 6) Allow sufficient time for client to accomplish tasks to fullest extent of ability - To enhance capabilities (Doenges, Moorhouse, and Murr) 7) Assist with necessary adaptation to accomplish ADLs. Begin with familiar, easily accomplished tasks. - To encourage client and build on successess (Doenges, Moorhouse, and Murr) 8) Review/modify program periodically to accommodate changes in abilities - Assist patient to adhere to plan of care to fullest extent (Doenges, Moorhouse, and Murr)

EVALUATION
Short-Term Goal Met: After 30 min of NI the patient was able to perform self-care activities within level of own ability.

Problem # 5: Low Self-Esteem Subjective Cue: Nahihiya ako sa mga sasabihin ng mga katrabaho ko at mga kapit bahay namen, pakiramdam ko sinumpa ata ako. As verbalized by the patient Objective Cues: - Fear of rejection or reaction by others - Negative feelings about body/abilities -Feelings of helplessness, hopelessness, or powerless - Lack of eye contact Nursing Diagnosis: Self-Esteem/Disturbed body image R/T to change in body image and function. Rationale: Development of a negative perception of self-worth in response to a current situation (Nursing Diagnosis book by Ackley, Ladwig)

NOC: Self-Esteem Short-Term Goal: After 1 hour of NI the patient will verbalize understanding of changes and acceptance of self in the present situation. NIC: Self-Esteem Enhancement Nursing Interventions: 1) Discussed situation/encouraged verbalization of fears and concerns. Explain relationship between nature of disease and symptoms. - Patient is very sensitive to body changes and may also experience feelings of guilt. (Doenges, Moorhouse, and Murr) 2) Listened to patients comments and responses to situation. - Provides clues to view of self, role changes, and needs and is useful for providing information at patients level of acceptance. (Doenges, Moorhouse, and Murr)

3) Supported and encouraged patient; provided care with a positive, friendly attitude. - Caregivers sometimes allow judgmental feelings to affect the care of patient and need to make every effort to help patient feel valued as a person. (Doenges, Moorhouse, and Murr) 4) Encouraged family/SO to verbalize feelings, visit freely/participate in care. - Family members may feel guilty about patients condition and may be fearful of impending death. They need nonjudgmental emotional support and free access to patient. Participation in care helps them feel useful and promotes trust between staff, patient, and SO. (Doenges, Moorhouse, and Murr) 5) Be aware of own feelings/reaction to patients sexual anxiety. - Behaviour may be disruptive, creating conflict between patient/staff, further reinforcing negative feelings and possibly eliminating patients desire to work thorugh situation/participate in rehabilitation. (Doenges, Moorhouse, and Murr)

EVALUATION
Short-Term Goal Met: After 1 hour of NI the patient will verbalize understanding of changes and acceptance of self in the present situation. May awa ang diyos at alam kong pansamantala lang ito. As verbalized by the patient