Nanda - Nursing Care Plan

Showing posts with label Pott Disease. Show all posts
Showing posts with label Pott Disease. Show all posts

Tuberculous Spondylitis - 11 Functional Health Patterns


Assessment is an early stage and the foundation of the nursing process. The assessment is done carefully to know the client's problems, in order to give direction to nursing actions. The success of the nursing process is highly dependent on the accuracy and precision in the assessment phase. Assessment phase consists of three activities, namely: data collection, data grouping, formulation of nursing diagnoses. (Lismidar 1990: 1)

The data collection

In technical data collection is done through anamnesis either on the client, family and those closest to the client. Physical examination done by way of, inspection, palpation, percussion and auscultation.

1. Identity of clients includes: name, age, sex, occupation, marital status, religion, ethnicity, education, address, date / time entered hospital and medical diagnostics.

2. History of present illness

The main complaint the client tuberculous spondylitis / pott disease are pain in the lower back, thus encouraging the client to the hospital for treatment. At the beginning of radicular pain can be found surrounding the chest or abdomen. Pain is felt up at night and weight gain especially during the movement of the spine. In addition to the main complaint the client can complain, decreased appetite, body feels weak, sweating and weight loss.

3. History of previous illness

On the occurrence of tuberculous spondylitis is usually preceded by the client in the history of ever suffered from pulmonary tuberculosis.

4. Family health history

On the client with tuberculous spondylitis disease one of the causes is the client or former contact with other patients who suffer from tuberculosis or the family environment is suffering from infectious diseases.

5. Psychosocial history

Clients will feel anxious about the disease in the suffering, so it looks sad, with a lack of knowledge about the disease, treatment and care against the patient will feel fear and anxiety grew so emotionally unstable and would not affect the socialization of the patient.


Tuberculous Spondylitis - 11 Functional Health Patterns

1. Health Perception/Health Management

The existence of medical treatment and hospital care will affect the client's perception about the habits of taking care of themselves, that is because not all clients understand the true course of their illness. So that created a false perception of health care. And also the possibility of the presence of a history of the state of housing, nutrition and economic levels that affect client health state clients.

2. Nutritional Metabolic Pattern

As a result of the disease process client felt his body became weak and amnesia. While the need for increasing the body's metabolism, so that the client will experience a disruption in nutritional status.

3. Elimination patterns

Clients will experience a change in the way the original elimination could to the bathroom, because of weakness and pain in the back and carrying on with the stylist immobilization treatment, so if you like bowel and bladder should be in bed with a tool. With the change in the client is not accustomed to so it will interfere with the process of elimination.

4. Activity Patterns

Due to physical weakness and pain in the back and managed care immobilization would cause the client to limit physical activity and diminished ability to perform physical activity.

5. Sleep and Rest Patterns

There is pain in the back and the changes in the environment or the effects of hospitalization will cause problems in fulfilling the need for sleep and rest.

6. Role Relationship Pattern

Since the sick and hospitalized clients to change roles or unable to take on the role as where it should be, whether it is the role of the family or community. This disruption affects interpersonal relationships.

7. Self-Perception-Self-Concept Pattern

Clients with tuberculosis spondylitis often feel ashamed of her body shape and sometimes isolating themselves.

8. Sensory and Cognitive Patterns

Sensory function was not impaired clients unless there is complications of paraplegia.

9. Sexual Reproduction Patterns

Sexual needs of clients in terms of the act of intercourse will be disrupted for a while, because in the hospital. But in terms of the outpouring of love and attention from her partner by way of day-to-day care is not interrupted or can be implemented.

10. Stress Patterns

In response to stress for clients who do not understand the disease, will experience stress. To overcome the anxiety that creates a feeling of stress, clients will be wondering about the disease to reduce stress.

11. Value / Belief Pattern

On the client who in their daily lives are always obedient to practice, then during his illness he would run well worship according to his ability. In this case worship for those on the run as well as the handling of stress by believing in god.

Chronic Pain and Body Image Disturbance - NCP Tuberculous Spondylitis

Chronic Pain and Body Image Disturbance - NCP Tuberculous Spondylitis


Pott disease, also known as tuberculous spondylitis is a rare infectious disease of the spine which is typically caused by an extraspinal infection. Pott's disease is often experienced as a local phenomenon that begins in the thoracic section of the spinal column. Pott’s Disease is a combination of osteomyelitis and arthritis which involves multiple vertebrae.

Back pain is the earliest and most common symptom. Patients with Pott’s disease usually experience back pain for weeks before seeking treatment and the pain caused by spinal TB can present as spinal or radicular. Although both the thoracic and lumbar spinal segments are nearly equally affected, the thoracic spine is frequently reported as the most common site of involvement. Together, thoracic and lumbar involvement comprise of 80-90% of spinal TB sites.

Neurologic abnormalities occur in 50% of cases and can include spinal cord compression with the following: paraplegia, paresis, impaired sensation, nerve root pain, cauda equina syndrome.

Fortunately, there are several ways to determine if tuberculosis spondylitis is the root cause of the symptoms. Blood tests can help determine if there is an elevation in the rate of erythrocyte sedimentation. A bone scan will determine if there is some indication of problems, which may lead to the scheduling of a bone biopsy. Conducting a CT scan as well as a radiograph of the spine is also likely to provide valuable information about the presence and current status of the disease.

Nursing Diagnosis and Interventions for Tuberculous Spondylitis / Pott disease

1. Chronic Pain: joints and muscles related to the inflammation of the joints.

Goal:
  • Comfortable feeling fulfilled
  • Pain is reduced / lost

Expected outcomes:
  • Clients reported a decrease in pain.
  • Demonstrate behavior that is more relaxed.
  • Demonstrate skills in the study of pain reduction with increasing success.

Interventions:
  • Assess the location, intensity and type of pain; observations on the progress of pain to a new area.
  • Provide appropriate analgesic therapy clinicians and examine its effectiveness against pain.
  • Use the back brace or corset when it is planned that way.
  • Give encouragement to change positions frequently to light and enhance a sense of comfort.
  • Teach and assist in alternative pain management techniques.

Rational :
  • Pain is a subject of experience that can only be defined by the client themselves.
  • Analgesics are drugs to reduce pain and how it reacts to pain clients.
  • Corset to maintain the spine.
  • With the change-change positions so that the muscles do not keep that muscle spasm and tension becomes limp and reduced pain.
  • Alternative methods such as relaxation times faster relief of pain or to distract the client so that the pain is reduced.
2. Body Image Disturbance related to disorders of body structures.

Goal: Clients can express their feelings and be able to use adaptive coping.

Expected outcomes : Clients can express feelings / care and use positive coping skills to address the image.

Interventions:
  • Give the client a chance to express feelings. Nurses must listen attentively.
  • With clients looking for alternative positive coping.
  • Develop communication and building relationships between families and friends as well as clients provide recreational activities and games in order to cope with changes in body image.

Rational:
  • Improving self-esteem and foster client relationships of mutual trust and the expression of feelings of self-acceptance can help.
  • Support nurses on the client can increase client confidence.
  • Providing encouragement for clients to view themselves in a positive way and not feel low self esteem.

Tuberculous Spondylitis - 11 Functional Health Patterns