NCP ON POTTS SPINE.docx

CDFDSF

1. BDM COLLEGE OF NURSING

NURSING CARE PLAN

ON

POTT S SPINE



SUBMITTED TO: SUBMITTED BY:
MRS. KAVITA MAM MS. AANCHAL SINGHAL
LECTURER M.SC NURSING 1
st
YEAR
(BDMCON)



SUBMITTED ON: 22/08/2019

2. INTRODUCTION ABOUT THE CLIENT:
Mrs. Kulsum is a resident of Uttar Pradesh. She is suffering fromPott’s Spine L3, L4 .She was
presented with complaint of lower backache since 2 months, history of fever, weight loss and
decrease appetite was also present but no motor and sensory loss was present.
REASON FOR SELECTING THIS TOPIC FOR CARE NOTE:
I found his case interesting and out of my curiosity .I selected Pott’s Spine L3, L4 as my topic
for Nursing care plan. As a part of nursing process, I wanted to learn the comprehensive care
which is required by such patients so that, this learning could help me develop and refine my
nursing care providing abilities for future purpose as well.

IDENTIFICATION DATA
1. CLIENT PROFILE
1. Name : Mrs. Kulsum
2. Age: 62years
3. Sex: Female
4. Marital status: Married
5. Ethnic orientation: Indian
6. Date of admission – 22/01/2019
7. Religious orientation: Muslim
8. Educational level: Illiterate
9. Language: Hindi
10. Occupational history: Housewife
11. Interest, hobbies. Recreational activities:Cooking
12. Diagnosis : Pott’s Spine L3 , L4

2. CHIEF COMPLAINTS AT THE TIME OF ADMISSION
Patient came with complaints of lower backache since 2 months, history of fever, weight
loss, spinal tenderness and decrease appetite was also present but no motor and sensory loss
was present .
3. HISTORY OF PRESENT ILLNESS

3. Patient was apparently well 2 months back whenshe developedlower backache since 2 months,
history of fever, weight loss and decrease appetite was also present but no motor and sensory
loss was present. Patient was treated symptomatically and diagnosed to Pott’s Spine, L3 , L4 for
which patient had been advised for bed rest and put on ATT drugs and on high protein diet.

4. PAST MEDICAL HISTORY
There is ano significant past medical history of abdominal TB ,DM and hypertension.

5. PAST SURGICAL HISTORY
Not significant.
6. FAMILY MEDICAL HISTORY
No history of DM/HTN/ hypothyroidism in family. No one from family member have any
communicable diseases like TB and non communicable diseases Like DM/HTN .
FAMILY TREE






7. PERSONAL AND SOCIAL HISTORY
Patient is non alcoholic and non smoker.






PHYSICAL EXAMINATION

4. GENERAL APPEARANCE
 Body built - Mesomorphic
 Nourishment - Moderately nourished
 Level of consciousness - Conscious
 Hygiene - Not maintained
 Activity - Restricted due to disease condition but
Active and passive range of motion exercises
Performed on her
 Posture & gait - Cannot determined

GENERAL PHYSICAL EXAMINATION
Level of consciousness :-Patient is conscious and oriented
Psychomotor patterns:- Intact
G.K, Memory and concentration :- Intact
 VITAL SIGNS (28-01-2019)
 Temperature - 98.4 degree Fahrenheit
 Pulse - 82/ min
 Respiration - 20/min
 Blood pressure –110/70mmHg
 VITAL SIGNS (29-01-2019)
 Temperature -97.5 degree Fahrenheit
 Pulse - 98/min
 Respiration - 20/min
 Blood pressure - 120/76 mm Hg

 ANTHROPOMETRIC MEASUREMENT
 Height - 5’6”
 Weight - 64kg
 BMI - 22.9 (Normal)
 ABG VALUES (10-01-2019)
Parameters Patient value Normal values Interpretation
PH 7.37 7.35-7.45 Normal
PaCo2 36.9 35-45 mm Hg Normal
HCO3 22 22-28 meq/l Normal
PaO2 89.7 75-100 mm Hg Normal

5. Interpretation :- Normal ABG
HEAD TO TOE EXAMINATION
SKIN
 Colour - Skin is wheatish in color
 Texture - Skin is dry
 Temperature98.6 degree Fahrenheit
 Lesions No macules, papules, vesicles present
 Clubbing :- Not present
 Edema : No edema present
HEAD
 Colour of hair - Black
 Shape of skull - Normal
 Scalp - Scalp is clean, no swelling or dandruff is present
 Pediculosis - No pediculosis
 Texture - Texture is soft.
 Hair distribution – Less
FACE
 Shape - Symmetrical
 Oedema - Absent
 Hydration - Face is hydrated
 Any abnormality - No any abnormality
EYE
 Vision - Normal
 Eye brows - Eye brows are normal
 Eye lashes - There is no evidence of any infection
 Eye lid - Normal
 Eye ball - Eye ball are normal
 Conjunctiva - Pale in colour
 Sclera- Whitish
 Cornea & iris - Normal
 Pupil - Pupil is reactive to light B/L equal 2mm and normal
 Lens - Lens are normal
EAR
 Hearing - Patient is able to hear properly

6.  External ear -Clear ear
 Tympanic membrane - There is no perforation
 Discharge - No discharge from ear
NOSE and SINUS
 Nostrils - Nostrils are normal
 Nasal septal deviation - There is no septal deviation
 Discharge - No discharge is present from nose
 Any bleeding from nose – No bleeding is present from nose
 Sinus - Sinuses were normal ( Frontal, Ethmoid, Sphenoid, and
Maxillary)
MOUTH
 Lips - Symmetrical, dehydrated, Slight black in colour
 Odour of mouth - Foul smell present
 Teeth - There is no dental caries & yellowish discoloration of teeth
 Mucous membrane & gums - There is no swelling present on gums
 Tongue - Pale, dry
 Tonsils - No inflammation or ulceration of tonsils
NECK
 Nuchal rigidity - Not present
 Lymph nodes - No lymphadenopathy
 Thyroid gland - Not palpable
 Trachea - Midline
 Carotid pulse - Present
CHEST
 Symmetry - Symmetrical
 Colour - Normal skin colour
 Lesions - No lesions
 Chest - Symmetrical in shape & no gynaecomestia present
AXILLA
 Redness - not present
 Lumps - absent
 Rash - absent
 Lymph nodes - not enlarged

7. SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
 Inspection- symmetrical
 Barrel chest - absent
 Kyphoscoliosis- absent
 Breathing pattern- 20breaths per minute on room air
 Palpation- no tenderness
 Tactile fremitus- absent
 Percussion- no free fluid present
 Air entry – B/L equal
 Auscultation :- no abnormal lung sounds present
CARDIOVASCULAR SYSTEM
 Inspection and palpation-Normal, no abnormality detected
 Auscultation-S1 and S2 normal, no murmur,
 Heart rate- 88 beats/min
 Pain – no chest pain
ABDOMEN
 Inspection -Not distended, tensed ,and Cullen and grey turner signs were absent
 Auscultation -Hypoactive bowel sounds
 Percussion - Dull, free fluid present
 Palpation -Tenderness not present
GENITALIA & RECTUM
 STDs - Absent
 Any enlargement - Absent
 Haemorrhoids - Absent
 Pelvic masses - Absent
 Rectal polyps - Absent
Foleys catheter present 16 French (22-01-2019)
EXTRIMITIES
 Movements - Pain felt duringFlexion and extension of the extremities
 Tremors - Absent
 Edema - Absent
 Reflexes - Normal

8.  Varicose vein - Absent
IV cannula present on Left hand (26-01-2019)
SPINE
 Spina bifida - Absent
 Scoliosis/kyphosis/lordosis - Absent
 Curvature - normal
 Sacral region - no oedema present
 Spinal movements :- Restricted and painful
Pain in back due to disease condition and tenderness present
NEUROLOGICAL TEST
 Coordination test- Cannot determined as patient is on complete bed rest
 Reflexes - Normal (patellar reflex, Babinski reflex)
 Test for sensation - Normal
 GCS - 15 (E4V5M6)
No sensory deficit , no cerebellar sign and no sign of meningeal irritation present.
DIET :- High protein diet
LABORATORY INVESTIGATION:
S.No NAME OF THE
INVESTIGATION
CLIENT
VALUES
28/01/19
29/01/19 NORMAL
VALUES(WITH
UNIT)
REMARKS
1 Hb 9.6 9.8 13-17gm/dl Low
2 Lymphocyte 24 26 20-45% Low
3 Monocyte 07 06 2-10% Normal
4 Eosinophil 1 1.2 1-6% Normal
5 Platelet 1.57 1.68 150000-450000
per micro litre of
blood
Normal
6 TLC 37,00 3500 4500-11000
WBC
per microlitre
Low
7 Blood urea 51 48 15-40mg/dl High
8 Sr. Creatinine 1.2 1.5 0.2-1.0mg/dl High

9. 9 Sr.Sodium 134 136 136-145mmol/L Normal
10 Sr.Potassium 4.3 3.9 3.5-5mmol/L Normal
11. SGOT 118 166 5 to 40 units per
litre of serum
High
12 SGPT 328 566 7 to 56 units per
litre of serum
High
Tridot (20-01-2019)= Negative
Interpretation :-Low Hb indicates Anemia,LFT is deranged,High TLC indicates infection
REPORTS :-
USG abdomen:-25-01-2019
Liver 14cm, No SOL/IHBRD, partially Gall bladder distended, spleen –normal and pancreas -
normal
MEDICATION :-
MEDICATION ACTION
1. Inj Streptomycin 0.5 mg IM OD Antibiotic
2. Tab Levofloxacin 500 mg OD Antibiotic
3. Tab Ethambutol 800 mg OD Anti tubercular drug
4. Tab Rantac 150 mg OD Antacid
5. Tab Diclofenac 50 mg SOS Analgesic
6. Tab Multivitamin 1 OD Multivitamin





NURSING ASSESSMENT

10.  Assessment of the patient done on regular bases for continuous two days .
 Assess the patient respiratory status, need for advance support or oxygenation for any
distress.
 Assess the vitals and other parameter like BP, intake and output and SPO2
 Assess level of activity tolerance and degree of fatigue, lethargy, and malaise when
performing routine ADLs
 The goals for the patient may include increased participation in activities, improvement
of nutritional status, improvement of skin integrity, decreased potential for injury,
improvement of overall health status, and absence of complications.
 Weight and fluid intake and output are measured and recorded daily.
 Patient is having stress and anxiety due to lack of financial support and loss of job.

NURSING DIAGNOSIS

1. Acute pain related to inflammatory process as evidenced by facial expression
2. Impaired physical mobility related to therapeutic restriction to movement as evidenced
by inability to move purposefully within physical environment, including bed mobility
3. Altered nutritional status less than the body requirement related to fatigue as evidenced
by weight loss
4. Impaired skin integrity related to decreased tissue perfusion as evidenced by dryness on
hands and feet
5. Self care deficit related to pain in back as evidenced by asking for help
6. Ineffective coping pattern related to fear of changes in body image and life expectancy
as evidenced by destructive behaviour towards self or others
7. Risk for infection related to presence of IV lines, Foleys catheter
8. Risk for aspiration related to bed rest.
NURSING CARE PLAN

NURSING
ASSESSMENT
NURSING
DIAGNOSIS
NURSING
INTERVENTION
NURSING
IMPLEMENTATION
EVALUATION
SUBJECTIVE
DATA- Pt. says
that he has pain
at the site of
surgery.

OBJECTIVE
Acute pain
related to
inflammatory
process as
evidenced by
facial
expression
To assess the
level of pain.


To provide the
comfortable
position and rest
Pain level was
assessed by pain scale
and pain score was
6\10.
Comfortable position
was given.

Pain level is
reduced.

11. DATA- I
observe the
facial
expression of
the patient.
to patient.

To provide the
diversional
therapy.
To provide the
medicine as per
physician
prescription.


Diversional therapy
was given.

Medication was given
i.e.brufen
SUBJECTIVE
DATA –
Patient says
that he is not
able to do his
activity of life
as well as he is
not able to
move.


OBJECTIVE
DATA- I
observe the
general
condition of the
patient.
Impaired
physical
mobility
related to
therapeutic
restriction to
movement as
evidenced by
inability to
move
purposefully
within
physical
environment,
including bed
mobility

To assess the
general condition
of the patient as
well as impaired
mobility pattern.

To provide the
psychological
support to the
patient

To provide the
help in doing
ADL.

To consult with
the
physiotherapist.


General condition
was assessed.




Psychological support
was given.



Help was provided
for maintaining ADL.


Consult was taken
from physiotherapist.
Activity pattern
is improved a
little bit.
SUBJECTIVE
DATA- Patient
says that he
feels warmth


OBJECTIVE
DATA
I observe the
vital sign of the
patient
Risk for
infection
related to
presence of
IV lines,
Foleys
catheter

To assess thelevel
of infection.

To maintain the
hygiene of the
patient.

To maintain the
environmental
hygiene.

To maintain the
aseptic condition.

To provide
medicine as per
doctor
Level of the infection
was assessed.

Hygiene of patient
was maintained.


Environmental
hygiene was
maintained.

Asespsis was
maintained.

Medication was given
as per doctors
order.i.e antibiotic
Risk of
infection is
reduced.

12. priscription


HEALTH EDUCATION
Home care
 Patient require complete bed rest
 Patient should take high protein diet
 Free range of motion exercises to be done
 Patient should take anti tubercular drugs on time
 Awareness to be given to people about relationship of TB and malnutrition
 Tell the patient that physical therapies for pain relieving modalities , postural education
for strength and flexibility should be followed.
 If any side effects from medications occur such as itching, change in colour of skin,
tiredness, visual changes or excessive fatigue , then call the doctor immediately
 Patient can use braces for back support.
 Multivitamins and high protein diet should be taken properly
 Tell the patient to maintain the hygiene to prevent from infection.
 Prevention of bed sore should be taken care of.
 Treat other co morbid conditions
 Gradual mobilization is encouraged in absence of neural deficits with spinal braces and
back extension exercises at 3-9 weeks.
 Patient should come for the follow up

13. BDM COLLEGE OF NURSING

NURSING CARE PLAN

ON

POTT S SPINE



SUBMITTED TO: SUBMITTED BY:
MRS. KAVITA MAM MS. JYOTI
LECTURER M.SC NURSING 1
st
YEAR
(BDMCON)



SUBMITTED ON: 22/08/2019