The patient reported back pain. A physical assessment revealed facial pain expressions, fatigue, and normal vital signs. The diagnosis is Pott's disease, a form of spinal tuberculosis causing back pain and stiffness. The nursing care plan includes applying warm compresses, gentle massage, encouraging position changes and stress management to reduce pain and fatigue. Medications of antibiotics and anti-inflammatories will also be administered.

1. NURSING CARE PLAN
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
“Sumasakit ang
likod ko” as
verbalized by
patient.
Objective:
• Facial mask of
pain.
• Self narrowed
focus.
• Fatigue.
• V/S taken as
follows:
T: 37.3
P: 80
R: 18
Bp: 120/90
• Acute pain
related to
inflammatory
process.
• Pott’s disease
is a form of
extrapulmonary
tuberculosis
that impacts
the spine. It
has an effect
that is
sometimes
described as
being a sort of
arthritis for the
vertebrae that
make up the
spinal column.
More properly
known as
tuberculosis
spondylitis. It is
often
experienced as
a local
phenomenon
that begins in
the thoracic
section of the
spinal column.
Early signs of
the presence of
Pott’s disease
generally begin
with back pain
that may seem
to be due to
• After 8 hours
of nursing
interventions
, the patient
will be able
to
incorporate
relaxation
skills and
diversional
activities into
pain control
program.
Independent:
• Investigate report
of pain, noting
characteristics,
location, intensity
(0-10 scale).
• Provide firm
mattress and
small pillows.
• Suggest patient
assume position
of proper comfort
while in bed or
chair. Promote
bed rest as
indicated.
• Encourage
frequent changes
of position.
• Apply warm or
moist compress
on the affected
area several
times a day.
• Provide gentle
massage.
• Helpful in
determining
pain
management
needs and
effectiveness of
the program.
• Soft or sagging
mattress and
large pillows
inhibits the
proper body
alignment.
• In acute phase,
total bed rest
may be
necessary to
limit pain.
• Prevents
general fatigue
and joint
stiffness.
• Heat promotes
muscle
relaxation and
mobility,
decreases pain
and relieves
morning
stiffness.
• Promotes
relaxation and
reduces muscle
tension.
• After 8
hours of
nursing
intervention
s, the
patient will
be able to
incorporate
relaxation
skills and
diversional
activities
into pain
control
program.

2. simple muscle
strain.
• Encourage use of
stress
management
techniques.
Collaborative:
• Administer non
steroidal anti-
inflammatory
drugs as
prescribed.
• Administer anti-
biotic as
prescribed.
• Promotes
relaxation,
provides sense
of control and
may enhance
coping
activities.
• These drugs
control mild to
moderate pain
and
inflammation by
inhibition of
prostaglandin
synthesis.
• To prevent
further
infection.