Saints John and Paul College

Bachelor of Science in Nursing

Calamba City

A CASE STUDY

on

CHRONICE OSTEOMYELITIS

___________________________

Presented to:

Ma. Teresita L. Siongco RN, MAN

Clinical Instructor

In Partial Fulfillment of the Requirements In

Related Learning Experience (RLE)

__________________________

Presented By:

Allyson Joy Macam

August 7, 2019
I. INTRODUCTION

Osteomyelitis is an infection of the bone and surrounding tissues. It occurs

most frequent in the femur, tibia, sacrum, and heels. Infection of the long bones is

generally accompanied by acute localized pain and redness or drainage, often with

a history of a recent trauma or newly acquired prostheses. Fever and malaise may

also be present.

In children, osteomyelitis is usually acute. Acute osteomyelitis comes on

quickly, is easier to treat, and overall turns out better than chronic osteomyelitis. In

children, osteomyelitis usually shows up in arm or leg bones.

Although generally bacterial in origin, osteomyelitis can also be caused by

a virus or fungus. Staphylococcus aureus is the most common infecting

microorganisms, but Escherichia coli (E. coli), Pseudomonas, Salmonella may

also be found.

Following inadequate treatment of acute osteomyelitis, the condition may

become chronic. Chronic osteomyelitis represents an infection that is well

established in bone and has been present for several weeks, months, or years.

Although chronic osteomyelitis resulting from untreated acute osteomyelitis

is no longer often seen in developed countries, it is still relatively common as a

sequela from open fractures or gunshot wounds. The classic form of chronic

osteomyelitis had its onset with acute osteomyelitis, as the abscess was forming

and the involved bone was ischemic. If the amount of ischemic bone was

substantial, it would remain as a sequestrum. Especially if the sequestrum was

contaminated, it would remain as a focus of recurring infection; even if not

contaminated, it's presence activated a host response similar to that of a foreign

body -an attempt to wall off the sequestrum. Chronic osteomyelitis is clinically

evident by low grade drainage and inflammation about the infected site. Pathologic

fracture or nonunion may accompany chronic osteomyelitis.

a. Objectives

 General Objectives:

This case study aims to present the condition called Osteomyelitis in

relation to a patient's clinical manifestations, treatment and general health

status.The student nurse will also be able to:

1. To gather the needed data that can help to understand how and why the

disease occurs

2. To enhance knowledge and acquire more information about

Osteomyelitis

3. To enumerate the clinical manifestations of the disease so as to provide

prompt intervention of its occurrence

4. To give an idea of how to render proper nursing care for clients with this

condition thus it can be applied for future exposures of students

5. To identify possible treatments that can be used to cure the disease

b. Patient’s Profile

PERSONAL DATA

Name: Ms. E

Address: 351 Yakal Area 3 Brgy. Capri Novaliches, Quezon City

Religion: Roman Catholic

Nationality: Filipino

DEMOGRAPHIC DATA

Date of Birth: September 18, 2007

Place of Birth: Quezon City

Age: 11

Gender: Female
 Status: Child

PATIENT PROFILE

Date Admitted: July 2, 2019 @ 1:30 pm

Attending Physician: Dr. Dimacali

Room/Ward: Children’s Ward

Hospital Record No: 110814

A case of Ms. E, 11 years old, female, Catholic, went to Philippine

Orthopedic Center last February 2, 2019 with chief complaints of pain at right thigh

and was given antibiotic treatments for her injury. 1 month prior to admission,

patient sustained an injury to her right leg which was not treated immediately due

to lack of knowledge of how serious it was. The client then realized that her injury

was not healing because of the continuous pain which caused her to limp while

walking and decided to revisit the hospital. On April 30, the patient was first

admitted at Philippine Orthopedic Center and was scheduled for debridement for

wound healing and was still with draining sinus from the wound. On July 5, 2019,

the patient underwent Debridement+ 1st stage Masquelet. On July 9, she

underwent her second Debridement+ Sequestrectomy and application of Antibiotic

cement spacer. The patient is still draining sinus from previous surgical site. No

past illnesses with significance to present condition. There is no history of

hypertension on maternal side and none on the paternal side. Client is on DAT

with SAP diet. There are no known food and drug allergies.

History of Present Illness

A month PTA, the client was playing and tripped and had a painful fall. The

patient thought that the pain was just from the injury but couldn’t hold it any longer

and was then brought at the Philippine Orthopedic Center.

 Focused Physical Assessment

Cardiovascular

Blood pressure reading was at 90/60 mmHg and a strong, steady pulse of

77 bpm. Capillary refill time of affected area is 1 second. No bluish discoloration

and edema of fingers and clubbing of nails noted.

Musculoskeletal

Client verbalizes that there is no pain on the affected area at the moment.

Ranges of motion on her right leg is not that limited but still limits her movements.

There are no tingling sensations or numbness on affected area. Patient can feed

independently. Bathing and changing diapers require assistance from other

people.

Elimination

Client hasn’t defecated in that day. She voids clear, dark yellow urine of 3-4 times

a day. No difficulties noted.

II. ANATOMY AND PHYSIOLOGY

Anatomy of the Femur

The femur is the only bone in the thigh and the longest bone in the body. It acts as

the site of origin and attachment of many muscles and ligaments, and can be divided into

three parts; proximal, shaft and distal.

Proximal

Proximally, the femur exhibits four key regions.

The femoral head projects medially and superiorly and

articulates with the acetabulum of the pelvis to form the

hip joint. Immediately lateral to the head is the neck that

connects the head with the shaft. It is narrower than the

head to permit a greater range of movement at the hip

joint.

Located superiorly on the main shaft, lateral to

the joining of the neck, the greater trochanter is a

projection to which the abductor and lateral rotator

muscles of the leg attach. Also located on the main

shaft, but inferiorly to the neck joint, is the lesser

trochanter. A much smaller projection than the greater

trochanter, the psoas major and iliacus

Shaft

The shaft descends in a slightly medial direction that is designed to bring the knees

closer to the body’s center of gravity, increasing stability. Due to the widening of the

female pelvis this angle is greater in women and can lead to increased knee instability.

Two key features of the shaft are the proximal gluteal tuberosity to which the

gluteus maximus attaches, and the distal adductor tubercle to which the adductor magnus

attaches.

Distal

Distally, the femur exhibits five key regions. Two rounded regions, termed the

medial and lateral condyles, articulate with the tibia at the most anterior projection of the

patella. Between the two condyles lies the intercondylar fossa, a depression in which key

knee ligaments attach; this significantly strengthens the knee joint and protects it against

torsional damage. Finally, the two epicondyles, the medial and lateral, lie immediately

proximal to the condyles; they are also regions where key internal knee ligaments attach.
Muscle

The large and powerful

muscles of the hip that move the femur

generally originate on the pelvic girdle

and insert into the femur. The muscles

that move the lower leg typically

originate on the femur and insert into

the bones of the knee joint. The

anterior muscles of the femur extend

the lower leg but also aid in flexing the

thigh. The posterior muscles of the

femur flex the lower leg but also aid in extending the thigh. A combination of gluteal and

thigh muscles also adducts, abduct, and rotate the thigh and lower leg.

III. PATHOPHYSIOLOGY

Healthy bone tissue is extremely resistant to infection. The presence of

bone necrosis, heavy contamination or foreign bodies, as well as general

 predisposing factors such as diabetes and peripheral vascular disease tip the

balance in favour of the bacterium.

Trauma or surgery can produce devitalised bone fragments. The other

single most potent bone necrotising factor is indeed ischaemia. In the chick model

of haematogenous osteomyelitis, patchy ischaemic bone necrosis occurs when

the infective process occludes the vascular tunnels. This creates an ideal culture

medium for bacteria, and at 48 hours, abscesses are formed. A sequestrum

develops within eight days.

The role of bone necrosis is pivotal to the establishment of experimental

chronic osteomyelitis by direct inoculum: Norden and Kennedy in 1970 used

intramedullary sodium morrhuate, a sclerosing agent, before direct inoculation of

S aureusin order to obtain osteomyelitis in rabbits. Inoculation of bacteria without

sodium morrhuate or vice versa failed to produce an infection.

IV. ACTUAL LABORATORIES

Recent Notable Lab Result:
Low:

 Hemoglobin = 98
 Hematocrit = 0.31
 RBC = 3.63
 MCHC = 31
High:

 Eosinophil = 0.14
 Platelet = 534
 ESR = 26

V. MEDICAL MANAGEMENT

A. X-RAY

Patient was diagnosed with Chronic Osteomyelitis at right femur

B. Pharmacologic Therapy

 Piperacillin + Tazobactam

Piperacillin and tazobactam injection is used to treat pneumonia and skin,

gynecological, and abdominal (stomach area) infections caused by bacteria.

Piperacillin is in a class of medications called penicillin antibiotics. It works by killing

bacteria that cause infection. Tazobactam is in a class called beta-lactamase

inhibitor. It works by preventing bacteria from destroying piperacillin.

Antibiotics such as piperacillin and tazobactam injection will not work for

colds, flu, or other viral infections. Taking or using antibiotics when they are not

needed increases your risk of getting an infection later that resists antibiotic

treatment.

Doctor’s Generic name Brand name Dosage Route

order
Piperacillin+ Piperacillin+ Zosyn 2.25g TIV IV
Tazobactam Tazobactam QID (q6)
2.25 gm/ IV (-)
ANST
Frequency Indication Contraindication Side effects Adverse
effect
QID -Nosocomial - History of -Diarrhea -Agitation
Pneumonia allergic reactions to -Nausea -Bruising
any of the -Vomiting -Cough
penicillins,
cephalosporins, or
β-lactamase
inhibitors.

Mechanism of action Nursing consideration

It is similar to that of - Obtain history of hypersensitivity to
other penicillins. penicillins, cephalosporins, or other drugs prior to
Interfere with administration.
bacterial cell wall
synthesis promotes - Lab tests: C&S prior to first dose of the
loss of membrane drug; start drug pending results.
integrity and leads to
death of the - Monitor hematologic status with prolonged
organism. therapy (Hct and Hgb, CBC with differential and
platelet count).
Tazobactam is an
inhibitor of a wide
variety of bacterial
beta–lactamases. It
has little
antibacterial activity
itself; however, in
 combination with - Monitor patient carefully during the first 30
piperacillin, it min after initiation of the infusion for signs of
extends the hypersensitivity.
spectrum of bacteria
that are susceptible
to piperacillin. Two-
drug combination
has antibiotic activity
against an extremely
broad spectrum of
gram-positive, gram-
negative and
anaerobic bacteria.

 Vitamin C tab

Vitamin C is a vitamin. Some animals can make their own vitamin C, but people

must get this vitamin from food and other sources. Good sources of vitamin C are fresh

fruits and vegetables, especially citrus fruits. Vitamin C can also be made in a laboratory.

Most experts recommend getting vitamin C from a diet high in fruits and vegetables

rather than taking supplements. Fresh-squeezed orange juice or fresh-frozen concentrate

are good sources.

It is also thought that vitamin C may increase the healing of burns, ulcers, fractures,

and other wounds. Vitamin C is also used to prevent long-term pain after surgery or injury.

Doctor’s Generic name Brand name Dosage Route

order
Ascorbic Ascorbic Acid Cevit 1-2 tablet/ daily PO
Acid 500
mg/ tab

Frequency Indication Contraindication Side effects Adverse

effect
BID Dietary Diarrhea, Amounts
supplement; Use of sodium nausea, higher than
Frank and ascorbate in vomiting, 2000 mg daily
subclinical patients on sodium abdominal are
scurvy; restriction; cramps/pain, POSSIBLY
Extensive Use of calcium or heartburn UNSAFE and
burns, delayed ascorbate on may occur. may cause a
fracture or patient receiving lot of side
wound healing, digitalis. effects,
sever febrile or including
chronic disease kidney stones
states; and severe
To prevent diarrhea. In
vitamin C in people who
patients with have had a
 poor nutritional kidney stone,
habits; amounts
To acidify urine greater than
Macular 1000 mg daily
degeneration. greatly
increase the
risk of kidney
stone
recurrence.

Mechanism of action Nursing consideration

Increases Secure doctor’s order
protection Do hand washing
mechanism of the Assess patient’s condition
immune system, Give medication on right timing
thus supporting Inform patient about the possible side effects of the
wound healing. drugs
Instruct patient to be cautious of the contraindications of
the drugs
Return the medication ticket on the right box for the next
timing
Do the charting or the documentation

 Ferrous Sulfate

This medication is an iron supplement used to treat or prevent low blood

levels of iron (such as those caused by anemia or pregnancy). Iron is an important

mineral that the body needs to produce red blood cells and keep you in good

health.

Doctor’s Generic name Brand name Dosage Route

order
Ferrous Ferrous sulfate Ferrous sulfate 2-3 mg/kg PO
Sulfate 1 tab
OD

Frequency Indication Contraindication Side effects Adverse

effects
OD The Patients Vomiting Large doses
prevention or receiving repeated Severe may
treatment of blood abdominal pain aggravate
iron deficiency transfusions; Diarrhea peptic ulcer,
anemia due to anaemia not due Dehydration regional
inadequate to iron deficiency. Hyperventilation enteritis,
diet, Pallor or and
malabsorption cyanosis ulcerative
pregnancy, and colitis.
blood loss. Severe
Iron
Poisoning
Mechanism of action Nursing consideration
Ferrous Sulfate is  Store all forms at room temperature.
an essential  Give between meals with water but may give with
component in the meals if gastrointestinal discomfort occurs.
formation of  Transient staining of mucous membranes and
hemoglobin, teeth will occur with liquid iron preparation. To
myoglobin and avoid, place liquid on the back of the tongue with
enzymes. It is dropper or use straw.
necessary for  Avoid simultaneous administration of antacids or
effective tetracycline.
erythropoiesis and  Do not crush sustained-release preparations.
transport or  Eggs and milk inhibit absorption.
utilization of  Monitor serum iron, total iron-binding capacity,
oxygen. reticulocyte count, hemoglobin, and ferritin.
 Monitor daily pattern of bowel activity and stool
consistency.
 Assess for clinical improvement, record of relief of
symptoms (fatigue, irritability, pallor, paresthesia,
and headache).

REFERENCES:

Books:

Black, Joyce. Medical – Surgical Nursing. Singapore: 2009 8th Edition

Lippincott Williams &Wilkins Nursing 2009 Drug Handbook

Internet:

 Femur

https://orthoinfo.aaos.org/en/diseases--conditions/femur-shaft-fractures-broken-

thighbone

https://emedicine.medscape.com/article/824856-overview#a5

https://boneandspine.com/shaft-femur-fracture/

https://boneandspine.com/proximal-femur-fractures/

https://commons.wikimedia.org/wiki/File:1122_Gluteal_Muscles_that_Move_the_

Femur_c.png

https://teachmeanatomy.info/lower-limb/bones/femur/

https://courses.lumenlearning.com/boundless-ap/chapter/the-lower-limb/

 Drug Study

https://www.webmd.com/drugs/2/drug-4127/ferrous-sulfate-oral/details

https://www.scribd.com/document/391426085/piperacillin-tazobactam

 NCP