Osteomyelitis 000 - 455

Copyright 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Musculoskeletal
Disorders

Osteomyelitis

Osteomyelitis
Severe infection of the
Bone
Bone marrow
Surrounding soft tissue
Caused by a variety of microorganisms
Most common infecting microorganism

Etiology and Pathophysiology
Antibiotics in conjunction with surgical
treatments have decreased mortality rate
and complications
Infecting microorganisms can invade by
Indirect entry
Direct entry

Direct Entry
Can occur at any age
Open wound where microorganisms can
gain entry to body
May also occur in presence of foreign
body


Direct Entry
Sequestrum continues to be an infected
island of bone, surrounded by pus
Difficult for blood-borne antibiotics or
white blood cells (WBCs) to reach
sequestrum
Sequestrum can move out of bone and
into soft tissue


Direct Entry
Once outside bone
Sequestrum may
Revascularize and then undergo removal by
normal immune process
Be surgically removed through debridement of
necrotic bone
If necrotic sequestrum is not resolved, it may
develop a sinus tract resulting in chronic,
purulent cutaneous drainage

Indirect Entry
Frequently affects growing bone in boys
<12 years old ---Why???

Most common sites of indirect entry
Distal femur
Proximal tibia
Humerus
Radius

Indirect Entry
Adults with increased risk
Vascular disorders
Genitourinary and respiratory infections
Spread infection from blood to bone
Vascular-rich bone sites
Pelvis
Tibia
Vertebrae

Development of Osteomyelitis
Fig 64-1

Clinical Manifestations
Acute Osteomyelitis
Initial infection
Infection of <1 month in duration
Both systemic and local

Acute Osteomyelitis
Systemic

Local
Constant bone pain that worsens with
activity
Swelling, tenderness, warmth at infection site
Restricted movement of affected part
Later signs: drainage from sinus tracts

of Chronic Osteomyelitis
Chronic an infection that persists
for longer than 1 month
Infection that has failed to respond
to initial course of antibiotic
therapy
Systemic signs ______
Signs and Symptoms
Constant bone pain
Swelling
Tenderness
Warmth at site
Continuous Drainage

Diagnostic Studies

Bone or soft tissue biopsy
Definitive way to determine causative
microorganism
Patients blood and/or wound culture
Frequently positive for presence of microorganism
Lab Studies
WBC
Erythrocyte sedimentation rate (ESR)


Radiologic Studies
Radiologic signs
Usually do not appear until 10 days to weeks after
start of clinical symptoms
Radionuclide bone scans
Helpful in diagnosis and usually positive in areas of
infection
Magnetic resonance imaging (MRI)
Computed tomography (CT)
Help identify extent of infection, including soft
tissue involvement


Collaborative Care
Acute Osteomyelitis
Vigorous and prolonged intravenous (IV)
antibiotic therapy
Treatment of choice for acute osteomyelitis
As long bone ischemia has not occurred
Cultures or bone biopsy should be done if
possible
Delaying antibiotic treatment may require
surgical debridement and decompression

Collaborative Care
Acute Osteomyelitis
Patients are often discharged to home care
or skilled nursing facility (SNF) with IV
antibiotics delivered via


Collaborative Care
Acute Osteomyelitis
Antibiotic therapy may be continued for
at home for _ to _ _____ or as long as
_ __ _ ______
Variety of antibiotics may be prescribed
Penicillin, nafcillin (Nafcil)
Neomycin, vancomycin
Cephalexin (Keflex)
Cefazolin (Ancef)

Collaborative Care
Chronic Osteomyelitis
Adults with chronic osteomyelitis may be
prescribed oral therapy + fluoroquinolone
for 6 to 8 weeks instead of IV antibiotics
Oral antibiotics may be given after acute
IV therapy to ensure resolution of
infection
Monitoring patients response

Nursing Care
Toxic effects:
Aminoglycosides - Nephrotoxic, ototoxic, optic neuritis, fluid
retention

Cephalosporins and Quinolones jaundice, colitis,
photosensitivity, crystalluria


Nursing Care/Patient Teaching
Measure

Preventive measures:
Monitor _ _ _; Keep patient well hydrated to
prevent ____________ or __________
Avoid direct sunlight, wear sunscreen
Monitor urinary function, hearing, vision
Assess for signs of yeast infections in genitourinary
and mouth


Collaborative Care
Surgical treatment for chronic
osteomyelitis
Removal of poorly vascularized tissue and
dead bone
Extended use of antibiotics
Antibiotic-impregnated polymethyl
methacrylate bead chains may also be
implanted

Collaborative Care
After debridement, wound may be closed
and a suction irrigation system inserted
Intermittent or constant irrigation of
affected bone with antibiotics
Protection on limb or surgical site with
casts or braces
Negative pressure to draw wound together

Collaborative Care
Hyperbaric oxygen therapy with 100%
oxygen as adjunct therapy
Stimulate circulation and healing
Orthopedic prosthetic devices, if source of
infection must be removed
Muscle flaps, skin grafting provide wound
coverage over dead space (cavity) in bone

Collaborative Care
Bone grafts may help restore blood flow
Amputation may be indicated if


Collaborative Care
Long-term and mostly rare complications
Septicemia
Septic arthritis
Pathologic fractures
Amyloidosis

Nursing Assessment
Important health information
Past health history
Bone trauma, open fracture, open or puncture
wounds, other infections
Medications
Surgery or other treatments

Nursing Assessment
Subjective data
IV drug use, malaise
Anorexia, weight loss, chills
Weakness, paralysis, muscle spasms
Local tenderness over affected area, increase
in pain in affected area

Nursing Assessment
Objective data
General: Restlessness, high, spiking
temperature, night sweats
Integumentary: Diaphoresis, erythema,
warmth, edema at infected bone
Musculoskeletal: Restricted movement,
wound drainage, spontaneous fractures


Nursing Diagnoses
Acute pain
RT Inflammatory process secondary to
infection
AEB Guarding, moaning, crying,
restlessness, altered muscle tone, decreased
activity; Statement of pain


Nursing Diagnoses

Impaired physical mobility
RT Pain, immobilization devices, weight-
bearing limitations
AEB Inability or unwillingness to change
positions

Nursing Diagnoses
Ineffective therapeutic regimen
management
RT Lack of knowledge regarding long-term
management of osteomyelitis
AEB Verbalization of concern and
uncertainty about procedures and skills
needed for home care

Other Nursing Diagnosis Labels
Fear, Anxiety

Powerlessness, Hopelessness

Planning
Overall goals
Have satisfactory pain and fever control
Not experience any complications associated
with osteomyelitis
Cooperate with treatment plan
Maintain a positive outlook on outcome of
disease

Nursing Implementation
Health promotion
Control infections already in body
Susceptible adults

Instruct susceptible adults and their families
on local and systemic manifestations

Acute intervention
Immobilization and non-weight bearing on
affected limb will decrease pain
Limb should be handled carefully to avoid
excessive manipulation and decrease pain
Manage patients pain level using
pharmacologic and non-pharmacologic
strategies

Acute intervention (contd)
Patient is frequently on bed rest in early
stages of acute infection
Good body alignment and frequent position
changes prevent complications associated with
immobility and promote comfort
Flexion contracture is a common sequela of
osteomyelitis

Patient frequently positions affected
extremity in a flexed position to promote
comfort
Contracture may then progress to deformity
___ ____ can develop quickly in lower
extremity if foot is not supported in a neutral
position by a splint or if there is excessive
pressure from a splint

Instruct patient to avoid activities that
increase circulation and swelling and serve as
stimuli to spread infection
Exercise, ____ application

Dressings to absorb exudate from draining
wounds


Teach patient potential adverse and toxic
reactions with prolonged and high-dose
antibiotic therapy
Lengthy antibiotic therapy can result in an
overgrowth of

Patient and family often frightened and
discouraged
Continued psychologic and emotional
support is an integral part of nursing
management

Ambulatory and home care
IV antibiotics can be administered to patient
in a skilled nursing facility or home setting
If at home
Patient and family must be instructed on correct
care and management of venous access device
Must also be taught how to administer antibiotic

Ambulatory and home care
Importance of continuing antibiotics after
symptoms have subsided should be stressed
Periodic nursing visits provide support and
decrease anxiety
Frequent dressing changes for open wounds
May require supplies and instruction in
technique

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Copyright 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

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