Download Osteomyelitis

Musculoskeletal
Disorders
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Osteomyelitis
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Osteomyelitis
• Severe infection of the
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Bone
Bone marrow
Surrounding soft tissue
• Caused by a variety of microorganisms
• Most common infecting microorganism
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Etiology and Pathophysiology
• Antibiotics in conjunction with surgical
treatments have decreased mortality rate
and complications
• Infecting microorganisms can invade by
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Indirect entry
Direct entry
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Direct Entry
• Can occur at any age
• Open wound where microorganisms can
gain entry to body
• May also occur in presence of foreign
body
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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
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Direct Entry
• Once outside bone
 Sequestrum may
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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
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Indirect Entry
• Frequently affects growing bone in boys
<12 years old ---Why???
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Most common sites of indirect entry
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Distal femur
Proximal tibia
Humerus
Radius
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Indirect Entry
• Adults with increased risk
 Vascular disorders
 Genitourinary and respiratory infections
 Spread infection from blood to bone
 Vascular-rich bone sites
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•
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Pelvis
Tibia
Vertebrae
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Development of Osteomyelitis
Fig 64-1
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Clinical Manifestations
Acute Osteomyelitis
• Initial infection
 Infection
of <1 month in duration
 Both systemic and local
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Clinical Manifestations
Acute Osteomyelitis
• Systemic
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• 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
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Clinical Manifestations
of Chronic Osteomyelitis
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•
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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
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Diagnostic Studies
• Bone or soft tissue biopsy
 Definitive way to determine causative
microorganism
• Patient’s blood and/or wound culture
 Frequently positive for presence of microorganism
• Lab Studies
 WBC
 Erythrocyte sedimentation rate (ESR)
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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
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Collaborative Care
Acute Osteomyelitis
• Vigorous and prolonged intravenous (IV)
antibiotic therapy
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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
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Collaborative Care
Acute Osteomyelitis
• Patients are often discharged to home care
or skilled nursing facility (SNF) with IV
antibiotics delivered via
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Collaborative Care
Acute Osteomyelitis
• Antibiotic therapy may be continued for
at home for _ to _ _____ or as long as
_ __ _ ______
• Variety of antibiotics may be prescribed
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Penicillin, nafcillin (Nafcil)
Neomycin, vancomycin
Cephalexin (Keflex)
Cefazolin (Ancef)
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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 patient’s response
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Nursing Care
• Toxic effects:
 Aminoglycosides - Nephrotoxic, ototoxic, optic neuritis, fluid
retention
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•
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Cephalosporins and Quinolones – jaundice, colitis,
photosensitivity, crystalluria
•
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Nursing Care/Patient Teaching
• Measure
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• 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
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Collaborative Care
Chronic Osteomyelitis
• Surgical treatment for chronic
osteomyelitis
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Removal of poorly vascularized tissue and
dead bone
Extended use of antibiotics
Antibiotic-impregnated polymethyl
methacrylate bead chains may also be
implanted
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Collaborative Care
Chronic Osteomyelitis
• 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
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Collaborative Care
Chronic Osteomyelitis
• Hyperbaric oxygen therapy with 100%
oxygen as adjunct therapy
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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
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Collaborative Care
Chronic Osteomyelitis
• Bone grafts may help restore blood flow
• Amputation may be indicated if
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Collaborative Care
• Long-term and mostly rare complications
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Septicemia
Septic arthritis
Pathologic fractures
Amyloidosis
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Nursing Assessment
• Important health information
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Past health history
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Bone trauma, open fracture, open or puncture
wounds, other infections
Medications
Surgery or other treatments
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Nursing Assessment
• Subjective data
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IV drug use, malaise
Anorexia, weight loss, chills
Weakness, paralysis, muscle spasms
Local tenderness over affected area, increase
in pain in affected area
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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
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Nursing Diagnoses
• Acute pain
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RT Inflammatory process secondary to
infection
AEB Guarding, moaning, crying,
restlessness, altered muscle tone, decreased
activity; Statement of pain
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Nursing Diagnoses
• Impaired physical mobility
 RT Pain, immobilization devices, weightbearing limitations
 AEB Inability or unwillingness to change
positions
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Nursing Diagnoses
• Ineffective therapeutic regimen
management
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RT Lack of knowledge regarding long-term
management of osteomyelitis
AEB Verbalization of concern and
uncertainty about procedures and skills
needed for home care
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Other Nursing Diagnosis Labels
• Fear, Anxiety
• Powerlessness, Hopelessness
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Planning
• Overall goals
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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
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Nursing Implementation
• Health promotion
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Control infections already in body
Susceptible adults
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•
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Instruct susceptible adults and their families
on local and systemic manifestations
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Nursing Implementation
• Acute intervention
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Immobilization and non-weight bearing on
affected limb will decrease pain
Limb should be handled carefully to avoid
excessive manipulation and decrease pain
Manage patient’s pain level using
pharmacologic and non-pharmacologic
strategies
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Nursing Implementation
• Acute intervention (cont’d)
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Patient is frequently on bed rest in early
stages of acute infection
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Good body alignment and frequent position
changes prevent complications associated with
immobility and promote comfort
Flexion contracture is a common sequela of
osteomyelitis
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Nursing Implementation
• Acute intervention (cont’d)
 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
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Nursing Implementation
• Acute intervention (cont’d)
 Instruct patient to avoid activities that
increase circulation and swelling and serve as
stimuli to spread infection
•
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Exercise, ____ application
Dressings to absorb exudate from draining
wounds
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Nursing Implementation
• Acute intervention (cont’d)
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Teach patient potential adverse and toxic
reactions with prolonged and high-dose
antibiotic therapy
Lengthy antibiotic therapy can result in an
overgrowth of …
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Nursing Implementation
• Acute intervention (cont’d)
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Patient and family often frightened and
discouraged
Continued psychologic and emotional
support is an integral part of nursing
management
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Nursing Implementation
• Ambulatory and home care
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IV antibiotics can be administered to patient
in a skilled nursing facility or home setting
If at home
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•
Patient and family must be instructed on correct
care and management of venous access device
Must also be taught how to administer antibiotic
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Nursing Implementation
• 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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