Transcript Osteomyelitis

Osteomyelitis
Dr. Belal Hijji, RN, PhD
March 14, 2012
Learning Outcomes
At the end of this lecture, students will be able to:
• Define osteomyelitis and explain its pathophysiology, clinical
manifestations, assessment and diagnostic findings, and
prevention.
• Discuss the medical and nursing management of a patient with
osteomyelitis.
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Definition
• Osteomyelitis is an infection of the bone by one of three
modes:
– Extension of soft tissue infection from pressure ulcer or
incision.
– Direct bone contamination from bone surgery, open fracture, or
traumatic injury.
– Bloodborne infection spread from other sites like tonsils,
infected teeth, and upper respiratory infections).
• Patients who are at high risk for osteomyelitis include those
who are poorly nourished, elderly, or obese, those with
impaired immune system, those with diabetes, rheumatoid
arthritis, and those receiving long-term corticosteroid therapy.
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Pathophysiology
• Staphylococcus aureus causes 70% to 80% of bone infections.
Other pathogens found in osteomyelitis include Proteus,
Pseudomonas species, Escherichia coli., and penicillinresistant, nosocomial, gram-negative infections.
• The initial response to infection is inflammation, increased
vascularity, and edema. After 2 or 3 days, thrombosis of the
blood vessels occurs in the area, resulting in ischemia with
bone necrosis. Unless the infective process is treated promptly,
a bone abscess forms.
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Clinical Manifestations
• When the infection is bloodborne, the onset is usually sudden,
occurring often with chills, high fever, rapid pulse, general
malaise. As the infection progresses, the infected area becomes
painful, swollen, and extremely tender [‫]حساس أو ضعيف‬. When
osteomyelitis results from adjacent infection or from direct
contamination, the area is swollen, warm, painful, and tender
to touch.
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Assessment and Diagnostic Findings
• In acute osteomyelitis, early x-ray findings demonstrate soft
tissue swelling. Radioisotope bone scans and MRI help with
early definitive diagnosis.
• Blood studies show leukocytosis and high erythrocyte
sedimentation rate (ESR). Wound and blood culture studies are
performed to identify appropriate antibiotic therapy.
• With chronic osteomyelitis, dense bone formations are seen on
x-ray. Bone scans may be performed to identify areas of
infection. ESR and WBC count are usually normal.
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Medical Management
• Medical Management aims to control and halt the infective
process, through IV antibiotic therapy (penicillin or
cephalosporin) for 3 – 6 weeks based on the results of blood
and wound cultures. After achieving infection control, the
antibiotic may be administered orally for up to 3 months.
• General supportive measures (eg, hydration, diet high in
vitamins and protein, correction of anemia) should be
instituted.
• The area affected with osteomyelitis is immobilized to
decrease discomfort and to prevent pathologic fracture of the
weakened bone. Warm wet soaks for 20 minutes several times
a day may be prescribed to increase circulation.
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Nursing Management of a Patient With Osteomyelitis
• Assessment. Physical examination reveals an inflamed,
markedly swollen, warm area that is tender. Purulent drainage
may be noted. The patient has fever. With chronic
osteomyelitis, the temperature elevation may be minimal,
occurring in the afternoon or evening.
• Nursing diagnoses.
– Acute pain related to inflammation and swelling
– Impaired physical mobility related to pain, use of immobilization
devices, and weight-bearing limitations.
– Risk for extension of infection: bone abscess formation
– Deficient knowledge related to the treatment regimen
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Nursing Management of a Patient With Osteomyelitis
• Planning and Goals. The patient’s goals are to:
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Relieve pain.
improve physical mobility.
control and eradicate infection.
know treatment regimen.
Nursing Management of a Patient With Osteomyelitis
• Nursing Interventions.
– Relief of pain.
• Immobilise the affected part with a splint to decrease pain.
• Monitor the neurovascular status of the affected extremity.
• Elevate the affected part to reduce swelling and associated
discomfort.
• Administer analgesics as prescribed.
– Improving physical mobility.
• The bone is weakened by the infective process and must be
protected by immobilization devices and by avoidance of
stress on the bone.
• Gently place the joints above and below the affected part
through their range of motion. Encourage full participation in
ADLs to promote general well-being.
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Nursing Management of a Patient With Osteomyelitis
• Nursing Interventions (Continued…).
– Control and eradication of infection.
• Monitor the patient’s response to antibiotic therapy.
• Observe the IV access site for evidence of phlebitis,
infection, or infiltration.
• With long-term, intensive antibiotic therapy, monitor the
patient for signs of superinfection (eg, oral or vaginal
candidiasis, loose or foul-smelling stools).
• Monitor the general health and nutrition of the patient. A diet
high in protein and vitamin C promotes healing.
• Encourage adequate hydration.
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Nursing Management of a Patient With Osteomyelitis
• Nursing Interventions.
– Knowledge of treatment regimen.
• Teach the patient and family the importance of strictly
adhering to the therapeutic regimen of antibiotics and
preventing falls or other injuries that could result in bone
fracture.
• Teach the patient how to maintain and manage the IV access
and IV administration equipment in the home.
• Provide information on medication education.
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Nursing Management of a Patient With Osteomyelitis
• Expected Patient Outcomes.
– Experiences pain relief
• Reports decreased pain
• Experiences no tenderness at site of previous infection
• Experiences no discomfort with movement.
– Increases physical mobility
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Participates in self-care activities
Maintains full function of unimpaired extremities
Demonstrates safe use of immobilizing and assistive devices
Modifies environment to promote safety and to avoid falls
Nursing Management of a Patient With Osteomyelitis
• Expected Patient Outcomes (Continued…).
– Shows absence of infection
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Takes antibiotic as prescribed
Reports normal temperature
Exhibits no swelling
Reports absence of drainage
Laboratory results indicate normal white blood cell count and
sedimentation rate
Nursing Management of a Patient With Osteomyelitis
• Expected Patient Outcomes (Continued…).
– Complies with therapeutic plan
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Takes medications as prescribed
Protects weakened bones
Demonstrates proper wound care
Reports signs and symptoms of complications promptly
Eats a diet that is high in protein and vitamin C
Keeps follow-up health appointments
Reports increased strength
Reports no elevation of temperature or recurrence of pain,
swelling, or other symptoms at the site