Osteomyelitis

Question 1

• Severe infection of bone, bone marrow, & surrounding soft tissue
• Most common microorganism is Staphylococcus aureus, but can be c/b variety of organisms

Answer 1

Etiology & Pathophysiology

• Indirect entry (hematogenous)
• Young boys
• Blunt trauma
• Vascular insufficiency disorders
• GI & respiratory infections

> Pelvis, tibia, & vertebrae, which are vascular-rich sites of bone, are most common infection sites

Question 2

• Direct entry - via open wound
• Foreign body presence (e.g., implant, orthopedic prosthetic device [e.g., plate, total joint prosthesis])

Answer 2

• Microorganisms grow → inc pressure in bone → ischemia & vascular compromise (of periosteum)
• Infection spreads through bone → cortex devascularization & necrosis

Question 3

Development of Osteomyelitis

Question 4

Clinical Manifestations: Acute osteomyelitis

• Infection of <1 month in duration

Local manifestations
- pain unrelieved by rest; worsens w/activity
- swelling, tenderness, warmth
- restricted movement

Answer 4

Systemic manifestations
- fever, night sweats
- chills, restlessness
- nausea, malaise, drainage (late) [from cutaneous sinus tract and/or fx site)

Question 5

Clinical Manifestations: Chronic Osteomyelitis

• infection lasting longer >1 month or has failed to respond to initial course of abx therapy
• either a continuous & persistent problem (a result of inadequate acute treatment) or a process of exacerbations and remissions

Answer 5

• Systemic signs diminished (fever, swelling, & erythema would be LESS LIKELY in chronic than acute)
• Sinus tracts often form
• Granulation tissue turns to scar tissue → avascular → ideal site for microorganisms to grow → away from abx penetration

Question 6

Diagnostic Studies

• Bone or soft tissue bx (definitive way)
• Blood &/or wound cultures
• WBC count ↑
• ESR ↑
• X-rays (won’t appear until about 10 days to wks >appearance of clin sx’s)
• Bone scans
• MRI/CT scans

Answer 6

Collaborative Care - Acute Osteomyelitis

• Vigorous & prolonged IV abx therapy (as long as bone ischemia hasn’t occurred)
• Cultures or bone bx (before rx therapy started)
• Surgical debridement & decompression (if abx therapy delayed)

Question 7

• Course of IV abx therapy 4-6 wks minimum (or as long as 3-6 mos)
• May be completed @ home or in SNF (via CVC or PICC)

Answer 7

• Variety of abx depending on microorganism
  > penicillin
  > nafcillin (Nafcil)
  > neomycin
  > vancomycin
  > cephalexin (Keflex)
  > cefazolin (Ancef)
  > cefoxitin (Mefoxin)
  > gentamicin (Garamycin)
  > tobramycin (Nebcin)

Question 8

Collaborative Care - Chronic Osteomyelitis

• Surgical removal
• Extended use of abx
• Abx-impregnated polymethyl methacrylate bead chains
• Intermittent or constant abx irrigation of bone

Answer 8

• Casts or braces
• Negative-pressure wound therapy
• Hyperbaric oxygen therapy
  > w/100% O2; is thought to stimulate circulation & healing within infected tissue
• Removal of prosthetic devices
• Muscle flaps, skin grafting, bone grafting (restore blood flow)
• Amputation

Question 9

• Oral fluoroquinolone (Cipro) for 6-8 wks for chronic osteomyelitis
• Oral abx therapy may also be given >acute IV therapy is completed to ensure resolution of infection

Answer 9

• Monitor pt’s response to rx therapy w/bone scans & ESR tests

Question 10

• Long-term & mostly rare complications
  > Septicemia
  > Septic arthritis
  > Pathologic fx’s
  > Amyloidosis

Answer 10

Subjective Data

Question 11

• Past health hx
  > bone trauma, open fx, open or puncture wounds, other infections (e.g., streptococcal sore throat, bacterial pneumonia, sinusitis, skin or tooth infection, chronic UTI)
• Medications
  > use of analgesics or abx
• Surgery or other treatments
  > bone surgery

Answer 11

• IV drug & alcohol abuse, malaise
• Anorexia, weight loss, chills
• Weakness, paralysis, muscle spasms
• Local tenderness, increase in pain w/movement of affected bone
• Irritability, withdrawal, dependency, anger

Question 12

Objective Data

• Restlessness, high spiking temp, night sweats
• Diaphoresis, erythema, warmth, edema

Answer 12

• Restricted movement, wound drainage, spontaneous fx’s
• ↑ WBC, + cultures, ↑ ESR, presence of sequestrum & involucrum

Question 13

Nursing Diagnoses

• Acute pain
• Ineffective self-health management
• Impaired physical mobility

Answer 13

Planning - Overall Goals

• Have satisfactory pain & fever control
• Do not experience any complications assoc w/osteomyelitis
• Cooperate w/treatment plan
• Maintain a positive outlook on outcome of dz

Question 14

Nursing Implementation - Health Promotion

• Control infections already in body
• Susceptible adults
  > Immunocompromised
  > Wear orthopedic prosthetic devices
  > Have vascular insufficiencies
• Instruct regarding local & systemic manifestations (monitoring & reporting)
  > sx’s of bone pain, fever, swelling, & restricted limb movement

Answer 14

Nursing Implementation - Acute Interventions

Question 15

• Immobilization & careful handling of affected limb (e.g., splint, traction)
• Assess & treat pain
  > NSAIDs, opioid analgesics, muscle relaxants; non-drug approaches
• Dressing care
  > sterile technique
• Proper positioning to prevent complications of immobility
  ! flexion contracture - d/t pt positioning of affected extrem in a flexed position to promote comfort

! footdrop - if foot is not correctly supported in neutral position by a splint or there’s excessive pressure from a splint, which can injure peroneal nerve

Answer 15

• Pt teaching re: adverse & toxic rxn’s to abx therapy
  ! Ototoxicity, nephrotoxicity, neurotoxicity
  ! Hives, diarrhea, bloody stools, throat & mouth sores
  ! Tendon rupture
• Monitor peak & trough lvls

Question 16

• tobramycin (Nebcin) & neomycin - hearing deficit, nephrotoxicity, & neurotoxicity
• cephalosporins (e.g., cefazolin [Ancef]) - hives, severe or watery diarrhea, blood in stools, & throat or mouth sores

Answer 16

• Tendon rupture (esp Achilles tendon) can occur w/use of fluoroquinolones (e.g., Cipro, Levaquin)

Question 17

• Lengthy abx therapy can result in overgrowth of Candida albicans & Clostridium difficile in the GU & GI tract, esp in ICP’d & older pts
• Pt & family are often frightened & discouraged
• Continued psychological & emotional support

Answer 17

Ambulatory & Home Care

• Pt teaching re: abx admin & management of venous access device
• Wound care/dressing changes
• Physical & psychological support
• Long-term IV therapy then long-term PO therapy often