1. Osteomyelitis Dr. Belal Hijji, RN, PhD March 14, 2012

2. 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. 2

3. 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. 3

4. Pathophysiology Staphylococcus aureus causes 70% to 80% of bone infections. Other pathogens found in osteomyelitis include Proteus, Pseudomonas species, Escherichia coli., and penicillin- resistant, 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. 4

5. 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. 5

6. 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. 6

7. 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. 7

8. 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 8

9. Nursing Management of a Patient With Osteomyelitis Planning and Goals. The patient’s goals are to: – Relieve pain. – improve physical mobility. – control and eradicate infection. – know treatment regimen. 9

10. 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. 10

11. 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. 11

12. 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. 12

13. 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 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 13

14. Nursing Management of a Patient With Osteomyelitis Expected Patient Outcomes (Continued…). – Shows absence of infection 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 14

15. Nursing Management of a Patient With Osteomyelitis Expected Patient Outcomes (Continued…). – Complies with therapeutic plan 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 15