Osteomyelitis Derived from the Greek word osteon, which means bone and myelo meaning marrow and

d itis that means inflammation. An infection of the bone, bone marrow, and surrounding soft tissue that results in inflammation, necrosis, and formation of new bone Osteomyelitis with vascular insufficiency - Seen most commonly in patients with diabetes and peripheral vascular disease, most commonly affecting the feet

High risk for osteomyelitis: Poorly nourished Elderly Obese Impaired immune system Chronic illnesses (ex. Diabetes, rheumatoid arthritis) Receiving long term corticosteroid therapy and immunosuppressive agents

Classification: Hematogenous osteomyelitis - Due to bloodborne spread of infection (ex. Infected tonsils, boils, infected teeth, URI) - Most common in infants and children Contiguous-focus osteomyelitis - From contamination from bone surgery, open fracture, or traumatic injury (ex. gunshot wound)

Pathophysiology Infection caused by infectious organisms (Staphylococcus aureus, gram-positive organisms: streptococci and enterococci, and gram-negative: Pseudomonas species)

bacteria lodge in the affected bone area

After 2-3 days, thrombosis of local blood vessels occurs

Organisms proliferate and destroy bone cells

Infection extends into the medullary cavity and under periosteum, spread in adjacent soft tissues and joints

Ischemia and bone necrosis

Initial response: inflammation, increased vascularity and edema

Bone abscess forms that abscess cavity contains dead bone tissue that collapses

Osteomyelitis

Clinical Manifestations: When the infection is bloodborne, Onset is sudden, with clinical and laboratory manifestations of sepsis (ex, chills, high fever, rapid pulse, general malaise) Painful, swollen, extremely tender Constant, pulsating pain that intensifies with movement When osteomyelitis occurs from spread of adjacent infection or direct contamination No symptoms of sepsis Area is swollen, warm, painful, and tender to touch Patient with chronic osteomyelitis Non healing ulcer that overlies the infected bone with connecting sinus that will intermittently and spontaneously drain pus Chronic osteomyelitis - X-ray = large, irregular cavities; raised periosteum; sequestra; dense bone formation - Bone scan = to identify areas of infection - ESR and WBC = maybe normal - Anemia = may be evident Prevention: elective orthopedic surgery should be postponed if the patient has a current infection during orthopedic surgery: 1. careful attention is paid to the surgical environment and to techniques to decrease direct bone contamination 2. administration of prophylactic antibiotic 3. removal of urinary catheters and drains as soon as possible treatment of focal infections Aseptic postoperative wound care Prompt management of soft tissue infections Medical Management: GOAL: to control and halt the infective process General supportive measures:

Diagnostic Findings: Acute osteomyelitis - X-ray = tissue edema and in about 2-3 weeks, area of periosteal elevation and bone necrosis are evident - Blood studies, culture and sensitivity = leukocytosis and elevated ESR - CT scan and MRI = bone changes and spread of contiguous soft tissue

Hydration, diet high in vitamins and protein, correction of anemia Area affected is immobilize

NURSING PROCESS: ASSESSMENT Patient reports an acute onset of signs and symptoms Assess for risk factors and history of previous injury, infection, orthopedic surgery Patient avoids pressure and movement of the area In acute hematogenous osteomyelitis, patient exhibits generalized weakness Physical examinations: inflamed, markedly edematous, warm area that is tender, purulent drainage may be noted, elevated temperature

Pharmacologic Therapy: - As soon as the culture specimen is obtained = IV antibiotic therapy begins - Around the clock dosing - After the results of culture and sensitivity = IV antibiotic therapy which the causative organism is sensitive is prescribes for 3-6 weeks and when controlled administer orally for up to 3 months - oral administration of drug without food or into empty stomach Surgical Management: - If infection does not respond to medication = surgical debridement - Antibiotic-impregnated beads may be placed in the wound for direct application of antibiotics for 2-4 weeks In chronic osteomyelitis: - Sequestrectomy - Saucerization - Closed suction irrigation system - Wound irrigation for 7-8 days

NURSING DIAGNOSIS Acute pain related to inflammation and edema Impaired physical mobility related to pain, use of immobilization devices, weight bearing limitations Risk for extension of infection: bone abscess formation Deficient knowledge related to the treatment regimen

NURSING INTERVENTIONS Relieving pain - Affected part may be immobilized with a splint

Monitor neurovascular status - Elevation reduces swelling - Prescribed analgesics should be given Improving physical mobility - Joints above and below the affected part should be gently moved through their range of motions - Encourage full participation in ADLs within the physical limitations to promote general well-being Controlling the Infectious process - Monitor patient response to antibiotic therapy and observes the IV access site for evidence of phlebitis, infection, or infiltration - Monitor for signs of superinfection - Takes measures to ensure adequate circulation to the affected area - Prevent fluid accumulation - Elevation of the area to promote venous drainage - Avoidance of pressure on the grafted - Change dressing using aseptic technique