SOUTHERN LUZON STATE UNIVERSITY

Lucban, Quezon

CHRONIC OSTEOMYELITIS
A Case Study

Presented to the Faculty

Of College of Allied Medicine

In partial fulfillment of the requirements

for the Degree Bachelor of Science in Nursing

Submitted by:
Abrigo, Ellennor F.
Job, Genesis
Olaivar, Monique S.

Submitted to:
Prof. Caroline Murallon

Summer Affiliation, 2010

 CHAPTER I
Objective of the Study

A. GENERAL OBJECTIVES:

B. SPECIFIC OBJECTIVES:
 CHAPTER II
Introduction of the Disease

Do what you love. Know your own bone; gnaw at it, bury it, unearth it, and gnaw it still.
-Henry David Thoreau

Osteomyelitis is a local or generalized pyogenic disease of the bone, bone

marrow and surrounding tissue. In children, the disease usually results from untreated
acute hematogenous osteomyelitis. Chronic osteomyelitis may also be seen after
traumatic injuries, especially in times of civil unrest or war, or as a complication of
surgical procedures such as open reduction and internal fixation of fractures. The long
bones are affected most commonly, and the femur and tibia account for approximately
half of the cases. Predisposing factors include poor hygiene, anemia, malnutrition, and
a coexisting infectious disease burden (parasites, mycobacteria, acquired autoimmune
deficiency syndrome), or any other factors that decrease immune function. Chronic
osteomyelitis is defined by the presence of residual foci of infection (avascular bone and
soft tissue debris), which give rise to recurrent episodes of clinical infection.

Eradication of the infection is difficult, and complications associated with both the
infection and their treatments are frequent. Our goals are to review the pathophysiology,
natural history, and management for children with chronic osteomyelitis within the
context of a developing world setting.
 CHAPTER III
Anatomy and Physiology

Human musculoskeletal system

A musculoskeletal system (also known as the locomotor system) is an organ

system that gives animals (including humans) the ability to move using
the muscular and skeletal systems. The musculoskeletal system provides form, support,
stability, and movement to the body.

It is made up of the body’s bone (the skeleton), muscles,

cartilage, tendons, ligaments, joints, and other connective tissue (the tissue that
supports and binds tissues and organs together). The musculoskeletal system's primary
functions include supporting the body, allowing motion, and protecting vital organs. The
skeletal portion of the system serves as the main storage system for calcium and
phosphorus and contains critical components of the hematopoietic system.

This system describes how bones are connected to other bones

and muscle fibers via connective tissue such as tendons and ligaments. The bones
provide the stability to a body in analogy to iron rods in concrete construction. Muscles
keep bones in place and also play a role in movement of the bones. To allow motion
different bones are connected by joints. Cartilage prevents the bone ends from rubbing
directly on to each other. Muscles contract (bunch up) to move the bone attached at the
joint.

There are, however, diseases and disorders that may adversely affect the
function and overall effectiveness of the system. These diseases can be difficult
to diagnose due to the close relation of the musculoskeletal system to other internal
systems. The musculoskeletal system refers to the system having its muscles attached
to an internal skeletal system and is necessary for humans to move to a more favorable
position.
Subsystems

Skeletal

Front view of a skeleton of an adult human

The Skeletal System serves many
important functions; it provides the shape and
form for our bodies in addition to supporting,
protecting, allowing bodily movement, producing
blood for the body, and storing minerals. The
number of bones in the human skeletal system is
a controversial topic. Humans are born with about
300 to 350 bones, however, many bones fuse
together between birth and maturity. As a result
an average adult skeleton consists of 206 bones.
The number of bones varies according to the
method used to derive the count. While some
consider certain structures to be a single bone
with multiple parts, others may see it as a single
part with multiple bones. There are five general
classifications of bones. These are long
bones, short bones, flat bones, irregular bones,
and sesamoid bones. The human skeleton is
composed of both fused and individual bones supported by ligaments, tendons,
muscles and cartilage. It is a complex structure with two distinct divisions. These are the
axial skeleton and the appendicular skeleton.

Function

The Skeletal System serves as a framework for tissues and organs to attach
themselves to. This system acts as a protective structure for vital organs. Major
examples of this are thebrain being protected by the skull and the lungs being protected
by the rib cage.

Located in long bones are two distinctions of bone marrow (yellow and red). The
yellow marrow has fatty connective tissue and is found in the marrow cavity. During
starvation, the body uses the fat in yellow marrow for energy. The red marrow of some
bones is an important site for blood cell production, approximately 2.6 million red blood
cells per second in order to replace existing cells that have been destroyed by the liver.
[4]
Here all erythrocytes, platelets, and most leukocytes form in adults. From the red
marrow, erythrocytes, platelets, and leukocytes migrate to the blood to do their special
tasks.

Another function of bones is the storage of certain

minerals. Calcium and phosphorus are among the main minerals being stored. The
importance of this storage "device" helps to regulate mineral balance in the
bloodstream. When the fluctuation of minerals is high, these minerals are stored in
bone; when it is low it will be withdrawn from the bone.

Muscular

Types of muscle and their appearance

There are three types of muscles—

cardiac,skeletal, and smooth. Smooth muscles are
used to control the flow of substances within
the lumensof hollow organs, and are not consciously
controlled. Skeletal and cardiac muscles
havestriations that are visible under a microscope due
to the components within their cells. Only skeletal and
smooth muscles are part of the musculoskeletal
system and only the skeletal muscles can move the
body. Cardiac
muscles are found in the heart and are used only to
circulate blood; like the smooth muscles, these
muscles are not under conscious control. Skeletal
muscles are attached to bones and arranged in
opposing groups around joints. Muscles are
innervated, to communicate nervous energy
to, by nerves, which conduct electrical currents from
the central nervous system and cause the muscles to
contract.
Contraction initiation

In mammals, when a muscle contracts, a series of reactions occur. Muscle

contraction is stimulated by the motor neuron sending a message to the muscles from
the somatic nervous system. Depolarization of the motor neuron results
in neurotransmitters being released from the nerve terminal. The space between the
nerve terminal and the muscle cell is called the neuromuscular junction. These
neurotransmitters diffuse across the synapse and bind to specific receptor sites on
the cell membrane of the muscle fiber. When enough receptors are stimulated,
an action potential is generated and the permeability of the sarcolemma is altered. This
process is known as initiation.

Tendons

A tendon is a tough, flexible band of fibrous connective tissue that connects

muscles to bones. Muscles gradually become tendon as the cells become closer to the
origins and insertions on bones, eventually becoming solid bands of tendon that merge
into theperiosteum of individual bones. As muscles contract, tendons transmit the forces
to the rigid bones, pulling on them and causing movement.

Joints, ligaments, and bursae

Human synovial joint composition

Joints

Joints are structures that connect individual

bones and may allow bones to move against each
other to cause movement. There are two divisions
of joints, diarthroses which allow extensive
mobility between two or more articular heads, and
false joints or synarthroses, joints that are
immovable, that allow little or no movement and
are predominantly fibrous. Synovial joints, joints
that are not directly joined, are lubricated by a solution called synovial that is produced
by the synovial membranes. This fluid lowers the friction between the articular surfaces
and is kept within an articular capsule, binding the joint with its taut tissue.
Ligaments

A ligament is a small band of dense, white, fibrous elastic tissue. Ligaments

connect the ends of bones together in order to form a joint. Most ligaments limit
dislocation, or prevent certain movements that may cause breaks. Since they are only
elastic they increasingly lengthen when under pressure. When this occurs the ligament
may be susceptible to break resulting in an unstable joint.

Ligaments may also restrict some actions: movements such

as hyperextension and hyperflexion are restricted by ligaments to an extent. Also
ligaments prevent certain directional movement.

Bursa

A bursa is a small fluid-filled sac made of white fibrous tissue and lined with
synovial membrane. Bursa may also be formed by a synovial membrane that extends
outside of the join capsule. It provides a cushion between bones and tendons and/or
muscles around a joint; bursa are filled with synovial fluid and are found around almost
every major joint of the body.
 CHAPTER IV
Overview of the Disease

A. REVIEW OF RELATED LITERATURE

Definition

Osteomyelitis (osteo- derived from

the Greek word osteon, meaning bone,
myelo- meaning marrow, and -itis
meaning inflammation) simply means
an infection of the bone or bone marrow.

It can be usefully subclassified on

the basis of the causative organism
(pyogenic bacteria or mycobacteria), the
route, duration and anatomic location of
the infection.

Causes

It can be caused by a variety of microbial agents (most common in

staphylococcus aureus) and situations, including:

• An open injury to
the bone, such as an
open fracture with the
bone ends piercing the
skin.
• An infection from
elsewhere in the body,
such as pneumonia or a
urinary tract infection that has spread to the bone through the blood
(bacteremia, sepsis).
 • A minor trauma, which can lead to a blood clot around the bone
and then a secondary infection from seeding of bacteria.
• Bacteria in the bloodstream bacteremia (poor dentition), which is
deposited in a focal (localized) area of the bone. This bacterial site in the
bone then grows, resulting in destruction of the bone. However, new bone
often forms around the site.
• A chronic open wound or soft tissue infection can eventually extend
down to the bone surface, leading to a secondary bone infection. (Black
and Hawks, 2005)

Risk Factors

Males are affected more often than females, often as a result of trauma.
Susceptibility to infection increases with IV drug use, diabetes,
immunocompromising diseases or a history of blood- stream infections. (Black
and Hawks, 2005)

Prognosis

Prognosis varies depending on how quickly an infection is identified, and what

other underlying conditions exist to complicate the infection. With quick, appropriate
treatment, only about 5% of all cases of acute osteomyelitis will eventually become
chronic osteomyelitis. Patients with chronic osteomyelitis may require antibiotics
periodically for the rest of their lives.

Mortality/Morbidity

• Mortality from osteomyelitis was 5-25% in the preantibiotic era. Currently,

the mortality rate approaches 0%.
• Complications of osteomyelitis include (1) septic arthritis, (2) destruction of
the adjacent soft tissues, (3) malignant transformation (eg, Marjolin ulcer
[squamous cell carcinoma], epidermoid carcinoma of the sinus tract), (4)
secondary amyloidoses, and (5) pathologic fractures.

Signs and Symptoms

 Clinical manifestations may slightly vary according to the site of
involvement. Infection in the long bones is accompanied by acute localized pain
and redness or drainage often with a history of recent trauma or newly acquired
prostheses. Fever and malaise may be present. Infection in the vertebrae usually
brings pain and mobility difficulties. The client with vertebral osteomyelitis often
reports a history of genitourinary infection or drug abuse. Osteomyelitis in the
foot is most commonly associated with vascular insufficiency. (Black and Hawks,
2005)

Acute osteomyelitis refers to the initial infection or an infection of less than

1 month duration. The clinical manifestations of acute myelitis are both systemic
and local. Systemic manifestations include fever, night sweat, chills restlessness,
nausea and malaise. Local manifestations include constant bone pain that is
unrelieved by rest and worsens with activity; swelling, tenderness and warmth at
the infection site; and restricted movement of the affected part. Later signs
include drainage from sinus tracts to the skin and/or the fracture site. (Lewis,
2004)

Chronic myelitis refers to a bone infection that persists for longer than 1
month or an infection that has failed to respond to the initial course of antibiotic
therapy. Systemic signs may be diminished, with local signs of infection more
common, including constant bone pain and swelling, tenderness and warmth at
the infection site. (Lewis, 2004)

Laboratory Studies

Laboratory
studies and X-rays or
bone scans are
important in the
definitive diagnosis of
osteomyelitis. Elevated
WBC and ESR, an
elevated level of C-
reactive protein (a protein that circulates in the blood and dramatically increases
in level when there is inflammation) usually occur. Along with clinical
manifestations, usually allow initial diagnosis and early treatment while the
physician waits for further evidence from blood cultures or needle aspirate
analysis. To diagnose a bone infection and identify the organisms causing it,
doctors may take samples of blood, pus, joint fluid, or the bone itself to test.
Usually, for vertebral osteomyelitis, samples of bone tissue are removed with a
needle or during surgery.

Radiographic changes related to osteomyelitis are generally evident within

7 to 10 days, but in some cases the diagnosis is not confirmed on X-rays until 3
to 4 weeks after infection develops. Early acute osteomyelitis is more efficiently
identified by radionuclide bone scans, which can detect lesions within 24 to 72
hours after the onset of infection. Because of its ability to distinguish between
soft tissue and bone marrow, magnetic resonance imaging It is also being used
increasingly for definitive diagnosis of osteomyelitis.

To diagnose osteomyelitis, the doctor will first perform a history, review of

systems, and a complete physical examination. In doing so, the physician will
look for signs or symptoms of soft tissue and bone tenderness and possibly
swelling and redness. The doctor will also ask you to describe your symptoms
and will evaluate your personal and family medical history. The doctor can then
order any of the following tests to assist in confirming the diagnosis:

• Blood tests: When testing the blood, measurements are taken to

confirm an infection: a CBC (complete blood count), which will show if
there is an increased white blood cell count; an ESR (erythrocyte
sedimentation rate); and/or CRP (C-reactive protein) in the bloodstream,
which detects and measures inflammation in the body.
• Blood culture: A blood culture is a test used to detect bacteria. A
sample of blood is taken and then placed into an environment that will
support the growth of bacteria. By allowing the bacteria to grow, the
infectious agent can then be identified and tested against different
antibiotics in hopes of finding the most effective treatment.
• Needle aspiration: During this test, a needle is used to remove a
sample of fluid and cells from the vertebral space, or bony area. It is then
sent to the lab to be evaluated by allowing the infectious agent to grow on
media.
• Biopsy: A biopsy (tissue sample) of the infected bone may be
taken and tested for signs of an invading organism.
• Bone scan: During this test, a small amount of Technetium-99
pyrophosphate, a radioactive material, is injected intravenously into the
 body. If the bone tissue is healthy, the material will spread in a uniform
fashion. However, a tumor or infection in the bone will absorb the material
and show an increased concentration of the radioactive material, which
can be seen with a special camera that produces the images on a
computer screen. The scan can help your doctor detect these
abnormalities in their early stages, when X-ray findings may only show
normal findings.

Treatment and Management

Elimination of the infecting organisms, both locally from the bone and
systemically from the body, is the major treatment goal for osteomyelitis. Prompt
treatment also prevents further bone deformity and injury, increases client
comfort, and avoids complications of impaired mobility. Surgery is initially
performed on the adult client with osteomyelitis to ensure effective debridement
and drainage, elimination if dead space, and adequate soft tissue coverage.
Antibiotics alone rarely resolve infection in adults, but they do work more
efficiently after surgical preparation of the treatment area. High doses of
parenteral antibiotics are frequently administered for 4 to 8 weeks to achieve a
bactericidal level in the bone tissue. Oral antibiotics are continued for another 4
to 8 weeks, with serial bone scans and ESR measurements performed to
evaluate the effectiveness of drug therapy. Open drainage wounds are packed
with gauze to promote drainage. If initial treatment is delayed or inadequate, the
necrotic bone separates from the living bone to form sequestra, which serves as
a medium for additional microorganism growth. Chronic osteomyelitis can result.
(Black and Hawks, 2005)

The objective of treating osteomyelitis is to eliminate the infection and

prevent the development of chronic infection. Chronic osteomyelitis can lead to
permanent deformity, possible fracture, and chronic problems, so it is important
to treat the disease as soon as possible.

Drainage: If there is an open wound or abscess, it may be drained through a

procedure called needle aspiration. In this procedure, a needle is inserted into
the infected area and the fluid is withdrawn. For culturing to identify the bacteria,
deep aspiration is preferred over often- unreliable surface swabs. Most pockets
of infected fluid collections (pus pocket or abscess) are drained by open
surgical procedures.

Medications: Prescribing antibiotics is the first step in treating osteomyelitis.

Antibiotics help the body get rid of bacteria in the bloodstream that may
otherwise re-infect the bone. The dosage and type of antibiotic prescribed
depends on the type of bacteria present and the extent of infection. While
antibiotics are often given intravenously, some are also very effective when given
in an oral dosage. It is important to first identify the offending organism
through blood cultures, aspiration, and biopsy so that the organism is not masked
by an initial inappropriate dose of antibiotics. The preference is to first make
attempts to do procedures (aspiration or bone biopsy) to identify the organisms
prior to starting antibiotics.

Splinting or cast immobilization: This may be necessary to immobilize the

affected bone and nearby joints in order to avoid further trauma and to help the
area heal adequately and as quickly as possible. Splinting and cast
immobilization are frequently done in children, although motion of joints after
initial control is important to prevent stiffness and atrophy.

Surgery: Most well-established bone infections are managed through open

surgical procedures during which the destroyed bone is scraped out. In the
case of spinal abscesses, surgery is not performed unless there is compression
of the spinal cord or nerve roots. Instead, patients with spinal osteomyelitis
are given intravenous antibiotics. After surgery, antibiotics against the specific
bacteria involved in the infection are then intensively administered during the
hospital stay and for many weeks afterward.

With proper treatment, the outcome is usually good for osteomyelitis,

although results tend to be worse for chronic osteomyelitis, even with surgery.
Some cases of chronic osteomyelitis can be so resistant to treatment that
amputation may be required; however, this is rare. Also, over many years,
chronic infectious draining sites can evolve into a squamous-cell type of skin
cancer; this, too, is rare. Any change in the nature of the chronic drainage, or
change of the nature of the chronic drainage site, should be evaluated by a
physician experienced in treating chronic bone infections. Because it is
important that osteomyelitis receives prompt medical attention, people who are at
 a higher risk of developing osteomyelitis should call their doctors as soon as
possible if any symptoms arise.

B. CURRENT TRENDS AND ISSUES

Radiology: Whole-body MR useful in detecting rare bone disease

Written by Editorial Staff
September 10, 2009

Whole-body MRI, because it is more likely to show abnormalities, can help

detect chronic recurrent multifocal osteomyelitis (CRMO), according to a study in
the September issue of Radiology.

CRMO is a rare disease characterized by aseptic inflammatory lesions of

bone in children and adolescents, the cause and pathogenesis of which are
poorly understood.

In the study, Jan Fritz, MD, from the department of radiology and
radiological science at Johns Hopkins University School of Medicine in Baltimore,
and colleagues reviewed two-plane radiographs, clinical findings and lab data for
13 children (median age, 13 years) with CRMO. They evaluated lesion depiction,
location and characterization and extraskeletal abnormalities, and compared MRI
findings with clinical and lab data and radiographic results.

The authors whole-body MRI depicted 101 lesions—an average of eight

affected anatomic sites per patient. It was seen most frequently in the distal
femur (21 of 101 lesions), proximal tibia (17 of 101), distal tibia (14 of 101) and
distal fibula (14 of 101). No lesions were found in the cranium, clavicle or upper
extremity.

In tubular bones (90 anatomic sites) involvement of the metaphysis was

present in 86 percent of patients; of the epiphysis, in 67 percent; of the diaphysis,
in 14 percent; and of the apophysis, in 3 percent, according to Fritz and
colleagues. For the 74 lesions located in the periphyseal region, a contiguous
physeal relationship was present in 89 percent. Multifocality was present in all
patients.
 The authors found that CRMO “manifests with a whole-body MRI pattern
of ill-defined edemalike lesions, most frequently located in the lower appendicular
skeleton in a periphysial location.” Multifocality was virtually always present, most
distributed symmetrically in the lower extremities and was frequently subclinical.

“Whole-body MRI depicted this pattern at a higher rate than did

radiography and clinical examination,” the authors reported, adding that whole-
body MRI is more likely to show abnormalities than are ESR and CRP values.

Whole-body MRI, the authors concluded, is useful in the radiation-free

detection of asymptomatic and radiographically hidden multifocal sites of disease
in patients with CRMO. The reason, the authors say, is that whole-body MRI
identifies characteristic, ill-defined, edemalike, periphyseal osseous lesions
predominantly in symmetrical lower extremity distribution.

Last Updated on Friday, September 11 2009

 CHAPTER V
Case Study Proper

VITAL INFORMATION
NAME: K.C.
ADDRESS: Caloocan City
AGE: 7 years old
SEX: Female
WEIGHT: 15.9 kg
NATIONALITY: Filipino
RELIGION: Roman Catholic
BIRTHDAY: April 03, 2002
STATUS: Child
ADMISSION DATE: March 22, 2010; 4:30 pm
WARD: Children’s ward
ATTENDING PHYSICIAN: Dr. Caltila
DIAGNOSIS: Chronic osteomyelitis: 3rd digit, right foot

A. GENERAL STUDY

General Appearance
Patient appears her stated age. She is awake sitting on bed with ongoing
IVF of D50.3NaCl 500cc to run for KVO @ 100cc level, inserted @ right basilic
vein. Patient is active and playful. Her right foot is slightly bigger than her left due
to inflammation process secondary to chronic osteomyelitis.

Body Structure
Other body parts look equal bilaterally and are in relative proportion to
each other.

Behavior
 She has good eye to eye contact. She does attend and responds to
questions appropriately.

Initial V/S
Temperature: 36.3oC
Cardiac Rate: 79bpm
Respiratory Rate: 35bpm

B. PHYSICAL ASSESSMENT

Method Actual
Area Assessed Normal Findings Remarks
Used Findings
Skin

• Color Inspection >Varies from light to >Brownish >Normal

deep brown, from
ruddy pink to light
pink, from yellow
overtones to olive

• Uniformity of Inspection >Generally uniform >Generally >Normal

skin color except in areas uniform except
exposed to the sun, in areas with
areas of lighter swelling tissues
pigmentations (palms,
lips and nail beds).

• Temperature >Uniform within >Uniform within

Palpation normal range(36.5- normal >Normal
37.5) range(36.3)

• Moisture >Moisture in the skin >Moisture in the

Inspection; folds and the axilla skin >Normal
Palpation (varies with folds and the
environmental axilla
temperature and
humidity, body
temperature and
activity)

• Turgor >Springs back to >Springs back

Inspection; normal when pinched to normal when >Normal
Palpation pinched

Inspection >Epidermis is >Epidermis is >Normal

• Thickness
uniformly thin over uniformly thin
most of the body over most of the
body

Palpation >Skin surfaces are >Skin surfaces >Normal

• Tenderness
non-tender are non-tender

Inspection >Absence of lesions >With lesions >Onset of

• Lesions infection

Inspection >Absence of edema >With swelling >Due to

• Edema of the right foot inflammation
Hair
• Distribution
Inspection >Evenly distributed > Evenly >Normal
over the scalp distributed over
the scalp
• Texture
Palpation >Fine or thick hair; >With straight, >Normal
straight, curly or kinky; thick hair
silky, resilient hair

• Color Inspection >Black color or gray >Black color >Normal

color, considering the
age

• Seborrhea Inspection >Absence of >Absence of >Normal

seborrhea seborrhea
Nails

• Appearance Inspection >Clean nails >Clean nails >Normal

• Color of nailbed Inspection >Pink >Pink >Normal

• Shape
Inspection >Convex to curvature >Convex to >Normal
curvature

• Texture Inspection >Smooth >Smooth >Normal

• Capllary refill Palpation >Return within 2-3 >Return within 2 >Normal

time seconds seconds
Head

• Shape and size Inspection >Rounded, smooth >Rounded, >Normal

skull contour smooth skull
contour

• Facial features Inspection >Symmetric or slightly >Symmetric >Normal

asymmetric facial
features

• Symmetry of Inspection >Symmetric facial >Symmetric >Normal

facial features movements facial
movements
Ears

Auricle
• Position Inspection >At the level of the >At the level of >Normal
external cantus of the the external
eyes cantus of the
eyes

• Texture Inspection >Smooth without >Smooth >Normal

lesion without lesion
External Auditory canal
• Discharges Inspection >None >None >Normal

• Color of canal Inspection >Pink >Pink >Normal

walls

Nose

• Color Inspection >Same color with the >Same color >Normal

face with the face

• Sinuses Inspection >Not inflamed >Not inflamed >Normal

 • Nares Inspection >No obstruction; oval >No obstruction; >Normal
and symmetric oval and
symmetric

• Lesion/ Palpation >Not tender, absence >Not tender, >Normal

Tenderness of lesion absence of
lesion

Lips

• Symmetry Inspection >Symmetrical >Symmetrical >Normal

• Color Inspection >Pinkish >Pinkish >Normal

• Texture Palpation >Smooth >Smooth >Normal

Teeth Inspection >Free from decays, >Free from >Normal

white, smooth and decays
shiny

Tongue

• Position Inspection >Center >Center >Normal

• Color Inspection >Pink >Pink >Normal

Neck

• Position Inspection >Centrally located on >Centrally >Normal

the shoulder located on the
shoulder

• Movement Inspection >Able to flex and >Able to flex >Normal

extend head without and extend head
pain and resistance without pain and
resistance

• Lymph nodes Palpation >Not palpable >Not palpable >Normal

Thyroid glands

• Consistency Inspection >Not visible when >Not visible >Normal

swallowing when
swallowing

• Size Palpation >Small >Small >Normal

Palpation >Smooth and free >Smooth and >Normal

• Texture
from nodules free from
nodules
Thorax and Lungs

Anterior thorax and

lungs

• Breathing Inspection > Quiet, Rhythmic and > Quiet, >Normal

patterns Effortless Respiration Rhythmic and
Effortless
Respiration
(RR: 35 bpm)

• Symmetry Inspection >Symmetrical >Symmetrical >Normal

• Lung breath Auscultation >No adventitious >No >Normal

sound adventitious
sounds
sound
 • Shape Inspection; >oval/elliptical >oval/elliptical >Normal
palpation

Heart
• Rate Auscultation >Regular rate(60-100) >Regular >Normal
rate(80bpm)

• Rhythm Auscultation >no murmur >no murmur >Normal

Abdomen
• Contour Inspection >Flat, rounded >Flat, rounded >Normal

Upper & lower

extremities

• Size Inspection >Equal size >Right foot is >Due to

slighty bigger swelling
than left

• Symme Inspection >Symmetrical >Symmetrical >Normal

try
Inspection >Evenly distributed >Evenly >Normal
• Distribu distributed
tion of hair
Inspection >Light to deep brown >Brownish >Normal
• Skin
color Inspection >No lesions, >With lesions on >Due to
deformities or right foot disease
• Lesions inflammation process

Musculoskeletal

• Joints Inspection >No swelling on the >With swelling >Due to

skin and tissues over on the skin and inflammation
the joints tissues over the process
joints of the right
foot

• ROM Inspection >Full ROM against >Active motion >Normal

gravity, full resistance, against gravity,
5/5 average
weakness, 5/5

C. HISTORY OF PRESENT ILLNESS

Two years PTA, patient had a small blister on the sole of the right foot.
Patient’s mother ignored the lesion for she perceived it as a minor cut only. No
treatment or consultation was done.

Two weeks PTA, patient’s mother noted swelling on the 3rd digit of the
right foot; this was associated with on and off fever.

On March 21, 2010, patient had high grade fever. They consult at a local
hospital and urinalysis was done. The patient was diagnosed of UTI, and was
 given antibiotics and pain medications. They were referred to the Philippine
Orthopedic Center (POC) for chronic osteomyelitis.

D. PAST MEDICAL HISTORY

The patient had a congenital heart defect—patent ductus arteriosus (PDA)

and an inborn soft palpable mass on the upper right buttocks.

On August 16, 2002, the patient was admitted to the Philippine Heart
Center after experiencing cyanosis and loss of breath PTA. On admission, she
was given oxygen and other unrecalled management according to her mother.
She was operated on October of the same year regarding her PDA condition.

Patient also had urinary tract infection (UTI) a year ago. She consulted to
a local doctor and was given antibiotics.

E. FAMILY HEALTH HISTORY

There is a history of high blood pressure on her father’s side but no

account for any congenital defects of both sides.

G. LABORATORY ANALYSIS

Composition Result Normal Values Interpretation Nursing Responsibility

March 23, 2010 • Assess for presence of,

existence of, & history of risk
Urinalysis: factors for infection.
• Monitor laboratory studies.
Color Light yellow Amber to • Monitor the ff. for signs of
yellowish infection.
 Elevated temp.
Transparency Hazy Clear  Color of
respiratory secretions
RBC 18-20 0-4 hpf
Actual infection  Appearance of
urine
Pus cells 20-22 0-5 hpf
• Administer or teach use of
antimicrobial drugs.
March 23, 2010 • Teach patient or caregiver to
wash hands often, especially
Blood after toileting, before meals
Chemistry: and after administering self-
care.
leukocyte 22.2 4.5-10 x 10^ g/L • Teach patient or caregiver the
signs & symptoms of infection
and when to report these to
the physician.
• Encourage to eat foods high
in Vitamin C like citrus fruits.
H. PATHOPHYSIOLOGY

Direct entry osteomyelitis can occur at any age when there is an open wound
(e.g. penetrating wounds, fractures) and microorganisms gain entry to the body.
Osteomyelitis may also occur in the presence of a foreign body such as an implant or
an orthopedic prosthetic device (e.g. plate, total joint prosthesis ). After gaining entrance
to the bone by way of the blood, the microorganisms then lodge in an area of the bone
in which circulation slows, usually the metaphysis. The microorganisms grow, resulting
in an increase in pressure because of the nonexpanding nature of most bones. This
increasing pressure eventually leads to ischemia and vascular compromise of the
periosteum. Eventually the infection passes through the bone cortex and marrow cavity,
ultimately resulting in cortical devascularization and necrosis. Once ischemia occurs,
the bone dies. The area of devitalized bone eventually separates from the surrounding
living bone forming sequestra. The part of the periosteum that continues to have blood
supply forms new bone called involucrum. (Lewis, 2004)

Once formed, a sequestrum continues to be a infected island of bone surrounded

by pus and difficult to reach by blood-borne antibiotics or white blood cells (WBCs).
Sequestrum may enlarge and serve as a site for microorganisms that spread to other
sites, including the lungs and the brain. The sequestrum can move out of the bone and
into the soft tissue. Once outside the bone, the sequestrum may revascularize and then
undergo removal by normal immune system process. Another possibility is that the
sequestrum can be surgically removed through debridement of the necrotic bone. If the
necrotic sequestrum is not resolved naturally or surgically, it may develop a sinus tract,
resulting n a chronic purulent cutaneous drainage.(Lewis, 2004)

Chronic osteomyelitis is either a continuous persistent problem (a result of

inadequate acute treatment) or process of exacerbations and remission. Over time,
granulation tissue turns to scar tissue. This vascular scar tissue provides an ideal site
for continued microorganism growth in impenetrable to antibiotics. (Lewis, 2004)
 Non-modifiable:
Modifiable:
- 7 years old
- penetrating wound
- Female

Bacterial invasion

Neutrophil invasion/
Inflammatory response

Pus formation Fever Leukocytosis Heat,

Leukocyte: 22.2 x 10^ g/L Redness
Swelling
Tenderness
Pus spread into vascular channels

Periosteum—lifts form the bone

Pain

Increased intraosseus response

Disruption in blood supply

Ischemic necrosis

Sequestra

Osteoblastic response

Involucrum

Osteomyelitis
 I. NURSING CARE PLAN

Assessment Nursing Diagnosis Nursing Plan Nursing Intervention Rationale Evaluation

Subjective: Risk for peripheral At the end of the nursing • Assess general • Provide basis for
neurovascular interventions, the patient condition of and understanding
• “Namamaga
dysfunction related will be able to maintain contributing factors to general, current
‘yung paa ko.” as
tointerruption of blood tissue perfusion as patient. situation of client.
verbalized
flow secondsary to evidenced by palpable • Evaluate • Decreased/absent
disease condition pulses, skin warm, presence/quality of pulse may reflect
Objective:
normal sensation and peripheral pulse distal vascular injury and
• slow healing of
stable vital signs. to injury via palpation. necessitates
lesion
immediate medical
• swelling of the
evaluation of
right foot
circulatory status.
• presence of
• Assess capillary • Return of color should
abscess on the
return, skin color, and be rapid (3-5 secs.).
right foot
warmth distal to White, cool skin
• weak pulse on
inflammation. indicates arterial
the right foot
impairment. Cyanosis
suggests venous
impairment.
• Maintain elevation of • Promotes venous
inflamed extremity drainage/decreases
unless contraindicated edema.
by confirmed
presence of
compartmental
syndrome.
• Investigate sudden • Osteomyelitis may
signs of limb cause damage to
ischemia, e.g., adjacent arteries, with
decreased skin resulting loss of distal
 temperature, pallor, blood flow.
and increased pain. • Enhances circulation
• Encourage patient to and reduces pooling
routinely exercise of blood, especially in
digits/joints distal to the lower extremities.
inflammation.

• Investigate reports of • Helpful in determining

Subjective: Altered comfort: pain At the end of the nursing pain, noting location pain management
• “Ang sakit ng paa related to inflammatory interventions, the patient and intensity (scale of and effectiveness of
ko.” as process secondary to will be able to 0-10), note interventions.
verbalized. disease condition incorporate relaxation precipitating factors
skills and diversional and nonverbal cues.
Objective: activities to reduce pain. • Maintain bed rest or • Bed rest may be
• pain scale-8/10 chair rest when necessary to limit
• with gurading indicated. pain/injury to joints.
behavior • Place pillows on • Rests painful and
with reluctance to affected area. maintains neutral
attempt position.
movement; • Encourage frequent • Prevents general
limited ROM changes of position to fatigue and joint
• with reports of move in bed, stiffness, stabilizes
pain supporting affected joint, decreasing joint
• with distracted joints above and movements and
behavior below, avoiding jerky associated pain.
movements.
• Involve in diversional • Refocuses attention,
activities appropriate provides stimulation,
for individual situation, and enhances self-
e.g., coloring of esteem and feelings
books, playing with of general well-being.
toys.
 • Assess skin lesions, • Indicates local
Objective: Actual infection related At the end of the nursing noting reports of infection/tissue
• leukocyte: 22.2 x to increased WBC count interventions, the patient increased pain or necrosis which is a
10^ g/L and presence of will achieve timely presence of edema, major sign of
• with purulent pyogenic wound healing; free of erythema, foul odor, osteomyelitis.
discharges on microorganisms in the signs of infection. or drainage.
right foot local infection • Provide sterile wound • May prevent cross-
• pus cells in urine: care, and exercise contamination and
20-22hpf meticulous any further
• presence of handwashing. complications.
lesion on right • Instruct patient not to • Minimizes opportunity
foot touch wound with bare for contamination.
hands.
• Monitor vital signs. • Tachycardia and
Note presence of chills/fever reflect
chills, fever and developing sepsis.
malaise.

Subjective: Impaired skin integrity • Examine the skin for • Provides information
• “May sugat po related to inflammatory At the end of the nursing open wounds, foreign regarding skin
ako sa paa” as response secondary to interventions, the patient bodies and circulation and
verbalized. disease condition will demonstrate discoloration. problems that may be
behaviors/techniques to caused by edema
Objective: prevent skin formation that may
breakdown/facilitate
• disruption of skin require further
healing as indicated. medical intervention.
surface of the
lower extremity • Demonstrate good • Maintaining a clean,
• destruction of skin hygiene, e.g., dry skin provides a
skin wash thoroughly and barrier to infection.
layers/tissues of pat dry carefully. Patting skin dry
the right foot instead of rubbing
• reports of pain, reduces risk of dermal
pressure in trauma to fragile skin.
affected/ • Discuss importance of • These provide patient
 surrounding area adequate nutrition information how
• invasion of body especially fluids, nutrition could elevate
structures proteins, vitamins B her chances of a
• with purulent and C, iron and faster recovery and
discharge on the calories. wound healing.
right foot • Establish a turning or • This provides the
repositioning patient’s guide
schedule. towards a proper skin
management
technique minimizing
more skin trauma.
• Emphasize principles • To avoid possible
of asepsis especially infection thus
hand washing and hindering the wound
avoidance of touching healing process.
wound with bare
hands.
• Demonstrate wound • To provide the patient
care technique such or patient’s SO on the
as wound cleansing. correct procedures
and techniques of
wound caring.

Subjective: Altered body • Assess general • Provides basis for

• “Nilalamig ako.” temperature: increased At the end of the nursing condition of and understanding
as verbalized related to presence of interventions, the contributing factors to general, current
pyogenic patient’s temperature will patient. condition of patient.
Objective: microorganisms in the decrease from 38.9oC to • Monitor vital signs • Notes progress and
• T: 38.9oC local circulation 36.8oC. especially changes of condition.
• RR: 39bpm temperature.
• skin warm to • Assess fluid loss and • Increases in
touch facilitate oral intake. metabolic rate and
• with flushed skin diaphoresis.
• perspiring • Provide tepid sponge • Enhances heat loss
profusely bath. by evaporation and
 • with teary eyes conduction.
• with purulent • Promote bed rest. • Reduces body heat
discharge on the production.
right foot • Provide cool • Dissipates heat by
circulating air by convection.
opening windows or
ensuring that patient
is not covered with
thick blankets.
• Assist patient in • Increases comfort.
changing into dry
clothing.

Subjective: Impaired physical • Assess degree of • Level of

• “Hindi ako mobility related to At the end of the nursing immobility produced activity/exercise
masyadong pain/discomfort interventions, the patient by pain. depends on
makalakad.” as will regain/maintain progression/resolution
verbalized. mobility at the highest • Instruct patient of inflammatory
possible level. in/assist with process.
Objective: active/passive ROM • Increases blood flow
• with reluctance to exercises of affected to muscles and bone
attempt and unaffected to improve muscle
movement; extremities. tone, maintain joint
limited ROM • Encourage patient to mobility.
• with decreased maintain upright and
muscle erect posture when • Maximizes joint
strength /control sitting, standing, and function, maintains
• inability to move walking. mobility.
purposefully • Discuss/provide safety
within the needs, e.g., raised
physical side rails.
environment, • Helps prevent
imposed accidental
restrictions injuiries/falls.
J. DRUG STUDY

*Common adverse effects in italic, life-threatening effects underlined

 DRUG ORDER INDICATIONS AND ADVERSE NURSING
SPECIFIC PHARMACOLOGIC
(Generic name, CONTRAINDICATIO EFFECTS OF THE RESPONSIBILITIES
ACTION ACTION OF DRUG
Dosage, Route, NS DRUG /PRECAUTIONS
Frequency, etc.)

Generic Name: ANTIINFECTIVE; Preferentially binds Indications: Body as a Whole: • Determine

Cefuroxime ANTIBIOTIC; to one or more of the It is effective for the Thrombophlebitis history of
400mg IV q8 SECOND- penicillin-binding treatment of (IV site); pain, hypersensitivity
GENERATION proteins (PBP) penicillinase- burning, cellulitis reactions to
Brand Name: CEPHALOSPORI located on cell walls producing Neisseria (IM site); cephalosporins,
Kefurox N of susceptible gonorrhoea (PPNG). superinfections, penicillins, and
organisms. This Effectively treats positive Coombs' history of
inhibits 3rd and final bone and joint test. allergies,
stage of bacterial infections, bronchitis, particularly to
cell wall synthesis, meningitis, GI: Diarrhea, drugs, before
thus killing the gonorrhea, otitis nausea, antibiotic- therapy is
bacteria. media, associated colitis. initiated.
pharyngitis/tonsillitis, • Inspect IM and
sinusitis, lower Skin: Rash, IV injection sites
respiratory tract pruritus, urticaria. frequently for
infections, skin and signs of phlebitis.
soft tissue infections, Urogenital: • Report onset of
urinary tract Increased serum loose stools or
infections, and is creatinine and BUN, diarrhea.
used for surgical decreased Although
prophylaxis, reducing creatinine pseudomembran
or eliminating clearance. ous colitis.
infection. • Monitor I&O
rates and pattern:
Contraindications: Especially
Hypersensitivity to important in
cephalosporins and severely ill
related antibiotics; patients receiving
pregnancy (category high doses.
Generic Name: B), lactation. Report any
Paracetamol significant
550mg/5mL q4; NON-OPIOID Paracetamol exhibits changes.
for T>=38.0oC ANALGESIC analgesic action by
peripheral blockage Side effects are
Brand Name: of pain impulse rare with
Gandol generation. It Indications: paracetamol when it
produces antipyresis To relieve mild to is taken at the
by inhibiting the moderate pain due to recommended
hypothalamic heat- things such as doses. Skin rashes,
blood disorders and Assessment & Drug
regulating centre. Its headache, muscle Effects
weak anti- and joint pain, acute inflammation
inflammatory activity backache and period of the pancreas
have occasionally • Monitor for
is related to pains. It is also used S&S of:
inhibition of to bring down a high occurred in people
taking the drug on a hepatotoxicity,
prostaglandin temperature. For this even with
synthesis in the reason, paracetamol regular basis for a
long time. One moderate
CNS. can be given to acetaminophen
children after advantage of
paracetamol over doses, especially
vaccinations to in individuals with
prevent post- aspirin and NSAIDs
is that it doesn't poor nutrition.
immunisation pyrexia
(high temperature). irritate the stomach
or causing it to Patient & Family
Paracetamol is often Education
included in cough, bleed, potential
Side effects of • Do not take
cold and flu
aspirin and other medications
remedies.
NSAIDs. (e.g., cold
preparations)
Contraindications:
containing
Hypersensitivity to
acetaminophen
acetaminophen or
without medical
phenacetin; use with
advice;
alcohol.
overdosing and
chronic use can
cause liver
damage and
other toxic
effects.
• Do not self-
medicate children
for pain more
than 5 d without
consulting a
physician.
• Do not use for
Course in the Ward
On March 22, 2010, patient was admitted to room-of-choice under children’s
ward. Her vital signs were monitored every shift and her diet was diet as tolerated.

The doctor ordered for her CBC, ESR, CRP, CT, BT, PT, PTT and UA. The
patient also underwent x-ray of her right foot.

Medication was given such as cefuroxime 750mg IV ANST then cefuroxime

400mg IV q8. She was started for venoclysis with D50.3NaCl 500cc @ KVO rate.

On March 29, 2010, the patient was for repeat UA, CBC, ESR, and CRP.
Her antibiotic medication was continued; and IVF was the same. She was prescribed
paracetamol 250mg/5mL q4 and for temp. >=38.0oC.
 CHAPTER VI
Evaluation

During the nurse-patient relationship, client’s condition was stable.

She does not experience any pain, fever and/or malaise though there is an
obvious swelling of her right foot and respiratory discharges scanty in amount, greenish
in color.

Patient was scheduled for surgery of her foot on March 31, 2010 but her doctor
delayed because of her intermittent condition of the heart as revealed by her x-rays, and
her lesion needs to be drained first. Her operation is still pending.
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