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SOUTHERN LUZON STATE UNIVERSITYLucban, Quezon
CHRONIC OSTEOMYELITISA Case Study
Presented to the FacultyOf College of Allied Medicine
In partial fulfillment of the requirementsfor the Degree Bachelor of Science in Nursing
Submitted by:Abrigo, Ellennor F.
Job, GenesisOlaivar, Monique S.
Submitted to:Prof. Caroline Murallon
Summer Affiliation, 2010
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CHAPTER IObjective of the Study
A. GENERAL OBJECTIVES:
B. SPECIFIC OBJECTIVES:
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CHAPTER IIIntroduction 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 longbones 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.
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CHAPTER IIIAnatomy 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 muscularand skeletal systems. The musculoskeletal system provides form, support,
stability, and movement to the body.
It is made up of the bodys 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 bonesand 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 byjoints. 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.
http://en.wikipedia.org/wiki/Organ_(anatomy)http://en.wikipedia.org/wiki/Organ_(anatomy)http://en.wikipedia.org/wiki/Muscular_systemhttp://en.wikipedia.org/wiki/Skeletal_systemhttp://en.wikipedia.org/wiki/Skeletonhttp://en.wikipedia.org/wiki/Musclehttp://en.wikipedia.org/wiki/Cartilagehttp://en.wikipedia.org/wiki/Tendonshttp://en.wikipedia.org/wiki/Ligamentshttp://en.wikipedia.org/wiki/Jointshttp://en.wikipedia.org/wiki/Connective_tissuehttp://en.wikipedia.org/wiki/Hematopoietic_systemhttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Musclehttp://en.wikipedia.org/wiki/Connective_tissuehttp://en.wikipedia.org/wiki/Tendonhttp://en.wikipedia.org/wiki/Ligamenthttp://en.wikipedia.org/wiki/Jointhttp://en.wikipedia.org/wiki/Cartilagehttp://en.wikipedia.org/wiki/Medical_diagnosishttp://en.wikipedia.org/wiki/Organ_(anatomy)http://en.wikipedia.org/wiki/Organ_(anatomy)http://en.wikipedia.org/wiki/Muscular_systemhttp://en.wikipedia.org/wiki/Skeletal_systemhttp://en.wikipedia.org/wiki/Skeletonhttp://en.wikipedia.org/wiki/Musclehttp://en.wikipedia.org/wiki/Cartilagehttp://en.wikipedia.org/wiki/Tendonshttp://en.wikipedia.org/wiki/Ligamentshttp://en.wikipedia.org/wiki/Jointshttp://en.wikipedia.org/wiki/Connective_tissuehttp://en.wikipedia.org/wiki/Hematopoietic_systemhttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Musclehttp://en.wikipedia.org/wiki/Connective_tissuehttp://en.wikipedia.org/wiki/Tendonhttp://en.wikipedia.org/wiki/Ligamenthttp://en.wikipedia.org/wiki/Jointhttp://en.wikipedia.org/wiki/Cartilagehttp://en.wikipedia.org/wiki/Medical_diagnosis8/8/2019 Case Study of Chronic Osteomyelitis
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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 fortissues 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 ofbone 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
http://en.wikipedia.org/wiki/Long_boneshttp://en.wikipedia.org/wiki/Long_boneshttp://en.wikipedia.org/wiki/Short_boneshttp://en.wikipedia.org/wiki/Flat_boneshttp://en.wikipedia.org/wiki/Irregular_boneshttp://en.wikipedia.org/wiki/Sesamoid_boneshttp://en.wikipedia.org/wiki/Axial_skeletonhttp://en.wikipedia.org/wiki/Appendicular_skeletonhttp://en.wikipedia.org/wiki/Tissue_(biology)http://en.wikipedia.org/wiki/Organshttp://en.wikipedia.org/wiki/Brainhttp://en.wikipedia.org/wiki/Skullhttp://en.wikipedia.org/wiki/Lungshttp://en.wikipedia.org/wiki/Rib_cagehttp://en.wikipedia.org/wiki/Bone_marrowhttp://en.wikipedia.org/wiki/Long_boneshttp://en.wikipedia.org/wiki/Long_boneshttp://en.wikipedia.org/wiki/Short_boneshttp://en.wikipedia.org/wiki/Flat_boneshttp://en.wikipedia.org/wiki/Irregular_boneshttp://en.wikipedia.org/wiki/Sesamoid_boneshttp://en.wikipedia.org/wiki/Axial_skeletonhttp://en.wikipedia.org/wiki/Appendicular_skeletonhttp://en.wikipedia.org/wiki/Tissue_(biology)http://en.wikipedia.org/wiki/Organshttp://en.wikipedia.org/wiki/Brainhttp://en.wikipedia.org/wiki/Skullhttp://en.wikipedia.org/wiki/Lungshttp://en.wikipedia.org/wiki/Rib_cagehttp://en.wikipedia.org/wiki/Bone_marrow8/8/2019 Case Study of Chronic Osteomyelitis
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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.
http://en.wikipedia.org/wiki/Human_musculoskeletal_system#cite_note-skeletalsystem-3http://en.wikipedia.org/wiki/Calciumhttp://en.wikipedia.org/wiki/Phosphorushttp://en.wikipedia.org/wiki/Cardiac_musclehttp://en.wikipedia.org/wiki/Skeletal_musclehttp://en.wikipedia.org/wiki/Smooth_musclehttp://en.wikipedia.org/wiki/Lumen_(anatomy)http://en.wikipedia.org/wiki/Involuntary_musclehttp://en.wikipedia.org/wiki/Involuntary_musclehttp://en.wikipedia.org/wiki/Striated_musclehttp://en.wikipedia.org/wiki/Microscopehttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Nervehttp://en.wikipedia.org/wiki/Central_nervous_systemhttp://en.wikipedia.org/wiki/Human_musculoskeletal_system#cite_note-skeletalsystem-3http://en.wikipedia.org/wiki/Calciumhttp://en.wikipedia.org/wiki/Phosphorushttp://en.wikipedia.org/wiki/Cardiac_musclehttp://en.wikipedia.org/wiki/Skeletal_musclehttp://en.wikipedia.org/wiki/Smooth_musclehttp://en.wikipedia.org/wiki/Lumen_(anatomy)http://en.wikipedia.org/wiki/Involuntary_musclehttp://en.wikipedia.org/wiki/Involuntary_musclehttp://en.wikipedia.org/wiki/Striated_musclehttp://en.wikipedia.org/wiki/Microscopehttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Nervehttp://en.wikipedia.org/wiki/Central_nervous_system8/8/2019 Case Study of Chronic Osteomyelitis
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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 offibrous 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 forcesto 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 orsynarthroses, joints that are
immovable, that allow little or no movement andare 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.
http://en.wikipedia.org/wiki/Motor_neuronhttp://en.wikipedia.org/wiki/Somatic_nervous_systemhttp://en.wikipedia.org/wiki/Depolarizationhttp://en.wikipedia.org/wiki/Neurotransmitterhttp://en.wikipedia.org/wiki/Cell_(biology)http://en.wikipedia.org/wiki/Neuromuscular_junctionhttp://en.wikipedia.org/wiki/Chemical_synapsehttp://en.wikipedia.org/wiki/Sarcolemmahttp://en.wikipedia.org/wiki/Action_potentialhttp://en.wikipedia.org/wiki/Sarcolemmahttp://en.wikipedia.org/wiki/Initiationhttp://en.wikipedia.org/wiki/Fibrous_connective_tissuehttp://en.wikipedia.org/wiki/Periosteumhttp://en.wikipedia.org/wiki/Synovial_jointhttp://en.wikipedia.org/wiki/Synarthrosishttp://en.wikipedia.org/wiki/Synovial_jointhttp://en.wikipedia.org/wiki/Synovial_membranehttp://en.wikipedia.org/wiki/Motor_neuronhttp://en.wikipedia.org/wiki/Somatic_nervous_systemhttp://en.wikipedia.org/wiki/Depolarizationhttp://en.wikipedia.org/wiki/Neurotransmitterhttp://en.wikipedia.org/wiki/Cell_(biology)http://en.wikipedia.org/wiki/Neuromuscular_junctionhttp://en.wikipedia.org/wiki/Chemical_synapsehttp://en.wikipedia.org/wiki/Sarcolemmahttp://en.wikipedia.org/wiki/Action_potentialhttp://en.wikipedia.org/wiki/Sarcolemmahttp://en.wikipedia.org/wiki/Initiationhttp://en.wikipedia.org/wiki/Fibrous_connective_tissuehttp://en.wikipedia.org/wiki/Periosteumhttp://en.wikipedia.org/wiki/Synovial_jointhttp://en.wikipedia.org/wiki/Synarthrosishttp://en.wikipedia.org/wiki/Synovial_jointhttp://en.wikipedia.org/wiki/Synovial_membrane8/8/2019 Case Study of Chronic Osteomyelitis
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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.
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CHAPTER IVOverview 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 orbone marrow.
It can be usefully subclassified on
the basis of the causative organism
(pyogenic bacteria ormycobacteria), 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).
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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
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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 1month 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
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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
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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 aprocedure 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
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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
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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 ofRadiology.
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 lesionsan 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.
http://www.molecularimaging.net/_news/topic/aseptic+inflammatory+lesionhttp://www.molecularimaging.net/_news/person/Jan+Fritzhttp://www.molecularimaging.net/_news/topic/whole-body+MRIhttp://www.molecularimaging.net/_news/topic/periphyseal+regionhttp://www.molecularimaging.net/_news/topic/aseptic+inflammatory+lesionhttp://www.molecularimaging.net/_news/person/Jan+Fritzhttp://www.molecularimaging.net/_news/topic/whole-body+MRIhttp://www.molecularimaging.net/_news/topic/periphyseal+region8/8/2019 Case Study of Chronic Osteomyelitis
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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 MRIidentifies characteristic, ill-defined, edemalike, periphyseal osseous lesions
predominantly in symmetrical lower extremity distribution.
Last Updated on Friday, September 11 2009
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CHAPTER VCase 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: Childrens 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 StructureOther body parts look equal bilaterally and are in relative proportion to
each other.
Behavior
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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
Area AssessedMethodUsed
Normal FindingsActual
FindingsRemarks
Skin
Color
Uniformity of
skin color
Temperature
Moisture
Turgor
Thickness
Tenderness
Lesions
Edema
Inspection
Inspection
Palpation
Inspection;Palpation
Inspection;Palpation
Inspection
Palpation
Inspection
Inspection
>Varies from light todeep brown, fromruddy pink to lightpink, from yellowovertones to olive
>Generally uniform
except in areasexposed to the sun,areas of lighterpigmentations (palms,lips and nail beds).
>Uniform withinnormal range(36.5-37.5)
>Moisture in the skinfolds and the axilla(varies withenvironmentaltemperature andhumidity, bodytemperature andactivity)
>Springs back tonormal when pinched
>Epidermis isuniformly thin overmost of the body
>Skin surfaces arenon-tender
>Absence of lesions
>Absence of edema
>Brownish
>Generally
uniform exceptin areas withswelling tissues
>Uniform withinnormalrange(36.3)
>Moisture in theskinfolds and theaxilla
>Springs backto normal whenpinched
>Epidermis isuniformly thinover most of thebody
>Skin surfacesare non-tender
>With lesions
>With swellingof the right foot
>Normal
>Normal
>Normal
>Normal
>Normal
>Normal
>Normal
>Onset ofinfection
>Due toinflammation
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Hair
Distribution
Texture
Color
Seborrhea
Inspection
Palpation
Inspection
Inspection
>Evenly distributedover the scalp
>Fine or thick hair;straight, curly or kinky;silky, resilient hair
>Black color or graycolor, considering theage
>Absence ofseborrhea
> Evenlydistributed overthe scalp
>With straight,thick hair
>Black color
>Absence ofseborrhea
>Normal
>Normal
>Normal
>Normal
Nails
Appearance
Color of nailbed
Shape
Texture
Capllary refilltime
Inspection
Inspection
Inspection
Inspection
Palpation
>Clean nails
>Pink
>Convex to curvature
>Smooth
>Return within 2-3seconds
>Clean nails
>Pink
>Convex tocurvature
>Smooth
>Return within 2seconds
>Normal
>Normal
>Normal
>Normal
>Normal
Head
Shape and size
Facial features
Symmetry offacial features
Inspection
Inspection
Inspection
>Rounded, smoothskull contour
>Symmetric or slightlyasymmetric facialfeatures
>Symmetric facialmovements
>Rounded,smooth skullcontour
>Symmetric
>Symmetricfacialmovements
>Normal
>Normal
>Normal
Ears
Auricle Position
Texture
External Auditory canal
Discharges
Color of canalwalls
Inspection
Inspection
Inspection
Inspection
>At the level of theexternal cantus of theeyes
>Smooth withoutlesion
>None
>Pink
>At the level ofthe externalcantus of theeyes
>Smoothwithout lesion
>None
>Pink
>Normal
>Normal
>Normal
>Normal
Nose
Color
Sinuses
Inspection
Inspection
>Same color with theface
>Not inflamed
>Same colorwith the face
>Not inflamed
>Normal
>Normal
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Nares
Lesion/Tenderness
Inspection
Palpation
>No obstruction; ovaland symmetric
>Not tender, absenceof lesion
>No obstruction;oval andsymmetric
>Not tender,absence of
lesion
>Normal
>Normal
Lips
Symmetry
Color
Texture
Inspection
Inspection
Palpation
>Symmetrical
>Pinkish
>Smooth
>Symmetrical
>Pinkish
>Smooth
>Normal
>Normal
>Normal
Teeth Inspection >Free from decays,white, smooth andshiny
>Free fromdecays
>Normal
Tongue
Position
Color
Inspection
Inspection
>Center
>Pink
>Center
>Pink
>Normal
>Normal
Neck
Position
Movement
Lymph nodes
Thyroid glands
Consistency
Size
Texture
Inspection
Inspection
Palpation
Inspection
Palpation
Palpation
>Centrally located onthe shoulder
>Able to flex andextend head withoutpain and resistance
>Not palpable
>Not visible whenswallowing
>Small
>Smooth and freefrom nodules
>Centrallylocated on theshoulder
>Able to flexand extend headwithout pain andresistance
>Not palpable
>Not visiblewhenswallowing
>Small
>Smooth andfree fromnodules
>Normal
>Normal
>Normal
>Normal
>Normal
>Normal
Thorax and Lungs
Anterior thorax andlungs
Breathingpatterns
Symmetry
Lung breathsounds
Inspection
Inspection
Auscultation
> Quiet, Rhythmic andEffortless Respiration
>Symmetrical
>No adventitioussound
> Quiet,Rhythmic andEffortless
Respiration(RR: 35 bpm)
>Symmetrical
>Noadventitioussound
>Normal
>Normal
>Normal
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Shape Inspection;palpation
>oval/elliptical >oval/elliptical >Normal
Heart
Rate
Rhythm
Auscultation
Auscultation
>Regular rate(60-100)
>no murmur
>Regularrate(80bpm)
>no murmur
>Normal
>Normal
Abdomen
Contour Inspection >Flat, rounded >Flat, rounded >Normal
Upper & lowerextremities
Size
Symmetry
Distribution of hair
Skincolor
Lesions
Inspection
Inspection
Inspection
Inspection
Inspection
>Equal size
>Symmetrical
>Evenly distributed
>Light to deep brown
>No lesions,deformities orinflammation
>Right foot isslighty bigger
than left
>Symmetrical
>Evenlydistributed
>Brownish
>With lesions onright foot
>Due toswelling
>Normal
>Normal
>Normal
>Due todiseaseprocess
Musculoskeletal
Joints
ROM
Inspection
Inspection
>No swelling on theskin and tissues overthe joints
>Full ROM againstgravity, full resistance,5/5
>With swellingon the skin andtissues over the
joints of the rightfoot
>Active motionagainst gravity,averageweakness, 5/5
>Due toinflammationprocess
>Normal
C. HISTORY OF PRESENT ILLNESS
Two years PTA, patient had a small blister on the sole of the right foot.
Patients mother ignored the lesion for she perceived it as a minor cut only. No
treatment or consultation was done.
Two weeks PTA, patients 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
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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 defectpatent 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 fathers side but no
account for any congenital defects of both sides.
G. LABORATORY ANALYSIS
Composition Result Normal Values Interpretation Nursing Responsibility
March 23, 2010
Urinalysis:
Color
Transparency
RBC
Pus cells
March 23, 2010
BloodChemistry:
leukocyte
Light yellow
Hazy
18-20
20-22
22.2
Amber toyellowish
Clear
0-4 hpf
0-5 hpf
4.5-10 x 10^ g/L
Actual infection
Assess for presence of,
existence of, & history of riskfactors for infection.
Monitor laboratory studies.
Monitor the ff. for signs ofinfection.
Elevated temp.
Color ofrespiratory secretions
Appearance ofurine
Administer or teach use ofantimicrobial drugs.
Teach patient or caregiver to
wash hands often, especiallyafter toileting, before mealsand after administering self-care.
Teach patient or caregiver thesigns & symptoms of infectionand when to report these tothe physician.
Encourage to eat foods highin Vitamin C like citrus fruits.
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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 othersites, 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)
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Bacterial invasion
Neutrophil invasion/Inflammatory response
Pus formation Fever Leukocytosis Heat,Leukocyte: 22.2 x 10^ g/L Redness
SwellingTenderness
Pus spread into vascular channels
Periosteumlifts form the bone
Pain
Increased intraosseus response
Disruption in blood supply
Ischemic necrosis
Sequestra
Osteoblastic response
Involucrum
Osteomyelitis
Non-modifiable:
- 7 years old- Female
Modifiable:
- penetrating wound
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I. NURSING CARE PLAN
Assessment Nursing Diagnosis Nursing Plan Nursing Intervention Rationale Evaluation
Subjective:
Namamagayung paa ko. asverbalized
Objective:
slow healing oflesion
swelling of theright foot
presence ofabscess on theright foot
weak pulse onthe right foot
Risk for peripheralneurovasculardysfunction relatedtointerruption of bloodflow secondsary to
disease condition
At the end of the nursinginterventions, the patientwill be able to maintaintissue perfusion asevidenced by palpable
pulses, skin warm,normal sensation andstable vital signs.
Assess generalcondition of andcontributing factors topatient.
Evaluate
presence/quality ofperipheral pulse distalto injury via palpation.
Assess capillaryreturn, skin color, andwarmth distal toinflammation.
Maintain elevation ofinflamed extremityunless contraindicatedby confirmedpresence of
compartmentalsyndrome.
Investigate suddensigns of limbischemia, e.g.,decreased skin
Provide basis forunderstandinggeneral, currentsituation of client.
Decreased/absent
pulse may reflectvascular injury andnecessitatesimmediate medicalevaluation ofcirculatory status.
Return of color shouldbe rapid (3-5 secs.).White, cool skinindicates arterialimpairment. Cyanosissuggests venousimpairment.
Promotes venousdrainage/decreasesedema.
Osteomyelitis maycause damage toadjacent arteries, withresulting loss of distal
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Subjective:
Ang sakit ng paa
ko. asverbalized.
Objective:
pain scale-8/10
with guradingbehaviorwith reluctance toattemptmovement;limited ROM
with reports ofpain
with distractedbehavior
Altered comfort: painrelated to inflammatory
process secondary todisease condition
At the end of the nursinginterventions, the patient
will be able toincorporate relaxationskills and diversionalactivities to reduce pain.
temperature, pallor,and increased pain.
Encourage patient toroutinely exercisedigits/joints distal toinflammation.
Investigate reports ofpain, noting locationand intensity (scale of
0-10), noteprecipitating factorsand nonverbal cues.
Maintain bed rest orchair rest whenindicated.
Place pillows onaffected area.
Encourage frequentchanges of position tomove in bed,supporting affected
joints above andbelow, avoiding jerkymovements.
Involve in diversionalactivities appropriate
for individual situation,e.g., coloring ofbooks, playing withtoys.
blood flow.
Enhances circulationand reduces poolingof blood, especially inthe lower extremities.
Helpful in determiningpain managementand effectiveness of
interventions.
Bed rest may benecessary to limitpain/injury to joints.
Rests painful andmaintains neutralposition.
Prevents generalfatigue and jointstiffness, stabilizes
joint, decreasing jointmovements andassociated pain.
Refocuses attention,provides stimulation,
and enhances self-esteem and feelingsof general well-being.
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Objective:
leukocyte: 22.2 x10^ g/L
with purulentdischarges onright foot
pus cells in urine:20-22hpf
presence oflesion on right
foot
Subjective:
May sugat poako sa paa asverbalized.
Objective:
disruption of skinsurface of thelower extremity
destruction of
skinlayers/tissues ofthe right foot
reports of pain,pressure inaffected/
Actual infection relatedto increased WBC countand presence ofpyogenicmicroorganisms in thelocal infection
Impaired skin integrityrelated to inflammatoryresponse secondary todisease condition
At the end of the nursinginterventions, the patientwill achieve timelywound healing; free ofsigns of infection.
At the end of the nursinginterventions, the patientwill demonstratebehaviors/techniques toprevent skinbreakdown/facilitatehealing as indicated.
Assess skin lesions,noting reports ofincreased pain orpresence of edema,erythema, foul odor,or drainage.
Provide sterile woundcare, and exercisemeticuloushandwashing.
Instruct patient not to
touch wound with barehands.
Monitor vital signs.Note presence ofchills, fever andmalaise.
Examine the skin foropen wounds, foreignbodies anddiscoloration.
Demonstrate goodskin hygiene, e.g.,
wash thoroughly andpat dry carefully.
Discuss importance of
Indicates localinfection/tissuenecrosis which is amajor sign ofosteomyelitis.
May prevent cross-contamination andany furthercomplications.
Minimizes opportunity
for contamination.
Tachycardia andchills/fever reflectdeveloping sepsis.
Provides informationregarding skincirculation andproblems that may becaused by edemaformation that mayrequire furthermedical intervention.
Maintaining a clean,dry skin provides a
barrier to infection.Patting skin dryinstead of rubbingreduces risk of dermaltrauma to fragile skin.
These provide patient
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surrounding area
invasion of bodystructures
with purulentdischarge on theright foot
Subjective:
Nilalamig ako.as verbalized
Objective:
T: 38.9oC
RR: 39bpm skin warm to
touch
with flushed skin
perspiringprofusely
Altered bodytemperature: increasedrelated to presence ofpyogenicmicroorganisms in thelocal circulation
At the end of the nursinginterventions, thepatients temperature willdecrease from 38.9oC to36.8oC.
adequate nutritionespecially fluids,proteins, vitamins Band C, iron andcalories.
Establish a turning orrepositioningschedule.
Emphasize principles
of asepsis especiallyhand washing andavoidance of touchingwound with barehands.
Demonstrate woundcare technique suchas wound cleansing.
Assess generalcondition of andcontributing factors topatient.
Monitor vital signsespecially
temperature. Assess fluid loss and
facilitate oral intake.
Provide tepid spongebath.
information hownutrition could elevateher chances of afaster recovery andwound healing.
This provides thepatients guidetowards a proper skinmanagementtechnique minimizingmore skin trauma.
To avoid possible
infection thushindering the woundhealing process.
To provide the patientor patients SO on thecorrect proceduresand techniques ofwound caring.
Provides basis forunderstandinggeneral, currentcondition of patient.
Notes progress andchanges of condition.
Increases inmetabolic rate anddiaphoresis.
Enhances heat lossby evaporation and
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with teary eyes
with purulentdischarge on theright foot
Subjective:
Hindi akomasyadongmakalakad. asverbalized.
Objective:
with reluctance toattemptmovement;limited ROM
with decreasedmusclestrength /control
inability to movepurposefully
within thephysicalenvironment,imposedrestrictions
Impaired physicalmobility related topain/discomfort
At the end of the nursinginterventions, the patientwill regain/maintainmobility at the highestpossible level.
Promote bed rest.
Provide coolcirculating air byopening windows orensuring that patientis not covered withthick blankets.
Assist patient inchanging into dryclothing.
Assess degree ofimmobility producedby pain.
Instruct patientin/assist withactive/passive ROMexercises of affectedand unaffectedextremities.
Encourage patient tomaintain upright anderect posture whensitting, standing, andwalking.
Discuss/provide safety
needs, e.g., raisedside rails.
conduction.
Reduces body heatproduction.
Dissipates heat byconvection.
Increases comfort.
Level ofactivity/exercisedepends onprogression/resolutionof inflammatoryprocess.
Increases blood flowto muscles and boneto improve muscletone, maintain jointmobility.
Maximizes jointfunction, maintainsmobility.
Helps preventaccidentalinjuiries/falls.
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J. DRUG STUDY
*Common adverse effects in italic, life-threatening effects underlined
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DRUG ORDER(Generic name,Dosage, Route,Frequency, etc.)
SPECIFICACTION
PHARMACOLOGICACTION OF DRUG
INDICATIONS ANDCONTRAINDICATIO
NS
ADVERSEEFFECTS OF THE
DRUG
NURSINGRESPONSIBILITIES
/PRECAUTIONS
Generic Name:Cefuroxime400mg IV q8
Brand Name:Kefurox
Generic Name:Paracetamol550mg/5mL q4;for T>=38.0oC
Brand Name:Gandol
ANTIINFECTIVE;ANTIBIOTIC;SECOND-GENERATIONCEPHALOSPORIN
NON-OPIOIDANALGESIC
Preferentially bindsto one or more of thepenicillin-bindingproteins (PBP)located on cell wallsof susceptibleorganisms. Thisinhibits 3rd and finalstage of bacterialcell wall synthesis,thus killing thebacteria.
Paracetamol exhibitsanalgesic action by
peripheral blockageof pain impulsegeneration. Itproduces antipyresisby inhibiting thehypothalamic heat-regulating centre. Itsweak anti-inflammatory activityis related toinhibition ofprostaglandinsynthesis in theCNS.
Indications:It is effective for thetreatment ofpenicillinase-producing Neisseriagonorrhoea (PPNG).Effectively treatsbone and jointinfections, bronchitis,meningitis,gonorrhea, otitismedia,pharyngitis/tonsillitis,sinusitis, lowerrespiratory tractinfections, skin andsoft tissue infections,urinary tractinfections, and isused for surgical
prophylaxis, reducingor eliminatinginfection.
Contraindications:Hypersensitivity tocephalosporins andrelated antibiotics;pregnancy (categoryB), lactation.
Indications:To relieve mild tomoderate pain due tothings such asheadache, muscleand joint pain,backache and periodpains. It is also usedto bring down a hightemperature. For thisreason, paracetamolcan be given tochildren aftervaccinations toprevent post-immunisation pyrexia(high temperature).Paracetamol is oftenincluded in cough,cold and fluremedies.
Contraindications:Hypersensitivity toacetaminophen or
phenacetin; use withalcohol.
Body as a Whole:Thrombophlebitis(IV site); pain,burning, cellulitis(IM site);superinfections,positive Coombs'test.
GI:Diarrhea,nausea, antibiotic-associated colitis.
Skin: Rash,pruritus, urticaria.
Urogenital:Increased serumcreatinine and BUN,decreased
creatinineclearance.
Side effects arerare withparacetamol when itis taken at therecommendeddoses. Skin rashes,blood disorders andacute inflammationof the pancreashave occasionallyoccurred in peopletaking the drug on aregular basis for along time. One
advantage ofparacetamol overaspirin and NSAIDsis that it doesn'tirritate the stomachor causing it tobleed, potentialSide effects ofaspirin andNSAIDs.
Determinehistory ofhypersensitivityreactions tocephalosporins,penicillins, andhistory ofallergies,particularly todrugs, beforetherapy isinitiated.
Inspect IM andIV injection sitesfrequently forsigns of phlebitis.
Report onset ofloose stools ordiarrhea.Although
pseudomembranous colitis.
Monitor I&Orates and pattern:Especiallyimportant inseverely illpatients receivinghigh doses.Report anysignificantchanges.
Assessment & DrugEffects
Monitor forS&S of:hepatotoxicity,even withmoderate
acetaminophendoses, especiallyin individuals withpoor nutrition.
Patient & FamilyEducation
Do not takeother medications(e.g., coldpreparations)containingacetaminophen
without medicaladvice;overdosing andchronic use cancause liverdamage andother toxiceffects.
Do not self-medicate childrenfor pain morethan 5 d withoutconsulting aphysician.
Do not use for
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Course in the Ward
On March 22, 2010, patient was admitted to room-of-choice under childrens
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.
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CHAPTER VIEvaluation
During the nurse-patient relationship, clients 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, andher lesion needs to be drained first. Her operation is still pending.
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Bibliography
Radiology: Whole-body MR useful in detecting rare bone disease. Molecular Imaging. 10 September2009. 03 April 2010
Rosalyn Carson-DeWitt, MD. Osteomyelitis: Prognosis. Answers.com. 2006. 03 April 2010
Human musculoskeletal system. Wikipedia, The Free Encyclopedia. 26 March 2010. 03 April 2010.< http://en.wikipedia.org/wiki/Human_musculoskeletal_system>
Chronic Osteomyelitis In Children. Global Help. June 2005. 03 April 2010