91890044 Case Osteomyelitis

7/27/2019 91890044 Case Osteomyelitis

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Submitted by: Ma. Kay Bernadette T. Lumbab, RN

Fulminating Osteomyelitis

I. INTRODUCTION

DEFINITION

Osteomyelitis is an infection of the bone. The bone becomes infected by one of

three modes:

Extension of soft tissue infection

Direct bone contamination from bone surgery, open fracture, or traumatic

injury

Hematogenous (blood borne) spread from other sites of infection.

Osteomyelitis resulting from hematogenous spread typically occurs in a bone

area or lowered resistance, possibly from subclinical trauma.

Postoperative surgical wound infections occur within 30 days after surgery. They

are classified as incisional or deep. If an implant has been used, deep postoperative

infections may occur within a year. Deep sepsis after arthroplasty may be classified

as follows:

Stage 1, acute fulminating: occurring during the first 3 months after

orthopaedic surgery; frequently associated with hematoma, drainage, or

superficial infection

Stage 2, delayed onset: occurring between 4 and 24 months after surgery

Stage 3, late onset: occurring 2 or more years after surgery, usually as a

result of hematogenous spread

Bone infections are more difficult to eradicate than soft tissue infections

because the infected bone becomes walled off. Natural body immune responses are

blocked, and there is less penetration by antibiotics. Osteomyelitis may become

chronic and may affect the patients quality of life.

ETIOLOGY

Staphylococcus aureus causes 70% to 80% of bone infections. Other

pathogenic organisms frequently found in the osteomyelitis include Proteus and

Pseudomonas species and Escherichia coli. The incidence of penicillin-resistant,

nosocomial, gram-negative, and anaerobic infections is increasing.


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PATHOPHYSIOLOGY

The initial response to infection is inflammation, increased vascularity, and

edema. After 2 to 3 days, thrombosis of the blood vessels occurs in the area,

resulting in ischemia with bone necrosis. The infection extends into the medullary

cavity and under the periosteum and may spread into adjacent soft tissues andjoints. Unless the infective process is treated promptly, a bone abscess forms. The

resulting abscess cavity contains dead bone tissue (the sequestrum), which does

not easily liquefy and drain. Therefore, the cavity cannot collapse and heal, as

occurs in soft tissue abscess. New bone growth (the involucrum) forms and

surrounds the sequestrum. Although healingappears to take place, a chronically

infected sequestrum remains and produces recurring abscess throughout the

patients life. This referred to as chronic osteomyelitis.


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CLINICAL MANIFESTATIONS

1. Localized bone pain

2. Tenderness, heat and edema in the affected area.

3. Guarding of the affected area

4. Restricted movement in the affected area

5. Systemic symptoms

High fever and chills acute osteomyelitis

Low grade fever and general weakness chronic osteomyelitis

6. Necrosis of bone tissue (sequestrum) and drainage from wound site may

be present

7. WBC and ESR are elevated

RISK FACTORS

Poorly nourished

Elderly

Obese

Impaired immune systems

With chronic illness (diabetes, rheumatoid arthritis)

Receiving long-term corticosteroid therapy

II. DIAGNOSTIC PROCEDURES


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Tests to consider

Test Result

sinus-tract cultures positive

MRI of joint infected areas typically appear withdecreased signal intensity on T1-weightedimages and increased signal intensity on T2-weighted images

CT of joint axial scans demonstrate abnormal thickeningof affected cortical bone, sclerotic change,encroachment of the medullary cavity, andabnormal chronic sinus drainage

radionuclide scans increased flow activity, blood pool activity,and positive signs of uptake on images taken3 hours after injection of methylenediphosphonate

III. MEDICAL MANAGEMENT

1. Analgesics (narcotic and non-narcotic)

2. Antibiotics

3. Dressing change sterile technique

4. Maintain proper body alignment and change position frequently to prevent

deformities

5. Immobilization of affected part

Test Result

WBC count may be elevated

plain radiograph of affected area infected areas typically appear dark; softtissue swelling, periosteal thickening, andfocal osteopenia may be apparent; lytic

changes are late changesblood cultures positive

ESR elevated (>70 mm/hour)

CRP elevated (>95.2 nanomols/L [>10 mg/L])

cultures from aspiration of joint/abscess

positive

cultures from bone after debridement positive


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6. Provide a diet high in CHON

IV. SURGICAL MANAGEMENT

Incision and drainage of bone abscess

Sequestrectomy removal of dead, infected bone and cartilage

Bone grafting after repeated infections involves placement of bone

tissue for healing, stabilization of placement

Amputation

V. NURSING MANAGEMENT

RELIEVNG PAIN

The affected part may be immobilized with a splint to decrease

pain and muscle spasm.

Monitor for neurovascular status of affected extremity.

Affected extremity should be handled with great care and

gentleness.

Elevation reduces swelling and associated discomfort.

Give/administer prescribed analgesics and other pain reducing

techniques.

IMPROVING PHYSICAL MOBILITY

Explain the rationale for the activity restrictions.

Encourage full participation in ADLs within the physical

limitations to promote general well-being.

CONTROLLING THE INFECTIOUS PROCESS

The nurse monitors the patients response to antibiotic therapy

and observes the IV access site for evidence of phlebitis,

infection, or infiltration.


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With long-term, intensive antibiotic therapy, the nurse monitors

the patient for signs of superinfection (ex. Oral or vaginal

candidiasis, loose or foul-smelling stools).

Change the dressings using aseptic technique.

If surgery is necessary, the nurse takes measures to ensure

adequate circulation, to maintain needed immobility, and to

comply with weight bearing restrictions.

Encourage to eat food rich in protein and vitamin C.

Encourage adequate hydration.

91890044 Case Osteomyelitis

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