casestudy osteomyelitis

1 Case Study: OSTEOMYELITIS

OBJECTIVES

General: This case study aims to present the condition called

Osteomyelitis in relation to a patient's clinical manifestations, treatment and general health status.

Specific: To gather the needed data that can help to understand how

and why the disease occurs To enhance knowledge and acquire more information about

Osteomyelitis To enumerate the clinical manifestations of the disease so

as to provide prompt intervention of its occurrence To give an idea of how to render proper nursing care for

clients with this condition thus it can be applied for future exposures of students

To identify possible treatments that can be used to cure the disease


ACKNOWLEDGEMENT

First of all, I owe my deepest gratitude to our Almighty God for guiding us all throughout our affiliation in Orthopedic Hospital and for giving me a chance and the ability to finish this study.

I also wish to express a sincere gratitude to my family as they untiringly support me and provide everything I need.

I also thank my friends for their constant encouragement.

And to my Clinical Instructor, Mrs. Elenita Carandang, I want to extend my gratitude for her guidance, support, encouragement and her desire to make us learn.

It is also my pleasure to thank the Dean of College of Nursing, Dean May Veridiano for being always considerate and approachable and for establishing a good quality of education in our department.

Finally, I thank my most beloved teachers and those special people who made me feel that they believe in me more than I do to myself.


INTRODUCTION:Background of the

Disease


Osteomyelitis

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.

It is an acute or chronic inflammatory process of the bone and its structures secondary to infection with pyogenic organisms.The bone becomes infected by one of three modes:• Extension of soft tissue infection (eg, infected pressure or vascular ulcer, incisional infection)• Direct bone contamination from bone surgery, open fracture, or traumatic injury (eg, gunshot wound)• Hematogenous (blood borne) spread from other sites of infection (eg, infected tonsils, boils, infected teeth, upper respiratory infections).

Osteomyelitis resulting from hematogenous spread typically occurs in a bone area of trauma or lowered resistance, possibly from subclinical (nonapparent) trauma. Patients who are at high risk for osteomyelitis include those who are poorly nourished, elderly, or obese. Also at risk are patients with impaired immune systems, those with chronic illness (eg, diabetes, rheumatoid arthritis), and those receiving long term corticosteroid therapy. Postoperative surgical wound infections occur within 30 days after surgery. They are classified as incisional (superficial, located


above the deep fascia layer) or deep (involving tissue beneath the deep fascia). 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 orthopedic surgery; frequently associated with hematoma, drainage, or superficial infectionStage 2, delayed onset: occurring between 4 and 24 months after surgeryStage 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 patient’s quality of life.

Causes

Bone infection can be caused by bacteria or fungi.

Infection may also spread to a bone from infected skin, muscles, or tendons next to the bone, as in osteomyelitis that occurs under a chronic skin ulcer (sore).

The infection that causes osteomyelitis can also start in another part of the body and spread to the bone through the blood.

A current or past injury may have made the affected bone more likely to develop the infection. A bone infection can also start after bone surgery, especially if the surgery is done after an injury or if metal rods or plates are placed in the bone.


In children, the long bones are usually affected. In adults, the feet, spine bones (vertebrae), and the hips (pelvis) are most commonly affected.

Risk factors are recent trauma, diabetes, hemodialysis, poor blood supply, and IV drug abuse. People who have had their spleen removed are also at higher risk for osteomyelitis.

Note that responsible pathogens may be isolated in only 35-40% of

infections. Bacterial causes of acute and direct osteomyelitis include the

following:

Acute hematogenous osteomyelitis (Note increasing reports of other

pathogens in bone and joint infections including community-

associated methicillin-resistant Staphylococcus aureus [MRSA],

Kingella kingae,and others.)

o Newborns (younger than 4 mo):

S aureus, Enterobacter species, and group A and

B Streptococcusspecies

o Children (aged 4 mo to 4 y):

S aureus, group A Streptococcus species, Haemophilus

influenzae, andEnterobacter species

o Children, adolescents (aged 4 y to adult):

S aureus (80%), group A Streptococcus species, H influenzae,

and Enterobacter species

o Adult:

S aureus and

occasionally Enterobacter or Streptococcus species

Direct osteomyelitis

o General

S aureus, Enterobacter species, and Pseudomonas species

o Puncture wound through an athletic shoe

S aureus and Pseudomonas species

o Sickle cell disease

S aureus and Salmonellae species


Etiology

Bacteria are the most common cause of osteomyelitis, especially Staphylococcus aureus. However, other bacteria such as Pseudomonas, Klebsiella, Salmonella, and Escherichia coli can be causative agents (Roberts & Lappe, 2000). Viruses, fungi, and parasites can also lead to the development of osteomyelitis.

Bone has several structural factors that make it difficult to treat osteomyelitis. The microscopic channels present in the bone do not allow access by the body’s natural defense cells, thus allowing organisms to readily proliferate. The bone’s microcirculation is easily damaged and destroyed by bacterial toxins. This impairs blood flow in the bone and leads to bone ischemia and necrosis. And finally, it is difficult for new bone to be formed to replace necrotic bone tissue and the integrity of the bone structure is weakened (McCance & Mourad, 2000b). Because it is difficult to treat osteomyelitis, prevention of osteomyelitis in the first place is the best treatment.

Osteomyelitis results from organisms that enter bone tissue from either exogenous sources or endogenous sources. Exogenous sources are from outside the body. Infections from exogenous sources can come from open fractures, surgery (especially total joint replacements), or puncture wounds. Animal or human bites can also introduce bacteria to the body that spreads to the bone. People with chronic health conditions such as drug/alcohol abuse, diabetes, or immunosuppression are more susceptible to developing osteomyelitis. Those who are poorly nourished are also more susceptible to osteomyelitis (Liddel, 2000b).

Endogenous sources of osteomyelitis, also known as hematogenous osteomyelitis, originate within the body and are blood-borne. Common sources of infection within the body are oral, respiratory, ear, sinus, gastrointestinal, and genitourinary .Children and the elderly are more susceptible to this form of osteomyelitis.

Whatever the etiology, it is important for the nurse to remember that osteomyelitis is very difficult to treat, especially if it is undetected in the early stages. Nurses should be particularly vigilant in assessing for osteomyelitis in all patients who are considered to be at risk. If osteomyelitis is not treated promptly in its acute stage, it can progress to chronic osteomyelitis and lead to loss of function, amputation, and even death.


Risk factors

Some of the risk factors that may increase a person’s susceptibility to

osteomyelitis include:

Long term skin infections.

Inadequately controlled diabetes.

Poor blood circulation (arteriosclerosis).

Risk factors for poor blood circulation, which include high blood

pressure, cigarette smoking, high blood cholesterol and diabetes.

Immune system deficiency.

Prosthetic joints.

The use of intravenous drugs.

Sickle cell anaemia.

Cancer.

Clinical Manifestations

When the infection is bloodborne, the onset is usually sudden, occurring often with the clinical manifestations of septicemia (eg, chills, high fever, rapid pulse, general malaise). The systemic symptoms at first may overshadow the local signs. As the infection extends through the cortex of the bone, it involves the periosteum and the soft tissues. The infected area becomes painful, swollen, and extremely tender. The patient may describe a constant, pulsating pain that intensifies with movement as a result of the pressure of the collecting pus. When osteomyelitis occurs from spread of adjacent infection or from direct contamination, there are no symptoms of septicemia. The area is swollen, warm, painful, and tender to touch. The patient with chronic osteomyelitis presents with a continuously draining sinus or experiences recurrent periods of pain, inflammation, swelling, and drainage. The low-grade infection thrives in scar tissue, because it has a reduced blood supply.

Possible Complications

When the bone is infected, pus is produced within the bone, which may result in an abscess. The abscess steals the bone's blood supply. The


lost blood supply can result in a complication called chronic osteomyelitis. This chronic infection can cause symptoms that come and go for years.

Other complications include:

Need for amputation Reduced limb or joint function Spread of infection

Diagnostic Procedures

A physical examination shows bone tenderness and possibly swelling and redness.

Tests may include:

Blood cultures/Tests

Medical history Bone biopsy (which is then cultured) Bone scan Bone x-ray C-reactive protein (CRP) Erythrocyte sedimentation rate (ESR) Needle aspiration of the area around affected bones Computed tomography (CT) scan Magnetic resonance imaging (MRI)

Treatment

The objective of treatment is to eliminate the infection and prevent it from getting worse.

Antibiotics will be given to destroy the bacteria that are causing the infection. You may be given more than one antibiotic at a time. Often, the antibiotics are given through an IV (intravenously, meaning through a vein) rather than by mouth. Antibiotics are taken for at least 4-6 weeks, sometimes longer.

Surgery may be needed to remove dead bone tissue if you have an infection that does not go away. If there are metal plates near the infection, they may be removed. The open space left by the removed bone tissue

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Case Study: OSTEOMYELITIS

may be filled with bone graft or packing material that promotes the growth of new bone tissue.

Infection of an orthopedic prosthesis may require surgical removal of the prosthesis and infected tissue surrounding the area. A new prosthesis may be implanted in the same operation or delayed until the infection has gone away.

If the patient has diabetes, it will need to be well controlled. If there are problems with blood supply, surgery to improve blood flow may be needed.

Outlook/Prognosis

When treatment is received, the outcome for acute osteomyelitis is usually good.

The outlook is worse for those with long-term (chronic) osteomyelitis, even with surgery. Amputation may be needed, especially in those with diabetes or poor blood circulation.

The outlook is guarded in those who have an infection of a prosthesis.

DEFINITION OF TERMS Sequestrum – a piece of dead bone that has become separated

during the process of necrosis from normal/sound bone. It is a complication (sequela) of Osteomyelitis.

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Involucrum - a layer of new bone growth outside existing bone seen in pyogenic osteomyelitis. It results from the stripping off of the periosteum by the accumulation of pus within the bone, and new bone growing from the periosteum.

Pyogenic – it refers to bacterial infections that make pus. Bone Graft - packing material that promotes the growth of new bone

tissue. Abscess – is a collection of pus (dead neutrophils) that has

accumulated in a cavity formed by the tissue in which the pus resides on the basis of an infectious process (usually caused by bacteria or parasites) or other foreign materials (e.g., splinters, bullet wounds, or injecting needles). It is a defensive reaction of the tissue to prevent the spread of infectious materials to other parts of the body.

Iatrogenic - caused by treatment or diagnostic procedures. An iatrogenic disorder is a condition that is caused by medical personnel or procedures or that develops through exposure to the environment of a health care facility.

Periosteum - is a membrane that lines the outer surface of all bones, except at the joints of long bones

Hematogenous - Originating in or spread by the blood Amputation – surgical removal of a body part. As a surgical

measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene.

Arthroplasty - is the operation for construction of a new movable joint.

Sepsis - serious medical condition that is characterized by a whole-body inflammatory state (called a systemic inflammatory response syndrome or SIRS) and the presence of a known or suspected infection

Hemodialysis - a method for removing waste products such as creatinine and urea, as well as free water from the blood when the kidneys are in renal failure

SOURCE: www.google.com

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Personal Background of the

Patient

PERSONAL DATAName: Patient K

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Address: Menville Pasay City

Occupation: none (student)

Religion: Roman Catholic

Nationality: Filipino

DEMOGRAPHIC DATADate of Birth: April 3, 2002

Place of Birth: Manila

Age: 7 years old

Gender: Male

Status: Child

PATIENT PROFILEDate Admitted: June 8, 2010

4:30pm

Attending Physician: Dr. Espinosa

Room/Ward: Pediatric Ward

Hospital Record No: 581670

HOME ENVIRONMENT AND OCCUPATION

Physical Environment: He lives with his parents and other siblings.

They live in a concrete home and he is

studying in a public school. His father provides

their needs while his mother is the one taking

care of her and her siblings.

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NUTRITIONAL PATTERN

Usual Meal: He often eats fried foods and doesn’t like to

eat vegetables. And he usually drinks 2-4

glasses of water every day.

SLEEP AND REST PATTERN

Usual Sleep Pattern: Usually sleeps at 8 or 9 o’clock in the evening

and wakes up at 6:30 in the morning.

Relaxation Techniques: Watching tv and sleeping

ELIMINATION PATTERN

Urinary: He urinates 3-5 times a day

Bowel: He defecates once a day.

PAST HEALTH HISTORY

Past Medical History

Patient had urinary tract infection (UTI) a year ago. He was brought to

a local doctor and was given antibiotics.

Usual Medications

Paracetamol

Cough Syrups

Vaccinations

BCG (1)

HepaB (3)

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Measles (1)

DPT (3)

Allergies

No known allergies to food and drugs

Family History

There is a history of high blood pressure and diabetes on his father’s

side.

HISTORY OF PRESENT ILLNESS

Reason for seeking medical care: swelling on the right lower leg

Six months prior to admission, the patient had a small wound on his right foot. Patient’s mother ignored the lesion for she perceived it as a minor wound only. No treatment or consultation was done.

Two weeks prior to admission, patient’s mother noted swelling on the right lower leg of her daughter and this was associated with on and off fever.

The day before the patient was admitted, he had a high grade fever. They consulted at a district hospital and they were referred to the Philippine Orthopedic Center (POC) for Osteomyelitis.

D50.3NaCl 500cc

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PHYSICAL EXAMINATION

Initial Vital Signs

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Temperature – 37.8°CCardiac Rate – 79bpmRespiratory Rate – 35bpm

WEIGHT: 15.9kg

GENERALThe patient appears his stated age. He is awake on bed with ongoing

IVF of D50.3NaCl 500cc. His right leg is slightly bigger than his left due to inflammation process secondary to Osteomyelitis. Other body parts look equal bilaterally and are in relative proportion to each other.

HEADSkull and Face

Rounded, normocephalic and symmetrical Uniform consistency; absence of nodules or masses Symmetric facial movements/features No tenderness Can move facial muscles at will

SCALP No tenderness nor masses Same color as the complexion No lesions

SKIN The skin color is deep brown/normal Generally uniform in color except in the area with swelling tissues With swelling/inflammation in right leg Slightly dry skin Temperature is above the normal range No itchiness With lesions on the affected extremity

HAIR Evenly distributed over the scalp Black Variable amount of body hair

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With straight thick hair Absence of seborrhea

NAILS Convex curvature Smooth in texture Pale nailbeds 2-3seconds capillary refill time Clean nails

Eyes,Eyebrows and Eyelashes Eyebrows symmetrically aligned Equally distributed eyelashes Skin intact ; no discharges Anecteric Sclera Pink palpebral conjunctiva No edema or tenderness present over lacrimal gland No eyeglasses

Ears Auricle symmetrical, at the level of external canthus of the eyes Mobile, firm and not tender,; pinna recoils after it is folded Normal voice tones audible No discharges Smooth without lesions

Nose and Sinuses

External nose is symmetric and straight Clear-watery discharge and flaring of the nares Same color with the face No tenderness or lesions when palpated Airway is patent (air moves freely as the client breathes through

the nares) Nasal septum intact and in midline

Mouth and Oropharynx

Outer lips is dry Tongue in central position, pink in color; with raised papillae;

moves freely

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NECK Centrally located on the shoulder Able to flex and extend head without pain and resistance Neck muscles equal in size, head is centered Coordinated, smooth movements without discomfort No palpable lymph nodes

THORAX AND LUNGS Quiet, rhythmic and effortless respiration No adventitious soundChest symmetric Chest wall intact; no tenderness, no masses No retractions

CARDIOVASCULAR Regular heart rate No chest pain No shortness of breath Adynamic precordium No murmurs

GASTROINTESTINAL Soft,nontender abdomen No dysphagia Normoactive bowel sounds

MUSCULOSKELETAL SYTEM With swelling on the skin and tissues over the infected bone. Thin extremities Decreased Activity Tolerance

EXTREMITIES Upper extremities are equal in size Right leg is bigger than the left due With lesions and swelling on the right leg

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Laboratory Examinations

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Complete Blood Count – Also known as full blood count or full blood exam or blood panel, is a test panel requested by a doctor or other medical professional that gives information about the cells in a patient’s blood.

Urinalysis – is an array of tests performed on urine and one of the most common methods of medical diagnosis.

Xray - are a form of electromagnetic radiation, just like visible light. In a health care setting, a machines sends are individual x-ray particles, called photons. These particles pass through the body. A computer or special film is used to record the images that are created.

CRP – (C-reactive Protein) is a protein found in the blood, the levels of which rise in response to inflammation.

ESR(Erythrocyte Sedimentation Rate) – also called a Biernacki Reaction, is the rate at which red blood cells precipitate in a period of one hour. It is a common hematology test which is a non-specific measure of inflammation.

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.

Laboratory Findings

A number of tests were done. Complete blood count shows increase number of white blood cells, Erythrocyte Sedimentation Rate is also increased and blood culture and C-reactive protein are positive. Xray result reveals evidence of osteomyelitis.

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Anatomy and Physiology

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Musculoskeletal System

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 thefunction 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

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 350 bones, however, many bones fuse

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together between birth and maturity. As a result an average adult skeleton consists of 206 bones. The number of bones varies according to themethod used to derive the count. While some consider certain structures to be a single bone with multiple parts, others may see it as a singlepart 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.

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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. Here all erythrocytes, platelets, and most leukocytes form in adults. From the redmarrow, erythrocytes, platelets, and leukocytes migrate to the blood to do their specialtasks.

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.

Types of Bone Tissue

Bone cells are called osteocytes, and the matrix of bone is made of calcium salts and collagen. The calcium salts are calcium carbonate (CaCO3) and calcium phosphate (Ca3(PO4)2), which give bone the strength required to perform its supportive and protective functions. Bone matrix is non-living, but it changes constantly, with calcium that is taken from bone into the blood replaced by calcium from the diet. In normal circumstances, the amount of calcium that is removed is replaced by an equal amount of calcium deposited. This is the function of osteocytes, to regulate the amount of calcium that is deposited in, or removed from, the bone matrix.

In bone as an organ, two types of bone tissue are present (Fig. 6–1). Compact bone looks solid but is very precisely structured. Compact bone is made of osteons or haversian systems, microscopic cylinders of bone

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matrix with osteocytes in concentric rings around central haversian canals. In the haversian canals are blood vessels; the osteocytes are in contact with these blood vessels and with one another through microscopic channels (canaliculi) in the matrix.

The second type of bone tissue is spongy bone, which does look rather like a sponge with its visible holes or cavities. Osteocytes, matrix, and blood vessels are present but are not arranged in haversian systems. The cavities in spongy bone often contain red bone marrow, which produces red blood cells, platelets, and the five kinds of white blood cells.

Classification of Bones

1. Long bones—the bones of the arms, legs, hands, and feet (but not the wrists and ankles). The shaft of a long bone is the diaphysis, and the ends are called epiphyses. The diaphysis is made of compact bone and is hollow, forming a canal within the shaft. This marrow canal (or medullary cavity) contains yellow bone marrow, which is mostly adipose tissue. The epiphyses are made of spongy bone covered with a thin layer of compact bone. Although red bone marrow is present in the epiphyses of children’s bones, it is largely replaced by yellow bone marrow in adult bones.2. Short bones—the bones of the wrists and ankles.3. Flat bones—the ribs, shoulder blades, hip bones, and cranial bones.4. Irregular bones—the vertebrae and facial bones.

Bone Tissue

Short, flat, and

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irregular bones are all made of spongy bone covered with a thin layer of compact bone. Red bone marrow is found within the spongy bone.

The joint surfaces of bones are covered with articular cartilage, which provides a smooth surface. Covering the rest of the bone is the periosteum, a fibrous connective tissue membrane whose collagen fibersmerge with those of the tendons and ligaments that are attached to the bone. The periosteum anchors these structures and contains both the blood vessels that enter the bone itself and osteoblasts that will become active if the bone is damaged.

The SkeletonThe human skeleton has two divisions: the axial skeleton, which

forms the axis of the body, and the appendicular skeleton, which supports the appendages or limbs. The axial skeleton consists of the skull, vertebral column, and rib cage. The bones of the arms and legs and the shoulder and pelvic girdles make up the appendicular skeleton. Many bones are connected to other bones across joints by ligaments, which are strong cords or sheets of fibrous connective tissue. The importance of ligaments becomes readily apparent when a joint is sprained. A sprain is the stretching or even tearing of the ligaments of a joint, and though the bones are not broken, the joint is weak and unsteady. We do not often think of our ligaments, but they are necessary to keep our bones in the proper positions to keep us upright or to bear weight. There are 206 bones in total.

MuscularTypes of muscle and their appearance

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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

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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.

TendonsA 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 bursaeHuman 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

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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.

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PATHOPHYSIOLOGY

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Modifiable Factors-Lifestyle-Punctured wound

Nonmodifiable Factors-Age-Gender

Bacterial invasion/infection on the open wound

Hematogenous spread of infection to the bone

Organisms invade the bone tissue and initiate and inflammatory response.

Fever,Leukocytosis,Inflammation and Pus Formation

Exudates continue to grow Vascular Engorgement due to Inflammation

Compromised Blood FlowPressure develops at the

site causing pain

Exudate extends into the medullary cavity and under the periosteum

Sequestrum

Osteoblastic Response

Involucrum

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EXPLANATION

The pathophysiology begins with the different factors that contribute to the development of the disease. Modifiable factors are lifestyle. The patient should change his choice of foods and the mother should take proper intervention for open wounds. and puncture wound. The non modifiable factors are age and gender because osteomyelitis is common among too young and too old people and in children, it is common in males.

The patient had an open wound and the disease process starts with the invasion of microorganisms in the said lesion. The iinfection spreads to the bone by blood stream. The infectious organism invades the bone tissue and initiates an inflammatory response. The inflammatory response leads to the development of edema and increased vascularity in the area. Leukocytes migrate to the site, and inflammatory exudate collects at the site and forms an abscess. Due to the vascular engorgement that develops, the vessels in the area thrombose and the blood flow to the site is compromised. As the site of infection expands and the exudate continues to grow, pressure develops at the site causing pain and leading to ischemia of the bone and eventually necrosis. The exudates extend into the medullary cavity and under the periosteum, stripping the periosteum off the bone and further compromising the vascular supply of underlying bone tissue.

The necrotic bone that develops forms an area referred to as sequestrum. The sequestrum is separated from the surrounding bone that is still living; it provides an area for bacteria to continue to live.

In response to bone destruction and disruption of the periosteum, the body initiates an intense osteoblastic activity. The osteoblasts stimulate the growth of new bone, which surrounds and encloses the area of dead bone. The new bone which surrounds the sequestrum is referred to as involucrum.

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Preventionand Treatment

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Prevention

As stated earlier, the prevention of osteomyelitis is the best treatment. Patients who have soft tissue infections should be treated promptly to decrease the likelihood of the infection spreading to the bone. Nurses should closely monitor patients who are at risk for the development of osteomyelitis, especially those with open fractures, to detect any early indications that an infection has developed at the site of injury. Patients with chronic illness, such as diabetes, should be taught the signs and symptoms of osteomyelitis and instructed to visually inspect the feet and lower extremities daily to detect any open areas.

Prophylactic antibiotics may be administered prior to orthopedic surgery to decrease the risk for osteomyelitis. Postoperative wound care should be performed using strict aseptic technique. Individuals who have had a total joint replacement may also be prescribed prophylactic antibiotics prior to invasive procedures or dental appointments. With preventive care or prompt treatment of local infections, osteomyelitis can be prevented in many patients.

Prompt and complete treatment of infections is helpful. High-risk people should see a health care provider promptly if they have signs of an infection anywhere in the body.

TreatmentElimination 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. Prompt identification of an antibiotic that the organism will be sensitive to is essential. It is important to begin antibiotic therapy prior to the onset of bone ischemia and necrosis. Once the blood supply to the bone is compromised, the antibiotic will not be able to reach the area of infection via the bloodstreamSurgery 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

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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. 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. The patient may also need analgesics for severe pain.

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.

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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.

Medical/Nursing Management Intravenous fluid

D5 0.3NaCl Laboratory Tests

Complete Blood Count Urinalysis Xray CRP ESR Blood culture

Medications Paracetamol Ceftin

Diet and Nutrition Diet as tolerated High Protein and Vitamin C

Immobilization of the affected extremity and ensuring adequate support Keeping the affected extremity elevated and maintaining proper alignment Monitoring the patient’s response to the antibiotic therapy Wound care and dressing

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Maintaining the functionality and muscle strength of unaffected body parts Scheduled for surgery

Health Teaching

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Patient and Family Health Teaching

Advise the patient to have ROM exercises as tolerated to maintain muscle and joint strength

Stress the importance of continuing the prescribed antibiotic therapy. Advise to report any adverse effects of the antibiotic before discontinuing the drug on his own. Explain that the success of antibiotic treatment depends on following the complete regimen.

Explain to the caregiver the wound care using aseptic technique for dressing changes

Discuss to the caregiver the proper disposal of contaminated dressings and removal of soiled linens. Stress also the importance of maintaining wound isolation.

Tell the patient/caregiver what signs and symptoms should they report to the physician/nurse(fever, chills, increased pain, malaise, increased/recurrent drainage from wound, diminished sensation, numbness, tingling, coolness)

Advise to eat foods high in protein and vitamin C. The patient should eat variety of fruits and vegetables, which can provide the body with the nutritional support it needs to fight infection.

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Nursing Care Plan


ASSESSMENT DIAGNOSIS PLANNINGINTERVENTION

EVALUATIONACTION RATIONALE

Subjective:“Namamaga po‘yung binti ko.” asverbalized

Objective:➣swelling of theright leg➣slow healing oflesion➣presence ofabscess on theright leg➣weak pulse onthe right foot

Risk for peripheralneurovasculardysfunction relatedto interruption of bloodflow secondary todisease condition

At the end of the nursinginterventions, the patientwill be able to maintaintissue perfusion as evidenced by palpable pulses, warm skin, normal sensation and stable vital signs.

➣Assess generalcondition of andcontributing factors topatient.

➣Evaluatepresence/quality ofperipheral pulse distal to injury via palpation.

➣Assess capillaryreturn, skin color, and warmth distal toinflammation.

➣Provide basis forunderstandinggeneral, currentsituation of client.

➣Decreased/absentpulse may reflectvascular injury andnecessitatesimmediate medicalevaluation ofcirculatory status.

➣Return of color shouldbe rapid (3-5 secs.).White, cool skinindicates arterialimpairment. Cyanosissuggests venousimpairment.

➣At the end of the nursing interventions, the patient is be able to maintain tissue perfusion in the affected extremity.


➣Maintain elevation of Inflamed extremity unless contraindicatedby confirmedpresence ofcompartmentalsyndrome.

➣Investigate sudden signs of limbischemia, e.g.,decreased skin temperature, pallor,and increased pain.

➣Encourage patient to routinely exercisedigits/joints distal toinflammation.

➣Promotes venous drainage/ decreases edema.

➣Osteomyelitis may cause damage toadjacent arteries, with resulting loss of distal blood flow.

➣Enhances circulationand reduces pooling of blood, especially inthe lower extremities.


ASSESSMENT DIAGNOSIS PLANNINGINTERVENTION

EVALUATIONACTION RATIONALE

Subjective:“May sugat poako sa binti ko ” asverbalized.

Objective:➣disruption of skin surface in the lower extremity➣destruction of skin layers /tissues of the right leg➣reports of pain,pressure inaffected/surrounding area➣invasion of bodystructures➣with purulentdischarge on theright leg

Impaired skin integrityrelated to open wound/abscess secondary todisease process

At the end of the nursing interventions, the patient will maintain optimal nutrition/ physical well-being

➣Examine the skin for open wounds, foreign bodies anddiscoloration.

➣Maintain good skin hygiene

➣Discuss importance of adequate nutritionespecially fluids,proteins, vitamins B

➣Provides informationregarding skincirculation andproblems that may be caused by edemaformation that may require further medical intervention.

➣Maintaining a clean, dry skin provides a barrier to infection.Patting skin dryinstead of rubbingreduces risk of dermaltrauma to fragile skin.

➣These provide information on how nutrition could elevatethe chances of a

At the end of the nursing interventions, the patient is able to maintain optimal nutrition/physical well-being


and C, iron andcalories to the mother

➣Establish a turning or repositioningschedule.

➣Emphasize principles of asepsis especially hand washing andavoidance of touching wound with bare hands.

➣Demonstrate to the mother wound care technique suchas wound cleansing.

faster recovery and wound healing.

➣This provides the patient’s guide towards a proper skinmanagementtechnique minimizingmore skin trauma.

➣To avoid possible furtherinfection that ishindering the wound healing process.

➣To provide the patientor patient’s SO on the correct procedures and techniques ofwound caring.

INTERVENTION


ASSESSMENT DIAGNOSIS PLANNING EVALUATIONACTION RATIONALE

Subjective:“Nilalamig ako.”as verbalized

Objective:➣T: 38°C➣skin warm totouch➣with flushed skin➣with teary eyes➣with purulentdischarge on theright leg

Altered bodytemperature: increasedrelated to presence ofpyogenicmicroorganisms infection

At the end of the nursinginterventions, thepatient’s temperature willdecrease from 38°C to 37.4°C

➣Assess generalcondition of andcontributing factors topatient.

➣Monitor vital signsespeciallytemperature.

➣Assess fluid loss and facilitate oral intake.

➣Provide tepid spongebath.

➣Promote bed rest.

➣Provide coolcirculating air byopening windows orensuring that patientis not covered withthick blankets.➣Assist patient inchanging into dryclothing.

➣Administer

Provides baseline data forunderstandinggeneral, currentcondition of patient.

➣Notes progress and changes of condition.

➣Increases inmetabolic rate anddiaphoresis.

➣Enhances heat loss by evaporation and conduction.

➣Reduces body heat production.

➣Dissipates heat by convection.

➣Increases comfort.

➣To decrease

At the end of the nursing intervention, the patient’s temperature will decrease and be maintained within normal range.


antipyretics as ordered

➣Administer medications/ antibiotics as indicated

➣Administer replacement fluids and electrolytes

body temperature

➣To treat the underlying cause

➣To support circulating volume and tissue perfusion

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Drug Study


CEFUROXIMECeftin

Classification DosageMode Of Action

Indication Contraindication Adverse EffectsNursing

Responsibility

Antiinfective, Antibiotic, Second Generation Cephalosporin

400mg IV q8°

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.

It is effective for thetreatment ofpenicillinaseproducingNeisseriagonorrhoea (PPNG).Effectively treatsbone and jointinfections, bronchitis,meningitis,gonorrhea, otitismedia,pharyngitis/tonsillitis,sinusitis, lowerrespiratory tractinfections, skin andsoft tissue infections,urinary tractinfections, and

Hypersensitivity tocephalosporins andrelated antibiotics

Body as a Whole:Thrombophlebitis(IV site); pain,burning, cellulitis(IM site);superinfections,positive Coombs'test.GI: Diarrhea,nausea, antibioticassociatedcolitis.Skin: Rash,pruritus, urticaria.Urogenital:Increased serumcreatinine and BUN,decreasedcreatinineclearance.

Determinehistory ofhypersensitivityreactions tocephalosporins,penicillins, andhistory ofallergies,particularly todrugs, beforetherapy isinitiated.· Inspect IM andIV injection sitesfrequently forsigns of phlebitis.· Report onset ofloose stools ordiarrhea.Althoughpseudomembranous colitis.· Monitor I&Orates and pattern:Especiallyimportant in


isused for surgicalprophylaxis, reducingor eliminatinginfection.

severely illpatients receivinghigh doses.Report anysignificantchanges.

PARACETAMOLAcetaminophen

Classification DosageMode Of Action

Indication Contraindication Adverse EffectsNursing

ResponsibilityAnalgesic, antipyretic

500mg/ tab q4° for temp. 37.8°C

Unclear. Pain relief may result from inhibition

➣Mild to moderate pain caused byheadache,mus

● Hypersensitivity to drug

Hematologic: thrombocytopenia, hemolyticanemia,

Observe for acute toxicity and overdose.● Caution


of prostaglandin synthesis in CNS,with subsequent blockage of pain impulses.Fever reduction may result fromvasodilation and increased peripheralblood flow in hypothalamus, which dissipatesheat and lowers body

temperature.

cle ache, backache, minorarthritis, common cold, toothache,or menstrual cramps or fever

neutropenia,leukopenia, pancytopeniaHepatic: jaundice, hepatotoxicityMetabolic: hypoglycemic comaSkin: rash, urticariaOther: hypersensitivity reactions (suchas fever)

parents or other caregiversnot to give acetaminophen to childrenyounger than age 2 without consulting prescriber first.● Tell patient, parents, or other caregivers not to use drug concurrently with other acetaminophen-containing products.● Advise patient, parents, or othercaregivers to contact prescriber if

fever or other symptoms persist despite taking recommended amount of drug.● Inform patients with chronic


alcoholism that drug may increase risk of severe liver damage.● As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, and behaviors mentioned above.

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EVALUATION

On June 8, 2010, patient was admitted to children’s ward. His vital signs were monitored every shift and her diet was diet as tolerated. The doctor ordered for her CBC, ESR, CRP and UA. The patient also underwent x-ray of her right leg. Medication was given such as cefuroxime 750mg IV ANST then cefuroxime 400mg IV q8. He was started for venoclysis with D50.3NaCl 500cc. On June 15, 2010, the patient was for repeat UA, CBC, ESR, and CRP. His antibiotic medication was continued; and IVF was the same. She was prescribed paracetamol 250mg/5mL q4 and for temp. 38°C.and above.

During the nurse-patient relationship, client’s condition was stable. He does not experience any pain, fever and/or malaise though there is an obvious swelling on his right foot and respiratory discharges scanty in amount, greenish in color. Patient was scheduled for surgery of her leg. Her lesion needs to be drained first and it was kept supported and immobilized. The mother should be instructed to report any signs of further complication or infection.

BIBLIOGRAPHY

Book References:Brunner and Suddarth,s Textbook of Medical and Surgical NursingTenth EditionSuzanne C. Smeltler, Brenda G. Bare

Essentials of Anatomy and Physiology5th EditionValerie C. Scanlon and Tina Sanders

Eternal Links:www.nlm.nih.gov/medlineplus/ency/article/000437.htmlen.wikipedia.org/wiki/Osteomyelitishttp://emedicine.medscape.com/article/785020-overviewhttp://kidshealth.org/teen/infections/bacterial_viral/osteomyelitis.htmlhttp://www.healthscout.com/ency/68/239/main.html

casestudy osteomyelitis

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