Chapter 64

Osteomyelitis

What is it?o Severe infection of the

Bone Bone marrow Surrounding soft tissue

o Most common infecting microorganism Staphylococcus aureus

Common causeso Trauma

o Acute infection originating elsewhere

o Puncture injury to soft tissue

o Infection in adjacent bone

o Orthopedic prosthetic device

Patho:o After entry, microorganisms lodge in an area of bone

where circulation slows Usually the metaphysis

o Microorganisms grow causing increased pressure within the bone

o Increased pressure leads to ischemia and vascular compromise of periosteum

o Eventually, infection passes through bone cortex and marrow cavity

o Once ischemia occurs, bone dies

o Sequestrum forms Devitalized bone separates from living bone

o Part of periosteum that continues to have a blood supply forms new bone

Involucrum

Signs and Symptomso Systemic

Fever, night sweats, chills, restlessness, nausea

o Local Constant bone pain that worsens with activity

Swelling, tenderness, warmth at infection site

Restricted movement of affected part

Lab Studies o Bone or soft tissue biopsy

Definitive way to determine causative microorganism

Patient’s blood and/or wound culture

o Elevated WBC count

o Erythrocyte sedimentation rate (ESR)

Radiologic signs o Usually do not appear until 10 days to weeks after start

of clinical symptoms

o Radionuclide bone scans Helpful in diagnosis and usually positive in areas

of infection

o Magnetic resonance imaging (MRI) o Computed tomography (CT)

Help identify extent of infection, including soft tissue involvement

Treatment o Vigorous and prolonged intravenous (IV) antibiotic

therapy Treatment of choice for acute osteomyelitis

Patients are often discharged to home care or skilled nursing facility with IV antibiotics

Antibiotic therapy may be continued at home for 4 to 6 weeks or as long as 3 to 6 months

Variety of antibiotics may be prescribed Penicillin, Nafcillin

Neomycin, Vancomycin o Monitor for visual or hearing changeso BUN and creatinine should be monitored

Cephalexin (Keflex)

Cefazolin (Ancef)

o Surgical treatment Removal of poorly vascularized tissue and dead

bone

Extended use of antibiotics Antibiotic-impregnated bead chains can be

implanted

o Hyperbaric oxygen therapy with 100% oxygen Stimulate circulation and healing

o Bone grafts Help restore blood flow

o Amputation Extensive bone destruction

Nursing Diagnoses o Acute pain

Inflammatory process secondary to infection

o Impaired physical mobility Pain, immobilization devices, weight-bearing

limitations

Inability or unwillingness to change positions

o Ineffective therapeutic regimen management Lack of knowledge regarding long-term

management of osteomyelitis

Nursing Implementation o Health Promotion

Control infections already in body Susceptible adults

o Acute Intervention Assessment and management of patient’s pain

level

Dressings to absorb exudate from draining wounds

Immobilization of affected area

Maintain proper body alignment

Bed rest Promotes healing

Reposition frequently

o Prevent complications related to immobility

o Teaching Activities to avoid

Examples: exercise, heat applicationo ↑ circulation and swelling

Adverse reactions with prolonged antibiotic therapy

Secondary infectionso Example: Candida albicans

o Emotional support Patient and family often frightened and

discouraged

Osteoporosis

What is it?o Chronic, progressive metabolic bone disease

Characterized by porous bone and low bone mass Structural deterioration of bone tissue

o Increased bone fragility

Risk factors o Female gender

Eight times more common in women than men Lower calcium intake than men

Bone resorption begins earlier and accelerates after menopause

Pregnancy and breastfeedingo Deplete woman’s skeletal reserve of

calcium

Longevity increases likelihood of osteoporosiso Women live longer than men

o Increasing age Decrease in hormones and weight-bearing activity

o Early menopause

o Excess alcohol intake

o Cigarette smoking

o Anorexia

o Oophorectomy

o Sedentary lifestyle Obesity: more stress on bones

o Insufficient calcium intake

o Low testosterone levels in men Patho: Normal vs. Osteoporotic Bone

o Osteoporosis: bone resorption exceeds bone deposition Occurs most commonly in spine, hips, and wrist

Many drugs can interfere with bone metabolism

Diseases associated with osteoporosis Intestinal malabsorption Kidney disease Rheumatoid arthritis Hyperthyroidism Chronic alcoholism Cirrhosis of the liver Hypergonadism Diabetes mellitus

Signs and Symptoms o “Silent disease”

Usual first signs

Back pain

Spontaneous fractureso Examples: back, hip, wrist

o Loss of height

o Spinal deformities Kyphosis

Diagnostic Studies o Dual-energy x-ray absorptiometry (DEXA)

Measures bone mass of spine, femur, forearm and total body

Uses minimal radiation, painless procedure

o Quantitative ultrasound Evaluates density, elasticity, and strength of

patella and calcaneus using ultrasound

Treatmento Proper nutrition

Prevention and treatment depend on adequate calcium intake

Increased calcium prevents future loss but will not form new bone

Good sources of calcium Milk , yogurt Turnip greens Spinach Cottage cheese Ice cream

Sardines

Poor sources of calcium Eggs Beef Poultry Pork Apples and bananas Potatoes and carrots

o Supplemental vitamin D May be recommended

o Exercise Should be encouraged to build up and maintain

bone mass

o Smoking cessation

o Decrease alcohol intake ↓ losing bone mass

o Drug therapy Estrogen replacement after menopause

Helps decrease bone resorption

Works best when combined with calcium supplementation

Calcitonin Secreted by thyroid gland

Inhibits bone resorption

Bisphosphonates Examples: etidronate (Didronel), alendronate

(Fosamax)

Inhibit bone resorption

Proven to increase bone mass by 5%

Medication teachingo Take med with full glass of water

o Take 30 min before food or any other meds

o Remain upright for at least 30 min after taking

Paget’s Disease

What is it?o Bone disorder in which there is excessive bone

resorption followed by replacement of the normal marrow with fibrous connective tissue

o Causes bones to become larger but weaker

o Structure of bone becomes unorganized

o Usually affects pelvis, long bones, spine, ribs, sternum, and skull

Signs and Symptomso Pain

Severe, persistent

Worsened by weight-bearing activities

o Cranial enlargement

o Barrel-shaped chest

o Asymmetric bowing of tibia and femur

o Pathologic fractures

o Loss of height

o Headaches

o Visual changes

Diagnostic Studieso Serum alkaline phosphatase ↑

Enzyme involved with bone cell formation

o X-rays Shows bone deformity and increased bone density

Treatmento Calcitonin

Slows rate of bone breakdown

o Pain reduction Examples: ASA, Tylenol, NSAIDs

o Orthotics Example: Heel lifts

o Physical therapy

o Bed rest should be avoided Helps prevent hypercalcemia

o Nutritional support Calcium and vitamin D

Intervertebral Lumbar Disk Damage

Degenerative disk disease

Degenerative Disk Diseaseo What is it?

Progressive degeneration of intervertebral disks Disk becomes thin and drys out

Compression of nerve roots and spinal cord can occur

Herniated intervertebral disko What is it?

Can occur from natural degeneration with age Repeated stress and trauma to spine

Most common sites of rupture: L4-5 and L5-S1

Can occur in cervical disks

Signs and Symptomso Low back pain

Can radiate down to the buttock to below the knee

Can be reproduced Raising leg and flexing the foot at 90 degrees

Diagnostic Studieso X-rays

o Myelogram Injects dye into sac around the nerve roots

Patient may experience a spinal headache Should resolve in 1-2 days with rest and

fluids

Treatmento Conservative

Restricted activity

Medication NSAIDs, short-term opioids, muscle relaxants

Epidural steroid injections

Ice or heat

Physical therapy

Surgical therapyo Laminectomy

Removal of protruding disk

o Diskectomy Decompress nerve root

o Spinal fusion Performed if unstable bone pieces are present

o Charite disk Artificial disk used with patients with degenerative

disk disease

Postoperative Careo Bedrest

o Log rolling Pillow can be placed in between legs for comfort

o Proper body alignment

o Monitor for spinal headache

o Frequent monitoring of peripheral neurologic status Every 2-4 hrs after for the first 48 hours Compare to baseline assessment

o Monitor bowel and bladder function Nerve damage possible