Osteomyelitis

OSTEOMYELITIS OSTEOMYELITIS •

Bone infection by pyogenic (pus forming) bacteria which can be chronic or acute – severity depends on virulence of organism.

3 MODES OF INFECTION • •

•

Extension of Soft Tissue Infection o Infected pressure or vascular ulcer o Incisional infection EXOGENOUS o Invasion of the bone by direct extension form the outside as a result of penetrating wound, open fx, contaminated during surgery o Direct bone contamination  Bone surgery  Open Fracture  Traumatic Injury (gunshot wound) stepping on nail – it goes to the bone HEMATOGENOUS (Blood Bourne) o Spreads from other sites of infection (infected tonsils, boils, infected teeth, upper respiratory infections) o Typically occurs bone area of trauma or lowered resistance, possible from subclinical (nonapparent) trauma o Children: relationship between type of organism and age o Caused by any organism

PATHOPHYSIOLOGY • • •

• • • •

In Adults the most common is: Staphylococcus Aureus – most common (70-80%). Strep is 2nd most common o They will invade the bone Initial response inflammation, Increased vascularity, edema 2-3 days thrombosis blood vessels occur in area resulting in ischemia with bone necrosis Unless treated promptly bone abscess forms which contains dead bone tissue which does not easily liquefy and drain cavity cannot collapse and heal New bone growth (involucnum) forms and surrounds sequestrum Chronically infected sequestrum remains and produces reoccurring abscesses throughout the patients life (chronic osteomyelitis) Increased incidence of PCN resistance

CLINICAL MANIFESTATIONS Adult Acute Phase o o o o

Aching, Malaise, Weakness Similar to flu Then develop VERY high fever and chilld Tenderness over the bony infected area– Guarding

Child o Happens Quickly - Local tenderness, Swelling, heat and redness over site Toxic appearance o Extreme pain – especially with movement; does not want you to touch o

o

Anorexia

ASSESSMENT AND DIAGNOSTIC FINDINGS •

Acute Osteomyelitis Blood cultures or drainage cultures Sed Rate and WBC Early x-ray shows soft tissue swelling (at concentrated area)  Takes 17 days to show destruction o 2 weeks irregular decalcification, bone necrosis, periosteal elevation, new born formation o History – Surgery, penetrating wounds o Local S/S of infection o Bone Scan (sooner than x-ray) o MRI o Blood studies ( leukocytes and sed rate) o Wound and blood cultures o o o

MEDICAL MANAGEMENT • •

IV Antibiotics – 4-6 weeks of megadoses of antibiotics Bed rest with immobilization of the area to  discomfort,  spread of infection, prevent pathologic fracture of weakened bone • HIGH Protein Diet, Increase Calcium and Vitamin D • Warm wet soaks X 20 min several times a day • Goal: Control and halt infective process o Antibiotic Therapy depends on blood, wound cultures  Increase does for long term access (Vanc) • Surgically exposed, purulent and necrotic material removed, area irrigated directly with sterile saline solution • Home health Nutrition: Increased Ca and Vitamin D

NURSING DIAGNOSIS • • • • •

Impaired physical mobility R/T pain, devices, weight bearing limitation Knowledge deficit R/T dz process and therapeutic regimen Pain R/T pathological process and surgery R/T inflammation, pain Ineffective coping R/T fear of unknown, perception of dz process, inadequate support system Disturbance self esteem R/T loss of body part or alteration in role performance

CHRONIC OSTEOMYELITIS • • • •

Once the bad part of the infection is almost gone they may hurt themselves or have to have surgery again; the infection comes back It is never totally cleared up and it tends to reoccur Bad situation Will see in the Hospital the entire time they are on antibiotics o

X-Ray: Large, irregular cavities, raised periosteum, sequestra, or dense bone formation

o o o o

•

Bone scans Normal leukocytes and sed rate Anemia may be evident Abscesses cultured

Hematogenous o o

o o o o

None of this was discussed in class Onset usually sudden Septicemia  Chills  High fever  Rapid pulse  General malaise Systemic symptoms may overshadow local signs Infection extends cortex of bone involves periosteum and soft tissue Infected area becomes: Painful, Swollen, Extremely Tender Patient may describe constant, pulsating pain that intensifies with movement R/T pressure of collecting pus.

HIGH RISK PATIENT • • • • •

Poorly nourished Elderly Obese Impaired immune system with chronic illness o Diabetes o Rheumatoid arthritis Long term corticosteroid therapy

Post Op surgical infection occurs within 30 days after surgery Bone Infection More difficult to eradicate than soft tissue because infected bone is walled off Natural body immune response blocked and there is less penetration of antibiotics May become chronic and affect quality of life •

Occurs from spread adjacent infection or direct contamination o No symptoms of septicemia o Area swollen, warm, painful, tender to touch

•

Chronic Osteomyelitis o Continuously draining sinus o Experiences recurrent periods of pain, inflammation, swelling, drainage o Low grade infection thrives on scar tissue with decreased blood supply

CLINICAL MANIFESTATIONS – Peds •

General Manifestations o Hx trauma to affected bone o Child appears very ill o Irritability o Restlessness o Increase temp

•

•

o Rapid pulse o Dehydration Local Manifestations o Tenderness o Increased warmth o Diffuse swelling over involved bone o Involved extremity painful especially with movement o Surrounding muscles tense and resist passive movement