Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Musculoskeletal Disorders

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Osteomyelitis

Osteomyelitis Severe infection of the Severe infection of the  Bone  Bone marrow  Surrounding soft tissue Caused by a variety of microorganisms Caused by a variety of microorganisms Most common infecting microorganism Most common infecting microorganism

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology Antibiotics in conjunction with surgical treatments have decreased mortality rate and complications Antibiotics in conjunction with surgical treatments have decreased mortality rate and complications Infecting microorganisms can invade by Infecting microorganisms can invade by  Indirect entry  Direct entry

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Direct Entry Can occur at any age Can occur at any age Open wound where microorganisms can gain entry to body Open wound where microorganisms can gain entry to body May also occur in presence of foreign body May also occur in presence of foreign body  

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Direct Entry Sequestrum continues to be an infected island of bone, surrounded by pus Sequestrum continues to be an infected island of bone, surrounded by pus Difficult for blood-borne antibiotics or white blood cells (WBCs) to reach sequestrum Difficult for blood-borne antibiotics or white blood cells (WBCs) to reach sequestrum Sequestrum can move out of bone and into soft tissue Sequestrum can move out of bone and into soft tissue

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Direct Entry Once outside bone Once outside bone  Sequestrum may Revascularize and then undergo removal by normal immune process Revascularize and then undergo removal by normal immune process Be surgically removed through debridement of necrotic bone Be surgically removed through debridement of necrotic bone  If necrotic sequestrum is not resolved, it may develop a sinus tract resulting in chronic, purulent cutaneous drainage

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Indirect Entry Frequently affects growing bone in boys <12 years old ---Why??? Frequently affects growing bone in boys <12 years old ---Why???   Most common sites of indirect entry Distal femur Distal femur Proximal tibia Proximal tibia Humerus Humerus Radius Radius

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Indirect Entry Adults with increased risk Adults with increased risk  Vascular disorders  Genitourinary and respiratory infections  Spread infection from blood to bone  Vascular-rich bone sites Pelvis Pelvis Tibia Tibia Vertebrae Vertebrae

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Development of Osteomyelitis Fig 64-1

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Acute Osteomyelitis Initial infection Initial infection  Infection of <1 month in duration  Both systemic and local

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Acute Osteomyelitis Systemic Systemic  Local Local  Constant bone pain that worsens with activity  Swelling, tenderness, warmth at infection site  Restricted movement of affected part  Later signs: drainage from sinus tracts

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations of Chronic Osteomyelitis Chronic – an infection that persists for longer than 1 month Chronic – an infection that persists for longer than 1 month Infection that has failed to respond to initial course of antibiotic therapy Infection that has failed to respond to initial course of antibiotic therapy Systemic signs ______ Systemic signs ______ Signs and Symptoms Signs and Symptoms  Constant bone pain  Swelling  Tenderness  Warmth at site  Continuous Drainage

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies Bone or soft tissue biopsy Bone or soft tissue biopsy  Definitive way to determine causative microorganism Patient’s blood and/or wound culture Patient’s blood and/or wound culture  Frequently positive for presence of microorganism Lab Studies Lab Studies  WBC  Erythrocyte sedimentation rate (ESR)

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Radiologic Studies Radiologic signs Radiologic signs  Usually do not appear until 10 days to weeks after start of clinical symptoms Radionuclide bone scans Radionuclide bone scans  Helpful in diagnosis and usually positive in areas of infection Magnetic resonance imaging (MRI) Magnetic resonance imaging (MRI) Computed tomography (CT) Computed tomography (CT)  Help identify extent of infection, including soft tissue involvement

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Acute Osteomyelitis Vigorous and prolonged intravenous (IV) antibiotic therapy Vigorous and prolonged intravenous (IV) antibiotic therapy  Treatment of choice for acute osteomyelitis  As long bone ischemia has not occurred  Cultures or bone biopsy should be done if possible Delaying antibiotic treatment may require surgical debridement and decompression Delaying antibiotic treatment may require surgical debridement and decompression

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Acute Osteomyelitis Patients are often discharged to home care or skilled nursing facility (SNF) with IV antibiotics delivered via Patients are often discharged to home care or skilled nursing facility (SNF) with IV antibiotics delivered via  

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Acute Osteomyelitis Antibiotic therapy may be continued for at home for _ to _ _____ or as long as _ __ _ ______ Antibiotic therapy may be continued for at home for _ to _ _____ or as long as _ __ _ ______ Variety of antibiotics may be prescribed Variety of antibiotics may be prescribed  Penicillin, nafcillin (Nafcil)  Neomycin, vancomycin  Cephalexin (Keflex)  Cefazolin (Ancef)

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Chronic Osteomyelitis Adults with chronic osteomyelitis may be prescribed oral therapy + fluoroquinolone for 6 to 8 weeks instead of IV antibiotics Adults with chronic osteomyelitis may be prescribed oral therapy + fluoroquinolone for 6 to 8 weeks instead of IV antibiotics Oral antibiotics may be given after acute IV therapy to ensure resolution of infection Oral antibiotics may be given after acute IV therapy to ensure resolution of infection Monitoring patient’s response Monitoring patient’s response

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Care Toxic effects: Toxic effects:  Aminoglycosides - Nephrotoxic, ototoxic, optic neuritis, fluid retention  Cephalosporins and Quinolones – jaundice, colitis, photosensitivity, crystalluria

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Care/Patient Teaching Measure Measure  Preventive measures: Preventive measures:  Monitor _ _ _; Keep patient well hydrated to prevent ____________ or __________  Avoid direct sunlight, wear sunscreen  Monitor urinary function, hearing, vision  Assess for signs of yeast infections in genitourinary and mouth

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Chronic Osteomyelitis Surgical treatment for chronic osteomyelitis Surgical treatment for chronic osteomyelitis  Removal of poorly vascularized tissue and dead bone  Extended use of antibiotics  Antibiotic-impregnated polymethyl methacrylate bead chains may also be implanted

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Chronic Osteomyelitis After debridement, wound may be closed and a suction irrigation system inserted After debridement, wound may be closed and a suction irrigation system inserted Intermittent or constant irrigation of affected bone with antibiotics Intermittent or constant irrigation of affected bone with antibiotics Protection on limb or surgical site with casts or braces Protection on limb or surgical site with casts or braces Negative pressure to draw wound together Negative pressure to draw wound together

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Chronic Osteomyelitis Hyperbaric oxygen therapy with 100% oxygen as adjunct therapy Hyperbaric oxygen therapy with 100% oxygen as adjunct therapy  Stimulate circulation and healing Orthopedic prosthetic devices, if source of infection must be removed Orthopedic prosthetic devices, if source of infection must be removed Muscle flaps, skin grafting provide wound coverage over dead space (cavity) in bone Muscle flaps, skin grafting provide wound coverage over dead space (cavity) in bone

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Chronic Osteomyelitis Bone grafts may help restore blood flow Bone grafts may help restore blood flow Amputation may be indicated if Amputation may be indicated if  

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Long-term and mostly rare complications Long-term and mostly rare complications  Septicemia  Septic arthritis  Pathologic fractures  Amyloidosis

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment Important health information Important health information  Past health history Bone trauma, open fracture, open or puncture wounds, other infections Bone trauma, open fracture, open or puncture wounds, other infections  Medications  Surgery or other treatments

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment Subjective data Subjective data  IV drug use, malaise  Anorexia, weight loss, chills  Weakness, paralysis, muscle spasms  Local tenderness over affected area, increase in pain in affected area

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Assessment Objective data Objective data  General: Restlessness, high, spiking temperature, night sweats  Integumentary: Diaphoresis, erythema, warmth, edema at infected bone  Musculoskeletal: Restricted movement, wound drainage, spontaneous fractures

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Diagnoses Acute pain Acute pain  RT Inflammatory process secondary to infection  AEB Guarding, moaning, crying, restlessness, altered muscle tone, decreased activity; Statement of pain

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Diagnoses Impaired physical mobility Impaired physical mobility  RT Pain, immobilization devices, weight- bearing limitations  AEB Inability or unwillingness to change positions

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Diagnoses Ineffective therapeutic regimen management Ineffective therapeutic regimen management  RT Lack of knowledge regarding long-term management of osteomyelitis  AEB Verbalization of concern and uncertainty about procedures and skills needed for home care

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Other Nursing Diagnosis Labels Fear, Anxiety Fear, Anxiety Powerlessness, Hopelessness Powerlessness, Hopelessness

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Planning Overall goals Overall goals  Have satisfactory pain and fever control  Not experience any complications associated with osteomyelitis  Cooperate with treatment plan  Maintain a positive outlook on outcome of disease

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Health promotion Health promotion  Control infections already in body  Susceptible adults  Instruct susceptible adults and their families on local and systemic manifestations

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Acute intervention Acute intervention  Immobilization and non-weight bearing on affected limb will decrease pain  Limb should be handled carefully to avoid excessive manipulation and decrease pain  Manage patient’s pain level using pharmacologic and non-pharmacologic strategies

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Acute intervention (cont’d) Acute intervention (cont’d)  Patient is frequently on bed rest in early stages of acute infection Good body alignment and frequent position changes prevent complications associated with immobility and promote comfort Good body alignment and frequent position changes prevent complications associated with immobility and promote comfort  Flexion contracture is a common sequela of osteomyelitis

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Acute intervention (cont’d) Acute intervention (cont’d)  Patient frequently positions affected extremity in a flexed position to promote comfort  Contracture may then progress to deformity  ___ ____ can develop quickly in lower extremity if foot is not supported in a neutral position by a splint or if there is excessive pressure from a splint

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Acute intervention (cont’d) Acute intervention (cont’d)  Instruct patient to avoid activities that increase circulation and swelling and serve as stimuli to spread infection Exercise, ____ application Exercise, ____ application  Dressings to absorb exudate from draining wounds

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Acute intervention (cont’d) Acute intervention (cont’d)  Teach patient potential adverse and toxic reactions with prolonged and high-dose antibiotic therapy  Lengthy antibiotic therapy can result in an overgrowth of …

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Acute intervention (cont’d) Acute intervention (cont’d)  Patient and family often frightened and discouraged  Continued psychologic and emotional support is an integral part of nursing management

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Ambulatory and home care Ambulatory and home care  IV antibiotics can be administered to patient in a skilled nursing facility or home setting  If at home Patient and family must be instructed on correct care and management of venous access device Patient and family must be instructed on correct care and management of venous access device Must also be taught how to administer antibiotic Must also be taught how to administer antibiotic

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Implementation Ambulatory and home care Ambulatory and home care  Importance of continuing antibiotics after symptoms have subsided should be stressed  Periodic nursing visits provide support and decrease anxiety  Frequent dressing changes for open wounds  May require supplies and instruction in technique