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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