Overview
Osteomyelitis is a severe infection of the bone, bone marrow, and
surrounding soft tissue. The most common infecting microorganism
is Staphylococcus aureus. A variety of microorganisms can cause
osteomyelitis, including Escherichia coli, Salmonella, Neisseria gonorrhoeae,
Staphylococcus epidermidis, Pseudomonas aeruginosa. Aerobic gramnegative bacteria alone or mixed with gram-positive organisms are often
found. The widespread use of antibiotics in conjunction with surgical
treatment has significantly reduced the mortality rate and complications
associated with osteomyelitis.
The infecting microorganisms can invade by indirect or direct entry.
The indirect entry (hematogenous) of microorganisms in osteomyelitis most
frequently affects growing bone in boys less than 12 years old, and is
associated with their higher incidence of blunt trauma. The most common
site of indirect entry in children are the distal femur, proximal tibia, humerus,
and radius
Osteomyelitis is classified as:
Hematogenous osteomyelitis (due to bloodborne spread of infection)
Contiguous-focus osteomyelitis, from contamination from bone surgery,
open fracture, or traumatic injury (gunshot wound)
Osteomyelitis with vascular insufficiency, seen most commonly among
patients with diabetes and peripheral vascular disease, most commonly
affecting the feet.
Patients who are at high risk for osteomyelitis include those who are
poorly nourished, elderly, or obese. Other patients at risk include those with
impaired immune systems, those with chronic illnesses (diabetes,
rheumatoid arthritis), and those receiving long-term corticosteroid therapy or
other immunosuppressive agents.
Incidence
The incidence of chronic osteomyelitis is increasing because of the
prevalence of predisposing conditions such as diabetes mellitus and
peripheral vascular disease. The increased availability of sensitive imaging
tests, such as magnetic resonance imaging and bone scintigraphy, has
improved diagnostic accuracy and the ability to characterize the infection.
Plain radiography is a useful initial investigation to identify alternative
diagnoses and potential complications. Direct sampling of the wound for
culture and antimicrobial sensitivity is essential to target treatment. The
increased incidence of methicillin-resistant Staphylococcus aureus
osteomyelitis complicates antibiotic selection. Surgical debridement is
usually necessary in chronic cases. The recurrence rate remains high despite
surgical intervention and long-term antibiotic therapy. Acute hematogenous
osteomyelitis in children typically can be treated with a four-week course of
antibiotics. In adults, the duration of antibiotic treatment for chronic
osteomyelitis is typically several weeks longer. In both situations, however,
empiric antibiotic coverage for S. aureus is indicated.
Clinical Manifestations
When the infection is bloodborne, onset is sudden, occur- ring with
clinical manifestations of sepsis (eg, chills, high fever, rapid pulse, and
general malaise)
Extremity becomes painful, swollen, warm, and tender.
Patient may describe a constant pulsating pain that intensifies with
movement (due to the pressure of collecting pus).
When osteomyelitis is caused by adjacent infection or direct
contamination, there are no symptoms of sepsis; the area is swollen,
warm, painful, and tender to touch.
Chronic osteomyelitis presents with a nonhealing ulcer that overlies
the infected bone with a connecting sinus that will intermittently and
spontaneously drain pus.
Prevention
Prevention of osteomyelitis is the goal
Elective orthopedic surgery should be postponed if the patient has a
current infection or a recent history of infection
During orthopedic surgery, careful attention is paid to the surgical
environment and to techniques to decrease direct bone contamination
Prophylactic antibiotics are administered to achieve adequate tissue
levels at the time of surgery and for 24 hours after surgery
Urinary catheters and drains are removed as soon as possible to
decrease the incidence of hematogenous spread of infection
Treatment of focal infections diminishes hematogenous spread
Aseptic postoperative wound care reduces the incidence of superficial
infections and osteomyelitis
Prompt management of soft tissue infections reduces extension of
infection to the bone
When patients who have had joint replacement surgery undergo dental
procedures or other invasive procedures, prophylactic antibiotics are
frequently recommended.
Assessment
Assess for risk factors (eg, older age, diabetes, longterm steroid
therapy) and for previous injury, infection, or orthopedic surgery.
Observe for guarded movement of infected area and generalized
weakness due to systemic infection.
Observe for swelling and warmth of affected area, purulent drainage,
and elevated temperature.
Note that patients with chronic osteomyelitis may have minimal
temperature elevations, occurring in the afternoon or evening.
Diagnostic Findings
Acute osteomyelitis: Early x-ray films show only soft tissue swelling.
Chronic osteomyelitis: X-ray shows large, irregular cavities, a raised
periosteum, sequestra, or dense bone formations.
Radioisotope bone scans and magnetic resonance imaging (MRI) help
with early definitive diagnosis.
Blood studies show leukocytosis and high erythrocyte sedimentation
rate (ESR).
Wound and blood culture studies are performed to identify appropriate
antibiotic therapy.
Bone scans may be performed to identify areas of infection. ESR and
WBC count are usually normal.
Planning and Goals
Relief of pain
improved physical mobility within therapeutic limitations,
Control and eradication of infection
Knowledge of the treatment regimen.
Medical Management
Initial goal of therapy is to control and halt the infective process
Antibiotic therapy depends on the results of blood and wound cultures
General supportive measures (hydration, diet high in vitamins and
protein, correction of anemia) should be instituted
The area affected with osteomyelitis is immobilized to decrease
discomfort and to prevent pathologic fracture of the weakened bone
Blood and wound cultures are performed to identify organisms and
select the antibiotic.
Intravenous antibiotic therapy is given around-the-clock; continues for
3 to 6 weeks.
Antibiotic medication is administered orally (on empty stomach) when
infection appears to be controlled; the medication regimen is continued
for up to 3 months.
Surgical debridement of bone is performed with irrigation; adjunctive
antibiotic therapy is maintained.
Nursing Interventions
Relieving Pain
Immobilize affected part with splint to decrease pain and muscle spasm.
Monitor neurovascular status of affected extremity.
Handle affected part with great care to avoid pain.
Elevate affected part to reduce swelling and discomfort.
Administer prescribed analgesic agents and use other tech- niques to
reduce pain.
Improving Physical Mobility
Teach the rationale for activity restrictions (bone is weakened by the
infective process).
Gently move the joints above and below the affected part through their
range of motion.
Encourage activities of daily living within physical limitations.
Controlling Infectious Process
Monitor response to antibiotic therapy. Observe intravenous sites for
evidence of phlebitis or infiltration.
Monitor for signs of superinfection with long-term, intensive antibiotic
therapy (eg, oral or vaginal candidiasis; loose or foul-smelling stools).
If surgery was necessary, ensure adequate circulation (wound suction,
elevation of area, avoidance of pressure on grafted area); maintain
immobility as needed; comply with weight-bearing restrictions.
Change dressings using aseptic technique to promote healing and
prevent crosscontamination.
Monitor general health and nutrition of patient.
Provide a balanced diet high in protein to ensure positive nitrogen
balance and promote healing; encourage adequate hydration.
Discharge Planning
Teaching Patients Self-Care
Advise patient and family to adhere strictly to the therapeutic regimen of
antibiotics and prevention of falls or other injury that could result in fracture.
Teach patient and family how to maintain and manage the intravenous
access site and intravenous administration equipment.
Provide in-depth medication education (eg, drug name, dosage, frequency,
administration rate, safe storage and handling, adverse reactions), including
need for laboratory monitoring.
Instruct patient to observe for and report elevated temperature, drainage,
odor, signs of increased inammation, adverse reactions, and signs of
superinfection.
Continuing Care
Complete home assessment to determine patients and familys ability to
continue therapeutic regimen.
Refer for a home care nurse if indicated.
Monitor patient for response to treatment, signs and symptoms of
superinfection, and adverse drug reactions.
Stress importance of follow-up health care appointments and recommend
age-appropriate health screening.
Evaluation
Expected Patient Outcomes
Experiences pain relief
Increases physical mobility
Shows absence of infection
Adheres to therapeutic plan
List of Nursing Diagnoses
Acute pain related to inammation and swelling
Impaired physical mobility associated with pain, immobilization
devices, and weight-bearing limitations
Risk for extension of infection: bone abscess formation
Deficient knowledge about treatment regimen
