Osteomyelitis is an infection of bone, bone marrow, and the soft tissue that surrounds the bone. It is generally caused by pyogenic (pus-producing) bacteria but may be the result of a viral or fungal infection. Osteomyelitis may be an acute or chronic condition. Acute osteomyelitis refers to an infection that is less than 1 month in duration from the time of the initial infection. Chronic osteomyelitis refers to a bone infection that persists for longer than 4 weeks or represents a persistent problem with periods of remission and exacerbations; the prevalence of chronic osteomyelitis is 2 cases per 10,000 people.
Osteomyelitis most commonly occurs in the long bones and, in particular, the tibia, femur, and fibula. The metaphysis (growing portion of a bone) of the distal portion of the femur and the proximal portion of the tibia are the most frequent sites because of the sluggish blood supply that occurs in those areas. After gaining entrance to the bone, the bacteria grow and form an abscess, which spreads along the shaft of the bone under the periosteum. Pressure elevates the periosteum, destroying its blood vessels and causing bone necrosis. The dead bone tissue (sequestra) cannot easily be liquefied and removed. The body’s healing response is to lay new bone (involucrum) over the sequestra. However, the sequestra is a perfect environment for bacteria, and chronic osteomyelitis occurs if the bacteria are not eliminated. Complications from osteomyelitis include chronic infection, skeletal and joint deformities, immobility, and altered growth and development.
Osteomyelitis is caused by direct or indirect invasion of an organism into the bone or its surrounding tissue. Any break in the skin, which normally acts as a protective barrier, can lead to direct infection. These breaks may be caused by abrasions, open fractures, or surgical instrumentation, such as the insertion of pins for skeletal traction. Indirect infections are caused by organisms that are transported through the bloodstream (hematogenous) from an infection in a distant site, such as otitis media, tonsillitis, or a furuncle (boil). The most common organisms responsible for osteomyelitis are Staphylococcus aureus and hemolytic streptococcus.
Previous trauma to a bone may predispose the area to osteomyelitis. Any delay in treatment of a fracture may also contribute to the development of osteomyelitis. Hematogenous osteomyelitis (originating in the blood) may occur in the adult who has undergone surgery or examination of the genitourinary tract or whose resistance has been lowered by debilitating illness. With older patients, the infection may become localized in the vertebra.
Nursing care plan assessment and physical examination
Question the patient about any previous bone trauma, open injuries, or surgical procedures. Elicit information about the patient’s general well-being, level of fatigue, and previous illnesses, specifically any infections. In the acute phase, the patient may report the chracteristic signs of an infection: high temperature, chills, fever, increased pulse, nausea, diaphoresis, general weakness, and malaise. In the chronic phase, the patient may report an exacerbation characterized by low-grade fever, fatigue, pain, and purulent drainage from a sinus tract.
Local and systemic signs and symptoms of osteomyelitis are generally present. Examination of the area reveals local infectious symptoms, such as redness or swelling and increased warmth. A foul-smelling draining wound may be present, with an intense pain or tenderness over the affected bone; you may note muscle spasms as well. The patient often protects the extremity by intentionally limiting movement in the joint closest to the affected area. Observe the patient’s gait to identify a limp or abnormal gait.
If the patient has an acute condition, assess the level of anxiety related to treatment plans, potential for sepsis, or potential of the illness to become chronic. In the chronic condition, the patient may be depressed and discouraged. A mistrust of the healthcare team may develop if interventions do not result in permanent resolution of the infection. Chronic pain and decreased mobility can lead to long-term disability, resulting in financial burdens, changes in body image or self-image, and alteration in family or social roles.
Nursing care plan primary nursing diagnosis: Pain (acute) related to swelling and inflammation.
Nursing care plan intervention and treatment plan
The most critical factor in eliminating osteomyelitis is prevention. To prevent direct infections, early care of injuries that break the skin and aseptic care of surgical wounds are essential. Indirect infections may be prevented by aggressive treatment of infections at any location. Early diagnosis and treatment are extremely important to prevent chronic osteomyelitis. With early treatment, the chances of effectively controlling acute osteomyelitis are quite good. The physician who suspects osteomyelitis prescribes broad-spectrum intravenous antibiotics immediately after blood, wound, or bone cultures are obtained to determine the causative organism.
Early and adequate débridement of open fractures to remove necrotic tissue limits bacterial growth. Administration of prophylactic antibiotics in patients with open fractures and after surgery to reduce fractures decreases the incidence of post-traumatic osteomyelitis; it is important for the antibiotics to reach the bone before bone necrosis occurs. If treatment is delayed and necrotic bone develops, there is a decrease in effectiveness of the antibiotic to combat infection.
The physician usually prescribes analgesics for pain. Heat applications may also decrease discomfort. Usually the patient limits his or her own activity, but the joints above and below the affected part are often immobilized with a splint or a bivalved cast to decrease pain and muscle spasm and to support wound healing. No weight bearing is permitted on the affected part. A diet high in calories, protein, calcium, and vitamin C is started as soon as possible to promote bone healing. If there is pus formation under the periosteum, the physician performs a needle aspiration and possibly insertion of a drainage tube to evacuate the subperiosteum area. If the response to antibiotics is slow and an abscess develops, an incision and drainage (I and D) may be done. The surgeon may place catheters in the wound for irrigation or for direct antibiotic instillation. Treatment for chronic osteomyelitis may include surgical débridement of devitalized and infected tissue so that permanent healing can take place. This operation, called a sequestrectomy, consists of the removal of the sequestrum and the overlying involucrum (sheath or covering).
Osteomyelitis often includes a prolonged hospital stay and in-depth preparation for long-term care in the home. Several strategies exist to manage the discomfort of fever and pain nonpharmacologically. Encourage oral fluids to prevent dehydration because of the elevated temperature and infectious process. Frequent positioning and distractions help with pain control. Use imagery and relaxation techniques to help control discomfort.
To prevent contamination to other areas of the body, use various types of sterile dressings to contain the exudate from draining wounds. The most common are dry, sterile dressings; dressings saturated in saline or antibiotic solution; and wet-to-dry dressings. Use aseptic technique when you change dressings, and dispose of contaminated dressings appropriately. Universal precautions are extremely important to prevent cross-contamination of the wound or spread of the infection to other patients.
Handle the involved extremity carefully to avoid increasing pain and the risk of a pathological fracture. To provide support, immobilization, and comfort, the extremity may be splinted. Proper application of the splint is extremely important because an improperly applied device can result in pressure ulcers or nerve damage. Regular skin assessments and conscientious skin care are important to prevent pressure sores from bedrest. Good body alignment, appropriate positioning of the affected extremity, and frequent position changes for the rest of the body prevent complications and promote comfort. Flexion deformity or contractures may occur if the patient is permitted to maintain a position of comfort instead of a position of function. Foot-drop can develop quickly in the lower extremity if the foot is not correctly supported. Promote range-of-motion, isotonic, and isometric exercises for the rest of the body to maintain joint flexibility and muscle strength.
Nursing care plan discharge and home health care guidelines
Patient education varies with the etiology of osteomyelitis; an individualized teaching plan needs to be developed for each patient. Regardless of the etiology, prolonged bedrest and parenteral antibiotic therapy are usually a part of the treatment plan. Discuss the cause and treatment of osteomyelitis with the patient, along with the importance of following the treatment plan. The major issues that need to be addressed are medication administration, activity, and signs and symptoms that may require notification of the physician. Discuss the need to contact the physician if increased pain, temperature, drainage, redness, or swelling develops. Also make certain the patient understands the signs of allergic drug reactions.
Emphasize the importance of long-term antibiotics that the patient requires, including the need to continue the medication even after the symptoms disappear. If intravenous or central line antibiotics are prescribed at home, arrange for assistance from home healthcare nurses. Also include the family in all patient teaching. Note that significant others are often responsible for delivering the care. Have the patient or significant other not only explain all procedures but also demonstrate all techniques.