Organism	Predisposing Problem
Staphylococcus aureus	Pressure ulcer, penetrating wound, open fracture, orthopedic surgery, vascular insufficiency disorders (e.g., diabetes, atherosclerosis)
Staphylococcus epidermidis	Indwelling prosthetic devices (e.g., joint replacements, fracture fixation devices)
Streptococcus viridans	Abscessed tooth, gingival disease
Escherichia coli	Urinary tract infection
Mycobacterium tuberculosis	Tuberculosis
Neisseria gonorrhoeae	Gonorrhea
Pseudomonas	Puncture wounds, IV drug use
Salmonella	Sickle cell disease
Fungi, mycobacteria	Immunocompromised host

The infecting microorganisms can invade by indirect or direct entry. The indirect entry (hematogenous) of microorganisms most frequently affects growing bone in boys younger than 12 years old, and is associated with their higher incidence of blunt trauma. Adults with vascular insufficiency disorders (e.g., diabetes mellitus) and genitourinary and respiratory tract infections are at higher risk for a primary infection to spread via the blood to the bone. The pelvis, tibia, and vertebrae, which are vascular-rich sites of bone, are the most common sites of infection.

eNursing Care Plan 64-1 Patient With Osteomyelitis

Nursing Diagnosis*

Risk for disuse syndrome related to pain, prescribed immobilization, and prolonged bed rest

Patient Goals

1. Maintains full range of motion in unaffected joints

2. Maintains intact skin and normal respiratory, bowel, and bladder function

3. Identifies methods to prevent complications of immobility

Outcomes (NOC)	Interventions (NIC) and Rationales
Immobility Consequences: Physiologic	Bed Rest Care
• Pressure sores _____ • Constipation _____ • Paralytic ileus _____ • Urinary calculi _____ • Urinary tract infection _____ • Bone fracture _____ • Contracted joints _____ • Venous thrombosis _____ • Lung congestion _____ Immobility Consequences: Psycho-Cognitive • Exaggerated emotions _____ • Sleep disturbance _____ • Negative body image _____ • Depression _____ • Apathy _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	• Use devices on the bed (e.g., sheepskin) that protect the patient from prolonged pressure injury. • Turn as indicated by the skin condition to prevent prolonged pressure. • Perform passive and/or active range-of-motion exercises to maintain joint mobility. • Monitor for constipation to identify deviations from baseline and initiate treatment • Monitor urinary function to identify deviations from baseline and initiate interventions. • Monitor pulmonary status to identify deviations from baseline and initiate interventions. • Assist with activities of daily living to promote independence and purpose. Positioning • Immobilize or support affected body part to reduce pain and prevent pathologic fractures. • Position in proper body alignment to prevent unusual position or muscle stretching from increasing pain. • Elevate affected body part to reduce swelling and provide comfort.

Nursing Diagnosis

Acute pain related to inflammatory process resulting from infection as evidenced by guarding, moaning, crying, restlessness, altered muscle tone, decreased activity, and pain rated as >4 on 10-point rating scale

Patient Goals

1. Reports satisfactory pain relief with pain <4 on 10-point scale

2. Uses analgesics and nondrug measures effectively to control pain

Outcomes (NOC)	Interventions (NIC) and Rationales
Pain Control	Pain Management
• Uses nonanalgesic relief measures _____ • Uses analgesics as recommended _____ • Reports uncontrolled symptoms to health care professional _____ • Recognizes associated symptoms of pain _____ • Reports pain controlled _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	• Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to plan appropriate interventions. • Evaluate effectiveness of pain-control measures used through ongoing assessment of pain experience. • Provide patient optimal pain relief with prescribed analgesics to relieve pain. • Use pain-control measures before pain becomes severe. • Teach the use of nondrug techniques (e.g., relaxation, guided imagery, distraction) to augment or reduce the need for analgesics.

Nursing Diagnosis

Ineffective self-health management related to lack of knowledge regarding long-term management of osteomyelitis as evidenced by verbalization of concern and uncertainty about procedures and skills needed for home care

Patient Goals

1. Describes treatment regimen and verbalizes confidence in ability to implement it at home

2. Demonstrates wound care, aseptic technique, care of IV access, and administration of antibiotics correctly

Outcomes (NOC)	Interventions (NIC) and Rationales
Treatment Behavior: Illness or Injury	Teaching: Psychomotor Skill
• Follows recommended treatment regimen _____ • Follows prescribed activity level _____ • Uses treatment devices correctly _____ • Follows medication regimen _____ • Performs self-care consistent with ability _____ • Monitors treatment’s effects _____ • Monitors changes in disease status _____ • Seeks advice from health care professional as needed _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated Knowledge: Infection Management • Treatment for diagnosed infection _____ • Signs and symptoms of exacerbation of infection _____ • Risk of drug resistance _____ • Importance of adherence to treatment _____ Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge	• Demonstrate skills (e.g., wound care, aseptic technique, antibiotic administration) for the patient. • Instruct patient to perform skills one step at a time. • Observe patient return demonstrate skills to evaluate patient’s knowledge and performance. • Provide written information/diagrams for future reference. Teaching: Prescribed Medication • Inform patient of both generic and brand names of each medication. • Instruct patient on purpose and action of each medication. • Instruct patient on dosage, route, and duration of each medication. • Evaluate patient’s ability to self-administer medications. • Instruct patient on possible adverse effects of each medication. • Inform patient of consequences of not taking or abruptly discontinuing medication(s) since long-term antibiotic therapy is required. • Provide patient with written information about action, purpose, and side effects of medications. Teaching: Disease Process • Describe rationale behind management/therapy/treatment recommendations to promote compliance. • Instruct patient on measures to prevent/minimize side effects of treatment for the disease.

^*Nursing diagnoses listed in order of priority.

eNursing Care Plan 64-2

Patient With Low Back Pain: Acute Management

Nursing Diagnosis*

Acute pain related to muscle spasm and ineffective comfort measures as evidenced by verbalization of back pain on movement, guarded movements, palpable muscle spasm, decreased physical activity, and rating pain as >4 on 10-point pain scale

Patient Goal

Reports satisfactory pain relief with pain <4 on 10-point scale

Outcomes (NOC)	Interventions (NIC) and Rationales
Pain Level • Reported pain _____ • Muscle tension _____ • Narrowed focus _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None Pain Control • Uses nonanalgesic relief measures _____ • Uses analgesics as recommended _____ • Reports pain controlled _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Pain Management • Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to plan appropriate interventions. • Evaluate effectiveness of pain-control measures used through ongoing assessment of pain experience. • Encourage patient to use adequate pain medication to relieve spasms and promote comfort. • Promote adequate rest/sleep to facilitate pain relief and to reduce paravertebral muscle spasm and resulting pain. • Teach the use of nondrug techniques (e.g., relaxation, distraction, hot/cold application, and massage) before pain occurs or increases, and along with other pain-relief measures to promote muscle relaxation and decrease tension. • Provide patient with optimal pain relief with prescribed analgesics to help decrease pain and inflammation. Positioning • Place in the designated therapeutic position (e.g., keep head of bed elevated 20 degrees and knee of bed flexed) to promote comfort by reducing stress on lower back muscles.

Outcomes (NOC)

Interventions (NIC) and Rationales

Pain Level

• Reported pain _____

• Muscle tension _____

• Narrowed focus _____

• Uses nonanalgesic relief measures _____

• Uses analgesics as recommended _____

• Reports pain controlled _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Pain Management

• Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to plan appropriate interventions.

• Evaluate effectiveness of pain-control measures used through ongoing assessment of pain experience.

• Encourage patient to use adequate pain medication to relieve spasms and promote comfort.

• Promote adequate rest/sleep to facilitate pain relief and to reduce paravertebral muscle spasm and resulting pain.

• Teach the use of nondrug techniques (e.g., relaxation, distraction, hot/cold application, and massage) before pain occurs or increases, and along with other pain-relief measures to promote muscle relaxation and decrease tension.

• Provide patient with optimal pain relief with prescribed analgesics to help decrease pain and inflammation.

Positioning

• Place in the designated therapeutic position (e.g., keep head of bed elevated 20 degrees and knee of bed flexed) to promote comfort by reducing stress on lower back muscles.

Nursing Diagnosis

Impaired physical mobility related to pain as evidenced by movement restrictions and muscle spasms

Patient Goals

1. Demonstrates return to prior level of mobility within prescribed restrictions

2. Demonstrates correct performance of exercises

Outcomes (NOC)	Interventions (NIC) and Rationales
Mobility • Gait _____ • Muscle movement _____ • Coordination _____ • Walking _____ • Body positioning performance _____ • Moves with ease _____ Coordinated Movement • Strength of muscle contraction _____ • Muscle tone _____ • Balanced movement _____ • Muscle tension _____ • Control of movement _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	Exercise Promotion: Stretching • Assist to develop an exercise plan that incorporates an orderly sequence of stretching movements, increments in the duration of the hold phase of the movement, and increments in number of repetitions for each slow-stretch-hold movement to control muscle spasms. • Instruct in ways to monitor own adherence to schedule and progress toward goal(s) (e.g., increments in joint ROM, awareness of releasing muscle tension, increasing duration of hold phase and number of repetitions without pain and fatigue, and increase in tolerance to vigorous exercise). • Provide illustrated, take-home, written instructions for each movement component to promote continuing exercise program. Exercise Promotion: Strength Training • Provide information about types of muscle resistance that can be used (e.g., free weights, weight machines, rubberized stretch bands, weight objects, aquatic). • Assist to develop a strength training program consistent with muscle fitness level, musculoskeletal constraints, functional health goals, exercise equipment resources, personal preference, and social support because muscle strength protects the low back. • Establish a follow-up schedule to maintain motivation, assist in problem solving, and to monitor progress. • Collaborate with family and other health professionals (e.g., activity therapist, exercise physiologist, occupational therapist, recreational therapist, physical therapist) in planning, teaching, and monitoring a muscle training program.

Outcomes (NOC)

Interventions (NIC) and Rationales

Mobility

• Gait _____

• Muscle movement _____

• Coordination _____

• Walking _____

• Body positioning performance _____

• Moves with ease _____

Coordinated Movement

• Strength of muscle contraction _____

• Muscle tone _____

• Balanced movement _____

• Muscle tension _____

• Control of movement _____

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

Exercise Promotion: Stretching

• Assist to develop an exercise plan that incorporates an orderly sequence of stretching movements, increments in the duration of the hold phase of the movement, and increments in number of repetitions for each slow-stretch-hold movement to control muscle spasms.

• Instruct in ways to monitor own adherence to schedule and progress toward goal(s) (e.g., increments in joint ROM, awareness of releasing muscle tension, increasing duration of hold phase and number of repetitions without pain and fatigue, and increase in tolerance to vigorous exercise).

• Provide illustrated, take-home, written instructions for each movement component to promote continuing exercise program.

Exercise Promotion: Strength Training

• Provide information about types of muscle resistance that can be used (e.g., free weights, weight machines, rubberized stretch bands, weight objects, aquatic).

• Assist to develop a strength training program consistent with muscle fitness level, musculoskeletal constraints, functional health goals, exercise equipment resources, personal preference, and social support because muscle strength protects the low back.

• Establish a follow-up schedule to maintain motivation, assist in problem solving, and to monitor progress.

• Collaborate with family and other health professionals (e.g., activity therapist, exercise physiologist, occupational therapist, recreational therapist, physical therapist) in planning, teaching, and monitoring a muscle training program.

Patient With Low Back Pain: Chronic Management

Nursing Diagnosis

Chronic pain related to progressive degenerative changes of the muscles and skeletal structures of the back as evidenced by verbal report of back pain over more than 6 months, fatigue, and protective and guarding behaviors

Patient Goal

Reports ability to control pain at an acceptable level with the use of preventive and nonpharmacologic measures

Outcomes (NOC)	Interventions (NIC) and Rationales
Pain Control • Uses preventive measures _____ • Uses nonanalgesic relief measures _____ • Uses analgesics appropriately _____ • Uses available resources _____ • Reports pain controlled _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated Pain: Disruptive Effects • Interrupted sleep _____ • Disruption of routine _____ • Impaired physical mobility _____ • Impaired self-care _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Pain Management • Evaluate effectiveness of pain-control measures used through ongoing assessment of pain experience. • Select and implement a variety of measures (e.g., pharmacologic, nonpharmacologic) to facilitate pain relief. • Collaborate with patient, significant other, and other health professionals to select and implement nondrug pain-relief measures (e.g., use of heat, transcutaneous electrical nerve stimulation) to provide information about supplementary methods of pain management. • Explore with patient factors that relieve/worsen pain to make adjustments in lifestyle so that pain is reduced. • Use therapeutic communication strategies to acknowledge pain experience and convey acceptance of patient’s response to pain. • Inform other health care professionals/family members of nondrug strategies being used by patient to encourage preventive approaches to pain management. • Explore with patient factors that improve/worsen pain to increase awareness of pain triggers. • Encourage patient to monitor own pain and to intervene appropriately to promote self management of the pain experience. • Promote adequate rest/sleep to facilitate pain relief.

Outcomes (NOC)

Interventions (NIC) and Rationales

Pain Control

• Uses preventive measures _____

• Uses nonanalgesic relief measures _____

• Uses analgesics appropriately _____

• Uses available resources _____

• Reports pain controlled _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Pain: Disruptive Effects

• Interrupted sleep _____

• Disruption of routine _____

• Impaired physical mobility _____

• Impaired self-care _____

• Evaluate effectiveness of pain-control measures used through ongoing assessment of pain experience.

• Select and implement a variety of measures (e.g., pharmacologic, nonpharmacologic) to facilitate pain relief.

• Collaborate with patient, significant other, and other health professionals to select and implement nondrug pain-relief measures (e.g., use of heat, transcutaneous electrical nerve stimulation) to provide information about supplementary methods of pain management.

• Explore with patient factors that relieve/worsen pain to make adjustments in lifestyle so that pain is reduced.

• Use therapeutic communication strategies to acknowledge pain experience and convey acceptance of patient’s response to pain.

• Inform other health care professionals/family members of nondrug strategies being used by patient to encourage preventive approaches to pain management.

• Explore with patient factors that improve/worsen pain to increase awareness of pain triggers.

• Encourage patient to monitor own pain and to intervene appropriately to promote self management of the pain experience.

• Promote adequate rest/sleep to facilitate pain relief.

Nursing Diagnosis

Ineffective coping related to effects of chronic pain as evidenced by verbalization of hopelessness and inability to cope, irritability, inability to meet role expectations, and ineffective or inappropriate use of coping behaviors

Patient Goals

1. Uses coping behaviors effectively to adapt to effects of chronic pain

2. Reports a positive sense of control and hope

3. Reports satisfaction with lifestyle

Outcomes (NOC)	Interventions (NIC) and Rationales
Pain: Disruptive Effects • Leisure activities _____ • Life enjoyment _____ • Sense of control _____ • Sense of hope _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised Coping • Verbalizes sense of control _____ • Verbalizes acceptance of situation _____ • Modifies lifestyle to reduce stress _____ • Uses effective coping strategies _____ • Reports decrease in negative feelings _____ • Reports increase in psychological comfort _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Coping Enhancement • Appraise and discuss alternative responses to situation. • Assist patient in developing an objective appraisal of the event. • Seek to understand patient’s perception of a stressful situation. • Support use of appropriate defense mechanisms. • Arrange situations that encourage patient’s autonomy to foster effective coping behaviors and adjustments to chronic pain. • Foster constructive outlets for anger and hostility. • Assist patient to identify positive strategies to deal with limitations and manage needed lifestyle or role changes. Hope Instillation • Encourage therapeutic relationships with significant others to increase hope through a connection with others. • Teach family about the positive aspects of hope (e.g., develop meaningful conversational themes that reflect love and need for patient) to promote hopeful state. • Develop plan of care that involves degree of goal attainment, moving from simple to more complex goals to promote hope for the future. • Provide patient/family opportunity to be involved with support groups for continuing support.

Outcomes (NOC)

Interventions (NIC) and Rationales

Pain: Disruptive Effects

• Leisure activities _____

• Life enjoyment _____

• Sense of control _____

• Sense of hope _____

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

Coping

• Verbalizes sense of control _____

• Verbalizes acceptance of situation _____

• Modifies lifestyle to reduce stress _____

• Uses effective coping strategies _____

• Reports decrease in negative feelings _____

• Reports increase in psychological comfort _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Coping Enhancement

• Appraise and discuss alternative responses to situation.

• Assist patient in developing an objective appraisal of the event.

• Seek to understand patient’s perception of a stressful situation.

• Support use of appropriate defense mechanisms.

• Arrange situations that encourage patient’s autonomy to foster effective coping behaviors and adjustments to chronic pain.

• Foster constructive outlets for anger and hostility.

• Assist patient to identify positive strategies to deal with limitations and manage needed lifestyle or role changes.

Hope Instillation

• Encourage therapeutic relationships with significant others to increase hope through a connection with others.

• Teach family about the positive aspects of hope (e.g., develop meaningful conversational themes that reflect love and need for patient) to promote hopeful state.

• Develop plan of care that involves degree of goal attainment, moving from simple to more complex goals to promote hope for the future.

• Provide patient/family opportunity to be involved with support groups for continuing support.

Nursing Diagnosis

Ineffective self-health management related to knowledge deficit, complexity of therapeutic regimen, or lack of perceived benefits regarding posture, exercises, and body mechanics as evidenced by verbalization that action has not been taken to reduce risk factors for progression of illness and to include treatment regimens in daily routines

Patient Goal

Integrates a program of appropriate posture, body mechanics, exercises, and weight management into daily routine

Outcomes (NOC)	Interventions (NIC) and Rationales
Knowledge: Body Mechanics • Proper standing posture _____ • Proper sitting posture _____ • Proper lying posture _____ • Proper lifting techniques _____ • Exercises to increase muscle strength _____ • Exercises to strengthen lower abdominal muscles _____ Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge	Teaching: Prescribed Activity/Exercise • Observe patient perform prescribed activity/exercise to identify incorrect techniques and intervene appropriately. • Instruct patient on good posture and body mechanics to reduce risk of reinjury, provide back support, and maintain proper body alignment. • Assist patient to incorporate activity/exercise regimen into daily routine/lifestyle to make desired behaviors a habit. • Refer patient to physical therapist/occupational therapist/exercise physiologist to develop abdominal and paravertebral muscle strength exercises and to provide increased support. Weight Management • Discuss risks associated with being overweight and underweight as increased abdominal weight alters posture and puts strain on low back. • Develop with patient a method to keep a daily record of intake, exercise sessions, and/or changes in body weight to evaluate management of therapeutic regimen.

Outcomes (NOC)

Interventions (NIC) and Rationales

Knowledge: Body Mechanics

• Proper standing posture _____

• Proper sitting posture _____

• Proper lying posture _____

• Proper lifting techniques _____

• Exercises to increase muscle strength _____

• Exercises to strengthen lower abdominal muscles _____

Measurement Scale

1 = No knowledge

2 = Limited knowledge

3 = Moderate knowledge

4 = Substantial knowledge

5 = Extensive knowledge

Teaching: Prescribed Activity/Exercise

• Observe patient perform prescribed activity/exercise to identify incorrect techniques and intervene appropriately.

• Instruct patient on good posture and body mechanics to reduce risk of reinjury, provide back support, and maintain proper body alignment.

• Assist patient to incorporate activity/exercise regimen into daily routine/lifestyle to make desired behaviors a habit.

• Refer patient to physical therapist/occupational therapist/exercise physiologist to develop abdominal and paravertebral muscle strength exercises and to provide increased support.

Weight Management

• Discuss risks associated with being overweight and underweight as increased abdominal weight alters posture and puts strain on low back.

• Develop with patient a method to keep a daily record of intake, exercise sessions, and/or changes in body weight to evaluate management of therapeutic regimen.

^*Nursing diagnoses listed in order of priority.

Direct entry osteomyelitis can occur at any age when there is an open wound (e.g., penetrating wounds, fractures) and microorganisms gain entry to the body. Osteomyelitis may also occur in the presence of a foreign body such as an implant or an orthopedic prosthetic device (e.g., plate, total joint prosthesis).

After gaining entry into the blood, the microorganisms grow, resulting in an increase in pressure because of the nonexpanding nature of most bone. This increasing pressure eventually leads to ischemia and vascular compromise of the periosteum. The infection spreads through the bone cortex and marrow cavity, ultimately resulting in cortical devascularization and necrosis.

Once ischemia occurs, the bone dies. The area of devitalized bone eventually separates from the surrounding living bone, forming sequestra. The part of the periosteum that continues to have a blood supply forms new bone called involucrum (Fig. 64-1). It is difficult for blood-borne antibiotics or white blood cells (WBCs) to reach the sequestrum. A sequestrum may become a reservoir for microorganisms that spread to other sites, including the lungs and brain. If the sequestrum does not resolve on its own or is debrided surgically, a sinus tract may develop, resulting in chronic, purulent cutaneous drainage.

FIG. 64-1 Development of osteomyelitis infection with involucrum and sequestrum.

Clinical Manifestations and Complications

Acute osteomyelitis refers to the initial infection or an infection of less than 1 month in duration. The clinical manifestations of acute osteomyelitis are both local and systemic. Local manifestations include constant bone pain unrelieved by rest that worsens with activity; swelling, tenderness, and warmth at the infection site; and restricted movement of the affected part. Systemic manifestations include fever, night sweats, chills, restlessness, nausea, and malaise. Later signs include drainage from cutaneous sinus tracts or the fracture site.

Chronic osteomyelitis refers to a bone infection that persists for longer than 1 month or an infection that has failed to respond to the initial course of antibiotic therapy. Chronic osteomyelitis is either a continuous, persistent problem (a result of inadequate acute treatment) or a process of exacerbations and remissions (Fig. 64-2). Systemic signs may be diminished, with local signs of infection more common, including constant bone pain and swelling and warmth at the infection site. Over time, granulation tissue turns to scar tissue. This avascular scar tissue provides an ideal site for continued microorganism growth that cannot be penetrated by antibiotics.

FIG. 64-2 Resection of femur due to osteomyelitis.

Long-term and mostly rare complications of osteomyelitis include septicemia, septic arthritis, pathologic fractures, and amyloidosis.

A bone or soft tissue biopsy is the definitive way to determine the causative microorganism. The patient’s blood and wound cultures are frequently positive for microorganisms.² An elevated WBC count and erythrocyte sedimentation rate (ESR) may also be found. X-ray signs suggestive of osteomyelitis usually do not appear until 10 days to weeks after the initial clinical symptoms, by which time the disease will have progressed. Radionuclide bone scans (gallium and indium) are helpful in diagnosis and are usually positive in the area of infection. Magnetic resonance imaging (MRI) and computed tomography (CT) scans may be used to help identify the extent of the infection.³

Collaborative Care

Vigorous and prolonged IV antibiotic therapy is the treatment of choice for acute osteomyelitis, as long as bone ischemia has not yet occurred. Cultures or a bone biopsy should be done if possible before initiating drug therapy. If antibiotic therapy is delayed, surgical debridement and decompression are often necessary.

Patients are often discharged to home care or a skilled nursing facility with IV antibiotics delivered via a central venous catheter or peripherally inserted central catheter. IV antibiotic therapy may be started in the hospital and continued at home for 4 to 6 weeks or as long as 3 to 6 months. A variety of antibiotics may be prescribed depending on the microorganism. These drugs include penicillin, nafcillin (Nafcil), neomycin, vancomycin, cephalexin (Keflex), cefazolin (Ancef), cefoxitin (Mefoxin), gentamicin (Garamycin), and tobramycin (Nebcin).

Drug Alert

Gentamicin (Garamycin)

• Assess patient for dehydration before starting therapy.

• Ensure renal function testing is done before starting therapy, especially in older patients.

• Monitor peak and trough levels for therapeutic effect and to minimize renal and inner ear toxicity.⁴

• Instruct patient to notify health care provider if any visual, hearing, or urinary problems develop.

In adults with chronic osteomyelitis, oral therapy with a fluoroquinolone (ciprofloxacin [Cipro]) for 6 to 8 weeks may be prescribed instead of IV antibiotics. Oral antibiotic therapy may also be given after acute IV therapy is completed to ensure resolution of the infection. The patient’s response to drug therapy is monitored through bone scans and ESR tests.

Treatment of chronic osteomyelitis includes surgical removal of the poorly vascularized tissue and dead bone and the extended use of antibiotics.⁵ Antibiotic-impregnated polymethyl methacrylate bead chains may also be implanted at this time to help combat the infection. After debridement of the devitalized and infected tissue, the wound may be closed and a suction irrigation system inserted. Intermittent or constant irrigation of the affected bone with antibiotics may also be initiated. Protection of the limb or the surgical site with casts or braces is often done. Negative-pressure wound therapy (vacuum-assisted wound closure) may be used (see pp. 181–182 in Chapter 12).

Hyperbaric oxygen with 100% oxygen may be given as an adjunct therapy in refractory cases of chronic osteomyelitis. This therapy is thought to stimulate circulation and healing in the infected tissue (see pp. 182–183 in Chapter 12). Orthopedic prosthetic devices, if a source of chronic infection, must be removed. Muscle flaps or skin grafting provides wound coverage over the dead space (cavity) in the bone. Bone grafts may help to restore blood flow. Amputation of the extremity may be indicated when bone destruction is extensive and to save the patient’s life or to improve quality of life.

Nursing Management Osteomyelitis

Nursing Assessment

Subjective and objective data that should be obtained from an individual with osteomyelitis are presented in Table 64-2.

TABLE 64-2

NURSING ASSESSMENT
Osteomyelitis

Subjective Data

Important Health Information

Past health history: Bone trauma, open fracture, open or puncture wounds, other infections (e.g., streptococcal sore throat, bacterial pneumonia, sinusitis, skin or tooth infection, chronic urinary tract infection)

Medications: Analgesics or antibiotics

Surgery or other treatments: Bone surgery

Functional Health Patterns

Health perception–health management: IV drug and alcohol abuse; malaise

Nutritional-metabolic: Anorexia, weight loss; chills

Activity-exercise: Weakness, paralysis, muscle spasms around affected bone

Cognitive-perceptual: Local tenderness over affected area, increase in pain with movement of affected bone

Coping–stress tolerance: Irritability, withdrawal, dependency, anger

Objective Data

General

Restlessness; high, spiking temperature; night sweats

Integumentary

Diaphoresis; erythema, warmth, edema at infected bone

Musculoskeletal

Restricted movement; wound drainage; spontaneous fractures

Possible Diagnostic Findings

Leukocytosis, positive blood and/or wound cultures, ↑ erythrocyte sedimentation rate; presence of sequestrum and involucrum on x-rays, radionuclide bone scans, CT, and MRI

Nursing Diagnoses

Nursing diagnoses for the patient with osteomyelitis may include, but are not limited to, the following.

• Acute pain related to inflammatory process secondary to infection

• Ineffective self–health management related to lack of knowledge regarding long-term management of osteomyelitis

• Impaired physical mobility related to pain, immobilization devices, and weight-bearing limitations

Additional information on nursing diagnoses for the patient with osteomyelitis is available in eNursing Care Plan 64-1 (on the website for this chapter).

Planning

The overall goals are that the patient with osteomyelitis will (1) have satisfactory pain and fever control, (2) not experience any complications associated with osteomyelitis, (3) cooperate with the treatment plan, and (4) maintain a positive outlook on the outcome of the disease.

Nursing Implementation

Bone Tumors

Primary bone tumors, both benign and malignant, are relatively rare in adults. They account for only about 3% of all tumors. Metastatic bone cancer in which the cancer has spread from another site is a more common problem.

Benign Bone Tumors

Benign bone tumors are more common than primary malignant tumors. The main types of benign bone tumors are osteochondroma, osteoclastoma, and endochroma (Table 64-3). These types of tumors are often removed by surgery.

TABLE 64-3

TYPES OF PRIMARY BONE TUMORS

Types	Description
Benign
Osteochondroma	• Most common benign bone tumor • Frequently located in metaphyseal portion of long bones, particularly leg, pelvis, or scapula • Occurs most often in persons ages 10-25 • Malignant transformation may occur (chondrosarcoma)
Osteoclastoma (giant cell tumor)	• Arises in cancellous ends of arm and leg bones • About 10% are locally aggressive and may spread to lungs • High rate of local recurrence after surgery and chemotherapy
Endochroma	• Intramedullary cartilage tumor usually found in cavity of a single hand or foot bone • Rare malignant transformation can occur • If tumor becomes painful, a surgical resection is done • Peak incidence in persons ages 10-20
Malignant
Osteosarcoma	• Most common primary bone cancer • Occurs mostly in young males between ages 10 and 25 • Most often in bones of arms, legs, or pelvis (see Fig. 64-3, A)
Chondrosarcoma	• Occurs in cartilage most commonly in arm, leg, and pelvic bones of older adults ages 50-70 • Can also arise from benign bone tumors (osteochondromas) • Wide surgical resection is mostly done, since tumor rarely responds to radiation and chemotherapy • Survival rate depends on stage, size, and grade of tumor (see Fig. 64-3, B)
Ewing’s sarcoma	• Develops in medullary cavity of long bones, especially femur, humerus, pelvis, and tibia • Usually occurs in children and teenagers • Use of wide surgical resection, radiation, and chemotherapy has greatly improved the 5-yr survival rate to 60%