Casestudy Osteomyelitis

1 Case Study: OSTEOMYELITIS
OBJECTIVES
General:
This case study aims to present the condition called
Osteomyelitis in relation to a patient's clinical manifestations,
treatment and general health status.
Specific:
To gather the needed data that can help to understand how
and why the disease occurs
To enhance knowledge and acquire more information about
Osteomyelitis
To enumerate the clinical manifestations of the disease so as
to provide prompt intervention of its occurrence
To give an idea of how to render proper nursing care for
clients with this condition thus it can be applied for future
exposures of students
To identify possible treatments that can be used to cure the
disease
ACKNOWLEDGEMENT
First of all, I owe my deepest gratitude to our Almighty God

for guiding us all throughout our affiliation in Orthopedic Hospital
and for giving me a chance and the ability to finish this study.
I also wish to express a sincere gratitude to my family as

they untiringly support me and provide everything I need.
I also thank my friends for their constant encouragement.
And to my Clinical Instructor, Mrs. Elenita Carandang, I want

to extend my gratitude for her guidance, support, encouragement
and her desire to make us learn.
It is also my pleasure to thank the Dean of College of

Nursing, Dean May Veridiano for being always considerate and
approachable and for establishing a good quality of education in
our department.
Finally, I thank my most beloved teachers and those special

people who made me feel that they believe in me more than I do
to myself.
INTRODUCTION:
Background of the
Disease
Osteomyelitis
Osteomyelitis (osteo- derived from the

Greek word osteon, meaning bone, myelo- meaning marrow, and -itis
meaning inflammation) simply means an infection of the bone or bone
marrow. It can be usefully subclassified on the basis of the causative
organism (pyogenic bacteria or mycobacteria), the route, duration and
anatomic location of the infection.
It is an acute or chronic inflammatory process of the bone and its
structures secondary to infection with pyogenic organisms.
The bone becomes infected by one of three modes:
Extension of soft tissue infection (eg, infected pressure or vascular ulcer,
incisional infection)
Direct bone contamination from bone surgery, open fracture, or traumatic
injury (eg, gunshot wound)
Hematogenous (blood borne) spread from other sites of infection (eg,
infected tonsils, boils, infected teeth, upper respiratory infections).
Osteomyelitis resulting from hematogenous spread typically occurs in
a bone area of trauma or lowered resistance, possibly from subclinical
(nonapparent) trauma. Patients who are at high risk for osteomyelitis
include those who are poorly nourished, elderly, or obese. Also at risk are
patients with impaired immune systems, those with chronic illness (eg,
diabetes, rheumatoid arthritis), and those receiving long term corticosteroid
therapy. Postoperative surgical wound infections occur within 30 days after
surgery. They are classified as incisional (superficial, located
above the deep fascia layer) or deep (involving tissue beneath the deep
fascia). If an implant has been used, deep postoperative infections may
occur within a year. Deep sepsis after arthroplasty may be classified as
follows:
Stage 1, acute fulminating: occurring during the first 3 months after
orthopedic surgery; frequently associated with hematoma, drainage, or
superficial infection
Stage 2, delayed onset: occurring between 4 and 24 months after surgery
Stage 3, late onset: occurring 2 or more years after surgery, usually as a
result of hematogenous spread
Bone infections are more difficult to eradicate than soft tissue
infections because the infected bone becomes walled off. Natural body
immune responses are blocked, and there is less penetration by antibiotics.
Osteomyelitis may become chronic and may affect the patients quality of
life.
Causes
Bone infection can be caused by bacteria or fungi.
Infection may also spread to a

bone from infected skin,
muscles, or tendons next to the
bone, as in osteomyelitis that
occurs under a chronic skin
ulcer (sore).
The infection that causes
osteomyelitis can also start in
another part of the body and
spread to the bone through the
blood.
A current or past injury may
have made the affected bone
more likely to develop the
infection. A bone infection can
also start after bone surgery,
especially if the surgery is done after an injury or if metal rods or
plates are placed in the bone.
In children, the long bones are usually affected. In adults, the feet,
spine bones (vertebrae), and the hips (pelvis) are most commonly affected.
Risk factors are recent trauma, diabetes, hemodialysis, poor blood

supply, and IV drug abuse. People who have had their spleen removed are
also at higher risk for osteomyelitis.
Note that responsible pathogens may be isolated in only 35-40% of

infections. Bacterial causes of acute and direct osteomyelitis include the
following:
Acute hematogenous osteomyelitis (Note increasing reports of other

pathogens in bone and joint infections including community-
associated methicillin-resistant Staphylococcus aureus [MRSA],
Kingella kingae,and others.)
o Newborns (younger than 4 mo):
S aureus, Enterobacter species, and group A and
B Streptococcusspecies
o Children (aged 4 mo to 4 y):
S aureus, group A Streptococcus species, Haemophilus
influenzae, andEnterobacter species
o Children, adolescents (aged 4 y to adult):
S aureus (80%), group A Streptococcus species, H influenzae,
and Enterobacter species
o Adult:
S aureus and
occasionally Enterobacter or Streptococcus species
Direct osteomyelitis
o General
S aureus, Enterobacter species, and Pseudomonas species
o Puncture wound through an athletic shoe
S aureus and Pseudomonas species
o Sickle cell disease
S aureus and Salmonellae species
Etiology
Bacteria are the most common cause of osteomyelitis, especially

Staphylococcus aureus. However, other bacteria such as Pseudomonas,
Klebsiella, Salmonella, and Escherichia coli can be causative agents
(Roberts & Lappe, 2000). Viruses, fungi, and parasites can also lead to the
development of osteomyelitis.
Bone has several structural factors that make it difficult to treat
osteomyelitis. The microscopic channels present in the bone do not allow
access by the bodys natural defense cells, thus allowing organisms to
readily proliferate. The bones microcirculation is easily damaged and
destroyed by bacterial toxins. This impairs blood flow in the bone and leads
to bone ischemia and necrosis. And finally, it is difficult for new bone to be
formed to replace necrotic bone tissue and the integrity of the bone
structure is weakened (McCance & Mourad, 2000b). Because it is difficult
to treat osteomyelitis, prevention of osteomyelitis in the first place is the
best treatment.
Osteomyelitis results from organisms that enter bone tissue from
either exogenous sources or endogenous sources. Exogenous sources are
from outside the body. Infections from exogenous sources can come from
open fractures, surgery (especially total joint replacements), or puncture
wounds. Animal or human bites can also introduce bacteria to the body that
spreads to the bone. People with chronic health conditions such as
drug/alcohol abuse, diabetes, or immunosuppression are more susceptible
to developing osteomyelitis. Those who are poorly nourished are also more
susceptible to osteomyelitis (Liddel, 2000b).
Endogenous sources of osteomyelitis, also known as hematogenous
osteomyelitis, originate within the body and are blood-borne. Common
sources of infection within the body are oral, respiratory, ear, sinus,
gastrointestinal, and genitourinary .Children and the elderly are more
susceptible to this form of osteomyelitis.
Whatever the etiology, it is important for the nurse to remember that
osteomyelitis is very difficult to treat, especially if it is undetected in the
early stages. Nurses should be particularly vigilant in assessing for
osteomyelitis in all patients who are considered to be at risk. If
osteomyelitis is not treated promptly in its acute stage, it can progress to
chronic osteomyelitis and lead to loss of function, amputation, and even
death.
Risk factors
Some of the risk factors that may increase a persons susceptibility to

osteomyelitis include:
Long term skin infections.
Inadequately controlled diabetes.
Poor blood circulation (arteriosclerosis).
Risk factors for poor blood circulation, which include high blood
pressure, cigarette smoking, high blood cholesterol and diabetes.
Immune system deficiency.
Prosthetic joints.
The use of intravenous drugs.
Sickle cell anaemia.
Cancer.
Clinical Manifestations
When the infection is bloodborne, the onset is usually sudden,

occurring often with the clinical manifestations of septicemia (eg, chills,
high fever, rapid pulse, general malaise). The systemic symptoms at first
may overshadow the local signs. As the infection extends through the
cortex of the bone, it involves the periosteum and the soft tissues. The
infected area becomes painful, swollen, and extremely tender. The patient
may describe a constant, pulsating pain that intensifies with movement as a
result of the pressure of the collecting pus. When osteomyelitis occurs from
spread of adjacent infection or from direct contamination, there are no
symptoms of septicemia. The area is swollen, warm, painful, and tender to
touch. The patient with chronic osteomyelitis presents with a continuously
draining sinus or experiences recurrent periods of pain, inflammation,
swelling, and drainage. The low-grade infection thrives in scar tissue,
because it has a reduced blood supply.
Possible Complications
When the bone is infected, pus is produced within the bone, which
may result in an abscess. The abscess steals the bone's blood supply. The
lost blood supply can result in a complication called chronic osteomyelitis.

This chronic infection can cause symptoms that come and go for years.
Other complications include:
Need for amputation

Reduced limb or joint function
Spread of infection
Diagnostic Procedures
A physical examination shows bone tenderness and possibly swelling and

redness.
Tests may include:
Blood cultures/Tests
Medical history
Bone biopsy (which is then cultured)
Bone scan
Bone x-ray
C-reactive protein (CRP)
Erythrocyte sedimentation rate (ESR)
Needle aspiration of the area around affected bones
Computed tomography (CT) scan
Magnetic resonance imaging (MRI)
Treatment
The objective of treatment is to eliminate the infection and prevent it

from getting worse.
Antibiotics will be given to destroy the bacteria that are causing the
infection. You may be given more than one antibiotic at a time. Often, the
antibiotics are given through an IV (intravenously, meaning through a vein)
rather than by mouth. Antibiotics are taken for at least 4-6 weeks,
sometimes longer.
Surgery may be needed to remove dead bone tissue if you have an
infection that does not go away. If there are metal plates near the infection,
they may be removed. The open space left by the removed bone tissue
may be filled with bone graft or packing material that promotes the growth
of new bone tissue.
Infection of an orthopedic prosthesis may require surgical removal of
the prosthesis and infected tissue surrounding the area. A new prosthesis
may be implanted in the same operation or delayed until the infection has
gone away.
If the patient has diabetes, it will need to be well controlled. If there
are problems with blood supply, surgery to improve blood flow may be
needed.
Outlook/Prognosis
When treatment is received, the outcome for acute osteomyelitis is

usually good.
The outlook is worse for those with long-term (chronic) osteomyelitis,

even with surgery. Amputation may be needed, especially in those with
diabetes or poor blood circulation.
The outlook is guarded in those who have an infection of a

prosthesis.
DEFINITION OF TERMS
Sequestrum a piece of dead bone that has become separated
during the process of necrosis from normal/sound bone. It is a
complication (sequela) of Osteomyelitis.
Involucrum - a layer of new bone growth outside existing bone seen

in pyogenic osteomyelitis. It results from the stripping off of
the periosteum by the accumulation of pus within the bone, and new
bone growing from the periosteum.
Pyogenic it refers to bacterial infections that make pus.
Bone Graft - packing material that promotes the growth of new bone
tissue.
Abscess is a collection of pus (dead neutrophils) that has
accumulated in a cavity formed by the tissue in which the pus resides
on the basis of an infectious process (usually caused
by bacteria or parasites) or other foreign materials (e.g., splinters,
bullet wounds, or injecting needles). It is a defensive reaction of the
tissue to prevent the spread of infectious materials to other parts of
the body.
Iatrogenic - caused by treatment or diagnostic procedures. An
iatrogenic disorder is a condition that is caused by medical personnel
or procedures or that develops through exposure to the environment
of a health care facility.
Periosteum - is a membrane that lines the outer surface of
all bones, except at the joints of long bones
Hematogenous - Originating in or spread by the blood
Amputation surgical removal of a body part. As a surgical
measure, it is used to control pain or a disease process in the
affected limb, such as malignancy or gangrene.
Arthroplasty - is the operation for construction of a new movable
joint.
Sepsis - serious medical condition that is characterized by a whole-
body inflammatory state (called a systemic inflammatory response
syndrome or SIRS) and the presence of a known or
suspected infection
Hemodialysis - a method for removing waste products such
as creatinine and urea, as well as free water from the blood when
the kidneys are in renal failure
SOURCE: www.google.com
Personal
Background of the
Patient
PERSONAL DATA
Name: Patient K
Address: Menville Pasay City
Occupation: none (student)
Religion: Roman Catholic

Nationality: Filipino
DEMOGRAPHIC DATA
Date of Birth: April 3, 2002
Place of Birth: Manila
Age: 7 years old
Gender: Male
Status: Child
PATIENT PROFILE
Date Admitted: June 8, 2010
4:30pm
Attending Physician: Dr. Espinosa
Room/Ward: Pediatric Ward
Hospital Record No: 581670
HOME ENVIRONMENT AND OCCUPATION

Physical Environment: He lives with his parents and other siblings.
They live in a concrete home and he is
studying in a public school. His father provides
their needs while his mother is the one taking
care of her and her siblings.
NUTRITIONAL PATTERN
Usual Meal: He often eats fried foods and doesnt like to

eat vegetables. And he usually drinks 2-4
glasses of water every day.
SLEEP AND REST PATTERN

Usual Sleep Pattern: Usually sleeps at 8 or 9 oclock in the evening
and wakes up at 6:30 in the morning.
Relaxation Techniques: Watching tv and sleeping
ELIMINATION PATTERN
Urinary: He urinates 3-5 times a day
Bowel: He defecates once a day.
PAST HEALTH HISTORY

Past Medical History
Patient had urinary tract infection (UTI) a year ago. He was brought to
a local doctor and was given antibiotics.
Usual Medications
Paracetamol
Cough Syrups
Vaccinations
BCG (1)
HepaB (3)
Measles (1)
DPT (3)
Allergies
No known allergies to food and drugs
Family History
There is a history of high blood pressure and diabetes on his fathers
side.
HISTORY OF PRESENT ILLNESS
Reason for seeking medical care: swelling on the right lower

leg
Six months prior to admission, the patient had a small wound on his
right foot. Patients mother ignored the lesion for she perceived it as a
minor wound only. No treatment or consultation was done.
Two weeks prior to admission, patients mother noted swelling on the
right lower leg of her daughter and this was associated with on and off
fever.
The day before the patient was admitted, he had a high grade fever.
They consulted at a district hospital and they were referred to the Philippine
Orthopedic Center (POC) for Osteomyelitis.
D50.3NaCl 500cc
PHYSICAL
EXAMINATION
Initial Vital Signs
Temperature 37.8C
Cardiac Rate 79bpm
Respiratory Rate 35bpm
WEIGHT: 15.9kg
GENERAL
The patient appears his stated age. He is awake on bed with ongoing
IVF of D50.3NaCl 500cc. His right leg is slightly bigger than his left due to
inflammation process secondary to Osteomyelitis. Other body parts look
equal bilaterally and are in relative proportion to each other.
HEAD
Skull and Face
Rounded, normocephalic and symmetrical
Uniform consistency; absence of nodules or masses
Symmetric facial movements/features
No tenderness
Can move facial muscles at will
SCALP
No tenderness nor masses
Same color as the complexion
No lesions
SKIN
The skin color is deep brown/normal
Generally uniform in color except in the area with swelling tissues
With swelling/inflammation in right leg
Slightly dry skin
Temperature is above the normal range
No itchiness
With lesions on the affected extremity
HAIR
Evenly distributed over the scalp
Black
Variable amount of body hair
With straight thick hair
Absence of seborrhea
NAILS
Convex curvature
Smooth in texture
Pale nailbeds
2-3seconds capillary refill time
Clean nails
Eyes,Eyebrows and Eyelashes

Eyebrows symmetrically aligned
Equally distributed eyelashes
Skin intact ; no discharges
Anecteric Sclera
Pink palpebral conjunctiva
No edema or tenderness present over lacrimal gland
No eyeglasses
Ears
Auricle symmetrical, at the level of external canthus of the eyes
Mobile, firm and not tender,; pinna recoils after it is folded
Normal voice tones audible
No discharges
Smooth without lesions
Nose and Sinuses

External nose is symmetric and straight
Clear-watery discharge and flaring of the nares
Same color with the face
No tenderness or lesions when palpated
Airway is patent (air moves freely as the client breathes through
the nares)
Nasal septum intact and in midline
Mouth and Oropharynx

Outer lips is dry
Tongue in central position, pink in color; with raised papillae;
moves freely
NECK
Centrally located on the shoulder
Able to flex and extend head without pain and resistance
Neck muscles equal in size, head is centered
Coordinated, smooth movements without discomfort
No palpable lymph nodes
THORAX AND LUNGS

Quiet, rhythmic and effortless respiration
No adventitious soundChest symmetric
Chest wall intact; no tenderness, no masses
No retractions
CARDIOVASCULAR
Regular heart rate
No chest pain
No shortness of breath
Adynamic precordium
No murmurs
GASTROINTESTINAL
Soft,nontender abdomen
No dysphagia
Normoactive bowel sounds
MUSCULOSKELETAL SYTEM
With swelling on the skin and tissues over the infected bone.
Thin extremities
Decreased Activity Tolerance
EXTREMITIES
Upper extremities are equal in size
Right leg is bigger than the left due
With lesions and swelling on the right leg
Laboratory
Examinations
Complete Blood Count Also known as full blood count or full

blood exam or blood panel, is a test panel requested by a doctor
or other medical professional that gives information about the cells
in a patients blood.
Urinalysis is an array of tests performed on urine and one of the
most common methods of medical diagnosis.
Xray - are a form of electromagnetic radiation, just like visible light.
In a health care setting, a machines sends are individual x-ray
particles, called photons. These particles pass through the body. A
computer or special film is used to record the images that are
created.
CRP (C-reactive Protein) is a protein found in the blood, the
levels of which rise in response to inflammation.
ESR(Erythrocyte Sedimentation Rate) also called a Biernacki
Reaction, is the rate at which red blood cells precipitate in a period
of one hour. It is a common hematology test which is a non-
specific measure of inflammation.
Blood culture - A blood culture is a test used to detect bacteria. A
sample of blood is taken and then placed into an environment that
will support the growth of bacteria. By allowing the bacteria to
grow, the infectious agent can then be identified and tested
against different antibiotics in hopes of finding the most effective
treatment.
Laboratory Findings
A number of tests were done. Complete blood count shows increase

number of white blood cells, Erythrocyte Sedimentation Rate is also
increased and blood culture and C-reactive protein are positive. Xray result
reveals evidence of osteomyelitis.
Anatomy
and Physiology
Musculoskeletal System
Musculoskeletal system (also known as the locomotor system) is
an organ system that gives animals (including humans) the ability to move
using the muscular and skeletal systems. The musculoskeletal system
provides form, support, stability, and movement to the body. It is made up
of the bodys bone (the skeleton), muscles, cartilage, tendons, ligaments,
joints, and other connective tissue (the tissue that supports and binds
tissues and organs together). The musculoskeletal system's primary
functions include supporting the body, allowing motion, and protecting vital
organs. The skeletal portion of the system serves as the main storage
system for calcium and phosphorus and contains critical components of the
hematopoietic system. This system describes how bones are connected to
other bones and muscle fibers via connective tissue such as tendons and
ligaments. The bones provide the stability to a body in analogy to iron rods
in concrete construction. Muscles keep bones in place and also play a role
in movement of the bones. To allow motion different bones are connected
by joints. Cartilage prevents the bone ends from rubbing directly on to each
other. Muscles contract (bunch up) to move the bone attached at the joint.
There are, however, diseases and disorders that may adversely affect the
function and overall effectiveness of the system. These diseases can be
difficult to diagnose due to the close relation of the musculoskeletal system
to other internal systems. The musculoskeletal system refers to the system
having its muscles attached to an internal skeletal system and is necessary
for humans to move to a more favorable position.
Subsystems
Skeletal
The Skeletal System serves many important functions; it provides the

shape and form for our bodies in addition to supporting, protecting, allowing
bodily movement, producing blood for the body, and storing minerals. The
number of bones in the human skeletal system is a controversial topic.
Humans are born with about 350 bones, however, many bones fuse
together between birth and maturity. As a result an average adult skeleton
consists of 206 bones. The number of bones varies according to the
method used to derive the count. While some consider certain structures to
be a single bone with multiple parts, others may see it as a single
part with multiple bones. There are five general classifications of bones.
These are long bones, short bones, flat bones, irregular bones,
and sesamoid bones. The human skeleton is composed of both fused and
individual bones supported by ligaments, tendons, muscles and cartilage. It
is a complex structure with two distinct divisions. These are the axial
skeleton and the appendicular skeleton.
Function
The Skeletal System serves as a framework for tissues and organs to

attach themselves to. This system acts as a protective structure for vital
organs. Major examples of this are thebrain being protected by the skull
and the lungs being protected by the rib cage.
Located in long bones are two distinctions of bone marrow (yellow
and red). The yellow marrow has fatty connective tissue and is found in the
marrow cavity. During starvation, the body uses the fat in yellow marrow for
energy. The red marrow of some bones is an important site for blood cell
production, approximately 2.6 million red blood cells per second in order to
replace existing cells that have been destroyed by the liver. Here all
erythrocytes, platelets, and most leukocytes form in adults. From the red
marrow, erythrocytes, platelets, and leukocytes migrate to the blood to do
their special
tasks.
Another function of bones is the storage of certain minerals. Calcium
and phosphorus are among the main minerals being stored. The
importance of this storage "device" helps to regulate mineral balance in the
bloodstream. When the fluctuation of minerals is high, these minerals are
stored in bone; when it is low it will be withdrawn from the bone.
Types of Bone Tissue
Bone cells are called osteocytes, and the matrix of bone is made of
calcium salts and collagen. The calcium salts are calcium carbonate
(CaCO3) and calcium phosphate (Ca3(PO4)2), which give bone the
strength required to perform its supportive and protective functions. Bone
matrix is non-living, but it changes constantly, with calcium that is taken
from bone into the blood replaced by calcium from the diet. In normal
circumstances, the amount of calcium that is removed is replaced by an
equal amount of calcium deposited. This is the function of osteocytes, to
regulate the amount of calcium that is deposited in, or removed from, the
bone matrix.
In bone as an organ, two types of bone tissue are present (Fig. 61).
Compact bone looks solid but is very precisely structured. Compact bone
is made of osteons or haversian systems, microscopic cylinders of bone
matrix with osteocytes in concentric rings around central haversian
canals. In the haversian canals are blood vessels; the osteocytes are in
contact with these blood vessels and with one another through microscopic
channels (canaliculi) in the matrix.
The second type of bone tissue is spongy bone, which does look
rather like a sponge with its visible holes or cavities. Osteocytes, matrix,
and blood vessels are present but are not arranged in haversian systems.
The cavities in spongy bone often contain red bone marrow, which
produces red blood cells, platelets, and the five kinds of white blood cells.
Classification of Bones
1. Long bonesthe bones of the arms, legs, hands, and feet (but not the
wrists and ankles). The shaft of a long bone is the diaphysis, and the ends
are called epiphyses. The diaphysis is made of compact bone and is
hollow, forming a canal within the shaft. This marrow canal (or medullary
cavity) contains yellow bone marrow, which is mostly adipose tissue. The
epiphyses are made of spongy bone covered with a thin layer of compact
bone. Although red bone marrow is present in the epiphyses of childrens
bones, it is largely replaced by yellow bone marrow in adult bones.
2. Short bonesthe bones of the wrists and ankles.
3. Flat bonesthe ribs, shoulder blades, hip bones, and cranial bones.
4. Irregular bonesthe vertebrae and facial bones.
Bone Tissue
Short,
flat, and
irregular bones are all made of spongy bone covered with a thin layer of
compact bone. Red bone marrow is found within the spongy bone.
The joint surfaces of bones are covered with articular cartilage,
which provides a smooth surface. Covering the rest of the bone is the
periosteum, a fibrous connective tissue membrane whose collagen fibers
merge with those of the tendons and ligaments that are attached to the
bone. The periosteum anchors these structures and contains both the
blood vessels that enter the bone itself and osteoblasts that will become
active if the bone is damaged.
The Skeleton
The human skeleton has two divisions: the axial skeleton, which
forms the axis of the body, and the appendicular skeleton, which supports
the appendages or limbs. The axial skeleton consists of the skull, vertebral
column, and rib cage. The bones of the arms and legs and the shoulder
and pelvic girdles make up the appendicular skeleton. Many bones are
connected to other bones across joints by ligaments, which are strong
cords or sheets of fibrous connective tissue. The importance of ligaments
becomes readily apparent when a joint is sprained. A sprain is the
stretching or even tearing of the ligaments of a joint, and though the bones
are not broken, the joint is weak and unsteady. We do not often think of our
ligaments, but they are necessary to keep our bones in the proper positions
to keep us upright or to bear weight. There are 206 bones in total.
Muscular
Types of muscle and their appearance
There are three types of muscles

cardiac,skeletal, and smooth. Smooth
muscles are used to control the flow of
substances within the lumensof hollow
organs, and are not consciously controlled.
Skeletal and cardiac muscles havestriations
that are visible under a microscope due to
the components within their cells. Only
skeletal and smooth muscles are part of the
musculoskeletal system and only the
skeletal muscles can move the body.
Cardiac muscles are found in the heart and
are
used
only to circulate blood; like the smooth
muscles, these muscles are not under
conscious control. Skeletal muscles
are attached to bones and arranged in
opposing groups around joints.
Muscles are innervated, to
communicate nervous energy to, by
nerves, which conduct electrical
currents from the central nervous
system and cause the muscles to
contract.
Contraction initiation
In mammals, when a muscle contracts, a series of reactions occur.

Muscle contraction is stimulated by the motor neuron sending a message
to the muscles from the somatic nervous system. Depolarization of the
motor neuron results in neurotransmitters being released from the nerve
terminal. The space between the nerve terminal and the muscle cell is
called the neuromuscular junction. These neurotransmitters diffuse across
the synapse and bind to specific receptor sites on the cell membrane of the
muscle fiber. When enough receptors are stimulated, an action potential is
generated and the permeability of the sarcolemma is altered. This process
is known as initiation.
Tendons
A tendon is a tough, flexible band of fibrous connective tissue that
connects muscles to bones. Muscles gradually become tendon as the cells
become closer to the origins and insertions on bones, eventually becoming
solid bands of tendon that merge into theperiosteum of individual bones. As
muscles contract, tendons transmit the forces to the rigid bones, pulling on
them and causing movement.
Joints, ligaments, and bursae

Human synovial joint composition
Joints
Joints are structures that

connect individual bones and may
allow bones to move against each
other to cause movement. There
are two divisions of joints,
diarthroses which allow extensive
mobility between two or more
articular heads, and false joints or
synarthroses, joints that are
immovable, that allow little or no
movement and are predominantly
fibrous. Synovial joints, joints that
are not directly joined, are
lubricated by a solution called synovial that is produced
by the synovial membranes. This fluid lowers the friction between the
articular surfaces and is kept within an articular capsule, binding the joint
with its taut tissue.
Ligaments
A ligament is a small band of dense, white, fibrous elastic tissue.

Ligaments connect the ends of bones together in order to form a joint. Most
ligaments limit dislocation, or prevent certain movements that may cause
breaks. Since they are only elastic they increasingly lengthen when under
pressure. When this occurs the ligament may be susceptible to break
resulting in an unstable joint. Ligaments may also restrict some actions:
movements such as hyperextension and hyperflexion are restricted by
ligaments to an extent. Also ligaments prevent certain directional
movement.
Bursa
A bursa is a small fluid-filled sac made of white fibrous tissue and

lined with synovial membrane. Bursa may also be formed by a synovial
membrane that extends outside of the join capsule. It provides a cushion
between bones and tendons and/or muscles around a joint; bursa are filled
with synovial fluid and are found around almost every major joint of the
body.
PATHOPHYSIOLOGY
Modifiable Factors Nonmodifiable Factors

-Lifestyle -Age
-Punctured wound -Gender
Bacterial invasion/infection on the open wound
Hematogenous spread of infection to the bone
Organisms invade the bone tissue and initiate

and inflammatory response.
Fever,Leukocytosis,Inflammation and Pus Formation
Exudates continue to grow Vascular Engorgement due to

Inflammation
Pressure develops at the

site causing pain Compromised Blood Flow
Exudate extends into the medullary cavity

and under the periosteum
Sequestrum
Osteoblastic Response
Involucrum
EXPLANATION
The pathophysiology begins with the different factors that contribute
to the development of the disease. Modifiable factors are lifestyle. The
patient should change his choice of foods and the mother should take
proper intervention for open wounds. and puncture wound. The non
modifiable factors are age and gender because osteomyelitis is common
among too young and too old people and in children, it is common in
males.
The patient had an open wound and the disease process starts with
the invasion of microorganisms in the said lesion. The iinfection spreads to
the bone by blood stream. The infectious organism invades the bone tissue
and initiates an inflammatory response. The inflammatory response leads
to the development of edema and increased vascularity in the area.
Leukocytes migrate to the site, and inflammatory exudate collects at the
site and forms an abscess. Due to the vascular engorgement that
develops, the vessels in the area thrombose and the blood flow to the site
is compromised. As the site of infection expands and the exudate continues
to grow, pressure develops at the site causing pain and leading to ischemia
of the bone and eventually necrosis. The exudates extend into the
medullary cavity and under the periosteum, stripping the periosteum off the
bone and further compromising the vascular supply of underlying bone
tissue.
The necrotic bone that develops forms an area referred to as
sequestrum. The sequestrum is separated from the surrounding bone that
is still living; it provides an area for bacteria to continue to live.
In response to bone destruction and disruption of the periosteum, the
body initiates an intense osteoblastic activity. The osteoblasts stimulate the
growth of new bone, which surrounds and encloses the area of dead bone.
The new bone which surrounds the sequestrum is referred to as
involucrum.
Prevention
and Treatment
Prevention
As stated earlier, the prevention of osteomyelitis is the best treatment.

Patients who have soft tissue infections should be treated promptly to
decrease the likelihood of the infection spreading to the bone. Nurses
should closely monitor patients who are at risk for the development of
osteomyelitis, especially those with open fractures, to detect any early
indications that an infection has developed at the site of injury. Patients with
chronic illness, such as diabetes, should be taught the signs and symptoms
of osteomyelitis and instructed to visually inspect the feet and lower
extremities daily to detect any open areas.
Prophylactic antibiotics may be administered prior to orthopedic
surgery to decrease the risk for osteomyelitis. Postoperative wound care
should be performed using strict aseptic technique. Individuals who have
had a total joint replacement may also be prescribed prophylactic
antibiotics prior to invasive procedures or dental appointments. With
preventive care or prompt treatment of local infections, osteomyelitis can
be prevented in many patients.
Prompt and complete treatment of infections is helpful. High-risk
people should see a health care provider promptly if they have signs of an
infection anywhere in the body.
Treatment
Elimination of the infecting organisms, both locally from the bone and
systemically from the body, is the major treatment goal for osteomyelitis.
Prompt treatment also prevents further bone deformity and injury, increases
client comfort, and avoids complications of impaired mobility. Prompt
identification of an antibiotic that the organism will be sensitive to is
essential. It is important to begin antibiotic therapy prior to the onset of
bone ischemia and necrosis. Once the blood supply to the bone is
compromised, the antibiotic will not be able to reach the area of infection
via the bloodstreamSurgery is initially performed on the adult client with
osteomyelitis to ensure effective debridement and drainage, elimination if
dead space, and adequate soft tissue coverage. Antibiotics alone rarely
resolve infection in adults, but they do work more efficiently after surgical
preparation of the treatment area. High doses of parenteral antibiotics are
frequently administered for 4 to 8 weeks to achieve a bactericidal level in
the bone tissue. Oral antibiotics are continued for another 4 to 8 weeks,
with serial bone scans and ESR measurements performed to evaluate the
effectiveness of drug therapy. Open drainage wounds are packed with
gauze to promote drainage. If initial treatment is delayed or inadequate, the
necrotic bone separates from the living bone to form sequestra, which
serves as a medium for additional microorganism growth. Chronic
osteomyelitis can result. The objective of treating osteomyelitis is to
eliminate the infection and prevent the development of chronic infection.
Chronic osteomyelitis can lead to permanent deformity, possible fracture,
and chronic problems, so it is important to treat the disease as soon as
possible.
Drainage: If there is an open wound or abscess, it may be drained through

a procedure called needle aspiration. In this procedure, a needle is inserted
into the infected area and the fluid is withdrawn. For culturing to identify the
bacteria, deep aspiration is preferred over often- unreliable surface swabs.
Most pockets of infected fluid collections (pus pocket or abscess) are
drained by open surgical procedures.
Medications: Prescribing antibiotics is the first step in treating

osteomyelitis. Antibiotics help the body get rid of bacteria in the
bloodstream that may otherwise re-infect the bone. The dosage and type of
antibiotic prescribed depends on the type of bacteria present and the extent
of infection. While antibiotics are often given intravenously, some are also
very effective when given in an oral dosage. It is important to first identify
the offending organism through blood cultures, aspiration, and biopsy so
that the organism is not masked by an initial inappropriate dose of
antibiotics. The preference is to first make attempts to do procedures
(aspiration or bone biopsy) to identify the organisms prior to starting
antibiotics. The patient may also need analgesics for severe pain.
Splinting or cast immobilization: This may be necessary to immobilize

the affected bone and nearby joints in order to avoid further trauma and to
help the area heal adequately and as quickly as possible. Splinting and
cast immobilization are frequently done in children, although motion of
joints after initial control is important to prevent stiffness and atrophy.
Surgery: Most well-established bone infections are managed through open

surgical procedures during which the destroyed bone is scraped out. In the
case of spinal abscesses, surgery is not performed unless there is
compression of the spinal cord or nerve roots. Instead, patients with spinal
osteomyelitis are given intravenous antibiotics. After surgery, antibiotics
against the specific bacteria involved in the infection are then intensively
administered during the hospital stay and for many weeks afterward. With
proper treatment, the outcome is usually good for osteomyelitis, although
results tend to be worse for chronic osteomyelitis, even with surgery. Some
cases of chronic osteomyelitis can be so resistant to treatment that
amputation may be required; however, this is rare. Also, over many years,
chronic infectious draining sites can evolve into a squamous-cell type of
skin cancer; this, too, is rare. Any change in the nature of the chronic
drainage, or change of the nature of the chronic drainage site, should be
evaluated by a physician experienced in treating chronic bone infections.
Because it is important that osteomyelitis receives prompt medical
attention, people who are at a higher risk of developing osteomyelitis
should call their doctors as soon as possible if any symptoms arise.
Medical/Nursing Management
Intravenous fluid
D5 0.3NaCl
Laboratory Tests
Complete Blood Count
Urinalysis
Xray
CRP
ESR
Blood culture
Medications
Paracetamol
Ceftin
Diet and Nutrition
Diet as tolerated
High Protein and Vitamin C
Immobilization of the affected extremity and ensuring adequate support
Keeping the affected extremity elevated and maintaining proper alignment
Monitoring the patients response to the antibiotic therapy
Wound care and dressing
Maintaining the functionality and muscle strength of unaffected body parts
Scheduled for surgery
Health
Teaching
Patient and Family Health Teaching
Advise the patient to have ROM exercises as tolerated to

maintain muscle and joint strength
Stress the importance of continuing the prescribed antibiotic
therapy. Advise to report any adverse effects of the antibiotic
before discontinuing the drug on his own. Explain that the
success of antibiotic treatment depends on following the
complete regimen.
Explain to the caregiver the wound care using aseptic technique
for dressing changes
Discuss to the caregiver the proper disposal of contaminated
dressings and removal of soiled linens. Stress also the
importance of maintaining wound isolation.
Tell the patient/caregiver what signs and symptoms should they
report to the physician/nurse(fever, chills, increased pain,
malaise, increased/recurrent drainage from wound, diminished
sensation, numbness, tingling, coolness)
Advise to eat foods high in protein and vitamin C. The patient
should eat variety of fruits and vegetables, which can provide
the body with the nutritional support it needs to fight infection.
Nursing Care
Plan
INTERVENTION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
ACTION RATIONALE
Subjective: Risk for At the end of the Assess general Provide basis At the end of the
Namamaga po peripheral nursing condition of and for nursing
yung binti ko. as neurovascular interventions, the contributing factors understanding interventions, the
verbalized dysfunction patient to general, current patient is be able to
related will be able to patient. situation of client.maintain tissue
Objective: to interruption of maintain perfusion in the
swelling of the blood tissue perfusion Evaluate Decreased/abse affected extremity.
right leg flow secondary as evidenced by presence/quality of nt
slow healing of to palpable pulses, peripheral pulse pulse may reflect
lesion disease warm skin, distal to injury via vascular injury
presence of condition normal sensation palpation. and
abscess on the and stable vital necessitates
right leg signs. immediate
weak pulse on medical
the right foot evaluation of
circulatory status.
Assess capillary
Return of color
return, skin color, should
and warmth distal to be rapid (3-5
inflammation. secs.).
White, cool skin
indicates arterial
impairment.
Cyanosis
suggests venous
impairment.
Maintain elevation
of Inflamed Promotes
extremity unless venous drainage/
contraindicated decreases
by confirmed edema.
presence of
compartmental
syndrome.
Investigate sudden
Osteomyelitis
signs of limb
ischemia, e.g., may cause
decreased skin damage to
temperature, pallor, adjacent arteries,
and increased pain. with resulting loss
of distal blood
flow.
Encourage patient
to routinely exercise Enhances
digits/joints distal to circulation
inflammation. and reduces
pooling of blood,
especially in
the lower
extremities.
INTERVENTION
ACTION RATIONALE
Subjective: Impaired skin At the end of the Examine the skin Provides At the end of the
May sugat po integrity nursing for open wounds, information nursing
ako sa binti ko related to open interventions, the foreign bodies and regarding skin interventions, the
as wound/abscess patient will discoloration. circulation and patient is able to
verbalized. secondary to maintain optimal problems that maintain optimal
disease process nutrition/ may be caused nutrition/physical
Objective: physical well- by edema well-being
disruption of being formation that
skin surface in may require
the lower further medical
extremity intervention.
destruction of
skin layers Maintain good skin Maintaining a
/tissues of the hygiene clean, dry skin
right leg provides a barrier
reports of pain, to infection.
pressure in Patting skin dry
affected/surround instead of rubbing
ing area reduces risk of
invasion of dermal
body trauma to fragile
structures skin.
with purulent Discuss
discharge on the These provide
importance of
right leg adequate nutrition information on
especially fluids, how nutrition
proteins, vitamins B could elevate
the chances of a
and C, iron and faster recovery

calories to the and wound
mother healing.
Establish a turning This provides

or repositioning the patients guide
schedule. towards a proper
skin
management
technique
minimizing
more skin trauma.
Emphasize
To avoid
principles of asepsis possible further
especially hand infection that is
washing and hindering the
avoidance of wound healing
touching wound with process.
bare hands.
Demonstrate to To provide the

the mother wound patient
care technique such or patients SO on
as wound cleansing. the correct
procedures and
techniques of
wound caring.
INTERVENTION

ACTION RATIONALE
Assess general Provides baseline

Subjective: Altered body At the end of the condition of and data for At the end of the
Nilalamig ako. temperature: nursing contributing factors to understanding
nursing
as verbalized increased interventions, the patient. general, current
related to patients condition of patient.
intervention, the
Objective: presence of temperature will patients
T: 38C pyogenic decrease from Monitor vital signs Notes progress temperature will
skin warm to microorganisms 38C to 37.4C especially and changes of decrease and be
touch infection temperature. condition. maintained within
with flushed skin normal range.
with teary eyes Assess fluid loss Increases
in
with purulent and facilitate oral metabolic rate and
discharge on the intake. diaphoresis.
right leg
Provide tepid Enhances heat
sponge loss by evaporation
bath. and conduction.
Promote bed rest. Reduces body

heat production.
Provide cool Dissipates heat

circulating air by by convection.
opening windows or
ensuring that patient
is not covered with
thick blankets.
Assist patient in Increases
changing into dry comfort.
clothing.
Administer To decrease
antipyretics as body temperature

ordered
Administer To treat the

medications/ underlying cause
antibiotics as
indicated
Administer To support
replacement fluids circulating volume
and electrolytes and tissue
perfusion
Drug Study
CEFUROXIME
Ceftin
Mode Of Nursing
Classification Dosage Indication Contraindication Adverse Effects
Action Responsibility
Antiinfective, 400mg IV Preferentially It is effective for Hypersensitivity to Body as a Whole: Determine

Antibiotic, q8 binds the cephalosporins Thrombophlebitis history of
Second to one or treatment of and (IV site); pain, hypersensitivity
Generation more of the penicillinasepro related antibiotics burning, cellulitis reactions to
Cephalosporin penicillin- ducing (IM site); cephalosporins,
binding Neisseria superinfections, penicillins, and
proteins gonorrhoea positive Coombs' history of
(PBP) (PPNG). test. allergies,
located on Effectively GI: Diarrhea, particularly to
cell walls treats nausea, drugs, before
of bone and joint antibioticassociated therapy is
susceptible infections, colitis. initiated.
organisms. bronchitis, Skin: Rash, Inspect IM and
This meningitis, pruritus, urticaria. IV injection sites
inhibits 3rd gonorrhea, otitis Urogenital: frequently for
and final media, Increased serum signs of phlebitis.
stage of pharyngitis/tons creatinine and Report onset of
bacterial illitis, BUN, loose stools or
cell wall sinusitis, lower decreased diarrhea.
synthesis, respiratory tract creatinine Although
thus killing infections, skin clearance. pseudomembran
the and ous colitis.
bacteria. soft tissue Monitor I&O
infections, rates and pattern:
urinary tract Especially
infections, and important in
is severely ill
used for patients receiving
surgical high doses.
prophylaxis, Report any
reducing significant
or eliminating changes.
infection.
PARACETAMOL
Acetaminophen
Mode Of Nursing
Classification Dosage Indication Contraindication Adverse Effects
Action Responsibility
Analgesic, 500mg/ Unclear. Pain Mild to Hypersensitivity Hematologic: Observe for
antipyretic tab q4 relief may moderate pain to drug thrombocytopenia, acute toxicity
for temp. result from caused by hemolytic and overdose.
37.8C inhibition headache,mus anemia, Caution
of cle ache, neutropenia, parents or other
prostaglandin backache, leukopenia, caregivers
synthesis in minor pancytopenia not to give
CNS, arthritis, Hepatic: jaundice, acetaminophen
with common cold, hepatotoxicity to children
subsequent toothache, Metabolic: younger than
blockage of or menstrual hypoglycemic coma age 2 without
pain cramps or Skin: rash, urticaria consulting
impulses. fever Other: prescriber first.
Fever hypersensitivity Tell patient,
reduction reactions (such parents, or other
may result as fever) caregivers not to
from use drug
vasodilation concurrently
and with other
increased acetaminophen-
peripheral containing
blood flow in products.
hypothalamus Advise patient,
, which parents, or other
dissipates caregivers to
heat and contact
lowers body prescriber if
temperature. fever or other

symptoms
persist despite
taking
recommended
amount of drug.
Inform
patients with
chronic
alcoholism that
drug may
increase risk of
severe liver
damage.
As
appropriate,
review all other
significant and
life-threatening
adverse
reactions and
interactions,
especially those
related to the
drugs, tests, and
behaviors
mentioned
above.
EVALUATION
On June 8, 2010, patient was admitted to childrens ward. His vital signs were
monitored every shift and her diet was diet as tolerated. The doctor ordered for her
CBC, ESR, CRP and UA. The patient also underwent x-ray of her right leg. Medication
was given such as cefuroxime 750mg IV ANST then cefuroxime 400mg IV q8. He was
started for venoclysis with D50.3NaCl 500cc. On June 15, 2010, the patient was for
repeat UA, CBC, ESR, and CRP. His antibiotic medication was continued; and IVF was
the same. She was prescribed paracetamol 250mg/5mL q4 and for temp. 38C.and
above.
During the nurse-patient relationship, clients condition was stable. He does not
experience any pain, fever and/or malaise though there is an obvious swelling on his
right foot and respiratory discharges scanty in amount, greenish in color. Patient was
scheduled for surgery of her leg. Her lesion needs to be drained first and it was kept
supported and immobilized. The mother should be instructed to report any signs of
further complication or infection.
BIBLIOGRAPHY
Book References:
Brunner and Suddarth,s Textbook of Medical and Surgical Nursing
Tenth Edition
Suzanne C. Smeltler, Brenda G. Bare
Essentials of Anatomy and Physiology

5th Edition
Valerie C. Scanlon and Tina Sanders
Eternal Links:
www.nlm.nih.gov/medlineplus/ency/article/000437.html
en.wikipedia.org/wiki/Osteomyelitis
http://emedicine.medscape.com/article/785020-overview
http://kidshealth.org/teen/infections/bacterial_viral/osteomyelitis.html
http://www.healthscout.com/ency/68/239/main.html

Casestudy Osteomyelitis

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1 Case Study: OSTEOMYELITIS

First of all, I owe my deepest gratitude to our Almighty God

I also wish to express a sincere gratitude to my family as

I also thank my friends for their constant encouragement.

And to my Clinical Instructor, Mrs. Elenita Carandang, I want

It is also my pleasure to thank the Dean of College of

Finally, I thank my most beloved teachers and those special

Osteomyelitis (osteo- derived from the

Bone infection can be caused by bacteria or fungi.

Infection may also spread to a

Risk factors are recent trauma, diabetes, hemodialysis, poor blood

Note that responsible pathogens may be isolated in only 35-40% of

Acute hematogenous osteomyelitis (Note increasing reports of other

Bacteria are the most common cause of osteomyelitis, especially

Some of the risk factors that may increase a persons susceptibility to

When the infection is bloodborne, the onset is usually sudden,

lost blood supply can result in a complication called chronic osteomyelitis.

Other complications include:

Need for amputation

A physical examination shows bone tenderness and possibly swelling and

Tests may include:

The objective of treatment is to eliminate the infection and prevent it

When treatment is received, the outcome for acute osteomyelitis is

The outlook is worse for those with long-term (chronic) osteomyelitis,

The outlook is guarded in those who have an infection of a

Involucrum - a layer of new bone growth outside existing bone seen

Religion: Roman Catholic

HOME ENVIRONMENT AND OCCUPATION

Usual Meal: He often eats fried foods and doesnt like to

SLEEP AND REST PATTERN

PAST HEALTH HISTORY

HISTORY OF PRESENT ILLNESS

Reason for seeking medical care: swelling on the right lower

Initial Vital Signs

Eyes,Eyebrows and Eyelashes

Nose and Sinuses

Mouth and Oropharynx

THORAX AND LUNGS

Complete Blood Count Also known as full blood count or full

A number of tests were done. Complete blood count shows increase

The Skeletal System serves many important functions; it provides the

The Skeletal System serves as a framework for tissues and organs to

Types of Bone Tissue

There are three types of muscles

In mammals, when a muscle contracts, a series of reactions occur.

Joints, ligaments, and bursae

Joints are structures that

A ligament is a small band of dense, white, fibrous elastic tissue.

A bursa is a small fluid-filled sac made of white fibrous tissue and

Modifiable Factors Nonmodifiable Factors

Bacterial invasion/infection on the open wound

Hematogenous spread of infection to the bone

Organisms invade the bone tissue and initiate

Fever,Leukocytosis,Inflammation and Pus Formation

Exudates continue to grow Vascular Engorgement due to

Pressure develops at the

Exudate extends into the medullary cavity

As stated earlier, the prevention of osteomyelitis is the best treatment.

Drainage: If there is an open wound or abscess, it may be drained through