Chronic Osteomyelitis

COLEGIO DE DAGUPAN College of Nursing

Chronic Osteomyelitis

Submitted to: Sir Oliver Melendez Sir Ronald Cruz

Philippine Orthopedic Center Children’s Ward

Submitted by: Calacsan, Liza Carerra, Precious Angelle Casingal, Mary Joy Castillo, Janine Corpuz, Dexther Dagarag, Darell Ann De Castro, Anna Liza De Francia, Sherrylyne Anne De Jesus, Jason De Guzman, Sue Abigail

BSN-III Block-I April 25, 2013

Table of Contents

I.

Introduction

II.

Statement of Objectives

III.

Client’s Profile

IV.

Chief complaint

V.

Present History of Illness

VI.

Past History of Illness

VII.

Family Health History

VIII.

Developmental History

IX.

Social & Environmental History

X.

Lifestyle and Health Practices

XI.

Health Assessment

XII.

Diagnostics

XIII.

Anatomy and Physiology

XIV. Pathophysiology XV.

Nursing Care Plan ( NCP)

XVI. Drug Study XVII. Discharge Plan

I. Introduction Osteomyelitis (sometimes abbreviated to OM, and derived from Greek words osteon, meaning bone, myelo- meaning marrow, and -itis meaning inflammation) is infection and inflammation of the bone or bone marrow It can be usefully sub classified on the basis of the causative organism (pyogenic bacteria or mycobacteria), the route, duration and anatomic location of the infection.

The length of time the infection has been present and whether there is suppuration (pus formation) or sclerosis (increased density of bone) is used to arbitrarily classify OM. Chronic OM is often defined as OM that has been present for more than one month. In reality, there are no distinct subtypes, instead there is a spectrum of pathologic features that reflect balance between the type and severity of the cause of the inflammation, the immune system and local and systemic predisposing factors. . On histologic examination, these areas of necrotic bone are the basis for distinguishing between acute osteomyelitis and chronic osteomyelitis. Osteomyelitis is an infective process that encompasses all of the bone (osseous) components, including the bone marrow. When it is chronic, it can lead to bone sclerosis and deformity.

Chronic osteomyelitis may be due to the presence of intracellular bacteria (inside bone cells) Also, once intracellular, the bacteria are able to escape and invade other bone cells. At this point, the bacteria may be resistant to some antibiotics. These combined facts may explain the chronicity and difficult eradication of this disease, resulting in significant costs and disability, potentially leading to amputation. Intracellular existence of bacteria in osteomyelitis is likely an unrecognized contributing factor to its chronic form. Most cases of osteomyelitis are caused by staphylococcus bacteria, a type of germ commonly found on the skin or in the nose of even healthy individuals. Germs can enter a bone in a variety of ways, including: 

Via the bloodstream. Germs in other parts of your body — for example, from pneumonia or a urinary tract infection — can travel through your bloodstream to a weakened spot in a bone. In children, osteomyelitis most commonly occurs in the softer areas, called growth plates, at either end of the long bones of the arms and legs.

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From a nearby infection. Severe puncture wounds can carry germs deep inside your body. If such an injury becomes infected, the germs can spread into a nearby bone.

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Direct contamination. This may occur if you have broken a bone so severely that part of it is sticking out through your skin. Direct contamination can also occur during surgeries to replace joints or repair fractures.

In children, the long bones are usually affected. In adults, the vertebrae and the pelvis are most commonly affected. Acute osteomyelitis almost invariably occurs in children. When adults are affected, it may be because of compromised host resistance due to debilitation, intravenous drug abuse, infectious root-canaled teeth, or other disease or drugs (e.g., immunosuppressive therapy). Staphylococcus aureus is the organism most commonly isolated from all forms of osteomyelitis. Bloodstream-sourced osteomyelitis is seen most frequently in children, and nearly 90% of cases are caused by Staphylococcus aureus. In infants, S. aureus, Group B streptococci (most common) and Escherichia coli are commonly isolated; in children from one to 16 years of age, S. aureus, Streptococcus pyogenes, and Haemophilusinfluenzae are common. In some subpopulations, including intravenous drug users and splenectomized patients, Gram-negative bacteria, including enteric bacteria, are significant pathogens. Signs and symptoms of osteomyelitis include: fever or chills, irritability or lethargy in young children, pain in the area of the infection, swelling, warmth and redness over the area of the infection. Sometimes osteomyelitis causes no signs and symptoms or has signs and symptoms that are difficult to distinguish from other proble Osteomyelitis complications may include: Bone death (osteonecrosis). An infection in your bone can impede blood circulation within the bone, leading to bone death. Your bone can heal after surgery to remove small sections of dead bone. If a large section of your bone has died, however, you may need to have that limb amputated to prevent spread of the infection. Septic arthritis. In some cases, infection within bones can spread into a nearby joint. Impaired growth. In children, the most common location for osteomyelitis is in the softer areas, called growth plates, at either end of the long bones of the arms and legs. Normal growth may be interrupted in infected bones. Skin cancer. If your osteomyelitis has resulted in an open sore that is draining pus, the surrounding skin at higher risk of developing squamous cell cancer. Osteomyelitis often requires prolonged antibiotic therapy, with a course lasting a matter of weeks or months. A PICC line or central venous catheter is often placed for this purpose. Osteomyelitis also may require surgical debridement. Severe cases may lead to the loss of a limb. Initial first-line antibiotic choice is determined by the patient's history and regional

differences in common infective organisms. A treatment lasting 42 days is practiced in a number of facilities. Local and sustained availability of drugs have proven to be more effective in achieving prophylactic and therapeutic outcomes. In 1875, American artist Thomas Eakins depicted a surgical procedure for osteomyelitis at Jefferson Medical College, in a famous oil painting titled The Gross Clinic. Prior to the widespread availability and use of antibiotics, blow fly larvae were sometimes deliberately introduced to the wounds to feed on the infected material, effectively scouring them clean. Hyperbaric oxygen therapy has been shown to be a useful adjunct to the treatment of refractory osteomyelitis. Open surgery is needed for chronic osteomyelitis, whereby the involucrum is opened and the sequestrum is removed or sometimes saucerization can be done.

II. Statement of Objectives A. General Objectives This case analysis aims to increase the understanding and knowledge of student nurses on how to care for patients with Chronic Osteomyelitis effectively and efficiently. B. Specific Objectives Specifically, this case analysis aims to: 1. Define Chronic Osteomyelitis and its effects to the body as a whole; 2. Illustrate the Pathophysiology of Chronic Osteomyelitis and in relation to the signs and symptoms specifically observed in the client; 3. Describe and identify the common signs and symptoms of Chronic Osteomyelitis. 4. Discuss the medical and surgical interventions for the management of Chronic Osteomyelitis 5. Formulate appropriate nursing care plans suited for the client based on the assessment findings; 6. Identify care measures to be given to the patient and family to promote continuity of care and independence after discharge.

III. Patient’s Profile

Name: X Address: Roxas Rd. Quarry 2, Brgy. May, Iba Teresa Rizal Age: 3 years old Gender: Male Religion: Roman Catholic Civil Status: Single Nationality: Filipino Date of Birth: April 10, 2010 Date of Admission: April 15, 2013 Ward and Room: Children’s ward, Cubicle 2 Admitting Diagnosis: Chronic Osteomyelitis femur left; Pathologic Funxn. P3rd femur left Attending Physician: Dr. G. Ola

IV. Chief Complaint

Chief Complaint: Pain on Left Thigh

V. Present History of Illness Present Health History Chief complaint: The patient had complaint of pain and swelling in the left thigh.

VI. Past History of Illness Past History of Illness The patient had an accident and fell from a length approximately 3 ft. land on his buttocks.

VII. Family Health History Family Health History Health problems such as Asthma, kidney diseases, diabetes, or mental illness were verbalized to be absent. No present illness is currently experienced by any member of the family.

VIII. Developmental History Cognitive/Mental Status He is very responsive upon interaction. He is well oriented about the time, date and place where he is right now. Emotional Status Patient X has a good support by his family especially with his grandmother. His grandmother supervised all his need. State of Mobility Patient X stays mostly on bed, and could not walk due to his cast. Perception and Coordination Status All of his senses were functioning. He is very responsive and coherent upon interaction.

IX. Social and Environmental History Social Status Patient X is male, 3years old currently residing at Roxas RD. Quarry 2, Brgy. MaiIba, Teresa Rizal. He is Roman Catholic in faith. In the ward, his grandmother accompanied him. He is approachable whenever he is called for attention.

X. Lifestyle and Health Practices Nutritional Status Before hospitalization Patient X usually prefers to eat meat especially process meats. He eats 3x a day but sometimes skip meals. During hospitalization he was in diet as tolerated due to his condition. Rest and Sleep Patterns Before Hospitalization he usually sleeps 6-8 hr around 10pm-6am and could have a naps and rest at daytimes. During Hospitalization As of now she sleeps for only 4-6hrs with intervals and could still have naps and rest at daytimes. Elimination Pattern Before Hospitalization he usually defecates once or twice a day and urinates 3-5 times a day. During Hospitalization As of now he defecates once a day and urinates 2-3 times a day.

XI. Health Assessment

Head- to- Toe Assessment Eye •Discharge: No •Color of sclera/conjunctiva: White/Pink •Corneal/lens/reaction to light: Yes •Eye movement: Both eyes move together while following the object •Vision problem: No

Ear •Appearance: Top of the pinna meets the eye occiput line •Discharge/Pain: No discharge or pain •Wax/redness of external auditory canals •Hearing problems: No

Nose •Discharge: No •Blockage: No •Bleeding: No •Septal defect: No septal defect, located centrally •Problem with smelling: No

Mouth •Color of lips/mucous membrane: Pink, moist mucous membrane •Sores/cracks/swelling/bleeding pain of gums, tongue: No •Dental carries/missing teeth, denture: White teeth, no carries and missing teeth. •Cracks lips: No •Enlargement of tonsils: Small tonsils Oral hygiene: Good

Inspect neck for •Mobility: Full and smooth range of movement, no stiffness or tenderness

Palpate neck for •Enlarged lymph nodes: No

•Enlarged thyroid gland: No •Enlarged neck veins: No

Examination of Chest Inspect chest for

•Shape of the chest: Normal •Equal movement of chest during breathing: Yes •Difficulty in breathing: No any difficulty, respiration was normal and regular •Chest percussion: Deep resonant sound over the lungs

Auscultate the chest for •Breathing sounds (front and black): Breath sounds are heard in all areas of the lungs •Heart sounds (4 areas): Clear and regular heart beats, no heart murmur

Examination of Abdomen Inspect abdomen for •Shape: Rounded or uniform shape •Enlarged veins: No

Auscultate for •Bowels sound: Bowel sound is present in all areas •Abdominal percussion: Tympanic and dullness

Palpate the abdominal for •Enlarged liver: No

•Enlarged spleen: No •Tenderness: No •Masses: No

Examination of Limbs Inspect/Palpate limbs for

•Joint mobility/tenderness/redness/swelling: Present of redness and edema or swelling of left of thigh •Color of nails: Pinkish

Palpate maxillae/groins for •Enlarged lymph nodes: Absent

Examination of Back Inspect back for

•Position of spine/movement: Spine is in the midline •Condition of skin/prone to bedsore: No

XII. Diagnostic Test

Diagnostic Procedure

Description Of The Procedure

Significance/Purpose of the Procedure

Alkaline Phosphate

An alkaline phosphatase (ALP) test measures the amount of the enzyme ALP in the blood.

April , 2013 Bone also contains high levels of alkaline phosphatase. Any disease that damages bone can release alkaline phosphatase into the blood.

Hematology Test

Date Of the Procedure

Concerned Blood is the transport with the study medium in the body so April , 2013 of blood, the any toxin or antibodies bloodwill be found in it. forming Blood tests may reveal organs, and elevated levels of blood diseases. white blood cells and other factors that may indicate that your body is fighting an infection. If your osteomyelitis was caused by an infection in the blood, tests may reveal what germs are to blame.

Findings and Implications  261.7 U/L

Hemoglobin Mass  114  99  104 Hematocrit  0.35  0.32 Leukocyte  16.72  13.16 Differential count Segmenter  0.64  0.64  0.59 Lymphocytes  0.28  0.27  0.29 Easinophils  0.02  0.03  0.04  Confirm an infection. Platelet count  477x10’gL  496x10’gL  728x10’gL CRP  Reactive  a blood test to help detect the presence of inflammation or an infection.Another

important role in innate immunity, as an early defense system against infection.  detects and measure inflammation. Semi quantitative CRP

 24 mg/L  most infections result in CRP levels above 952 nanomols/L (100 mg/L). Indices MCV  80 fL  74 fL\ MCH  26 pg  23 pg MCHC  33%  31% RBC Morphology ESR WESTERNGREN MTD  116  40  usually elevated in both acute and chronic osteomyelitis, decreasing after successful treatment.  Detects and measures inflammation

PTT  12.4 secs APTT  28.2 secs Bld type  A RH typing  Positive

XIII. Anatomy and Physiology of the Bone Compact bone Is the hard material that makes up the shaft of long bones and the outside surfaces of other bones. Compact bone consists of cylindrical units called osteons. Each osteon contains concentric lamellae (layers) of hard, calcified matrix with osteocytes (bone cells) lodged in lacunae (spaces) between the lamellae. Smaller canals, or canaliculi, radiate outward from a central canal, which contains blood vessels and nerve fibers. Osteocytes within an osteon are connected to each other and to the central canal by fine cellular extensions. Through these cellular extensions, nutrients and waste are exchanged between the osteocytes and the blood vessels. Perforating canals provide channels that allow the blood vessels that run through the central canals to connect to the blood vessels in the periosteum that surrounds the bone.

Consists of thin, irregularly shaped plates called trabeculae, arranged in a latticework network. Trabeculae are similar to osteons in that both have osteocytes in lacunae that lie between calcified lamellae. As in osteons, canaliculi present in trabeculae provide connections between osteocytes. However, since each trabecula is only a few cell layers thick, each osteocyte is able to exchange nutrients with nearby blood vessels. Thus, no central canal is necessary. Main features of a long bone (refer to Figure 1): 

The diaphysis, or shaft, is the long tubular portion of long bones. It is composed of compact bone tissue.

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The epiphysis (plural, epiphyses) is the expanded end of a long bone. It is in the epiphyses where red blood cells are formed.

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The metaphysis is the area where the diaphysis meets the epiphysis. It includes the epiphyseal line, a remnant of cartilage from growing bones.

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The medullary cavity, or marrow cavity, is the open area within the diaphysis. The adipose tissue inside the cavity stores lipids and forms the yellow marrow.

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Articular cartilage covers the epiphysis where joints occur.

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The periosteum is the membrane covering the outside of the diaphysis (and epiphyses where articular cartilage is absent). It contains osteoblasts (bone-forming cells), osteoclasts (bone-destroying cells), nerve fibers, and blood and lymphatic vessels. Ligaments and tendons attach to the periosteum.

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The endosteum is the membrane that lines the marrow cavity.

Here are the main features of short, flat, and irregular bones: 

In short and irregular bones, spongy bone tissue is encircled by a thin layer of compact bone tissue.

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In flat bones, the spongy bone tissue is sandwiched between two layers of compact bone tissue. The spongy bone tissue is called the diploë.

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The periosteum covers the outside layer of compact bone tissue.

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The endosteum covers the trabeculae that fill the inside of the bone.

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In certain bones (ribs, vertebrae, hip bones, sternum), the spaces between the trabeculae contain red marrow, which is active in hematopoiesis.

Bone Structure Figure 1

XIV. PATHOPHYSIOLOGY OF CHRONIC OSTEOMYELITIS

Predisposing Factor Gender:

Precipitating Factor

Male

Bone Trauma

Age: Pre School Age

Skin Infection

Direct inoculation of Staphylococcus Aureus Into the bone as a result of trauma Leading to bone damage

Bacterial lodge in the affected bone area

Leukocytes enter the infected bone area

Pus spreads into the bone’s blood vessels impairing The flow and areas of devitalized infected bone

Circulatory

Inflammatory Response

Impairment Leading to Ischemia Fever Sequestra

Pain Swelling Redness

XVII. Discharge Planning

Health Teachings:  

Instruct the mother of patient to take the child medications religiously The patient probably needs to take this medicine for at least 3 - 6 weeks. Sometimes, he will need to take it for several months.

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The child must eat healthy foods from all of the five food groups: fruits, vegetables, breads, dairy products, meat and fish.

Out-Patient: 

Regular visits of the child to your caregiver may help him stay healthy.

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It is important to take care of his skin.

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Keep his wound clean.

Contact a doctor if: 

He has a fever.

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He has new drainage or an odor from the healing wound or incision site.

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His skin is itchy, swollen, or has a rash.