SOUTHERN LUZON STATE UNIVERSITY Lucban, Quezon

CHRONIC OSTEOMYELITIS
A Case Study

Presented to the Faculty Of College of Allied Medicine

In partial fulfillment of the requirements for the Degree Bachelor of Science in Nursing

Submitted by: Abrigo, Ellennor F. Job, Genesis Olaivar, Monique S.

Submitted to: Prof. Caroline Murallon

Summer Affiliation, 2010

CHAPTER I Objective of the Study

A.

GENERAL OBJECTIVES:

B.

SPECIFIC OBJECTIVES:

CHAPTER II Introduction of the Disease

Do what you love. Know your own bone; gnaw at it, bury it, unearth it, and gnaw it still.
-Henry David Thoreau

Osteomyelitis is a local or generalized pyogenic disease of the bone, bone marrow and surrounding tissue. In children, the disease usually results from untreated acute hematogenous osteomyelitis. Chronic osteomyelitis may also be seen after traumatic injuries, especially in times of civil unrest or war, or as a complication of surgical procedures such as open reduction and internal fixation of fractures. The long bones are affected most commonly, and the femur and tibia account for approximately half of the cases. Predisposing factors include poor hygiene, anemia, malnutrition, and a coexisting infectious disease burden (parasites, mycobacteria, acquired autoimmune deficiency syndrome), or any other factors that decrease immune function. Chronic osteomyelitis is defined by the presence of residual foci of infection (avascular bone and soft tissue debris), which give rise to recurrent episodes of clinical infection. Eradication of the infection is difficult, and complications associated with both the infection and their treatments are frequent. Our goals are to review the pathophysiology, natural history, and management for children with chronic osteomyelitis within the context of a developing world setting.

CHAPTER III Anatomy and Physiology

Human musculoskeletal system

A 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
Front view of a skeleton of an adult human

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 300 to 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.
[4]

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.

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. circulate blood; like the smooth muscles, Cardiac these muscles are found in the heart and are used only to muscles are not under conscious control. Skeletal muscles are attached to bones and arranged in opposing innervated, groups to around communicate joints. Muscles nervous are 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 false joints, diarthroses which joints or synarthroses, allow joints extensive that are mobility between two or more articular heads, and 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.

CHAPTER IV Overview of the Disease

A.

REVIEW OF RELATED LITERATURE

Definition
Osteomyelitis (osteo- derived from the Greek word osteon, meaning bone, myelomeaning meaning marrow, and -itis 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.

Causes
It can be caused by a variety of microbial agents (most common in staphylococcus aureus) and situations, including: An open injury to

the bone, such as an open fracture with the bone ends piercing the skin. An infection from elsewhere in the body, such as pneumonia or a urinary tract infection that has spread to the bone through the blood (bacteremia, sepsis).

A minor trauma, which can lead to a blood clot around the bone Bacteria in the bloodstream bacteremia (poor dentition), which is

and then a secondary infection from seeding of bacteria. deposited in a focal (localized) area of the bone. This bacterial site in the bone then grows, resulting in destruction of the bone. However, new bone often forms around the site.

A chronic open wound or soft tissue infection can eventually extend

down to the bone surface, leading to a secondary bone infection. (Black and Hawks, 2005)

Risk Factors
Males are affected more often than females, often as a result of trauma. Susceptibility to infection increases with IV drug use, diabetes, immunocompromising diseases or a history of blood- stream infections. (Black and Hawks, 2005)

Prognosis
Prognosis varies depending on how quickly an infection is identified, and what other underlying conditions exist to complicate the infection. With quick, appropriate treatment, only about 5% of all cases of acute osteomyelitis will eventually become chronic osteomyelitis. Patients with chronic osteomyelitis may require antibiotics periodically for the rest of their lives.

Mortality/Morbidity

Mortality from osteomyelitis was 5-25% in the preantibiotic era. Currently, the mortality rate approaches 0%. Complications of osteomyelitis include (1) septic arthritis, (2) destruction of the adjacent soft tissues, (3) malignant transformation (eg, Marjolin ulcer [squamous cell carcinoma], epidermoid carcinoma of the sinus tract), (4) secondary amyloidoses, and (5) pathologic fractures.

Signs and Symptoms

Clinical manifestations may slightly vary according to the site of involvement. Infection in the long bones is accompanied by acute localized pain and redness or drainage often with a history of recent trauma or newly acquired prostheses. Fever and malaise may be present. Infection in the vertebrae usually brings pain and mobility difficulties. The client with vertebral osteomyelitis often reports a history of genitourinary infection or drug abuse. Osteomyelitis in the foot is most commonly associated with vascular insufficiency. (Black and Hawks, 2005) Acute osteomyelitis refers to the initial infection or an infection of less than 1 month duration. The clinical manifestations of acute myelitis are both systemic and local. Systemic manifestations include fever, night sweat, chills restlessness, nausea and malaise. Local manifestations include constant bone pain that is unrelieved by rest and worsens with activity; swelling, tenderness and warmth at the infection site; and restricted movement of the affected part. Later signs include drainage from sinus tracts to the skin and/or the fracture site. (Lewis, 2004) Chronic myelitis 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. Systemic signs may be diminished, with local signs of infection more common, including constant bone pain and swelling, tenderness and warmth at the infection site. (Lewis, 2004)

Laboratory Studies
Laboratory studies and X-rays or bone important scans in are the

definitive diagnosis of osteomyelitis. Elevated WBC and ESR, an elevated level of Creactive protein (a protein that circulates in the blood and dramatically increases in level when there is inflammation) usually occur. Along with clinical manifestations, usually allow initial diagnosis and early treatment while the physician waits for further evidence from blood cultures or needle aspirate

analysis. To diagnose a bone infection and identify the organisms causing it, doctors may take samples of blood, pus, joint fluid, or the bone itself to test. Usually, for vertebral osteomyelitis, samples of bone tissue are removed with a needle or during surgery. Radiographic changes related to osteomyelitis are generally evident within 7 to 10 days, but in some cases the diagnosis is not confirmed on X-rays until 3 to 4 weeks after infection develops. Early acute osteomyelitis is more efficiently identified by radionuclide bone scans, which can detect lesions within 24 to 72 hours after the onset of infection. Because of its ability to distinguish between soft tissue and bone marrow, magnetic resonance imaging It is also being used increasingly for definitive diagnosis of osteomyelitis. To diagnose osteomyelitis, the doctor will first perform a history, review of systems, and a complete physical examination. In doing so, the physician will look for signs or symptoms of soft tissue and bone tenderness and possibly swelling and redness. The doctor will also ask you to describe your symptoms and will evaluate your personal and family medical history. The doctor can then order any of the following tests to assist in confirming the diagnosis: Blood tests: When testing the blood, measurements are taken to

confirm an infection: a CBC (complete blood count), which will show if there is an increased white blood cell count; an ESR (erythrocyte sedimentation rate); and/or CRP (C-reactive protein) in the bloodstream, which detects and measures inflammation in the body. 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. Needle aspiration: During this test, a needle is used to remove a sample of fluid and cells from the vertebral space, or bony area. It is then sent to the lab to be evaluated by allowing the infectious agent to grow on media. Biopsy: A biopsy (tissue sample) of the infected bone may be Bone scan: During this test, a small amount of Technetium-99 taken and tested for signs of an invading organism. pyrophosphate, a radioactive material, is injected intravenously into the

body. If the bone tissue is healthy, the material will spread in a uniform fashion. However, a tumor or infection in the bone will absorb the material and show an increased concentration of the radioactive material, which can be seen with a special camera that produces the images on a computer screen. The scan can help your doctor detect these abnormalities in their early stages, when X-ray findings may only show normal findings.

Treatment and Management

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. Surgery 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. (Black and Hawks, 2005) 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 surgical procedures.

by

open

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 in an oral dosage. It is important to infection. While antibiotics are often given intravenously, some are also very effective when given 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. 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. of the spinal cord or nerve roots. Instead, patients bacteria involved in the In the case of spinal abscesses, surgery is not performed unless there is compression with spinal osteomyelitis are given intravenous antibiotics. After surgery, antibiotics against the specific 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.

B.

CURRENT TRENDS AND ISSUES

Radiology: Whole-body MR useful in detecting rare bone disease
Written by Editorial Staff

September 10, 2009

Whole-body MRI, because it is more likely to show abnormalities, can help detect chronic recurrent multifocal osteomyelitis (CRMO), according to a study in the September issue of Radiology. CRMO is a rare disease characterized by aseptic inflammatory lesions of bone in children and adolescents, the cause and pathogenesis of which are poorly understood. In the study, Jan Fritz, MD, from the department of radiology and radiological science at Johns Hopkins University School of Medicine in Baltimore, and colleagues reviewed two-plane radiographs, clinical findings and lab data for 13 children (median age, 13 years) with CRMO. They evaluated lesion depiction, location and characterization and extraskeletal abnormalities, and compared MRI findings with clinical and lab data and radiographic results. The authors whole-body MRI depicted 101 lesionsan average of eight affected anatomic sites per patient. It was seen most frequently in the distal femur (21 of 101 lesions), proximal tibia (17 of 101), distal tibia (14 of 101) and distal fibula (14 of 101). No lesions were found in the cranium, clavicle or upper extremity. In tubular bones (90 anatomic sites) involvement of the metaphysis was present in 86 percent of patients; of the epiphysis, in 67 percent; of the diaphysis, in 14 percent; and of the apophysis, in 3 percent, according to Fritz and colleagues. For the 74 lesions located in the periphyseal region, a contiguous physeal relationship was present in 89 percent. Multifocality was present in all patients.

The authors found that CRMO manifests with a whole-body MRI pattern of ill-defined edemalike lesions, most frequently located in the lower appendicular skeleton in a periphysial location. Multifocality was virtually always present, most distributed symmetrically in the lower extremities and was frequently subclinical. Whole-body MRI depicted this pattern at a higher rate than did radiography and clinical examination, the authors reported, adding that wholebody MRI is more likely to show abnormalities than are ESR and CRP values. Whole-body MRI, the authors concluded, is useful in the radiation-free detection of asymptomatic and radiographically hidden multifocal sites of disease in patients with CRMO. The reason, the authors say, is that whole-body MRI identifies characteristic, ill-defined, edemalike, periphyseal osseous lesions predominantly in symmetrical lower extremity distribution.
Last Updated on Friday, September 11 2009

CHAPTER V Case Study Proper

VITAL INFORMATION
NAME: K.C. ADDRESS: Caloocan City AGE: 7 years old SEX: Female WEIGHT: 15.9 kg NATIONALITY: Filipino RELIGION: Roman Catholic BIRTHDAY: April 03, 2002 STATUS: Child ADMISSION DATE: March 22, 2010; 4:30 pm WARD: Childrens ward ATTENDING PHYSICIAN: Dr. Caltila DIAGNOSIS: Chronic osteomyelitis: 3rd digit, right foot

A.

GENERAL STUDY
General Appearance
Patient appears her stated age. She is awake sitting on bed with ongoing IVF of D50.3NaCl 500cc to run for KVO @ 100cc level, inserted @ right basilic vein. Patient is active and playful. Her right foot is slightly bigger than her left due to inflammation process secondary to chronic osteomyelitis.

Body Structure
Other body parts look equal bilaterally and are in relative proportion to each other.

Behavior

She has good eye to eye contact. She does attend and responds to questions appropriately.

Initial V/S
Temperature: Cardiac Rate: Respiratory Rate: 36.3oC 79bpm 35bpm

B.

PHYSICAL ASSESSMENT
Area Assessed
Skin Color Inspection >Varies from light to deep brown, from ruddy pink to light pink, from yellow overtones to olive >Generally uniform except in areas exposed to the sun, areas of lighter pigmentations (palms, lips and nail beds). >Uniform within normal range(36.537.5) >Moisture in the skin folds and the axilla (varies with environmental temperature and humidity, body temperature and activity) >Springs back to normal when pinched >Epidermis is uniformly thin over most of the body >Skin surfaces are non-tender >Absence of lesions >Absence of edema >Brownish >Normal

Method Used

Normal Findings

Actual Findings

Remarks

Uniformity of skin color

Inspection

>Generally uniform except in areas with swelling tissues

>Normal

Temperature

Palpation

>Uniform within normal range(36.3) >Moisture in the skin folds and the axilla

>Normal

Moisture

Inspection; Palpation

>Normal

Turgor

Inspection; Palpation Inspection

>Springs back to normal when pinched >Epidermis is uniformly thin over most of the body >Skin surfaces are non-tender >With lesions >With swelling of the right foot

>Normal >Normal

Thickness

Tenderness Lesions Edema

Palpation Inspection Inspection

>Normal >Onset of infection >Due to inflammation

Hair

Distribution

Inspection

>Evenly distributed over the scalp >Fine or thick hair; straight, curly or kinky; silky, resilient hair >Black color or gray color, considering the age >Absence of seborrhea >Clean nails >Pink >Convex to curvature >Smooth >Return within 2-3 seconds

> Evenly distributed over the scalp >With straight, thick hair >Black color

>Normal

Texture

Palpation

>Normal

Color

Inspection

>Normal

Nails

Seborrhea

Inspection

>Absence of seborrhea >Clean nails >Pink >Convex to curvature >Smooth >Return within 2 seconds

>Normal

Appearance Color of nailbed Shape

Inspection Inspection Inspection Inspection Palpation

>Normal >Normal >Normal >Normal >Normal

Head

Texture Capllary refill time Shape and size

Inspection

>Rounded, smooth skull contour >Symmetric or slightly asymmetric facial features >Symmetric facial movements

>Rounded, smooth skull contour >Symmetric

>Normal

Facial features

Inspection

>Normal

Ears

Symmetry of facial features

Inspection

>Symmetric facial movements

>Normal

Auricle Position

Inspection

>At the level of the external cantus of the eyes >Smooth without lesion >None >Pink

>At the level of the external cantus of the eyes >Smooth without lesion >None >Pink

>Normal

Texture

Inspection Inspection Inspection

>Normal >Normal >Normal

External Auditory canal Discharges Nose Color Sinuses Color of canal walls

Inspection Inspection

>Same color with the face >Not inflamed

>Same color with the face >Not inflamed

>Normal >Normal

Nares

Inspection

>No obstruction; oval and symmetric >Not tender, absence of lesion

>No obstruction; oval and symmetric >Not tender, absence of lesion

>Normal

Lesion/ Tenderness

Palpation

>Normal

Lips Symmetry Color Texture Inspection Inspection Palpation Inspection >Symmetrical >Pinkish >Smooth >Free from decays, white, smooth and shiny >Symmetrical >Pinkish >Smooth >Free from decays >Normal >Normal >Normal >Normal

Teeth

Tongue Neck Position Inspection >Centrally located on the shoulder >Able to flex and extend head without pain and resistance >Not palpable >Centrally located on the shoulder >Able to flex and extend head without pain and resistance >Not palpable >Normal Position Color Inspection Inspection >Center >Pink >Center >Pink >Normal >Normal

Movement

Inspection

>Normal

Lymph nodes

Palpation

>Normal

Thyroid glands Consistency Inspection >Not visible when swallowing >Small >Smooth and free from nodules >Not visible when swallowing >Small >Smooth and free from nodules >Normal

Size Texture

Palpation Palpation

>Normal >Normal

Thorax and Lungs Anterior thorax and lungs

Breathing patterns

Inspection

> Quiet, Rhythmic and Effortless Respiration

> Quiet, Rhythmic and Effortless Respiration (RR: 35 bpm) >Symmetrical >No adventitious sound

>Normal

Symmetry Lung breath sounds

Inspection Auscultation

>Symmetrical >No adventitious sound

>Normal >Normal

 Heart

Shape

Inspection; palpation Auscultation Auscultation

>oval/elliptical

>oval/elliptical

>Normal

Rate Rhythm

>Regular rate(60-100) >no murmur

>Regular rate(80bpm) >no murmur

>Normal >Normal

Abdomen Contour Upper & lower extremities Size

Inspection

>Flat, rounded

>Flat, rounded

>Normal

Inspection

>Equal size

>Right foot is slighty bigger than left >Symmetrical >Evenly distributed >Brownish >With lesions on right foot

>Due to swelling >Normal >Normal >Normal >Due to disease process

try

Symme

Inspection Inspection Inspection Inspection

>Symmetrical >Evenly distributed >Light to deep brown >No lesions, deformities or inflammation

Distribu tion of hair color Skin Lesions

Musculoskeletal Joints Inspection >No swelling on the skin and tissues over the joints >With swelling on the skin and tissues over the joints of the right foot >Active motion against gravity, average weakness, 5/5 >Due to inflammation process

ROM

Inspection

>Full ROM against gravity, full resistance, 5/5

>Normal

C.

HISTORY OF PRESENT ILLNESS

Two years PTA, patient had a small blister on the sole of the right foot. Patients mother ignored the lesion for she perceived it as a minor cut only. No treatment or consultation was done. Two weeks PTA, patients mother noted swelling on the 3rd digit of the right foot; this was associated with on and off fever. On March 21, 2010, patient had high grade fever. They consult at a local hospital and urinalysis was done. The patient was diagnosed of UTI, and was

given antibiotics and pain medications. They were referred to the Philippine Orthopedic Center (POC) for chronic osteomyelitis.

D.

PAST MEDICAL HISTORY

The patient had a congenital heart defectpatent ductus arteriosus (PDA) and an inborn soft palpable mass on the upper right buttocks. On August 16, 2002, the patient was admitted to the Philippine Heart Center after experiencing cyanosis and loss of breath PTA. On admission, she was given oxygen and other unrecalled management according to her mother. She was operated on October of the same year regarding her PDA condition. Patient also had urinary tract infection (UTI) a year ago. She consulted to a local doctor and was given antibiotics.

E.

FAMILY HEALTH HISTORY

There is a history of high blood pressure on her fathers side but no account for any congenital defects of both sides.

G.

LABORATORY ANALYSIS
Result Normal Values Interpretation Nursing Responsibility
Assess for presence of, existence of, & history of risk factors for infection. Monitor laboratory studies. Monitor the ff. for signs of infection. Elevated temp. Color of respiratory secretions Appearance of urine Administer or teach use of antimicrobial drugs. Teach patient or caregiver to wash hands often, especially after toileting, before meals and after administering selfcare. Teach patient or caregiver the signs & symptoms of infection and when to report these to the physician. Encourage to eat foods high in Vitamin C like citrus fruits.

Composition
March 23, 2010 Urinalysis: Color Transparency RBC Pus cells March 23, 2010 Blood Chemistry: leukocyte

Light yellow Hazy 18-20 20-22

Amber to yellowish Clear 0-4 hpf 0-5 hpf Actual infection

22.2

4.5-10 x 10^ g/L

H.

PATHOPHYSIOLOGY
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 entrance to the bone by way of the blood, the microorganisms then lodge in an area of the bone in which circulation slows, usually the metaphysis. The microorganisms grow, resulting in an increase in pressure because of the nonexpanding nature of most bones. This increasing pressure eventually leads to ischemia and vascular compromise of the periosteum. Eventually the infection passes 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 blood supply forms new bone called involucrum. (Lewis, 2004) Once formed, a sequestrum continues to be a infected island of bone surrounded by pus and difficult to reach by blood-borne antibiotics or white blood cells (WBCs). Sequestrum may enlarge and serve as a site for microorganisms that spread to other sites, including the lungs and the brain. The sequestrum can move out of the bone and into the soft tissue. Once outside the bone, the sequestrum may revascularize and then undergo removal by normal immune system process. Another possibility is that the sequestrum can be surgically removed through debridement of the necrotic bone. If the necrotic sequestrum is not resolved naturally or surgically, it may develop a sinus tract, resulting n a chronic purulent cutaneous drainage.(Lewis, 2004) Chronic osteomyelitis is either a continuous persistent problem (a result of inadequate acute treatment) or process of exacerbations and remission. Over time, granulation tissue turns to scar tissue. This vascular scar tissue provides an ideal site for continued microorganism growth in impenetrable to antibiotics. (Lewis, 2004)

Modifiable: penetrating wound

Non-modifiable: 7 years old Female

Bacterial invasion

Neutrophil invasion/ Inflammatory response Pus formation Fever Leukocytosis Leukocyte: 22.2 x 10^ g/L Heat, Redness Swelling Tenderness

Pus spread into vascular channels

Periosteumlifts form the bone Pain Increased intraosseus response

Disruption in blood supply

Ischemic necrosis

Sequestra

Osteoblastic response

Involucrum

Osteomyelitis

I. NURSING CARE PLAN

Assessment
Subjective: Namamaga yung paa ko. as verbalized Objective: slow healing of lesion swelling of the right foot presence of abscess on the right foot weak pulse on the right foot

Nursing Diagnosis
Risk for peripheral neurovascular dysfunction related tointerruption of blood flow secondsary to disease condition

Nursing Plan
At the end of the nursing interventions, the patient will be able to maintain tissue perfusion as evidenced by palpable pulses, skin warm, normal sensation and stable vital signs.

Nursing Intervention
Assess general condition of and contributing factors to patient. Evaluate presence/quality of peripheral pulse distal to injury via palpation.

Rationale
Provide basis for understanding general, current situation of client. Decreased/absent pulse may reflect vascular injury and necessitates immediate medical evaluation of circulatory status. Return of color should be rapid (3-5 secs.). White, cool skin indicates arterial impairment. Cyanosis suggests venous impairment. Promotes venous drainage/decreases edema.

Evaluation

Assess capillary return, skin color, and warmth distal to inflammation.

Maintain elevation of inflamed extremity unless contraindicated by confirmed presence of compartmental syndrome. Investigate sudden signs of limb ischemia, e.g., decreased skin

Osteomyelitis may cause damage to adjacent arteries, with resulting loss of distal

temperature, pallor, and increased pain. Encourage patient to routinely exercise digits/joints distal to inflammation.

blood flow. Enhances circulation and reduces pooling of blood, especially in the lower extremities.

Subjective: Ang sakit ng paa ko. as verbalized. Objective: pain scale-8/10 with gurading behavior with reluctance to attempt movement; limited ROM with reports of pain with distracted behavior

Altered comfort: pain related to inflammatory process secondary to disease condition

At the end of the nursing interventions, the patient will be able to incorporate relaxation skills and diversional activities to reduce pain.

Investigate reports of pain, noting location and intensity (scale of 0-10), note precipitating factors and nonverbal cues. Maintain bed rest or chair rest when indicated. Place pillows on affected area. Encourage frequent changes of position to move in bed, supporting affected joints above and below, avoiding jerky movements. Involve in diversional activities appropriate for individual situation, e.g., coloring of books, playing with toys.

Helpful in determining pain management and effectiveness of interventions. Bed rest may be necessary to limit pain/injury to joints. Rests painful and maintains neutral position. Prevents general fatigue and joint stiffness, stabilizes joint, decreasing joint movements and associated pain. Refocuses attention, provides stimulation, and enhances selfesteem and feelings of general well-being.

Objective: leukocyte: 22.2 x 10^ g/L with purulent discharges on right foot pus cells in urine: 20-22hpf presence of lesion on right foot

Actual infection related to increased WBC count and presence of pyogenic microorganisms in the local infection

At the end of the nursing interventions, the patient will achieve timely wound healing; free of signs of infection.

Assess skin lesions, noting reports of increased pain or presence of edema, erythema, foul odor, or drainage. Provide sterile wound care, and exercise meticulous handwashing. Instruct patient not to touch wound with bare hands. Monitor vital signs. Note presence of chills, fever and malaise. Examine the skin for open wounds, foreign bodies and discoloration.

Indicates local infection/tissue necrosis which is a major sign of osteomyelitis. May prevent crosscontamination and any further complications. Minimizes opportunity for contamination. Tachycardia and chills/fever reflect developing sepsis.

Subjective: May sugat po ako sa paa as verbalized. Objective: disruption of skin surface of the lower extremity destruction of skin layers/tissues of the right foot reports of pain, pressure in affected/

Impaired skin integrity related to inflammatory response secondary to disease condition

At the end of the nursing interventions, the patient will demonstrate behaviors/techniques to prevent skin breakdown/facilitate healing as indicated.

Demonstrate good skin hygiene, e.g., wash thoroughly and pat dry carefully.

Discuss importance of

Provides information regarding skin circulation and problems that may be caused by edema formation that may require further medical intervention. Maintaining a clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin. These provide patient

surrounding area invasion of body structures with purulent discharge on the right foot

adequate nutrition especially fluids, proteins, vitamins B and C, iron and calories. Establish a turning or repositioning schedule.

Emphasize principles of asepsis especially hand washing and avoidance of touching wound with bare hands. Demonstrate wound care technique such as wound cleansing.

information how nutrition could elevate her chances of a faster recovery and wound healing. This provides the patients guide towards a proper skin management technique minimizing more skin trauma. To avoid possible infection thus hindering the wound healing process. To provide the patient or patients SO on the correct procedures and techniques of wound caring. Provides basis for understanding general, current condition of patient. Notes progress and changes of condition. Increases in metabolic rate and diaphoresis. Enhances heat loss by evaporation and

Subjective: Nilalamig ako. as verbalized Objective: T: 38.9oC RR: 39bpm skin warm to touch with flushed skin perspiring profusely

Altered body temperature: increased related to presence of pyogenic microorganisms in the local circulation

At the end of the nursing interventions, the patients temperature will decrease from 38.9oC to 36.8oC.

Assess general condition of and contributing factors to patient. Monitor vital signs especially temperature. Assess fluid loss and facilitate oral intake. Provide tepid sponge bath.

with teary eyes with purulent discharge on the right foot

Promote bed rest. Provide cool circulating air by opening windows or ensuring that patient is not covered with thick blankets. Assist patient in changing into dry clothing. Impaired physical mobility related to pain/discomfort Assess degree of immobility produced by pain. Instruct patient in/assist with active/passive ROM exercises of affected and unaffected extremities. Encourage patient to maintain upright and erect posture when sitting, standing, and walking. Discuss/provide safety needs, e.g., raised side rails.

conduction. Reduces body heat production. Dissipates heat by convection.

Increases comfort.

Subjective: Hindi ako masyadong makalakad. as verbalized. Objective: with reluctance to attempt movement; limited ROM with decreased muscle strength /control inability to move purposefully within the physical environment, imposed restrictions

At the end of the nursing interventions, the patient will regain/maintain mobility at the highest possible level.

Level of activity/exercise depends on progression/resolution of inflammatory process. Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility. Maximizes joint function, maintains mobility.

Helps prevent accidental injuiries/falls.

J. DRUG STUDY
*Common adverse effects in italic, life-threatening effects underlined

DRUG ORDER (Generic name, Dosage, Route, Frequency, etc.) Generic Name: Cefuroxime 400mg IV q8 Brand Name: Kefurox

SPECIFIC ACTION

PHARMACOLOGIC ACTION OF DRUG

INDICATIONS AND CONTRAINDICATIO NS Indications: It is effective for the treatment of penicillinaseproducing Neisseria gonorrhoea (PPNG). Effectively treats bone and joint infections, bronchitis, meningitis, gonorrhea, otitis media, pharyngitis/tonsillitis, sinusitis, lower respiratory tract infections, skin and soft tissue infections, urinary tract infections, and is used for surgical prophylaxis, reducing or eliminating infection. Contraindications: Hypersensitivity to cephalosporins and related antibiotics; pregnancy (category B), lactation.

ADVERSE EFFECTS OF THE DRUG Body as a Whole: Thrombophlebitis (IV site); pain, burning, cellulitis (IM site); superinfections, positive Coombs' test. GI: Diarrhea, nausea, antibioticassociated colitis. Skin: Rash, pruritus, urticaria. Urogenital: Increased serum creatinine and BUN, decreased creatinine clearance.

NURSING RESPONSIBILITIES /PRECAUTIONS Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated. Inspect IM and IV injection sites frequently for signs of phlebitis. Report onset of loose stools or diarrhea. Although pseudomembran ous colitis. Monitor I&O rates and pattern: Especially important in severely ill patients receiving high doses. Report any significant changes.

ANTIINFECTIVE; ANTIBIOTIC; SECONDGENERATION CEPHALOSPORI N

Preferentially binds to one or more of the penicillin-binding proteins (PBP) located on cell walls of susceptible organisms. This inhibits 3rd and final stage of bacterial cell wall synthesis, thus killing the bacteria.

Generic Name: Paracetamol 550mg/5mL q4; for T>=38.0oC Brand Name: Gandol

NON-OPIOID ANALGESIC

Paracetamol exhibits analgesic action by peripheral blockage of pain impulse generation. It produces antipyresis by inhibiting the hypothalamic heatregulating centre. Its weak antiinflammatory activity is related to inhibition of prostaglandin synthesis in the CNS.

Indications: To relieve mild to moderate pain due to things such as headache, muscle and joint pain, backache and period pains. It is also used to bring down a high temperature. For this reason, paracetamol can be given to children after vaccinations to prevent postimmunisation pyrexia (high temperature). Paracetamol is often included in cough, cold and flu remedies. Contraindications: Hypersensitivity to acetaminophen or phenacetin; use with alcohol.

Side effects are rare with paracetamol when it is taken at the recommended doses. Skin rashes, blood disorders and acute inflammation of the pancreas have occasionally occurred in people taking the drug on a regular basis for a long time. One advantage of paracetamol over aspirin and NSAIDs is that it doesn't irritate the stomach or causing it to bleed, potential Side effects of aspirin and NSAIDs.

Assessment & Drug Effects Monitor for S&S of: hepatotoxicity, even with moderate acetaminophen doses, especially in individuals with poor nutrition. Patient & Family Education Do not take other medications (e.g., cold preparations) containing acetaminophen without medical advice; overdosing and chronic use can cause liver damage and other toxic effects. Do not selfmedicate children for pain more than 5 d without consulting a physician. Do not use for

Course in the Ward

On March 22, 2010, patient was admitted to room-of-choice under childrens ward. Her vital signs were monitored every shift and her diet was diet as tolerated. The doctor ordered for her CBC, ESR, CRP, CT, BT, PT, PTT and UA. The patient also underwent x-ray of her right foot. Medication was given such as cefuroxime 750mg IV ANST then cefuroxime 400mg IV q8. She was started for venoclysis with D50.3NaCl 500cc @ KVO rate. On March 29, 2010, the patient was for repeat UA, CBC, ESR, and CRP. Her antibiotic medication was continued; and IVF was the same. She was prescribed paracetamol 250mg/5mL q4 and for temp. >=38.0oC.

CHAPTER VI Evaluation
During the nurse-patient relationship, clients condition was stable. She does not experience any pain, fever and/or malaise though there is an obvious swelling of her right foot and respiratory discharges scanty in amount, greenish in color. Patient was scheduled for surgery of her foot on March 31, 2010 but her doctor delayed because of her intermittent condition of the heart as revealed by her x-rays, and her lesion needs to be drained first. Her operation is still pending.

Bibliography
Radiology: Whole-body MR useful in detecting rare bone disease. Molecular Imaging. 10 September 2009. 03 April 2010 <http://www.molecularimaging.net/index.php?option=comarticles&view =article&id=18689:radiology-whole-body-mr-useful-in-detecting-rare-bone-disease> Rosalyn Carson-DeWitt, MD. Osteomyelitis: Prognosis. Answers.com. 2006. 03 April <http://www.google.com.ph/search?hl=tl&q=osteomyelitis+prognosis&meta=&aq=f&aqi =&aql=&oq=&gs_rfai=> 2010

Human musculoskeletal system. Wikipedia, The Free Encyclopedia. 26 March 2010. 03 April 2010. < http://en.wikipedia.org/wiki/Human_musculoskeletal_system> Chronic Osteomyelitis In Children. Global Help. June 2005. 03 April 2010 < http://www.globalhelp.org/publications/articles/article_chronicosteomyelitis.html

Chronic Osteomyelitis. eMedicine. 10 February 2009. 03 April 2010 <http://emedicine.medscape.com /article/393345-overview>