WELCOME

1. WELCOME

2. Osteomyelitis. Presented by: Santhosh Thomas Lecturer Yenepoya Nursing College Date: 28/11/2018.

3. Learning Objectives. The students will learn: • Definition Of Osteomyelitis. • Incidence Of Osteomyelitis. • Etiology Of Osteomyelitis . • Pathophysiology Of Osteomyelitis. • Diagnosis Of Osteomyelitis . • Management Of Osteomyelitis.

4. Incidence •  The overall prevalence is 1 case per 5,000 children. • Neonatal prevalence is approximately 1 case per 1,000. • The incidence of vertebral osteomyelitis is approximately 2.4 cases per 100,000 population.

5. Direct trauma and contiguous focus osteomyelitis are more common among adults and adolescents than in children. • Vertebral osteomyelitis is more common in persons older than 45 years.

6. Definition. • Osteomyelitis is an infection and inflammation of the bone and bone marrow. Osteomyelitis is an infectious usually painful inflammatory disease of bone often of bacterial origin that may result in the death of bone tissue. 

7. Classification. • Suppurativeosteomyelitis • Acute suppurativeosteomyelitis • Chronic suppurativeosteomyelitis • Primary (no preceding phase) • Secondary (follows an acute phase)

8. Non-suppurativeosteomyelitis • Diffuse sclerosing • Focal sclerosing (condensing osteitis) • Proliferative periostitis (periostitisossificans, Garré'ssclerosingosteomyelitis) • Osteoradionecrosis.

9. Risk Factors. • Fractures due to trauma and road traffic accidents • Gun shot wounds • Radiation damage • Paget`s disease • Osteoporosis • Systemic disease : Malnutrition, Acute Leukemia, Uncontrolled diabetes, sickle cell anemia, Chronic alcoholism

10. Etiology • Staphylococcus aureus causes 70% to 80% of bone infections. • Proteus , Pseudomonas species and Escherichia coli. • Bone is normally resistant to infection. However, when microorganisms are introduced into bone can cause osteomyelitis.

11. Pathophysiology • Entry of microorganism by • Direct entry • Indirect entry. • Indirect • Extension of soft tissue infection (eg, infected pressure or vascular ulcer, incisional infection) • Hematogenous (bloodborne) spread from other sites of infection (eg, infected tonsils, infected teeth, upper respiratory infections)

12. Direct • Direct bone contamination from bone surgery, open fracture, prosthesis or traumatic injury (eg, RTA )

13. Clinical Manifestations. • Pain (several weeks / months) • Limping • Swelling & Local tenderness • Muscle wasting • Body temperature usually normal (no fever)

14. Factors affect the extent of infection. • Virulence of the infecting organism, • Underlying disease • Immune status of the host, • The type, location, and vascularity of the bone.

15. Unless the infective process is treated promptly, a bone abscess forms. The resulting abscess cavity contains dead bone tissue (the sequestrum), which does not easily liquefy and drain • New bone growth (the involucrum) forms and surrounds the sequestrum.

16. Diagnosis. • Marked tenderness over the involved site. • leukocytosis may be present , ESR ↑, CRP ↑ • Blood culture ( 60% positive). • Cultures of aspirated cellulitis or priosteal space before antibiotic therapy.

17. Radiography : • finding of acute systemic osteomyelitis, at about 9 days, is loss of the periosteal fat line • Periosteal elevation and periosteal destruction are later findings • technetium 99m bone scans . • MRI is particularly useful for extended of infection or when infection is a complication of trauma , surgery, sickle cell anemia.

18. Medical Management. • Initial IV antibiotic should be based on result of Gram stain of bone aspiration ,blood culture, age associated disease. • Initial IV antibiotic should cover S.aureus • (oxacillin,nafcillinmethicillin, clindamycin) • Possibility of methicilin –resistant staph should be considered . • Gram- negative organism if wound contamination or IV drug abuse .

19. The response to appropriate IV antibiotic usually occur in 48 hr . • Lack of improvement in fever and pain after this time indicates that surgical drainage may be necessary or an unusual pathogen may be present .

20. Surgical drainage may be appropriate at earlier time if : • sequestrum is present • disease is chronic or atypical • the hip joint is involved • Presence of spinal cord compression. • standard therapy usually consist of antibiotic for 4-6 weeks

21. After initial inpatient treatment and a good clinical response, including decreases in CRP or ESR, consideration may be given for home therapy with IV antibiotics or oral antibiotics.

22. Surgical Management. • It may require • Surgical Debridement  • Amputation.

23. Nursing Management Assesment: • Acute pain. • Impaired physical mobility • Extension of infection • Knowledge

24. Nursing Diagnoses • Acute pain related to inflammation and swelling • Impaired physical mobility related to pain, use of immobilization devices, and weight-bearing limitation. • Risk for extension of infection: bone abscess formation • Deficient knowledge related to the treatment regimen

25. Nursing Interventions. Relieving pain • The affected part may be immobilized with a splint to decrease pain and muscle spasm. • The nurse monitors the neurovascular status of the affected extremity. The wounds are frequently very painful, and the extremity must be handled with great care and gentleness.

26. Elevation reduces swelling and associated discomfort. • Pain is controlled with prescribed analgesics and other pain reducing techniques.

27.  Improving physical mobility • Treatment regimens restrict activity. The bone is weakened by the infective process and must be protected by immobilization devices and by avoidance of stress on the bone. • The patient must understand the rationale for the activity restrictions.

28. The joints above and below the affected part should be gently placed through their range of motion. • The nurse encourages full participation in ADLs within the physical limitations to promote general well-being

29. Controlling the infectious process • The nurse monitors the patient’s response to antibiotic therapy and observes the IV access site for evidence of phlebitis, infection, or infiltration.

30. With long-term, intensive antibiotic therapy, the nurse monitors the patient for signs of superinfection (e.g., oral or vaginal candidiasis, loose or foul-smelling stools).

31. If surgery was necessary, the nurse takes measures to ensure adequate circulation (wound suction to prevent fluid accumulation, elevation of the area to promote venous drainage, avoidance of pressure on grafted area), to maintain needed immobility, and to comply with weight-bearing restrictions.

32. The nurse changes dressings using aseptic technique to promote healing and to prevent cross-contamination. The nurse continues to monitor the general health and nutrition of the patient. A diet high in protein and vitamin C ensures a positive nitrogen balance and promotes healing. The nurse encourages adequate hydration as well.

33. Long bone osteomyelitis is difficult to treat and is responsible for significant morbidity and expense. The goal of treatment is to arrest its spread and repair the damage it has caused. Appropriate treatment includes culture-directed antibiotic therapy and operative debridement of all necrotic bone and soft tissue.

34. Summary. • I discussed on the definition, incidence, etiology, pathophysiology, classification, diagnosis and management of osteomyelitis in the about slides.

35. Conclusion. • The sooner you treat osteomyelitis, the better. In cases of acute osteomyelitis, early treatment prevents the condition from becoming a chronic problem that requires ongoing treatment. Besides the pain and inconvenience of repeated infections, getting osteomyelitis under control early provides the best chance for recovery.

36. References • Black, J.M et al. Medical Surgical Nursing. 4th ed. (Philadelphia: W.B. Saunders Co.,), 1993. • Smeltzer, Susanne C et al. Text Book of Medical Surgical Nursing. Vol. 2. (New Delhi: Lippincott Williams & Wilkins), 2009.

37. References. • Hinkle, J.L. & Cheever, K.H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (14th ed.). Philadelphia: WoltersKluwer. • Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). St. Louis: Elsevier.