CHRONIC OSTEOMYELITIS

By BSN 4B GROUP C
INTRODUCTION
Definition
Definition
Osteomyelitis- pus-producing infection of the bone.'osteo' meaning bone / myelo (marrow
cavity), 'itis' which refers to the inflammation .

Causes
Causes
• contiguous invasion- direct contamination of an open fracture or wound
• vascular insufficiency
• hematogenous spread
• Staphylococcus aureus.
Chronic osteomyelitis occurs due to loss of blood supply to bone. This condition persists
for
Thisa condition
period of persists
time, usually
for a period
more than
of time,
2 weeks.
usually more than 2 weeks. Chronic
1.
Osteomyelitis
Sequestrum,
is polymicrobial
which is an infected,
- more than
deadone
bone
infectious
that has agent
separated
is involved.
from the living bones.
2.
1. Involucrum,
Sequestrum, which surrounds
is an infected,
the dead
deadbone.
bone that has separated from the living bones.
2. Involucrum, which surrounds the dead bone.

Epidemiology
US
Epidemiology
- 1 in 675 hospital of osteomyelitis admission / 50, 000 cases every year.Philippines - 239
cases
US - 1ofin chronic
675 hospital
osteomyelitis
of osteomyelitis
per 100,000
admission
hospital
/ 50, 000
admission
cases every year.
Philippines - 239 cases of chronic osteomyelitis per 100,000 hospital admission
PATIENT’S PROFILE
Name : Patient J
Age : 24 years old
Sex : Male
Ethnic Background : Igorot
Address : Itogon, Benguet
Civil Status : Single
Religion : Roman Catholic
Occupation : Miner
Admitting Diagnosis : Chronic Osteomyelitis
Final/Principal Diagnosis : Chronic Osteomyelitis Distal Tibia (Left)
Date and Time Admitted : November 5, 2021
Date Handled : November 11-13, 2021 (7-3 shift)

CHIEFCOMPLAINT
Swollen ankle with purulent discharges.
PRESENT HISTORY OF ILLNESS
Four months prior to admission, the patient suffered from fever and left ankle
pains which comes back over time. He disregarded these and self-medicated with over-
the-counter medications for relief. Seven days prior to admission, patient observes
presence of swelling on his left ankle. After a few days, patient noticed progression of
swelling and presence of pus draining from his left ankle, hence admitted.

PAST HISTORY OF ILLNESS

On May 23, 2021, the patient was confined in the Orthopedics ward of BGHMC
due to an open fracture. This happened when he was working at the mining area. A big
stone rush into his left ankle which caused of his fracture. In the hospital, they head to put
internal fixation to immobilize the affected ankle.
SOCIAL AND ENVIRONMENTAL HISTORY
Patient J was conversant, friendly and responsive to the questions being asked during the
assessment. He mentioned that he has a lot of friends in his work. He worked as a miner in a small
mining company in their place at Itogon, Benguet. Their house is four kilometers away from the
health center and is also near his workplace. Their house is a semi-concrete building with 3
separate bedrooms, one kitchen and one comfort room. A nearby spring water is used in washing
their clothes, dishes, cooking and bathing. Their source of drinking water is from a refilling station
close to them. They also have an electric power supplied by BENECO. Their garbage was claimed
to be segregated to biodegradable and non-biodegradable.

LIFESTYLE AND HEALTH PRACTICES

Patient J verbalizes that he often eats meat, fried foods and doesn’t like to eat vegetables because of
the nature of his work, and because he needs more protein in his diet, he prefers to eat bulk meal with
meat. According to him vegetables irritates his stomach and often urge him to go to the bathroom. He
usually drinks 3 to 5 glasses of water every day. He started smoking cigarettes at the age of 16 and
consumed one pack of cigarettes a day and drinks alcohol beverages such as 2x2 gin often. He
usually sleeps at 11 o’clock in the evening and wakes up 9 o’clock in the morning. He spends his day
watching television, surfing the internet and sleeping
HEALTH ASSESSMENT
A. General Survey
Received patient awake on bed; with an intact hep-lock on the right arm. He was conversant, but
appears weak, feverish and in pain with grimaces noted. There is presence of dry and intact elastic
bandage on his left ankle. His left ankle is characterized with dark discoloration, tender, swollen,
minimal loss of sensation, and warm to touch.

B. Head to Toe Assessment

1. Head Upon palpation, he is warm to touch with a temperature of 38 degrees Celsius
8. Cardiac Pulse rate is elevated and it ranges from 75-112 beats per minute. Blood pressure is
still within normal range with 110/80-120/90 mmHg.

12. Musculoskeletal Normally firm and showed smooth coordination. No muscle weakness noted. Left
ankle is swollen and tender. Range of motion in the lower extremities specifically in
the left ankle is
limited. He is using crutches as assistance when walking.
13. Integumentary General skin tone color is brown in complexion. Nails are not well-trimmed and hair
is evenly distributed. The skin is warm to touch but his left ankle is cold to touch,
swollen, and tender. A dark discoloration was also noted from the ankle to almost
2/3 part of his leg and upon palpation, skin turgor was noted after 3 seconds.
 C. 13 Areas of Assessment

1. Psychosocial and Psychological Status

Patient J is a 24-year-old male.
He works in a private mining in Itogon, Benguet.
According to Erik Erikson’s Psychosocial Theory, the patient is under the sixth stage which is Intimacy vs.
Isolation (ages 19 to 40 years). It is at this age wherein it covers the period of early adulthood when people
are exploring personal relationships. During this time, young adults face the challenge of forming close
relationships with others and develop intimate friendships and partnerships.

2. Mental and Emotional Status

Patient J is coping up from his situation. He thinks positively and hoping to be get well so he could go back
to his work. He complains pain on his leg ankle with a pain scale score of 10/10 and appears weak. He acts
according to his age.

3. Environmental Status
Patient J was admitted on Orthopedic Ward at BGHMC. He is bothered sometimes to the noise around.

4. Sensory Status
a. Visual Status
b. Auditory – Minimal cerumen accumulation noted.
c. Olfactory Status
d. Gustatory Status
e. Tactile Status – Less sensation on affected leg
5. Motor Status
Patient J experience walking difficulty especially on his left leg and guarding behavior noted. Range of
motion is limited on the lower extremities. On the left ankle swelling and tenderness are present. He needs
assistance in his daily activities. He walks with a limp and he uses crutches.

6. Thermoregulatory Status

Date Time Temperature

November 11, 2021 7am 38 °C
10am 37.5 °C
2pm 37 °C
November 12, 2021 7am 37.3 °C
10am 36.9 °C
2pm 37 °C
November 13, 2021 7am 36.8 °C
10am 37 °C
2pm 36.5 °C
7. Respiratory Status
Date Time RR SPO2
7am 23cpm 93%
November 11, 2021 10am 21cpm 93%
2pm 22cpm 93%
7am 23cpm 94%
November 12, 2021 10am 19cpm 93%
2pm 20cpm 93%
7am 20cpm 95%
November 13, 2021 10am 22cpm 95%
2pm 19cpm 95%

8. Circulatory Status
Date Time PR BP
November 11, 2021 7am 112bpm 108bpm 110/60 mmHg
10am 100bpm 110/60 mmHg
2pm 120/70 mmHg
November 12, 2021 7am 85bpm 110/60 mmHg
10am 80bpm 120/80 mmHg
2pm 77bpm 120/70 mmHg
November 13, 2021 7am 76bpm 120/70 mmHg
10am 80bpm 120/90 mmHg
2pm 75bpm 110/80 mmHg
9. Nutritional Status
Patient J has a normal eating pattern although he prefers to eat protein-rich foods than that of vegetables.
This may be due to the nature of his work. Protein is the building block for muscle build-up which is
necessary to maintain strength in lifting heavy materials in the mining area. During hospitalization, the
patient was prescribed a more balanced diet with equal amounts of carbohydrates, protein and fats.

10. Elimination Status

Patient J urinates normally and characterized as yellowish in color. During shift 1000mL of urine output. He
eliminates normally.

Date Time URINE STOOL

November 11, 2021 3-11pm 3 1
November 12, 2021 3-11pm 4 0
November 13, 2021 3-11pm 4 0
11. Sleep, Rest and Comfort Status
He cannot sleep adequately because of the pain from his leg ankle. He is also
disturbed by the noises around him.

12. Fluids and Electrolytes Status

Patient J is in hep-lock. He consumes 6-8 glasses or 1000-2000cc of water in a day
and he is fond of drinking coffee and soft drinks also.

13. Integumentary Status

Patient J skin is brown complexion and hair is black and evenly distributed. He is warm to touch and has a
flushed skin. His left ankle is swollen, tender, and a small open wound with draining pus is noted. Poor skin
turgor of more than 3 seconds and dark discoloration on the affected area were also noted.
DIAGNOSTICS

Diagnostic
Findings & Implications
Procedure
Soft tissue swelling with obliteration of tissue planes and mass formation
Implication: Fluid, pus, cells and other substances build-up as a result of
infection.
 
Sequestration surrounded by decalcified areas of granulation tissue
Implication: Presence of devitalized bone and its surrounding dead tissue
that has separated from the healthy tissues as a result of a bone infection.
Plain Radiograph of  
Ankle Subperiosteal lamination
Implication: Indicates formation of a new bone (involucrum)
 
 
Sinus tracts
Implication: External migration of dead pieces of cells with breakdown of
skin and subcutaneous tissue
DIAGNOSTICS

Diagnostic
Findings & Implications
Procedure
Soft tissue swelling with obliteration of tissue planes and mass formation
Implication: Fluid, pus, cells and other substances build-up as a result of
infection.
 
Sequestration surrounded by decalcified areas of granulation tissue
Implication: Presence of devitalized bone and its surrounding dead tissue
that has separated from the healthy tissues as a result of a bone infection.
Plain Radiograph of  
Ankle Subperiosteal lamination
Implication: Indicates formation of a new bone (involucrum)
 
 
Sinus tracts
Implication: External migration of dead pieces of cells with breakdown of
skin and subcutaneous tissue
Diagnostic Procedure Findings Implication
   
RBC: The RBC level is lower than the normal which is
78.50fL 80-100ml, this indicates a reduced hematocrit
  and hemoglobin level resulting less blood
Complete Blood   circulation to the body tissue.
Count
WBC: A high white blood cell count may indicate
11, 500 per microliter that the immune system is working to destroy an
infection. It may also be a sign of physical or
emotional stress.
Erythrocyte 58.00 The result is very high than the normal range
which is 0-10mm/hr, therefore, there is high per-
Sedimentation
centage of inflammation.
Rate (ESR )
 
C-Reactive Protein 0.9mg/dL The result is high within the normal range which
(CRP) is 0-0.3 mg/dl. Hence indicates an inflammation.

Urinalysis   Unremarkable
 PATHOPHYSIOLOGY
REVIEW
REVIEW
DRUGS TREATMENT/MANAGEMENT

DRUG NAME MECHANISM OF ACTION INDICATION

CEFTRIAXONE  Bind to the bacterial cell wall Treatment of the following

Brand: Rocephin membrane causing cell death. infections caused by susceptible
  Bactericidal action against organisms such as skin structure
Antibiotic susceptible bacteria. infection, respiratory tract infection,
    bone and joint infection.
DOSE: 250mg q 12hr
   
ROUTE: Intravenous

CYTARABINE Inhibits DNA synthesis by Used mainly in combination

Brand: Cytosar inhibiting DNA polymerase. chemotherapeutic regimens for the
    treatment of leukemia and non-
Antineoplastics Therapeutic Effects: Death of Hodgkin's lymphomas.
  rapidly replicating cells  
DOSE: 33.7mg particularly malignant ones.
   
ROUTE: Intravenous
 
 DRUG NAME  MECHANISM OF ACTION INDICATION
COTRIMOXAZOLE It works by stopping the growth Used to treat certain
Brand: Bactrim of bacteria. It acts by sequential bacterial infections such as
blockade of folic acid enzymes pneumonia, bronchitis and
Anti-bacterial sulfonamide in the synthesis pathway. infection of the urinary
    tract, ears and intestines.
DOSE: 400/80/5mL  
   
ROUTE:
Intravenous
Thought to produce analgesia by Mild pain or fever.
PARACETAMOL blocking pain impulses by  
Brand: Panadol inhibiting synthesis of  
  prostaglandin in the CNS or of
Non-opioid analgesics, other substances that sensitive
Antipyretics pain receptors to stimulation.
   The drug may relieve fever
DOSE: 300mg/2ml through central action in the
  hypothalamic heat-regulating
ROUTE: Oral center.
 DRUG NAME MECHANISM OF ACTION INDICATION
FENTANYL CITRATE Unknown. Binds with opiate For analgesic action of
 Brand: Sublimaze receptors in the CNS, altering short duration during
  perception of and emotional the anesthetic periods,
Opioid analgesics response to pain. premedication, induction
    and maintenance, and in the
DOSAGE: Source: immediate postoperative
100mcg/2ml AMP (Wilkins, Nursing 2008 Drug period (recovery room) as
  Handbook, 2008) the need arises.
FREQUENCY:  
As necessary  
 
ROUTE:
IV, IM
NURSING CARE PLANS
A.
List of Problems:

1. Chronic Pain related to tissue destruction as evidenced by verbal report of pain and
guarding behavior.

2. Hyperthermia related to the body’s response to infection characterized by flushed skin,

hypotension, skin warm to touch, tachycardia, and tachypnea.

3. Impaired physical mobility related to musculoskeletal impairment characterized by

change in gait, discomfort, and decreased ROM.

4. Impaired Skin Integrity related to purulent drainage secondary to Chronic

Osteomyelitis.

5. Risk for fall related to impaired mobility.

DISCHARGE PLAN

Diet/Nutrition 1. Advice the patient to have a diet plan which includes a healthy balance of iron-rich
food such as green leafy vegetables, lean meat, nuts, seeds and fortified breakfast
cereals. Iron helps in increasing red blood cells which transports oxygen into the body.
2. Encourage to have a diet rich in vitamin C such as broccoli, tomatoes, peppers, oranges
and strawberries to enhance absorption of iron.
3. Emphasize to the patient to eat foods high in protein and calcium such as chicken,
milk, tofu, beans, fish, peanut butter, nuts, steak, pork, eggs and cheese. Protein helps
build healthy tissue and heal wounds from infected tissues. Calcium helps in the
recovery, formation and strengthening of the bones.
4. Encourage to drink plenty of water.

Activity 1. Advise the patient to follow activity restrictions of heavy exercises such as lifting as
recommended by the physician.
2. Encourage to discontinue smoking.
3. Instruct to take enough rest and sleep.
4. Encourage out of bed activity such as stretching, and walking to improve muscle
strength and functioning
DISCHARGE PLAN

Medication 1. Explain to the patient the drugs prescribed.

2. If the doctor prescribes antibiotics, advice the patient to take it as directed. Instruct the
patient to not stop taking the medication just because he feels better. Patient need to
take the full course of antibiotics.
3. Explain to the patient to give medicine to decrease pain and to not wait until the pain
becomes severe.
4. Advise the patient to contact healthcare provider if medicines are not helping or if
there are any unusual side effects.
5. Advice the patient to ask the doctor before taking a pain medication that is not
prescribed by the physician, if the patient can take over the counter medicine.

OtherS 1. Instruct the patient to ask healthcare providers on the proper way of cleaning purulent
wound.
2. Advise to follow scheduled follow up check-ups.
3. Instruct patient to report to physician any problems or unusual symptoms.
LEARNING INSIGHTS
 THANK YOU.

Elsie C. Alalag, Yazel Shannen S. Comafay, Zyra Mae T. Diano,

Heinz Erika G. Fernandez, Jelenie B. Habbiling, Basema A. Hashhash,
Ahmed K. Jaghman, Jessie Jeng B. Navarro, Xyra Mae G. Pait, and Angelica C.
Vita