Case Study of Chronic Osteomyelitis

8/8/2019 Case Study of Chronic Osteomyelitis

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SOUTHERN LUZON STATE UNIVERSITYLucban, Quezon

CHRONIC OSTEOMYELITISA Case Study

Presented to the FacultyOf College of Allied Medicine

In partial fulfillment of the requirementsfor the Degree Bachelor of Science in Nursing

Submitted by:Abrigo, Ellennor F.

Job, GenesisOlaivar, Monique S.

Submitted to:Prof. Caroline Murallon

Summer Affiliation, 2010


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CHAPTER IObjective of the Study

A. GENERAL OBJECTIVES:

B. SPECIFIC OBJECTIVES:


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CHAPTER IIIntroduction 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 longbones 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.
http://www.brainyquote.com/quotes/quotes/h/henrydavid396567.htmlhttp://www.brainyquote.com/quotes/quotes/h/henrydavid396567.html


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CHAPTER IIIAnatomy 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 muscularand 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 bonesand 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 byjoints. 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.
http://en.wikipedia.org/wiki/Organ_(anatomy)http://en.wikipedia.org/wiki/Organ_(anatomy)http://en.wikipedia.org/wiki/Muscular_systemhttp://en.wikipedia.org/wiki/Skeletal_systemhttp://en.wikipedia.org/wiki/Skeletonhttp://en.wikipedia.org/wiki/Musclehttp://en.wikipedia.org/wiki/Cartilagehttp://en.wikipedia.org/wiki/Tendonshttp://en.wikipedia.org/wiki/Ligamentshttp://en.wikipedia.org/wiki/Jointshttp://en.wikipedia.org/wiki/Connective_tissuehttp://en.wikipedia.org/wiki/Hematopoietic_systemhttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Musclehttp://en.wikipedia.org/wiki/Connective_tissuehttp://en.wikipedia.org/wiki/Tendonhttp://en.wikipedia.org/wiki/Ligamenthttp://en.wikipedia.org/wiki/Jointhttp://en.wikipedia.org/wiki/Cartilagehttp://en.wikipedia.org/wiki/Medical_diagnosishttp://en.wikipedia.org/wiki/Organ_(anatomy)http://en.wikipedia.org/wiki/Organ_(anatomy)http://en.wikipedia.org/wiki/Muscular_systemhttp://en.wikipedia.org/wiki/Skeletal_systemhttp://en.wikipedia.org/wiki/Skeletonhttp://en.wikipedia.org/wiki/Musclehttp://en.wikipedia.org/wiki/Cartilagehttp://en.wikipedia.org/wiki/Tendonshttp://en.wikipedia.org/wiki/Ligamentshttp://en.wikipedia.org/wiki/Jointshttp://en.wikipedia.org/wiki/Connective_tissuehttp://en.wikipedia.org/wiki/Hematopoietic_systemhttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Musclehttp://en.wikipedia.org/wiki/Connective_tissuehttp://en.wikipedia.org/wiki/Tendonhttp://en.wikipedia.org/wiki/Ligamenthttp://en.wikipedia.org/wiki/Jointhttp://en.wikipedia.org/wiki/Cartilagehttp://en.wikipedia.org/wiki/Medical_diagnosis


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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 fortissues 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 ofbone 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
http://en.wikipedia.org/wiki/Long_boneshttp://en.wikipedia.org/wiki/Long_boneshttp://en.wikipedia.org/wiki/Short_boneshttp://en.wikipedia.org/wiki/Flat_boneshttp://en.wikipedia.org/wiki/Irregular_boneshttp://en.wikipedia.org/wiki/Sesamoid_boneshttp://en.wikipedia.org/wiki/Axial_skeletonhttp://en.wikipedia.org/wiki/Appendicular_skeletonhttp://en.wikipedia.org/wiki/Tissue_(biology)http://en.wikipedia.org/wiki/Organshttp://en.wikipedia.org/wiki/Brainhttp://en.wikipedia.org/wiki/Skullhttp://en.wikipedia.org/wiki/Lungshttp://en.wikipedia.org/wiki/Rib_cagehttp://en.wikipedia.org/wiki/Bone_marrowhttp://en.wikipedia.org/wiki/Long_boneshttp://en.wikipedia.org/wiki/Long_boneshttp://en.wikipedia.org/wiki/Short_boneshttp://en.wikipedia.org/wiki/Flat_boneshttp://en.wikipedia.org/wiki/Irregular_boneshttp://en.wikipedia.org/wiki/Sesamoid_boneshttp://en.wikipedia.org/wiki/Axial_skeletonhttp://en.wikipedia.org/wiki/Appendicular_skeletonhttp://en.wikipedia.org/wiki/Tissue_(biology)http://en.wikipedia.org/wiki/Organshttp://en.wikipedia.org/wiki/Brainhttp://en.wikipedia.org/wiki/Skullhttp://en.wikipedia.org/wiki/Lungshttp://en.wikipedia.org/wiki/Rib_cagehttp://en.wikipedia.org/wiki/Bone_marrow


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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. 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.
http://en.wikipedia.org/wiki/Human_musculoskeletal_system#cite_note-skeletalsystem-3http://en.wikipedia.org/wiki/Calciumhttp://en.wikipedia.org/wiki/Phosphorushttp://en.wikipedia.org/wiki/Cardiac_musclehttp://en.wikipedia.org/wiki/Skeletal_musclehttp://en.wikipedia.org/wiki/Smooth_musclehttp://en.wikipedia.org/wiki/Lumen_(anatomy)http://en.wikipedia.org/wiki/Involuntary_musclehttp://en.wikipedia.org/wiki/Involuntary_musclehttp://en.wikipedia.org/wiki/Striated_musclehttp://en.wikipedia.org/wiki/Microscopehttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Nervehttp://en.wikipedia.org/wiki/Central_nervous_systemhttp://en.wikipedia.org/wiki/Human_musculoskeletal_system#cite_note-skeletalsystem-3http://en.wikipedia.org/wiki/Calciumhttp://en.wikipedia.org/wiki/Phosphorushttp://en.wikipedia.org/wiki/Cardiac_musclehttp://en.wikipedia.org/wiki/Skeletal_musclehttp://en.wikipedia.org/wiki/Smooth_musclehttp://en.wikipedia.org/wiki/Lumen_(anatomy)http://en.wikipedia.org/wiki/Involuntary_musclehttp://en.wikipedia.org/wiki/Involuntary_musclehttp://en.wikipedia.org/wiki/Striated_musclehttp://en.wikipedia.org/wiki/Microscopehttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Nervehttp://en.wikipedia.org/wiki/Central_nervous_system


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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 offibrous 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 forcesto 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 orsynarthroses, joints that are

immovable, that allow little or no movement andare 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.
http://en.wikipedia.org/wiki/Motor_neuronhttp://en.wikipedia.org/wiki/Somatic_nervous_systemhttp://en.wikipedia.org/wiki/Depolarizationhttp://en.wikipedia.org/wiki/Neurotransmitterhttp://en.wikipedia.org/wiki/Cell_(biology)http://en.wikipedia.org/wiki/Neuromuscular_junctionhttp://en.wikipedia.org/wiki/Chemical_synapsehttp://en.wikipedia.org/wiki/Sarcolemmahttp://en.wikipedia.org/wiki/Action_potentialhttp://en.wikipedia.org/wiki/Sarcolemmahttp://en.wikipedia.org/wiki/Initiationhttp://en.wikipedia.org/wiki/Fibrous_connective_tissuehttp://en.wikipedia.org/wiki/Periosteumhttp://en.wikipedia.org/wiki/Synovial_jointhttp://en.wikipedia.org/wiki/Synarthrosishttp://en.wikipedia.org/wiki/Synovial_jointhttp://en.wikipedia.org/wiki/Synovial_membranehttp://en.wikipedia.org/wiki/Motor_neuronhttp://en.wikipedia.org/wiki/Somatic_nervous_systemhttp://en.wikipedia.org/wiki/Depolarizationhttp://en.wikipedia.org/wiki/Neurotransmitterhttp://en.wikipedia.org/wiki/Cell_(biology)http://en.wikipedia.org/wiki/Neuromuscular_junctionhttp://en.wikipedia.org/wiki/Chemical_synapsehttp://en.wikipedia.org/wiki/Sarcolemmahttp://en.wikipedia.org/wiki/Action_potentialhttp://en.wikipedia.org/wiki/Sarcolemmahttp://en.wikipedia.org/wiki/Initiationhttp://en.wikipedia.org/wiki/Fibrous_connective_tissuehttp://en.wikipedia.org/wiki/Periosteumhttp://en.wikipedia.org/wiki/Synovial_jointhttp://en.wikipedia.org/wiki/Synarthrosishttp://en.wikipedia.org/wiki/Synovial_jointhttp://en.wikipedia.org/wiki/Synovial_membrane


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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.
http://en.wikipedia.org/wiki/Ligamenthttp://en.wikipedia.org/wiki/Extension_(kinesiology)http://en.wikipedia.org/wiki/Flexionhttp://en.wikipedia.org/wiki/Ligamenthttp://en.wikipedia.org/wiki/Extension_(kinesiology)http://en.wikipedia.org/wiki/Flexion


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CHAPTER IVOverview of the Disease

A. REVIEW OF RELATED LITERATURE

Definition

Osteomyelitis (osteo- derived from

the Greek word osteon, meaning bone,

myelo- meaning marrow, and -itis

meaning inflammation) simply means

an infection of the bone orbone marrow.

It can be usefully subclassified on

the basis of the causative organism

(pyogenic bacteria ormycobacteria), 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).
http://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Bone_marrowhttp://en.wikipedia.org/wiki/Pyogenichttp://en.wikipedia.org/wiki/Mycobacteriahttp://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Bone_marrowhttp://en.wikipedia.org/wiki/Pyogenichttp://en.wikipedia.org/wiki/Mycobacteria


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A minor trauma, which can lead to a blood clot around the bone

and then a secondary infection from seeding of bacteria.

Bacteria in the bloodstream bacteremia (poor dentition), which is

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 bloodstream 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


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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 1month 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 scans are

important in the

definitive diagnosis of

osteomyelitis. Elevated

WBC and ESR, an

elevated level of C-

reactive 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


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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

taken and tested for signs of an invading organism.

Bone scan: During this test, a small amount of Technetium-99

pyrophosphate, a radioactive material, is injected intravenously into the


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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 aprocedure 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


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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.

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


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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 ofRadiology.

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.
http://www.molecularimaging.net/_news/topic/aseptic+inflammatory+lesionhttp://www.molecularimaging.net/_news/person/Jan+Fritzhttp://www.molecularimaging.net/_news/topic/whole-body+MRIhttp://www.molecularimaging.net/_news/topic/periphyseal+regionhttp://www.molecularimaging.net/_news/topic/aseptic+inflammatory+lesionhttp://www.molecularimaging.net/_news/person/Jan+Fritzhttp://www.molecularimaging.net/_news/topic/whole-body+MRIhttp://www.molecularimaging.net/_news/topic/periphyseal+region


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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 whole-

body 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 MRIidentifies characteristic, ill-defined, edemalike, periphyseal osseous lesions

predominantly in symmetrical lower extremity distribution.

Last Updated on Friday, September 11 2009
http://www.molecularimaging.net/_news/topic/radiationhttp://www.molecularimaging.net/_news/topic/radiation


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CHAPTER VCase 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 StructureOther body parts look equal bilaterally and are in relative proportion to

each other.

Behavior


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

questions appropriately.

Initial V/S

Temperature: 36.3oC

Cardiac Rate: 79bpm

Respiratory Rate: 35bpm

B. PHYSICAL ASSESSMENT

Area AssessedMethodUsed

Normal FindingsActual

FindingsRemarks

Skin

Color

Uniformity of

skin color

Temperature

Moisture

Turgor

Thickness

Tenderness

Lesions

Edema

Inspection

Inspection

Palpation

Inspection;Palpation

Inspection;Palpation

Inspection

Palpation

Inspection

Inspection

>Varies from light todeep brown, fromruddy pink to lightpink, from yellowovertones to olive

>Generally uniform

except in areasexposed to the sun,areas of lighterpigmentations (palms,lips and nail beds).

>Uniform withinnormal range(36.5-37.5)

>Moisture in the skinfolds and the axilla(varies withenvironmentaltemperature andhumidity, bodytemperature andactivity)

>Springs back tonormal when pinched

>Epidermis isuniformly thin overmost of the body

>Skin surfaces arenon-tender

>Absence of lesions

>Absence of edema

>Brownish

>Generally

uniform exceptin areas withswelling tissues

>Uniform withinnormalrange(36.3)

>Moisture in theskinfolds and theaxilla

>Springs backto normal whenpinched

>Epidermis isuniformly thinover most of thebody

>Skin surfacesare non-tender

>With lesions

>With swellingof the right foot

>Normal

>Normal

>Normal

>Normal

>Normal

>Normal

>Normal

>Onset ofinfection

>Due toinflammation


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Hair

Distribution

Texture

Color

Seborrhea

Inspection

Palpation

Inspection

Inspection

>Evenly distributedover the scalp

>Fine or thick hair;straight, curly or kinky;silky, resilient hair

>Black color or graycolor, considering theage

>Absence ofseborrhea

> Evenlydistributed overthe scalp

>With straight,thick hair

>Black color

>Absence ofseborrhea

>Normal

>Normal

>Normal

>Normal

Nails

Appearance

Color of nailbed

Shape

Texture

Capllary refilltime

Inspection

Inspection

Inspection

Inspection

Palpation

>Clean nails

>Pink

>Convex to curvature

>Smooth

>Return within 2-3seconds

>Clean nails

>Pink

>Convex tocurvature

>Smooth

>Return within 2seconds

>Normal

>Normal

>Normal

>Normal

>Normal

Head

Shape and size

Facial features

Symmetry offacial features

Inspection

Inspection

Inspection

>Rounded, smoothskull contour

>Symmetric or slightlyasymmetric facialfeatures

>Symmetric facialmovements

>Rounded,smooth skullcontour

>Symmetric

>Symmetricfacialmovements

>Normal

>Normal

>Normal

Ears

Auricle Position

Texture

External Auditory canal

Discharges

Color of canalwalls

Inspection

Inspection

Inspection

Inspection

>At the level of theexternal cantus of theeyes

>Smooth withoutlesion

>None

>Pink

>At the level ofthe externalcantus of theeyes

>Smoothwithout lesion

>None

>Pink

>Normal

>Normal

>Normal

>Normal

Nose

Color

Sinuses

Inspection

Inspection

>Same color with theface

>Not inflamed

>Same colorwith the face

>Not inflamed

>Normal

>Normal


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Nares

Lesion/Tenderness

Inspection

Palpation

>No obstruction; ovaland symmetric

>Not tender, absenceof lesion

>No obstruction;oval andsymmetric

>Not tender,absence of

lesion

>Normal

>Normal

Lips

Symmetry

Color

Texture

Inspection

Inspection

Palpation

>Symmetrical

>Pinkish

>Smooth

>Symmetrical

>Pinkish

>Smooth

>Normal

>Normal

>Normal

Teeth Inspection >Free from decays,white, smooth andshiny

>Free fromdecays

>Normal

Tongue

Position

Color

Inspection

Inspection

>Center

>Pink

>Center

>Pink

>Normal

>Normal

Neck

Position

Movement

Lymph nodes

Thyroid glands

Consistency

Size

Texture

Inspection

Inspection

Palpation

Inspection

Palpation

Palpation

>Centrally located onthe shoulder

>Able to flex andextend head withoutpain and resistance

>Not palpable

>Not visible whenswallowing

>Small

>Smooth and freefrom nodules

>Centrallylocated on theshoulder

>Able to flexand extend headwithout pain andresistance

>Not palpable

>Not visiblewhenswallowing

>Small

>Smooth andfree fromnodules

>Normal

>Normal

>Normal

>Normal

>Normal

>Normal

Thorax and Lungs

Anterior thorax andlungs

Breathingpatterns

Symmetry

Lung breathsounds

Inspection

Inspection

Auscultation

> Quiet, Rhythmic andEffortless Respiration

>Symmetrical

>No adventitioussound

> Quiet,Rhythmic andEffortless

Respiration(RR: 35 bpm)

>Symmetrical

>Noadventitioussound

>Normal

>Normal

>Normal


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Shape Inspection;palpation

>oval/elliptical >oval/elliptical >Normal

Heart

Rate

Rhythm

Auscultation

Auscultation

>Regular rate(60-100)

>no murmur

>Regularrate(80bpm)

>no murmur

>Normal

>Normal

Abdomen

Contour Inspection >Flat, rounded >Flat, rounded >Normal

Upper & lowerextremities

Size

Symmetry

Distribution of hair

Skincolor

Lesions

Inspection

Inspection

Inspection

Inspection

Inspection

>Equal size

>Symmetrical

>Evenly distributed

>Light to deep brown

>No lesions,deformities orinflammation

>Right foot isslighty bigger

than left

>Symmetrical

>Evenlydistributed

>Brownish

>With lesions onright foot

>Due toswelling

>Normal

>Normal

>Normal

>Due todiseaseprocess

Musculoskeletal

Joints

ROM

Inspection

Inspection

>No swelling on theskin and tissues overthe joints

>Full ROM againstgravity, full resistance,5/5

>With swellingon the skin andtissues over the

joints of the rightfoot

>Active motionagainst gravity,averageweakness, 5/5

>Due toinflammationprocess

>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


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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

Composition Result Normal Values Interpretation Nursing Responsibility

March 23, 2010

Urinalysis:

Color

Transparency

RBC

Pus cells

March 23, 2010

BloodChemistry:

leukocyte

Light yellow

Hazy

18-20

20-22

22.2

Amber toyellowish

Clear

0-4 hpf

0-5 hpf

4.5-10 x 10^ g/L

Actual infection

Assess for presence of,

existence of, & history of riskfactors for infection.

Monitor laboratory studies.

Monitor the ff. for signs ofinfection.

Elevated temp.

Color ofrespiratory secretions

Appearance ofurine

Administer or teach use ofantimicrobial drugs.

Teach patient or caregiver to

wash hands often, especiallyafter toileting, before mealsand after administering self-care.

Teach patient or caregiver thesigns & symptoms of infectionand when to report these tothe physician.

Encourage to eat foods highin Vitamin C like citrus fruits.


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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 othersites, 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)


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Bacterial invasion

Neutrophil invasion/Inflammatory response

Pus formation Fever Leukocytosis Heat,Leukocyte: 22.2 x 10^ g/L Redness

SwellingTenderness

Pus spread into vascular channels

Periosteumlifts form the bone

Pain

Increased intraosseus response

Disruption in blood supply

Ischemic necrosis

Sequestra

Osteoblastic response

Involucrum

Osteomyelitis

Non-modifiable:

- 7 years old- Female

Modifiable:

- penetrating wound


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I. NURSING CARE PLAN

Assessment Nursing Diagnosis Nursing Plan Nursing Intervention Rationale Evaluation

Subjective:

Namamagayung paa ko. asverbalized

Objective:

slow healing oflesion

swelling of theright foot

presence ofabscess on theright foot

weak pulse onthe right foot

Risk for peripheralneurovasculardysfunction relatedtointerruption of bloodflow secondsary to

disease condition

At the end of the nursinginterventions, the patientwill be able to maintaintissue perfusion asevidenced by palpable

pulses, skin warm,normal sensation andstable vital signs.

Assess generalcondition of andcontributing factors topatient.

Evaluate

presence/quality ofperipheral pulse distalto injury via palpation.

Assess capillaryreturn, skin color, andwarmth distal toinflammation.

Maintain elevation ofinflamed extremityunless contraindicatedby confirmedpresence of

compartmentalsyndrome.

Investigate suddensigns of limbischemia, e.g.,decreased skin

Provide basis forunderstandinggeneral, currentsituation of client.

Decreased/absent

pulse may reflectvascular injury andnecessitatesimmediate medicalevaluation ofcirculatory status.

Return of color shouldbe rapid (3-5 secs.).White, cool skinindicates arterialimpairment. Cyanosissuggests venousimpairment.

Promotes venousdrainage/decreasesedema.

Osteomyelitis maycause damage toadjacent arteries, withresulting loss of distal


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Subjective:

Ang sakit ng paa

ko. asverbalized.

Objective:

pain scale-8/10

with guradingbehaviorwith reluctance toattemptmovement;limited ROM

with reports ofpain

with distractedbehavior

Altered comfort: painrelated to inflammatory

process secondary todisease condition

At the end of the nursinginterventions, the patient

will be able toincorporate relaxationskills and diversionalactivities to reduce pain.

temperature, pallor,and increased pain.

Encourage patient toroutinely exercisedigits/joints distal toinflammation.

Investigate reports ofpain, noting locationand intensity (scale of

0-10), noteprecipitating factorsand nonverbal cues.

Maintain bed rest orchair rest whenindicated.

Place pillows onaffected area.

Encourage frequentchanges of position tomove in bed,supporting affected

joints above andbelow, avoiding jerkymovements.

Involve in diversionalactivities appropriate

for individual situation,e.g., coloring ofbooks, playing withtoys.

blood flow.

Enhances circulationand reduces poolingof blood, especially inthe lower extremities.

Helpful in determiningpain managementand effectiveness of

interventions.

Bed rest may benecessary to limitpain/injury to joints.

Rests painful andmaintains neutralposition.

Prevents generalfatigue and jointstiffness, stabilizes

joint, decreasing jointmovements andassociated pain.

Refocuses attention,provides stimulation,

and enhances self-esteem and feelingsof general well-being.


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Objective:

leukocyte: 22.2 x10^ g/L

with purulentdischarges onright foot

pus cells in urine:20-22hpf

presence oflesion on right

foot

Subjective:

May sugat poako sa paa asverbalized.

Objective:

disruption of skinsurface of thelower extremity

destruction of

skinlayers/tissues ofthe right foot

reports of pain,pressure inaffected/

Actual infection relatedto increased WBC countand presence ofpyogenicmicroorganisms in thelocal infection

Impaired skin integrityrelated to inflammatoryresponse secondary todisease condition

At the end of the nursinginterventions, the patientwill achieve timelywound healing; free ofsigns of infection.

At the end of the nursinginterventions, the patientwill demonstratebehaviors/techniques toprevent skinbreakdown/facilitatehealing as indicated.

Assess skin lesions,noting reports ofincreased pain orpresence of edema,erythema, foul odor,or drainage.

Provide sterile woundcare, and exercisemeticuloushandwashing.

Instruct patient not to

touch wound with barehands.

Monitor vital signs.Note presence ofchills, fever andmalaise.

Examine the skin foropen wounds, foreignbodies anddiscoloration.

Demonstrate goodskin hygiene, e.g.,

wash thoroughly andpat dry carefully.

Discuss importance of

Indicates localinfection/tissuenecrosis which is amajor sign ofosteomyelitis.

May prevent cross-contamination andany furthercomplications.

Minimizes opportunity

for contamination.

Tachycardia andchills/fever reflectdeveloping sepsis.

Provides informationregarding skincirculation andproblems that may becaused by edemaformation that mayrequire furthermedical intervention.

Maintaining a clean,dry skin provides a

barrier to infection.Patting skin dryinstead of rubbingreduces risk of dermaltrauma to fragile skin.

These provide patient


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surrounding area

invasion of bodystructures

with purulentdischarge on theright foot

Subjective:

Nilalamig ako.as verbalized

Objective:

T: 38.9oC

RR: 39bpm skin warm to

touch

with flushed skin

perspiringprofusely

Altered bodytemperature: increasedrelated to presence ofpyogenicmicroorganisms in thelocal circulation

At the end of the nursinginterventions, thepatients temperature willdecrease from 38.9oC to36.8oC.

adequate nutritionespecially fluids,proteins, vitamins Band C, iron andcalories.

Establish a turning orrepositioningschedule.

Emphasize principles

of asepsis especiallyhand washing andavoidance of touchingwound with barehands.

Demonstrate woundcare technique suchas wound cleansing.

Assess generalcondition of andcontributing factors topatient.

Monitor vital signsespecially

temperature. Assess fluid loss and

facilitate oral intake.

Provide tepid spongebath.

information hownutrition could elevateher chances of afaster recovery andwound healing.

This provides thepatients guidetowards a proper skinmanagementtechnique minimizingmore skin trauma.

To avoid possible

infection thushindering the woundhealing process.

To provide the patientor patients SO on thecorrect proceduresand techniques ofwound caring.

Provides basis forunderstandinggeneral, currentcondition of patient.

Notes progress andchanges of condition.

Increases inmetabolic rate anddiaphoresis.

Enhances heat lossby evaporation and


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with teary eyes

with purulentdischarge on theright foot

Subjective:

Hindi akomasyadongmakalakad. asverbalized.

Objective:

with reluctance toattemptmovement;limited ROM

with decreasedmusclestrength /control

inability to movepurposefully

within thephysicalenvironment,imposedrestrictions

Impaired physicalmobility related topain/discomfort

At the end of the nursinginterventions, the patientwill regain/maintainmobility at the highestpossible level.

Promote bed rest.

Provide coolcirculating air byopening windows orensuring that patientis not covered withthick blankets.

Assist patient inchanging into dryclothing.

Assess degree ofimmobility producedby pain.

Instruct patientin/assist withactive/passive ROMexercises of affectedand unaffectedextremities.

Encourage patient tomaintain upright anderect posture whensitting, standing, andwalking.

Discuss/provide safety

needs, e.g., raisedside rails.

conduction.

Reduces body heatproduction.

Dissipates heat byconvection.

Increases comfort.

Level ofactivity/exercisedepends onprogression/resolutionof inflammatoryprocess.

Increases blood flowto muscles and boneto improve muscletone, maintain jointmobility.

Maximizes jointfunction, maintainsmobility.

Helps preventaccidentalinjuiries/falls.


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J. DRUG STUDY

*Common adverse effects in italic, life-threatening effects underlined


31/34

DRUG ORDER(Generic name,Dosage, Route,Frequency, etc.)

SPECIFICACTION

PHARMACOLOGICACTION OF DRUG

INDICATIONS ANDCONTRAINDICATIO

NS

ADVERSEEFFECTS OF THE

DRUG

NURSINGRESPONSIBILITIES

/PRECAUTIONS

Generic Name:Cefuroxime400mg IV q8

Brand Name:Kefurox

Generic Name:Paracetamol550mg/5mL q4;for T>=38.0oC

Brand Name:Gandol

ANTIINFECTIVE;ANTIBIOTIC;SECOND-GENERATIONCEPHALOSPORIN

NON-OPIOIDANALGESIC

Preferentially bindsto one or more of thepenicillin-bindingproteins (PBP)located on cell wallsof susceptibleorganisms. Thisinhibits 3rd and finalstage of bacterialcell wall synthesis,thus killing thebacteria.

Paracetamol exhibitsanalgesic action by

peripheral blockageof pain impulsegeneration. Itproduces antipyresisby inhibiting thehypothalamic heat-regulating centre. Itsweak anti-inflammatory activityis related toinhibition ofprostaglandinsynthesis in theCNS.

Indications:It is effective for thetreatment ofpenicillinase-producing Neisseriagonorrhoea (PPNG).Effectively treatsbone and jointinfections, bronchitis,meningitis,gonorrhea, otitismedia,pharyngitis/tonsillitis,sinusitis, lowerrespiratory tractinfections, skin andsoft tissue infections,urinary tractinfections, and isused for surgical

prophylaxis, reducingor eliminatinginfection.

Contraindications:Hypersensitivity tocephalosporins andrelated antibiotics;pregnancy (categoryB), lactation.

Indications:To relieve mild tomoderate pain due tothings such asheadache, muscleand joint pain,backache and periodpains. It is also usedto bring down a hightemperature. For thisreason, paracetamolcan be given tochildren aftervaccinations toprevent post-immunisation pyrexia(high temperature).Paracetamol is oftenincluded in cough,cold and fluremedies.

Contraindications:Hypersensitivity toacetaminophen or

phenacetin; use withalcohol.

Body as a Whole:Thrombophlebitis(IV site); pain,burning, cellulitis(IM site);superinfections,positive Coombs'test.

GI:Diarrhea,nausea, antibiotic-associated colitis.

Skin: Rash,pruritus, urticaria.

Urogenital:Increased serumcreatinine and BUN,decreased

creatinineclearance.

Side effects arerare withparacetamol when itis taken at therecommendeddoses. Skin rashes,blood disorders andacute inflammationof the pancreashave occasionallyoccurred in peopletaking the drug on aregular basis for along time. One

advantage ofparacetamol overaspirin and NSAIDsis that it doesn'tirritate the stomachor causing it tobleed, potentialSide effects ofaspirin andNSAIDs.

Determinehistory ofhypersensitivityreactions tocephalosporins,penicillins, andhistory ofallergies,particularly todrugs, beforetherapy isinitiated.

Inspect IM andIV injection sitesfrequently forsigns of phlebitis.

Report onset ofloose stools ordiarrhea.Although

pseudomembranous colitis.

Monitor I&Orates and pattern:Especiallyimportant inseverely illpatients receivinghigh doses.Report anysignificantchanges.

Assessment & DrugEffects

Monitor forS&S of:hepatotoxicity,even withmoderate

acetaminophendoses, especiallyin individuals withpoor nutrition.

Patient & FamilyEducation

Do not takeother medications(e.g., coldpreparations)containingacetaminophen

without medicaladvice;overdosing andchronic use cancause liverdamage andother toxiceffects.

Do not self-medicate childrenfor pain morethan 5 d withoutconsulting aphysician.

Do not use for


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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.


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CHAPTER VIEvaluation

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, andher lesion needs to be drained first. Her operation is still pending.


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Bibliography

Radiology: Whole-body MR useful in detecting rare bone disease. Molecular Imaging. 10 September2009. 03 April 2010

Rosalyn Carson-DeWitt, MD. Osteomyelitis: Prognosis. Answers.com. 2006. 03 April 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

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Case Study of Chronic Osteomyelitis