Osteomyelitis is an infection of the bone. Though healthy bones are typically resistant to infection, bacteria may enter susceptible bones through the bloodstream, directly from fractures or surgical procedures, and from infected surrounding tissues.
Osteomyelitis may be acute or chronic. Acute osteomyelitis is most common and very serious due to its systemic nature. Chronic osteomyelitis is a long-term recurring infection despite treatment.
Prompt and proper treatment is vital to avoid complications like sepsis, growth disturbances (in children), and bone necrosis that may cause permanent damage requiring amputation.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Hyperthermia
- Ineffective Protection
- Ineffective Tissue Perfusion
- Risk for Infection
Nursing Process
Collaboration across different medical and surgical disciplines is necessary for osteomyelitis treatment to be effective.
Antibiotics only partially penetrate infected bone, so surgical debridement or removal of diseased bone is frequently indicated first.
The nurse will administer and teach the patient about antibiotic therapy and prepare the patient for surgical interventions.
Patients must be educated about the prolonged nature of therapy and the importance of adherence to treatment guidelines to aid healing and lower the risk of recurrence.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to osteomyelitis.
Review of Health History
1. Note the patient’s general symptoms.
Signs and symptoms of osteomyelitis include:
- Pain
- Fever
- Chills
- Irritability
- Fatigue
- Lethargy
- Drainage, swelling, and warmth in the affected area
- Decreased range of motion to the affected area
2. Determine the possible cause of bone infection.
Staphylococcus aureus is the most common bacteria that causes osteomyelitis due to characteristics that allow it to adhere to bone. Pathogens are able to infect bone through the bloodstream or secondary to trauma, such as a penetrating accident or surgery.
3. Assess the patient’s risk factors.
The following risk factors increase the incidence of osteomyelitis:
- <20 or >50 years of age
- Open wounds
- Recent joint replacement surgery
- Fracture repair with implanted rods, pins, or screws
- Puncture injuries (IV drug injection)
- Pressure injuries
4. Review the patient’s medical history.
Osteomyelitis is more likely to occur in people who are immunocompromised, such as those with HIV/AIDS or patients receiving chemotherapy. Chronic conditions like diabetes or peripheral vascular disease increase the risk of ulcers in the lower extremities that may become infected, leading to osteomyelitis.
5. Note the onset of symptoms.
Acute osteomyelitis often appears within two weeks or less. Meanwhile, chronic osteomyelitis may develop six weeks or later after the initial bone infection.
Physical Assessment
1. Assess for signs of infection.
The patient may display nonspecific signs of infection, like fever and chills. The nurse should assess for localized signs of inflammation, such as pain, swelling, and erythema. In chronic posttraumatic osteomyelitis (osteomyelitis after trauma or surgery), signs of inflammation may be present, along with impaired mobility and limb function.
2. Monitor wound healing.
Closely monitor wounds or incisions for signs of infection, excessive scarring, and poor healing/closure.
3. Assess the musculoskeletal status.
Evaluate the patient’s range of motion, any limitations in movement, or pain with mobility.
4. Consider alterations in children.
Symptoms in children are variable, but may also include decreased movement, pain, swelling, and redness in the affected limb. Newborns with osteomyelitis may not have any symptoms other than decreased limb movement.
Diagnostic Procedures
1. Obtain specimens for laboratory tests.
The following laboratory tests can help diagnose osteomyelitis:
- Complete blood count (CBC)
- Leukocyte count (rarely exceeding 15,000/µL)
- Inflammatory markers
- Erythrocyte Sedimentation Rate (ESR)
- C-reactive protein (CRP)
- Blood cultures (positive in half of patients)
2. Prepare the patient for imaging.
To help confirm the diagnosis of osteomyelitis, anticipate an order for the following imaging tests:
- Plain radiograph (X-ray)
- Computed tomography (CT) (to guide needle biopsies)
- Magnetic resonance imaging (MRI) (highest sensitivity and specificity)
- Ultrasonography
- Nuclear medicine imaging (bone scan)
3. Administer a probe-to-bone test.
If the nurse is able to touch bone through an ulcer using a blunt sterile instrument, this is considered highly diagnostic for osteomyelitis.
4. Consider biopsy.
Open or percutaneous needle bone biopsy offers a definitive diagnosis of osteomyelitis and identifies the pathogen to guide effective antibiotic treatment.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient suffering from osteomyelitis.
1. Assist with surgical debridement.
Surgical debridement is necessary in many cases of osteomyelitis to remove necrotic bone or drain abscesses and allow antibiotics to penetrate the area more effectively.
2. Assist with antibiotic therapy.
Antibiotics are the cornerstone of treating osteomyelitis. Broad-spectrum antibiotics may be initiated until the pathogen is identified and targeted antibiotic therapy can begin. Educate patients that antibiotic therapy may last for weeks or even months in chronic cases to eradicate the infection. Many patients can continue IV therapy at home. Ensure the patient has a support system to maintain a commitment to completing treatment.
3. Prepare for additional surgical procedures.
Severe cases of osteomyelitis may require further surgical interventions. The nurse may assist with the pre-op or post-op care of the patient after surgical procedures such as:
- Removal of infected hardware
- Filling dead space after debridement with vascularized tissue
- Bone grafts to reconstruct damaged bones
- Amputation
4. Ensure the proper care of central or peripheral lines.
Long-term IV antibiotic therapy may require a central venous catheter (CVC) or a peripherally inserted central venous catheter (PICC). To prevent complications, maintain aseptic technique when accessing these lines and sterile technique during dressing changes.
5. Assist with negative pressure wound therapy.
Vacuum-assisted closure, also known as a wound vac, can help with the wound healing process by removing exudate, increasing blood flow, and encouraging wound closure to promote healing.
6. Maintain tight glycemic control.
The infection caused by osteomyelitis can lead to hyperglycemia and glucose fluctuations in patients with diabetes, which worsens the infection and inflammation. Ensure the patient’s glucose levels remain within a tight range to prevent complications in healing.
7. Coordinate wound care.
Osteomyelitis will require meticulous wound care. Coordinate home health visits or appointments at an outpatient clinic to provide ongoing wound assessment and care.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for osteomyelitis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for osteomyelitis.
Acute Pain
Acute pain associated with osteomyelitis can be caused by inflammation and tissue necrosis.
Nursing Diagnosis: Acute Pain
Related to:
- Inflammation
- Tissue necrosis
As evidenced by:
- Verbalization of pain
- Tenderness with palpation
- Guarding behaviors
- Facial grimacing
- Increased vital signs
Expected outcomes:
- Patient will be able to verbalize relief from pain.
- Patient will verbalize a decrease in pain scale from pain relief measures.
- Patient will demonstrate adequate rest and comfort as evidenced by vital signs within expected limits.
Assessment:
1. Assess the pain scale of the patient.
The pain scale is a measurable element that the nurse can use to better understand the severity of pain.
2. Determine the pain characteristics.
Pain in osteomyelitis is localized pain and tenderness of the affected area.
3. Assess for nonverbal signs of pain.
Nonverbal signs of pain include guarding the affected site, facial grimacing, self-focus, and changes in vital signs.
Interventions:
1. Reposition as needed.
Repositioning and turning can decrease the stimulation of the pain and pressure receptors.
2. Administer pain medication as prescribed.
Mild or moderate pain may be controlled with non-steroidal anti-inflammatory drugs (NSAIDs). More severe pain or pain related to debridement or surgical intervention may require oral or IV opioid medications.
3. Elevate or immobilize the site.
Elevation or splinting of an extremity may improve pain by increasing circulation.
4. Collaborate with physical and occupational therapists.
Physical and occupational therapists assist in pain management through exercise, stretching, and other techniques.
5. Anticipate referral to a pain specialist.
Osteomyelitis and its treatment can be very painful and prolonged. Acute pain can turn into chronic pain depending on the severity and pain tolerance of the patient, which may need a referral to a pain specialist.
Hyperthermia
Hyperthermia associated with osteomyelitis can be caused by increased metabolic rate and infection.
Nursing Diagnosis: Hyperthermia
Related to:
- Increased metabolic rate
- Infection
- Inflammatory response
- Trauma
As evidenced by:
- Increased body temperature
- Warmth to touch
- Flushed skin
- Tachypnea
- Tachycardia
Expected outcomes:
- Patient will demonstrate core body temperature within normal limits.
- Patient will demonstrate blood pressure, heart rate, and respiratory rate within normal limits.
Assessment:
1. Monitor the patient’s body temperature.
When osteomyelitis worsens causing sepsis, fever may be very high.
2. Obtain culture and sensitivity.
Wound and blood cultures should be obtained prior to antibiotic therapy. However, it is permissible to begin empiric antibiotics while awaiting C&S results.
3. Assess for other signs of infection.
Monitor for symptoms of pain, redness, and warmth in the area. A bone can become infected by an infection that has spread from adjacent tissue or through the bloodstream.
Interventions:
1. Provide a tepid sponge bath.
Tepid sponge baths lower body temperature and provide comfort to the patient.
2. Apply a cooling blanket.
A cooling blanket can lower the internal body temperature by surface cooling. Monitor closely to prevent a rapid drop in body temp.
3. Initiate antibiotics.
Long-term antibiotics are required for the treatment of osteomyelitis to control the infectious process. Instruct patients that antibiotic therapy may be required for weeks.
4. Instruct on symptoms.
Teach the patient and family that if fever, chills, warmth to the skin, or skin flushing is observed that the body is attempting to fight off infection and to seek immediate assistance.
Ineffective Protection
The bones are typically well-protected from infection, but some patients may be at an increased risk for osteomyelitis.
Nursing Diagnosis: Ineffective Protection
Related to:
- Immunosuppression
- Difficulty managing complex treatment regimen
- Ineffective health self-management
- Chronic infection
As evidenced by:
- Impaired tissue healing
- Pressure injury
- Leukopenia
- Immobility
Expected outcomes:
- Patient will verbalize how to manage their treatment regimen.
- Patient will demonstrate precautions to prevent further spread of infection.
Assessment:
1. Note factors that contribute to the patient’s increased risk for inadequate protection.
Various medical conditions can increase the risk for osteomyelitis, such as patients with a weakened immune system from HIV or cancer. Patients who recently underwent orthopedic surgery or experienced a fracture with or without repair are more susceptible to osteomyelitis.
2. Monitor for signs of infection.
Osteomyelitis may present with a fever, chills, or signs of infection at the surgical site or wound, including redness, swelling, or warmth.
Interventions:
1. Instruct on antibiotic adherence.
Antibiotic therapy is crucial to eradicate the infection in the bones. Ensure the patient understands the importance of adhering to the antibiotic regimen, which may take up to six weeks or longer to treat osteomyelitis.
2. Utilize aseptic technique when accessing central lines.
IV antibiotics are commonly used to treat osteomyelitis, and a central line may be indicated due to lengthy treatment regimens. Strict aseptic technique is necessary to prevent introducing bacteria into the bloodstream and causing further complications.
3. Monitor for signs of sepsis.
The nurse should closely monitor for complications of osteomyelitis, such as sepsis, which may cause fever, hypotension, and a change in mental status.
4. Encourage a nutrient-rich diet.
A diet high in protein to aid in tissue repair, antioxidant-rich fruits and vegetables, and plenty of water to maintain hydration is beneficial in patients with osteomyelitis to boost their immune system to help fight the infection.
Ineffective Tissue Perfusion
Ineffective tissue perfusion associated with osteomyelitis can be caused by swelling of the vessels, thrombosis, tissue destruction, edema, and abscess formation.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Inflammatory reaction
- Thrombosis of vessels
- Tissue destruction
- Edema
- Abscess formation
As evidenced by:
- Bone necrosis
- Continuation of the infectious process
- Delayed healing
- Pain
- Erythema
- Swelling
- Altered sensation in the affected area
- Weak peripheral pulses
Expected outcomes:
- Patient will demonstrate improved perfusion as evidenced by decreased pain, erythema, and swelling.
- Patient will demonstrate no signs of infection, such as fever and abscess formation.
Assessment:
1. Identify the causative factors.
Bone becomes vulnerable to infection with the presence of bacteria through trauma, ischemia, or the presence of foreign bodies. Assess for recent surgical procedures, fractures, or open wounds.
2. Assess the extent of infection.
Imaging scans like MRI or CT scans can be used before surgery to determine the severity of the infection in the affected area.
3. Assess the circulatory status.
Assess the circulation in the affected area by checking for the presence of swelling, redness, warmth, pain, and peripheral pulses.
4. Assess the healing status.
Heat, redness, swelling, and discomfort are the classic signs of an infection. It is crucial to determine if increases in pain, heat, edema, and erythema are associated with the inflammatory phase of wound healing or infection.
Interventions:
1. Establish blood flow at the site.
Blood circulation distributes nutrients throughout the body, aids in controlling waste production, enhances site recovery, and speeds up the healing process. Healthy blood flow across vessels, arteries, veins, and capillaries maximizes perfusion.
2. Manage chronic conditions and lifestyle factors.
Diabetes, peripheral vascular disease, sickle cell disease, neuropathy, smoking, malnutrition, and more affect the revascularization of the affected area. These need to be addressed before surgical intervention.
3. Provide DVT prophylaxis.
Anticoagulants should be administered as ordered to promote circulation and prevent the development of blood clots.
4. Prepare for possible surgery.
Depending on the degree of vascular insufficiency, procedures to restore adequate blood flow, such as debridement or vascular surgery may be necessary.
5. Prevention through pressure ulcer prophylaxis.
Patients who are immobile or bed-bound are at an increased risk of experiencing osteomyelitis due to pressure ulcers. By implementing appropriate interventions such as turning schedules and skin care, this can be prevented.
Risk for Infection
Open wounds, penetrating trauma from an accident or surgery, or a bloodstream infection increase the risk of infection in susceptible bones.
Nursing Diagnosis: Risk for Infection
Related to:
- Recent orthopedic surgery
- Pressure ulcer/wound
- Fracture
- Compromised immune system
- IV drug use
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will display a resolution of signs and symptoms of infection.
- Patient will adhere to the prescribed antibiotic regimen.
Assessment:
1. Assess for underlying medical conditions.
Review the patient’s medical history for conditions that cause immunosuppression or complicate wound healing, such as diabetes mellitus.
2. Assess for symptoms of systemic or localized infection.
Osteomyelitis may cause pain, redness, and warmth in the affected area. Patients may also experience systemic symptoms such as fever and chills.
3. Assess results of diagnostic tests.
The WBC count and erythrocyte sedimentation rate may increase with osteomyelitis. A bone biopsy can help determine the causative agent of the patient’s bone infection.
Interventions:
1. Assist in the debridement of diseased bone.
Surgical removal of abscesses and necrotic bone is often necessary to prevent further spread of the infection to other bones, tissues, and the bloodstream. Debridement also allows for better antibiotic absorption.
2. Administer antibiotic therapy as indicated.
Aggressive and prolonged antibiotic therapy is essential for patients with osteomyelitis.
3. Instruct on and demonstrate proper hand hygiene.
The nurse must adhere to strict handwashing guidelines when administering IV medications or providing wound care to a patient with osteomyelitis. Educate the patient and family members on correct handwashing techniques.
4. Provide wound care.
The patient with osteomyelitis will require monitoring of their surgical site or wound for healing or complications. Advise the patient on receiving wound care services either at home or at a wound care clinic.
References
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Gandhi, J. (2022, July 11). Osteomyelitis workup: Laboratory studies, imaging studies, biopsy. Diseases & Conditions – Medscape Reference. Retrieved March 2024, from https://emedicine.medscape.com/article/1348767-workup#showall
- Johns Hopkins Medicine. (2021). Osteomyelitis. Johns Hopkins Medicine, based in Baltimore, Maryland. https://www.hopkinsmedicine.org/health/conditions-and-diseases/osteomyelitis
- Momodu, I. I., & Savaliya, V. (2023, May 31). Osteomyelitis – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved March 2024, from https://www.ncbi.nlm.nih.gov/books/NBK532250/
- National Center for Biotechnology Information. (2022). Osteomyelitis (Nursing) – StatPearls – NCBI bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK568766/
- Silvestri, L. A., & Silvestri, A. E. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
- Osteomyelitis – Diagnosis and treatment – Mayo Clinic. (2022, November 8). Top-ranked Hospital in the Nation – Mayo Clinic. Retrieved March 2024, from https://www.mayoclinic.org/diseases-conditions/osteomyelitis/diagnosis-treatment/drc-20375917
- Osteomyelitis (Bone infection): Causes, symptoms & treatment. (2021, December 1). Cleveland Clinic. Retrieved March 2024, from https://my.clevelandclinic.org/health/diseases/9495-osteomyelitis
- Osteomyelitis. (2021, August 8). Johns Hopkins Medicine, based in Baltimore, Maryland. Retrieved March 2024, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/osteomyelitis
