Osteomyelitis is an infection of the bone. Bones may become prone to infection from trauma, surgery, ischemia, or bacteria from surrounding tissues.
Osteomyelitis can result from a systemic bacterial infection that extends to the bones (sepsis or bacteremia). This form typically affects a child’s long bones, such as the femur or humerus. Adult cases of osteomyelitis frequently involve the vertebral bones along the spinal column. Staphylococcus aureus is typically the cause of infection, while other bacteria or fungi may also be the source.
A neighboring infection brought on by a traumatic accident, repeated drug injections, surgery, decubitus ulcers, or the application of a prosthetic device can cause osteomyelitis. Additionally, those with diabetes are more likely to develop ulcers in the lower extremities from impaired blood supply promoting infection. In these circumstances, the microorganism has a direct portal of entry into the compromised bone.
Osteomyelitis is more likely to occur in people with compromised immune systems. Patients with sickle cell disease or HIV or those taking immunosuppressive agents like chemotherapy or steroids are at higher risk.
Depending on the cause of the infection, osteomyelitis may be acute or chronic.
Signs and symptoms of osteomyelitis include:
- Pain in the infected area
- Fever
- Irritability
- Fatigue
- Lethargy
- Purulent drainage
- Swelling and inflammation to the infected area
- Warmth and tenderness to the infected area
- Decreased range of motion to the affected area
Osteomyelitis can be diagnosed through blood work, imaging and bone scans, and biopsies.
Delayed or inadequate treatment may lead to worsening infection and necrosis. Loss of limbs may occur in severe cases.
The Nursing Process
Collaboration across different medical and surgical disciplines is necessary for osteomyelitis treatment to be effective. The two essential therapy components are surgery and extended antibiotics.
As antibiotics only partially penetrate infected fluid collections like abscesses and injured or necrotic bone, surgical debridement of all diseased bone is frequently necessary. As a result, necrotic tissue and bone removal may be required.
The nurse will administer and teach the patient about antibiotic therapy. If surgical debridement is not an option, due to the location of the infection (such as pelvic osteomyelitis), antibiotics for an extended period will be prescribed.
Patients must be educated about the prolonged nature of therapy and the importance of compliance with the treatment guidelines. This helps with sufficient wound healing and lowers the risk of recurrence.
Nursing Care Plans Related to Osteomyelitis
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
Ineffective Tissue Perfusion 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.
Ineffective Tissue Perfusion 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.
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
Hyperthermia 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.
Hyperthermia 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.
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
Acute Pain 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.
Acute Pain Intervention
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.
References and Sources
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Johns Hopkins Medicine. (2021). Osteomyelitis. Johns Hopkins Medicine, based in Baltimore, Maryland. https://www.hopkinsmedicine.org/health/conditions-and-diseases/osteomyelitis
- 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.
