Nursing Care Plan on Osteomyelitis

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.

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 Assessment

Effective nursing assessment and intervention are crucial in diagnosing, treating, and preventing complications associated with osteomyelitis.

Initial Evaluation

The initial evaluation of a patient with suspected osteomyelitis involves a comprehensive assessment that includes medical history, physical examination, and diagnostic testing.

Medical History

Review the patient’s medical history to identify risk factors and potential sources of infection. Key aspects include:

• Recent surgeries, especially orthopedic procedures
• Open fractures or injuries
• Presence of chronic conditions such as diabetes, which can impair wound healing
• History of intravenous drug use
• Previous infections and antibiotic treatments

Physical Examination

Conduct a thorough physical examination focusing on signs and symptoms indicative of osteomyelitis:

• Localized pain and tenderness in the affected area
• Swelling, redness, and warmth over the infected bone
• Restricted movement and functional impairment
• Fever and signs of systemic infection
• Pus or drainage from wounds or surgical sites

Diagnostic Tests

Obtain baseline laboratory and imaging tests to confirm the diagnosis and assess the extent of the infection:

• Blood Tests: Elevated white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels indicate infection and inflammation.
• Blood Cultures: Identify the causative organisms to guide antibiotic therapy.
• Imaging Studies: X-rays, MRI, or CT scans can reveal bone abnormalities, including lytic lesions and areas of necrosis.
• Bone Biopsy: Confirm the presence of infection through histological examination and culture of bone tissue.

Nursing Interventions

In effective management of osteomyelitis, by administering appropriate treatments, and offering continuous support, nurses play a pivotal role in improving health outcomes and quality of life for patients.

Antibiotic Therapy

Administering appropriate antibiotics is the cornerstone of osteomyelitis treatment. Nurses play a critical role in ensuring the timely initiation and adherence to antibiotic regimens:

• Collaborate with the healthcare team to select the appropriate antibiotics based on culture and sensitivity results.
• Monitor the patient for therapeutic response and potential adverse reactions to antibiotics.
• Educate the patient and caregivers on the importance of completing the full course of antibiotics.

Pain Management

Effective pain management is essential for patient comfort and recovery:

• Assess the patient’s pain levels regularly using standardized pain scales.
• Administer analgesics as prescribed and evaluate their effectiveness.
• Implement non-pharmacological pain relief methods such as ice application, elevation, and relaxation techniques.

Surgical Intervention

In cases where antibiotic therapy alone is insufficient, surgical intervention may be necessary:

• Prepare the patient for surgical debridement or removal of necrotic bone tissue.
• Provide postoperative care, including wound management and monitoring for signs of infection.
• Educate the patient on postoperative care and the importance of follow-up appointments.

Wound Care

Proper wound care is vital to prevent secondary infections and promote healing:

• Monitor surgical sites and open wounds for signs of infection or complications.
• Perform wound cleaning and dressing changes as prescribed.
• Educate the patient and caregivers on home wound care techniques.

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 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.

Nursing Diagnoses and Rationales for Osteomyelitis

1. Acute Pain

Rationale: Osteomyelitis, an infection of the bone, often results in significant pain due to inflammation, pressure from pus accumulation, and bone destruction. Pain management is crucial for patient comfort and recovery. Nurses should assess the intensity, location, and characteristics of the pain regularly. Providing appropriate pain relief measures, such as analgesics, heat or cold therapy, and positioning, can help alleviate discomfort and improve the patient’s ability to engage in necessary activities and treatments.

2. Impaired Physical Mobility

Rationale: Pain, inflammation, and structural damage caused by osteomyelitis can limit the patient’s movement and physical function. This limitation can further exacerbate muscle weakness and joint stiffness. Nurses should assess the patient’s mobility and functional status, and collaborate with physical therapists to develop a tailored exercise program that includes range of motion exercises and strengthening activities to maintain and improve mobility, prevent complications, and enhance the patient’s overall quality of life.

3. Risk for Infection

Rationale: Osteomyelitis involves an active infection within the bone, which can spread to surrounding tissues or other parts of the body if not properly managed. Strict adherence to infection control practices is essential to prevent the spread of infection. Nurses should monitor for signs and symptoms of systemic infection, such as fever, chills, and increased white blood cell count. Administering prescribed antibiotics and ensuring proper wound care and hygiene are critical interventions to contain the infection and promote healing.

4. Impaired Skin Integrity

Rationale: Surgical interventions, such as debridement or the insertion of drainage tubes, are often necessary in the treatment of osteomyelitis. These procedures, along with prolonged immobility and the presence of infection, increase the risk of impaired skin integrity. Nurses should regularly assess the condition of the skin, particularly around surgical sites and pressure points. Implementing preventive measures, such as repositioning, use of pressure-relieving devices, and meticulous wound care, can help maintain skin integrity and promote recovery.

5. Knowledge Deficit

Rationale: Patients and their families may have limited understanding of osteomyelitis, its causes, treatment options, and the importance of adherence to the prescribed medical regimen. Education is a key component of nursing care. Nurses should provide comprehensive information about the disease process, the importance of completing antibiotic therapy, wound care techniques, signs of potential complications, and lifestyle modifications to support recovery. Empowering patients with knowledge enhances their ability to manage their condition effectively.

6. Risk for Ineffective Peripheral Tissue Perfusion

Rationale: Osteomyelitis can lead to compromised blood flow to the affected area, increasing the risk of ischemia and delayed healing. Nurses should assess peripheral circulation regularly, including skin temperature, color, capillary refill, and pulses. Interventions such as elevating the affected limb, avoiding constrictive clothing, and collaborating with healthcare providers for possible vascular assessments or interventions can help improve tissue perfusion and promote healing.

7. Disturbed Body Image

Rationale: The presence of infection, surgical scars, and potential deformities resulting from osteomyelitis can impact a patient’s body image and self-esteem. Nurses should provide emotional support and encourage open communication about the patient’s feelings and concerns. Referring patients to counseling services or support groups can offer additional resources to help them cope with changes in their appearance and body function.

8. Altered Nutrition: Less Than Body Requirements

Rationale: The metabolic demands of infection, coupled with decreased appetite and potential difficulties in obtaining or preparing food, can result in inadequate nutrition. Nurses should assess the patient’s nutritional status and collaborate with dietitians to develop individualized meal plans that meet the patient’s dietary needs. Providing high-protein, high-calorie foods, and ensuring an adequate intake of vitamins and minerals can support the healing process and overall health.

9. Social Isolation

Rationale: Prolonged treatment, hospitalization, and physical limitations due to osteomyelitis can result in decreased social interactions and feelings of isolation. Nurses should encourage patients to maintain connections with family and friends through visits, phone calls, or virtual communication. Facilitating participation in social activities, when appropriate, and promoting involvement in support groups can help patients stay engaged and maintain a sense of community.

10. Anxiety

Rationale: The chronic nature of osteomyelitis, coupled with the fear of potential complications and the uncertainty of treatment outcomes, can lead to significant anxiety. Nurses should assess the patient’s anxiety levels and provide reassurance through clear communication about the treatment plan and expected outcomes. Techniques such as relaxation exercises, guided imagery, and referral to mental health professionals can help patients manage their anxiety and improve their overall well-being.

REFERENCES

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