infective bone disease

NUR2163

Infective Bone Disease
Osteomyelitis

 OM is an infection of the bone,
bone marrow and surrounding soft
tissue cause by pyogenic bacteria
such as staphylococcus aureus,
pneumococci, salmonella, E. Coli,
pseudomonas, Klebseilla, proteus
and clostridium – gas gangrene.

 Direct contamination of bone from an
open wound such as an open fracture,
gunshot or puncture wound.

 Bacteria can invade bone tissue from
the adjacent soft tissue infection e.g.
client with venous stasis or arterial
ulcers of lower extremities (peripheral
vascular disease) or long term
complications of diabetes mellitus.

 After entry, bacteria lodge in the bone
which then stimulate an inflammatory
and immune system response.

 Phagocytosis takes place releasing
enzymes that destroy the bone tissue

 Pus forms followed by edema and
vascular congestion

 Infection travels to other segments of
the bones and reach the outer margins
of the bone which raises the
periosteum.

 Lifting of the periosteum from the
bone cortex, distrups the blood
vessels supplying the bone.





Adult over age 50 at high risk
because:

1. Low immune system.
2. Associated with chronic diseases.
3. Blood circulation compromise
4. Changes in skin, sensation and

morbidity.
5. Not demonstrate typical signs of

infection.

 Limping over the involved extremity
 Localized tenderness epiphyseal

region
 Discharge and ulceration
 Swelling, erythema and warm
 Enlargement of lymph nodes
 High fever with chills
 Abrupt onset of pain
 Tachycardia
 Nausea and vomiting
 Anorexia and malaise

 Blood test - ESR & WBC elevated (acute)
 Blood C & S and tissue biopsy to identify

type of organism
 Ultrasound to detect sub periosteal fluid

collections , abscess, periosteal thickening
 Bone scan to determine if the infection is

active and changes to the bone occurs
 CT Scan to detect sequestra, sinus tract

and soft tissue abscess
 MRI to detect epidural abscesess

 Antibiotic therapy: 4 – 6 weeks
Oral ciproflxacin
IV cloxacillin
Local: gentamycin or vancomycin

beads
 Surgical debridement (chronic OM)
 Wound irrigation
 Skin graft
 Amputation if antibiotic therapy

failed in chronic OM

• Lengthy hospitalization
• Frequent hospitalization
• Prognosis uncertain
• Functional deficit
• Ongoing expenses
• Loss of financial support
• Role changes in the family
• Option of amputation

1. Monitor temperature every 4 hour to
identify level of infection.

2. Maintain strict hand washing practice
to help prevent spread of infection.

3. Administer the antibiotic such
infusion cloxacillin 1 gm QID to treat
the infection.

4. Assist in blood level of antibiotic such
cloxacillin level to evaluate the
antibiotic level in blood.

5. Encourage patient to:

 Drinks 2 – 3 liter of water.

 Eat well balance diet with optimal
dietary kcal and protein intake.

 Sufficient nutrition support during
inflammatory process.

6. Maintain body hygiene to enhanced
healing process of the wound.

7. Assist in blood culture procedure to
indicate inadequate antimicrobial
management.

8. Follow guideline of wound
management:

 Wear glove touching wound or non
intact skin.

 Wash hand thoroughly before and
after removing glove.

 Remove or change dressing when it
become wet.

 Cleanse wound prior to assessment .

 Measure wound size, and depth.

 Evaluate wound edges.

 To prevent transmitting and
controlling the pathogen.

1. Asses the level of pain:
◦ Intensity.
◦ Location.
◦ Onset.
◦ Duration.
◦ Quality – burning, itching,
stabbing.
◦ Aggravating and alleviating factors.

2. Observe the dressing such very tight
bandage and position of leg.

3. Observe the neurovascular assessment
every hour to identify early signs of
vascular and nerve complication.

4. Administer the analgesic as
prescribed to reduce pain.

5. Observe the good effect and side
effect of analgesia to identify the
dose of opiates required.

6. Use a splint or immobilizer to support and
reduce the pain.

7. Elevate the limb using the pillow or as
prescribe to encourage the venous return
to the heart.

8. Avoid excessive manipulation such handle
the area gently may help to reduce the
pain.

9. Explain the nature of pain following bone
or soft tissue injury.

Rationale information help to overcome
some misconception patient about their
pain.

1. Discuss the following topic:
◦ Importance of hand washing after
toileting or touching the dressing.
◦ Taking all the antibiotic as prescribe.
◦ Avoid taking yogurt which consist live
bacteria to avoid yeast infection
related to prolong antibiotic therapy.
◦ Take analgesia to reduce the pain
and becoming severe.

2. Provide information relate to

 Side effect of analgesia such as
constipation.

 Where to do the dressing.

 Maintaining good nutrition with adequate
supply of protein and kilocalories.

 Complication of prolong immobilization.

3. Rest and limited weight bearing for the
affected extremities.

4. Encourage the patient to do active ROM to
unaffected extremities.

1. Provide information regarding the disease
process and diagnostic test to help the
patient to understand the management of
the disease.

2. Inform the patient to maximize the
treatment phase by active participation.

3. Involve the multidisciplinary team to create a
positive and participate in their care.

4. Provide information related to disease
process, and treatment leading to increase
compliance.

5. Promote positive outlook and help the
patient to make plan for the future due to
potentially for long term disability.

6. Appropriate professional support such
employer can reduce the anxiety and enable
the patient to regain a sense of control over
the situation.





 Arthroplasty is a reconstruction joint surgery,
the incision makes at the joint, then resection
or removal of articular surface of both bones
at the joint. The bones are reshaped to allow
free motion and ligament attachments are
preserved and than the implant made from
metal and polyethylene replace at the
resection site.

1. Osteoarthritis (OA)
2. Rheumatoid arthritis
3. Avascular necrosis
4. Hip fracture
5. Bone tumors
6. Paget’s disease
7. Ankylosing spondylitis
8. Juvenile rhematoid arthritis

1. When the hip joint hurts seriously and the
pain radiates from primary (sources) to
the inner thigh.

2. When the ability to perform activity of
daily living has lost and cannot walk
normally.

3. When the pain cannot be effectively
relieve by medication or rehabilitation.

4. When the X-ray finding is abnormal /
some changes at the hip joint.

 Total Hip Replacement: Both the ball and the
socket are replaced with a metallic or plastic
cup (with or without screws), while the ball is
replaced with a ball attached to a long stem.
The stem is fixed into the upper thigh bone
(femur) with either a porous bone ingrowth
surface, or, with cement. The movement of
the hip occurs as the head or ball rotates on
the surface of the cup.











1. Teach or provide skin preparation such
as shower with shampoo or antibacterial
solution before operation to reduce
transient bacteria that may introduce into
the surgical site.

2. Assist in routine investigation such

 FBC
 Nasal swab
 Swab skin
 Throat swab
 Urine FEME

3. Refer to dentist for dental assessment
before operation to identify source of
infection such as dental carries.

4. Administered antibiotic IV zinacef 1.5 gm
(as ordered) before surgery and continue
post operatively to reduce risk of
infection.

5. Monitor temperature, pulse and
respiration 4 – 6 hourly post operatively
to identify early signs of infection.

6. Observe the wound for any redness,
warm, pain and discharges to identify
early signs of infection.

7. Observed for any bleeding from the
wound post operatively to minimize risk
of wound infection.

8. Perform dressing prn:

 practice aseptic technique

 apply opsite dressing
 STO or CTO day 14 POD.

1. Assess level of pain including quality,
intensity, location, aggravating and
relieving factors. Rationale: Accurate
assessment of pain provides a basis
evaluation of intervention.

2. Check vital sign including blood prrssure,
pulse and respiration hourly.

Rationale: Signs and symptoms of pain
include tachycardia, increase respiration,
elevated blood pressure reading.

3. Perform neurovascular assessment on the
affected limb hourly to identify disruption
of blood and nerve supply that lead to
pain.

4. Give analgesia as ordered to reduce pain.

5. Observe incision wound to identify excessive
bleeding which lead to pain.

6. Encourage client to do diversion therapy to
divert the feeling of pain such as reading,
hearing to music.

1. Perform neurovascular assessment on the
affected limb hourly to identify disrupt of
blood supply due to dislocation.

2. Maintain abduction pillow in between the
leg for THR to prevent internal hip
rotation and dislocation.

3. Administer analgesia to promote rest and
reduce the muscle spasm.

4. Encourage client to do full ROM with
limited degree to promote proper joint
movement and support.

5. Assess signs of prosthesis dislocation
such pain, shortening of limb or rotation
of limb.



6. Emphasize health education to prevent
internal hip rotation:

 Do not cross legs
 Do not bend legs up beyond 90 degrees
 Do not sleep on operated side
 Do not turn toes in (pigeon-toed)
 Do not sit in low chairs or sofas including

a low toilet seat

 Do not lean towards non-operated side
 Do not sit in a bath tub
 Do not mop the floor
 Do not walk on an uneven road.
 May drive a car after six months of surgery.
 Sit with the legs stretch out and support

level of seat when driving.

7. Come to hospital as soon as possible when
any of the following occurs:

 The wound is red, swelling, hot, painful
and secreting fluid or blood.

 The leg or foot is swelling or hurts.
 Had or hear a loud noise or cracking

displacement sound on the hip joint
 Notice other symptoms such as deformity

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