Osteomyelitis is the medical term for an infection in a bone.

Infections can reach a bone by traveling through

your bloodstream or spreading from nearby tissue. Infections can also begin in the bone itself if trauma
exposes your bone to germs. Bone infections commonly affect the long bones of your body, such as your leg
bones and upper arm bone, as well as your spine and pelvis.

Osteomyelitis often occurs in children as an acute condition. In adults, osteomyelitis may occur as either the
acute and chronic form.

Once considered incurable, osteomyelitis can be successfully treated today. Still, osteomyelitis is a serious
condition, requiring aggressive treatment to prevent spread of your infection and to save the affected bone.

Etiology

Osteomyelitis is caused by

• Contiguous spread (from infected tissue or an infected prosthetic joint)

• Bloodborne organisms (hematogenous osteomyelitis)
• Open wounds (from contaminated open fractures or bone surgery)

Age group Most common organisms

S. aureus, Enterobacter species, and group A and B Streptococcus

Newborns (younger than 4 mo)
species

S. aureus, group A Streptococcus species, Haemophilus influenzae, and

Children (aged 4 mo to 4 y)
Enterobacter species

Children, adolescents (aged 4 y S. aureus (80%), group A Streptococcus species, H. influenzae, and
to adult) Enterobacter species

Adult S. aureus and occasionally Enterobacter or Streptococcus species

Diagnosis
• ESR or C-reactive protein
• X-rays, MRI, or radioisotopic bone scanning
• Culture of bone, abscess, or both
Symptoms and Signs

Signs and symptoms of osteomyelitis depend on whether the condition is acute, lasting several months or less,
or chronic, lasting several months to years.

Signs and symptoms of acute osteomyelitis include:

• Fever that may be abrupt

• Irritability or lethargy in young children
• Pain in the area of the infection
• Swelling, warmth and redness over the area of the infection

Signs and symptoms of chronic osteomyelitis include:

• Warmth, swelling and redness over the area of the infection

• Pain or tenderness in the affected area
• Chronic fatigue
• Drainage from an open wound near the area of the infection
• Fever, sometimes

Sometimes osteomyelitis causes no signs and symptoms or has signs and symptoms that are difficult to
distinguish from other problems. For instance, osteomyelitis of the hip, spine or pelvis may have few signs and
symptoms. Osteomyelitis that occurs after a broken bone (fracture) or deep wound may cause pain and swelling
that you may attribute to your injury, not an infection.
Risk factors

• An increased risk of infections. Certain situations allow germs more opportunities to access your
body, putting you at an increased risk of infection, which can lead to osteomyelitis. Examples include
people who illegally inject drugs, people on dialysis, people who use urinary catheters and people who
have had tubes placed in their bodies to give doctors easier access to major veins (central lines).
• Poor circulation. People with poor circulation include those with diabetes, peripheral arterial disease
and sickle cell disease. When the arteries are damaged or blocked, your body has difficulty
distributing the infection-fighting cells needed to keep a small infection from growing larger.
• A recent injury. A broken bone that breaks the skin or a deep puncture wound exposes your body to
germs that can cause infection and increase your risk of osteomyelitis. Carefully follow your doctor's
instructions on taking antibiotics and taking precautions to prevent infection.
• Orthopedic surgery. Surgery to repair broken bones or replace worn joints puts you at risk of
infection. Follow your surgeon's instructions to help avoid infection after your surgery.

Treatments and drugs

Surgery
Drain the infected area. Opening up the area around your infected bone allows your surgeon to drain any pus
or fluid that has accumulated in response to the infection.

• Remove diseased bone and tissue. In a procedure called debridement, the surgeon removes as much
of the diseased bone as possible, taking a small margin of healthy bone to ensure that all the infected
areas have been removed. Surrounding tissue that shows signs of infection also may be removed.
• Restore blood flow to the bone. Your surgeon may fill any empty space left by the debridement
procedure with a piece of bone or other tissue, such as skin or muscle, from another part of your
body. Sometimes temporary fillers are placed in the pocket until you're healthy enough to undergo a
bone graft or tissue graft. The graft helps your body repair damaged blood vessels and form new
bone.
• Remove any foreign objects. In some cases, foreign objects, such as surgical plates or screws placed
during a previous surgery, may need to be removed.

Antibiotics

Once the bacterium or fungus causing your infection has been identified and you've undergone
surgery, if necessary, your doctor selects the antibiotic most likely to be effective in fighting your
particular type of infection. Antibiotics are administered most often through a vein in your arm
(intravenously) or, in some cases, they can be taken orally. You typically take antibiotics for four to six
weeks, or even longer. In some cases, you may need to take antibiotics for the rest of your life.

Antibiotics carry a risk of side effects, including nausea, vomiting and diarrhea. Allergic reactions also
can occur. Talk to your doctor about the side effects to expect from your specific medication.

PATIENT’S PROFILE

Patient’s Name: Big Brother

Address: Santa Rita, Aurora, Isabela

Sex: Male

Age: 57 years old

Civil status: Married

Occupation: Farmer

Religion: Roman Catholic

Admission:

Date: September 24, 2009

Time: 2:15 pm
Discharge:

Date: September 28, 2009

Time: 3:00 pm

Attending Physician: Dr. Acosta

Admission Diagnosis: Osteomyelitis Right Femur

Chief complain: Removal of Implant at right thigh

NURSING HISTORY

Present health History

On August 25, 2008 Patient Big Brother went at the back of their house approximately 7 o’clock in
the evening to check if his chicken were complete and in their own respective cage. While he was walking
towards the cage of the chicken he didn’t noticed a hole that was a 2 feet deep and 1 foot in diameter and
accidentally stepped his right foot in the hole and he didn’t balance his self then he fell down to the
ground. According to Big Brother, while he was falling down he heard a sound that seems came from a
breaking of a bone. Suddenly, he felt the onset of the pain in his right thigh. He shouts for help,
immediately his wife and his youngest son fetched him and he was supported by his wife and son in walking.
He was delivered to Cauayan Medical Specialist Hospital for admission. The Doctor found out that he had a
broken bone at the right thigh after he undergone X-ray and scheduled him for putting implant at his
right thigh.

On August 27, 2008 he was successfully operated by the Doctors. After 1 week of being admitted to
the hospital, patient Big Brother was discharged and advised by the doctors to have a once a week
consultation to the hospital for his condition and continue his medication at home..

He was taking care by his wife and his youngest son when he got home. His wife was the one
responsible in cleaning his wound and according to the patient it was cleaned by his wife twice a day by the
use of betadine and alcohol. But after two months of being discharged at the hospital, they noticed some
changes on the wound because there is a presence of much pus around the wound and there’s also
hematoma around the wound and the wound at the right thigh also swollen. According to the patient he
also heard a burst of something inside the operated thigh and after a week there’s an accumulation og
discharge to his wound.

He consulted his doctor about that matter and it found out that there’s an infection of the wound so
his doctor advised him to take an antibiotic. According to the patient even though he takes antibiotic
there’s no any changes happened to the wound, and according to him he experienced fever due to the
infection he has. Patient Big Brother advised to continue his medicine, until he was scheduled for the
removal of his implant at the same hospital.

On October 26, 2009 at exactly 12 noon the operation started with vital signs of: BP- 140/90, RR- 21,
and a PR- 88 the operation was successfully ended at exactly 1:05 pm. Patient Big brother got 20 stapled
wound there’s also a debribment application of antibiotic beads after the removal of the implant.

On October 28, 2009 at exactly 3:00 pm he was sent home.

Past Health History

Patient Big Brother experienced only mild health problem like fever, cough and colds, headache,
dizziness and when he experienced those, he asked his wife to buy medicine from the store like
paracetamol, neozep, biogesic and alaxan to take it but sometimes he prefer to take a rest only.

By the year of 2005 he experienced vehicular accident. His left arm got lacerated at about 5 inches
long and was admitted at the nearest hospital at their town and went home at the same day.
Family history

According to Big brother According to the S.O no one in her family has a history of hypertension,
cancer, heart disease, GIT problems

Medical History

On august 25, 2009 he was admitted to CMSH due to the accident he experienced and was successfully
operated by the Doctors. After 1 week of being admitted to the hospital, patient Big Brother was
discharged and advised by the doctors to have a once a week consultation to the hospital for his condition
and continue his medication at home..

And it was his second time to be admitted in the hospital for the removal of the implant in his right
thigh

Personal and Social History

The patient lives in a quite community with warm neighbors. She is a roman catholic according to her she
seldom goes to church because he doesn’t wants what he always saw on church like people always went to
church even though they are sinful. She actively participates on their activities in their barangay like
fiesta, birthdays. He also plays “tong-its” together with her friends once a week and that’s also one way of
getting close to his neighborhood.
 GORDON’S 11 FUNCTIONAL PATTERN

1. Health Perception-Health Management Pattern

●Before hospitalization

Believed that “he is healthy” as long as she can able to perform her activities of daily living and also
with the absence of disease. If he is not feeling well, he will just have a rest and take some OTC (over the
counter) drugs if his condition is no longer tolerable by him.

●During hospitalization

His reaction to admission is bounded by fear and anxiety especially for the possible complications that
might suffer from her illness and burdens of financial constraints from the hospital expenses. Despite her
condition he is still filled with hope for early recovery and to be cured significantly.

2. Nutrition-Metabolic Pattern

●Before hospitalization

The patient usually eats three times a day with no snacks in between. He usually eats vegetables, the
primary food that is conveniently available to them and fishes and meat as the secondary food available.
According to the patient, he usually consumed 1-2 cups of rice and ½-1 cup of vegetable every meal. He ate
fish and meat 1-2 times a week and can consume ½ cup of fish or meat if it is available. Big Brother drinks
8-10 glasses of water a day and can drink 1 cup of soft drink once a week. He also said that he takes 1 cup
of coffee every morning.

●During hospitalization

The patient ate 3 times a day during his confinement at the hospital. He also ate vegetable, meat and
fish at the hospital but he didn’t eat a lot of food because he didn’t want the taste of the food and he
prevents to defecate frequently because he can’t walk yet due to operated thigh. He consumed ½ - ¾ cup
of rice and a ¼ - ½ of served viand. During hospitalization patient Big Brother can drinks only 5-6 glasses
of water every day.

3. Sleep-Rest Pattern

●Before hospitalization

His usual sleep pattern was 7-9 hours and can able to take a nap for 2 hours in the afternoon.

●During hospitalization

The usual sleep pattern of the patient ranging from 5-6 hours a day. According to the patient he
experienced difficulty in sleeping because of the pain he experienced from his infected wound especially
after the removal of the implant.

4. Elimination Pattern

●Before hospitalization

The patient able to urinate from 4-5 times a day with a color of yellow and able to defecate 2
times with a yellow stool.

●During hospitalization

The patient urination ranging from 7-10 times a day with color of yellow but according to him
since the first day of his admission he didn’t defecate.
5. Activity-Exercise Pattern

●Before hospitalization

The patient day to day activity is to take good care of his grandson, walking playing tong-it
with his neighborhood and friends. Able to take a bath, toileting, dressing and tooth brushing. Patient
can able to take a bath 4-5 times a week and performed tooth brushing 1-2 times a day. He also loves
watching T.V from 4-5 hours a day. Due to his condition patient Big Brother can’t performed activities
in their farm so he passed the responsibility in managing their farm in his 20 years old youngest son.

●During hospitalization

The patient only lied on the bed most of the time. His activities on the hospital are watching T.V 6-7
hours a day. Most of the Time he asked help from his wife like eating, urinating because patient can’t move out of the
bed due to the removal of the implant in his right thigh.

6. Cognitive-Perceptual Pattern

●Before hospitalization

The patient can able to read and write. He uses tagalong and Ilocano as his primary dialect. Since, he was the
father he usually takes the initiative to make decision always but sometimes he consult his family regarding some
matter in their family.

●During hospitalization

The patient can able to read and write also. Since he was hospitalized her wife is the one who makes
decision in their house but her wife also consult his opinion in some matter in their family especially
financial matter

7. Role-Relationship Pattern

●Before hospitalization

The patient can able to comprehend and speaks tagalong and Ilocano to other people. He was a good
father and husband towards his family. He reminds and guided his children in everything they do. He is
also a jolly person approachable person.

●During hospitalization

Even though his in the hospital he didn’t forget his role as a father. He always checks the condition of
his children in their home. He also stays happy even though he is sick.

8. Self-Perception-Self-Concept Pattern

●Before hospitalization

He believed that he will recover in just a matter of months and he didn’t take seriously his
condition because according to him it’s just a mild health problem and many people experienced it ad
can able to recover.

●During hospitalization

He wants to recover fast to back in his normal life. According to him, he missed already the
things he used to do before the accident and he also wants to become independent in doing simple
things like dressing.

9. Sexuality-Reproductive Pattern

GENERAL: According to the patient he has a desire to have a sexual intercourse but he is already
impotent. He’s just paying attention in taking good care of his grandson.
10. Coping Stress Tolerance Management

●Before hospitalization

When he face a problem he got angered but sometimes he planned to keep quiet and planned to do
some activities such as resting, take a nap and watching T.V.

●During hospitalization

During hospitalization he got strength from his family in recovering. He also watched TV and
socialized from other to divert his attention from his problems,

11. Value-Belief System

●Before hospitalization

He rarely attend mass during Sunday because according to him he doesn’t want what he always saw in the
church such as seeing sinful people attending mass.

●During hospitalization

According to him he also prays especially that he has health problem now. He prays that he can recover fast
and for the health of his family also..
SKELETAL SYSTEM

1. BONE

Functions Bones have eleven main functions:

Mechanical

• Protection — Bones can serve to protect internal organs, such as the skull protecting the brain or the
ribs protecting the heart and lungs.
• Shape — Bones provide a frame to keep the body supported.
• Movement — Bones, skeletal muscles, tendons, ligaments and joints function together to generate and
transfer forces so that individual body parts or the whole body can be manipulated in three-
dimensional space. The interaction between bone and muscle is studied in biomechanics.

Synthetic

• Blood production — The marrow, located within the medullary cavity of long bones and interstices of
cancellous bone, produces blood cells in a process called haematopoiesis.

Metabolic

• Mineral storage — Bones act as reserves of minerals important for the body, most notably calcium and
phosphorus.
• Growth factor storage — Mineralized bone matrix stores important growth factors such as insulin-like
growth factors, transforming growth factor, bone morphogenetic proteins and others.
• Fat Storage — The yellow bone marrow acts as a storage reserve of fatty acids
• Acid-base balance — Bone buffers the blood against excessive pH changes by absorbing or releasing
alkaline salts.
• Detoxification — Bone tissues can also store heavy metals and other foreign elements, removing them
from the blood and reducing their effects on other tissues. These can later be gradually released for
excretion.[
• Endocrine organ - Bone controls phosphate metabolism by releasing fibroblast growth factor - 23
(FGF-23), which acts on kidney to reduce phosphate reabsorption

CATEGORIES OF BONE

• Short bones are roughly cube-shaped, and

have only a thin layer of compact bone
surrounding a spongy interior. The bones
of the wrist and ankle are short bones, as
are the sesamoid bones.
•
• Flat bones are thin, flattened and
generally curved, Most of the bones of
the skull are flat bones, as is the sternum.

• Irregular bones As implied by the name,

their shapes are irregular and
complicated. The bones of the spine and
hips are irregular bones.

• Long bones are characterized by a shaft, the

diaphysis, that is much greater in length than
width. Most bones of the limbs, including those
of the fingers and toes, are long bones.
•
STRUCTURE OF THE LONG BONE

• The diaphysis, or shaft, is the long tubular portion of long bones. It is composed of compact
bone tissue.
• The epiphysis (plural, epiphyses) is the expanded end of a long bone.
• The metaphysis is the area where the diaphysis meets the epiphysis. It includes the
epiphyseal line, a remnant of cartilage from growing bones.
• The medullary cavity, or marrow cavity, is the open area within the diaphysis. The adipose
tissue inside the cavity stores lipids and forms the yellow marrow.
• Articular cartilage covers the epiphysis where joints occur.
• The periosteum is the membrane covering the outside of the diaphysis (and epiphyses where
articular cartilage is absent). It contains osteoblasts (bone-forming cells), osteoclasts
(bone-destroying cells), nerve fibers, and blood and lymphatic vessels. Ligaments and
tendons attach to the periosteum.
• The endosteum is the membrane that lines the marrow cavity.

TYPES OF BONES

Compact bone or (Cortical bone)

The hard outer layer of bones is composed of compact bone tissue, so-called due to its minimal gaps
and spaces. This tissue gives bones their smooth, white, and solid appearance, and accounts for 80%
of the total bone mass of an adult skeleton. Compact bone may also be referred to as dense bone.

Trabecular bone

Filling the interior of the organ is the trabecular bone tissue (an open cell porous network also
called cancellous or spongy bone), which is composed of a network of rod- and plate-like elements
that make the overall organ lighter and allowing room for blood vessels and marrow. Trabecular
bone accounts for the remaining 20% of total bone mass but has nearly ten times the surface area
of compact bone.
 2. Joints

Human synovial joint composition

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 or synarthroses, joints that are immovable, that allow little or no movement
and are predominantly fibrous. Synovial joints, joints that are not directly joined, are lubricated by a solution
called synovia 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.

3. Tendons

A tendon is a tough, flexible band of fibrous 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 the periosteum of individual bones. As muscles contract, tendons
transmit the forces to the rigid bones, pulling on them and causing movement.

4. 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.

Lower Limb

The thigh, leg, and

foot constitute the

lower limb. The

bones of the lower

limbs are

considerably larger

and stronger than

comparable bones

of the upper limbs

because the lower

limbs must support

the entire weight of the body while walking, running, or jumping. illustrates features of the 30 bones of

each lower limb.

COURSE IN THE WARD

DATE AND TIME PHYSICIAN’S ORDER RATIONALE NURSING

INTERVENTION
September 24, 2009 >Admit to ROC under the >to provide satisfactory >brought patient to the
service of Dr. Acosta care for patient room of choice

>secure consent for the >for lawful purposes >secured consent to

admission and patient

>TPR every shift and > Serves as a baseline >monitored and recorded
record data checking the vital signs
present health status of
the patient.

>Diet as tolerated >informed patient and SO

>to prevent patient from
the required diet for the
frequent defecating and
patient

>Oxtics:
>to determine the oxygen
-CBC >prepared the proceeding
carrying capacity of the
lab test
blood and immune
function

>prepared the proceeding

>to determine the
-blood cross match lab test
compatibility of the
patient’s blood from the
donor

>IVF: D5W 1L x 8 hours >administered and

>for more calibrated
regulated well as
medication purposes
indicated by the physician

>referred any changes to

>Attending physician the physician
>to take out order for
inform
immediate action to the
patient
>prepared patient for the
>for removal of implant procedure
>facilitates wound healing

>referred any problem to

>REFER >to provide immediate the physician
intervention for any
complication that may
arise
>maintained potency of
2:55 pm >prepare 1 unit FWB >for the availability of the blood
properly typed and cross the blood before
matched transfusion

>Regulated well 1 unit of

6:30 pm >transfer 1 unit FWB/ >for the replacement of FWB
WB properly typed and lack blood components
cross matched to run for
6 hours

September 26, 2009 >Monitored and recorded

1:30 pm >V/S every 15 mins until >to monitored v/s of the v/s every 15 mins until
stable patient until stable stable

>Instructed patient and

>Flat on bed >recovery from S.O the required
anesthesia positions and its purpose.

>Instructed S.O to give

 >DAT after 6 hours >to enhance appetite of the desired food of the
the patient patient as long as it can
bring nourishment to the
body

> Observed sterile

>IVF: > To provide salts needed technique in IVF
- D5NSS 1L x 8º to maintain electrolyte insertion. Regulate well
- D5LR 1L x 8º balance; To provide
and check its patency.
- D5NM x 8º glucose (dextrose), the
main fuel for metabolism;
To provide water-soluble
vitamins and medications;
and to establish a lifeline
for rapidly needed
medications.

> medication >gave medicine on time as

- cefazolin 500 mg IV >for bone infection ordered by the physician
every 8º ANST
>gave medicine on time as
-ketorolac 30 mg IV >for short management of ordered by the physician
every 6 hours ANST pain

>referred any problem to

September 27, 2009 >REFER >to provide immediate the physician
intervention for any
complication that may
arise
>administered at the
>decrease Ketorolac 30 >to prevent overdose right time as ordered by
mg IV every 8º the physician

>Administered medicine
>Tramadol capsule TID >for moderate- on time and as ordered by
moderately pain the physician.
 PATHOPHYSIOLOGY OF OSTEOMYELISIS

PRECIPITATING FACTOR ETIOLOGY PREDISPOSING FACTOR

-injury exposure of the Staphylococus Aureus -age

To local infection
-poor circulation

Entry of microorganism to open wound

It will enter to a fractured bone

Increase WBC and enter the infected area

Bacteria release enzyme (leukocidins)

WBC engulf dead cell

Dead cell will turn into pus

Pus will spread in the bones and blood vessel impairing blood flow Hematoma

Resulting in ischemia w/ bone necrosis

Extend into the medullary cavity extend into the perosteum some spread in soft
tissue and joint

sequestrum form pain swelling accumulation of pus

bome formation

fever pain swelling redness redness