Osteomyelitis Nursing Diagnosis & Care Plan

Osteomyelitis is an infection of the bone that mainly affects children but can also affect adults. It can be an acute and also chronic condition.  

Contents

Overview of Osteomyelitis 

Nursing Diagnosis for Osteomyelitis 

Nursing Care Plans for Osteomyelitis 

Terminology: 

  • The term osteomyelitis consists of three different words that reveal the meaning of osteomyelitis. 
    • Osteo stands for bone
    • myel relates to myelo and stands for marrow 
    • the ending –itis indicates an inflammatory process
  • So osteomyelitis means inflammation of the bone and bone marrow. 

Pathophysiology

  • Osteomyelitis is the inflammation of the bone and bone marrow and usually results from an infection. 
  • Bacteria, viruses, or fungi can cause it.
  • It occurs when pathogens enter the bone structures and cause an infection.
  • These germs create an inflammatory response that causes leaky blood vessels and edema in surrounding tissues. 
  • During this inflammatory response, leukocytes (a form of white blood cells) rush to the affected area and secret enzymes in an attempt to kill the foreign bacteria.
  • In this process, pus is formed and causes increased pressure within the bone structures. This leads to rupture within bone structures and may occlude blood supply, leading to ischemia and bone death. 
  • The necrotic bone that forms separates from the healthy bone structure. This necrotic encapsulation is called sequestrum (infected dead bone resulting from osteomyelitis). 
  • The sequestrum is not connected to viable structures of the bone, such as the osteons housing blood supply. This makes treatment difficult because medication such as antibiotics cannot reach the infected area.
  • At the same time, new bone cells are formed around the necrotic bone. This is called the involucrum.
  • Many infections are caused by Staphylococcus aureus, Pseudomonas, and Enterobacteriaceae.
  • Adults mostly experience an infection in the vertebrae (spine), whereas children may experience these infections in long bones.

Causes 

There are several different ways bacteria can be introduced into bone and bone marrow. 

  • Hematogenous spread: bacteria reach the bone tissue via the bloodstream. Reasons might be 
    • IV drug use 
    • Hemodialysis from contaminated equipment 
  • Direct inoculation:
    • Trauma: Bone fractures such as open fractures may allow bacteria from the environment to enter directly into the bone.
    • Surgery: Bacteria may be introduced during surgery 
  • Contiguous spread: Infection of the bone from surrounding tissue such as a chronic wound 

Risk Factors 

  • Weakened immune system  
  • Cancer 
  • Chronic steroid use 
  • Sickle cell disease 
  • Diabetes 
  • HIV 
  • Dialysis 
  • IV drug abuse 
  • Chronic comorbidities 
  • Elderly 
  • Prosthetic joints 
  • Poor circulation 

Signs and Symptoms 

As mentioned earlier, osteomyelitis may present with acute or chronic signs and symptoms.

Acute Osteomyelitis: 

  • Malaise 
  • Fever (temperature above 101° F), chills, weakness, headache if the infection is systemic 
  • Erythema, swelling, and warmth around the affected area
  • Pain at the affected area; a constant localized pulsating sensation that worsens with movement 
  • Bone pain 
  • Stiffness of the affected area
  • Compromised mobility of the affected site or limb/ loss of ROM (range of motion) 

Chronic Osteomyelitis: 

  • Commonly foot ulcers 
  • Localized pain 
  • Drainage from the affected area

Diagnosis 

  • History & Physical 
  • Physical exam 
  • CBC – may show an elevated white blood cell count (WBC)
  • Inflammatory markers – may show an increased erythrocyte sedimentation rate (ESR) 
  • Blood cultures – show if infectious organisms have escaped into the bloodstream 
  • Imaging studies:
    • X-ray – may show a change in bone density indicating bone destruction by bacteria
    • Bone scan – enhanced visualization of the bone through radioactive material; may allow seeing early changes in bone structure 
    • MRI – provides more precise images; ability to visualize fluid in the bone and how extensively the infection has spread
  • Bone biopsy – tissue sample that can be examined for organisms 

Treatment 

  • Antibiotics 
  • Splinting
  • Rest
  • Surgery 

Complications 

  • Bone abscess 
  • Bone death (necrosis) 
  • Spread of infection 
  • Blood infection (septicemia) 
  • Sepsis 
  • Infection does not respond to IV treatment 

Nursing Diagnosis for Osteomyelitis

Acute Pain r/t infectious process and swelling

Hyperthermia r/t inflammatory response secondary to infection

Ineffective Tissue Perfusion r/t ischemia due to disease process 

Deficient Knowledge r/t new diagnosis; surgery 

Risk for Impaired Skin Integrity: Risk factors: medical equipment such as cast or splint; invasive procedures 

Risk for Infection: Risk factors: chronic disease, inadequate primary defenses, increased exposure to pathogens 

Impaired Physical Mobility r/t loss of integrity of the bone structure, stiffness of affected body part

Nursing Care Plans for Osteomyelitis 

Acute Pain r/t infectious process and swelling

Expected Outcome: The patient will report an acceptable pain level of 3 or less on a 0 to 10 pain scale, as evidenced by vital signs within normal limits and a relaxing effect and body posture.

Assess the patient’s pain level using an accepted pain assessment tool such as the numeric pain scale. Note characteristics of pain. 

Precipitating events 
Quality of pain 
Radiation of pain 
Severity of pain 
Timing 

Precipitating events such as movement and positioning may contribute to pain. In addition, quality, severity, and location may indicate how advanced the infection already is.
Monitor vital signs at least every four hours.

An increased blood pressure, heart rate, and respiration may indicate uncontrolled pain.
Administer pain medication as ordered. 

Osteomyelitis pain can range from mild to moderate to severe. Some patients may even be pain-free. Nevertheless, pain management may slightly differ depending on whether patients suffer from acute or chronic pain. Pain medications such as acetaminophen, naproxen, Ibuprofen, or even opioids such as oxycodone or morphine may be ordered by the physician. 
Encourage bed rest. 

The least movement of the affected area promotes healing and alleviates pain. The area may be supported with a splint device to ensure minimal movement or disturbance.
Be considerate during wound care and use appropriate timing with pain medication. 

Using a gentle approach to dressing changes and wound care may help with pain control. Another way to maximize pain control is to provide wound care during peaks of pain medications. For example, the nurse may wait for thirty minutes to one hour before performing wound care after administering oral pain medication. 
Elevate the involved area to reduce swelling. 

Often the inflammatory process causes the area to become edematous, and the skin becomes tight, causing discomfort. Elevation may help reduce swelling and alleviate pain. 
Provide hot and cold packs if not contraindicated. 

Cold packs help reduce swelling, whereas warm applications may help with pain relief and increase range of motion. 
Provide resources to help with distraction. 

Activities such as watching television, listening to music, or even face-timing family members and friends may help divert attention away from the pain.

Hyperthermia r/t to inflammatory response secondary to infection

Expected Outcome: The patient will maintain a core body temperature within normal limits as evidenced by consistent temperature measurements of less than 100° Fahrenheit, dry skin, and normal respiration rate. 

Monitor the patient’s temperature at designated times and as clinically indicated. 

Following a trend of the patient’s temperature helps determine the effectiveness of antipyretic medications and antibiotics. 
Obtain temperature measurements from the same site and with the same tool. 

Different sites and methods may skew measurements and cause trends to be inaccurate. 
Administer antipyretics as ordered. 

Antipyretic medications may help reduce fever for a period of time.
Remove warm clothing and adjust the room temperature. 

These external factors may affect the patient’s body temperature. 
Provide temperature lowering measurements such as a fan or cold cloth to the forehead. 

These measures may help lower body temperature. 
Offer tepid baths. 

Using lukewarm water during baths instead of hot water may help to keep the temperature from rising. 

Ineffective Tissue Perfusion r/t ischemia due to disease process 

Expected Outcome: The patient will have adequate tissue perfusion as evidenced by the absence of pain, absence of necrotic bone tissue, and dry, warm, intact skin.

Anticipate surgical intervention in patients with chronic, unrelieved osteomyelitis. 

To remove necrotic bone tissue, the surgeon may perform a sequestrectomy or debridement to revascularize viable tissue. 
Assess the patient’s neurovascular status.  Note pain, movement, sensation, warmth, temperature, pulses, and capillary refill. 

Pain 
Pressure, paresis, paralysis 
Paresthesia 
Pallor
Pulselessness

These signs indicate a neurovascular compromise. 
Consider a treatment called hyperbaric oxygen therapy (HBO).

Osteomyelitis is associated with reduced blood flow to the bone and therefore limited oxygen supply needed for wound healing.  The patient is exposed to high amounts of oxygen that permeates the tissues. As a result, this therapy treatment increases tissue perfusion and wound healing.

Knowledge Deficit r/t new diagnosis; surgery

Expected Outcome: The patient will verbalize an understanding of the disease process and demonstrate the necessary skills to prevent reinfection, as evidenced by complying with the prescribed treatment regimen. 

Teach about the importance of taking antibiotics as prescribed. 

Patients need to know that antibiotics should be taken until finished and not to skip or delay doses. 
Teach about line care if the patient is sent home with an intravenous line. 

Some patients may return home with a PICC line to receive long-term antibiotics. But again, knowing how to care for it and keeping the site clean helps reduce the risk for infection.
Educate about signs and symptoms of neurovascular compromise. 

Sudden changes in sensation, numbness or increased pain may indicate ischemia.
Educate about signs and symptoms of infection. 

Redness, swelling, pain, and warmth at the site may indicate infection. 
Educate about the principles of infection control and wound care after surgery. 

Patients and families need to know wound and incision care to prevent infection. 

More Care Plans:

Risk for Infection Nursing Diagnosis & Care Plan

Impaired Skin Integrity Nursing Diagnosis & Care Plan

Impaired Physical Mobility Nursing Diagnosis & Care Plan

Activity Intolerance Nursing Diagnosis & Care Plan

Acute Pain Nursing Diagnosis & Care Plan

References:

Momodu II, Savaliya V. Osteomyelitis. 2021 Aug 11. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 30335283.

Osteomyelitis. (n.d.). Retrieved from https://www.hopkinsmedicine.org/health/conditions-and-diseases/osteomyelitis.

Osteomyelitis: Causes, Symptoms, Diagnosis & Treatments. (n.d.). Retrieved from https://my.clevelandclinic.org/health/diseases/9495-osteomyelitis.

Osteomyelitis Treatment, Symptoms, Definition & Causes. (n.d.). Retrieved from https://www.medicinenet.com/osteomyelitis/article.htm.

Osteomyelitis Bone Infection – Everything You Need To Know – Dr. Nabil Ebraheim. (2019, February 3). [Video file]. Retrieved from https://www.youtube.com/watch?v=qvP6v6zC_bE.

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