Musculoskeletal system. This is the lecture on osteomyelitis, amputations, and wound care. Brief overview of the pathophysiology.
Osteomyelitis is an infection of the bone that results in inflammation, necrosis, and formation of new bones. It can be classified as hematogenous osteomyelitis, which is due to blood-borne spread of infection. contiguous which is from contamination from bone surgery, open fractures, or traumatic injuries such as gunshot wounds, or osteomyelitis with vascular insufficiency which is commonly seen among patients with diabetes and peripheral vascular disease, and this most commonly will affect the feet. Patients who are at high risk for osteomyelitis include older adults, and those who are poorly nourished or obese.
Other patients at risk include those with an impaired immune system, those with chronic illness like diabetes or rheumatoid arthritis, or those receiving long-term corticosteroids or immunopressive agents, and also those who use IV drugs. Post-operative surgical wound infections typically occur within 30 days after surgery. They can be classified as incisional or deep. Deep would be more in line with a patient that had received some kind of implant and that received that got infected.
Osteomyelitis may become chronic and it may affect the patient's entire quality of life. More than 50% of bone infections are caused by staphylococcus aureus and increasingly by a variety that is methicillin resistant. or MRSA.
Surgical site ink markers have been linked to infections by cross-contamination. Therefore, these are now considered one patient or one-time use. Additional pathogens might be gram positive organisms, Streptococci and Enterococci, plus gram negative bacteria including Pseudomonas. The initial response to infection is inflammation, increased vascularity, and edema. After two or three days, thrombosis of the local blood vessels occurs resulting in ischemia with bone necrosis.
The infection then extends into the medullary cavity and under the periosteum and may spread into the adjacent soft tissues and joints. Unless the infective process is treated promptly, a bone abscess forms. The resulting abscess cavity contains sequestrum or dead bone tissue which does not easily liquefy and drain.
Therefore, the cavity cannot collapse and heal as it does in soft tissue abscesses. New bone growth forms and surrounds the sequestrum. Although healing appears to have taken place, a chronically infected sequestrum remains and produces recurring abscesses.
through the patient's life resulting in chronic osteomyelitis clinical manifestations include signs and symptoms of sepsis sepsis is life-threatening organ dysfunction caused by a dysregulated host response to an infection and septic shock is a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality. Despite the increased sophistication of antibiotic therapy, the incident of both sepsis and septic shock has continued to rise. More than 30 million people die suffer or die from sepsis worldwide every year. and the number of hospital admissions related to sepsis has increased by triple over the last decade. Finding and aggressively treating the source of infection and quickly restoring tissue perfusion are important interventions that may positively influence the clinical outcome.
As the body responds to this infectious process, both pro-inflammatory and anti-inflammatory cytokines are released. and activate the coagulation system, which begins to form clots, whether or not bleeding is present. This results not only in microvascular occlusions that further disrupt cellular perfusion, but also in inappropriate consumption of the clotting factors. The imbalance of the inflammatory response and the clotting and fibrinolysis cascades are considered critical elements of the devastating physiologic progression that occurs in patients with sepsis. Sepsis is an evolving process that may result in septic shock and life-threatening organ dysfunction if not recognized and treated early.
In the early stages of septic shock, BP may remain in normal limits or the patient may be hypotensive but responsive to fluids. The heart rate increases progressing to tachycardia, hyperthermia, and fever. with warm flush skin and bounding pulses are present. Respiratory rate becomes elevated, urinary output may remain normal for a time or may decrease. GI status may be compromised as evidenced by nausea, vomiting, or diarrhea, or just decreased gastric motility.
Hepatic dysfunction is evidenced by rising bilirubin levels and worsening coagulopathies. Signs of hypermetabolism include increased serum glucose and insulin resistance. Changes in mental status such as confusion or agitation may be present and lactate level is elevated because of the maldistribution of blood.
Inflammatory markers such as the WBC count, plasma C reactive protein and prola procalcitonin levels are also elevated the substance progresses tissues become less perfused and acidotic compensation begins to fail and the patient begins to show signs of organ dysfunction the cardiovascular system also begins to fail the bp does not any longer respond to fluid resuscitation or vasoactive agents and the signs of end organ damage are evident such as acute kidney injury pulmonary dysfunction hepatic dysfunction confusion progressing to non-responsiveness as sepsis progresses to septic shock the bp drops and the skin becomes cool pale and mottled temperature may be normal or below normal heart and respiratory rates remain rapid urine production ceases and multiple organ dysfunction progresses to death. So that's why it's very important that we know the signs of this so that we can intercept this process before we get to septic shock. When an infection is in the bloodstream, the onset is usually sudden, occurring within a clinical and occurring often with the clinical and laboratory manifestations of SysDENIC systems at first may overshadow the local signs. The big point here is finding the source of the infection and getting the right antibiotics started. This can begin from an infection in the bone such as osteomyelitis.
When osteomyelitis occurs from spread of adjacent infection or from direct contamination, there are no manifestations of sepsis. The surface area that overlies the infected bone is swollen, warm, painful, and tender to the touch. The patient with chronic osteomyelitis presents with a non-healing ulcer that overlies the infected bone with a connecting sinus that will intermittently and spontaneously drain the exudate. Diabetic osteomyelitis can occur without any external wounds.
Microvascular and macrovascular pathophysiological changes along with an impaired immune response by patients with diabetes who have poor glycemic control can exacerbate the spread of infection from other The priority physical assessments would include monitoring vital signs, being mindful of heart rate, respiratory rate, and temperature, which in some instances with sepsis can actually become hypothermic rather than always hyperthermic. Either one is possible. Obviously, we want to do a skin assessment and see if we can identify the wound and see if it's open.
We want to do a musculoskeletal assessment to check for the patient's mobility. Additionally, we might assess for pain. Doing a complete pain assessment that takes into consideration all the aspects of a pain assessment.
We also want to be aware of pre-operative assessment on a patient and post-operative assessments on a patient. So the focus of a pre-operative assessment should be to establish a good baseline for where the patient is beginning prior to surgery. And then a post-operative, we want to compare the data from our current post-operative assessment with our pre-operative assessment, but we're also monitoring very closely for complications due to surgery. The most important lab values to take into consideration are blood cultures, the complete blood count, a C-reactive protein, and the ESR, which is the erythrocyte sedimentation rate.
So blood cultures are ordered prior to starting antibiotics they need to be drawn. It can take up to three days for the results to come in. It consists of drawing two samples of blood from two locations on the patient and one of each of those samples will be anaerobic and the other will be anaerobic and that's labeled on the bottles where you draw the labs. Hopefully you all get a chance to see that done. or even participate in this kind of lab draw when you're at your clinicals at the hospital.
Of course the CBC complete blood count will identify white cell status. If it's elevated then it indicates infection. Sepsis can either create too many white blood cells or it can use up the body's supply of white blood cells and end up with a low white blood cell count. So we're also, in addition to monitoring white blood cells, we need to be watching for band cells or the immature granulocytes, which are the immature WBCs sent into circulation prior to their being fully mature because the body is being so overwhelmed with infection that it's sending out even the immature blood cells to fight.
It's pulling out all of the stops because it's being overwhelmed by the infection. The C-reactive protein is a marker of infection or inflammation in the body. And the ESR is a type of blood test that measures how quickly the erythrocytes settle at the bottom of the test tube. It contains the blood sample. Normally, red blood cells settle relatively slowly.
A faster than normal rate indicates inflammation in the body. Inflammation is part of your immune response that can be a reaction to an infection or an injury. It also may be a sign of chronic disease, an immune disorder, or other medical conditions. Additional surgical interventions may actually include amputation, of the affected body parts if the antibiotic therapy fails. The most important medications for this condition tend to be your anti-infectives and your pain medications.
As I said earlier, patients will likely receive a PICC line for long-term administration of the antibiotics and they may likely discharge either to rehabilitation or to their homes with the PICC line and will require teaching for maintaining the line and completing the therapy. Sometimes culture and sensitivity tests will aid the provider in selecting the appropriate antibiotic but while waiting for these test results that often can take one to three days the patients will be given a broad spectrum antibiotic to begin to treat the infection. Some of the antibiotics that you need to be familiar with include cefazolin, vancomycin, penicillin g, ceftriaxone, levofloxacin, piperacillin, and clindamycin.
Additionally, patients often have dull pain when they have these abscesses or osteomyelitis. Diabetics that have peripheral neuropathy may not feel any pain whatsoever. Pain management will be similar to that.
of management for fractures and so you can review that medication list in regards to osteomyelitis as well. Nursing priorities and planning care. If a patient has an MRSA positive organism in the opened wound, then They'll be on contact isolation precautions. So it's very important to adhere to the isolation precautions, to teach the patient about the precautions, and to teach their visitors, family members or friends, that the isolation precautions apply to them as well.
And they need to understand that this organism is transmissible. and that they want to protect themselves from this organism and transmitting it to others. We can plan on having wound care. If the wound is already open, then that will be handled according to provider's orders.
And if it's a surgical incision, we'll have particular care instructions for that as well. Then we'll also be looking at doing some pain management, depending upon the assessment that we get of the patient's pain. Additionally, we'll be looking at post-operative care. So the patient may have received a debridement or an amputation, or they may have had implantation of antibiotic beads, depending upon where the infection is. and the bone, how much the bone has been affected, how effective the antibiotic treatment has been, if this is a chronic wound or if it's just progressively getting worse. The implantation of the antibiotic beads often will happen if a patient had a joint surgery.
such as a total knee arthroplasty or a total hip arthroplasty, that becomes infected. And so sometimes they will implant antibiotic beads into that joint space to try to increase the effectiveness of the eradication of the infection. We're looking at medication, including antibiotics, probably IV administration, and then pain medication. We also want to be mindful of the patient's weight-bearing status.
If this is on a weight-bearing limb, such as a leg or foot, sometimes patients will be required to wear a special shoe. It's called a surgical shoe. is supportive of their foot without being closed in.
It's kind of like a sandal that has Velcro straps on it that helps the foot not to be pressed into a confining shoe space. Also, we're going to think about their ambulation assistance and what kind of equipment they're going to need. So you're most likely Complications are going to be pain, altered mobility, side effects.
or adverse effects from long-term antibiotic therapy, which can include super infections, which is an infection you get because your body's system of normal flora has been suppressed because of the antibiotics. So one of the organisms that sometimes takes advantage of this system would be the the Candida and it will It manifests maybe in oral cavity for thrush or vaginally a yeast infection in different ways that these long-term antibiotics can create a super infection and another one that is sometimes happens and can have its own long-term consequences is a C. diff infection.
So we want to monitor these patients for the the stool that they're outputting and watch for these stomach cramps and diarrhea that might indicate that they're becoming c-diff positive and then another complication that can happen would be infections of the soft tissues like cellulitis and that can happen whether the osteomyelitis is actually surgically corrected in some form or not. So we want to monitor for that as well. Some of the life threatening complications that can happen is if the injury ends up becoming a septic infection in the bloodstream. If there's a surgery involved then we can have bleeding.
We can have non-healing wound with a chronic infection. bone necrosis and abscess, and septicemia, which is blood poisoning. Okay, so now on to patient education and health promotion. So we will have to educate the patient about the PICC line, the purpose of it, the care of it, antibiotic therapy, the length that they're going to be on this antibiotic. Whether they'll be going back and forth to an infusion center to receive their therapy, or if they'll be able to manage it at home.
Sometimes patients can take their medications, get them to the house and deliver them to themselves, administer them to themselves. We want to talk to them about prevention of further injuries or infections. Nutrition is a big thing so that they can heal and rebuild their bone and eradicate the infection, and safe ambulation.
Promoting self-care is really important. We want to encourage them to be as independent as they can and then help them with the gaps. I have a little bit more to say about the previous slide.
I went ahead and clicked it just a little too soon. Additionally, we might be looking at teaching them their wound care for their whatever wound they have. If it's a surgical incision, if it's an open wound that was debrided that will now have to heal over time. So we'll need to make sure that we demonstrate proper wound care to them and make sure that they know what supplies they're going to need and that they can get their supplies to take care of this wound at home.
On to this slide that we're currently on, the holistic and psychosocial considerations, we want to think about loss and grief and this really comes into play. when the patient had to have an amputation because of their osteomyelitis. So if the patient experiences an amputation, especially something as much as, you know, below the knee amputation, above the knee amputation, either of these cases, that's a lot of loss involved in the loss of that limb and it's going to influence their self-care.
and their independence and their dependence. in their own care. And then we need to think about phantom limb pain and never tell the patient that their foot is gone and therefore it can't hurt them. Because phantom limb pain is actually very real sensation. It usually begins about two weeks after surgery.
That doesn't mean it can't happen sooner. And it needs to be treated. just like regular pain is treated.
So we give pharmacological or non-pharmacological methods in order to treat that. Here is a link for a really great video on sterile wound dressing change that I would like you guys to watch. I think you'll find it very helpful and useful.
in caring for patients. And I was going to put in several slides about amputations, and then I decided instead that you would be assigned to that practice and learn case study in chapter 42 about amputations, and it covers very well all the material and it'll give you a chance to dig into the textbook to find the answers to the questions throughout that case study and by the time you complete it you should have a pretty good grasp on why why the patient got an amputation and the kind of care that he received the problems that can come up from from an amputation and then the next few slides are NCLEX questions all about amputations and osteomyelitis. Okay and that brings us to the end of this brief lecture on osteomyelitis. Definitely do the assigned elements that are in the lip and caught material on fractures and amputations and all the different parts of from chapters 41 and 42. You'll find those really helpful in understanding some of these processes and caring for patients with these needs and if you have any. questions or concerns please email me or talk to me after class on Monday and I'll see what I can do to help you get a grip on this stuff.
All right y'all thank you very much.