OSTEOMYELITIS

Osteomyelitis is an infection of the bone. It can be caused by a variety of microbial

agents (most common in staphylococcus aureus) and situations, including:

 An open injury to the bone, such as an open fracture with the bone ends piercing
the
skin.

 An infection from elsewhere in the body, such as pneumonia or a urinary tract

infection
that has spread to the bone through the blood (bacteremia, sepsis).

 A minor trauma, which can lead to a blood clot around the bone and then a
secondary
infection from seeding of bacteria.

 Bacteria in the bloodstream bacteremia (poor dentition), which is deposited in a

focal
(localized) area of the bone. This bacterial site in the bone then grows, resulting
in
destruction of the bone. However, new bone often forms around the site.
  A chronic open wound or soft tissue infection can eventually extend down to the
bone
surface, leading to a secondary bone infection.

There are three main types of osteomyelitis:

 Acute osteomyelitis, where the bone infection develops within two weeks
of an initial infection, injury or the onset of an underlying disease.

 Sub-acute osteomyelitis, where the bone infection develops

within;one ot two months of an initial infection, injury or onset of an
underlying disease.

 Chronic osteomyelitis, where the bone infection develops two months or

more after an initial infection, injury or onset of an underlying disease

SIGNS AND SYMPTOMS

The symptoms of osteomyelitis can include:

o Pain and/or tenderness in the infected area

o Swelling and warmth in the infected area

o Fever

o Nausea, secondarily from being ill with infection

o General discomfort, uneasiness, or ill feeling

o Drainage of pus through the skin

Additional symptoms that may be associated with this disease include:

o Excessive sweating

o Chills

o Lower back pain (if the spine is involved)

o Swelling of the ankles, feet, and legs

o Changes in gait (walking pattern that is a painful, yielding a limp

CAUSES / ETIOLOGY

 Newborns (younger than 4 months)

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

Bones, which usually are well protected from infection, can become infected through
three routes:

 The bloodstream (which may carry an infection from another part of the body to
the bones)
 Direct invasion (infection)
 Infections in adjacent bone or soft tissues

PATHOPHYSIOLOGY

 Osteomyelitis tends to occlude local blood vessels, which causes bone necrosis
and local spread of infection.
 Infection may expand through the bone cortex and spread under the periosteum,
with formation of subcutaneous abscesses that may drain spontaneously through
the skin.
 In vertebral osteomyelitis, paravertebral or epidural abscess can develop.
 If treatment of acute osteomyelitis is only partially successful, low- grade chronic
osteomyelitis develops.

DIAGNOSTIC EXAM

 CBC- WBC may be elevated (indicates presence of active infection).

 ESR (erythrocyte sedimentation rate) - may be elevated (indicates inflammatory
process).
 Bone Scan (indicates infected bone).
 Bone lesion biopsy or culture (may reveal the causative organism).
 Needleaspiration:During this test, a needle is used to remove a sample of fluid
and cells from the vertebral space, or bony area. It is then sent to the lab to be
evaluated by allowing the infectious agent to grow on media.
 Biopsy:A biopsy (tissue sample) of the infected bone may be taken and tested
for signs of an invading organism.

PRONOSIS AND PREVENTION

The prognosis for people with osteomyelitis is usually good with early and proper
treatment. However, sometimes, chronic osteomyelitis develops, and a bone abscess
may recur weeks to months or even years later.

Certain people who have artificial joints or metal components attached to a bone should
take preventive antibiotics before surgery, including dental surgery, because these
people may be at increased risk of infection from bacteria normally present in the mouth
and other parts of the body. People can ask their health care practitioner for expert,
detailed recommendations regarding preventive antibiotics. People undergoing surgical
or dental procedures should tell their surgeon, orthopedist, or dentist that they have an
artificial joint or metal component attached to a bone so that preventive antibiotics can
be taken.

TREATMENT

Medical management for clients with Osteomyelitis are as follows:

 Analgesics as prescribed.
 Antibiotics as prescribes.
 Dressing changes- use sterile technique.
 Maintain proper body alignment and change position frequently to prevent
deformities.
 Immobilization of affected part.

Surgery if needed:
 Incision ad Drainage of bone abscess.
 Sequestrectomy- removal of dead, infected bone and cartilage.
 Bone grafting is recommended after repeated infections

NURSING INTERVENTION

 control the patient's pain with prescribed analgesics and nonpharmacologic

techniques
 Perform tepid sponging if the temperature is above 40c

 monitor his response to antibiotic therapy

 observe the patient's I.V. site for signs of complications

 monitor the area of infection and neurovascular status (if an extremity is involved)
 apply gentle range-of-motion exercises to the joints above and below the affected
site
  unless contraindicated, provide nutritional support in the form of a high protein
diet
 teach your patient how to take prescribed antibiotics and how to recognize
possible adverse reactions.

NURSING DIAGNOSIS

 Pain related to inflammation and swelling

 Impaired physical mobility associated with pain
 Risk for extension of infection: bone abscess formation
 Deficient knowledge about treatment regimen

COMPLICATIONS

If not treated promptly it results in chronic osteomyelitis, which may be complicated by:

1. Septicaemia: due to invasion of the blood by the organisms

2. Septic embolism resulting in abscess in the kidneys, lungs, heart, etc.

3. Destruction of the growth plate resulting in the limb length discrepancy especially
in children.

4. Amyloidosis may develop in long standing cases

5. Secondary malignancies like sarcomas (rare) and Squamous cell carcinoma of

the sinus tract may also develop.

Other complications of amputations

Besides infection the following complications may be seen:

o Hematoma formation
o Skin flap necrosis
o Joint deformities
o Neuromas of the ends of the cut nerves
o Phantom limb pain sensation
Osteomyelitis of the First Metatarsophalangeal Joint with Resection - Medical
Illustration, Human Anatomy Drawing
 ARTHRITIS
The word "arthritis" means "joint inflammation." Inflammation is one of the body's natural
reactions to disease or injury, and includes swelling, pain, and stiffness. Inflammation
that lasts for a very long time or recurs, as in arthritis, can lead to tissue damage.

1.OSTEOARTHRITIS
This is the most common type of arthritis. It occurs when the cartilage covering
the end of the bones gradually wears away. Without the protection of the
cartilage, the bones begin to rub against each other and the resulting friction
leads to pain and swelling. Osteoarthritis can occur in any joint, but most often
affects the hands and weight-bearing joints such as the knee, hip and facet joints
(in the spine). Osteoarthritis often occurs as the cartilage breaks down, or
degenerates, with age or overuse. For this reason, osteoarthritis is sometimes
called degenerative joint disease.

Risk Factors:
• female
• genetic pre-disposition
• Obesity
• Mechanical joint stress
• Trauma
• Congenital and developmental disorders
• Inflammatory joint diseases
• Endocrine and metabolic diseases

Signs and symptoms

 Deep aching joint pain that gets worse after exercise, or putting weight
on it, and is relieved by rest
 Grating of the joint with motion
 Joint swelling
 Limited movement
 Morning stiffness / Stiffness after periods of inactivity, such as sleeping
or sitting.
 Upon assessment may include edema and tenderness around the
joints and bony enlargements of distal interphalangeal joints
( HERBERDEN’S NODES
Etiology

Exact cause or etiology is unknown butthere are several factors

that increase ape rson ’s risk of developing Osteoarthritis. It includes:

Age
 Age is the strongest risk factor for developing Osteoarthritis. The
chance of developing the disease increases with age. Most people
over
age 60 have osteoarthritis to some degree.

Injury

 Traumatic injury to a joint increases your risk of developing

Osteoarthritis in that joint.

Joint Overuse
 Joints that are used repeatedly in certain jobs or sports may be
more likely to develop Osteoarthritis. Occupations that involve
frequent knee bending increase the risk of knee OA, and those that
require frequent lifting appear linked to hip OA.

Obesity
 Obesity increases the risk for osteoarthritis of the knee and hip.
Excess
weight causes stress on joints that weren't made to support that
weight.

Gender
 Before age 45, osteoarthritis occurs more frequently in men. After
age 45, osteoarthritis is more common in women.

Heredity
 A person could have a defect in one of the genes responsible for
making cartilage. This can cause cartilage to deteriorate more rapidly.
 Pathophysiology

Loss of articular cartilage, organ AO, synovial joint, subchondral

bone, synovium , meniscus, ligaments, neuromuscular apparatus

In load-bearing areas of the articular cartilage

Thickening of cartilage
(with patchy synovitis)
↓
Breached integrity of joint
(cartilage softens and bone thins)
↓
Fibrillation (vertical clefts)
↓
Deep cartilage ulcers that may extend to bone
↓
Weak fibrocarilaginous bone
↓
Metabolically active cartilage
(osteophytes)
↓
Hypocellular cartilage
↓

Remodelling and hypertrophy

Appositional bone growth in subchondral region
(sclerosis in x-ray)
Bone abrasion like ivory (eburnation)
Periarticular muscle wasting

Anatomy and Physiology

Joints allow the limbs to bend and the back to flex. There are three different kinds of
joints described but the ones of principal interest to us are synovial joints. In addition,
joints between adjacent facets of the vertebrae, as well as the junction of pelvis and
vertebrae are synovial joints. A diagram of a typical synovial joint is illustrated in Figure
 Try CR's teaching tool to learn the parts of the knee joint.

The synovial joint consists of two bone ends covered by

articular cartilage. The articular cartilage is smooth and
resilient and enables frictionless movement of the joint. The
joint stability is maintained by a fibrous joint capsule, which
attaches to both bones and collateral ligaments, which are
at the sides of most joints. Collateral ligaments are
important in maintaining stability in joints such as the
fetlock, carpus, elbow, hock and stifle. There are also intra-
articular ligaments, the best example of which are the
cruciate (cross) ligaments maintaining integrity of the
femorotibial compartments of the stifle joint. In addition,
there are other ligaments (outside the joint cavity) that also
support the integrity of joints. The best examples are the
distal sesamoidean ligaments and suspensory ligament that
together with the sesamoid bones make up the suspensory
apparatus and hold the fetlock in its correct position.
Disruption of any of these structures leads to a failure of
support of the fetlock joint (one of the common catastrophic
injuries in the racehorse) (Figure 2).

The joint capsule itself is made up of the fibrous capsule (previously mentioned and
providing structural integrity) and an inner lining layer called the synovial membrane.
The synovial membrane secretes the synovial fluid, which provides lubrication within the
joint itself. There are various disease processes that affect the nature of this synovial
fluid because of inflammation and disease in the synovial membrane. The most
common sign that the horse owner or trainer sees of any kind of arthritis (inflammation
in the joint) is excessive fluid production. This is because of inflammation of the synovial
membrane (synovitis). The fluid produced by inflamed synovial membrane generally has
a lower viscosity (more watery). This is a sign of disturbance in production of hyaluronic
acid, which is the key ingredient providing lubrication in the joint fluid.
 

The joint is a very well engineered structure. Frictionless motion is provided by the
combination of a smooth articular cartilage surface as well as lubrication of both the
articular cartilage and the synovial membrane together which make up the entire
surface area of the inside of the joint. Shock absorption to the joint is provided by a
combination of structures, including articular cartilage, subchondral bone (the bone
beneath the cartilage), and the soft tissue structures (joint capsule and ligaments).
Because of its resilient nature and ability to compress, articular cartilage in itself is a
good shock absorber but its thickness and overall volume is far less than bone or soft
tissues. Hence, the soft tissues and the bone are the primary shock absorbers in the
joint and any disease that affects bone (fractures, etc) or soft tissue (fibrosis due to
chronic inflammation) is going to interfere with this shock absorption. Resilience of the
soft tissue is important for normal motion as well as shock absorption. It has been
alluded to previously that friction comes from both articular cartilage and synovial
membrane. Hyaluronic acid provides lubrication to the synovial membrane surface. Until
recently it has been felt that it does not provide any lubrication to the articular cartilage
but more recently with some new research, it has been shown that hyaluronic acid, in
addition to another protein structure called lubricin, is involved in the lubrication of
articular cartilage. This substance moving over the surface of the joints is called
boundary lubrication. A second mechanism of lubrication of the cartilage is effected by
fluid being squeezed out of the cartilage onto the surface when weightbearing occurs.
When weightbearing ceases, the fluid is absorbed back into the cartilage, ready for a
next cycle of weightbearing.

Diagnostic exam
ESR
Serum chemistry
Blood counts
Urinalysis
Synovial fluid analysis
WBC < 2,000/µL
Mononuclear predominance

Preventive Measures

 Weight reduction
 Reducing injuries
 Perinatal screening for congenital hip disease

Treatment
The goals of treatment are to:
 Increase the strength of the joints
 Maintain or improve joint movement
  Reduce the disabling affects of the disease •
 Relieve pain

Nursing Intervention
 Teaching the patient to balance exercises and rest.
- Exercise helps maintain joint and overall movement. Water exercises,
such as swimming, are especially helpful.
- Do a variety of physical activity. Alternate periods of heavy activity
with periods of rest. For example, if you do weight training one day, do
aerobic exercise the next day. Repetitive stress on joints for long periods
of time can cause the excessive wear and tear that can lead to
osteoarthritis

 Instruction to moist heat application

 Encourage client to maintain weight
- Eating a healthy balanced diet
-Losing weight if you are overweight
- Excess weight puts stress on your joints, especially your hips,
knees, back, and feet.
 Encourage client to practice good posture.
- Good posture protects your joints from excessive pressure,
especially your neck, back, hips, and knees.
 Imagery, relaxation, and diversion are helpful to reduce pain.
 Quadriceps strengthening exercises may relieve pain and disability
of the knees.
-Instruct the patient to straighten the leg out while lying down and
tense the leg muscles, straightening the knee, while raising the
heel slightly. The contraction is held for a count of 5 and released
for a count of 5. The exercise is done on each leg 10 to 15 times
hourly while the patient is awake. Commercial breaks on television
are a good reminder to do this.

Nursing diagnosis

Chronic pain related to joint tenderness and edema

Impaired Physical Mobility related to joint deterioration

Complications
Reduced mobility
Disability
Septic arthritis
 HIP OA FOOT OA KNEE OA

Patellofemoral Osteoarthritis - Medical Illustration, Human Anatomy Drawing

2. GOUTY ARTHRITIS
Gout is a painful condition that occurs when the bodily waste product uric acid is
deposited as needle-like crystals in the joints and/or soft tissues. In the joints, these
uric acid crystals cause inflammatory arthritis, which in turn leads to intermittent
swelling, redness, heat, pain, and stiffness in the joints.

Signs and symptoms

 Tophi ( accumulation of sodium urate crystals)

 Redness
 Swelling
 Warmth
 Severe pain
 Gouty neuropathy

Etiology

*Predisposing/Modifiable

a) Weight. Being overweight increases the risk of developing hyperuricemia and

gout because there is more tissue available for turnover or breakdown, which
leads to excess uric acid production.
b) Alcohol consumption. Drinking too much alcohol can lead to hyperuricemia,
because alcohol interferes with the removal of uric acid from the body.
c) Diet. Higher levels of consumption of meat (especially organ meats such as liver,
kidney, and brain and as well as meat extracts and gravies), dried beans and
peas, sardines, anchovies, and seafood are associated with an increased risk of
gout. Also, a higher level of consumption of dairy products is associated with a
decreased risk of gout.
d) Lead exposure. In some cases, exposure to lead in the environment can cause
gout.
e) Medications. A number of medications may put people at risk for developing
hyperuricemia and gout. They include: 1)diuretics, such as furosemide (Lasix*),
hydrochlorothiazide (Esidrix, Hydro-chlor), and metolazone (Diulo, Zaroxolyn),
which are taken to eliminate excess fluid from the body in conditions like
hypertension, edema, and heart disease, and which decrease the amount of uric
acid passed in the urine. 2)salicylate-containing drugs, such as aspirin. 3)niacin,
a vitamin also known as nicotinic acid. 4)cyclosporine (Sandimmune, Neoral), a
medication that suppresses the body’s immune system (the system that protects
the body from infection and disease). This medication is used in the treatment of
 some autoimmune diseases, and to prevent the body’s rejection of transplanted
organs. 5)levodopa (Larodopa), a medicine used to support communication
along nerve pathways in the treatment of Parkinson’s disease.

*Precipitating/Non-modifiable

a) Family history of gout. If other members of your family have had gout,
you're more likely to develop the disease.

b) Age and sex. Gout occurs more often in men than it does in women,
primarily because women tend to have lower uric acid levels than men do.
After menopause, however, women's uric acid levels approach those of men.
Men also are more likely to develop gout earlier — usually between the ages
of 40 and 50 — whereas women generally develop signs and symptoms after
menopause.

c) Medical conditions. Certain diseases and conditions make it more likely that
you'll develop gout. These include untreated high blood pressure
(hypertension) and chronic conditions, such as diabetes, high levels of fat and
cholesterol in the blood (hyperlipidemia), and narrowing of the arteries
(arteriosclerosis).

Pathophysiology

ETIOLOGY: overproduction of uric acid

Concentrated in the blood and in the synovial fluid, myocardium

Elevation of uric acid

Tophi

Deposition of tophi in the different parts of the body ( great toe, hands & feet)

Inflammation of the joints

Gouty arthritis
 Anatomy and physiology

I.

Your foot is made up of 3 sections. Your forefoot is comprised of 4 smaller toes

(phalanges) and 1 big toe (hallux). Your midfoot (metatarsal bones) and hindfoot (tarsal
bones) make up your foot arches, instep, heel and ankle; these are responsible for
weight bearing and propulsion. Your arches contain bones, ligaments, muscles and
tendons of your foot, which require a lot of stability and flexibility.

Your foot bones work with your foot muscles to move your foot in 4 directions:
dorsiflexion (moving foot upward), plantar flexion (moving foot downward towards sole),
abduction (moving foot outward) and adduction (moving foot inward). Your lower leg
muscles have long tendons that cross your ankle and attach to your foot and toe bones
to help move your foot. Your extensor muscles and tendons attach on the top of your
foot, and your flexor, abductor and adductor muscles and tendons attach on the bottom
of your foot. Your achilles tendon is the strongest and largest tendon in your body and it
connects your calf muscles (gastrocnemius and soleus) to your heel bone (calcaneus),
allowing your foot to push off when your calf muscles tighten. It is essential for walking,
running and jumping.

Stage of Gouty Arthritis

ASYMPTOMATIC HYPERURICEMIA: patient has elevated blood uric acid levels but no
other symptoms.

--------------------------------------------------------------------------------------------------------------------
 CHRONIC TOPHACEOUS GOUT: disease has caused permanent damage. With
proper treatment, most never progress to this advanced stage.

Diagnostic exam

 X-ray
 Arthrocentesis
 Arthroplasty
 Synovial fluid analysis

Medical Management

– Hyperuricemia, tophi, joint destruction treated after the acute

inflammatory process

– Uricosuric agents to correct hyperuricemia

– Colchicine or NSAIDs

– Allopurinol—limited due to risk of toxicity

Nursing Intervention

o Provide a diet with LOW purine

o Avoid Organ meats, aged and processed foods

 o STRICT dietary restriction is NOT necessary

o Encourage an increased fluid intake (2-3L/day) to prevent stone formation

o Instruct the patient to avoid alcohol

o Provide alkaline ash diet to increase urinary pH

o Provide bed rest during early attack of gout

o Position the affected extremity in mild flexion

o Administer anti-gout medication and analgesics

o Avoid alcohol

o Maintain normal body weight

o Instruction to continue medications to maintain effectiveness

Nursing diagnosis

PAIN related to joint inflammation, traction, surgical intervention

1. Assess patient’s perception of pain

2. Instruct patient alternative pain management like meditation, heat and cold
application, TENS and guided imagery

3. Administer analgesics as prescribed:Usually NSAIDS, Meperidine can be given for

severe pain

4. Assess the effectiveness of pain measures

IMPAIRED PHYSICAL MOBILITY

1. Instruct patient to perform range of motion exercises, either passive or active

2. Provide support in ambulation with assistive devices

3. Turn and change position every 2 hours

4. Encourage mobility for a short period and provide positive reinforcements for small
accomplishments

SELF-CARE DEFICITS

1. Assess functional levels of the patient

2. Provide support for feeding problems

 Place patient in Fowler’s position

 Provide assistive device and supervise mealtime

 Offer finger foods that can be handled by patient

 Keep suction equipment ready

3. Assist patient with difficulty bathing and hygiene

 Assist with bath only when patient has difficulty

 Provide ample time for patient to finish activity

3. RHEUMATTOID ARTHRITIS
• Rheumatoid Arthritis (RA) is an inflammatory disorder that primarily involves the
synovial membrane of the joints

• Occurs between the ages of 30 and 50; peak between 40-60 years of age

• Women affected 2-3x more than men

• Believed to be an autoimmune response to unknown antigens

Clinical Manifestations:

Determined by the stage and severity of the disease

– joint pain, swelling, warmth, erythema, and lack of function

– Palpitation of joints reveals spongy or boggy tissue

 – Fluid can usually be aspirated from the inflamed joint

– Begins with small joints in hands, wrists and feet

– Progressively involves knees, shoulders, hops, elbows, ankles, cervical

spine, and TMJ

– Symptoms are acute in onset, bilateral and symmetric

– Morning stiffness lasts for more than 30 minutes

– Deformities of the hands and feet result from misalignment and

immobilization

Assessment and Diagnostic Findings

– Several factors lead to diagnosis of RA

– Rheumatoid nodules, joint inflammation, extra-articular changes

– Laboratory findings:

– Rheumatoid Factor (RF) found in 80% of patients

– ESR elevated

– RBC and C4 decreased

– C-reactive Protein (CRP) and antinuclear antibody (ANA) may be +

– Arthrocentesis and x-rays can be performed

Medical Management

Includes education, a balance of rest and exercise, and referral to community

agencies for support

– Early RA:

• Medical management includes therapeutic doses of salicylates or

NSAIDs; includes new COX-2 inhibitors, gold, penicillamine

• Occupational and physical therapy

• Reconstructive surgery and corticosteroids

– Assessment:

a) Assess patient’s self-image

 b) Assess joints by inspecting palpating, and inquiring about tenderness,
swelling, and redness
c) Assess joint mobility, ROM, and muscle strength

– Nursing Interventions:

a) Pain relief measures

b) Relief of fatigue

c) Increasing mobility

d) Improving sleep

e) Monitoring for potential complications

f) Increase knowledge of disease

g) Promoting self-care

 Difference of normal, osteoarthritis and rheumatoid arthritis

NORMAL JOINT OSTEOARTRHITIS RHEUMATOID

ARTHRITIS