NURSING PROCESS: THE PATIENT WITH OSTEOMYELITIS
The patient reports an acute onset of signs and symptoms (eg, lo-calized pain, swelling, erythema, fever) or recurrent drainage of an infected sinus with associated pain, swelling, and low-grade fever. The nurse assesses the patient for risk factors (eg, older age, dia-betes, long-term corticosteroid therapy) and for a history of pre-vious injury, infection, or orthopedic surgery. The patient avoids pressure on the area and guards movement. In acute hematoge-nous osteomyelitis, the patient exhibits generalized weakness due to the systemic reaction to the infection.
Physical examination reveals an inflamed, markedly swollen, warm area that is tender. Purulent drainage may be noted. The pa-tient has an elevated temperature. With chronic osteomyelitis, the temperature elevation may be minimal, occurring in the afternoon or evening.
Based on the nursing assessment data, nursing diagnoses for the patient with osteomyelitis may include the following:
· Acute pain related to inflammation and swelling
· Impaired physical mobility related to pain, use of immobi-lization devices, and weight-bearing limitations
· Risk for extension of infection: bone abscess formation
· Deficient knowledge related to the treatment regimen
The patient’s goals may include relief of pain, improved physical mobility within therapeutic limitations, control and eradication of infection, and knowledge of treatment regimen.
The affected part may be immobilized with a splint to decrease pain and muscle spasm. The nurse monitors the neurovascular status of the affected extremity. The wounds are frequently very painful, and the extremity must be handled with great care and gentleness. Elevation reduces swelling and associated discomfort.Pain is controlled with prescribed analgesics and other pain-reducing techniques.
Treatment regimens restrict activity. The bone is weakened by the infective process and must be protected by immobilization devices and by avoidance of stress on the bone. The patient must understand the rationale for the activity restrictions. The joints above and below the affected part should be gently placed through their range of motion. The nurse encourages full participation in ADLs within the physical limitations to promote general well-being.
The nurse monitors the patient’s response to antibiotic therapy and observes the IV access site for evidence of phlebitis, infection, or infiltration. With long-term, intensive antibiotic therapy, the nurse monitors the patient for signs of superinfection (eg, oral or vaginal candidiasis, loose or foul-smelling stools).
If surgery was necessary, the nurse takes measures to ensure adequate circulation (wound suction to prevent fluid accumula-tion, elevation of the area to promote venous drainage, avoidance of pressure on grafted area), to maintain needed immobility, and to comply with weight-bearing restrictions. The nurse changes dressings using aseptic technique to promote healing and to pre-vent cross-contamination.
The nurse continues to monitor the general health and nutri-tion of the patient. A diet high in protein and vitamin C ensures a positive nitrogen balance and promotes healing. The nurse en-courages adequate hydration as well.
The patient and family must learn and recognize the importance of strictly adhering to the therapeutic regimen of antibiotics and preventing falls or other injuries that could result in bone frac-ture. The patient needs to know how to maintain and manage the IV access and IV administration equipment in the home. Med-ication education includes medication name, dosage, frequency, administration rate, safe storage and handling, adverse reactions, and necessary laboratory monitoring. In addition, aseptic dress-ing and warm compress techniques are taught.
The nurse carefully monitors the patient for the development of additional painful areas or sudden increases in body tempera-ture. The nurse instructs the patient and family to observe and report elevated temperature, drainage, odor, increased inflam-mation, adverse reactions, and signs of superinfection.
Management of osteomyelitis, including wound care and IV an-tibiotic therapy, is usually performed at home. The patient must be medically stable, physically able, and motivated to adhere strictly to the therapeutic regimen of antibiotic therapy. The home care environment needs to be conducive to promotion of health and to the requirements of the therapeutic regimen.
If warranted, the nurse completes a home assessment to de-termine the patient’s and family’s abilities regarding continuation of the therapeutic regimen. If the patient’s support system is ques-tionable or if the patient lives alone, a home care nurse may be needed to assist with intravenous administration of the antibi-otics. The nurse monitors the patient for response to the treat-ment, signs and symptoms of superinfections, and adverse drug reactions. The nurse stresses the importance of follow-up health care appointments (Chart 68-9).
Expected patient outcomes may include:
1) Experiences pain relief
a) Reports decreased pain
b) Experiences no tenderness at site of previous infection
c) Experiences no discomfort with movement
2) Increases physical mobility
a) Participates in self-care activities
b) Maintains full function of unimpaired extremities
c) Demonstrates safe use of immobilizing and assistive devices
d) Modifies environment to promote safety and to avoid falls
3) Shows absence of infection
a) Takes antibiotic as prescribed
b) Reports normal temperature
c) Exhibits no swelling
d) Reports absence of drainage
e) Laboratory results indicate normal white blood cell count and sedimentation rate
f) Wound cultures are negative
4) Complies with therapeutic plan
a) Takes medications as prescribed
b) Protects weakened bones
c) Demonstrates proper wound care
d) Reports signs and symptoms of complications promptly
e) Eats a diet that is high in protein and vitamin C
f) Keeps follow-up health appointments
g) Reports increased strength
h) Reports no elevation of temperature or recurrence of pain, swelling, or other symptoms at the site
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