OSTEOMYELITIS

Definition (osteo- derived from the Greek word osteon, meaning bone, myelo- meaning marrow, and -itis meaning inflammation) simply means an infection of the bone or bone marrow. The three (3) common route of onfection are: Bloodstream (hematogenous) Adjacent soft tissue infection (contagious focus) Direct introduction of the microorganism into the bone Pathophysiology and Etiology 1. Bacteria lodge and multiply in the bone. 2. Pressure increases as a pus collects in rigid bone, contributing to ischemia and vascular occlusion, and leading to bone necrosis. 3. Staphylococcus aureus is the mosy common infecting microorganisms; following are also prevalent: Escherichia coli, Pseudomonas, Klebsiella, Salmonella, and Proteus. 4. Hematogenous osteomylitis is the most common method of spread in prebuscent children. Clinical Manifestations 1. Infection of long bones with acute pain and signs of sepsis. 2. Localized pain and drainage. 3. Symptoms vary in adult and children according to the site of involvement. 4. general body malaise 5. pyrexia- 40 degree celcius 6. rapid pulse 7. face flushed 8. tongue furred 9. fretfulness 10. anorexia and constipation 11. urine contains albumin 12. increased blood sedimentation rate 13. increased WBC Diagnostic Evaluation Acute osteomylitis diagnosis made on initial clinical signs (history, physical examination, CBC and ESR). Aerobic and anerobic cultures bone and tissue to identify the organisims. ESR elevated; WBC and haemoglobin decreased.

Radiographic evidence of osteomyelitis lags behind symptoms by 7 to 10 days. Plain film evidence of infection 3 to 4 weeks later. Bone necrosis seen 10-14 days on x-rays. Radionucleide bone scans used to diagnose early acute osteomyelits. MRI is being used increasingly as distinguishes between soft tissue and bone marrow.

Management Acute: full recovery possible with minimal loss of function. Chronic: develops with an adequate or ineffective course of antibiotics or with delayed treatment. Surgical Intervention Needle aspiration or needle biopsy done initially. Surgical intervention may be needed to obtain a culture of the organism. Surgical decompression is considered when the patient does not improve after 36 to 48 hours of antimicrobial therapy. Debridement of wounds may be done. Use of abtibiotic- impregmented beads (removed after 2 to 4 weeks and replaced with bone graft) is also recommended.

Pharmacologic Intervention Employed quickly after the appearance of symptoms to avoid chronicity. Parenteral antimicrobial therapy is based on blood/wound cultures. Type of medication depends on organisms, but include: a. Penicillins ( Pen G, Pen V) b. Semisynthetic penicillins (nafcillin, oxavillin, methacillin) c. Extended-spectrum penicillins (ampicillin, carbenicillin, amoxicillin) d. Beta-lactam agents ( imipenem) e. Tetracyclines f. Cephalosporins g. Aminoglycosides Complications o Non-healing wounds o Sepsis o Immobility Nursing Diagnoses - Pain/ Chronic pain related to inflammatory processes. - Knowledge deficit: Disease and Medications - Impaired physical mobility related to prolonged rest of the affected part. Nursing Interventions Relieving Pain Administer opiods for acute pain; non-narcotics for chronic pain

 Administer medications around the clock instead of PRN to establish a consistent blood level. Report increase in pain that may indicate worsening infection. Increasing Knowledge Describe the infectious process and rationale for prolonged treatment with osteomyelits. Explain IV antibiotic therapy, potential side effects, and reactions. Explain strict adherence to infection control practices to prevent the spread of infection in some cases. Explain strict adherence to infection control practices to prevent the spread of infection in some cases. Promoting Rest Without Complications Support the affected extremity (splint, traction) to minimize pain. If patient is on bed rest, prevent hazards of immobility (passive ROM, position changes, cough and deep-breathing). Encourage distraction activities. Patient Education and Health Maintenance Advise the patient to adhere to infection control principlesproper handwashing, disposal of wound drainage, and dressing to prevent reinfection or transmission of infection at home. Stress adherence to medication regimen, which may be prolonged, with frequent follow-up visits. Teach care of indwelling device for medication delivery (such as Hickman catheter).

OSTEOSARCOMA
Definition Osteosarcoma is an aggressive malignant neoplasm arising from primitive transformed cells of mesenchymal origin (and thus asarcoma) that exhibit osteoblastic differentiation and producemalignant osteoid. It is the most common histological form of primary bone cancer. Cause: Unkown Etiology: Rapid bone growth- adolescents, ages 1025, male Environmental factors- exposure to radiation Genetic predisposition- the gene is also associated with familial retinoblastoma, a cancer of the eye that occurs in children. Bone dysplasias.

Manifestations Localized pain Bone fracture (may occur after what seems like a routine movement) Bone pain Limitation of motion Limping (if the tumor is in the leg) Pain when lifting (if the tumor is in the arm) Tenderness, swelling, or redness at the site of the tumor

Pathophysiology 1. Osteoblast 2. DNA mutation 3. Malignant osteoblast (abnormal) 4. Proliferation of abnormal osteoblast 5. Formation of osteoid or immature bone 6. Signs and symptoms are then observed such as pain, swelling, and tenderness. Assessment 1. Encourage patient to discuss problem and course of symptoms. 2. Note patient and familys understanding of the disease, coping with the problem andmanagement of pain. 3. Palpate mass gently on physical examination. 4. Note size and associated soft-tissue swelling, pain and tenderness of the mass. 5. Assess neuromascular status and range of motion extremity. 6. Evaluate motility and ability to perform activities of daily living. Diagnostic Procedures

X-ray MRI CT scan Biopsy CBC Blood chemistry Urine analysis

Sternal marrow puncture

Surgical Procedures Amputation of affected extremity Limb- Salvage Surgery- the bone and muscle affected by osteosarcoma are removed, leaving a gap in the bone that is filled by either a bone graft of more often a special metal prosthesis.

Nursing Diagnosis

Acute or chronic pain Risk for injury: pathologic fracture related to tumor Ineffective coping Activity intolerance

Nursing Intervention 1. Provide quiet environment and calm activities to prevent or lessen pain. 2. Provide comfort measure such as back rub, change position and use of heat or cold application. 3. Encourage diversional activities 4. Administer analgesics as indicated to maximal dose as needed. 5. Encourage the patient to increase fluid intake. 6. Encourage rest periods to prevent fatigue. 7. Provide accurate information about the situation, medication and treatment. 8. Assess muscle strength, gross and fine motor coordination. 9. Provide pillows for cushion and support. 10. Keep side rails up all the time.

Complications

Alopecia Reduction in number of leucocytes and platelets Septicemia Bleeding Anemia Kidney damage Hearing loss

PERIPHERAL NEUROPATHY

Definition Peripheral neuropathy refers to damage to nerves of the peripheral nervous system, which may be caused either by diseases of or trauma to the nerve or the sideeffects of systemic illness. The four cardinal patterns of peripheral neuropathy are : polyneuropathy, mononeuropathy, mononeuritis multiplex and autonomic neuropathy The most common form is (symmetrical) peripheral polyneuropathy, which mainly affects the feet and legs. The form of neuropathy may be further broken down by cause, or the size of predominant fiber involvement,:large fiber or small fiber peripheral neuropathy.

Causes:

Frequently the cause of a neuropathy cannot be identified and it is designated idiopathic. Diabetes with poor glycemic control Chronic kidney diseases Infections such as HIV or liver infection Autoimmune disorders such as arthritis or SLE Low level og B12 Poor blood flow to the legs Underactive thyroid gland Drug and toxins may damage nerves (ie., Glue, Lead, mercury, solvent.) Pressure on a nerve near a body part may be a cause Bone fracture alcoholism

Signs and Symptoms Those with diseases or dysfunctions of their nerves can present with problems in any of the normal nerve functions. sensory function, there are commonly

loss of function (negative) symptoms numbness, tremor, and gait abnormality. Gain of function (positive) symptoms tingling, pain, itching, crawling, and pins and needles.

Pain can become intense enough to require use of opioid (narcotic) drugs (i.e., morphine, oxycodone). Skin can become so hypersensitive that patients are prohibited from having anything touch certain parts of their body, especially the feet. People with this degree of sensitivity cannot have a bedsheet touch their feet or wear socks or shoes, and eventually become housebound. Motor symptoms include loss of function (negative) symptoms weakness, tiredness, heaviness, and gait abnormalities; and

Diagnostic Exam Physical Examination, History Electroencephalography Blood test

Medical Management Elimination/control of cause may slow progression Treating cause of nerve damage Stop drinking alcohol Need surgery to stop injury to a nerve You may have therapy to get better muscle strength and control

Nursing Management Patient are at risk for falls, thermal injuries and trauma so assistive device may help.

 Check bath water to avoid thermal injury. Footwear should be accurately sized. Driving may be limited/ eliminated thereby disrupting the patients sense of independence.