Ch 68: Musculoskeletal Problems

what is osteomyelitis?

A severe infection of the bone, bone marrow, and surrounding soft tissue.

what is the most common causative organism of osteomyelitis?

Staphylococcus aureus

What are the two main types of pathogen entry in osteomyelitis?

Indirect (hematogenous) entry and direct (contiguous) entry.

What is the most common site of osteomyelitis in adults?

the vertebrae

What causes direct entry osteomyelitis?

open wounds, fractures, surgery, or foreign bodies like implants and prosthetics

What areas are common sites of osteomyelitis in patients with diabetes or vascular disease?

The feet (due to ulcers) and pressure points like hips or sacrum

What happens after microorganisms enter the bone in osteomyelitis?

they multiply, increasing pressure within the bone, causing ischemia and vascular compromise

How does osteomyelitis lead to bone necrosis?

Infection increases pressure, obstructs blood flow, and causes ischemia leading to bone death.

What defines acute osteomyelitis?

an initial bone infection or one lasting less than 1 month

What are local signs of acute osteomyelitis?

constant bone pain worsened by activity and unrelieved by rest; swelling, tenderness, warmth at the site; restricted movement

What are systemic signs of acute osteomyelitis?

fever, night sweats, chills, restlessness, nausea, and malaise

What are later signs of acute osteomyelitis?

drainage from sinus tracts in the skin or fracture site

What defines chronic osteomyelitis?

a bone infection lasting longer than 1 month or failing to respond to initial antibiotic therapy.

what is the clinical pattern of chronic osteomyelitis?

Continuous or recurrent infection with exacerbations and remissions.

What are the common local signs of chronic osteomyelitis?

Constant bone pain, swelling, and warmth at the infection site.

Why is chronic osteomyelitis harder to treat?

Granulation tissue turns into scar tissue, which is avascular and resists antibiotic penetration.

What are rare, long-term complications of osteomyelitis?

Septicemia, septic arthritis, pathologic fractures, and amyloidosis

What is the definitive test for identifying the causative organism in osteomyelitis?

bone or soft tissue biopsy

Which laboratory tests are often positive in osteomyelitis?

blood cultures and wound cultures

What are common lab findings in osteomyelitis?

increased WBC count, elevated ESR, and high CRP (especially in acute infections)

When do x-ray changes typically appear in osteomyelitis?

2 to 4 weeks after onset of clinical symptoms

Why might CT scans be preferred over x-rays in osteomyelitis diagnosis?

they better assess the extent of the infection

Why is MRI useful in the acute phase of osteomyelitis?

it detects bone marrow edema (early sign of infection)

What nuclear imaging test shows early abnormalities in osteomyelitis?

radionuclide bone scan (technetium-99m)

What is the role of a WBC scan (indium-111-labeled cells) in osteomyelitis diagnosis?

Helps pinpoint the precise location of infection.

What is the treatment of choice for acute osteomyelitis before bone ischemia occurs?

prolonged antibiotic therapy

What should ideally be done before starting antibiotics in osteomyelitis?

obtain cultures or perform a bone biopsy

What surgical interventions may be needed for soft tissue abscess or ulceration in osteomyelitis?

surgical debridement or drainage

How long might IV antibiotic therapy continue at home for osteomyelitis?

4 to 6 weeks; some may require 3 to 6 months.

What is used to administer prolonged IV antibiotics at home or in a facility?

A central venous access device (CVAD).

What does treatment of chronic osteomyelitis typically include?

Surgical removal of necrotic bone and extended antibiotic use.

What oral antibiotic is often used in adults with chronic osteomyelitis?

Ciprofloxacin (a fluoroquinolone) for 6 to 8 weeks.

How is the patient’s response to osteomyelitis treatment monitored?

Through bone scans and ESR testing.

What are key aspects of a patient’s health history that may indicate a risk for osteomyelitis?

Bone trauma, open fracture, puncture wounds, and other infections (e.g., strep throat, pneumonia, sinusitis, skin/tooth infection, chronic UTI)

Which medications should the nurse assess for in a patient suspected of osteomyelitis?

Analgesics and antibiotics

What surgical history may be relevant in the assessment of osteomyelitis?

previous bone surgery

Which substance use history is important when assessing for osteomyelitis?

IV drug use and alcohol use

What nutritional-metabolic signs and symptoms are associated with osteomyelitis?

anorexia, weight loss, chills

What activity-exercise symptoms may be reported in osteomyelitis?

Weakness, paralysis, and muscle spasms around the affected area

What local sensory symptoms are common in osteomyelitis?

Local tenderness and increased pain with movement of the affected area

What coping/stress tolerance findings may be present in osteomyelitis?

Irritability, withdrawal, dependency, anger

What general objective findings might the nurse observe in osteomyelitis?

Restlessness, high spiking fever, night sweats

What musculoskeletal signs are common in osteomyelitis?

Restricted movement, wound drainage, and spontaneous fracture

what skin changes might be seen with osteomyelitis?

diaphoreses, redness, warmth, and edema at infection site

What diagnostic findings support the diagnosis of osteomyelitis?

Positive blood/wound cultures, increased ESR & WBC, presence of sequestrum/involucrum on x-ray, bone scan, CT, or MRI

What are the three main clinical problems associated with osteomyelitis?

pain, musculoskeletal problems, and infection

What is the first overall goal for a patient with osteomyelitis?

achieve satisfactory pain and fever management

What is the second overall goal for a patient with osteomyelitis?

remain free from complications

What is the third overall goal for a patient with osteomyelitis?

adhere to treatment plan

What is the priority antibiotic-related nursing intervention for osteomyelitis?

Administer IV antibiotics as ordered and teach the patient/caregiver about side effects and treatment duration

How should the nurse assess for worsening osteomyelitis infection?

regularly assess the wound for signs of infection and report any worsening symptoms

What pain management strategies are used for osteomyelitis?

give prescribed analgesics, assess pain response, and encourage non-drug methods like guided imagery and relaxation breathing

What should the nurse assess and treat regarding muscle spasms in osteomyelitis?

assess for spasms, give muscle relaxants as ordered, and evaluate the patient’s response

Why is careful handling of the affected limb important in osteomyelitis care?

to avoid undue manipulation and prevent further damage or pain

What neurovascular assessments are critical in osteomyelitis?

assess neuromuscular status and notify HCP immediately of any significant changes (e.g. tingling, decreased sensation)

What dressing change technique is used for osteomyelitis wounds?

change dressings using sterile technique as ordered

When are contact precautions necessary in osteomyelitis care?

implement contact precautions as needed based on infection control policies

What instructions should APs follow when helping with osteomyelitis care?

handle the limb carefully, assist with ROM, and report any pain, tingling, or decreased sensation to the RN

How does the nurse collaborate with the physical therapist for osteomyelitis patients?

assess mobility, teach ambulation, coordinate pain control before PT, and discuss needed home modifications

What does collaboration with an occupational therapist involve for osteomyelitis care?

Assess ADL impact, teach use of assistive devices to promote independence while respecting activity restrictions.

What types of infections should be controlled to prevent osteomyelitis?

UTI, respiratory tract infections, and pressure injuries

Who is at risk for developing osteomyelitis?

Immunocompromised patients, those with diabetes, orthopedic prosthetics, or vascular insufficiency

What symptoms should patients at risk for osteomyelitis report to their HCP?

Bone pain, fever, swelling, and restricted limb movement

Why is caregiver education important in preventing osteomyelitis?

Caregivers help monitor health and recognize early signs of infection

Why is immobilization (e.g., splint or traction) used in osteomyelitis?

to reduce pain and prevent further injury

What types of pain medications may be used for osteomyelitis?

NSAIDs, opioids, and muscle relaxants

What types of wound dressings might be used for osteomyelitis?

Dry sterile, saline- or antibiotic-soaked, wet-to-dry, or negative-pressure dressings

How should dressings be handled to prevent the spread of infection?

carefully handle and discard them to avoid bacterial transfer

Why is frequent position changing important in osteomyelitis care?

to maintain comfort and prevent complications from immobility

What is a common limb positioning issue in lower extremity osteomyelitis?

flexion contracture due to keepingthe leg flexed for comfort

What complication can develop from poor foot positioning in bed?

footdrop from Achilles tendon contracture

What adverse reactions should be monitored for with high-dose antibiotics?

hearing loss, renal impairment, neurotoxicity (e.g., weakness, vision changes)

Why monitor for signs of Candida or C. difficile infections?

antibiotic use may disrupt normal flora, especially in older adults or immunosuppressed patients

What are signs of Candida overgrowth to report?

Whitish-yellow lesions in the mouth or perianal itching/discharge

What type of support is important due to the long, uncertain treatment?

ongoing emotional support for patients and caregivers

What should be taught regarding CVAD management at home?

how to care for the line and administer IV antibiotics

Why is follow-up lab testing important during home antibiotic therapy?

To monitor antibiotic effectiveness and detect side effects

Why is it important to complete the full course of antibiotics?

to prevent recurrence of chronic infection, even if symptoms improve

What wound care might patients need at home?

dressing changes with supplies and instruction

What kind of support is needed for chronic osteomyelitis?

Continued physical and psychological support

what are the expected outcomes for patient with osteomyelitis?

• Have satisfactory pain management

• Adhere to the recommended treatment plan

• Show a consistent increase in mobility and range of motion (ROM)

What is osteoporosis?

A chronic, progressive metabolic bone disease characterized by low bone mass and deterioration of bone tissue, leading to increased fragility.

Why is osteoporosis called the “silent thief”?

Because it slowly robs the skeleton of its strength without obvious symptoms until a fracture occurs.

Who is most commonly affected by osteoporosis?

Women, especially postmenopausal, due to lower calcium intake, smaller body frame, earlier bone loss, and hormonal changes.

When is a bone density test recommended for women?

at age 65 or older. earlier for higher risk women (e.g., low body weight, smokers, history of fractures).

What are major modifiable risk factors for osteoporosis?

Low calcium/vitamin D intake, physical inactivity, smoking, alcohol use, and long-term corticosteroid use.

What are nonmodifiable risk factors for osteoporosis?

Aging, female gender, family history, small body frame, white or Asian ethnicity

What are common diseases that increase osteoporosis risk?

IBD, malabsorption syndromes, kidney disease, RA, hyperthyroidism, cirrhosis, hypogonadism, diabetes.

What medications can interfere with bone metabolism?

Corticosteroids, antiseizure drugs (e.g., phenytoin), aluminum antacids, heparin, chemotherapy, excess thyroid hormone.

What are the 4 factors that determine peak bone mass?

Heredity, nutrition, exercise, and hormone function.

When is peak bone mass typically reached?

Before age 20.

At what age does bone loss typically begin?

around 35-40

Why do women experience rapid bone loss at menopause?

due to sharp decline in estrogen levels

What is bone remodeling?

a continuous process where osteoblasts build bone and osteoclasts reabsorb bone

What bones are most commonly affected by osteoporosis?

spine, hips, and wrists

What are early clinical manifestations of osteoporosis?

back pain and spontaneous fractures

What does loss of bone mass in osteoporosis lead to?

weaker bones prone to spontaneous fractures from minimal trauma

What are consequences of vertebral fractures in osteoporosis?

increased risk of future fractures, gradual height loss, and kyphosis (“dowager’s hump”).

Why is osteoporosis often undetected by x-ray?

X-rays cannot detect bone loss until 25%–40% of calcium is lost.

What are typical lab values in osteoporosis (serum calcium, phosphorus, alkaline phosphatase)?

Usually normal; alkaline phosphatase may be increased after a fracture