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    Chapter 64.docx - Amazon Simple Storage Service (Amazon S3) Chapter 64.docx - Amazon Simple Storage Service (Amazon S3) Document Transcript

    • Chapter 64<br />Osteomyelitis <br />
      • What is it?
      • Severe infection of the
      • Bone
      • Bone marrow
      • Surrounding soft tissue
      • Most common infecting microorganism
      • Staphylococcus aureus
      • Common causes
      • Trauma
      • Acute infection originating elsewhere
      • Puncture injury to soft tissue
      • Infection in adjacent bone
      • Orthopedic prosthetic device
      • Patho:
      • After entry, microorganisms lodge in an area of bone where circulation slows
      • Usually the metaphysis
      • Microorganisms grow causing increased pressure within the bone
      • Increased pressure leads to ischemia and vascular compromise of periosteum
      • Eventually, infection passes through bone cortex and marrow cavity
      • Once ischemia occurs, bone dies
      • Sequestrum forms
      • Devitalized bone separates from living bone
      • Part of periosteum that continues to have a blood supply forms new bone
      • Involucrum
      • Signs and Symptoms
      • Systemic
      • Fever, night sweats, chills, restlessness, nausea
      • Local
      • Constant bone pain that worsens with activity
      • Swelling, tenderness, warmth at infection site
      • Restricted movement of affected part
      • Lab Studies
      • Bone or soft tissue biopsy
      • Definitive way to determine causative microorganism
      • Patient’s blood and/or wound culture
      • Elevated WBC count
      • Erythrocyte sedimentation rate (ESR)
      • Radiologic signs
      • Usually do not appear until 10 days to weeks after start of clinical symptoms
      • Radionuclide bone scans
      • Helpful in diagnosis and usually positive in areas of infection
      • Magnetic resonance imaging (MRI)
      • Computed tomography (CT)
      • Help identify extent of infection, including soft tissue involvement
      • Treatment
      • Vigorous and prolonged intravenous (IV) antibiotic therapy
      • Treatment of choice for acute osteomyelitis
      • Patients are often discharged to home care or skilled nursing facility with IV antibiotics
      • Antibiotic therapy may be continued at home for 4 to 6 weeks or as long as 3 to 6 months
      • Variety of antibiotics may be prescribed
      • Penicillin, Nafcillin
      • Neomycin, Vancomycin
      • Monitor for visual or hearing changes
      • BUN and creatinine should be monitored
      • Cephalexin (Keflex)
      • Cefazolin (Ancef)
      • Surgical treatment
      • Removal of poorly vascularized tissue and dead bone
      • Extended use of antibiotics
      • Antibiotic-impregnated bead chains can be implanted
      • Hyperbaric oxygen therapy with 100% oxygen
      • Stimulate circulation and healing
      • Bone grafts
      • Help restore blood flow
      • Amputation
      • Extensive bone destruction
      • Nursing Diagnoses
      • Acute pain
      • Inflammatory process secondary to infection
      • Impaired physical mobility
      • Pain, immobilization devices, weight-bearing limitations
      • Inability or unwillingness to change positions
      • Ineffective therapeutic regimen management
      • Lack of knowledge regarding long-term management of osteomyelitis
      • Nursing Implementation
      • Health Promotion
      • Control infections already in body
      • Susceptible adults
      • Acute Intervention
      • Assessment and management of patient’s pain level
      • Dressings to absorb exudate from draining wounds
      • Immobilization of affected area
      • Maintain proper body alignment
      • Bed rest
      • Promotes healing
      • Reposition frequently
      • Prevent complications related to immobility
      • Teaching
      • Activities to avoid
      • Examples: exercise, heat application
      • ↑ circulation and swelling
      • Adverse reactions with prolonged antibiotic therapy
      • Secondary infections
      • Example: Candida albicans
      • Emotional support
      • Patient and family often frightened and discouraged
      Osteoporosis <br />
      • What is it?
      • Chronic, progressive metabolic bone disease
      • Characterized by porous bone and low bone mass
      • Structural deterioration of bone tissue
      • Increased bone fragility
      • Risk factors
      • Female gender
      • Eight times more common in women than men
      • Lower calcium intake than men
      • Bone resorption begins earlier and accelerates after menopause
      • Pregnancy and breastfeeding
      • Deplete woman’s skeletal reserve of calcium
      • Longevity increases likelihood of osteoporosis
      • Women live longer than men
      • Increasing age
      • Decrease in hormones and weight-bearing activity
      • Early menopause
      • Excess alcohol intake
      • Cigarette smoking
      • Anorexia
      • Oophorectomy
      • Sedentary lifestyle
      • Obesity: more stress on bones
      • Insufficient calcium intake
      • Low testosterone levels in men
      • Patho: Normal vs. Osteoporotic Bone
      • Osteoporosis: bone resorption exceeds bone deposition
      • Occurs most commonly in spine, hips, and wrist
      • Many drugs can interfere with bone metabolism
      • Diseases associated with osteoporosis
      • Intestinal malabsorption
      • Kidney disease
      • Rheumatoid arthritis
      • Hyperthyroidism
      • Chronic alcoholism
      • Cirrhosis of the liver
      • Hypergonadism
      • Diabetes mellitus
      • Signs and Symptoms
      • “Silent disease”
      • Usual first signs
      • Back pain
      • Spontaneous fractures
      • Examples: back, hip, wrist
      • Loss of height
      • Spinal deformities
      • Kyphosis
      • Diagnostic Studies
      • Dual-energy x-ray absorptiometry (DEXA)
      • Measures bone mass of spine, femur, forearm and total body
      • Uses minimal radiation, painless procedure
      • Quantitative ultrasound
      • Evaluates density, elasticity, and strength of patella and calcaneus using ultrasound
      • Treatment
      • Proper nutrition
      • Prevention and treatment depend on adequate calcium intake
      • Increased calcium prevents future loss but will not form new bone
      • Good sources of calcium
      • Milk , yogurt
      • Turnip greens
      • Spinach
      • Cottage cheese
      • Ice cream
      • Sardines
      • Poor sources of calcium
      • Eggs
      • Beef
      • Poultry
      • Pork
      • Apples and bananas
      • Potatoes and carrots
      • Supplemental vitamin D
      • May be recommended
      • Exercise
      • Should be encouraged to build up and maintain bone mass
      • Smoking cessation
      • Decrease alcohol intake
      • ↓ losing bone mass
      • Drug therapy
      • Estrogen replacement after menopause
      • Helps decrease bone resorption
      • Works best when combined with calcium supplementation
      • Calcitonin
      • Secreted by thyroid gland
      • Inhibits bone resorption
      • Bisphosphonates
      • Examples: etidronate (Didronel), alendronate (Fosamax)
      • Inhibit bone resorption
      • Proven to increase bone mass by 5%
      • Medication teaching
      • Take med with full glass of water
      • Take 30 min before food or any other meds
      • Remain upright for at least 30 min after taking
      Paget’s Disease<br />
      • What is it?
      • Bone disorder in which there is excessive bone resorption followed by replacement of the normal marrow with fibrous connective tissue
      • Causes bones to become larger but weaker
      • Structure of bone becomes unorganized
      • Usually affects pelvis, long bones, spine, ribs, sternum, and skull
      • Signs and Symptoms
      • Pain
      • Severe, persistent
      • Worsened by weight-bearing activities
      • Cranial enlargement
      • Barrel-shaped chest
      • Asymmetric bowing of tibia and femur
      • Pathologic fractures
      • Loss of height
      • Headaches
      • Visual changes
      • Diagnostic Studies
      • Serum alkaline phosphatase ↑
      • Enzyme involved with bone cell formation
      • X-rays
      • Shows bone deformity and increased bone density
      • Treatment
      • Calcitonin
      • Slows rate of bone breakdown
      • Pain reduction
      • Examples: ASA, Tylenol, NSAIDs
      • Orthotics
      • Example: Heel lifts
      • Physical therapy
      • Bed rest should be avoided
      • Helps prevent hypercalcemia
      • Nutritional support
      • Calcium and vitamin D
      Intervertebral Lumbar Disk Damage<br />Degenerative disk disease<br />
      • Degenerative Disk Disease
      • What is it?
      • Progressive degeneration of intervertebral disks
      • Disk becomes thin and drys out
      • Compression of nerve roots and spinal cord can occur
      • Herniated intervertebral disk
      • What is it?
      • Can occur from natural degeneration with age
      • Repeated stress and trauma to spine
      • Most common sites of rupture: L4-5 and L5-S1
      • Can occur in cervical disks
      • Signs and Symptoms
      • Low back pain
      • Can radiate down to the buttock to below the knee
      • Can be reproduced
      • Raising leg and flexing the foot at 90 degrees
      • Diagnostic Studies
      • X-rays
      • Myelogram
      • Injects dye into sac around the nerve roots
      • Patient may experience a spinal headache
      • Should resolve in 1-2 days with rest and fluids
      • Treatment
      • Conservative
      • Restricted activity
      • Medication
      • NSAIDs, short-term opioids, muscle relaxants
      • Epidural steroid injections
      • Ice or heat
      • Physical therapy
      • Surgical therapy
      • Laminectomy
      • Removal of protruding disk
      • Diskectomy
      • Decompress nerve root
      • Spinal fusion
      • Performed if unstable bone pieces are present
      • Charite disk
      • Artificial disk used with patients with degenerative disk disease
      • Postoperative Care
      • Bedrest
      • Log rolling
      • Pillow can be placed in between legs for comfort
      • Proper body alignment
      • Monitor for spinal headache
      • Frequent monitoring of peripheral neurologic status
      • Every 2-4 hrs after for the first 48 hours
      • Compare to baseline assessment
      • Monitor bowel and bladder function
      • Nerve damage possible