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fractures occur. Structural bowing of the legs causes malalignment of the hip, knee, and ankle joints, which contributes to the development of arthritis and back and joint pain (Josse, et al., 2007).

Clinical Manifestations
Pagets disease is insidious; most patients never experience symptoms. Some patients do not experience symptoms but have skeletal deformity; a few patients have symptomatic deformity and pain. The condition is most frequently identied on x-ray studies performed during a routine physical examination or during a workup for another problem. Sclerotic changes, skeletal deformities (eg, bowing of the femur and tibia, enlargement of the skull, deformity of pelvic bones), and cortical thickening of the long bones occur. In most patients, skeletal deformity involves the skull or long bones. The skull may thicken, and the patient may report that a hat no longer ts. In some cases, the cranium, but not the face, is enlarged. This gives the face a small, triangular appearance. Most patients with skull involvement have impaired hearing from cranial nerve compression and dysfunction. Other cranial nerves may also be compressed. The femurs and tibiae tend to bow, producing a waddling gait. The spine is bent forward and is rigid; the chin rests on the chest. The thorax is compressed and immobile on respiration. The trunk is exed on the legs to maintain balance and the arms are bent outward and forward and appear long in relation to the shortened trunk (Porth & Matn, 2009). Pain, tenderness, and warmth over the bones may be noted. The pain is mild to moderate, deep, and aching; it increases with weight bearing if the lower extremities are involved. Pain and discomfort may precede skeletal deformities of Pagets disease by years and are often wrongly attributed by the patient to old age or arthritis. The temperature of the skin overlying the affected bone increases because of increased bone vascularity. Patients with large, highly vascular lesions may develop high-output cardiac failure because of the increased vascular bed and metabolic demands.

and stability are adequate. Severe degenerative arthritis may require total joint replacement. Loss of hearing is managed with hearing aids and communication techniques used with hearing-impaired people (eg, speech reading, body language) (see Chapter 59).
Pharmacologic Therapy

Patients with moderate to severe disease may benet from specific antiosteoclastic therapy. Several medications reduce bone turnover, reverse the course of the disease, relieve pain, and improve mobility. Calcitonin, a polypeptide hormone, retards bone resorption by decreasing the number and availability of osteoclasts. Calcitonin therapy facilitates remodeling of abnormal bone into normal lamellar bone, relieves bone pain, and helps alleviate neurologic and biochemical signs and symptoms. Calcitonin is administered subcutaneously or by nasal inhalation. Side effects include ushing of the face and nausea. The effect of calcitonin therapy is evident in 3 to 6 months through reduction of bone loss and pain. Bisphosphonates produce rapid reduction in bone turnover and relief of pain (Keating & Scott, 2007). They also reduce serum alkaline phosphatase and urinary hydroxyproline levels. Food inhibits absorption of these medications. Adequate daily intake of calcium and vitamin D is required during therapy. Plicamycin (Mithracin), a cytotoxic antibiotic, may be used to control the disease. This medication is reserved for severely affected patients with neurologic compromise and for those whose disease is resistant to other therapy. This medication has dramatic effects on pain reduction and on serum calcium, alkaline phosphatase, and urinary hydroxyproline levels. It is administered by IV infusion; hepatic, renal, and bone marrow function must be monitored during therapy. Clinical remissions may continue for months after the medication is discontinued.

Gerontologic Considerations
Because Pagets disease tends to affect elderly people, careful assessment of a patients pain and discomfort is necessary. Patient teaching helps the patient understand the treatment regimen, the need for a diet with adequate calcium and vitamin D, and how to compensate for altered musculoskeletal functioning. The home environment is assessed for safety to prevent falls and to reduce the risk of fracture. Strategies for coping with a chronic health problem and its effect on quality of life need to be developed.

Assessment and Diagnostic Findings

Elevated serum alkaline phosphatase concentration and urinary hydroxyproline excretion reect increased osteoblastic activity. Higher values suggest more active disease. Patients with Pagets disease have normal blood calcium levels. Xrays conrm the diagnosis of Pagets disease. Local areas of demineralization and bone overgrowth produce characteristic mosaic patterns and irregularities. Bone scans demonstrate the extent of the disease. Bone biopsy may aid in the differential diagnosis (Porth & Matn, 2009).

Musculoskeletal Infections
OSTEOMYELITIS
Osteomyelitis is an infection of the bone that results in inammation, necrosis, and formation of new bone (Davis, 2005). Osteomyelitis is classied as: Hematogenous osteomyelitis (ie, due to bloodborne spread of infection) Contiguous-focus osteomyelitis, from contamination from bone surgery, open fracture, or traumatic injury (eg, gunshot wound)

Medical Management
Pain usually responds to NSAIDs. Gait problems from bowing of the legs are managed with walking aids, shoe lifts, and physical therapy. Weight is controlled to reduce stress on weakened bones and malaligned joints. Asymptomatic patients may be managed with diets adequate in calcium and vitamin D and periodic monitoring. Fractures, arthritis, and hearing loss are complications of Pagets disease. Fractures are managed according to location. Healing occurs if fracture reduction, immobilization,

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Osteomyelitis with vascular insufciency, seen most commonly among patients with diabetes and peripheral vascular disease, most commonly affecting the feet (Davis, 2005) Patients who are at high risk for osteomyelitis include those who are poorly nourished, elderly, or obese. Other patients at risk include those with impaired immune systems, those with chronic illnesses (eg, diabetes, rheumatoid arthritis), and those receiving long-term corticosteroid therapy or other immunosuppressive agents. Postoperative surgical wound infections occur within 30 days after surgery. They are classied as incisional (supercial, located above the deep fascia layer) or deep (involving tissue beneath the deep fascia). If an implant has been used, deep postoperative infections may occur within a year. Deep sepsis after arthroplasty may be classied as follows: Stage 1, acute fulminating: occurring during the rst 3 months after orthopedic surgery; frequently associated with hematoma, drainage, or supercial infection Stage 2, delayed onset: occurring between 4 and 24 months after surgery Stage 3, late onset: occurring 2 or more years after surgery, usually as a result of hematogenous spread Bone infections are more difcult to eradicate than soft tissue infections because the infected bone is mostly avascular and not accessible to the bodys natural immune response. Also, there is decreased penetration by antibiotics. Osteomyelitis may become chronic and may affect the patients quality of life.

tender. The patient may describe a constant, pulsating pain that intensies with movement as a result of the pressure of the collecting purulent material (ie, pus). When osteomyelitis occurs from spread of adjacent infection or from direct contamination, there are no symptoms of sepsis. The area is swollen, warm, painful, and tender to touch (Davis, 2005; Forman, Forman & Rose, 2005). The patient with chronic osteomyelitis presents with a nonhealing ulcer that overlies the infected bone with a connecting sinus that will intermittently and spontaneously drain pus (Davis, 2005).

Assessment and Diagnostic Findings

In acute osteomyelitis, early x-ray ndings demonstrate soft tissue edema. In about 2 to 3 weeks, areas of periosteal elevation and bone necrosis are evident. Radioisotope bone scans, particularly the isotope-labeled white blood cell (WBC) scan, and magnetic resonance imaging (MRI) help with early denitive diagnosis. Blood studies reveal leukocytosis and an elevated ESR. Wound and blood culture studies are performed, although they are only positive in 50% of cases. Therefore, treatment with antibiotics may be prescribed without denitively isolating the offending organism (Davis, 2005). With chronic osteomyelitis, large, irregular cavities; raised periosteum; sequestra; or dense bone formations are seen on x-ray. Bone scans may be performed to identify areas of infection. The ESR and the WBC count are usually normal. Anemia, associated with chronic infection, may be evident. Cultures of blood specimens and drainage from the sinus tract are frequently unreliable; antibiotic therapy is many times prescribed presumptively without isolating the offending pathogen (Davis, 2005).

Pathophysiology
Over 50% of bone infections are caused by Staphylococcus aureus. Other pathogens that are frequently found in osteomyelitis include gram-positive organisms that include streptococci and enterococci, followed by gram-negative bacteria that include Pseudomonas species (Venugopalan & Martin, 2007). The initial response to infection is inflammation, increased vascularity, and edema. After 2 or 3 days, thrombosis of the local blood vessels occurs, resulting in ischemia with bone necrosis. The infection extends into the medullary cavity and under the periosteum and may spread into adjacent soft tissues and joints. Unless the infective process is treated promptly, a bone abscess forms. The resulting abscess cavity contains dead bone tissue (the sequestrum), which does not easily liquefy and drain. Therefore, the cavity cannot collapse and heal, as it does in soft tissue abscesses. New bone growth (the involucrum) forms and surrounds the sequestrum. Although healing appears to take place, a chronically infected sequestrum remains and produces recurring abscesses throughout the patients life. This is referred to as chronic osteomyelitis.

Prevention
Prevention of osteomyelitis is the goal. Elective orthopedic surgery should be postponed if the patient has a current infection (eg, urinary tract infection, sore throat) or a recent history of infection. During orthopedic surgery, careful attention is paid to the surgical environment and to techniques to decrease direct bone contamination. Prophylactic antibiotics, administered to achieve adequate tissue levels at the time of surgery and for 24 hours after surgery, are helpful. Urinary catheters and drains are removed as soon as possible to decrease the incidence of hematogenous spread of infection. Treatment of focal infections diminishes hematogenous spread. Aseptic postoperative wound care reduces the incidence of supercial infections and osteomyelitis. Prompt management of soft tissue infections reduces extension of infection to the bone. When patients who have had joint replacement surgery undergo dental procedures or other invasive procedures (eg, cystoscopy), prophylactic antibiotics are frequently recommended.

Clinical Manifestations
When the infection is bloodborne, the onset is usually sudden, occurring often with the clinical and laboratory manifestations of sepsis (eg, chills, high fever, rapid pulse, general malaise). The systemic symptoms at rst may overshadow the local signs. As the infection extends through the cortex of the bone, it involves the periosteum and the soft tissues. The infected area becomes painful, swollen, and extremely

Medical Management
The initial goal of therapy is to control and halt the infective process. Antibiotic therapy depends on the results of blood and wound cultures. General supportive measures (eg, hydration, diet high in vitamins and protein, correction of anemia) should be instituted. The area affected with osteomyelitis is immobilized to decrease discomfort and to prevent pathologic fracture of the weakened bone (Sheff, 2005).

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Pharmacologic Therapy

As soon as the culture specimens are obtained, IV antibiotic therapy begins, based on the assumption that infection results from a staphylococcal organism that is sensitive to a penicillin or cephalosporin. The aim is to control the infection before the blood supply to the area diminishes as a result of thrombosis. Around-the-clock dosing is necessary to maintain a high therapeutic blood level of the antibiotic. After results of the culture and sensitivity studies are known, an antibiotic to which the causative organism is sensitive is prescribed. IV antibiotic therapy continues for 3 to 6 weeks. After the infection appears to be controlled, the antibiotic may be administered orally for up to 3 months. To enhance absorption of the orally administered medication, antibiotics should not be administered with food (Davis, 2005; Sheff, 2005).
Surgical Management

corticosteroid therapy) and for a history of previous injury, infection, or orthopedic surgery. The patient avoids pressure and movement of the area. In acute hematogenous osteomyelitis, the patient exhibits generalized weakness due to the systemic reaction to the infection. Physical examination reveals an inamed, markedly edematous, warm area that is tender. Purulent drainage may be noted. The patient has an elevated temperature. With chronic osteomyelitis, the temperature elevation may be minimal, occurring in the afternoon or evening.

Nursing Diagnoses
Based on the nursing assessment data, nursing diagnoses for the patient with osteomyelitis may include the following: Acute pain related to inammation and edema Impaired physical mobility related to pain, use of immobilization devices, and weight-bearing limitations Risk for extension of infection: bone abscess formation Decient knowledge related to the treatment regimen

If the infection is chronic and does not respond to antibiotic therapy, surgical dbridement is indicated. The infected bone is surgically exposed, the purulent and necrotic material is removed, and the area is irrigated with sterile saline solution. Antibiotic-impregnated beads may be placed in the wound for direct application of antibiotics for 2 to 4 weeks (Kent, Rapp & Smith, 2006). IV antibiotic therapy is continued. In chronic osteomyelitis, antibiotics are adjunctive therapy to surgical dbridement. A sequestrectomy (removal of enough involucrum to enable the surgeon to remove the sequestrum) is performed. In many cases, sufcient bone is removed to convert a deep cavity into a shallow saucer (saucerization). All dead, infected bone and cartilage must be removed before permanent healing can occur. A closed suction irrigation system may be used to remove debris. Wound irrigation using sterile physiologic saline solution may be performed for 7 to 8 days. The wound is either closed tightly to obliterate the dead space or packed and closed later by granulation or possibly by grafting. The dbrided cavity may be packed with cancellous bone graft to stimulate healing. With a large defect, the cavity may be lled with a vascularized bone transfer or muscle ap (in which a muscle is moved from an adjacent area with blood supply intact). These microsurgery techniques enhance the blood supply. The improved blood supply facilitates bone healing and eradication of the infection. These surgical procedures may be staged over time to ensure healing. Because surgical dbridement weakens the bone, internal xation or external supportive devices may be needed to stabilize or support the bone to prevent pathologic fracture (Davis, 2005).

Planning and Goals

The patients goals may include relief of pain, improved physical mobility within therapeutic limitations, control and eradication of infection, and knowledge of the treatment regimen.

Nursing Interventions
Relieving Pain 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 analgesic agents and other pain-reducing techniques. Improving Physical Mobility 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 moved through their range of motion. The nurse encourages full participation in ADLs within the physical limitations to promote general well-being. Controlling the Infectious Process

NURSING PROCESS THE PATIENT WITH OSTEOMYELITIS

Assessment
The patient reports an acute onset of signs and symptoms (eg, localized pain, edema, erythema, fever) or recurrent drainage of an infected sinus with associated pain, edema, and low-grade fever. The nurse assesses the patient for risk factors (eg, older age, diabetes, long-term

The nurse monitors the patients response to antibiotic therapy and observes the IV access site for evidence of phlebitis, infection, or inltration. 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 is necessary, the nurse takes measures to ensure adequate circulation to the affected area (wound suction to prevent uid accumulation, elevation of the area to promote venous drainage, avoidance of pressure on the grafted area), to maintain needed immobility, and to ensure the

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CHART

HOME CARE CHECKLIST

68-9

Osteomyelitis
PATIENT CAREGIVER

At the completion of the home care instruction, the patient or caregiver will be able to: Describe osteomyelitis. Relieve pain with pharmacologic and nonpharmacologic interventions. State weight-bearing and activity restrictions. Demonstrate safe use of ambulatory aids and assistive devices. Describe use of prescribed medications. Comply with antibiotic regimen. Promote healing through aseptic dressing changes. Demonstrate proper wound care. Report signs and symptoms of continuing infection or superinfection.

        

  

patients adherence to weight-bearing restrictions. The nurse changes dressings using aseptic technique to promote healing and to prevent cross-contamination. The nurse continues to monitor the general health and nutrition of the patient. A diet high in protein promotes a positive nitrogen balance and healing. The nurse encourages adequate hydration as well. Promoting Home and Community-Based Care
TEACHING PATIENTS SELF-CARE.

follow-up health care appointments and recommends ageappropriate health screening (Chart 68-9).

Evaluation
Expected Patient Outcomes 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 edema d. Reports absence of drainage e. Laboratory results indicate normal white blood cell count and erythrocyte sedimentation rate f. Wound cultures are negative 4. Adheres to 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. Consumes a diet high in protein f. Keeps follow-up health care appointments g. Reports increased strength h. Reports no elevation of temperature or recurrence of pain, edema, or other symptoms at the site

The patient and family are taught about the importance of strictly adhering to the therapeutic regimen of antibiotics and preventing falls or other injuries that could result in bone fracture. They need to learn to maintain and manage the IV access and IV administration equipment in the home. Teaching includes medication name, dosage, frequency, administration rate, safe storage and handling, adverse reactions, and necessary laboratory monitoring. In addition, aseptic dressing and warm compress techniques are taught. The nurse carefully monitors the patient for the development of additional sites that are painful or sudden increases in body temperature. The nurse instructs the patient and family to observe for and report elevated temperature, drainage, odor, signs of increased inammation, adverse reactions, and signs of superinfection.

CONTINU ING CARE. Management of osteomyelitis, including wound care and IV antibiotic therapy, is usually performed at home. The patient must be medically stable and physically able and motivated to adhere strictly to the therapeutic regimen of antibiotic therapy. The home care environment needs to be conducive to the promotion of health and to the requirements of the therapeutic regimen. If warranted, the nurse completes a home assessment to determine the patients and familys abilities regarding continuation of the therapeutic regimen. If the patients support system is questionable or if the patient lives alone, a home care nurse may be needed to assist with IV administration of the antibiotics. The nurse monitors the patient for response to the treatment, signs and symptoms of superinfections, and adverse drug reactions. The nurse stresses the importance of