BACKGROUND

As a Bachelor of Nursing science curriculum & under practicum of Child health nursing, we
require doing four weeks practicum in Hospital. We were posted in various wards at T.U.T.H
and Kanti Children Hospital for the fulfillment of this requirement. During this practicum we
have to perform one case study of the child and provide care to the patient in a holistic approach.
Therefore I have chosen a case of Acute Osteomyelitis in Annex ward of Kanti Children’s
Hospital. This case study was designed so as to gain a comprehensive knowledge of the disease
and to provide holistic care of the patient.

I had performed the complete study of the patient and his disease. For this I have consulted many
books and web sites & compared it with the patient. While caring the patient, I have applied the
rehabilitation process and holistic approach. From this case study, I have gained complete
knowledge about the disease and its management. This case study includes all the information
about the patient, disease process, causes, sign and symptoms, pathphysiology, treatment,
nursing management, care plans, drugs regimen and discharge planning.
OBJECTIVES OF THE CASE STUDY

A. General Objectives
To gain knowledge and to further understand the nature & extent of disease so as to prepare and
arm ourselves with knowledge whenever we encounter the same case in future, and also to have
a clear and better understanding about Osteomyelitis particularly on its disease process,
treatments, diagnostic exam, preventive and nursing management and to provide holistic nursing
care based on scientific approach to the selected case.

B. Specific Objectives
 To know the latest facts & keep ourselves updated with the newest information about the
diseases.
 To provide the holistic nursing care to the client using nursing process.
 To apply knowledge from basic sciences and nursing theories in planning comprehensive
care of the client.
 To be familiar with the disease & medical used that may help us in doing health teaching
with our client.
 To formulate nursing diagnosis and priorities nursing care plan according to patient’s needs.
 To provide individualized quality care to the patient by using a holistic nursing care and
problem solving approach.
 To provide emotional and physical support to patient and his family during the treatment
process.
 To facilitate communication by providing proper counseling to the patient and his family
regarding his condition.
 To collaborate with client, family members and other health worker to plan the discharge and
follow up care.
 To be well acquainted with the equipment, procedures and facilities used in the management
of patients with specific case.
 To teach patient and patient families about the disease and its complication management and
promotion of health.
 To study, document and present a case report on Osteomyelitis.
PATIENT’S PROFILE
BIOGRAPHICAL DATA OF PATIENT
Date of interview : 071/5/18
Name of the patient : Mr. Abhisek Gubaju

Mother’s name : Muna Gubaju

In patient number : 96169
Age/Sex : 12 years/male
Ward : Annex-1
Date of admission : 071/5/12 at 2 pm
Bed No. : 25
Religion : Hindu
Provisional Diagnosis : Acute Osteomyelitis, right tibia with
abscess
Ethnicity : Newar
Marital Status : Unmarried
Address : Balaju, Kathmandu
Age Group : School age (middle childhood)
Education : 6 class
Occupation : Student
Attending Dr. :
Date of Discharge : 2071/5/19
Total hospital stay : 8 days

HEALTH HISTORY OF PATIENT

1. Chief Complaints
  Pain and swelling of right lower limb for 7 days
 Patient complained that he developed fever for 2 days
 Joint pain and tenderness

2. History of Present Illness

According to the patient and patient’s mother, he was apparently well a week back. After that
swelling starts to begin on right lower limb. There was a small abscess at first but suddenly it
starts to increase in size and severe pain and then he was taken to Baipass Samudayek hospital
near the locality. There he was treated with Cap. Megapen 500 mg,QID for a week and Tab.
Flexon 1 tab, PO, SOS. Patient became still symptomatic after taking medicine for a week and
they came Kanti Children Hospital for further evaluation. He was brought to the Emergency,
diagnosed as Osteomyelitis and plan for operation.

3. History of Past Illness:

He had no history of any childhood illness like mumps, measles, whooping cough, polio,
rheumatic fever, tuberculosis, malnutrition etc but he had history of hospitalization 5 years back
as diagnosed with Pleural effusion. He got admitted on International friendship hospital for 19
days. Not known allergic history till now.

Obstetric History

 ANC visit : Yes

 Frequency : 6times
 Place :Teaching hospital, Maharajgunj
 Illness/Infection during pregnancy : No
 Type of delivery : Normal Vaginal Delivery
 Duration of pregnancy : Term
 Condition of baby at birth : Good
 Cried immediately : Yes
 Weight :3.5 kg
 Any complication at birth : No
 Duration of breast feeding :3 years
 Age of weaning : 5months
Immunization and birth history:

He was born in hospital with the help of health personnel. He has completed all immunization
according to NIP protocol.

Immunization Status:

Type of vaccine Given Age of completion Remark

BCG Yes Within a week
DPT/Polio:
1st Yes 6weeks of birth
2nd Yes 4weeks after 1st dose
3rd Yes 4weeks after 2nd dose

Hepatitis B:
1st Yes 6weeks of birth (with DPT)
2nd Yes 4weeks after 1st dose
3rd Yes 4weeks after 2nd dose
Measles Yes 9 months after birth
Others - -

4. Developmental history (milestones)

Crawl : 4 months
Sitting with support : 7 months
Creeps : 9 months
Stand with support : 10 months
Walk with support : 12 months
Eruption of first deciduous teeth : 7 month (lower incision)
Eruption of permanent teeth: 5 years
5. Personal History:
 Hospital delivery
 Studied at class 6
 Student by occupation
 Has regular bowel and bladder habit
 No any history of allergies

6. Health Seeking Practice

The patient’s family has faith in god and believes in evil spirit. They do believe in traditional health
practice dhamijhakri. But the patient doesn’t believe in such practice. So, when he became ill their parents
also go to the traditional healer as well as come to hospital

7. Family History
 He is from the rich family. The source of income of family is business. No family history of
significant diseases like Hypertension, Diabetes, Asthma, Cancer except his grand-mother. His
grandmother was asthma patient.

8. Social History

The housing facility of the patient is good. There is adequate room for each family member. The
sanitation around the home is well managed. Sanitary latrine used. They either boil or filter the
drinking water. The relationship of patient within the family members, siblings and friend is
good.

GENOGRAM

48yrs

Index
55yrs

: Patient

: Male
18 yrs
: Female

: Deceased female

: Deceased male

: Marriage

: Offspring

: Siblings
PHYSICAL EXAMINATION

Physical examination is the process by which a medical professional assess the patient's body for
signs of disease .It generally follows the talking of the medical history. It is also known as
medical examination, clinical examination or check-up. Medical examination and physical
examination aids in determining the correct diagnosis and treatment.

Vital signs and clinical Measurement

Temperature : 37.40C

Pulse : 82/min

Respiration : 26/min

Blood Pressure: 100/50mm of hg

Height : 150 cm

Weight : 36 kg

General appearance

State of consciousness : alert, oriented, conscious

Nutritional status : maintained as children in relation to age, well nourshied

Facial expression : interactive, not depressed

Hygiene status : maintained

Gait : can’t stand

Examination, head to toe

Head:

Shape : round

Size : normal and symmetrical

Color of hair : smooth black color hair,

Cleanliness : maintained
Nodules : not found

Injuries : no any scar, depression and injuries

Face

Shape : symmetrical, no facial palsy

Appearance : normal, no swelling and puffiness

Eyes

Size and shape : normal and symmetrical

Position : lie in an imaginary lie drawn from outer canthus to ear

Eyelids : No drooping, no swelling and discharge present in both

Sclera : whitish, no sign of jaundice

Conjunctiva : pinkish red, no sign of anemia and infection

Cornea : transparent, shin, no corneal opacity, no abrasions and white spots

Pupil reflex : bilaterally pupil was reactive to light, constrict equally

Corneal reflex : present

Eye movement : both eyes moves together and follow object

Extra-ocular movement: normal; followed the pen when swept through the 6 cardinal
direction
Lymph nodes : pre-auricular, post-auricular lymph nodes are not palpable

Ears
Shape and size : Bilaterally symmetrical
Location : both were just 1/3 level above the outer canthus of the eye
Discharge : No presence of discharge but presence of mild wax
Tympanic membrane : pinkish and intact
Hearing : intact, good
Tinnitus : not present
Pain : No pain and itching
Nose

Location : Centrally located nose between two eyes

Shape : symmetrical, no deviation and deformities

Discharge : No discharge and bleeding

Patency : Patent, no polyp, masses, lesion and foreign bodies

Nostrils : Both nostrils were equal and no flaring

Mucosal lining : Red and moist, no ulceration

Smell : No normal sense of smell, can’t differentiate the smell of soap

Mouth/ Teeth/ Throat

Lips : Moist and pink lips, no cracks and ulcer

: No sign of dehydration, no stomatitis
Mucous membrane : Pink and moist
Teeth : Dental caries presents in two lower premolar teeth
: missing upper canine and eruption of left lower molar
Tongue : moist and pinkish in color, not coated, centrally located, no tongue tie
Tonsils : Pink and small tonsils, not enlarged, not palpable
Uvula : located in center behind the soft palate and pink in color

Neck

Size and symmetry : normal and symmetrical

Mobility : good range of motion

Trachea : centrally located at midline

Swallowing : No difficulty in swallowing

Jugular / subclavian vein : No distended jugular and subclavian vein

Thyroid gland : not palpable

Lymph nodes : Sub-mental, clavicular lymphnodes not palp

Chest & Lungs

Respiratory system (Lungs)
 No dyspnea
 No hemoptysis
 Complain of cough during physical examination but not before Chest (lungs)
On Inspection

Shape and size : Normal in shape, size & symmetry, sternum located at the mid line
Chest movement : Bilaterally symmetrical expansion of the chest
Diameter : Later diameter is greater than anterior-posterior diameter
Chest in-drawing : No intercostal retraction
Abnormalities : no abnormal masses, Scar on left costal margin due to insertion of chest
tube 5 years back (history of pneumothorax)
On Palpation

 No depression or abnormalities noted

 No tenderness over the chest
 Vocal fremitus: normal, not exaggerated
On Percussion

 Resonant sound over the lung field present

On Auscultation

 Bilaterally equal air entry present

 No adventitious sound present, no wheeze, crackles.
Cardiovascular system (Heart):

Heart (auscultate four areas)

Aortic area : 2nd right inter-coastal space close to sternum

Pulmonary area : 2nd left inter-coastal space close to sternum

Tricuspid area : 5th inter-costal space close to sternum

Mitral area : 5th left inter-costal space, mid-clavicle line just below the nipple

 Normal S1 & S2 heart sound over four area of the heart (Aortic area, Pulmonic area,
triscupid area, mitral area)
 No murmur present
 Heart sound normal & regular
 Peripheral pulse: Palpable in all peripheral sites
 Apical pulse was 84/min

Gastro-Intestinal System
 Normal appetite
 No nausea, vomiting, dyspepsia, heart burn
 No abdominal pain
 Change in bowel habit(constipation)
 No Haematemesis, hemorrhoid, melena
 On inspection
 No scar of injury or operation.
 Oval shaped abdomen
 No prominent abdominal veins, no herniation
 On auscultation
 Bowel sound present in all four quadrants.
 On percussion
 Tympanic sound present all over the four quadrants.
 On palpation
 No tenderness present.
  No extra growth or mass palpable
 No organ palpable.
Genitourinary System

Was not examined as patient refused for examination and according to the patient he doesn’t
have any anatomical abnormalities.

 No fissures in anus, any irritation & distended vein

Musculo-Skeletal System: Limbs/ Extremities

Symmetry : bilaterally symmetrical in shape and size

Motion : good range of motion except right lower limb

Deformity : right leg was bandaged

Edema/swelling : absent

Joint mobility : no full range of motion of right leg due to surgical procedure

Strength : normal strength of left leg, right leg has………

: Muscle power of upper and left lower limbs: 5/5

Spine and back

Position of spine : normal, medially located with no any deviation

Condition of skin : normal, no any breakdown, dimples and sinuses

On auscultation : normal breath sound

Reflexes

 Biceps : intact
 Triceps : intact
 Knee jerk reflexes : intact
 Ankle jerk reflexes : intact
 Planter reflex: dorsiflexion of toe and fanning of others fingers
 Nervous System: Examination of the nervous system was done by testing of muscle strength,
sensations, balance and coordination.

Examination
 The muscle strength was examined by pushing
against the patient' hands and feet and asking his
to resist the push.
 Sensation was examined by asking him to close
the eyes and placing fingers in his different parts
and asking him to identify the location of the
touch
Findings
 Equal strength on both hands and
left feet; no muscular weakness.
 Felt sensation equally in the area
or touch.

 GROWTH AND DEVELOPMENT OF SCHOOL AGE

SN. According to Book According to Patient

1. Physical Growth
Weight: 6 years-21kg, 12 years-40 kg Weight is 36 kg which is average weight
Height: 117-150cm Height is within the normal limit; 150cm
Muscular development less developed comparison Because of skeletal development as compared
to skeletal system. child seems thin and cylindrical.

2. Intellectual(cognitive) Development
Understands the principle of combination, they can Present in my patient.
add, subtract and count objects.
3. Moral Development
School age child adopts and internalize the moral Present in my patients. He respects his seniors
values of their parents. and also greets his teachers, uncle aunt.

4. Spiritual Development
Learns the differences between the natural and Believes in the god and his favorite god is
supernatural power and comforted by prayers or Ganesh.
other religious rituals.
 DEVELOPMENTAL MILESTONE OF SCHOOL AGE:

The segment of the life span that extends from age 6-12 years is called school age. It is also
called middle childhood. This period begins with entrance into the wider sphere of influence
represented by the school environment, which has a significant influence on development and
relationship.

1. Motor development
2. Language development
3. Personal and social development
4. Play
5. Psychosocial development
6. Psychosexual development
7. Cognitive development
8. Moral and spiritual development

I. Motor Skill Development

 Gross and fine motor skills continue to mature throughout the school age years.

A. Gross Motor Development

S.N Milestone Fully Partially Not
Achieved achieved Achieved
1. During middle childhood, coordination, balance and 
rhythm improve facilitating the opportunity to involve in
variety of sports.
2. They enjoy gross motor activities like bicycling, skating, 
jumping, skipping, dance, swimming etc.
 B. Fine Motor Development

S.N Milestone Fully Partially Not

Achieved achieved Achieved
1. Have refined fine motor skill due to myelination of the 
neuron.
2. Eye, hand coordination and balance improve, movement 
are more graceful, dressing and grooming skill developed

II. Language Development

S.N Language Behavior Fully Partially Not
Achieved achieved Achieved
1. The child develops formal adult articulation. 

2. They learn to arrange words in terms of structure, develops 

ability to read, write, calculate, use shorter and more compact
sentences

III. Personal and Social Development

S.N Social Development Fully Partially Not
Achieved achieved Achieved
1. Child becomes increasingly involved in more complex 
activities, decision making and goal directed activities.
2. Widen social relationship when exposed within the new 
environment (school).In addition to parents and the
schools, peer group relationships are also important
during school years.
3. They can learn different social skills, to gain 
independency.
4. They have intimate same sex friend with whom they share   
 secrets, adventures.
5. Peer group identification and association are essential to 
child's socialization at this age.
6. Parents are the primary influential and necessary to 
normal child's personality, setting standard of behavior,
establishing value system.

IV. Play Therapy

S.N Play Therapy Fully Partially Not

Achieved achieved Achieved
1. Play becomes more competitive and complex and includes 
team sports, quiet games, activities like puzzles, quiet board
games reading, video games etc.
2. Rules, regulations, and rituals are important aspect of game. 
3. Toys and games activities that promote growth and 
development are- Books and crafts, Music and arts, Athletic
activities, Team game activities, Board cards puzzle games,
TV program and videogame.

V. Psycho Social Development

('Industry Verses Inferiority'-Erikson)

If the child has achieved first three stage of developmental task, now he/she focuses mastering
industry. A sense of industry or stage of accomplishment involves learning skills and preparing
and participating meaningful and socially productive or useful task. They become eager to
complete the task by themselves. He/ she is very interested in learning how things are made and
work. There is increase in neuromuscular abilities in gaining new skills increased interest in
carrying out new responsibilities. The sense of industry also includes the child's ability to
cooperate and compete with others. It is the period of learning to share the work, involve in
group activities.
If the child is not able to perform the responsibilities associated with accomplishing the sense of
industry, he/she may develop the feeling of inferiority. The feeling of inferiority may develop
either from the child himself or from social criticism. If the child has mental or physical
disabilities he/she is unable to perform certain skills and feel handicapped or inadequate.

In my Patient-This stage is present in my patient if he does not get the marks as expected by
him then he becomes sad. He wants to be praised by his parents, his teachers.

VI. Psychosexual Development ('Latency stage'- Freud)

Starting at the age of 6 years and throughout the school age, the child enters a calm period in the
development of sexuality called latency. Freud theorized that the school- age child identifies with
the same sex parent by modeling the behaviour and emotion of this parent. In this stage overt
sexual interest is repressed and sublimated. Child attention is focused on peer activities and
relationship with same sex.

In my Patient-This Period is also present in my patient. He prefers and enjoys playing with
same sex peers and has friends of same sex.

VII. Cognitive Development

Thought processes undergo dramatic changes as the child moves from the intuitive thinking of
the preschool years to the logical operations of the school-age years. The school-age child gains
new knowledge and develops more efficient problem- solving ability and greater flexibility of
thinking.

VIII. Moral and Spiritual Development

There is an orientation towards respecting authority, obeying rules and maintaining social order.
it is during school-age that children develop an interest in religion. They are still concrete
thinkers and are guided by their family’s religious and cultural beliefs.
 DEVELOPMENTAL TASK OF SCHOOL AGE

Since my patient has passed the pre scholar period and entered into school period. He has
achieved all the developmental task of preschooler like

S.N Developmental task of School Age(According to book) Fully Partially Not

Achieved achieved Achieved
1. Increasing neuromuscular skills so that he can participate in 
games and work with others. Learning physical skills for
ordinary games.
2. Learning to get along with the similar age mates. 

3. Learning ways to communicate with others realistically. 

4. Learning an appropriate masculine or feminine social role for 

social acceptance.
5. Developing fundamental skills in reading, writing, and 
calculating.
6. Achieving personal independence. Decreasing dependency on 
family and gaining some satisfaction from pair and other
adults.

7. Developing conscience, morality and values. 

8. Building a positive attitude towards own self and others. 

9. Becoming a more active and cooperative in family 

participation.
DISEASES PROCESS:
( ACUTE OSTEOMYELITIS)
 This is an acute inflammation of the of bone/ joint and bone marrow, which is usually
caused by the local infection of the bone by accident/ compound fracture, surgery,
amputation etc. Osteomyelitis can occur in infants, children, and adults. Different types of
bacteria typically affect the different age groups. In children, osteomyelitis most commonly
occurs at the ends of the long bones of the arms and legs, affecting the hips, knees, shoulders,
and wrists. In adults, it is more common in the bones of the spine (vertebrae), feet, or in the
pelvis.
 In chronic osteomyelitis sinus formation is usual. Subacute osteomyelitis is associated
with a chronic abscess within the bone (Brodie’s abscess).symptoms may be limited to
local pain. Relapses may occur when the general health becomes poor and the patient’s
power of resistance is lowered. Discharging sinuses may be present, and deformity may
occur from interference with bone growth or instability of joints. Pathological fracture
may occur.
Chronic osteomyelitis is sometimes seen following an injury, e.g. an open fracture, or
following orthopedic surgery.

 Tubercular osteomyelitis:
This is usually due to haematogenous spread from a reactivated primary focus in the
lungs or gastrointestinal tract. The spine is commonly affected( pott’s diseases), with the
damage to the bodies of two neighbouring vertebrae leading to vertebral collapse and
angulation of the spine. Later an abscess forms. Pus can track along tissue planes and
discharge at a point far from the affected vertebrae. Symptoms consist of local pain and
later swelling if pus has collected. Systemic symptoms of malaise, fever and night sweat
occurs. Treatment is as far as pulmonary tuberculosis but extended to 9 months together
with initial immobilization
  Incidence: occurring most common in boys under the age of sixteen years
The most common site of local infection is the metaphysis of long bone.
Osteomyelitis can occur in sickle cell diseases.
 Pathophysiology:
Organism enters the periosteum of the bone.
Inflammatory process causes exudate suppuration ( pus formation) and necrosis of the
local tissue
Pressure on the softened tissue breaks and a small piece of bone (sequestrum) gets
inside the bone cavity.
This might leads to sinus formation an continuous/ frequent discharge and form and
unhealing area. At times even the growth of the bone is retarted.

On the basis of the route of infection, acute osteomyelitis can be classified as hematogenous or
exogenous (see the images below). Hematogenous osteomyelitis is predominantly seen in
children and involves the highly vascular long bones, especially those of the lower limb. In
adults, hematogenous spread is more common to the lumbar vertebral bodies than elsewhere. In
neonatal osteomyelitis, isotopic bone scans are reportedly normal in most patients.

Chest radiograph in an 8-year-old girl who presented with

staphylococcal pneumonia. Streptococcal osteomyelitis in a 3-year-old

patient presenting with periosteal new-bone formation of the tibia.
Before puberty, infection starts in the metaphyseal sinusoidal veins. Because bones are relatively
rigid structures, focal edema accumulates under pressure and leads to local tissue necrosis,
breakdown of the trabecular bone structure, and removal of bone matrix and calcium. Infection
spreads along the haversian canals, through the marrow cavity, and beneath the periosteal layer
of the bone. Subsequent vascular damage causes the ischemic death of osteocytes, leading to the
formation of a sequestrum. Periosteal new-bone formation on top of the sequestrum is known as
involucrum.

Osteomyelitis may be acute, subacute, or chronic. With acute osteomyelitis, the presenting
complaint is usually local pain, swelling, and warmth. These often occur in association with
fever and malaise.

Differentiating acute osteomyelitis from bone infarction in patients with sickle cell disease is a
major challenge. The 2 conditions must be differentiated on the basis of clinical findings and
imaging studies because both are common in patients with sickle cell disease. The 2 diseases are
managed differently.

Fine-needle aspiration (FNA) or needle biopsy may be used under ultrasonographic,

fluoroscopic, or CT guidance to obtain samples of pus, tissue, or both to establish a histologic
diagnosis of acute osteomyelitis.

The disease process involves 5 stages:

1. Inflammation: This stage represents initial inflammation with vascular congestion and increased
intraosseous pressure; obstruction to blood flow occurs with intravascular thrombosis.
2. Suppuration: Pus within the bones forces its way through the haversian system and forms a
subperiosteal abscess in 2-3 days
3. Sequestrum: Increased pressure, vascular obstruction, and infective thrombus compromise the
periosteal and endosteal blood supply, causing bone necrosis and sequestrum formation in
approximately 7 days
4. Involucrum: This is new bone formation from the stripped surface of periosteum
5. Resolution or progression to complications: With antibiotics and surgical treatment early in the
course of disease, osteomyelitis resolves without any complications

Causes:

There are several different ways to develop the bone infection of osteomyelitis. The first is for
bacteria to travel through the bloodstream (bacteremia) and spread to the bone, causing an
infection. This most often occurs when the patient has an infection elsewhere in the body, such
as pneumonia, an abscessed tooth, or a urinary tract infection that spreads through the blood to
the bone.

An open wound over a bone can lead to osteomyelitis. This happens most commonly with
underlying peripheral vascular disease, peripheral neuropathy, or diabetes. With an open fracture
(compound fracture), the bone that punctures through the skin is exposed to bacteria. This
increases the risk of osteomyelitis.
A recent surgery or injection around a bone can also expose the bone to bacteria and lead to
osteomyelitis.

Patients with conditions or taking medications that weaken their immune system are at a higher
risk of developing osteomyelitis. Risk factors include cancer, chronic steroid use, sickle cell
disease, human immunodeficiency virus (HIV), diabetes, hemodialysis, intravenous drug users,
infants, and the elderly.

Osteomyelitis can be due either to metastatic heamtogenous spread (e.g from a boil)or to
local infection.

 malnutrition, debilitating diseases and decreased immunity may play part in the
pathogenesis
 staphylococcus is the organism responsible for 80% of cases of acute osteomyelitis. there
is frequently a history of a lesion in the skin, such as boil or infected abrasion, or, an
infected abrasion, or, an infected tooth or upper respiratory tract infection.
 Other organism includes Haemophilus influenza and salmonella:



Clinical manifestation: Symptoms of Osteomyelitis

Acute osteomyelitis develops rapidly over a period of seven to 10 days. The symptoms for acute
and chronic osteomyelitis are very similar and include:

 Fever, irritability, fatigue

 Nausea
 Tenderness and swelling around the affected bone
 Lost range of motion

Osteomyelitis in the vertebrae makes itself known through severe back pain, especially at night.

General symptoms:
The classic presentation is with fever and localized pain with overlying erythema.Pyrexia, often
400C
Tachycardia, the face flushed and the tongue furred.
Chills, malaise and sweating
Sudden pain and voluntary restrictions of movement. Even slight mpain.ovement leads to severe
Anorexia and constipation are usually present
Anemia quickly occurs in severe cases
Patients look severely ill, restless, nauseated irritable, vomits,
Severe throbbing, deep seated pain and high fever.
Tenderness, swelling. There is excruciating pain, with local heat and swelling; an area of
exquisite local tenderness is an important diagnostic sign;

Diagnostic tests:
 examination of the blood raised blood-sedimentation rate
 Leucocytosis (Increased WBC)
 Hemoglobin might be little reduced.
 If discharge is present, send for culture and sensitivity for appropriate antibiotics.
 The urine may contains Albumin
 X- ray of the limb shows destructive bone changes, pieces of sequestrum in the cavity

Differential Diagnoses

 Animal Bites
 Cellulitis
 Deep Venous Thrombosis and Thrombophlebitis
 Gas Gangrene
 Gout and Pseudogout
 Hand Infections
 Juvenile Rheumatoid Arthritis
 Lumbar (Intervertebral) Disk Disorders
 Neoplasms, Spinal Cord
 Pediatrics, Limp
 Pediatrics, Sickle Cell Disease
 Plantar Fasciitis
 Septic Arthritis

INVESTIGATION DONE IN MY PATIENT:

Diagnostic tests' report of patient
On 5/12: From Emergency
1. Complete blood count
 Investigations Patient's value Normal value
Hemoglobin 10.5 gm/dl 12-16gm/dl
WBC 16000/mm3 4000-11000/mm3
Platelets 180000/cmm
ESR 50
DLC:
Neutrophils 75% 40-75%
Monocytes 2% 2-10%
Eosinophils 2% 1-6%
Lymphocytes 15% 20-45%
polymorph 85

The primary treatment for osteomyelitis is parenteral antibiotics that penetrate bone and joint
cavities. Treatment is required for at least 4-6 weeks. After intravenous antibiotics are initiated
on an inpatient basis, therapy may be continued with intravenous or oral antibiotics, depending
on the type and location of the infection, on an outpatient basis.

The following are recommendations for the initiation of empiric antibiotic treatment based on the
age of the patient and mechanism of infection:

 With hematogenous osteomyelitis (newborn to adult), the infectious agents include S

aureus, Enterobacteriaceae organisms, group A and B Streptococcus species, and H
influenzae. Primary treatment is a combination of penicillinase-resistant synthetic
penicillin and a third-generation cephalosporin. Alternate therapy is vancomycin or
clindamycin and a third-generation cephalosporin, particularly if methicillin-resistant S
aureus (MRSA) is considered likely. Linezolid is also used in these circumstances. In
addition to these above-mentioned antibacterials, ciprofloxacin and rifampin may be an
appropriate combination therapy for adult patients. If evidence of infection with gram-
negative bacilli is observed, include a third-generation cephalosporin.
 In patients with sickle cell anemia and osteomyelitis, the primary bacterial causes are S
aureus and Salmonellae species. Thus, the primary choice for treatment is a
fluoroquinolone antibiotic (not in children). A third-generation cephalosporin (eg,
ceftriaxone) is an alternative choice.
 When a nail puncture occurs through an athletic shoe, the infecting agents may include S
aureus and Pseudomonas aeruginosa. The primary antibiotics in this scenario include
ceftazidime or cefepime. Ciprofloxacin is an alternative treatment.
 For patients with osteomyelitis due to trauma, the infecting agents include S aureus,
coliform bacilli, and Pseudomonas aeruginosa. Primary antibiotics include nafcillin and
 ciprofloxacin. Alternatives include vancomycin and a third-generation cephalosporin
with antipseudomonal activity.

Complication:
-persistent discharging sinuses leads to chronic ill-health and amyloid diseases.
-pathological fracture and deformity
Interference with bone growth
Malignancy in an ulcer or a sinus track

 Bone abscess
 Paravertebral/epidural abscess
 Bacteremia
 Fracture
 Loosening of the prosthetic implant
 Overlying soft-tissue cellulitis
 Draining soft-tissue sinus tracts

Treatment: The primary treatment for osteomyelitis is parenteral antibiotics that penetrate bone
and joint cavities. Treatment is required for at least 4-6 weeks. After intravenous antibiotics are
initiated on an inpatient basis, therapy may be continued with intravenous or oral antibiotics,
depending on the type and location of the infection, on an outpatient basis.

The following are recommendations for the initiation of empiric antibiotic treatment based on the
age of the patient and mechanism of infection:

 With hematogenous osteomyelitis (newborn to adult), the infectious agents include S

aureus, Enterobacteriaceae organisms, group A and B Streptococcus species, and H
influenzae. Primary treatment is a combination of penicillinase-resistant synthetic
penicillin and a third-generation cephalosporin. Alternate therapy is vancomycin or
clindamycin and a third-generation cephalosporin, particularly if methicillin-resistant S
aureus (MRSA) is considered likely. Linezolid is also used in these circumstances. In
addition to these above-mentioned antibacterials, ciprofloxacin and rifampin may be an
appropriate combination therapy for adult patients. If evidence of infection with gram-
negative bacilli is observed, include a third-generation cephalosporin.
 In patients with sickle cell anemia and osteomyelitis, the primary bacterial causes are S
aureus and Salmonellae species. Thus, the primary choice for treatment is a
fluoroquinolone antibiotic (not in children). A third-generation cephalosporin (eg,
ceftriaxone) is an alternative choice.
 When a nail puncture occurs through an athletic shoe, the infecting agents may include S
aureus and Pseudomonas aeruginosa. The primary antibiotics in this scenario include
ceftazidime or cefepime. Ciprofloxacin is an alternative treatment.
 For patients with osteomyelitis due to trauma, the infecting agents include S aureus,
coliform bacilli, and Pseudomonas aeruginosa. Primary antibiotics include nafcillin and
ciprofloxacin. Alternatives include vancomycin and a third-generation cephalosporin
with antipseudomonal activity.

1. Conservative treatment consists of antimicrobial therapy as soon as the result of the blood
count is available. Usually penicillin is given initially. Appropriate antibiotics are used
after the results of the culture and sensitivity test result.
2. Relief of pain by analgesic and by means of rest of the whole body and immobilization
of the affected part
In case of refractory osteomyelitis not responding to treatment, hyperbaric O2 therapy and
antibiotics and surgery is carried out. Surgical drainage and removal of dead bone
(sequestrum) may be possible but recurrence is common. FLUID BALANCE:
The maintenance of fluid balance is of vital importance. If large quantities of fluid can’t
be taken by mouth, it must be given intravenously, and if anemia is present, transfusion
of whole blood may necessary
REST OF THE AFFECTED PART:
Splintage is applied according to the affected and should allow of free inspection and
palpation

CONVALSCENCE:
Rest in the bed and immobilization is continued until the general condition is good
and recalcification and the healing of the affected bone has occurred. Exercise for the
unaffected limbs are commenced.
3.

Surgical treatment:
 This may be undertaken early in the treatment, if an obvious sub-periosteal abscess is
present or after a few days, when local tenderness persists. It is directed towards the
removal of pus and relief of tension in bone, and consists of drainage of a sub-periosteal
abscess with or without drilling of the bone. In severe cases, the wound may be left open
to allow free drainage; in others, it may be closed. Continuous suction drainage of the
wound may be advised.
TREATMENT AND CLOSED PLASTER:
After incision and drainage of an abscess a complete padded plaster cast may be applied.
This may quickly become stained with pus, but so long as the patient remains apyrexial
and well, it is not more often than is absolutely necessary. simple dry gauze dressing are
advised; saline or savlon is used for cleansing the skin, and strong antiseptics should not
be used.

Nursing management:
 A fracture –board supports the matress and a cardle is used to support the weight of the
bed clothes.
 Vitals sign should be monitored four hourly
 A light nourishing diet should be given, the bowels pattern should be regulated
 Turn frequently to prevent pressure sores, and the affected limb must be handled with the
utmost gentleness.
 Support with simple splint; this will rest the part and relieve pain
 Support to prevent contracture deformity
 Respiratory exercise, deep breathing and coughing exercise.
 Advised for plenty of fluids and roughage diet to prevent from constipation.
 High calorie diet
 If nausea vomiting occur give intravenous infusion as per needed.
 If there is surgical, medicated drains, then take care of it.
  If BIP pack to allow healing by granulation formation, remove that within 24-48 hours as
prescription.
 In severe infected condition, the wound may be drained with antibiotics solutions like
sulphonamide solution/ Betadine solution, wound infusion and drainage. So maintain
aseptic technique and principles.
 Prevents infection to others in the environment.
 Careful dressing to be done.
 If there is quite a loss of bone structure do not allow to stand or allow no weight bearing
for several weeks to prevent fracture of the limbs, until new bone tissue are grown.
 When lower limbs are affected, sometimes crutch walking is needed to be taught before
discharge. Teach, moniter, supervises that he/ she can use the crutch well then only
discharge

Prognosis: diagnosis and treatment within a few days carries a good prognosis. Delayed The
prognosis for osteomyelitis varies but is markedly improved with timely diagnosis and aggressive
therapeutic intervention.

POST-OPERATIVE ORDER:
1. Inj. fluclox 750mg, I/V, QID
2. Inj. Xone, 1gm, IV,BD
3. Tab. Flexon, 1tab, PO,TDS after 6 hours

Emergency management:
1. Inj.voveran, ½ amp, IM, SOS
2. Inj. Ondem,4mg, IV,SOS.
Date: 5/12: inj. NS 2 pint+ DNS I pint, over 24 hour
Stop at 5/13
PATIENTS PROGRESS NOTE
Date: 2071/5/12 1st Day of Admission
Patient was received to Annex ward from recovery room after corticotomy at 2pm. Patient was
conscious and well oriented to place, time and person. Patient general condition seems weak.
Vitals sign was monitored; Temperature was 99.90F. Inj. Ringer lactate continued from
Operation Theater and Romovac drain was presents at the incision site for drainage. Patient kept
Nil per oral till 6 hours. Prescribed medicine carried out. At the receive time patient’s chief
complaints was pain. So, inj buscopan……and inj ondem 4mg iv stat given as prescribed.
 Vitals on received time( 2pm): Temp: 99.90 F Pulse: 96/min Resp: 28/min BP:
90/50mm Hg
 2071/5/12 (6pm): Temp- 97.40 F Pulse: 84/ min Resp: 26/ min B.P: 100/50 mm of Hg
 Orientation about the ward and some general orientation about the hospital were given.
Patient party was anxious during admission. So, psychological support was given.

Date: 2071/513, 2nd Day of Admission

Today is the second day of admission. Patient’s general condition seems improving. Patient is on
soft diet. Prescribed medicine was given. Vitals sign monitored. Assist the patient for morning
care; oral care and nail care. Advise the patient for elevation of leg and passive range of motion
exercise. A pillow was kept below the leg for elevation.
 Vital sign:
6am: Temp: 970 F Pulse: 82/ min Respiration: 24/ min B.P: 100/50 mm of Hg
6pm: Temp: 1020 F Pulse: 86/ min Respiration: 28/ min B.P: 100/ 60 mm of Hg
 Intake/ output:
Total intake= 900 ml over 24 hour
Total output= 1050 ml over 24 hour
Balance: - 150 ml
  Today’s chief complains: Patient’s complain of lower right limbs pain. Temperature
was elevated to 1020 F. Advised the patient to elevate legs. Tab. flexon, a tab was given.
Tapid sponging was applied and advice the patient for liquid diet.
 Intravenous fluid ( DNS) was stopped

Date: 2071/5/14, on 3rd day of admission

Patient’s general condition seems improving. Patient looks cheerful. Patient’s vital sign was
normal .Prescribed medicine was given .Intake and output of 24 hour was recorded. Patient had
normal bladder pattern but hasn’t passed stool after surgery. Advised for liquid intake and
encouraged the patient for raw vegetables, roughage diet. Informed to the on- duty staff. Patient
was in normal diet

 Vital sign:
6am: Temp: 96.60 F Pulse: 84/ min, Respiration: 20/min, B.P: 90/ 50 mm of Hg
6pm: Temp: 97 0 F Pulse: 80/ min, Respiration: 22/min, B.P: 100/ 50 mm of Hg

 Intake/ output:
Total intake=1100 ml
Total output=1070ml

Care given: Back care was given and Ghonson’s baby oil was applied and patient party was
encouraged to do so daily. Two hourly position changed. Patient was encouraged for deep
breathing and coughing exercise and passive range of motion exercise of the affected limbs.

Date: 2071/5/15, on 4th day of admission

Patient general condition was fair. Vital sign was monitored and within in normal range.
Prescribed medicine was given. Patient was anxious, fear of pain because dressing was planned
So, psychological support was given. Dressing was done, Romovac drain was out; drain was 30
ml. No any sign of infection in the wound site.
Vital sign:
6am: Temp: 97. 4 0 F Pulse: 80/min Respiration: 24/min Blood pressure: 100/ 60 mm of Hg
6pm: Temp: 97. 6 0 F Pulse: 86/min Respiration: 24/min Blood pressure: 100/ 60 mm of H
Intake/ output:
Total intake=1200ml
Total output= 1000ml
Chief complaints: Pain at the intravenous cannula site.
Care: Cannula site was assessed and there was redness, swelling. Then cannula was removed
and changed to another site. Ice pack was applied to the affected site.

Date: 071/5/16, 5th day of admission

Patient’s general condition was improved. Prescribed medication given and vital sign is in
normal range. Patients complain of constipation. Advise for roughage diet, fruits and liquid diet.
Two hourly position changed and range of motion exercise. Family members were encouraged to
participate in patient’s care. Family members were encouraged to sit with patient as much as
possible which helps to reduce the fair.

 Vital sign
6am:Temperature: 970 F pulse: 88/ min Respiration: 22/min Blood pressure: 110/60 mm of Hg
6pm: Temperature: 970 F pulse: 88/ min Respiration: 22/min Blood pressure: 110/60 mm of Hg
Total Intake=1450 ml
Total output=14000 ml

Date: 071/5/17, 6th day of admission

Patient’s condition was improved. Vital signs are in normal range and prescribed medicine
given. Patient verbalize that he was feeling well and show concern for discharge. Explain about
the disease condition, advice for continuing medicine, regular follow up.
 Vital sign:
6am: Temperature: 980F Pulse: 86/ min Respiration: 24/ min Blood pressure: 110/ 60 mm of Hg
6pm: Temperature: 980F Pulse: 84/ min Respiration: 22/ min Blood pressure: 110/ 60 mm of Hg
Intake/ output:
Total Intake= 1300 ml
Total output=1150 ml

Date: 071/5/18, 7th day of admission:

Patient self passed stool. Report collected; pus for culture and sensitivity.pus cell sterile after
incubation at 370C for 24 hours

Date: 071/5/19, 8th day of admission:

Cannula site changed. Complai of pain at surgical site. So. Tab flexon, 1 tab, p/o stat given.
Dressing done. Patient complain of cough, informed to on- duty staff. Deep breathing
coughing was adviced. Nail care was given.

Discharge teaching was given on following topics:

 Smoking cessation.
 Nutrition (balance diet) and fibrous diet to prevent from constipation.
 Advice for regular exercise to reduce the weight.
 Advice for personal hygiene and modify lifestyles.
 Purpose, time and way of taking medicine and its side effects and advice not to
discontinue the medicine abruptly without order of doctor.
 Alarming signs which needs attention of health care provider
 Follow up care.

Patient is discharged on following medication:

 Tab Thyronorm 25 mcg PO OD (on empty stomach) continue

 Tab Lascilactone (20/50) 1 tab PO OD (at 8am)
 Tab Losartan 50mg PO DD Continue