AsuhanAsuhan KeperawatanKeperawatan PadaPada KlienKliendengandengan OsteomyelitisOsteomyelitis

OlehOlehIra Ira SuarilahSuarilah

Dept.Kep.Medikal-BedahDept.Kep.Medikal-BedahPSIK-FK UNAIRPSIK-FK UNAIR

OsteomyelitisOsteomyelitis

is an infection of the bone that occurs mostis an infection of the bone that occurs mostfrequently in the lower frequently in the lower extremities.Mostextremities.Mostcommonly, it develops after severe localcommonly, it develops after severe localtrauma with an associated open fracture.trauma with an associated open fracture.

The adjacent soft tissue structures areThe adjacent soft tissue structures areinjured together with the bone, and caninjured together with the bone, and canform a poorly form a poorly vascularizedvascularized and scarred and scarredtissue bed.tissue bed. Simple Simple debridementdebridement and andantibiotic therapy are often unsuccessful inantibiotic therapy are often unsuccessful intreating lower extremity treating lower extremity osteomyelitisosteomyelitis.. As a As aresult, patients frequently present afterresult, patients frequently present aftermultiple failed treatments and with resistantmultiple failed treatments and with resistantor or polymicrobialpolymicrobial bacterial infection. bacterial infection.

OsteomyelitisOsteomyelitis

is an is an infectioninfection of of bonebone, usually, usuallycaused by caused by pyogenicpyogenic bacteriabacteria or ormycobacteriamycobacteria. It can be usefully. It can be usefullysubclassifed on the basis of thesubclassifed on the basis of thecausative organism, the route,causative organism, the route,duration and anatomic locationduration and anatomic locationof the infection.of the infection.

EtiologyEtiology

Acute osteomyelitis almostAcute osteomyelitis almostinvariably occurs in children.invariably occurs in children.when adults are affected it maywhen adults are affected it maybe because of compromisedbe because of compromisedhost resistance due tohost resistance due todebilitation, intravenous drugdebilitation, intravenous drugabuse, disease or drugs (e.g.abuse, disease or drugs (e.g.immunosuppressiveimmunosuppressive therapy). therapy).

CausesCauses

The vast predominance of hematogenously seededThe vast predominance of hematogenously seededosteomyelitis is caused by osteomyelitis is caused by Staphylococcus aureusStaphylococcus aureus..Escherichia coliEscherichia coli, and , and streptococcistreptococci are other common are other commonpathogenspathogens. In some subpopulations, including. In some subpopulations, includingintravenous drug users and intravenous drug users and splenectomizedsplenectomized patients, patients,Gram negativeGram negative bacteria, including enteric bacilli, are bacteria, including enteric bacilli, aresignificant pathogens.significant pathogens.

Staphylococcus aureusStaphylococcus aureus is also the most common is also the most commonorganism seen in osteomyelitis seeded from areas oforganism seen in osteomyelitis seeded from areas ofcontiguous infection, but here Gram negative organismscontiguous infection, but here Gram negative organismsand and anaerobesanaerobes are somewhat more common, and mixed are somewhat more common, and mixedinfections may be seen.infections may be seen.

In osteomyelitis involving the vertebral bodies, about halfIn osteomyelitis involving the vertebral bodies, about halfthe cases are due to the cases are due to Staphylococcus aureusStaphylococcus aureus, and the, and theother half are due to other half are due to tuberculosistuberculosis (spread (spreadhematogenously from the hematogenously from the lungslungs). Tubercular osteomyelitis). Tubercular osteomyelitisof the spine was so common before the initiation ofof the spine was so common before the initiation ofeffective antitubercular therapy that it acquired a specialeffective antitubercular therapy that it acquired a specialname, name, Pott's diseasePott's disease, by which it is sometimes still known, by which it is sometimes still known

Successful treatment for chronicSuccessful treatment for chronicosteomyelitisosteomyelitis in this setting in this settingrequires:requires:

Effective Effective debridementdebridement Antibiotic therapy andAntibiotic therapy and VascularizedVascularized soft tissue soft tissue

coverage - preferably with acoverage - preferably with amuscle flapmuscle flap

Successful treatment for chronicSuccessful treatment for chronicosteomyelitisosteomyelitis in this setting in this settingrequires:requires:

Osteomyelitis often requiresOsteomyelitis often requiresprolonged prolonged antibioticantibiotic therapy, lasting therapy, lastinga matter of weeks or months, anda matter of weeks or months, andmay require surgical may require surgical debridementdebridement..Severe cases may lead to the loss ofSevere cases may lead to the loss ofa limb. Initial first line antibiotics isa limb. Initial first line antibiotics isdetermined by the patient's historydetermined by the patient's historyand regional differences of commonand regional differences of commoninfective organisms. For example, ininfective organisms. For example, ina 1 year old child, it would bea 1 year old child, it would beappropriate to start a combination ofappropriate to start a combination ofFlucloxacillin and Fusidic Acid.Flucloxacillin and Fusidic Acid.

ClinicalClinicalExampleExample

a a chronic chronic osteomyelitisosteomyelitis of 20 years duration. The patient of 20 years duration. The patienthad multiple surgical procedures and treatments withhad multiple surgical procedures and treatments withantibiotics, but continued to have a draining sinus in theantibiotics, but continued to have a draining sinus in thelower leg.lower leg. In the area adjacent to the draining sinus, soft In the area adjacent to the draining sinus, softtissue swelling and signs of chronic infection andtissue swelling and signs of chronic infection andprevious surgical treatment can be seen.previous surgical treatment can be seen.X-rays revealed the presence of chronic X-rays revealed the presence of chronic osteomyelitisosteomyelitis in inthe tibia.the tibia. Areas of Areas of radiolucencyradiolucency are present at the base are present at the baseof the wound that are compatible with erosion of boneof the wound that are compatible with erosion of bonedue to infection.due to infection. Although the bone is stable with no Although the bone is stable with noevidence of fracture or non-union, the extent and chronicevidence of fracture or non-union, the extent and chronicnature of the infection may have required nature of the infection may have required debridementdebridementthat would weaken or destabilize the tibia.that would weaken or destabilize the tibia.

A A debridementdebridement was performed to remove the bulk of the was performed to remove the bulk of thesurrounding inflammatory tissue and infected bone. Thissurrounding inflammatory tissue and infected bone. Thisleft a defect of soft tissue and a raw surface of tibia.left a defect of soft tissue and a raw surface of tibia.Enough bone was still present to provide lower extremityEnough bone was still present to provide lower extremitystability.stability. Some scarring was left behind to minimize the Some scarring was left behind to minimize thesize of the open wound and to reduce post-operativesize of the open wound and to reduce post-operativediscomfort.discomfort. The bulk of the unstable and thin scar would The bulk of the unstable and thin scar wouldbe excised at the flap procedure.be excised at the flap procedure.A A latissimuslatissimus muscle flap was used to fill the defect in the muscle flap was used to fill the defect in thetibia and resurface the area of scar tissue that wastibia and resurface the area of scar tissue that wasremoved.removed. The The latissimuslatissimus muscle has a long vascular muscle has a long vascularleash and could reach proximal to the point where theleash and could reach proximal to the point where thepatient's anterior patient's anterior tibialtibial artery showed evidence of injury. artery showed evidence of injury.

AsuhanAsuhan keperawatankeperawatan padapada klienkliendengandengan osteomyelitisosteomyelitis::

PengkajianPengkajian:: RiwayatRiwayat jatuhjatuh?? RiwayatRiwayat frakturfraktur?? RiwayatRiwayat infeksiinfeksi?? RiwayatRiwayat penggunaanpenggunaan antibiotikantibiotik yang lama? yang lama?

TujuanTujuan

InfeksiInfeksi dapatdapat diatasidiatasi ditandaiditandai dengandenganleukositleukosit kurangkurang daridari atauatau = =11.000mg/dL11.000mg/dL

HasilHasil kulturkultur menunjukkanmenunjukkanStaphylococcus aureusStaphylococcus aureus. . EscherichiaEscherichiacolicoli, dan , dan streptococcistreptococci pasif pasif

Bone scan menunjukkan matriksBone scan menunjukkan matrikstulang rapattulang rapat

X-ray X-ray menunjukkanmenunjukkan pertumbuhanpertumbuhancalleuscalleus

intervensiintervensi

NutrisiNutrisi adekuatadekuat PengetahuanPengetahuan yang yang signifikansignifikan AntibiotikAntibiotik continues continues Support Support psikososialpsikososial