Article: Osteomyelitis in the Diabetic Patient

Pages: 11 (3435 words)  ·  Bibliography Sources: 11  ·  Level: Master's  ·  Topic: Disease  ·  Buy This Paper

SAMPLE EXCERPT:

[. . .] He ignored the lesion believing it was only a minor injury. No consultation or treatment was carried out. Within three weeks, the leg swelling and a high grade fever raised concerns and prompted him to seek medical attention.

A physical examination confirmed bone tenderness and tissue inflammation. A battery of tests including blood cultures revealed elevated white blood cell counts and an increased ESR. Patient B's CRP test was positive. Finally, a bone x-ray led to an official diagnosis of osteomyelitis. The patient went on to receive several rounds of antibiotic therapy. A solid nursing management plan was instituted to help alleviate pain and remedy the condition. A fairly early diagnosis and swift implementation of the treatment plan played a vital role in his successful recovery. Subsequent patient education lowered the risk of reoccurrence.

Patient B - Nursing Management Plan

In developing a nursing management plan for diabetic patients with osteomyelitis, it is important to begin with very specific goals that address patient's needs and also create the best possible scenario for avoiding reoccurrence. Customary goals are to relieve pain, improve physical mobility, control or eradicate infection and develop a treatment regimen to prevent the recurrence of problems.5(p1021) Patient B's plan includes the following:

TABLE 1-5 -- NURSING INTERVENTIONS FOR PATIENT B

Relief of pain

Immobilize the affected part with a temporary splint to decrease pain.

Monitor the neurovascular status of the affected extremity.

Elevate the affected part to reduce swelling and associated discomfort.

Administer analgesics as prescribed.

Improving physical mobility

The bone is weakened by the infective process and must be protected by immobilization devices and by avoidance of stress on the bone.

Gently place the joints above and below the affected part of the foot through their range of motion. Encourage full participation in activities of daily living (ADLs) to promote general well-being.

Eliminate infection

Monitor the patient's response to antibiotic therapy.

Observe the IV access site for evidence of phlebitis or infection

Monitor the general health and nutrition of the patient. A diet high in protein and vitamin C promotes healing.

With long-term, intensive antibiotic therapy, monitor the patient for signs of superinfection (e.g., oral candidiasis or foul-smelling stools).

Encourage adequate hydration.

Treatment & Prevention Knowledge

Teach the patient and family the importance of strictly adhering to the therapeutic regimen of antibiotics and preventing falls or other injuries that could result in bone fracture.

Teach the patient how to maintain and manage the IV access and IV administration equipment in the home.

Provide information on medication education.

TABLE 2-5 -- EXPECTED PATIENT OUTCOMES

Experiences pain relief

Reports decreased pain.

Experiences no tenderness at site of previous infection.

Experiences no discomfort with movement.

Increases physical mobility

Participates in self-care activities.

Maintains full function of unimpaired extremities.

Demonstrates safe use of immobilizing and assistive devices.

Modifies environment to promote safety and to avoid falls.

Shows absence of infection

Takes antibiotic as prescribed.

Reports normal temperature.

Exhibits no swelling.

Reports absence of drainage.

Laboratory results indicate normal white blood cell count.

Complies with therapeutic plan

Takes medications as prescribed.

Protects weakened bones.

Reports no elevation of temperature or recurrence of pain, swelling, or other symptoms at the site.

Demonstrates proper wound care.

Wears appropriate footwear.

Keeps follow-up health appointments.

Reports increased strength.

Eats a diet that is high in protein and vitamin C

Reports signs and symptoms of complications promptly.

It is worth noting that Patient B. could have been spared from this encounter with osteomyelitis with proper education in foot care and with very simple preventative measures. Several factors contributed to the development and escalation of his condition, including his diabetic status, poor diet, walking barefoot, low personal motivation, and delayed response to the initial foot injury. In addition, as a diabetic, Patient B. should have been maintaining annual foot exams with a qualified healthcare professional for potential foot problems.

Diabetic patients, particularly those with demonstrated risk factor(s), should be undergo a podiatry exam every 1-6 months.5(p1031) The absence of symptoms does not mean that the feet are healthy; a patient might have neuropathy, peripheral vascular disease or even an ulcer without any complaints. Patient B's left foot injury received no treatment causing the wound to stall, become infected and progress to the bone. Lack of proper diabetes management and improper preventative measures caused this patient pain and suffering that could have had a much more catastrophic end.11(p38) Festered foot wounds and resulting instances of osteomyelitis can and do lead to amputation in extreme cases.

Education and Prevention

Education, presented in a structured and organized manner, plays an important role in the prevention of osteomyelitis in diabetic patients. The aim is to enhance patient motivation and skills. Diabetics must learn how to recognize potential foot problems and be aware of the steps they need to take in response. Educators must demonstrate appropriate skill sets using a mixture of methods. It is essential to evaluate whether the patient has understood the messages, is motivated to act, and has sufficient self-care skills.5(p1032) Furthermore, healthcare professionals should receive periodic education to improve care for high-risk individuals. The following is a list of items which should be covered when instructing the high-risk patient 11(p40-44):

Daily feet inspection, including areas between the toes. This is best carried out by another person, particularly if the patient experiences vision problems.

Daily inspection of the inside of shoes.

Daily change of socks.

Regular washing of feet with careful drying between the toes.

Moderate water temperatures - always below 37° C.

Refraining from using heaters or hot - water bottles to warm feet.

Avoidance of barefoot walking indoors or outdoors.

Avoidance of chemical agents or plasters to remove corns and calluses. A healthcare provider should assist with removal.

Avoidance of tight shoes or shoes/socks with rough edges and uneven seams.

Avoidance of lubricating oils or creams for dry skin.

Cutting nails straight across to avoid injury.

Notifying the healthcare provider at once if a blister, cut, scratch or puncture wound of any kind has developed.

Foot ulcers

Ill-fitting shoes are the most frequent cause of foot ulcers. Therefore, the shoes of all diabetic patients should be examined meticulously. Most ulcers can be classified as neuropathic, ischemic or neuro-ischemic.4(pS19) Neuropathic ulcers frequently occur on the plantar surface of the foot, or in areas overlying a bony deformity 3(p350) Ischemic and neuro-ischemic ulcers are more common on the tips of the toes or the lateral border of the foot.2(p811) If an ulcer does not improve despite optimal treatment, more extensive vascular evaluation should be performed.

The depth of an ulcer can be difficult to determine due to the presence of overlying callus or necrosis. Therefore, neuropathic ulcers with calluses and necrosis should be debrided as soon as possible. This debridement should not be performed in ischemic or neuro-ischemic ulcers without signs of infection.9(p906) In neuropathic ulcers the debridement can usually be performed without general anesthesia. Patients with an ulcer deeper than the subcutaneous tissues should be treated intensively and, depending on local resources and infrastructure, hospitalization must be considered.3(p352)

The cause of the ulceration should be determined in order to reduce the chance of recurrences.5(p1029) Ulcers on contralateral foot should be prevented and heel protection provided during periods of bed rest. Once the episode is over, the diabetic patient should be included in a comprehensive foot-care program with life-long observation.

Proper Footwear

Inappropriate footwear can create major problems and complications for the diabetic patient. Appropriate footwear should be used both indoors and outdoors, and should be adapted for any existing altered biomechanics and deformities.8(p50) This is essential for prevention. Patients who have not lost foot sensation can select off-the-shelf footwear by themselves. In patients with neuropathy and/or ischemia, extra care must be taken when fitting footwear - particularly when foot deformities are also present. In a high-risk patient, callus, nail and/or skin pathology should be treated regularly, preferably by a trained foot care specialist.11(p45) Foot deformities should also be addressed -- preferably non-surgically (e.g. with an orthosis).4(pS21)

Shoes should not be too tight or too loose and should be 1-2 cm longer than the foot itself.8(p50) The internal width should be equal to the width of the foot at the site of the metatarsal phalangeal joints, and the height should allow enough room for the toes. The fit must be evaluated with the patient in standing position, preferably at the end of the day. If the fit is too tight due to deformities or if there are signs of abnormal loading of the foot (e.g. callus, ulceration), patients should be referred for special footwear which may include insoles and orthoses.

Key Points

Patient and family foot care education is critical in the prevention of osteomyelitis in diabetic patients. Teaching is the first step to decrease instances of amputation due to severe cases of the disease. Patients should have adequate instruction in proper foot care, identification of warning signs, and… [END OF PREVIEW]

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