Osteomyelitis

By: Jacob Newman

Personal Hx:
KC is a 75 y/o Female admitted for left mandible infection
Dx:
Chronic osteomyelitis of the mandible.
Poor wound healing.
Malnourished upon admission.
Rheumatoid Arthritis.

Wound Picture

Osteomyelitis
Definition: Osteomyelitis is inflammation and destruction
of bone caused by bacteria, mycobacteria, or fungi. 1
Signs/Symptoms: Weight loss, fatigue, erythema, swelling,
localized warmth, tenderness, septic arthritis, and skin
cancer. 1,2

Osteomyelitis
Etiology
Common causes:
Open wounds from contaminated fractures or bone
surgery
Bloodborne organisms
Contiguous spread from infected tissue or infected
prosthetic joint 80% of cases
Ischemia, and foreign bodies predispose to
osteomyelitis.
Common labs:
Elevated CRP
Elevated ESR

Diagnosing Osteomyelitis
Bone Biopsy
Golden standard2

Determine bacteria
X-rays
Bone destruction, soft tissue swelling, periosteal
elevation - 2-4 weeks1
CT and MRI
Abscesses
Abnormalities

Osteomyelitis Treatment
Treatment
Antibiotics1,2
Typically administered 4-6 weeks
Actinomyces bacteria

Surgery for abscess

Surgery1,2

Drain puss
Remove diseased bone tissue
Restore blood flow to bone

Remove foreign objects

Additional Treatments for KC
Hyperbaric oxygen treatment: Helps with radiation
soft-tissue injury.

Actinomycosis (Lumpy Jaw) 3

Client Hx:
PMH:
Sarcoma
Partial mandibulectomy 3/7/2013
Resection of margins 4/11/2013
Radiation therapy complete 6/24/2013
Anterior and posterior implants placed 2014
Posterior implant replaced with bone graft 7/2014
Actinomycosis with left oral cavity/mandibular
resection 5/21/2015
Partial mandibulectomy 11/20/2015
ORN mandible with 50 HBO2 rxs summer fall 2015
Osteomyelitis left mandible 1/2016

Client Hx:
PMH:
Left mandibulectomy with fibular free flap 1/28/2016
PEG tube placed 2/8/2016
Free flap didnt take, redone. Not draining 2/12/2016
Hypothyroidism
RA Crippled hands
HTN
Type II DM

Client Hx:
Family Hx:
DM
Arthritis
Graves disease
Social Hx:
Widow
Children help feed her

Anthropometrics
Weight hx:
Admit weight: 34 kg (BS), BMI 13.7 - 1/28
Day 2 weight: 42.4 kg (UR), BMI 17 1/30
Day 6 weight: 44.6 kg (UR), BMI 18 2/3
Day 9 weight: 47.3 kg (UR), BMI 19 2/6
Day 11 weight: 46.5 kg (UR), BMI 18.8 2/8
Day 15 weight: 45.8 kg (UR), BMI 18.5 2/12

Biochemical
Lab

Values

Alb

2.3 L
(2/19)

2.0 L
(2/13)

Glu

128 H
(2/19)

122 H 138 H 156 H 129 H

(2/17) (2/16) (2/14) (2/10)

Ca

7.6 L
(2/19)

7.9 L 7.3 L 8.0 L 8.4

(2/17) (2/16) (2/14) (2/13)

Na

131 L
(2/19)

131 L 131 L 134 L 133 L 135 L

(2/17) (2/16) (2/13) (2/13) (2/7)

1.6 L 1.8 L 1.4 L 1.4 L 4.5

(2/19) (2/18) (2/17) (2/16) (2/13)

CO2

17 L
(2/19)

19
18 L
19
(2/17) (2/16) (2/14)

Medications
Clindamycin 600 mg IVPB Q6
Metformin 500 mg BID
Ca+ carbonate 1000mg daily

Cipro 200 mg IVPB BID

Thiamine 100 mg daily
Arava 20 mg daily
Prednisone 1 mg Q 48 hrs
Levothyroxine 125 mcg daily
Heparin 5000 U sq Q8
Hydrocodone 10-15 ml PRN Q4 (pain)

Cholestyramine 4gm
Diltiazem HCL 240 mg
Magnesium sulfate 2 gm
Humalog 1 U Q6

Medications
MVI daily
Lactated ringers Q13
Imodium PRN
Mg Sulfate
Ambien 5 mg bedtime
KCl 20-40 meq as directed
Vitamin C 250 mg BID

Vitamin D 2000 IU
Zinc sulfate 220 mg
Vitamin A 8000 IU
Potassium Chloride 20 meq
Lovenox
Lactobacillus GG BID
Lopressor 25 mg BID

Nutrition Focused Physical

Findings
Skin: Wounds on neck

Senses: Denies change in smell/taste/hearing.

Visual loss with HBO2 therapy in fall 2015,
cataracts.
Joints: All stiff hands are crippled
Legs: Bowed
GI: Inability to chew/swallow. Denies N/V.
Diarrhea likely due to medications and TF. PEG
placement.

Wound Picture

Food/Nutrition Related Hx:

Prior to sarcoma diagnoses was a light eater.
After initial surgery patient required EN for a short time.
PTA, family reports, following a fractured jaw
diminished PO intake x3-4 months.
Upon admittance drinking 1-2 Ensures per day with
mechanically soft/pureed/pureed foods. Her
physician instructed to increase Ensure to 5-6/day, d/t
pain wasnt able to.
Fibersource HN through nasogastric tube
60 ml/hr

Impact peptide 1.5 20 ml/hr

Fibersource HN 60 ml/hr with 20 ml/hr flush (49%
caloric), (54% protein)

Nutrition Diagnosis
PES/Diagnosis 1: Malnutrition related to alteration in
GI function as evidenced by inability to take PO as
evidenced by chewing and swallowing difficulties,
and 17% weight loss x4 months. (NC-4.1)
PES/Diagnosis 2: Masticatory difficulty related to
major oral surgery as evidenced by multiple
osteomyelitic surgeries. (NC-1.2)

Nutrition Prescription
Estimated Needs:
1484-1696 Kcal, 59-72 g/protein
35-40 Kcal/kg (ABW)
1.4-1.7 gm/protein/kg (ABW)

1450-1750 Kcal, 64-82 g/protein

32-38 Kcal/kg
1.4-1.8 g/protein/kg
MSJ x 1.5 = 1355

1200-1530 Kcal, 48-61 g/protein

35-40 Kcal/kg (ABW)
1.4-1.7 gm/protein/kg

985-1065 Kcal, 51-68 g/protein

29-31 Kcal/kg

1.5-2 g/protein/kg

Nutrition Intervention
Enteral Nutrition (ND-2.1)1
Fibersurce HN 1.2 with goal rate of 60ml/hr
1728 Kcal
77 g/protein
1,166 ml/fluid

Benefiber packet TID

MVI
Thiamine

Wound pack

Goals
Maintain weight/lean body mass
Adequate protein for good post operation healing
59-72 g protein

Kcals and protein to meet estimated needs

1484-1694 Kcal

59-72 g protein

Nutrition related labs WNL

K
Mg
P

Monitoring and Evaluation

Anthropometric Measurements
Maintain weight (AD-1.1.2)
Food and Nutrition Intake
Total energy intake (FH-1.1.1.1)
Monitor TF intake

Lab Values
Electrolyte Profile (BD-1.2)
Monitor P, K, Mg

Prognosis of Patient
Nutritional status of patient is improved
Prevented refeeding syndrome
BMI greatly improved, unsure if that has helped with
lean body mass
Nutrition only meeting ~ 50 % of protein and caloric
needs.

Applications/
Recommendations
British Journal of Community Nursing: Maintaining
adequate hydration and nutrition in adult enteral tube
feeding4
Educate other health care providers of signs/symptoms
of refeeding syndrome and dehydration.
Error in feeding can be rectified

Balance feeding and fluid

Upsala Journal of Medical Sciences: Head and neck

cancer patients perceptions of quality of life and how
it is affected by the disease and enteral tube feeding
during treatment5
Patients perception was that quality of life isnt altered
by need for tube feed, and type of tube feed didnt
matter.

Recommendations
Cyclic feedings as early as possible to allow for
adequate nutrition due to interruptions of continuous
feeds.
Increase protein due to wound healing.
Get PEG placed earlier.

Resources
1.

Porter RS, et all. Merck Manual 19th Ed. Merck Sharp and Dohme
Whitehouse Station, NJ: Merck and Co inc.; 2011

2.

Osteomyelitis. Mayo Clinic website

http://www.mayoclinic.org/diseasesconditions/osteomyelitis/basics/definition/con-20025518
Updated September 25, 2015. Accessed February 17, 2016.

3.

Actinomycosis (lumpy jaw) Medline Plus website

https://www.nlm.nih.gov/medlineplus/ency/imagepages/17245
.htm Updated November 20/2013. Accessed February 18, 2016.

4.

Dunn S. Maintaining adequate hydration and nutrition in adult

enteral tube feeding. British Journal Of Community
Nursing [serial online]. July 2, 2015;20(Sup7):S16-S23. Available
from: Academic Search Premier, Ipswich, MA. Accessed
February 20, 2016.

5.

Ehrsson Y, Sundberg K, Laurell G, Langius-Eklf A. Head and

neck cancer patients perceptions of quality of life and how it is
affected by the disease and enteral tube feeding during
treatment. Upsala Journal Of Medical Sciences [serial online].
November 2015;120(4):280-289. Available from: Academic
Search Premier, Ipswich, MA. Accessed February 20, 2016.