General Objective

The purpose of this study is to analyze and improve understanding of, to develop necessary nursing skills and to apply the appropriate nursing care while maintaining confidentiality of patient having Osteosarcoma.

Specific Objective

To present a case of osteosarcoma in a 16 year old patient. To understand condition about Osteosarcoma. To improve our physical assessment skill in patient with Osteosarcoma. To correlate laboratory results to its normal value. To illustrate the anatomy and physiology of the affected part or organ To know the pathophysiology of the chosen case. To be aware of the causes, clinical manifestations and complications. To formulate a drug study with regards to the patient’s condition. To develop effective nursing skill on how to manage proper care to a patient with

this kind of disease To provide client a nursing care plan and discharged plan to assure total wellness

during hospitalization, up to the time of discharge.

I. Introduction

a. Background of the study

i. Incidence, rate, gender, age, ratio

Incidence: Osteosarcoma is the eighth most common form of childhood cancer, comprising 2.4% of all malignancies in pediatric patients, and approximately 20% of all bone cancers.

Incidence rates for osteosarcoma in U.S. patients under 20 years of age are estimated at 5.0 per million per year in the general population, with a slight variation between individuals of black, Hispanic, and white ethnicities (6.8, 6.5, and 4.6 per million per year, respectively. It is slightly more common in males (5.4 per million per year) than in females (4.0 per million per year).

There is a preference for origination in the metaphyseal region of tubular long bones, with 42% occurring in the femur, 19% in the tibia, and 10% in the humerus. About 8% of all cases occur in the skull and jaw, and another 8% in the pelvis

Rate and Age: Osteogenic sarcoma is the sixth leading cancer in children under age 15. Osteogenic sarcoma affects 400 children under age 20 and 500 adults (most between the ages of 15-30) every year in the USA. Approximately 1/3 of the 900 will die each year, or about 300 a year. A second peak in incidence occurs in the elderly, usually associated with an underlying bone pathology such as Paget's disease, medullary infarct, or prior irradiation.

Ratio: 1/3 over 900Gender: Many osteosarcoma are diagnosed among 1is 25years old Filipino women.

ii. Rationale for choosing the case

Our group had chosen the case of Osteosarcoma for the specific patient, for us to be more knowledgeable on how important it is to take good care of ourselves from the tremendous attack of cancer cells. Another reason is that Osteosarcoma is the tsixth leading cause of mortality rate in the children under 15 years old and we as a group would like to have awareness on how it is being developed and what are the chances that one could survive from this.

iii. Significance of the study

As a student nurse, this study will be able to expand the knowledge and skills on nursing management to and of course this will be more effective through using health education especially during the attack of pain. This study will motivate the student to the effect of osteosarcoma. This study serves as a reference on how osteosarcoma affects the activity of daily living. Doing a case study in nursing practice will improve the nursing knowledge and enhance the nursing’s scientific base.

iv. Scope of limitation of study

The study would only focus in Osteosarcoma which is indicative to the client’s health condition and its underlying nursing care and management relevant for the client. The study will confine at Philippine Orthopedic Center for two weeks of exposure.

v. Conceptual/theoretical theory

Myra Levine’s defined her theory with four major concepts in Conservation Model Theory Conservation of energy meaning that all human being reserve her/his energy by taking rest period after all the activities they have done to re-energize their body for the next day. By utilizing the proper technique on how to conserve the energy the body will maintain the homeostasis to prevent some diseases. 2. Conservation of structural integrity as nurse we need to provide proper care for the patient to prevent other complications that patient may acquire. We need to provide comfort for the patient not only by giving medicines but preserving the cleanliness of environment, giving oral care, perineal and wound care etc. 3. Conservation of personal integrity the goal of this concept is to help the patient to regain his higher degree of harmony within the mind and body and soul offer our self to the patient giving them the encouraging words to the patients give them spiritual advice and listening to their emotional conditions, insights of their life and opinions to be able to express their feelings. 4. Conservation of Social integrity as a nurse we should gradually help the patient to enter again in the community provide and encourage an atmosphere of realistic hope, provide gradual implementation and continuation of necessary behavior and lifestyle create plans managing interaction within the community itself between the community and the larger society to meet collective needs.

vi. Related Literature

Osteosarcoma is also called osteogenic sarcoma, a malignant (cancerous) tumor that arises from bone itself, and is thus called a primary bone cancer. Primary bone cancers are relatively rare overall. Approximately 2,400 new cases of osteosarcoma occur in the United States every year.

Osteosarcoma occurs most frequently during childhood or adolescence. About 60% of cases of this disease develop during the second decade of life. The incidence of osteosarcoma rises again among people in their 40s and 50s.

Osteosarcoma may occur in any bone, but develops most commonly in long bones, particularly near the knee or in the upper arm. The cancer starts growing within a bone and forms an expanding, ball-like mass. The tumor eventually breaks through the surface of the bone and begins to invade adjoining structures such as muscles. If untreated, the disease usually appears elsewhere in the same limb and metastasizes to distant parts of the body, such as the lungs.

Causes►unknown►DNA mutation – either inherited or acquired after birth►familial susceptibility►injury

►infection ►metabolic or hormonal disturbance

Risk Factors: (children)►repeated trauma►tall for the age►genetics►hereditary abnormalities including exostoses (bony growths), retinoblastoma,

Ollier's disease, osteogenesis imperfecta, polyostotic fibrous dysplasia, and Paget's disease

►also been linked to exposure to ionizing irradiation associated with radiation therapy for other types of cancer

►family history of certain types of cancer►exposure to significant amounts of radiation

Risk Factors: (adult)►high fat diet ►lack of exercise► smoking►drinking alcohol

Clinical Manifestation

►pain (sharp or dull) at the site of the tumor

► increased pain with activity or lifting

►limited motion/decreased movement of affected limb

►limping

►weight loss ►the bony mass may be palpable, tender and fixed with an increased in skin

temperature over the mass and venous destention

►shiny and stretched skin with prominent superficial veins

►muscular weakness

►malaise

►anorexia

►toxaemia

►acidosis

►fever

Diagnostic Procedure

► multiple imaging studies of the tumor and sites of possible metastasis, such as:

► x-rays - a diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film

► bone scans - a nuclear imaging method to evaluate any degenerative and/or arthritic changes in the joints; to detect bone diseases and tumors; to determine the cause of bone pain or inflammation. This test is to rule out any infection or fractures.

►magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body. This test is done to rule out any associated abnormalities of the spinal cord and nerves.

►computed tomography scan (Also called a CT or CAT scan) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

►complete blood count (CBC) - a measurement of size, number, and maturity of different blood cells in a specific volume of blood.

►blood tests (including blood chemistries)

►biopsy of the tumor

Treatment

►antibiotics – to prevent and treat infections

► surgery

► resections - partial excision of a bone or other structure

►bone graft - a piece of bone taken from the patient that is used to take the place of remove bone or a bony defect at another site

►skin graft - using the skin from other part of the body to repair a defect or trauma of the skin

►limb-sparing (limb salvage) – used to remove the tumor and adjacent tissue

►reconstruction

►amputation

► chemotherapy

► radiation therapy

► resections of metastasis – spreading of the tumor to other locations

►rehabilitation including physical and occupational therapy and psychosocial adapting

►prosthesis fitting and training

► sterna marrow puncture

Prognosis

►Stage I – rare and includes poresteal osteosarcoma or low-grade osteosarcoma

- It has an excellent prognosis (>90%) with wide resection

►Stage II – depends on the site of the tumor (proximal tibia, femur, pelvis,etc.), size of the tumor mass (in cm) and the degree of necrosis from neoadjuvant chemotherapy (prior to surgery)

- The prognosis for patients with metastatic oateosarcoma improves with longer times to metastasize (more than 12-24 months), a smaller number of metastasis and their resectability. Those with a longer length of time (>24 months) and few nodules (2 or fewer) have the best prognosis with a 2-year survival after the metastasis of 50%, 5 year of 40% and 10 year 20%.

- If metastasis are both local and regional, the prognosis is worse.

►Initial presentation of Stage III osteosarcoma with lung metastasis depends on the respectability of the primary tumor and lung nodules, degree of necrosis of the primary tumor and maybe the number of metastasis. Overall prognosis is 30% or greater depending.

II. CLINICAL SUMMARY

A. GENERAL DATA PROFILE

Name : Patient MRAddress : # Arona’s Extension Sta. Mesa ManilaAge : 16 years oldBirthday : December 16, 1993Nationality : Filipino Religion : Roman CatholicOccupation : StudentFather : Melchor TuralbaMother : Sheryl TuralbaDate of Admission : April 06, 2010

Admitting Diagnosis : pathologic fracture secondary to first bone tumor, probably malignant to consider osteosarcoma

Admitting Physician : Dr. Sanidad

B. CHIEF COMPLAINT

Prior to admission patient complaint of bone mass at lateral part of the right thigh associated with pain and swelling.

C. NURSING HISTORY

HISTORY OF PRESENT ILLNESS

One month prior to admission, the patient has palpable mass with redness at the lateral part of the right thigh and had undergone manipulation “hilot” thrice. The patient verbalized that “dati sumasakit na talaga kapag naglalaro ako ng basketball pero nawawala din tapos nung na aksidente ako sa pagbibisikleta di na nawala ‘yung sakit...”

a. Childhood illness

FeverCough and coldMumpsChicken foxMeasles

b. Immunizations

Complete immunization

c. Allergies

No known allergies to foods and allergies.

d. Accidents

With previous bicycle accident

e. Hospitalizations

Once hospitalized due to a minor accident before being referred at the Philippine Orthopedic Center

f. Medications used or currently taking

Dolcet i cap TIDCefalexin 500mg/cap i cap TID

D. FAMILY HISTORY

LEGEND:

FatherMother

Decesead

MOTHER FATHER

Decesead

ASTHMAASTHMAAlive and

well(HYPER

TENSION)

Alive and well

(HYPERTENSION)

DeceseadOvariancancer

Alive and well

Alive and well

Alive and well

Alive and well

Alive and well

ASTHMA

Patient

(OSTEO SARCOMA

)

RENAL FAILURE

Alive and well

Alive and well

Alive and well

HISTORY- THEORIES OF GROWTH AND DEVELOPMENT

Psychosocial Theory according to Erik Erikson

Stage Age Central Task Indication of positive

resolution

Indication of negative

resolution

Adolescents 12-18 years old

Identity vs. Role confusion

Patient should act accordingly to his sexuality, dress behave, fitted to his gender. He should engage to heterosexual relationship. Self consistency indicates the positive resolution at this stage. The significant others surround him helps the patient to organize acts as so that the patient will want to be free for more productive social activities & relationships.

Identity crisis is one negative aspect of this stage people who do have this situational crisis engage in homosexual relationship they act on un appropriate to their gender, wear dress unproperly. As nurse we should engage the client in activities it helps in identifying self as an individual

Psychosexual Theory according to Sigmund Freud

Stage Age Characteristics Indication

Genitals 13-20 years old According to the patient he solve his own problem, h decides want he wants to do his own life. He ask help if he think he cant do by his own. He said that he listen to his parents, brothers,sisters, &

friends. He also said that after he finish the study he will find job in order to help financially his family. And after that he told to us that he wanted to start and create a new family to live away from his parents. It means that he is in the stage of independent life.

E. ENVIRONMENT/LIVING CONDITION

The environment where he lives can be found near main road. This place has many motor vehicles that can be seen either in the street or road. The place is slightly congested.

F. PHYSICAL ASSESSMENT

PARAMETERS NORMAL FINDINGS

ACTUAL FINDINGS

INTERPRETATION

General Appearance

-clean in appearance and well groomed - cooperative

With balance skeletal traction

Slightly thin

Conscious and coherent

Due to the disease process

Client decreased in weight due to loss of appetite

Skin - with good skin turgor

Good skin turgor With normal findings

Hair -evenly distributed hair-thick hair

> evenly distributed hair-thick hair

With normal findings

Nails - with good capillary refill of 1-2 seconds -with pinkish nail beds-with clean and short nails

>With good capillary refill of 2-3 sec.

>With clean and short nails

With normal findings

Skull and face -mouth uniform consistency; absence of nodules and masses-rounded smooth skull contour-symmetrical facial movement

-mouth uniform consistency; absence of nodules and masses-rounded smooth skull contour-symmetrical facial movement

With normal findings

Eyes -no eye discharge-with anecteric sclera-eyebrows hair evenly distributed/skin intact- (+) blink reflex-with pinkish conjunctiva

>With slightly pale conjunctiva

- Due to poor sleeping habits and anemia brought about by Osteosarcoma

Ears -auricle color same as facial skin-auricle are mobile firm and not tender-able to hear on both ears-no edema and discharge

>Without discharges

-able to hear on both ears

With normal findings

Mouth -pinkish lips -without missing teeth-with pink gums-no foul odor-with symmetrical contour

>With dry lips Due to poor intake of foods

Musculoskeletal (upper and lower extremities)

-symmetrical -no atrophy -with full range of motion

With scar on right wrist

With steinman’s pin at tiba and fibula

With palpable mass on the right knee at with increase in temperature

(+ ) 12 x 10 cms mass @ right knee

- scar is due to previous vehicular accident

Due to insertion of steinman’s pin

No wounds

With limited extension @ 45 degree

Distal thigh warm to touch

Abdomen -no abdominal distention-flat rounded abdomen-symmetrical contour-no surgical incision

With soft and non-tender abdomen upon palpation

with complaint of difficulty to defecate

abdominal muscle weakness

Due to limited motion

G. PATTERNS OF FUNCTIONING

FUNCTIONAL HEALTH PATTERN

BEFORE HOSPITALIZATION

DURING HOSPITALIZATION

INTERPRETATION

•Health management patter

> medicated by the Doctor

fake healer

> it was her second time to be hospitalized

>He is seeking medical attention in severe cases that needed immediate attention then consulted to fake healer

•Nutritional/metabolica. number of meals

per day b. appetite

c. glass of water per day

d. body built

e. weight

>3x a day

>with good appetite

12 glasses of water

>with normal body built

>50 kg.

>3x a day

>with slightly poor appetite

8 glasses of water

>with slightly thin body built

>46 kg.

>The number of meals he is taking is the same but the appetite is poor, the intake of water he is taking per day decrease since the day he was hospitalized. His body built became slightly thin and his weight was decreased

•Elimination a. frequency of

urination>4-5x per day >4x per day >The frequency of

his urination is still

b. amount of urine per day

c. frequency of bowel movement

d. consistency of the feces

e. amount defecated per day

>Moderate

>Once a day

>Formed

>Moderate

>Scanty

>Once a day

>Slightly soft

>Scanty

the same.

>The frequency of his bowel elimination was the same as before but it become slightly soft and scanty in amount due to limited mobility and the amount of water she drink

•Activity and exercisea. exerciseb. fatigabilityc. ADL

Active exercise>Not easily get tired>Independent

>Easily get tired>Slightly dependent

He cannot do anything alone without the help of other

•Cognitive/ perceptuala. orientationb. responsiveness

>Oriented to time, place and person>Respond approximately to verbal and physical stimuli

>Oriented to time, place and person>Respond approximately to verbal and physical stimuli

The cognitive and perception status of the patient is still normal and active.

•Roles/ relationshipa. as a daughter

b. as a sister

c. as a boyfriend

>With good relationship with his parents and he provided financial aid to the family

>With good relationship with his brother and sister

>With good relationship with his girlfriend

>With good relationship with his parents and he provided financial aid to the family

>With good relationship with his brother and sister

>With good relationship with his girlfriend

>He still has good relationship with his family

•Self perception/self concept

>Have a high self worth/importance

>Have a low self worth/importance

>He has a low self worth

•Coping/stress >He seeks for some advice to his friends and relatives when he has problems, burdens and stresses

>He is not always talking with his family to lessen her stress

>He has no good coping mechanism

•Value/ beliefs >He has awareness that God exist

>His awareness to God become more strong than before

>Even if he suffered from osteosarcoma, the patient never blame God instead his awareness became more stronger than before

H. COURSE IN THE WARD

April 05, 2010 Monday 2:00 AM The patient was submitted in Philippine Orthopedic Center with

the diagnosis of pathologic fracture; secondary to 1st degree bone tumor DNB malignant tumor to consider osteosarcoma he was admitted at Male Traction Ward via wheelchair accompanied by father with deformity at Right extremity. Sought consults ion under Dr. Santidad. The patient was conscious, 50 kl. In weight. His initial vital signs are BP 110/70 mmhg, 81 bpm, 22 cpm, and 37.0 degree Celsius. The Doctor’s order laboratory examinations such as: CBC, CT, BT, PT, PTI, Bld typing, ESR, and CRP to determine any malfunctions in the pt. He was taken chest x-ray and pelvis @ right thigh APL to detect any deformity in his bone structure. In the afternoon he had undergone an operation for Steinman pin insertion done by dra. Santila under local anesthesia. The Steinman pin was inserted at right leg with 10x5lbs wt with temporary traction and was accompanied by nurse helper and helper to the ward. The doctor ordered dolcet 1 tab for the management of severe pain, the patient is for TP, ALP, LDH, and CA.

April 06, 2010 TuesdayAt the second day at POC, the patient has balanced skeletal

traction to maintain the anatomical position of the fractured bone with weights applied at right leg 10 lbs traction weight and 5 lbs suspension weight. Still with dolcet 1 tab to manage pain. The patient was afebrile with body temperature of 36.5 ‘c.

April 07, 2010 WednesdayAt the third day the patient was still conscious, afebrile and has

BST at the right leg. He was for xray of right knee APL with awaits result. Still with dolacet 1 tab for severe pain.

April 10, 2010 SaturdayThe doctor ordered cefalexin 50 mg 1 cap TID for infection and

the patient was for blood transfusion. In the afternoon the patient has normal vital signs of 120/90 mmhg, 80 bpm, 18cpm, and 36 ‘c. The patient was blood transfused of 3 ‘’u’’ of FWB with consent informed and signed by the father.

I. LABORATORY DIAGNOSTIC EXAM

HEMATOLOGY

April 5, 2010

COMPONENT RESULT NORMAL RANGE

INTERPRETATION

IMPLICATION NURSING RESPONSIBILITIES

Hemoglobin 130 127-185g/l Normal Instruct the client to

maintain an adequate fluid intake.

Hematocrit .36 0.37-.54g/l Below Normal High: Iron

deficiency anemia

If the microhematocrit method is used, explain that the finger will be

cleansed with an alcohol sponge and pricked with

a needle to obtain capillary blood

Leukocyte Count 11.60 4.5-10x10g/l

High A rise in the WBC is usually caused by conditions that stimulate the bone marrow to produce white blood cells to fight off invading organisms.

Instruct the client to check the side effects of patent medicines, such as cold medications, which could cause agranulocytosis, severe leukopenia.

Components (Indices)MCV 83 82-92 fl Normal Instruct the client to eat

foods rich in iron. Explain to the client who is taking iron supplements that the stool usually appear dark in color (tarry appearance)

MCH 30 28-32 % NormalMCHC 36 32-38 pg Normal

DIFFERENTIAL COUNTSegmenters 0.72 0.50-0.70 Slightly high Infection

Lymphocytes 0.19 .20-0.40 Below normal

Low: sepsis, Instruct the client to report any signs and symptoms of infection, such as a presence of a fever. Encourage the client to rest,\. take medications such as antibiotics as prescribed. Increase fluid intake as appropriate, and monitor temperature.

Monocytes 0.08 0.00-0.07Eosinophils 0.01 0.00-0.05

Riticulocytes 0.5-2.0%Platelet count 204 150-

400x10 ^g/l

Normal Instruct the client to avoid injury if possible. Mild injury could cause bleeding.

April 6, 2010

TEST NAME

RESULT NORMAL VALUE

Interpretation Implication Nursing Responsibility

Alkaline phos 334 0-664 u/l Normal Inform the client that

other enzyme tests may be ordered to verify diagnosis

Total protein 87.8 66.0-87.0 g/l

Normal

Albumin 54.2 38.0-51.0g/l

High Teach the client the importance of maintaining adequate amount of protein in the diet with health care provider’s approval. Protein should increase the serum albumin level and decrease peripheral edema unless the client has cirrhosis of the liver.

Calcium 2.15 2.02-2.60mmol/l

Normal

LDH 785.9 225.0-450.0u/l

Instruct the client to notify the nurse of any recurrence of chest discomfort or to seek medical care for indigestion of several days

Glob 33.63 32-48g/l NormalA/G Ratio 1.61 1.50-3.10

ratioNormal Teach the client the

importance of maintaining adequate amount of protein in the diet with health care provider’s approval. Protein should increase the serum albumin level and decrease peripheral edema unless the client has cirrhosis of the liver.

III. CLINICAL DISCUSSION OF THE DISEASE

1. ANATOMY AND PHYSIOLOGY

The skeletal system provides support and protection, allows body movements, stores minerals and fats, and is the site of blood cell production.

Four types of bone tissue:

Long bones - are longer than they are wide, most of the bones of the upper and lower limbs are long bones. Examples: femur, tibia, and fibula of the leg, the humerus, radius, and ulna of the arm, and the phalanges of the fingers and toes.

Short bones- -are approximately are broad as they are long, such as the bones of the wrist and ankles.

Flat bones - -have a relatively thin and flattened shape.

Irregular bones - include the vertebrae and facial bones, with shapes that do not readily fit into three other categories.

There are two kinds of bone tissue:

Compact bone - is the hard material that makes up the shaft of long bones and the outside surfaces of other bones.

Spongy bone - consists of thin, irregularly shaped plates called trabeculae, arranged in a latticework network.

Parts of the long bones:

Diaphysis

-a long tubular portion of long bones, it is composed of compact bone tissue. It has the medullary cavity or marrow cavity, an open area within the diaphysis, the adipose tissue inside the cavity stores lipids and forms the yellow marrow.

Epiphysis

-the expanded end of a long bone

Metaphysis

-is the area where the diaphysis meets the epiphysis. It includes the epiphyseal line, a remnant of cartilage from growing bones.

Layers of bone tissue: Periosteum

-is the membrane covering the outside of the diaphysis (and epiphyses where articular cartilage is absent). It contains osteoblasts (bone-forming cells), osteoclasts (bone-destroying cells), nerve fibers, and blood and lymphatic vessels. Ligaments and tendons attach to the periosteum.

Endosteum

-is the membrane that lines the marrow cavity.

2. PATHOPHYSIOLOGY (BOOK BASED/ CLIENT BASED)

BOOK BASED

CausesDNA mutation injury

infection metabolic or hormonal disturbance

Risk Factors repeated traumatall for the agehereditary abnormalities including

Paget's diseaseexposure to ionizing irradiation

associated with radiation therapy family history of certain types of cancer

Osteoblast

Malignant Osteoblast (abnormal)

High grade mecenchymal tumor

Distal femurProximal tibia

Proximal humerusProliferation of abnormal

osteoblast

Formation of osteoid or immature bone(thin, wispy and purposeless fragment of bone)

Pain, swelling, tenderness Bulky tumor that destroys trabeculae of disease area

Metastasize through bloodstream

Lungs, bones, visceral organs

PATHOPHYSIOLOGY (CLIENT BASED)

s

> genetics>gender>ageactivity

Malignant neoplasm/tumor arising in the tissue of mesoderm

al

Dilatation of vessels

Elevation of periosteum

Bone mass

pathologic fracture

> pain> swelling> limited motion

surgical biopsy

malignant

Balanced Skeletal Traction

OSTEOSARCOMA

basketballbicycle accident

Fake healer

Metastasize through bloodstream

Lungs, bones, visceral organs

3. DRUG STUDY

NAME OF THE DRUG

ACTION INDICATI-ON

DOSAGE AND

PREPARA-TION

ADVERSE REACTION

NURSING CONSIDERATION

Cephalexin

Antibiotic

Inhibit bacterial wall synthesis rendering cell wallosmotically unstable leading to cell deathby binding to the cell wall membrane

Upper, lower respirartory tract, urinary tract skin, bone infections, otitis media

i tab TID CNS: Headache, dizziness, weakness, paresthesiaRespiratory: DyspneaGI: Nausea, vomiting, diarrhea, anorexia, pain,. GlossitisHEMALeukopenia, thrombocytopenia, agranulocytis, anemia ,. Neutropenia, lympocytosis, eusinophiliaINTEG:Rash, urticaria, dermatitis

Assess patient for previous sensitivity reaction to penicillin or other cephalosporinis common

Assess for sign and symptoms of infection including characteristics of wounds sputum, urine stool and wbc > 10,000/mm3

Identify urine output ,if deceasing notify the prescriber, also checked for increased BUN

Monitor electrolytes: potassium, sodium, chloride..

Dolcet Binds to opiod receptors& inhibits the reuptake of noreipinephrine& serotonin; causes many effects similar to the opiods

Mild to moderate pain

500mg/cap i cap TID

CNS: sedation, dizziness, headache, confusionCV:hypotension, tachycardia, bradycardiaGI: nausea, vomiting, dry mouth, constipation

Observed 10 rights in giving medication

Assess for history of hypersensitivity to drug, intoxication with alcohol, past or present history of opiod addiction

Instruct pt. to report severe nausea ,dizziness and severe constipation

IV. NURSING PROCESS

A. LONG TERM OBJECTIVES

The study aims to know more about the case and reduce complications of the client through the collaborative management with physician, nurses, physical therapist together with the nutritionist.

B. PRIORITIZED LIST NURSING PROBLEM

PROBLEM RANKING JUSTIFICATION

Acute pain related to physical injuring agents

1 Many alterations happen under acute pain & we ranked this as a first to be prioritizes since our patient experienced this to prevent or reduce pain.

Risk for infection related to presence of steinman’s pin inserted at left knee

2 We rank this as second, because we know insertion of anything in the body may cause an infection. This can be prevented through the proper care.

Imbalancednutrition less than body requirements r/t decreased appetite secondary to treatments

3 Nutrition is important in our body, since our patient has a slightly poor appetite we include this in the prioritized problem.

Risk for constipation r/t immobilization as evidenced by decrease peristaltic movement

4 Since our patient has a limited movement and always lying on bed he can experience constipation.

C. NURSING CARE PLAN (BASED ON THE SEQUENCE OF PRIORITZED PROBLEM)

ASSESSMENT DIAGNOSIS PLANNING

INTERVENTION

RATIONALE EVALUATION

SUBJECTIVE:“Masakit gawa ng may bakal, lalo na kapag malamig, kagaya kagadi sobrang sakit”

OBJECTIVES:

Acute pain related to physical injuring agents

At the end Of nursing intervention and collaborative medical management, the patient will report

>Note client age/ developmental level & current condition affecting ability

>Assess for referred pain

>To help determine the possibility of underlying conditions

>To report pain parameter

Goal met as evidence by:

The patient will reported that the pain was lessen With PS=4/10

With steinman’s pin at left knee

Pain Scale-7/10

BP- 130/80 mmHg

P- 104 bpm

irritable at times

the pain is reduce from 7 out of 10 down to 4 out of 10

>Obtain client’s assessment of pain to include location, characteristics, duration @ aggravating factors

>Accept client description of pain

>Monitor skin color/ temp, V/S

>Provide comfort measures like repositioning

˃Provide/recommend non pharmacological measures that reliefs of pain e.g. quite dimly room, relaxation techniques (guided imagery, destructing and diversional activities.

˃Administer analgesic as indicated to maximum dosage as needed.

>To rule out worsening of underlying conditions

>Pain is a subjective experience and cannot be felt by others

>Usually altered in acute pain

>To promote non pharmacological pain management

˃Measures that reduce cerebral vascular pressure and that slow sympathetic response and effective in relieving headache and associated complications

˃To maintain acceptable level of pain. Notify physician if regimen is inadequate to pain control goal.

BP=120/70mmHg P- 91 bpm

SUBJECTIVE:

OBJECTIVES:

With open wound

With steinman’s pin at the right distal femur

Risk for infection related to presence of steinman’s pin inserted at the right distal fmur

At the end of nursing interventions, the patient will identify interventions to prevent or reduce risk for infection

Verbalized understandi

˃Observe for localized signs of infection at insertion site

˃Teach proper hand washing techniques to patient’s and caregiver

˃To assess causative or contributing factors that may help for further observations and management to prevent infection

˃To reduce existing risk factors, hand washing is the first line of defense against infection

At the end of the nursing interventions, the patient and his care giver gained knowledge and how to prevent infection

The patient verbalized his understanding

With dry and intact dressing

ng of individual causative/risk factors

˃Cleanse incision site, change dressing as needed

˃Encourage deep breathing exercise, coughing, and position change such as turning side to side

˃Give health teachings such as:

a. increase fluid intake

˃To prevent wound contamination

˃For mobilization of respiratory secretions

˃To maintain proper hydration

and asked some related questions

SUBJECTIVE:

> Hindi ako makakain ng maayos wala ako ganang kumain.

OBJECTIVES:

˃slightly thin in appearance

˃with slightly poor appetite

˃weight- 50 kg

Imbalancednutrition less than body requirements r/t loss of appetite

At the end of nursing intervention patient will demonstrate behaviors,lifestyle changes to regain or maintain appropriate weight.

> Assess weight

>Auscultate bowel sounds

>Evaluate total daily food intake

>Minimize unpleasant odor

>Provide oral care before and after meals

>Promote adequate/ timely fluid intake

>Emphasize importance of well-balanced

>daily weighing provides data to evaluate nitrogen balance > certain conditions and medications and prolonged immobility can disturb G.I function

> identify theneed for medications and teaching

> unpleasant odor effect negative impact to appetite

>poor oral hygiene leads to bad odor and taste, which can diminish appetite

>these fluid restriction help prevent gastric distention

>during illness, good nutrition can reduce the risk of complications and speed recovery

Goal met as evidenced by:

pt seen in good appetite

patient intake food rich in nutrients

weight- 46kg

SUBJECTIVE:

>Hindi ako makadumi tatlong araw na po.

OBJECTIVES:

with slightly pale in conjunctiva

with dry lips noted

Seen lying on bed frequently

with

complaint of difficulty to defecate

abdominal

muscle weakness

Risk for constipation r/t immobilization as evidenced by decrease peristaltic movement

At the end of nursing intervention patient and s.o will understand the technique of active exercise

Explained passive and active exercise

Auscultated bowel sounds

Promote exercise program

Provide adequate fluid intake necessary for treatment regimen

Advice to eat foods such as vegetables and fruits

Advice patient to eat food rich in fiber

Administer stool mild softener as orderedDiscuss rationale to encourage continuation of successful intervention

Regular physical activity ais elimination b improving abdimonal muscle tone and stimulating appetite and peristalsis

Bowel sounds indicate the nature of peristaltic activity

To encourage patient help his status

Increase in fluid intake help to softened stool

High fiber content stimulates peristalsis

A sense of normalcy and familiarity can help reduce embarrassment and promote relaxation which may aid defecation

Seen patient eat high in fiber foods

Patient stated that he normally lose his bowel movement

Seen patient eat high in fiber foods

Patient stated that he normally lose his bowel movement

Subjective:

>Hindi ko kayang gumalaw pag hndi ako inaalalayan

Objective:

>Weak in appearance

>With limited range of motion

>Irritable at times

>With pain scale of 7/10

>Bradypnea

>Difficulty in turning

>Impaired physical mobility related to decreased muscle strength secondary to pathological disease

>At the end of the nursing intervention patient maintain position of function & skin integrity as evidence by absence of contractures foot drop, decubitus, and so forth

>Explain the rationale for bed exercises & early ambulation

>Encourage use of trapeze

>Plan diversional activities for stress management

>Observe movement when client is un aware of observation

>Support affected body parts using pillows

>Encourage participation in self-care

>Instruct in use of siderails overhead trapeze,

>Aggressive pursuit of ROM exercises & early ambulation. Can decrease deep vein thrombosis & muscle wasting & increase in strength

>Shoulder and arm muscles need strengthening to use assistive device

>Diversional activity can help client to refocus on matters other than his condition associated fears

>To rate any in congruencies with reports of abilities

>To maintain position of function & reduce risk of pressure ulcers

>Enhances self concept & sence of independence

>To reduce the risk of incidental

Goal met as evidenced by;

>Patient response to interventions as evidenced by using safety measures such as ( side rails,overhead trapeze)

>Seen patient participating in self care routine

roller pads injury

Subjective

Parang wala na akong silbi sa aking buhay

Objective

>action are congruent with

>expressed feelings & thought

>Lact of eye contact

>Excessively seeks reassurance

>Situational low self esteem related to social role changes

>At the end of four hours intervention patient will demonstrate behaviours to restore positive self esteem

>Note non-verbal body language

>Provide feedback of self negative remarks

>Assist to client problem solving situations developing plans of action & setting goals to achieved desired outcomes

>Encourage expression of feelings

>Encourage visitors

>Help the client to identify positive attributes & possible opportunities

>Provide reliable information & clarify

>Incongruencies between non verbal communication requires clarification

>To allow the client to experienced different remarks

>Enhances commitment to plan, optimizing outcomes

>Facilitate grieving the loss

>Frequent visits support person, can help the client feel that he is still a worthwhile this should promote a positive self concept>The nurse must be inforce positive aspects & encourage the client to reincorporate them into his new concept>Misconceptions can needlessly increase anxiety & damage

Goal met as evidenced by;

Patient expressed his concerns patient seem participate in treatment program

Patient share his new positive outlook in life

any concepts concept

D. DSCHARGE PLAN (M.E.T.H.O.D)

Medication

Dolcet i cap TID Cefalexin 500mg/cap i cap TID

Environment

a. Maintain a quiet, clean and calm environment for easy and good recovery of the patient.

b.Provide safety measure c. Place bedside urinals near patient’s bed for easy access when nature calls.

T reatment

Health Teaching

Provide with normal growth and development activities Advise patient to take the medicine continuously at home. Advise patient to avoid lifting heavy objects and use of too much force to

prevent more serious injury. Avoid strenuous activities. Proper personal hygiene. The importance of exercise on both extremities. Instruct to do deep breathing and coughing exercises. Advise to always keep back dry.

OPD

After discharge, advice patient to come back to specific date said by the doctor

Diet

High protein and rich in vitamin C foods to promote healing.

PHILIPPINE ORTHOPEDIC CENTER

OSTEOSARCOMA

Case Presentation

By;

Affiliation BSNIV GROUP 4