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I. INTRODUCTION
A case of Cecil Casem, 28 years old, married, high school graduate and from Luna, La
Union. She was to consider Osteosarcoma after so many diagnostic procedures done to her. The
results was then confirmed in other hospitals to have this disease. On April 16, 2012, patient had
undergone Hip Disarticulation on the right knee.
Osteosarcoma is a deadly form of musculoskeletal cancer that most commonly causes
patients to die from pulmonary metastatic disease and which has a 5-year survival rate of 15-
20%. It is regarded to be the most common highly malignant bone tumor which often affects the
adolescents and young adults. The symptoms and chances of recovery for children and
adolescents appear to be the same.
Radiography is almost always the initial imaging modality used in the investigation and
with histolopathologic studies done for the definitive diagnosis. The present management for
osteogenic sarcoma involves amputation or disarticulation collaborated with chemotherapy.
Etiology
Rapid bone growth appears to predispose persons to osteosarcoma, as suggested by the
increased incidence during the adolescent growth spurt, and osteosarcoma’s typical location in
the metaphyseal area adjacent to the growth plate (physis) of long bones.
There are some evidences of genetic predisposition for osteosarcoma in patients with
bone dysplasia (Paget disease, fibrous dysplasia, enchondromatosis, and hereditary multiple
exostoses and retinoblastoma). It is thought that the combination of constitutional mutation of
the RB gene and radiation therapy might develop chances for osteogenic mutation. The only
known environmental risk factor is exposure to radiation. But in most cases of osteogenic
sarcoma no definite cause can be determined.
Clinical Presentation
Pain, as a rule the first symptom, is of dull, constant, aching character and often interferes
with sleep. The usual physical examination findings include a palpable mass which may or may
not be present. The mass may be tender and warm, though these signs are indistinguishable from
osteomyelitis. In the case of lower limb lesions, the discomfort may result in a slight limp.
Pathologic fracture is uncommon in osteogenic sarcoma. In rapidly growing tumors, distention of
the superficial veins and elevation of the skin temperature over the lesion are common.
Pulsations or a bruit may sometimes be detectable. The range of motion might be decreased if a
joint is involved. Involvement of local or regional lymph nodes is unusual. Auscultation is
usually uninformative unless disease is extensive. In more than half of patients the serum
alkaline phosphatase level is elevated, reflecting the osteoblastic activity of the tumor cells.
Incidence
The incidence of osteosarcoma is slightly higher in males than in females with males (5.2
per million per year) and females (4.5 per million per year). It is very rare in young children (0.5
cases per million per year in children <5 y), incidence increases steadily with age, increasing
more dramatically in adolescence, corresponding with the growth spurt.
Treatment
The orthopedic surgeon is of paramount importance in the care of patients with
osteosarcoma. Since osteosarcomas are not particularly responsive to radiotherapy, surgery is
the only option for definitive tumor removal (local control). In addition, an oncologic type of
total joint prosthesis or complex bone reconstruction may be required following surgical
resection. Therefore, close involvement of the orthopedic surgeon with the medical oncologist at
the time of diagnosis, as well as during and after chemotherapy, is critical.
The primary aim of definitive resection is patient survival. As such the margins on all
sides of the tumor must contain normal tissue (wide margin). The thickness of the margin is
important only for the marrow, where an adequate margin is thought to be 5-7 cm from the edge
of abnormality depicted on MRI or bone scan. But amputation may be the treatment of choice in
some circumstances.
When amputation is decided, a well planned rehabilitative program should be designed in
partnership with the physiatrist and physical therapist for the patient’s post-amputation recovery.
The most important prognostic factor for long-term survival is response to chemotherapy.
Preoperative (neoadjuvant) chemotherapy followed by limb-sparing surgery (which can be
accomplished in > 80% of patients) followed by postoperative (postadjuvant) chemotherapy is
standard management. The use of neoadjuvant chemotherapy has been found to facilitate
subsequent surgical removal by causing tumor shrinkage and has also provided oncologists with
an important risk parameter. Patients who have a good histopathological response to neoadjuvant
chemotherapy (>95% tumor cell kill or necrosis) have a better prognosis than those whose
tumors do not respond as favorably. The effective drugs are doxorubicin, ifosfamide, cisplatin,
and high-dose methotrexate with leucoverin rescue.
Prognosis
The present understanding of outcome and prognosis for osteosarcoma is driven by
certain serum markers, clinical staging, and histologic response to chemotherapeutic agents. The
overall 5-year survival rate for patients diagnosed between 1974 and 1994 was 63% (59% for
males, 70% for females). Patients with elevated alkaline phosphatase at diagnosis are more
likely to have pulmonary metastases. In patients without metastases, those with an elevated LDH
are less likely to do well than are those with a normal LDH. Long term survival rates in
extremity osteosarcoma range from 60 to 80%. Osteosarcoma is radioresistant; radiation therapy
has no role in the routine management.
II. OBJECTIVE
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 28 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 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.
III. PATIENT’S PROFILE
Name : Cecil Casem
Address : Luna, La Union
Age : 28years old
Birthday : September 15, 1983
Nationality : Filipino
Religion : Born Again
Occupation : Housekeeper
Spouse : Amante Casem
Date& Time of Admission : April 10, 2012 @ 6:55 PM
Admitting Diagnosis : To consider osteosarcoma right Knee
Admitting Physician : Dr. Eric Piscawen
IV. PAST AND PRESENT ILLNESS
Present Illness
1 year prior to admission, patient noted a slowly growing mass on the right knee which
initially was associated with pain or tenderness and there was limitation of motion noted. The
condition was tolerated and no consultation sought because of financial restraints.
Few months prior to admission, patient started to complain of dull, constant, aching pain
with progressive increase in the size of the mass in the right kneee. The pain was also
aggravated during ambulation. She was brought to Lorma for consultation and done some
diagnostic procedure like X-ray, MRI and CT scan according to the patient. Patient brought to
ITRMC for reassurance to the disease. She has then diagnosed benign cancer.
1 month PTA, patient was then brought again by his husband for consultation where an
open biopsy was advised. Patient complied open biopsy and confirmed on other hospital in
Manila and revealed osteosarcoma. She was then advised for surgery and thus this admission.
Past Illness
a. Childhood illness
Fever
Cough and cold
Mumps
Chicken fox
Measles
b. Immunizations
Complete immunization
c. Allergies
No known allergies to foods
d. Accidents
With no previous accident
e. Hospitalizations
With no previous hospitalization
V. PHYSICAL ASSESSMENT
PARAMETERS NORMAL FINDINGS
ACTUAL FINDINGS
INTERPRETATION
General Appearance -clean in appearance and well groomed
- cooperative
>Endomorphic built
>Intact and Dry dressing
>Weak in appearance
>Conscious and coherent
Due to the disease process
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
-eyebrows hair evenly distributed/skin
intact
- (+) blink reflex
-with pinkish conjunctiva
>With slightly pale conjunctiva
Due to poor sleeping habits brought about by Osteosarcoma
Ears
-auricle color same
>Without discharges With normal findings
as facial skin
-auricle are mobile firm and not tender
-able to hear on both ears
-no edema and discharge
>able to hear on both ears
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
>amputated hip at right knee
>phantom pain
Due to surgical operation done
Abdomen -no abdominal distention
-flat rounded abdomen
-symmetrical contour
-no surgical incision
>With soft and non-tender abdomen upon palpation
>abdominal muscle weakness
Due to limited motion
VI. 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.
VII. PATHOPHYSIOLOGY
BOOK BASED
CLIENT BASED
CausesDNA mutation injury
infection metabolic or hormonal disturbance
Risk Factorsrepeated 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 femur
Proximal tibiaProliferation 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 bloodstreamLungs, bones, visceral organs
VIII. DIAGNOSTIC PROCEDURE
>gender>ageactivity
Malignant neoplasm/tumor arising in the tissue of mesodermal origin
Dilatation of vessels Elevation of periosteum
Bone mass
Pathologic fracture
> pain> swelling> limited motion
surgical biopsy
malignant
Balanced Skeletal Traction
OSTEOSARCOMA
>sales lady>labandera>house helper
Fake healer
Some of her diagnostic procedures are not present in her chart. Only Complete Blood
Count and Hematology are compiled on her chart.
Complete Blood Count
Results Normal Findings
Hg 110 g/L 120 – 160 g/L
Hct 33 vol % 38 – 47 vol %
Hematology
Results Normal Findings
WBC 5.61 x 109/L 4.00 – 10.00
RBC 3.49 x 1012/L 4 – 5.50
Hgb 102 g/L 120 – 160
Hct 31.7 % 40 – 54
PCT 577 x 109/L 150 - 450
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.
biopsy of the tumor
XI. DISCHARGED PLANNING
Medication
Cefalexin 500mg i cap TID
Environment/Economic Status/Exercise
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.
d. Patient has middle economic status and they need for extra job for the medication.
e. Have regular exercise
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.
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.
XII. EVALUATION
The patient is now recovering from her surgery. She is experiencing phantom pain after it
and she can’t accept of the missing part of her body. But after few nursing care plan rendered to
her, she accept what happened and from now on she is able to trust God and more stronger than
before.
Student nurse, I am now knowledgeable about Osteosarcoma on how it affects the body,
the causes, the risk factors and the clinical manifestation of the disease. I also find out the
treatments and procedures suited for patients with osteosarcoma. I’m able to render some of the
nursing care plan for her.
XIII. BIBLIOGRAPHY
1. eMedicine Online
2. Wikipedia
3. Google
4. Physical Assessment Book