TARLAC STATE UNIVERSITYCOLLEGE OF NURSING

Lucinda Campus,Brgy. Ungot, Tarlac City Philippines 2300Tel No.: (045) 982-6062 Fax: (045) 982-0110 website: www.tsu.edu.ph

A Case Study on Osteosarcoma

In Partial Fulfillment of the Requirements of the SubjectNursing Care Management 103 RLE

Presented to the FacultyOf the Tarlac State University

College of Nursing

Presented by:BSN III - C Group C4

Querido, Richen T.Raiz, Jayscent F.

Rodriguez II, Rolando D.Sabat, Aprillyn A.Santos, Marivic C.

Santos, Willa Milafrosa M.Sotelo, Jeffrey R.

Suarez, Christine Karen A.Sumang, Jerico B.

Sumaoang, Maria Luisa S.

Date Submitted:June 03, 2010

Introduction

Primary malignant musculoskeletal tumors are relatively rare and arise from

connective tissue and supportive tissue cells (sarcomas) or bone marrow elements

(multiple myeloma). Malignant primary musculoskeletal tumors include osteosarcoma,

chondosarcoma, Ewing’s sarcoma, and fibrosarcoma. Osteogenic sarcoma

(osteosarcoma) is the most common and most often fatal primary malignant bone tumor.

Prognosis depends on whether the tumor has metastasized to the lungs at the time the

patient seeks health care.

Osteogenic sarcoma appears most frequently in males between the ages of 10 and

25 years (in bones that grow rapidly), in older people with Paget’s disease and as a result

of radiation exposure and accounts 5% of all childhood illness. Clinical manifestations

include pain, edema, limited motion, and weight loss (which are considered ominous

findings). The bony mass may be palpable, tender, and fixed, with an increased skin

temperature over the mass and venous distention. The primary lesion may involve any

bone, but the most common sites are the distal femur, proximal tibia, and the proximal

humerus.

According to the U.S. Surveillance, Epidemiology and End Results Program(2),

osteosarcomas contribute 36% of all types of bone cancer, followed by chondrosarcomas

and Ewing's sarcomas with around 30% and 16% respectively. The incidence of

osteosarcoma appears to be more frequent in two periods of life, during adolescence and

old age.In Asia, the Philippines (Manila) has the highest rate of males while Thailand

(Khon Kaen) has the highest frequency in females. It is interesting that Singapore Indians

have the lowest male/female ratio of bone cancer in the world (0.5), while Israeli on-Jews

show the second highest worldwide male/female ratio (4.0).

Objectives

Nurse – centered

General:

The objective of our case study is to gain more knowledge and skills with regards to the disease chosen and to be able to do effective and appropriate nursing interventions to the patient based on the knowledge gained.

Specific:

Gather the patient’s data, personal data, past and present health history and family health history

To familiarize the disease process, definition and etiology of the disease and Signs and symptoms and treatment and prevention

To gain knowledge about the medical management and procedure concerning the disease and nursing management to be rendered

To render nursing intervention and to apply the formulated nursing care plan

Patient Centered

General:

To be able to know his/her existing condition and to be able to participate well with procedures and things he/she needs to comply for the success of his/her disease treatment.

Specific:

To increase the patient’s level of awareness about the existence of the disease. To gain cooperation with the health care provider in implementing the nursing

intervention as well as compliance to medical management. To apply knowledge gained from the health care provider. To know what other complications may arise, if left untreated

Reasons in choosing the Case Study

Our group chose this case study to gain more additional knowledge about the

disease. The group wants to know more about the disease, its treatment, and the proper

nursing management for patients with this kind of disease. The case will help the group in

dealing with patient with this condition.

Promotion of health, prevention of diseases and illnesses, rehabilitation and

restoration of good health are important in doing the case. In the accomplishment of this

case study, the group will be able to know and develop more fully our skills in

assessment, planning, nursing care plans, implementation/interventions and evaluation

for this particular chosen condition.

Importance of the Study

The case study is primarily important because it enhances the students’ skills,

knowledge and attitude on the practice of the nursing process. It provides broader

comprehension about the condition chosen through research and actual observation as it

serves as a training ground and practice in developing learned skills in the assessment and

management of Osteosarcoma.

Through this case study, a holistic approach in assessing patient’s health will be

delivered, where it can be immediately attended to and given proper interventions. It

serves as a way to familiarize the students with the different medical approaches toward

the ongoing curative phase. This study serves as a tool for future upcoming nursing

students of the school. To share to other student nursing colleagues to understand the

dynamics of Osteosarcoma as to the book based management and actual clinical

interventions. Furthermore, this study may be used as a spring board for a more advanced

and in-depth study that is in accordance to changing and developing society.

II) NURSING PROCESS

A) ASSESSMENT Date: June 1 ,

2010

1) Personal Data

a) Demographic Data

Name: Child OS

Age: 6 years old

Sex: Female

Civil Status: Single

Occupation: N/A

Religious Affiliation: Roman Catholic

Position in the family: Daughter

Address: Xevera, Mabalacat, Pampanga

Date of Birth: February 4, 2004

Place of Birth: Tarlac City

Nationality: Filipino

Health Care Financing: Phil health

Usual Source of medical Care: Rural Health Unit

Date of Admission: May 17, 2010

Admitting diagnosis: T/C Septic Knee left, Osteosarcoma

on the right femur S/P Hip

Disarticulation

Final diagnosis: Osteosarcoma right distal femur, S/P

hip

Disarticulation

b) Environmental Status

Child OS and her family are currently residing at Mabalacat

Pampanga. According to her grandmother, their house is a mixed of

concrete and wood with two bed rooms, a small living room and

kitchen. Their water source for drinking, laundry, bath, and

dishwashing is from a water pump around 5 meters away from their

house. They have their own bathroom located at the back of their

house with a water sealed latrine. The mother described their place as

a congested one. Their major source of lighting facility is electricity.

Their place is near the elementary school and barangay hall. Pedicab,

tricycle and jeep are their primary mode of transportation.

c) Lifestyle

Her grandmother stated that upon child OS’s admission she usually

sleeps at around 7-8 in the evening and wakes up at around 6-7 in the

morning. She usually takes a nap for about half an hour to an hour or

so every day. In the middle of the day she’s fond of watching

television, playing with her toys, writing and drawing. She eats more

on meat and chicken and less on vegetables.

3. History of Past Illness

According to the patient’s grandmother, patient experienced an illness

(grandmother don’t remember the specific disease/illness that patient experienced) that

threatened the patient’s life when she was 8 months old. Interventions were done to cure

patient’s illness. According to the patient, side effect or complications of the disease will

manifest as she grows up.

Early 2010, she met an accident. She was hit by a bicycle and strokes her knee.

She had bruises at different parts of the body. After two weeks, her grandmother noticed

that patient has difficulty in walking but patient stated that she was just tired. After a

week her grandmother again noticed that there is atrophy on patient’s right leg that

caused them to seek for medical attention. The physician ordered for x-ray, bone biopsy

and bone scan which revealed malignant tumor on the femur. Because the cancer already

metastasized to the rest of her right leg, patient had undergone disarticulation of her right

hip. Management continued as well as chemotherapy and the like.

According to the patient’s grandmother, patient had not completed immunization.

She also denies any allergies to food, medications and other environmental factors. She

experienced cough, fever and colds and managed it with over the counter medications

like paracetamol.

4. History of Present Illness

Three weeks prior to admission, April 19, 2010, patient hit her left knee with

mother knee. Patient noted pain and swelling. No interventions were done that time.

One week prior to admission, May 10, 2010, patient noted persistence and

increase severity of pain and swelling. Prolonged consult to our institution work-up was

done and was sent home.

Day of admission, May 17, 2010, results came in, patient is subsequently with

chest pain, dysphagia, vomiting episodes, mild swelling and tenderness of the left knee.

Admitting diagnosis was primary bone tumor probably malignant osteosarcoma

recurrence r/o septic. Antibiotics are given via IV.

5. Physical Assessment Date: June 01,

2010

13 Areas of Assessment

a. Social Status

Child OS is the eldest among the two siblings and she currently lives with her

family. She grows up with her grandmother. She usually plays with other children. She

maintains good relationship with her classmates as well as other family members.

Norms:

The ability to interact successfully with people and within the environment of

which each person is a part, to develop and maintain intimacy with significant others and

to develop respect and tolerance for those with different opinion and beliefs are

necessary determinant for a person’s social state. (Kozier,2004)

Families consist of persons and their responsibilities within the family. A family

structure of parents and their offspring is known as the nuclear family (Kozier, 2004)

The ability to achieve balance between work and leisure time is also a needed

factor. A person’s belief about education, employment and home influence personal

satisfaction and relationships with others (Kozier, 2004)

Analysis:

The patient does not have abnormality with regards to her social status. She

established good relationship with others.

b. Mental Status

Upon assessment the patient was awake. She was wearing a t-shirt and short

during the assessment. She cried a little during the interview because of pain but started

to tell stories afterwards. She responds to the questions correctly and maintains eye

contact upon conversing. She possesses appropriate facial expression with frequent

frowning due to pain felt at the Right leg which is again swelling and has tenderness.

Norms:

Physical Appearance and Behavior

Posture and movements: The patient should appear relaxed with the appropriate

amount of concern for the assessment. The patient should exhibit erect posture,

and symmetrical body movements. (Estes, 2006)

Dress, Grooming and Personal Hygiene: The patient should be clean and well-

groomed, and should wear appropriate clothing for age, weather, and socio-

economic status. (Estes, 2006)

Facial Expression: Facial expressions should be appropriate to the content of the

conversation and should be symmetrical. (Estes, 2006)

Affect: The appropriateness and degree of affect should vary with the topics and

the patient’s cultural norms, and be reasonable, or eurorhythmic (normal).

(Estes, 2006)

Communication: The patient should be able to produce spontaneous, coherent

speech. The speech should have an effortless flow with normal inflections,

volume, pitch, articulation, rate, and rhythm. Content of the message should make

sense. (Estes, 2006)

Cognitive Abilities and Mentation

Attention: The patient should be able to correctly repeat the series of 5 numbers.

(Estes, 2006)

Memory: The patient should be able to correctly respond to questions and to

identify all the objects requested. (Estes, 2006)

Analysis:

Patient’s mental status is normal, since she can answer the questions ask but stop

for a while and cry when she’s in pain.

c. Emotional Status

The patient’s grandmother stated that whenever she has problem she tells it to her

grandmother or her mother. She cried during the interview but it was managed by her

grandmother. Afterwards she exhibits happiness and actively joins the conversation. He

was able to convey emotions appropriate to her feeling according to her mother.

Norms:

A person expresses himself as an optimistic and a positive thinker in life. There

should no presence of fear, anxiety, grieving etc. The patient should have the ability to

manage stress and to express emotions appropriately. It also involves the ability to

recognize, accept, and express feelings and to accept one’s imitations. (Kozier, 2004)

Analysis:

There is no abnormality noted on the patient’s emotional status. She was able to

display the emotions that she needs to display from what she feels.

d. Sensory Perception

Sense of Sight

From a distance her eyes appeared to be symmetrical and round, the sclera is white

in color and the iris appeared to be colored black. There are no lesions, redness.

Nodules and tenderness noted in her eyes including in the lacrimal glands.

Norms:

Eyes symmetrically aligned, equal movement, eye bilaterally blinking, sclera appears

white, skinny smooth conjunctiva, no edema and tenderness on lacrimal gland.

Pupillary constriction should occur when struck by light. (Estes, 2004)

Analysis:

Patient’s eyesight is normal based from the assessment done.

Sense of Taste

According to the patient’s grandmother, she was able to distinguish different taste of

food like salty, sour sweet and the like. Upon inspecting the mouth, the lips are

reddish in color and are moist. The tongue is also moist with the absence of lesion

and redness.

Norms:

Tongue is reddish/pink in color, central in position, no lesions, raised papillae (taste

buds), moves freely, no tenderness no palpable nodules. (Estes, 2006)

Analysis:

Patient’s tongue color is normal but she is choosy and refuse to eat the hospital food

delivered that time we assess her.

Sense of Hearing

The grandmother stated that she does not experience any difficulties in hearing. The

group also observed that she responds accordingly to any questions that are asked to her

without the need to repeat it.

Norms:

Normal voice tones are audible. (Kozier, etal, 2004) For the auditory accuracy, the

patient should be able to repeat the words whispered from the distance of 2 feet.

(Health Assessment and Physical Examination, Estes 2006)

Analysis:

The patient’s hearing has no abnormality.

Sense of Smell

The patient nose is symmetrical and is located at the midline of the face with no

nodules, lesion and tenderness noted. The patient was able to identified different smells

by verbalizing the odor of objects used like an alcohol and perfume while her eyes were

closed.

Norms:

The nose must be symmetrical and along the midline of the face. Each nostril must

be patent and able to recognize the smell of an object. (Estes, 2006)

Analysis:

The assessment of the patient’s sense of smell revealed normal findings.

Tactile Sensitivity

In the assessment of this area, the patient was asked to close her eyes while she was

lightly poked with the sharp ends of the pencils by her mother and she was able to

recognize it. Still with eyes closed she was able to feel and identify a gentle pressure

applied on the different site on her body. She also pointed the areas where she felt

pain (left leg) which she rated 7/10 where 10 is the highest.

Norms:

The skin contains receptors for pain, touch, pressure and temperature. Sensory

signals that help determine precise locations on the skin are transmitted along rapid

sensory pathways, and less distinct signals such as pressure or poorly localized touch

are sent via slower or sensory pathways. (Estes, 2006)

Analysis:

The patient does not have any problem on sensations. She can identify pain sensation

especially on the leg affected by osteosarcoma.

e. Motor Stability

The patient has right hip disarticulation because of that she stayed at bed most of

the time. She was able to flex and extend her upper extremities without any pain and

difficulty. She was also to perform active Range of Motion exercises without any

difficulty and no limitations were noted but experienced pain on the left leg that caused

her to immobilize the leg often.

Norms:

Normal muscle strength allows for complete voluntary range of joint motion

against both gravity and moderate to full resistance. Muscle strength is equal bilaterally.

A healthy person can perform the different Range of Motion (ROM). (Health Assessment

and Physical Examination, Mary Ellen Zator Estes 5th Edition).

Analysis:

Because patient’s right leg was disarticulated, her motor ability is abnormal

because she cannot perform activities of daily living to the fullest because of her

condition.

f. Body Temperature

Temperature

Date and Time Results

June 01, 2010

10:00am 37.00C

Norms

The normal body temperature ranges from 36.5 to 37.5oC (Kozier 2004)

Analysis

During the assessment the patient’s body temperature are within normal limits.

g. Respiratory Status

Respiratory Rate

Date and Time Results

June 01, 2010

10:00am 27

Norms

In the resting adult, the normal respiratory rate is 12 to 20 breaths per minute

(Pillitterri, 200). In children the normal respiratory rate is 20 – 30 breaths per minute.

Analysis

The patient had a fast breathing with irregular rate and depth of breathing.

h. Circulatory Status

Circulatory Status

Date and Time Results

June 01, 2010

10:00am 84bpm

Norms

Normal pulse rate is 80-120 bpm in preschoolers. (Kozier, 2006).

Analysis

Patient’s pulse rate is within the normal range.

i. Elimination Status

The grandmother of the patient stated that her child’s urine color is light yellow

and she urinates up to 5 times a day. She denied any pain during urination. She also

added that the patient defecated regularly at about twice a day with normal straining

before but altered upon hospitalization because she has difficulty in defecation.

Norms

A person’s urinary habits depend on social culture, personal habits, and physical

activities. Personal habits regarding urination are affected by the social propriety of

leaving to urinate, the availability of a private clean facility, and initial bowel training.

Voiding can be postponed for only so long before the urge normally becomes too great to

control. (Kozier, 2004)

The normal urine output for patients 14 years old and above is 1,200to 1,500 mL.

(Kozier, 2004)

The frequency of defecation is highly individual, varying from several times per

day to 2 to 3 times per week. The amount defecated also varies from person to person.

(Kozier, 2004)

Feces are normally brown, due to the presence of stercobilin and urobilin, which

are derived from bilirubin. Another factor that affect fecal color is the action of bacteria

such as E. coli or Staphylocci, which are usually present in the large intestines. The

action of chyme is also responsible for the odor of feces. (Kozier, 2004)

Analysis:

Her urinary status is still normal as well as the elimination but upon

hospitalization it varies because of long time staying flat on bed and without exercise.

j. Nutritional Status

According to the patient’s grandmother, patient loves to eat fried chicken and

other fried foods. Per serving she eats one cup of rice in average. She is also fond of

eating junk foods and consumes two packs of it in a day. She usually consumes 7-8

glasses of water a day. On her hospital stay, she eats less than what compared to

the amount that she consumed before hospitalizations. She only drinks two to three

glasses of water at most.

Patient’s BMI:

Height: 137 cm

Weight: 30 kg

Norms:

An adequate diet is the foundation of good nutrition and it should consist

of a wide variety of natural foods.(Abelos, 2005)

If a man is at risk for nutritional deficits, a more precise estimation of

adequate weight gain can be calculated. This is done by calculating the body

mass index. (Pilliterri, 2007)

Caloric needs is 2,500, while protein needs is 60 g daily. (Pilliterri, 2007)

BMI ranges

Range Interpretation

<18.5 Underweight

19 - 24.9 Normal

25 – 30 Overweight

>30 Obese

(Black, 2008)

Analysis

The patient’s food intake has decreased from her usual intake it may be associated

with the effects of chemotherapeutic agents. Her BMI is below the normal range due to

decreased food intake and decreased interest to food intake as verbalized by her

grandmother.

k. Skin and Appendages

The patient’s skin is light brown in color. She has right hip disarticulation. She

has erythema, swelling and tenderness on the left leg.

Norms

The skin is whitish pink to brown in color, depending on the race of the patient.

There is no presence of increase vascularity and smooth, moist and firm upon palpation.

Nail beds are pink to brown in color depending on the race of the patient. It should be

smooth and slightly rounded or flat. Capillary refill comes back after 2 seconds. (Health

Assessment and Physical Examination, Estes)

Analysis

Patient skin and appendages especially on the left shows abnormality due to

metastasized sarcoma on the leg which caused it to be erythematous and swollen.

l. Reproductive Status

The patient is only six years old. She does not experienced menarche yet.

Norms:

The onset of menstruation occurs between 9-16 years of age, and ends at

menopause, which occurs between 45 to 55 years of age. The onset of puberty, which

occurs between the ages of 8 to 9, is marked by significant increases in estrogen

production and the development of secondary sexual characteristics. The menstrual flow

last from 2 to 7 days and the cycle continue every 25 to 34 days, with the average being

28 days.

Analysis:

Based on the given norms above, the client’s reproductive status is normal.

m. Rest and Sleep

The patient usually sleeps for about 8-9 hours daily with frequent interruptions

due to pain at the left hjp which is swelling and has tenderness. Her grandmother also

stated that she doesn’t have any difficulty in falling asleep. She also added that at time

she would have afternoon naps of about an hour or so but had been disturbed because of

pain that she felt on her left hip.

Norms:

Sleep is a basic human need; it is a universal, biological process common to all

people. It has been suggested that maintaining a regular sleep wake rhythm is more

important than the number of hours actually slept. Some people, for example, can

function well on as little as 5 hours of sleep each night.(Kozier, 2004)

Middle-aged adults generally maintain the sleep pattern established at a younger

age. They usually sleep 6-8 hours per night. (Kozier, 2004)

Analysis

Patient’s rest and sleep status was disturbed by the pain that he felt from her left

leg.

Anatomy and Physiology

A musculoskeletal system (also known as the locomotor system) is an organ

system that gives animals (including humans) the

ability to move using the muscular and skeletal

systems. The musculoskeletal system provides

form, support, stability, and movement to the

body.

It is made up of the body's bones (the skeleton),

muscles, cartilage,[1] tendons, ligaments, joints,

and other connective tissue (the tissue that

supports and binds tissues and organs together).

The musculoskeletal system's primary functions

include supporting the body, allowing motion, and protecting vital organs. The skeletal

portion of the system serves as the main storage system for calcium and phosphorus and

contains critical components of the hematopoietic system.

This system describes how bones are connected to other bones and muscle fibers via

connective tissue such as tendons and ligaments. The bones provide the stability to a

body in analogy to iron rods in concrete construction. Muscles keep bones in place and

also play a role in movement of the bones. To allow motion, different bones are

connected by joints. Cartilage prevents the bone ends from rubbing directly on to each

other. Muscles contract (bunch up) to move the bone attached at the joint.

There are, however, diseases and disorders that may adversely affect the function and

overall effectiveness of the system. These diseases can be difficult to diagnose due to the

close relation of the musculoskeletal system to other internal systems. The

musculoskeletal system refers to the system having its muscles attached to an internal

skeletal system and is necessary for humans to move to a more favorable position.

Skeletal

The Skeletal System serves many important functions; it provides the shape and form for

our bodies in addition to supporting, protecting, allowing bodily movement, producing

blood for the body, and storing minerals.[4] The number of bones in the human skeletal

system is a controversial topic. Humans are born with about 300 to 350 bones, however,

many bones fuse together between birth and maturity. As a result an average adult

skeleton consists of 206 bones. The number of bones varies according to the method used

to derive the count. While some consider certain structures to be a single bone with

multiple parts, others may see it as a single part with multiple bones. [5] There are five

general classifications of bones. These are Long bones, Short bones, Flat bones, Irregular

bones, and Sesamoid bones. The human skeleton is composed of both fused and

individual bones supported by ligaments, tendons, muscles and cartilage. It is a complex

structure with two distinct divisions. These are the axial skeleton and the appendicular

skeleton.

Function

The Skeletal System serves as a framework for tissues and organs to attach themselves to.

This system acts as a protective structure for vital organs. Major examples of this are the

brain being protected by the skull and the lungs being protected by the rib cage.

Located in long bones are two distinctions of bone marrow (yellow and red). The yellow

marrow has fatty connective tissue and is found in the marrow cavity. During starvation,

the body uses the fat in yellow marrow for energy.[7] The red marrow of some bones is an

important site for blood cell production, approximately 2.6 million red blood cells per

second in order to replace existing cells that have been destroyed by the liver. [4] Here all

erythrocytes, platelets, and most leukocytes form in adults. From the red marrow,

erythrocytes, platelets, and leukocytes migrate to the blood to do their special tasks.

Another function of bones is the storage of certain minerals. Calcium and phosphorus are

among the main minerals being stored. The importance of this storage "device" helps to

regulate mineral balance in the bloodstream. When the fluctuation of minerals is high,

these minerals are stored in bone; when it is low it will be withdrawn from the bone.

Muscular

Skeletal Muscle Smooth Muscle Cardiac Muscle

Types of muscle and their appearance

There are three types of muscles—cardiac, skeletal, and smooth. Smooth muscles are

used to control the flow of substances within the lumens of hollow organs, and are not

consciously controlled. Skeletal and cardiac muscles have striations that are visible under

a microscope due to the components within their cells. Only skeletal and smooth muscles

are part of the musculoskeletal system and only the skeletal muscles can move the body.

Cardiac muscles are found in the heart and are used only to circulate blood; like the

smooth muscles, these muscles are not under conscious control. Skeletal muscles are

attached to bones and arranged in opposing groups around joints. Muscles are innervated,

to communicate nervous energy to, by nerves, which conduct electrical currents from the

central nervous system and cause the muscles to contract.

Conclusion

As a student nurse’s, it is important that we are equipped with enough information

and knowledge on how to prevent further complication that may arise. We found out

ways on how we can acquire and prevent having this kind of a disease.

Through this case study, our knowledge in this particular disease becomes

broader. We are confident that the next time we are going to handle a patient with a

Osteosarcoma in order to provide better nursing interventions.

Proper dissemination of information is needed to be able to increase the

awareness of people especially in children because early detection is very important in

order to prevent further complication of the disease.

IV. Recommendations:

When we assessed the patient we advise the mother to let her daughter continue her

Continue medications as prescribed

Prescribed medication must be taken on time

Strenuous exercise should be avoided

Encouraged to take enough rest to regain strength

Take home medications as doctors’ order

Report unusual signs and symptoms

Advised the client to have enough bed rest

Upon discharge patient education should emphasize the importance of close

follow up care

Encourage to practice personal hygiene properly like washing of foods

thoroughly before cooking and if raw, wash their hands also before and after

using the rest room and before eating. Or handling any objects, wash kitchen

utensils before using them

Follow her diet, increase fluid intake