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Case Study of Osteosarcoma and Pathologic Fracture

of the Humerus

Submitted By: BSN – III. Group I

Arago, Alvin

Banaag, Glady Maicel

Cordero, Marissa

Dimayacyac, Lyka

Formaran, Jheny

Hilario, Joeven

Submitted To:

Dr. Ma. Purisima B. Macatangay

Dean of College of Nursing, RN, MAN, Ph.D

OBJECTIVES:

General Objectives:

To learn important information about bone tumors specifically

osteosarcoma, enabling the group gain deeper knowledge and understanding,

towards giving a safe and quality nursing care for patients with said condition.

Specific Objectives:

>Nurse-centered objectives

To focus on bone tumors and give a brief discussion of fracture of

the humerus.

To review the anatomy and physiology of the affected area and to

discuss the pathophysiology osteosarcoma including its predisposing

factors.

To outline and analyze the drug used by the patient in the course of

treatment.

To plan and carry out nursing interventions appropriate in the

management of the disease.

>Patient-centered objectives

To have an idea and be familiar about the risk bone tumors and bone

fractures.

To be able to gain insights about the condition enable to render an

appropriate actions/management so that the patient will prevent

further complications.

I. INTRODUCTION

Bone Tumor is neoplasm in the skeletal system. They maybe primary or

metastatic tumor from primary cancer elsewhere in the body. Metastatic Tumor are more

common than primary bone tumor. There are two types of bone tumor the Benign Tumor

and Malignant Bone Tumor. Benign bone tumor

includes: Osteoma, Chondroma, Csteochondroma

and Giant Cell Tumor. This tumor tends to grow

slowly and usually do not destroy the supporting or

surrounding tissue or spread to other part of the

body. Malignant bone tumor is an ill defined, lack

sharp border and extend beyond the confines of the

bone. There are several types of malignant bone

tumor which includes Osteosarcoma, Ewing/s

Sarcoma and Chondroma.

Osteosarcoma is an ancient disease that is still incompletely understood. The term

sarcoma was introduced by the English surgeon Jhon Abernalty in 1804 and was derived

from Greek roots meaning fleshy excrescene. In 1805, the French surgeon Alexis Boyer

first used the term osteochondroma. It gross appearance was described 1847 by Baron

Guillaume Dupuytren as a whitish or reddish mass, lardaceous and firm at an early stage

of the disease; but presenting at a later period, points of softening, cerebriform matter,

extravasting blood and white or straw colored fluid of a viscid consistence in its interior.

The incidence of osteosarcoma is slightly higher in males than 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 years.). Incidence increases

steadily with age, increasing more dramatically in adolescence, corresponding with the

growth spurt. Osteosarcoma is deadly form of musculoskeletal cancer that most

commonly causes patients to die from pulmonary metastatis disease and which has 5 year

survival rate of 15-20%.

Fracture of the humerus represents 3-5% of all

fractures it is related to bimodal age distribution. It

may occur in children due to accident resulting to

injury or trauma to the bones and in elderly due to

weakened bones which are prone to fracture when

accidentally fall. Fracture of the humerus can be

described according to its location, it can be either,

proximal, middle or distal third and its pattern spiral,

transverse and comminuted.

A pathologic fracture is a broken bone caused by disease leading to weakness of

the bone. This process is most commonly due to osteoporosis, but may also be due to

other pathologies such as: cancer, infection, inherited bone disorders,or a bone cyst. Only

a small number of conditions are commonly responsible for pathological fractures,

including osteoporosis, osteomalacia, paget's disease, osteitis, osteogenesis imperfecta,

benign bone tumors and cysts, secondary malignant bone tumours and primary malignant

bone tumours.

Fragility fracture is a type of pathologic fracture that occurs as result of normal

activities, such as a fall from standing height or less.This definition arises because a

normal human being ought to be able to fall from standing height without breaking any

bones, and a fracture therefore suggests weakness of the skeleton.

II. PATIENT’ PROFILE

Name: Patient X

Permanent Address: # 0522 Bulihan, Bulacan

Birthdate : Oct. 11 1945

Age: 67 yrs. Old

Nationality: Filipino

Religion: Roman Catholic

Date of Admission: March 14, 2013

Admitting Diagnosis: Primary Bone Tumor L2 vertebra, No neurologic deficit,

pathologic fracture humerus @ right arm

A. Past History

Patient X is a mother of three siblings. She is a vendor, selling “kakanin” such as

suman, puto, bibingka etc. According to her in terms of nutrition she loves to eat

vegetables, fruits, and meat however, she is not fond of drinking milk which might

precipitate the occurrence of disruption in continuity of bone. At the age of 66 she notices

a palpable mass on her back specifically lumbar 2 vertebra. Then last December 2012 she

started to experience the signs and symptoms of bone tumor primary night time

awakening due to the persistent pain on the affected area.

Patient X is neither a known asthmatic nor had medications. She claims to have

no history of previous hospitalization or serious illness.

B. Present History

Patient X confined at Philippine Orthopedic Center having a chief complaint of

pain in right arm and diagnosis of Primary Bone Tumor L2 vertebra, No neurologic

deficit, pathologic fracture humerus @ right arm. At the time of admission the patient is

conscious and coherent. According to the patient fracture resulted from accident fall and

broke her arm. The diagnosis exam done to her are X-ray and MRI, in laboratory test, she

undergone CBC.

III. REVIEW OF SYSTEMS

IV.GORDON’S FUNCTIONAL HEALTH PATTERN

Health Perception – Health Management Pattern

The patient seeks consultation to her personal doctor, but sometimes she takes any

medication which is prescribed by the doctor. Because of persistent pain, she was forced

to go to the hospital and diagnosed of primary bone tumor.

Nutritional Metabolic Pattern

There is no restriction in the patient’s diet. She usually includes fruits and

vegetables in her diet, moreover, she is fond of eating high fat foods and she refused to

drink milk.

Elimination Pattern

Due to her condition, the patient has indwelling Foley catheter. In terms of bowel

movement, it is irregular, she told us that she moved bowel every 2 -3 days.

Activity – Exercises Pattern

The patient did not engage in any form of exercises, she considered household

chores as a means of exercises. But since she was hospitalized, she was not able to

perform any form of exercises and according to her there is numbness in her lower

extremities leading to immobilization.

Sleep – Rest Pattern

The patient experienced disturbance in sleeping because of the pain especially at

night.

Cognitive – Perceptual Pattern

She can easily understand and interact with people. The patient was able to follow

instructions as ordered by the physician; however, she lacks knowledge regarding her

condition.

Self – Perception – Self – Concept Pattern

She is conscious and coherent upon interaction. Due to her condition, she was

confined to bed and experiencing difficulty in moving associated with numbness and

weakness of lower extremities.

Role – Relationship Pattern

The patient has good relationship with the family members. According to her

daughter, she is a good mother. The family always support her financially and

emotionally especially during hospitalization.

Coping – Stress Tolerance Pattern

She used the power of praying/ prayer, rosary and bible to cope with daily stress.

Values/ Belief Pattern

She has a positive outlook in life. She believe and still hoping for her condition to

become better.

V. ANATOMY AND PHYSIOLOGY

PARTS OF THE HUMERUS

VERTEBRAL COLUMN

VI. PATHOPHYSIOLOGY

PREDISPOSING FACTORS:Children:

Genetics Teenage growth spurt Benign bone tumors Injury/Trauma Metabolic and hormonal

imbalance

PREDISPOSING FACTORS:Adults:

High fat diet Lack of exercise Smoking Alcoholism Injury/Trauma Metabolic and hormonal

imbalance

OSTEOBLAST

DNA MUTATION

MALIGNANT OSTEOBLASTPROLIFERATION OF ABNORMAL OSTEOBLAST

FORMATION OF IMMATURE BONE

Pain Swelling Tenderness

OSTEOSARCOMA

VII. LABORATORY RESULTS

HEMATOLOGY TEST:

Blood Component Normal Values ResultsHemoglobin 110 – 158 g/L 72 g/LHematocrit 0.37 – 0.54 g/L 0.23

Leucocytes Count 4.5 – 10 x 101/L 3.24Platelet Count 150 – 400 x 109/L 49

LIPID PROFILE:

Lipid Normal Values ResultsHemoglobin < 35 – 85 mg/dL 28

Hematocrit < 160 mg/dL 171

POTASSIUM LEVEL:

Potassium Normal Values ResultsK 3.5 – 5 meq/L 3.1 meq/L

VIII. DRUG STUDY

1.BRAND NAME: Kalium Durule

GENERIC NAME: Potassium Chloride

MECHANISM OF ACTION: Replaces potassium and maintains potassium level.

INDICATION: To prevent hypokalemia.

CONTRAINDICATION: Contraindicated in patient with severe renal impairement with oliguria, anuria, or with acute dehydration or other conditions linked to extensive tissue breakdown.

ADVERSE REACTION: paresthesia of limbs, confusion, weakness G.I: nausea, vomiting. abdominal pain, diarrhea.

o METABOLIC: hyperkalemia.

o RESPIRATORY: respiratory paralysis.

NURSING CONSIDERATION:

Drug is commonly used orally with potassium wasting diuretics to maintain potassium level.

Monitor ECG and electrolyte level during therapy.

Many adverse reaction may reflect hyperkalemia.

2.BRAND NAME: Feosol

GENERIC NAME: Ferrous Sulfate

MECHANISM OF ACTION: Provides elememtal iro, an essential component in the formation of hemoglobin.

INDICATION: For iron deficiency

CONTRAINDICATION: Contraindicated in patient with peptic ulcer disease, regional enteritis or ulcerative colitis.

ADVERSE REACTION: G.I: nausea, epigastric pain, vomiting, constipation. Black stool, anorexia. Other: temporarily stined teeth from suspension.

NURSING CONSIDERATION:

Check for constipation; record color and amount of stool.

G.I upset may be related to dose.

Monitor hemoglobin level, hematocrit and reticulocyte count during therapy.

Tell patient to take tablet with juice or water but not with milk or antacid.

3.BRAND NAME: Tramadol

GENERIC NAME: Ultram

MECHANISM OF ACTION: Inhibits the reuptake of serotonin and norepinephrine in CNS.

INDICATION: Moderate to moderately severe pain

CONTRAINDICATION: Contraindicated in patient who have previously demonstrated hypersensitivity to tramadol, any other component of this product or opiods.

ADVERSE REACTION:

CNS: dizziness, headache, vertigo, seizures, anxiety.

EENT: visual disturbance.

G.I: constipation, nause4a, vomiting, abdominal pain.

SKIN: diaphoresis, pruritus and rash.

NURSING CONSIDERATION:

Assess type of location and intensity of pain before and 2-3hours (peak) administration.

Assess BP, and RR before and periodically during administration.

Assess bowel function routinely.

For better analgesic effect, give drugs before onset of intense pain.

4.BRAND NAME: Losec, Prilosec

GENERIC NAME: Omeprazole

MECHANISM OF ACTION: Inhibits activity of acid (proton) pump and binds to hydrogen-potassium adenosine triphosphatase at secretory surface of gastric parietal cells to block formation of gastric acid.

INDICATION: Treatment of gastroesophageal reflux disease.

CONTRAINDICATION: Contraindicated in patient hypersensitive to drug or its component.

ADVERSE REACTION:

CNS: dizziness, headache. G.I:abdominal pain. Constipation, diarrhea, nausea, vomiting.

MUSCULOSKELETAL: back pain,

RESPIRATORY: cough, upper respiratory tract infection.

SKIN: rash

NURSING CONSIDERATION:

Instruct patient to take drugs 30mins. before meals.

Caution patient to avoid hazardous activities if he gets dizzy.

Tell patient to swallow tablet or capsule whole anot to open, crush, or chew them.