osteosarcoma case
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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
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