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This document presents a case study of a 19-year-old female diagnosed with osteosarcoma in the left humerus. It describes the patient's history, including 5 months of left shoulder pain. Diagnostic tests including x-ray, CT scan and biopsy confirmed osteosarcoma. The patient underwent chemotherapy and fourth quarter amputation of the left humerus. The document discusses the anatomy and physiology of the musculoskeletal system and osteosarcoma, including risk factors, symptoms, diagnostic tests, treatment options and prognosis.
This document presents a case study of a 19-year-old female diagnosed with osteosarcoma in the left humerus. It describes the patient's history, including 5 months of left shoulder pain. Diagnostic tests including x-ray, CT scan and biopsy confirmed osteosarcoma. The patient underwent chemotherapy and fourth quarter amputation of the left humerus. The document discusses the anatomy and physiology of the musculoskeletal system and osteosarcoma, including risk factors, symptoms, diagnostic tests, treatment options and prognosis.
This document presents a case study of a 19-year-old female diagnosed with osteosarcoma in the left humerus. It describes the patient's history, including 5 months of left shoulder pain. Diagnostic tests including x-ray, CT scan and biopsy confirmed osteosarcoma. The patient underwent chemotherapy and fourth quarter amputation of the left humerus. The document discusses the anatomy and physiology of the musculoskeletal system and osteosarcoma, including risk factors, symptoms, diagnostic tests, treatment options and prognosis.
The Faculty of College of Nursing Our Lady of Fatima University
In Partial Fulfillment Of The Requirements for the Related Learning Experience NCM 106 Bachelor of Science in Nursing
BERMUDEZ, ANNALIZA, B. BANTUCAN, PRINCESS, C. AUGUST 2014
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TABLE OF CONTENTS
INTRODUCTION --------------------------------------------------------------------------------- 3 BIOGRAPHICAL DATA ---------------------------------------------------------------------------------- 4 PHYSICAL ASSESSMENT ---------------------------------------------------------------------------------- 5 ANATOMY AND PHYSIOLOGY ---------------------------------------------------------------------------------- 6-7 MEDICAL MANAGEMENT ---------------------------------------------------------------------------------- 8 NURSING MANAGEMENT --------------------------------------------------------------------------------- 8 PATHOPHYTSIOLOGY ------------------------------------------------------------------------------- 9 APPENDICES PATHOPHYTSIOLOGY ------------------------------------------------------------------------------- 11 LABORATORY AND DIAGNOSTIC TEST ---------------------------------------------------------------------- 12-16 NURSING CARE PLAN ------------------------------------------------------------------------------------------- 17-18 BIBLIOGRAPHY---------------------------------------------------------------------------------------------------------- 19
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INTRODUCTION
Osteosarcoma is the most primary malignant neoplasm of bone that occurs in children and young adults. Accounts for 60% of malignant bone lesions in the first two decades of life. On average, 400 cases are diagnosed per year. The overall survival rate for patients diagnosed between 2008 and 2013 is 63%. The highest occurrence in adolescence is 15 19 years old. The exact cause of Osteosarcoma is unknown; however risk factors include the (a) Rapid Bone Growth appears to predispose persons to this disease. This most commonly occurs during the adolescence growth spurt in the metaphysical area nearby the growth plate of long bodies (b) exposure to radiation is an experimental factor that causes a secondary form of Osteosarcoma. (c) Abnormal development in bone tissue, such as Paget disease is also risk factors that may be involved in genetic predisposition. Osteosaccoma manifestations are pain and swelling of the affected area is the most common clinical findings. On rare occasions, fever and night sweats may occur. Treatment is preoperative or post operative chemotherapy. Resection, a procedure performed for the specific purpose of removal and allograft replacement, the process of transplanting tissue and organs. Medications are Antineoplastic agents, these agents disrupt DNA replication or cell division, thereby, inhibiting tumor growth and promoting tumor cell death. Antiemetic gents, reduce the effects associated with chemotherapy. For diagnostic imaging MRI appearance (T1 weighted image) of Osteosarcoma of the proximal humerus. Note dramatic tumor extension into adjacent soft tissues regions. Radiographic appearance ( pain x-ray) of proximal humeral Osteosarcoma. The prognosis for patients diagnosed with Osteosarcoma depends primarily on whether metastases are detectable at diagnosis. Patients who presents with metastases have a very poor prognosis with long term survival rates of less than 25%. For the patients with initially localized disease, the prognosis depends mainly on 2 variables: respectability and response to chemotherapy. Those who have completely resectable disease and those whose tumors have an excellent histologic response to neoadjuvant chemotherapy have the best chance for cure
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BIOGRAPHIC DATA
July 23, 2014 we have our interview to our patient namely D, M 19 y/old, female born on December 18 1994, live in Ormoc City, Province of Leyte. She is single and Filipino her religion is Roman Catholic, shes a student only, undergraduate of Criminology she cannot continue her study because of her situation. According to her she has 5 siblings in the province, she doesnt have any vices like smoking, drinking alcohol but she is playing Volleyball in her school. The favorite food of her are vegetables, meat and fruits, she a have an allergy to shrimp when she eat shrimp she becomes like a shrimp in color and have the rashes. HISTORY OF PRESENT ILLNESS Patient is a not known hypertensive, not known diabetic. Patient history stated 5 months. The patient stated acute pain on left shoulder risking characteristic graded 5/1, occurring when cold and spontaneously relieved. There was also a note of irritation of motion up to 90 degree. Note for the weight loss; Patient sought consult at a local hospital, where x-ray was done and showed mass over the left humerus. Patient was referred to our institution under the service of orthopedic department. CT- scan was done and showed osteoblastic lesion at left proximal humerus with associated soft tissue component. Interval history showed persistence of left shoulder pain with rigidity. Biopsy was done last 03 June 2014 consistent as osteosarcoma. Patient was advised for chemotherapy. Date of Admission: June 24, 2014, time of admission: 11:45 PM Ward: Female/ Oncology Ward. Working Diagnosis: Osteosarcoma, Humerus Left status post fourth quarter amputation left. PAST MEDICAL HISTORY Patient has no previous history of allergies. She had stated of having previous records of hospitalization. She was admitted last May 2, 2014 at De Los Santos hospital for Bone x-ray examination, May 17, 2014 for MRI examination. DEVELOPMENTAL STAGE In developmental stage, the patient is in adolescence stage. She is 19 years old. In her central task, she is in identity vs role confusion. Sense of self plans to actualize ones abilities for her indicators for positive resolution and for her negative resolution, Ability to have possible anti social behavior. And She come to anti social because in her condition. According to the patient when the time she knows her condition she losses his faith and she afraid for what happen to herself and she also said that she is worthless.
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PHYSICAL ASSESSMENT
Patient is conscious, coherent, and ambulatory not in cardio respiratory distress. Her vital signs are Temperature- 36.5.0 C, Pulse Rate- 750 bpm, Respiratory Rate- 20cpm, Blood Pressure- 110/70 mmHg. Skin is tones without unusual discoloration in normal but the patient actual findings is pallor due to decrease blood supply. Head is generally round in shape and no tenderness palpated and it is normal in findings. Hair is black can be black or brown depending on the race evenly distributed covers the whole scalp, maybe thick or thin, coarse or smooth neither brittle nor dry. Lighter in color than the complexion in color and findings is oily in appearance due to decrease protein. Eyes are symmetrical and line with each other pupils are equally rounded and reactive to light and accommodation in normal and findings are, with slightly pale conjunctiva due to sleeping habits and anemia brought by osteosarcoma. Ears are Symmetrical, no nodules or masses on palpation and no ear discharges. Mouth is pinkish lips, pick gums without missing teeth, any foul odor,and patients findings is dry lips due to poor intake of food. Upper and lower extremities is symmetrical, no trophy, with full range of motion, findings is Amputated on left humerus, Immobilized to range of motion experiencing muscle weakness due to surgery brought by osteosarcoma. Abdomen is soft and non tender abdomen upon palpitation abdominal muscle weakness due to limited motion.
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ANATOMY ANG PHYSIOLOGY
A musculoskeletal system ( locomotor system ) is an organ system that gives 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 bodys bones (the skeleton), muscles, cartilages, tendons, ligaments, joints and other connective tissues (the tissue that supports the binds tissues and organs together.) the musculoskeletal systems primary function include supporting the body, allowing motion, and protecting the vital organs. The skeletal portion of the system serves as the main storage system for calcium and phosphorus and contains critical components of the hermatopoetic system. The system describes how bones are connected to other bones and muscles fibers via connective tissue such as tendons and ligaments. The bones provide the stability a e body in analogy to iron rods in concrete construction. Muscles keep bones in a 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 to move the bone attached at the joint. However, disease and disorders that may adversely affect the function and overall effectiveness of the system. These disease can be difficult to diagnose due to the close relation of the musculoskeletal system to other internal refers to the system having its muscles attached to an internal skeletal system and is necessary for humans to moves to a more favorable position.
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SKELETAL
The skeletal system serves may important functions; it provides the shape and form for our bodies in additions to supporting, protecting allowing bodily movement, producing blood for the body, and storing minerals. The number of bones in the human skeletal is a controversial topic. Humans are born with about 300-350 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 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. There are 5 generals classifications of bones. These are Long Bones, Short Bones, Flat Bones, Irregular Bones and Sesamoid Bones. The human skeletal 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 axial skeleton and appendicular skeleton.
FUNCTION The skeletal system serves as framework for tissues and organs to attach themselves to. These system acts as a protective structure for vital organs. Major example of this is 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 fats in yellow marrow for energy. The red marrow of some bones is a site for the 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. Here all erythrocytes, platelets and most leukocytes form in adults. From the red marrow erythrocytes, platelets and most leukocytes migrate to the blood to do their special task. Another function of bones is 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 There are three types of musclesCardiac, skeletal, and smooth. Smooth muscles are used to control the flow of substance within the lumens of hallow organs and are not consciously controlled. Skeletal and cardiac muscles have striations that a visible under a microscopic 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 muscle, these muscles are not under conscious control. Skeletal muscles are attached to bone 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 contr
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TREATMENT
Medical Management: Treatment of osteosarcoma begins after a biopsy of tumor cells. Before the major surgery, the patient is subjected to a series of bloodtransfussion.Last July 3, 2014 patient undergo blood transfusion to maintain the pretransfussion hemoglobin level needed, with the 2 units packed of RBC, fresh whole blood. And repeated again last July 16, 2014 Packed of RBC 16 Units fresh whole blood. July 14, 2014 the client was scheduling for the Fore Quarter Amputation on her Left Humerus, wider General Anesthesia.
NURSING RESPONSIBILITIES
The patient stated acute pain on left shoulder risking characteristic graded 5/1, occurring when cold and spontaneously relieved. There was also a note of irritation of motion up to 90 degree. Note for the weight loss. And undergo major surgery. We advised the mother to let her daughter to continue her medications as prescribed. Provide quiet environment and calm activities to prevent or lessen pain. Provide comfort measure such as back rub, change position and use of heat or cold application. Encourage divisional activities. Administer analgesics as indicated to maximal dose as needed. Encourage the patient to increase fluid intake. Encourage rest periods to prevent fatigue. Provide accurate information about the situation, medication and treatment. Assess muscle strength, gross and fine motor coordination. Provide pillows for cushion and support. Keep side rails up all the time. Assist the patient and family to cope with the problem. Provide quiet environment and calm activities to prevent or lessen pain. Provide wound care. Provide nursing care of post-op amputation. Provide with normal growth and development activities. Encourage rest periods to prevent fatigue. Provide emotional support. Assess the pain and provide analgesics and other pain control measures as needed. For the wound care, proper dressing and cleaning. Change the dressing every day to prevent infection.
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PATHOPHYSIOLOGY
The etiology in mutation in DNA is unknown, predisposing factors include young age (19 years old), female, precipitating factors include strenuous activity. Once there is a mutation in DNA the photo oncogenes becomes oncogene and the tumor suppressor gene will deactivate or it will be loss its function. Photo oncogene is a good cell that provides signals that lead to cell division and tumor suppressor gene works as guardian cells. When the oncogene is activated and the tumor suppressor lose its function or deactivate, the cell will became malignant until it will create a daughter cell that is malignant osteobleast. Then the malignant osteoblast will proliferate until there will be uncontrolled growth of tumor. The existence of uncontrolled growth will cause increase pressure inside that will result to pain and swelling. There is also a fatigue, anorexia, pallor, and dizziness, and general body weakness, anemia because of the blood transfusion. The medical treatment for this is left humerus amputation.
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APPENDICES
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PATHOPHYSIOLOGY
Predisposing factor: 19 yrs old Female
Precipitating factor: Strenuous Activity Deactivation of tumor suppressor gene Mutation of the Osteoblast Activation of Oncogenes Proliferation of malignant Osteoblast Uncontrolled growth of tumor in the bone
OSTEOSARCOMA Cancer cells metastasize Tumor at parietal part of the head Increase pressure inside Pain and swelling Anorexia Pallor Anemia Fatigue Body Weakness
Blood Transfusion LEGEND: Factor Process & Cause Sign & Symptoms Diagnosis Diagnostics
Left Humerus Amputation OSTEOSARCOMA FORE QUARTER |12
DATE
EXAMINATION
INDICATION
IMPRESSION MAY 2, 2014
BONE X-RAY
Is used to look for injuries or conditions affecting the bone,
- Normal chest findings - Left shoulder; motted sclerosis with evidenced of bone destruction is seen involving the proximal end of the humerus.
MAY 17, 2014
MRI
Provide detailed images of soft tissues in the body.
- Ill defined Lytic bones lesion with a large peri-osseous solid tumor the JUNE 21, 2014
CT SCAN
Test that produces detailed cross-sectional images of parts of the body.
- Negative for nodules. No enlargement lypmpnodes. Osteoblastic lesion at the Left humerus with associates soft tissue component.
JULY 10, 2014 BIOPSY
- The most definitive method to determine the tumor is malignant or benign. - Fore Quarter Amputation on Left Humerus
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LABORATORY AND DIAGNOSTIC TEST
July 21, 2014
TEST RESULT NORMAL VALUE ANALYSIS INTERPRETATION HEMATOLOGY
Hemoglobin
Hematocrit
WBC
RBC
118.0
0.43
6.18
8.72
120-160
0.40-0.50
4.0- 5.4
4.0- 10.0
Abnormal
Normal
Abnormal
Normal
Low hemoglobin was anemia, the patient was described as being anemic
Measure of the packed cell volume of red cells, express as a percentage of the total blood volume
There was some king of infection
A low Red blood cells it was being referred as with infection
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July 24, 2014
IMMUNOLOGY
RESULT
UNIT
RESPONSE
INTERPRETATION
HBsAg II
0.360 Coi No response Less than 1
Anti HBs
942.8 Ui/ l Response Greater than 10
HBeAg
0.21 Coi No response Less than 1
Anti- HBe
0.091 Coi Response Less than 1
Anti- HBc
0.005 Coi Response Greater than 1
Anti- HBc Igm
0.071 coi No response Less than 1
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MEDICATIONS
DRUG ACTION INDICATION SIDE EFFECT CONTRAINDICATION NURSING CONSIDERATION June 6, 2014
LACTULOSE 30cc ODHS LAXATIVE
URSODEOXYCHOLI C ACID 250 mg/cap, 1 cap TID
June 17, 2014
Paracetamol 500mg/tab 1 tab q 4H
The drug passes unchanged into the colon where bacterial break it down to organic acids that increase the osmotic pressure in the colon.
A naturally occurring bile acid that suppresses hepatic synthesis of cholesterol and inhibits intestinal absorption of cholesterol
Reduces fever by acting directly on the hypothalmi c heat- regulating center to Treatment for constipation
Treatment of selected patients with radiolucent non calcified gallstones in gallbladder.
Temporary reduction of fever, temporary relief of minor aches and pain that caused by common - Abdomin al fullness - Flatulenc e - Belching
- Diarrhea - Headach e - Fatigue
- Chest pain - Dyspnea - Headach e
Contraindicated with allergy to lactulose, low- galactose diet.
Contraindicated with allergy of bile salts hepatic impairment and calcified stones.
Contraindicated with allergy to acetaminophen
- The drug may be mixed in water, juice to make it more tolerable. - Bowel moveme nt will be increased for two to three per day.
- Take the drug 3 times a day. - This drug dissolve your gallstone s, it does not cure the problem that caused the stones.
- Do not exceed recomme nded dose. - Do not take OSTEOSARCOMA FORE QUARTER |16
TRAMADOL 500mg/ tab 1 tab PO q 6H
AMPICILLIN SULBACTAM 1.5g TIV q 6H
JULY 14, 2014
KETOROLAC 30mg TIV q 6H cause vasodilatio n and sweating.
Binds to mu-opiod receptors and inhibits the reuptake of norepineph rine and serotonic.
Bacterial action against sensitive organs, inhibits synthesis of bacterial cell wall
Anti inflammato ry and analgesics activity inhibits prostaglan din and leukotriene s colds and influenza.
Relief to moderate to serve chronic pain in adults who need around the clock treatment
Bronchitis, pneumonia, lung abcess otitis and tonsillitis
Short term managemen t of pain
- Dizziness - Sedation - Drowsine ss - sweating
- stomatiti s - thrombo plebitis - other skin effect
- fever - itching weight gain - changes in vision
Contraindicated with allergy to tramadol or opiods or acute intoxication with alcohol
Hypersensitivity penicillin associated cholestatic jaundice or hepatic dysfunction.
Contraindicated with significant renal impairment during labor and delivery, and longer than 10days unless prescribe r - Dissolve orally disintegra ting tablets in your mouth and swallow without water. - Report severe nausea contipati on.
- Check IV sites for signs of thrombos is - Do not give IM in same site of injection
- Every effort will be made to administe r drug on time to control pain
SUBJECTIVE: masakit ang naoperahan sa akin as verbalized by the patient
OBJECTIVE:
-(+)facial mask of pain 8/10 pain scale
-Restlessness
-Guarding behavior
-irritability
Vital signs: BP: 110/70mmhg T- 36.5 C P- 81bpm R- 19cpm Acute pain related to inflammation as evidenced by the facial mask of pain, guarding behaviors, restlessness, and irritability. SHORT TERM GOAL
After 4 hours of nursing intervention the patient will be able to decrease level of pain to 8/10 to 6/10
LONG TERM GOAL
After 24 hours of nursing intervention the patient will be able to decrease the level of pain to 8/10 to 4/10 INDEPENDENT - Evaluate pain regularly
- Provide nonpharmacolo gical comfort measures such as repositioning.
- Provide cutaneuos, stimulation such as heat and cold packs or massage.
DEPENDENT
- Administer analgesics as indicated ( NSAIDs)
- to provide informati on about need for the efcetiven ess
- may relieve pain and enhance circulatio n
- May decrease inflamma tion, muscles spasms reducing associate pain.
- Use for mild to moderate pain or adjuncts to opiod theraphy when pain is moderate to severe. SHORT TERM GOAL
After 4 hours of nursing intervention the patient wouldl be able to decreased level of pain to 8/10 to 6/10
LONG TERM GOAL
After 24 hours of nursing intervention the patient would be able to decreased the level of pain to 8/10 to 4/10
Hindi ako makakain ng maayos at wala akong gana kumain as verbalized by the patient.
OBJECTIVE:
- Inadequate food intake
- Thin in appearance
- Weight loss
( 60kg-51kg)
- Altered taste sensation - Anorexia
VITAL SIGNS:
BP: 110/70mmhg T- 36.5 C P- 81bpm R- 19cpm Imbalanced nutrition less than body requirements related emotional distress as evidenced by inadequate food intake, thin in appearance, anorexia and weight loss SHORT TERM GOAL
After 4 hours of nursing intervention the patient will be able to decrease emotional distress and regain in food intake.
LONG TERM GOAL
After 24 hours of nursing intervention the patient will be able to normalize emotion and increase in food intake. INDEPENDENT - Monitor daily food intake
- Weigh daily as indicated
- Encourage patient to eat high-calorie, nutrient-rich diet with adequate fluid intake
- Encourage open communicatio n regarding anorexia
DEPENDENT
- Administer medications as indicated ( VITAMINS A, D, and B ) - Refer to dietician or nutritional support team
- to identifies nutritional strength - To measure if the weight is depleted. - To maintain adequate caloric and protein intake.
-Often source of emotional distress or may feel rejected or frustrate
-prevent deficit related to decreased absorption of fat soluble vitamins SHORT TERM GOAL
After 4 hours of nursing intervention the patient would be able to decreased emotional distress and regain in food intake.
LONG TERM GOAL
After 24 hours of nursing intervention the patient would be able to normalized emotion and increased in food intake.
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BIBLIOGRAPHY REFERENCES
More information from the following are more additional sources of our case study; - Oncology Nursing by Martha E. Langhorne - Brunner and Suddarths Textbook of Medical- Surgical Nursing (12 th ed ) - Doenges, M., Moorhouse, M., Murr, A. (2012). Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales (12 th ed). - Pathophysiology for the Health Professions (3 rd ed.), - http://www.sarcoma.org/publications/mcs/ch17.pdf