Osteosarcoma

OSTEOSARCOMA FORE QUARTER LEFT HUMERUS
A Case Study Presented to

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

OSTEOSARCOMA FORE QUARTER |2

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


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


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.


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.


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.


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


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.


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.


APPENDICES


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

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


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


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


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

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


NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

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


NURSING CARE PLAN

ASSESSMENT DIAGNOSTIC PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:

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.


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

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OSTEOSARCOMA FORE QUARTER LEFT HUMERUS

A Case Study Presented to

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