Clinical Case Study Maghari Black.docx

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Acknowledgements Finishing this case study has been a delight for me, as I had received so much from so many. I happily thank all of you. To the way and light, our God, who enlightened me in my lowest lows. Your gift of strength and perseverance helped me get through the toughest year yet. To my adviser, Mr. Francis Archangel P. Milloren, RN, for his valuable feedback and patient guidance all throughout the course of this case study. His constructive criticism and unbiased feedback were of the utmost importance in finishing this case study and help me to transform it into an authentic source of information. To my friends, whom together with, I have endured the four years of gruesome battle to become registered nurses. The last few months will be cherished the most, and I wish you all the best in life. To my dearest family, for the unwavering love and support, and for putting up with the cluttered tables and empty coffee mugs. All five of you are deeply loved. To my parents; my father Joemarie and my mother Merced, for the gentle encouragement and warm love. All of my hard work are for you. The greatest credit and gratitude would go to my patient and his legal guardian, for giving their full consent in participating in this case study.

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And to every single person who helped me in any way, thank you for believing in me. Ora et labora! Cebu Normal University COLLEGE OF NURSING Cebu City Form 1 APPROVAL SHEET FOR CASE STUDY

Name of Patient for Case Study: Heyrosa, William A. Diagnosis: Osteosarcoma Distal Femur Left Name of Student: Mariedith J. Maghari Date at which care was started: November 15, 2017 Ended: November 17, 2017 This is to certify that I, as the Clinical Instructor, accept her as my advisee on her case study.

Mr. Francis Archangel P. Milloren, RN Printed Name and Signature of Adviser

Date

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Cebu Normal University COLLEGE OF NURSING Cebu City

Form 2 APPROVAL SHEET FOR FINAL PRINTING

Title of Paper: Fall Into the Unknown: A Case of Osteosarcoma Distal Femur Left Name of Student: Mariedith J. Maghari

After having checked the entries of this case study, as adviser of the author, I hereby gave my approval for final printing and binding subject to policies and guidelines in the production of this paper.

Mr. Francis Archangel P. Milloren, RN Printed Name and Signature of Adviser

Date

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Table of Contents Acknowledgements......................................................................................................................ii Approval Sheet For Case Study................................................................................................iii Approval Sheet for Final Printing..............................................................................................iv Statement of the Problem.......................................................................................................3 Significance of the Study........................................................................................................4 Nursing Students..................................................................................................................4 Nursing Service....................................................................................................................4 Nursing Academe.................................................................................................................5 Future Researchers.............................................................................................................5 Methodology.............................................................................................................................5 Research Design..................................................................................................................5 Research Locale..................................................................................................................6 Data Gathering Procedure..................................................................................................7 Chapter 2......................................................................................................................................9 Results and Discussion...............................................................................................................9 Patient’s Profile........................................................................................................................9 Past Medical History................................................................................................................9 Surgical History........................................................................................................................9 History of Present Illness........................................................................................................9 Review of System..................................................................................................................11 Head, Ears, Eyes, Nose, and Throat...............................................................................11 Respiratory..........................................................................................................................11 Musculoskeletal..................................................................................................................11 Cardiovascular....................................................................................................................12 Integumentary.....................................................................................................................12 Gastrointestinal..................................................................................................................12 Genito-Urinary....................................................................................................................12 Neurologic...........................................................................................................................12 Psychological......................................................................................................................13 Anatomy and Physiology......................................................................................................14 Psychopathophysiology........................................................................................................16 Medical Management............................................................................................................27

Drugs and Therapeutics........................................................................................................27 Nursing Care Plans............................................................................................................29 Focus Charting...................................................................................................................31 Discharge Plan...................................................................................................................33 Chapter 3....................................................................................................................................35 Summary, Conclusion, and Recommendations.....................................................................35 Summary.................................................................................................................................35 Conclusion..............................................................................................................................36 Recommendations.................................................................................................................36 References..............................................................................................................................38 APPENDICES............................................................................................................................48 Appendix A..............................................................................................................................49 Nursing History and Physical Assessment.....................................................................49 Appendix B..............................................................................................................................60 Ideal Diagnostic Procedures.............................................................................................60 Appendix C.............................................................................................................................61 Ideal Surgical Management..............................................................................................61 Appendix D.............................................................................................................................62 Drug Studies.......................................................................................................................62 Appendix E..............................................................................................................................66 Nursing Care Plans............................................................................................................66 Appendix F..................................................................................................................................74 Compliance Checklist........................................................................................................74 Curriculum Vitae.........................................................................................................................75

List of Figures

Figure 1.1

The Femur……………………………………………………………...15

Figure 1.2

Psychopathophysiology of Osteosarcoma……………………….....17

List of Tables

Table 1.1

Hematology (ESR)…………………………………………………….18

Table 1.2

Complete Blood Count………………………………………………..18

Table 1.3

Complete Blood Count………………………………………………..20

Table 1.4

Clinical Chemistry (Albumin)….......................................................21

Table 1.5

C-Reactive Protein…...………………………………………………..21

Table 1.6

Serology Report (HBSAg)...…………………………………………..22

Table 1.7

Blood Typing……………………………………………………………22

Table 1.8

Prothrombine Time…………………………………………………….22

Table 1.9

Total Calcium…….…………………………………………………….22

Table 1.10

Urinalysis……………………………………………………………….23

Chapter 1 Introduction

Background and Rationale In life, there comes a time when everything is quite uncertain, where all sorts of change happen. A child entering the twilight years of being just a child and slowly turning into an adolescent attests the existence of the unknown. An adolescent adjusting from having play as work to juggling work and play is one of the greatest challenges of this stage in life. Everyone else is competitive, everyone else has something to show and prove.

A child growing into this

environment is pushed to share talents and redeeming qualities to prove that he deserves to have a place in the world [CITATION Ang10 \l 13321 ]. But, to be diagnosed with a malignancy at such a young age serves to prove even more that uncertainty is certain; and the circumstance of limited capacity to do what should be done by an adolescent trying to outgrow puberty may cripple the dreams of a child who is just trying out his newfound wings. The femur is the longest bone in the body, and the only bone in the thigh. Its main function is to transmit forces that act upon the femur from the strength of the muscles of the thigh and hip that act on the femur to move the leg. The distal end of the femur has lateral and medial condyles, which articulate with the patella and tibia, forming the knee joint [CITATION Oli17 \l 13321 ]. Any alteration in this part of the femur may greatly affect lower limb movement such as walking, running, and jumping and interferes with the active life of a normal, growing adolescent[ CITATION Tim17 \l 13321 ].

Normally, when human cells grow and divide, new cells replace damaged, old cells as needed by the body. However, cancer cells break this orderly process. These fast-growing cells divide without stopping which may form tumor growth [CITATION Nat15 \l 13321 ]. Tumors may be classified as benign and malignant. Benign tumors are those that are localized and do not resurface after surgery, while malignant tumors are those considered as cancer [ CITATION Dor05 \l 13321 ]. Cancer is a Latin term that literally means “crab”, because of the malignant cells’ crab-like characteristics of invading other surrounding and distant tissues [CITATION How10 \l 13321 ]. Primary bone cancer is a type of malignant tumor formation that starts in the bone, amounting to only 0.2% of all types of cancer [ CITATION Can17 \l 13321 ]. Osteosarcoma is a type of cancer where cancer cells are found on the bone. It is the most common type of bone tumor, which usually affects those between the ages of 10 to 25 years old [CITATION GBa04 \l 13321 ]. Still, osteosarcomas make up only 2% of childhood cancers all over the world [CITATION Ame17 \l 13321 ]. A majority of osteosarcomas are found in the bones surrounding the knee, specifically the growing ends or metaphysis of a bone [CITATION EHa09 \l 13321 ]. Pain in the affected area that is worse at night is the most common and earliest symptom of osteosarcoma. Pain often increases with activity, resulting to a limp when the tumor grows in a leg bone. Swelling is another common symptom, although it may not occur until several weeks after the pain starts. Lumps or palpable mass occur depending on the where the tumor is. As this

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disease commonly affects active young people, symptoms are usually attributed to over-stress or trauma [CITATION Amr16 \l 13321 ]. In the United States, an estimated 1000 new cases are reported every year. In the Philippines, bone cancer is the 24 th leading type of malignancy, 21 st among females and 18th among males. Osteosarcoma is the most common type of malignant bone tumor in the country, with incidence rates increasing at age 60 [ CITATION Dep17 \l 13321 ]. This case study intends to disseminate a reliable source of information about

osteosarcoma.

This

study

means

to

deliver

information

about

osteosarcoma that the general public could understand. Ultimately, this study deems to increase awareness on how osteosarcoma may affect the lives of the patients and their families, how to get appropriate treatment, and how to manage activities of daily living when osteosarcoma occurs. Statement of the Problem The study aims to answer questions regarding the nature and management of a patient with Osteosarcoma Left Distal Femur. Specifically, this study aims to answer the following questions: 1. What is osteosarcoma? 2. What are the factors contributing to the occurrence of this condition? 3. What are the assessment findings of a patient diagnosed with osteosarcoma in terms of: a. Physical Assessment? b. Laboratory Assessment? 4. What are the appropriate nursing diagnoses for a patient with osteosarcoma?

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5. What are the nursing interventions (independent, dependent, and collaborative) that the nurse could provide to the patient with osteosarcoma? 6. What are the medical-surgical interventions rendered to this particular patient? 7. What is the prognosis of the patient? Significance of the Study This study will be of best relevance to the general public who wish to know more on the case of osteosarcoma, and serve as a reliable secondary source of information. Furthermore, this case study would also be significant to the following: Other patients with osteosarcoma. As this is a narrative of care specifically for osteosarcoma, patients having the same condition may anticipate possible treatment and care upon reading this case study. Nursing Students. The study will provide an in-depth information that will aid them to understand the selected condition better and serve as a guide to render appropriate and effective care to their clients having the same condition. Nursing Service. The knowledge imparted by the study may serve as a reference point for improvement in the care of patients having the same condition. Nursing Academe. The study may serve as an additional resource of learning for student nurses in caring for patients with osteosarcoma and similar

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conditions. This case study also serves as an avenue for clinical instructors to promote comprehensive learning for nursing students Future Researchers. The results of this case study may serve as reference for future related studies, specifically in the care of patients with osteosarcoma. Methodology The methodology entails actual situation and conditions that affected the course of patient care, along with an in-depth description of the events that transpired during the delivery of care. Research Design The study utilized the case study design, a qualitative form of research. All information reflected in the study are pre-existing and concurrently happening, where no generation of new data through experimentation has occurred. A case study’s key features are its professional application and scientific credentials. Case studies in healthcare require in-depth interviews with the key informants, observation review of medical records, and may include excerpts from patient’s diary or personal writings. Nursing case studies have a practical function where they could immediately be applicable to the patient’s treatment or diagnosis [CITATION Don09 \l 13321 ]. Research Locale The case study was conducted at the Ward VIII-Orthopedic Ward of Vicente Sotto Memorial Medical Center or VSMMC (formerly Southern Islands

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Hospital), located at B. Rodriguez St., Cebu City. VSMMC is a general tertiary medical training center owned by the Philippine Government. It aims to provide affordable and accessible healthcare services that is acceptable to all regardless of social status. The orthopedic ward is a charity ward having approximately a 120-bed capacity, utilizing a functional nursing modality of care. Most of the clients attended to are adult males, where a majority of the cases admitted are fractures of the bone. More so, the ward also caters disorders of the spine, and oncologic cases. Oncologic cases, however, are not placed in priority beds as practiced in the ward. Research Instrument The study made use of direct observation and in-depth interview to collect data. A theory-based physical assessment form developed by the College of Nursing of Cebu Normal University served as a guide in conducting the interview. The interview went on as a semi-structured one, and additional questions and observations were employed to fill in possible gaps that the questionnaire did not cover. Betty Neuman’s theory was the basis of the questionnaire, where a cephalocaudal and holistic approach was used to assess the patient’s condition. It also contained psychological, maturational, socio-cultural, and spiritual assessments. Discharge planning and nursing diagnoses were also included in the form.

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Nursing care plans prepared by the student nurse researcher were applied following the day of writing. A written drug study also aided the researcher in preparing the patients medications. Nursing care paraphernalia were checked every day by the clinical instructor to ascertain safe and proper use of the equipment. Data Gathering Procedure Data gathering commenced with choosing a patient who was viable to be under the care of the researcher for three (3) consecutive days. After doing so, rapport was established with the patient and his guardian, because the patient was still a minor. An informed consent was obtained from the patient and guardian, emphasizing their agreement to be the subject of the case study. An interview and direct physical assessment were done using the assessment form. Both the patient and his guardian were the sources of information, and their statements coincided with each other, with the patient asking help from his guardian to explain some points from time to time. Apart from the assessment and

interview,

total

care

was

rendered

and

direct

observation

were

simultaneously done. This included vital signs taking, regulation of intravenous fluid, recording of input and output, medication administration, bedside and selfcare, and health teachings on boosting the immunity and safe movement. Review of the patient’s chart and other medical documents was done as a secondary source of information. The assessment was completed on the second day and additional data were gathered. Medical-legal records were again checked for additional orders.

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Total care and concurrent assessment continued on the second day to monitor the patient’s progress. Interview regarding the confirmation of the malignancy was done on the third day. Follow-up questions were asked to verify the data obtained from the two-day interaction, all the while rendering total care and monitoring the patient’s progress. Termination of the nurse-patient relationship was done on the same day. Medical-legal documents were checked for the last time for new orders.

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Chapter 2 Results and Discussion Patient’s Profile A case of W.H., 14 years old, male, Filipino, from Canduman, Mandaue City, Cebu was admitted to Vicente Sotto Memorial Medical Center with a chief complaint of severe throbbing pain from a prominent swelling on the left distal end of his thigh. No other complaints were reported. The patient is an active child who enjoys sports such as football and basketball, as verbalized by his relatives. The patient also related that he has many friends at school and his neighbourhood. He prefers eating green leafy vegetables and lean meat such as pork and chicken. Past Medical History The patient had no history of malignancy and tumors, on both maternal and paternal side. A familial history of hypertension, diabetes mellitus, and unspecified heart disease on his maternal side is, however, noted. He does not have any previous hospitalizations and is a fully-immunized child. Surgical History The patient had no previous surgical operations. History of Present Illness One month prior to admission, the patient was about to use their home’s comfort room when he slipped and sustained a fall. He landed on his left knee,

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without support from his upper extremity to lessen the impact of the fall. The patient immediately felt a severe, sharp pain on his knee, radiating to the areas surrounding it. He verbalized the pain to have a score of 10/10 in the pain scale. A few days after the incident, the affected area developed a bruise and continued to throb. A few weeks after the incident, the distal third of his thigh developed a swelling with no fever, no limitation of movement, and other associated symptoms. One week prior to admission, the patient sought consult at the Out-Patient Department (OPD) of Vicente Sotto Memorial Medical Center (VSMMC) and was advised for laboratory work-up and Magnetic Resonance Imaging (MRI) of the left leg. The patient was then prescribed with Ibuprofen PRN for pain. Hours prior to admission, the patient came in at the OPD for follow up with the MRI result, revealing the need for perimeter testing. The patient was then advised for admission and prepare for biopsy of the affected part. On November 6, 2017, the patient was admitted at the Orthopedic Department of VSMMC, where further laboratory tests and treatment were done. On November 17, 2017, confirmation of malignancy was done by the patient’s physician by interpreting the histopathology report that has just arrived the morning of the same day. After initial laboratory analyses, a diagnosis of Osteosarcoma Distal Femur Left was determined.

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Review of System Head, Ears, Eyes, Nose, and Throat. The patient’s head is normocephalic, symmetrical and proportional to his body. He has evenly distributed black hair, no lice infestations, dandruff, and tenderness upon palpation. Eyebrows and eyelashes are also evenly distributed and symmetrically aligned, with no discharges, swelling, and tenderness upon palpation. Both eyes move in a fluid and coordinated motion in all cardinal gazes, with pupils equally round and reactive to light and accommodation. Sclera is white with no redness, lesions, or any other abnormalities noted. Olfactory function is normal, with ears symmetrical and pinna aligned with the outer canthus of eyes; recoils after being folded. Patient was able to hear and respond to normal spoken voice tones on both ears, as well as whispered words from a 2-feet distance. Outer lips are of uniform pink color, moist, and without lesions. Trachea is at the midline, with no palpable lymph nodes and able to move in full range of motion. Respiratory. Patient’s shoulders and scapula are aligned, Crackles where heard during patient’s inspiration at the upper lung fields upon auscultation. Chest expansion is symmetrical with an approximation of 4-5 cm. Musculoskeletal. Patient has a palpable, tender lump on the distal third of his femur. Externally, the swelling appears to be 6 cm wide and elevated from the skin surface by 5 cm with a green-purple discoloration. Constant, throbbing pain was verbalized by the patient that is relieved only by analgesics, reaching a pain score of 8/10. Patient had a limited lower extremity range of movement

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because of the swollen mass, and patient often playfully hops to reach his neighboring beds. Cardiovascular. The patient had a normal blood pressure of 90/60, and a heart rate of 89 bpm. Distinct S1 and S2 sounds were heard, with absent heart murmurs and palpitations. Jugular distention was not evident. Peripheral pulses were bounding and evident, even with the popliteal pulse near the palpable mass. No signs of edema were seen. Capillary refill time of 2 seconds was assessed. Integumentary.

Skin appears to be pink, with no lesions or ulcers.

However, bruises were seen on the swelling of his thigh. Patient’s skin was also dry and cool to touch. Gastrointestinal. Normal bowel sounds were noted, adequately audible with 19 gurgling sounds per quadrant heard per minute. Abdomen was symmetrical, flat, and soft, with no tenderness and rigidity upon palpation. Patient has a good appetite and functional gag reflex. The patient usually defecates once a day in the morning with formed, solid brown stools. Stool appears to be firm, dark brown in color, with the size of a fist and absence of blood and other abnormalities, at least once a day. Patient has a varied pattern of bowel movement, from every day to every other day. Genito-Urinary. Patient’s bladder is not distended, with no rigid borders upon palpation. Patient urinates about three-four (5-6) times a day with clear,

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yellowish urine amounting to 110 ml per episode. Patient did not report any discomfort on his abdominal region and during urination. Neurologic. Patient appears to be alert, with a pleasant mood, and a joyful affect. Patient is oriented to person, time and place, and could easily recall recent, intermediate, and remote memories. Reflexes are normal with both left and right hand grasps strong. The patient usually wakes up at 5:00 in the morning to get ready for school, and verbalized feeling refreshed after a good night’s sleep. He usually sleeps from 9:00 pm until his usual waking hours. He does not have afternoon naps or “siesta” because he is still in school. However, his normal sleep-rest pattern was disrupted because of the poorly-ventilated and humid ward. No other abnormalities noted. Reproductive System The patient is undergoing puberty, as his voice was evidently transitioning from a high-pitched and low-pitched tone. Secondary sex characteristics were also developing, as the patient related changes in his physical form that were all normal. The patient related no problems such as penile discharges, and shared that he has not yet had any sexual relations. Psychological. Patient verbalized that he is “confused why he has been given this fate” and questions “his being too young to be diagnosed with a malignancy”. Objective cues of mild anxiety, such as excessive sweating and mannerisms were evident while the patient was being interviewed. Symptoms

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slowly dispersed as the patient, his significant other, and the interviewer got deeper into the conversation. The patient, as shared by his guardian, is an active child that has many friends in school and their neighbourhood. Undergoing the psychosocial task of Identity vs. Role confusion, the patient admitted that he still has not figured out what to do with his life, now with his school and leisure activities put to a halt and with his treatment still unclear. In the Genital Stage of development, the patient is still undergoing puberty as related above. Some of his secondary sex characteristics, such as deepening of his voice, has not yet fully developed. He also shared that he has not had any romantic or sexual relations whatsoever. The patient’s Cognitive level of development showed that he is on the Operational stage, where he is guided by logical thinking and understands the existence of matter and quantity, as learned in school. Abstract thinking has not yet been fully developed as his answers to abstraction questions deemed literal and superficial. The patient also has in the Conventional Stage of Moral Development as the patient conforms to what is asked of him from school and from his parents. He obeys so that he won’t get punished. Anatomy and Physiology The femur is the longest and the strongest bone in the body. It is the only bone in the thigh, and acts as the site of origin and attachment of many bones and ligaments. It is further divided into three parts; the proximal, shaft, and distal.

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The proximal end. This area of the femur forms the hip joint together with the pelvis. It consists of a head and a neck, and two bony prominences called trochanters. The head directly articulates with the acetabulum, forming the hip joint. It has a smooth surface with a depression on the medial aspect to accommodate the ligament of head of femur. The neck connects the head of the femur with the shaft. Cylindrical in shape, it projects in a superior and medial direction, allowing for an increased range of movement at the hip joint. The lesser and greater trochanters provide leverage to muscles that rotate the thigh on its axis.

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Figure 1.1 The Femur The shaft. This part of the femur is almost cylindrical in form, a little broader above than that in the center, but broadest and flattened from before backward below. It is slightly arched, so as to be convex in front, and concave behind, where it is strengthened by a prominent longitudinal ridge, called the linea aspera. The shaft descends in a medial direction, bringing the knees closer to body’s center of gravity thus increasing stability. The distal end. This portion of the femur is characterized by the presence of lateral and medial condyle. These articulate with the tibia and patella, forming the knee joint. Psychopathophysiology The cause of osteosarcoma is mainly unknown. However, certain predisposing factors may increase the likelihood of developing osteosarcoma. Being 10-25 years old, male, growth spurt, tall height for age, hormonal, and metabolic imbalances are the risk factors for this condition. A fall sustained by the patient was a precipitating factor of this condition. When the DNA of the affected cell starts to mutate, the oncogene, or the cell that causes cancer is activated, all the while deactivating the suppressor gene that is tasked to prevent and suppress the mutation of cells. Continued cell mutation causes malignant osteoblasts to form. These malignant osteoblasts then proliferate, forming osteoid tissue, or immature bone matrix tissue that manifests as the tumor. Uncontrolled growth of tumor in the bone causes red

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brown marrow suppression and cell compression. When the red brown marrow is suppressed, decreased blood cell production happens. Decreased red blood cell production causes anemia, fatigue, and shortness of breath, while decreased white

blood

cell

production

causes

lowered

infection

resistance.

Cell

compression on the other hand may lead to fractures and causes pain along with swelling of the affected part.

18 Predisposing Factors Precipitating Factors

Age (10-25 years old) Male Growth Spurt Hormonal and Metabolic Imbalance

Injury

Unknown Etiology

DNA mutates

Oncogene activates

Suppressor gene is deactivated

Malignant osteoblasts form

Malignant osteoblasts proliferate

Formation of osteoid tissue

Uncontrolled growth of tumor in the bone

Red brown marrow is suppressed

Decreased red blood cell production

Anemia

Cell compression

Decreased white blood cell production

Lowered infection resistance

Fatigue Shortness of breath

Compression of nerve endings

Pain

Swelling

WBC: 12.10 X1011/HPF

Figure 1.2 Pathophysiology of Osteosarcoma

Cellular damage and hemorrhage

Cough

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20

Management

21 Diagnostic Procedures

The following are actual laboratory values gathered during the care of the patient. Hematology Hematology is a branch of medicine about the study of blood, and blood diseases, the blood-forming organs. Hematology tests include laboratory assessments of blood formation and blood disorders. Erythrocyte Sedimentation Rate (ESR) Erythrocyte

sedimentation

rate

(ESR)

test

indirectly

measures

inflammations in the body, determining the presence of inflammation caused by tumors, autoimmune diseases, and infection. On October 23, the patient had a blood extraction to be sent for hematology analysis. Table 1.1 Hematology Test ESR

Result

Unit

45

mm/h r

Referenc e <15

Interpretation High

The table shows a marked increase, indicating a high percentage of sedimentation resulting from the destruction of red blood cells. The patient has experienced fatigue in the past week due to the destruction of the RBC’s, as related by other studies revealing that a high value of ESR is common in most osteosarcoma cases. Marked destruction of RBC’s occur when higher cell demand of it happens to supply nutrient to the growing malignancy.

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Complete Blood Count (CBC)

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A complete blood count is a blood test that evaluates one’s overall health and detects disorders such as infection, leukemia, and anemia. This test measures several components and features of the blood. The following are results of the CBC on October 24, 2017 and November 7, 2017, respectively. Table 1.2 Complete Blood Count Test Result Unit Reference WBC count 12.11 X109/L 4.5 – 11.5 RBC count 5.20 X1012/L 4.6 – 6.0 Hemoglobin 142 g/L 140– 180 Hematocrit 0.40 L/L 0.40 – 0.54 Mean Corpuscular Volume 74.8 fL 80 – 100 Mean Corpuscular 26.6 Pg 26 – 32 Hemoglobin Mean Corpuscular 338 g/L 320 – 360 Hemoglobin Concentration Red Cell Distribution 13.9 % 11.5 – 14.5 Width Platelet Count 394 X109/L 150 – 450

Interpretation High Normal Normal Normal Low Normal

Neutrophil Lymphocytes Monocytes Eosinophils Basophils

Normal Normal Normal High Slight increase

58 36 6.7 5.4 0.28

% % % % %

50 – 70 18 – 42 2 – 11 1–3 0–2

Table 1.3 Complete Blood Count

Normal Normal Normal

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Test Result WBC count 12.35 RBC count 5.1 Hemoglobin 144 Hematocrit 0.41 Mean Corpuscular 73.4 Volume Mean Corpuscular 26.0 Hemoglobin Mean Corpuscular 352 Hemoglobin Concentration Red Cell Distribution 13.2 Width Platelet Count 376 Neutrophil Lymphocytes Monocytes Eosinophils Basophils

55.5 32.9 5.1 6.2 0.3

Unit Reference X109/L 4.5 – 11.5 X1012/L 4.6 – 6.0 g/L 140– 180 L/L 0.40 – 0.54 fL 80 – 100

Interpretation High Normal Normal Normal Low

Pg

26 – 32

Normal

g/L

320 – 360

Normal

%

11.5 – 14.5

Normal

X109/L

150 – 450

Normal

% % % % %

50 -70 18 – 42 2 – 11 1–3 0–2

Normal Normal Normal High Normal

In osteosarcoma, the production of blood cells are suppressed as the bone marrow is affected. To meet the demands of normal and malignant cells, the bone marrow is forced to create more RBC’s despite being suppressed by the tumor itself. This leads to an increase in RBC count and higher sedimentation rate. It is also suggestive of an infection as higher demands of RBC are needed to regenerate infected cells. This results development of infection is supported by marked increase in WBC and agranulocyte formation. Anemia is also present, as reflected on the alterations in RBC size, as well as a low MCV width. Anemia related to malformation of RBC results from the compression of bone marrow, affecting its function of blood cell formation. An increase in the basophil and

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eosinophil count indicates infection, as manifested by the patient’s cough. This may also indicate the body’s attempt to localize the inflammation caused by the aberration.

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Clinical Chemistry Clinical chemistry of the blood includes the albumin and C-Reactive protein components of the blood. Tests were done on November 16, 2017 and October 24, 2017 respectively. Table 1.4 Clinical Chemistry Test Albumin

Resul t 4.03

Unit g/dL

Referenc e 3.5 – 5.0

Interpretation Normal

The table reflects normal finding of albumin composition in the blood. C-Reactive Protein C-Reactive Protein is a blood test that measures inflammation and infection. Increased levels may indicate chronic inflammatory diseases, burns, trauma, and heart attack. Relatively high levels may indicate cancer. Table 1.5 Immunology Section` Test C-Reactive Protein (CRP)

Resul t 8.03

Unit mg/L

Referenc e <2 – 8

Interpretation Slight increase

Cellular trauma is present as the progressing growth of the malignancy affects surrounding and normal tissue, causing internal bleeding as manifested by bruising and swelling of the affected part.

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Table 1.6 Serology Report Test HBSAG

Result Non-reactive

Method ICT

Interpretation Patient does not have Hepatitis B infection

The result shows that the patient does not have a Hepatitis B infection as reflected on the test taken on October 24, 2017. Table 1.7 Blood Typing Test

Result “AB” Positive (+)

Blood Type Rh

The patient has an AB+ blood type as reflected on the blood test taken on November 7, 2017. Table 1.8 Blood Coagulation Test Prothrombine Time

Result 13.6

Unit Secs.

Reference 10.2 - 13.9

Interpretation Normal

The result shows normal blood coagulation as reflected on the test taken on November 7, 2017. Table 1.9 Blood Chemistry Test Total Calcium

Resul t 9.96

Unit mg/d L

Referenc e 9.2-11

Interpretation Normal

The result shows normal calcium levels in the body as reflected on the test taken on November 11, 2017.

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Table 1.10 Urinalysis Test Color

Result Light yellow

Transparency Specific Gravity pH Glucose

Clear 1.005 6.0 Negative

Protein

Negative

RBC WBC Squamous E. Cells Bacteria

Unit

3 1

mg/d L mg/d L /hpf /hpf

Rare Rare

/hpf /hpf

Reference Yellow (light/pale to dark/deep amber) Clear/Cloudy 1.005 - 1.025 4.5 - 8.0 ≤130

Interpretation Normal

≤150

Normal

≤2

High Normal

- ≤2 - 5 ≤15-20

None

Normal Normal Normal

Normal Normal

On the test taken on November 11, 2017, the result is suggestive of a tumor, resulting from abnormal changes in the blood. Tumors release erythropoietin that causes increased production of RBC’s or polycythemia. Physical trauma to the urinary tract may also be considered. Magnetic Resonance Imaging (MRI) This diagnostic procedure provides a detailed anatomic view of tissues and evaluate joint pathologies, presence of dead tissue, neoplasms, and blood flow. Date taken: November 10, 2017 Examination: Left Thigh Interpretation:

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MRI examination of the left thigh was performed with axial T2W and Fat suppressed images as well as T2 coronal and T1 and T2 sagittal images. There is lytic osseous and marrow replacement lesion involving the distal third of the right femoral diaphysis extending a length of 13.8 cm with its interior margin just above the epiphyseal plate. The marrow cavity at this level is completely replaced with abnormal signs, heterogeneous on T1 and T2 of predominantly of low T1 signals with component of T1 shortening. There is focal and frank cortical break-through with a large exophytic soft tissue mass component directed medially, seen measuring at east about 6.5 x 5.4 x 12.0 cm (AP x T x CC). The overlying muscles particularly the vastus medialis are displaced. The femoral neurovascular structures are intact. The rest of the visualized femur appears intact. Impression: Distal femoral diaphyseal osseous tumor mass lesion with cortical disruption and multioculated soft tissue extra-osseous extension medially. Malignancy is the primary consideration. Rule in osteosarcoma. The result suggests the presence of malignancy and supports the preliminary diagnosis of osteosarcoma, where marked changes in the bone marrow were visualized, along with the surrounding cell structure. Other parts

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surrounding the affected area, such as the femur itself itself, showed no irregularities. Computed Tomography Scan (CT Scan) Computed Tomography Scan involves special x-ray tests that yield crosssectional images of the body with the aid of a computer. CT Scans are also referred to as Computerized axial Tomography, Date taken: November 11, 2017 Multislice CT scan (256 slice) of the chest (with contrast). Interpretation: Contrast-enhanced multislice CT scan of the chest demonstrate both lung parenchyma with no focal lesion seen. The trachea and main bronchi are normal in caliber. The superior mediastinal vessels are preserved. There are no enlarged mediastinal or hilar lymph node seen. The cardiac chambers and pericardial sac are intact. The thoracic aorta and esophagus are within normal limits. The rest of the soft tissues and visualized osseous structures are unremarkable. Impression: Unremarkable contrast enhanced multislice of the chest. The CT Scan showed negative signs of lung metastasis. Histopathology Report

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Histopathology is a diagnostic modality that examines tissue samples under a microscope, using treatment and procedures that are unique and specific to each type of tissue. Date taken: 11/17/2017 Specimen: Mass Left Thigh Gross: The specimen consists of three (3) irregular fragments of brown tissues aggregately measuring 10 mm. The specimen is totally processed. Microscopic: Section shows fragments of fibromuscular tissues and in one area is a small neoplastic lesion composed of proliferating atypical, round, ovoid, and spindle-shaped cells possessed with pleomorphic and hyperchromatic nuclei with indistinct cytoplasmic borders. They form sheets and have small capillary channels and calcification. There are extravasated red blood cells and inflammatory cells including some hemosaiderin-laden macrophages. Diagnosis: Histologic features suggestive of a mesenchymal tumor probably malignant Remarks: Interpretation limited by small sample size and deep-seated tumor.

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The result indicates a malignant tumor growth on the mesenchyma, a type of connective tissue, indicating osteosarcoma. Medical Management As of date, no medical intervention has been done to resolve the patient’s condition. Medical interventions are yet to be decided as the patient is still newly diagnosed. Current medications are focused on palliative treatment such as managing pain with analgesics and infection prophylaxis. Drugs and Therapeutics The patient was prescribed with Cefuroxime Axetil 500 mg/tab BID for infection last given on November 16, 2017 at 8 AM. Cefuroxime axetil is an antibiotic and second-generation cephalosphorin derivative, under Category B of the pregnancy risk component. Its main action is to inhibit cell wall synthesis that promotes osmotic instability of the bacteria, and is usually bactericidal. An important consideration for this is that Cefuroxime axetil may lead to bone marrow suppression. Laboratory values must be constantly assessed for severe adverse reactions. The physician also prescribed Celecoxib 200 mg/tab BID for pain, but was discontinued and was replaced with Tramadol 500 mg/tab PRN for breakthrough pain. Celecoxib is a non-steroidal anti-inflammatory medication, and is a cyclooxygenase-2 (COX-2) inhibitor. Mainly under Category C of the pregnancy risk component, Celecoxib is considered under Category D when in the 3rd trimester of pregnancy. The medication was last given on November 12, 2017 at 6 o’clock in the evening. Diarrhea

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is a side effect of the drug and must be monitored for bowel changes, along with arrhythmias that could be fatal. Pain score must be properly assessed and accepted to be given proper treatment. Tramadol Hydrochloride on the other hand is a centrally active analgesic that falls under Category C of the Pregnancy Risk component. With its primary action to be unknown, Tramadol is thought to bind to opioid receptors and inhibit reuptake of norpepinephrine and serotonin. This PRN drug has not yet been administered since being ordered on November 13, 2017. Safety should be addressed as visual distrubances, dizziness, and seizure may be a side effect of the drug. An important consideration for this is that the nurse must acknowledge the patient’s pain and see if non-pharmacologic interventions would still be applicable for the patient. Surgical Management As of final assessment of the patient, he has not had any surgical procedure to treat his condition. However, the patient was to be re-assessed by his physician as soon as the histology report arrives. The histopathology report was attached on the chart on the last day of care, November 18, 2017, at 10 0’clock in the morning. However, no re-assessment by the physician was made during the shift.

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Nursing Management The following are the planned and actual nursing care rendered to the patient. Nursing Care Plan 1 Acute Moderate Pain related to compression of nerve pathway secondary to Osteosarcoma distal femur left The priority nursing diagnosis is Acute Moderate Pain related to swollen left leg secondary to Osteosarcoma distal femur left. With pain being a natural and common reaction to malignancies, it is important to treat this symptom as it prevails throughout the progress of the disease. Pain interferes with an individual’s activities of daily living, and affects the physical and emotional condition of the suffering individual. The patient related through the interview that he was in pain, reaching a pain score as high as 10/10 if not treated with an analgesic. When asked how he was feeling at the moment, he answered that his left leg was throbbing with a pain score of 7/10. He had a swollen left leg that was warm to touch, and patient occasionally grimaces because of the pain, especially when moving and ambulating. The goal of this care plan is to decrease the patient’s pain score from moderate to mild, or possibly none. Interventions include teaching deep-breathing exercises, guided imagery, and distractions such as playing with mobile devices to facilitate nonpharmacological techniques to relieve pain. The patient would also be assisted with re-positioning himself on bed and to preferred position of comfort. The patient is to be advised not to bear weight on affected leg and to limit

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unnecessary movements to decrease possibility of increased pain. Analgesics are given to relieve pain. Nursing Care Plan 2 Impaired Tissue Integrity related to compression of affected tissue secondary to osteosarcoma distal femur left . Malignancies affect the normal cellular structure of its affected part and causes cellular aberrations, often showing as swelling and tumors. The patient presented with a swollen left leg about the size of a closed fist at the end of his left leg. The swelling was warm to touch and had a purple-bluish discoloration. Based on his histopathologic report, the affected tissues were irregularly shaped and were very proliferative. The goal of this care plan is to limit further tissue damage due to external factors and aid in preventing complications that may arise from a neglected impairment of tissue. Interventions may include keeping the patient from doing unnecessary movements, placing a warm compress above the swelling. Proper diet with high amounts of protein for optimal tissue repair was encouraged, along with milk to support the growth of a growing adolescent. The patient was also encouraged not to rub or touch the impaired area to prevent further injury. Nursing Care Plan 3 Impaired Physical Mobility related to altered musculoskeletal ability secondary to Osteosarcoma Distal Femur Left The third nursing care plan deals with the patient’s impaired mobility. Because of his swollen leg, the patient has restricted movement, and an altered

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way of walking in order to prevent discomfort as he moves. Pain is commonly associated with this, as well as his affected leg is directly above the distal femur, the bone responsible for lower limb movement and ambulation. The patient presented with an impaired gait, and oftentimes hopping to potential and perceived injury as per his verbalization. He was afraid that bearing down on his left leg would further increase his pain and discomfort. The goal of this care plan is to improve physical mobility and maintain tolerable ambulation. Interventions include encouraging the procurement of crutches as ordered by the physician, and teaching on the use of the said assistive device. The patient is discouraged on hopping as his way of ambulation, as it increases his risk for falls and further injury. It is also advised for the patient to ask help from his significant others in case he needs to go to the comfort room or go about the ward. The SOs were also asked to keep watch on the patient, as he was an active child despite his current condition. Focus Charting Focus charting involves the actual care rendered to the patient during the eight hour shift. Although the nursing care plans prepared by the student nurse are not the same with the chosen focus documented in the chart, interventions from the planned care are incorporated in chosen focus of the shift. Day 1 F: Impaired Physical Mobility Patient was received sitting on bed, awake, coherent, with ISA at right arm, with palpable swelling at left knee, verbalized discomfort upon movement,

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facial grimace noted, seen hopping on one foot while ambulating, and with baseline vital signs of T= 36.8 oC, PR= 89 bpm, RR=22 cpm, BP= 90/60 P/S= 5/10 Interventions started with establishing rapport, followed by taking and charting of vital sign. The patient was also assisted with activities of daily living and to position of comfort, instructed on the use of side rails, encouraged to use crutches, emphasized the importance of safe physical mobility, encouraged ambulation as tolerable. Patient was then seen ambulating with the help of SO from bed to comfort room. Day 2 F: Acute Mild Pain Patient was received sitting on bed, awake, coherent, with ISA at right arm, with palpable swelling at left knee, verbalized discomfort upon movement, facial grimace noted, seen hopping on one foot while ambulating, verbalized throbbing pain at affected knee, and with baseline vital signs of T= 36.9 oC, PR= 88 bpm, RR=21 cpm, BP= 90/60 P/S= 7/10. Interventions included taking and monitoring of vital signs, along with assessing level of pain and discomfort. Patient was then taught on deep breathing exercises and diversion activities such as playing with mobile phone and reading his comics. Patient was also encouraged not to do unnecessary movements and to have adequate rest. Intravenous analgesic medication was

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given by the medication nurse on duty. After thirty minutes, patient reported a lowered pain score of 2/10. Day 3 F: Ineffective Airway Clearance Patient was received sitting on bed, awake, coherent, with ISA at right arm, crackles heard upon auscultation of right lower lung fields, with shallow respirations noted, non-productive cough noted, verbalized itchy throat, verbalized to not have and with baseline vital signs of T= 36.8 oC, PR= 88 bpm, RR=23 cpm, BP= 90/60 P/S= 4/10. Interventions included taking and monitoring of vital signs, along with assessing respirations. Patient was taught on deep breathing exercises, along with hacking up and spitting out his secretions. The patient’s SO was taught with chest physiotherapy. Knowledge on handwashing and good hygiene was reinforced, as well as proper diet to increase immunity. Seen patient coughing with minimal sputum noted. Discharge Plan Following effective treatment, patient will be discharged to his home in Canduman, Mandaue City. Although the patient was not yet discharged during the shift, probable date of discharge would have been November 25, 2017. In order to relieve pain, the patient must take Celecoxib 200 mg/tablet twice a day, at 8 o/clock in the morning and 6 o’clock in the evening, along with Cefuroxime 500 mg/tablet twice a day for concurrent and possible infection, preferably with

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meals to prevent stomach upset, and follow with water to facilitate swallowing. Patient was advised to keep the environment clean to prevent infection as individuals with malignancies are more susceptible to infection to ambulate as tolerable to promote proper blood flow, and if possible with the aid of crutches. Patient was encouraged to perform range of motion exercises extending and flexing his upper and lower extremities to maintain joint function and facilitate optimal blood flow; refrain to bear weight on the affected leg; limit extraneous activities to prevent fatigue and have adequate sleep and rest. Patient will have to return to VSMMC Outpatient Department, Orthopedics Department on December 1, 2017 at 8:00 o’clock in the morning and look for Dr. Guada Giselle S. Rarang for check-up and further management. The need for crutches was emphasised and was instructed with the proper use of assistive device. Patient was also taught on the importance of proper hygiene to prevent the spread and contract of infection. Report immediately to the physician if severe leg pain, high grade fever (above 38.5oC), and cough lasting for more than 2 weeks occurs and seek medical attention promptly. The patient must know the relevance of proper and adequate nutrition for optimal tissue growth and increased immune defense and maintain a diet composed of lean meat, citrus fruits, and milk. For the patient, continue to embrace faith and do not hesitate to confide in a trusted individual your feelings and emotions.

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Chapter 3 Summary, Conclusion, and Recommendations Summary The case study was about a 14 year old male admitted for the first time at Vicente Sotto Memorial Medical Center for his complaints of severe pain from a swelling on his left leg. After sustaining a fall, the patient tolerated the growing pain and swelling on his left leg. Upon initial assessment, the physician ordered laboratory tests that showed signs of a malignancy. The physician gave an admitting diagnosis of Swollen Left Leg. His current admission and recent diagnostics showed remarkable signs of osteosarcoma, such as elevated serum alkaline phosphatase and LDH, both significant markers for osteosarcoma, along with a histopathology report that is suggestive of a malignancy. The study presented a holistic nursing care approach to showcase the occurrence of the diseases after rendering a cumulative of 32 hours of care. Throughout the span of care, the patient was compliant to care rendered and showed signs of increased hope that his condition will be treated. On the final day of care, the patient has had a diagnosis of Osteosarcoma Distal Femur Left, with further medical management to be arranged by his physician. Further laboratory tests were run and the results supported the diagnosis, and the patient showed slow progression of the disease.

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Conclusion The care of a patient with osteosarcoma can be challenging as the word “cancer” can be fearsome for a growing child. This disease is relatively uncommon, and for a child afflicted with such a condition, it is understandable if he is fearful about his condition as uncertainty is one of the disease’s natures. It is therefore important for healthcare providers to give quality care and interventions necessary for the patient’s condition. Care specifically set for a child with this condition is what the patient needs. This would be of great help for a child and his family that is unsure on what to do next. Generally, a patient with a non-metastatic osteosarcoma has a 70% chance of survival following a successful chemotherapy treatment and surgery. Low-grade tumors are also seen to have a good prognosis post-treatment. Following the care rendered and the diagnostic examinations taken, the patient showed a favourable prognosis that may merit a malignant-free condition should the surgery be pushed through. Lung metastasis was not evident, which may also lead to a favourable outcome post-surgery. The student nurse researcher also sees a good prognosis for the patient as he is compliant to care rendered, and has a positive outlook on his condition that may aid his emotional and psychological well-being. Recommendations As the researcher, the student nurse recommends that the nursing care be patient-centered, and that the emotional aspect of care would also be observed and rendered to an ailing child. The patient is also advised to impose limitations

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on movement as needed, as current medical care is not yet specific to his diagnosis, and for him to be positive about his condition. It is highly recommended for the patient to follow the doctor’s orders, especially the procurement of crutches that would enable him to ambulate more effectively and safely. It is also recommended by the researcher for other researchers to also present a case study of the same diagnosis, if ever available and possible, to help further explain the nature of the disease. Students who are to create a case study of the same condition may also emphasize the need to further address the emotional and psychological aspect of the condition. The researcher also sees it relevant for the general public to be aware of the warning signs of cancer and seek immediate medical treatment as soon as the manifestations are evident.

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APPENDICES

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Appendix A Nursing History and Physical Assessment Cebu Normal University College of Nursing Cebu City Mission-Vision: “Care Using Knowledge and Compassion” Theory-based (Betty Neuman) ASSESSMENT FORM Name of Student: MAGHARI, MARIEDITH J. Area of Assignment: WARD VIII Name of Clinical Instructor: MR. FRANCIS ARCHANGEL P. MILLOREN, RN Inclusive Dates: NOVEMBER 15-18, 2017 6AM-2PM I.

CLIENT’S PROFILE & CENTRAL CORE

Client’s Initials: W.H. Age: 14 years old Gender: Male Religion: Roman Catholic Status: Single/Child Allergies: no known food and drug allergies Diet: Diet As Tolerated Height: 157 cm Weight: 55 kg Date & time of Admission: November 6, 2017 AT 7:16 PM Mode of Admission: Ambulatory Impression/Diagnosis: Osteosarcoma Distal Femur Left Reason for seeking health care: Severe pain on left leg with visible and palpable mass Vital Signs: T: 36.8oC PR: 89 bpm RR: 19 cpm BP: 90/60 Pain score: 8/10 General Physical Description: Seen patient without IVF, with well-kept hair, clean clothes and appearance, with medium body build for age, visible and palpable large mass on left thigh noted. General Behavior exhibited: Patient is alert and eager to answer questions, has a pleasant atmosphere, but exhibits facial grimace from time to time. Physician in-charge: Dr. Guada Giselle S. Rarang, Orthopedics Nurse-on-Duty: Ms. Marivic P. Suarez, RN II.

STRESSORS & REACTIONS TO STRESSORS A. Client’s Complaints Upon Admission

55

Patient complained of severe throbbing pain, unrelieved by previously prescribed analgesic. No other complaints were verbalized by patient and significant other. Stressors as perceived by the client and SO’s: A constant stressor verbalized by the SO is that his son is not properly attended in the orthopedic ward, as he is not on a medical bed but is admitted to the extension of the ward. Both the mother and the uncle wish for the patient to be transferred to the pediatric ward. The patient however sees no problem with this and sees it fit to stay in the orthopedic ward because his condition for him is orthopedic in nature. B. Identification and Reactions variables/subsystems:

to

Stressors

by

person

1. Intrapersonal a. Physiological (Head to Toe) Past medical history: Illnesses: None Surgery: None History of chronic disease: None Immunization History: (specify the number of doses received) 1 BCG 1 DPT 1 OPV 1 AMV 1 MMR 1 Hep B 1 TT 1 HiB 1 MMV 1 Rubella Vaccine 1 Others Smoking: x pcks/day x pck/year Alcoholic Beverages: x Type x Amount x Frequency of Use x Date of Last Drink Illicit drugs: x Type x Amount x Frequency of Use x Date of Last Use Medication (prescription/OTC) Medicine Ibuprofen caplet

Dose 1

200 mg PO

Frequenc y q 8 hrs

Last Dose

Indicatio n 11/07/ 2017 8 Pain am

56

Allergies: x Foods x Drugs Perception of health: x good / fair x poor Dietary Preferences: Patient prefers to eat green leafy vegetables and lean meat such as pork chicken. Physical Assessment: Central Nervous System Level of Consciousness: / Alert x Drowsy x Obtunded x Comatose Mood (subjective): x pleasant x calm x euphoric x fearful Affect (objective): x surprise x sadness x disgust x flat

x

Lethargic

x

Stupurous

x

irritable

x / x

happy anxious others(specify)

x x x x

anger joy fear blunted

x full Orientation Level: / person / place / time Memory: / Recent / Intermediate / Remote Pupils: Right 3 mm size PERRLA Reaction Left 3 mm size PERRLA Reaction Reflexes: Normoflexia (+2 on all extremities) grade (describe) Grasps: Right Left / Strong x Weak / Strong x Weak Others: x Numbness x Tingling x Restless x Mannerism Pain: None: 8/10

57

Provoking/Precipitating factors: Movement Quality/Location: Throbbing pain at distal end of left thigh Radiating or non-radiating: Radiating to entire thigh and upper portion of leg Severity/intensity: Severe Timing: Constant but relieved by analgesic Visual Acuity: / Normal x blind (R/L) Hearing: / Normal x deaf(R/L) x tinnitus Touch: / normal Smell: / normal

x x

glasses x contacts Prosthesis: (artificial eye) R/L

x x x

impaired (R/L) hearing aid drainage from ears

x

abnormal (specify)

x

abnormal

Communication: x Broca’s Aphasia x Global Aphasia

x

Wernicke’s Aphasia

Cardiovascular System Pulse Rate and Characteristics: / regular x irregular / strong x weak 89 Right Upper Extremity 89 Left Upper Extremity 88 Right Lower Extremity 89 Left Lower Extremity Heart Sounds: / S1 / S2 x Others (specify) Blood Pressure: 90/70 standing 90/60 lying 90/60 sitting Extremities: Temperature: Upper Extremities / cool x warm Lower Extremities / cool x warm Capillary Refill Time: 2 second/s Homan's Sign: / Negative x Positive Claudication: / Negative x Positive Nails: / Normal x Thickened x Clubbing x Other (specify) Respiratory System Chest:

/

symmetrical

x

asymmetrical (specify)

58

Respirations:

23 cpm rate abnormal depth (shallow/deep, abdominal/diaphragmatic) / regular x irregular (specify) x periods of apnea x dyspnea at rest x x

Cough:

x

orthopnea dyspnea on exertion x others(specify) / present (specify) _x_ dry / soft / productive x nonproductive x whooping x odor white color thick consistency

absent

/

Sputum:

x

Normal

Breath Sounds: /

Adventitious (specify

location) x absent / crackles x rhonchi x friction rub x wheezing Respiratory devices: x CTT: x

Tracheostomy:

x

ETT:

x

Oxygen Therapy:

N/A N/A N/A N/A

Gastrointestinal System Prescribed Diet: Diet as tolerated Appetite: / Normal Gag Reflex: x Present GIT problems: x Nausea x Dysphagia x Diarrhea x Hemorrhoids

x x x x x x

Abnormal (specify) Absent Vomiting Constipation Incontinence Others (specify)

59

Feeding Ability: Mouth:

/ x x x Oral Prosthesis: none Defecation Pattern: firm fistful Abdomen: / x x x x Bowel sounds: x / Bowel Diversions: x Integumentary System / / / / / x

Able x pink x moist x lesions/ulcerations

Unable (specify) inflammed dry x Others(specify)

Consistency dark brown Color Amount OD Frequency symmetry / flat rounded x obese Ascites / Soft Firm x Tender Distended Hypoactive x Hyperactive Normoactive x Absent Ostomies (specify)

x

color: pallor, ashen, pink, jaundice, cyanotic, ruddy temperature: warm, cool (around mass, other areas) dry, moist, clammy, diaphoretic skin integrity: intact, impaired (specify) turgor: good, poor edema: pitting/non-pitting, dependent, bipedal, periorbital, anasarca pruritus

/

bruises/lesions (around and over palpable mass)

x

decubitus ulcer (describe)

Urinary System Bladder Patterns:

light yellow color 100 cc Amount Clear Turbidity5-6/day Frequency Urinary problems: x Dysuria x Nocturia x Urgency x Hematuria x Retention x Burning x Hesitancy x Incontinence Elimination Assistive Devices: x catheterization (specify) Musculoskeletal System Self-Care Ability: (0=Independent 1=Assistive device; 2=Assistance from others; 3=Assistance from person and equipment; 4=Dependent/Unable) Self-care 0 1 2 3 4 Self-care 0 1 2 3 4

60

Feeding

/

Bathing Dressing Bed Mobility

X X / X X / X X /

Problems:

x

X x x x

tremors

Assistive Devices:

/

splint/brace others (specify) Gait:

Transferrin g x x Ambulating x X Toileting x x

x x /

x x

x x / x x /

x x x x

x

/

atrophy

swelling

none x crutches x commode x walker x cane x wheelchair

x x

x normal / abnormaI (limping/hopping on one foot because of pain while bearing weight) Range of Motion: x normal / limited (patient has difficulty extending/flexing left lower extremity) Posture: / normal x Kyphosis x Lordosis x Scoliosis Deformities: / None x Yes (specify) Amputation: / None x Yes (specify) Reproductive System Sexual concerns: Female:

N/A LMP N/A GPTPAL Score N/A Menopause (specify) Family Planning: N/A No N/A Yes (type) Vaginal bleeding: N/A No N/A Yes (describe) History of sexually transmitted disease: N/A None N/A Yes(specify) Last Pap Smear: N/A Male: Prostate problems / No Penile discharges: / No Last prostate exam: N/A Congenital Problems: x hypospadia History of sexually transmitted disease x Yes(specify)

x x

Yes (type) Yes (type

x epispadia / None

61

b. Psychological Overt signs of stress: (crying, wringing of hands, clenched fists) Coping Strategies: Patient is a happy-go-lucky child who often jokes about his condition, and goes to talk to his uncle for guidance. Impact of Hospitalization/Illness (financial, self-care, role performance): Patient has stopped schooling as of the moment to manage his condition. His hobbies and sports have also been stopped as it may affect his condition._______________________ Recent Major loss: none__________________________________ Living Arrangement: x Alone x Nuclear / Extended Number of Children: N/A Occupation: none_______________________________________ Employment Status: x employed x unemployed Social activities: /

active

x

limited

x

none

Protestant Muslim

/ x

Catholic Buddhist

x Jewish x others

c. Spiritual Religion:

x x

(specify) Religious Practices/Restrictions: Patient regularly goes to church on Sundays together with his mother, uncle, and grandfather. Concerns related to spiritual or religious customs? Patient has not been able to hear mass since his admission. d. Developmental Psychosocial Task: Identity vs. Role Confusion Patient admitted that he still has not figured out what to do with his life, now with his school and leisure activities put to a halt and with his treatment still unclear. Psychosexual Task: Genital Stage Patient is still undergoing puberty, as some of his secondary sex characteristics, such as deepening of his voice, has not yet fully developed. He also shared that he has not had any romantic or sexual relations whatsoever. Cognitive level: Operational

62

Patient is able to understand the existence of space, time, and quantity, along with logical thinking. Moral Development: Conventional Patient conforms to what is asked of him from school and from his parents. He obeys so that he won’t get punished. 2. Interpersonal (between persons) and Extrapersonal (within the community) a. Socio-cultural Community participation: The patient has many friends in his neighborhood. He usually plays basketball with them during the weekends. Health cultural beliefs: The patient is a relatively healthy individual who has not been hospitalized therefore. His efforts to be treated shows that he believes in the importance and relevance of healthcare from professionals. Political Affiliations: The patient is a minor who has verbalized no interest in political organizations and has not much thought on his political views.

Stressors as perceived by the nurse: The patient has been waiting long for his final diagnosis, and for its absolute confirmation to be postponed in a span of almost two months has causes the patient and his family substantial anxiety that affects their day to day lives. I.

NURSING DIAGNOSES (in priority)

Classification Physiological

Nursing Problems (at least 5) 1. Acute Moderate Pain related to swollen leg secondary to cellular aberration 2. Impaired Physical Mobility related swollen leg secondary to cellular aberration 3. Impaired Airway Clearance related to retained mucous secretions secondary to cough

63

4. Risk for Infection related to lowered immunologic response secondary to cellular aberration Psychological

5. Anxiety related unclear medical plans by physician

Socio-cultural Spiritual Developmental

II.

Discharge Planning

Client’s Initials: W.H. Diagnosis: Osteosarcoma Distal Femur Left Probable Date: December 8, 2018 Destination: Canduman, Mandaue City, Cebu Transportation: Public Utility Vehicle Medications Take the following medications and follow correct timing, frequency and dosage. May be taken after meals and follow with water. 1. Celecoxib 200 mg/capsule, 1 capsule after breakfast and dinner and follow with water. 2. Cefuroxime 500 mg/tablet, 1 tablet after breakfast and dinner and follow with water. Environment & Perform range of motion exercises to maintain joint Exercise function and facilitate optimal blood flow. Refrain to bear weight on the affected leg.

Treatments

Return to VSMMC Outpatient Department, Orthopedics Department and look for Dr. Guada Giselle S. Rarang for check-up and further management.

Health Education

To reduce the risk of infection, be hygienic, regularly wash hands with soap and water, keep the area clean,

64

and use clean towels, clothes and bed linen etc.

Observable symptoms

Report immediately to the physician if severe leg pain, high grade fever (above 38.5oC), and cough lasting for more than 2 weeks occurs and seek medical attention promptly.

Dietary Prescription

Know the relevance of proper and adequate nutrition for optimal tissue growth and increased immune defense and maintain a diet composed of lean meat, citrus fruits, and milk.

Spirituality

Resume spiritual belief when in full recovery like attending mass every Sunday. Do not hesitate to share thoughts and emotions to trusted individual.

------------SIGNED-----------MARIEDITH J. MAGHARI Name/Signature of Student Rating Scale: 5 expected 4 3 2 1 expected

=

when the student gives much more than what is

= = = =

when the student gives more than what is expected when the student gives what is expected when the student gives less than what is expected when the student gives much less than what is

Summary of Scores Components Client’s Profile Client’s Complaints

Highest Possible Score 5 5

Actual Score 4 4

65

Past Medical History Central Nervous System Cardiovascular System Respiratory System GIT System Integumentary System Urinary System Musculoskeletal System Reproductive System Psychological Spiritual Developmental Socio-Cultural Nursing Diagnoses Discharge Planning TOTAL

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 85

---------------------------SIGNED--------------------------MR. FRANCIS ARCHANGEL P. MILLOREN, RN Name/ Signature of Clinical Instructor

5 5 5 5 5 5 5 4 4 5 5 5 5 4 4 79

66

Appendix B Ideal Diagnostic Procedures Total-body bone scanning is a nuclear imaging procedure where tiny radioactive materials are injected into the vein. Commonly, areas of the body where cell and tissue repair occurs takes up the largest amount of the radioactive tracer. Another diagnostic procedure for the patient is a radiographic image or xray of the affected limb. No x-ray result was attached in the chart, even though an x-ray helps determine if the damage extends to the bone, resulting to possible fracture of the bone.

67

Appendix C Ideal Surgical Management

Before the use of chemotherapy in the 1970’s, osteosarcoma was treated primarily with amputation. However, 80% of patients subsequently developed recurrent diseases such as pulmonary metastasis. Adjuvant post-operative chemotherapy is now of critical relevance in treating osteosarcoma. Moreover, osteosarcomas are relatively not responsive to radiotherapy, leaving surgery as the best option. The most common approach to a localized osteosarcoma is treated with a limb-sparing surgery following a neoadjuvant chemotherapy to reduce the malignancy. In a limb-sparing surgery involves removal of the tumor and surrounding tissue, preventing recurrence.

It is performed in the most

conservative technique possible for the benefit of the patient, especially that the patient is still a child. Should an above the knee amputation be performed, it is important that reconstructive surgery and rehabilitation are considered. Prosthetics and artificial limbs are to be prescribed by the orthopaedic along with specifications from the rehabilitative services Appendix D Drug Studies DRUG DATA Generic

CLASSI FICATIO N Therape utic

MECHANI SM OF ACTION Inhibits cell wall

INDICA TION Treatme nt of

CONTRAIND I CATIONS Hypersensitiv ity to

SIDE EFFECTS

NURSING RESPONSIBILITIES

CNS: Headache, dizziness,

Before -Check doctor’s order.

62

68 Name Cefuroxi me Axetil Trade Name Ceftin Patient Dose 500 mg/tab BID PO

Antibioti c Pharma cologic Second generati on cephalos phorin Pregnan cy Risk Categor yB

Maximu m Dose 500 mg PO BID

Metabolis m: T ½: 12hr

Excretion : urine Onset: varies

Route PO

Peak: immediate ; 30mins2hr Source: Lippincot t William and Wilkins’s Nursing Drug Handbo ok 2013

Duration: 18-24hr Drug halflife: 60120 min

Source: Lippincott William and Wilkins’s Nursing Drug Handbook 2013

Source: Lippincot t William and Wilkins’s Nursing Drug Handboo k 2013

DRUG DATA

Pharmaco kinetics:

Distributi on: crosses placenta enters breast milk

Minimu m Dose 250 mg PO BID

Availabil ity Capsules : 10mg 20mg Tablet:20 mg Powder for oral suspensi on 20mg

synthesis, promoting osmotic instability, usually bactericida l.

CLASSIFI CATION

infection s of lower respirato ry tract, urinary tract, skin and skin structure s; treatme nt of uncompl icated gonorrh ea, otitis media, pharyngi tis, and tonsilitis caused by suscepti ble strains of specific microorg anisms Patient’ s Indicati on Prevent infection /treat infection

Source: Lippinco tt William and Wilkins’s Nursing Drug Handbo ok 2013

MECHANIS M OF ACTION

cefuroxime/ penicillins

lethargy, paresthesias

Precautions Renal Impairment Pregnancy/L actation

GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, pseudomembran eous colitis, hepatotoxicity

Interactions Drug-Drug Benzodiazepi ne, phenytoin, warfarin=incr ease serum levels and potential risk for toxicity Sucralfate=d ecreased absorption

GU: Nephrotoxicity Hematologic: Bone marrow depression (decreased WBC, decreased platelets, decreased Hct) Hypersensitivity : Ranging from rash to fever to anaphylaxis; serum sickness reaction Local: pain, abcess at injection site, phlebitis, inflammation at IV site

Source: Lippincott William and Wilkins’s Nursing Drug Handbook 2013

INDICATI ON

Other: Superinfections, disulfram-like reaction with alcohol

Source: Lippincott William and Wilkins’s Nursing Drug Handbook 2013

CONTRAINDICA TIONS

-Check for allergies. -Assess history of hepatic and renal impairment. -Assess skin status, LFTs, renal function tests, culture of affected area, sensitivity tests. -Culture infection, and arrange for sensitivity tests before therapy. During -Confirm patient. -Give oral drug with food to decrease GI upset and enhance absorption. -Have vitamin K available in case hypoprothrombinemia occurs. -Arrange for culture and sensitivity tests during therapy -Inform patient to swallow the tablets whole. After -Inform that the ff. are normal side effects: stomach upset or diarrhea. -Inform about adverse/side effects. -Instruct to report any abnormal reactions. -Inform patient to take full course of therapy even if you are feeling better. -Document intervention. Source: Lippincott William and Wilkins’s Nursing Drug Handbook 2013

SIDE EFFECTS

NURSING RESPONSIBILITIE S

63

69 Generic Name Celecoxi b

Therapeut ic NSAID

Trade Name Celebrex

Pharmaco logic Antiinflammato ry

Patient’s Dose 200 mg cap BID PO PRN Pain

Pregnanc y Risk Category C

Maximu m Dose 200 mg OD Minimu m Dose 100 OD Availabil ity capsules (50mg, 100mg, 200mg, 400mg) Route Per Orem

Source: Lippincot t William and Wilkins’s Nursing Drug Handboo k

DRUG DATA

Absorptio n: Bioavailabi lity unknown. Distributi on: 97% bound to plasma proteins; extensive tissue distribution . Metabolis m and Excretion: Mostly metabolize d by the hepatic CYP2C9 isoenzyme ; <3% excreted unchanged in urine and feces.

Source: Lippincott William and Wilkins’s Nursing Drug Handbook CLASSIFI CA TION

Analgesic and antiinflammatory activities related to inhibition of the COX-2 enzyme, which is activated in inflammation to cause the signs and symptoms associated with inflammation; does not affect the COX-1 enzyme, which protects the lining of the GI tract and has blood clotting and renal functions.

Relief of signs and symptoms of osteoarthri tis, rheumatoi d arthritis, ankylosing spondylitis, and juvenile rheumatoi d arthritis. Managem ent of acute pain including primary dysmenorr hea. Patient’s Indication For relief of Pain

Peak Unknown Onset 24-48 hour Duration 12-24 hour Half-life 11 hours

Source: Lippincott William and Wilkins’s Nursing Drug Handbook

MECHANIS M OF ACTION

Source: Lippincott William and Wilkins’s Nursing Drug Handbook

INDICATI ON

Contraindicated with allergies to sulfonamides, celecoxib, NSAIDs, or aspirin; significant renal impairment; pregnancy (third trimester); lactation. Precautions Use cautiously with impaired hearing, hepatic and CV conditions Interactions Drug-Drug -CYP2C9 inhibitors may ↑ levels. May ↓ effectiveness of ACE inhibitors , thiazide diuretics, and furosemide -Fluconazole ↑ levels (use lowest recommended dosage). -May ↑ risk of bleeding with warfarin and aspirin. -May ↑ serum lithium levels. -Does not inhibit the cardio protective effect of low-dose aspirin

Source: Lippincott William and Wilkins’s Nursing Drug Handbook CONTRAINDICA TIONS

CNS: dizziness, headache , insomnia CV: HF, MYOCAR DIAL INFARCTI ON, STROKE, THROMB OSIS, edema, hypertensi on GI: GI BLEEDIN G, abdominal pain, diarrhea, dyspepsia , flatulence, nausea Derm: EXFOLIA TIVE DERMATI TIS, STEVEN SJOHNSO N SYNDRO ME, TOXIC EPIDERM AL NECROL YSIS, rash

Source: Lippincott William and Wilkins’s Nursing Drug Handbook SIDE EFFECTS

Before -Check for doctor’s orders and identify patient’s identity. -Monitor complete blood count, electrolyte levels. -Assess for history of drug allergies. -Check for last drug administration. -Maintain asepsis. During -Confirm patient. -Capsules may be swallowed whole or opened and mixed it with apple –juice. -Avoid taking aspirin or alcohol use Celecoxib exactly as prescribed and not to increase dosage or take longer. -Explain use of drug to the patient. After -Assess for therapeutic response of pain relief, decreased stiffness, swelling. -Observe for bleeding, bruising and weight gain. -Monitor liver function test. -Monitor CBC for HgB and Hct -Chart intervention.

Source: Lippincott William and Wilkins’s Nursing Drug Handbook

NURSING RESPONSIBILITIE S

70 Generic Name Tramadol Trade Name Ultram Maximum Dose 50 mg

Therapeuti c classification Analgesic Pharmacologic Classification Opioid agonist

Minimum Dose 50 mg

Pregnancy Risk Category C

Availa bility Tablets: 50 mg

Centrally acting synthetic analgesic compound not chemically related to opioid that is thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin

General Indication: Moderate to moderately severe pain in adults Pt’s indication: Breakthroug h Pain

Pharmacokinet ics Onset:

Pt’s dosage 50 mg per tab, 1 tab PRN

unknown Duration: unknown

Source: Lippincott William and Wilkins’s Nursing Drug Handbook

Contraindicated in patients hypersensitive to the drug or any of its components and in those with acute intoxication from alcohol, hypnotics, centrally-acting analgesics, opioids, or psychotropic drugs. Use cautiously in patients at risk for seizures or respiratory depression; patients with increased intracranial pressure or head injury, acute abdominal conditions, or renal or hepatic impairment; and patients physically dependent on opioids .

Relieves pain

Route PO

Source: Lippincot t William and Wilkins’s Nursing Drug Handboo k

Analgesic and antiinflammatory.

Peak: 2 hr Absorption: rapid and almost compete Distribution: about 20% protein bound Metabolism: extensively metabolized Half-life: 6 -7 hours

Source: Lippincot t William and Wilkins’s Nursing Drug Handboo k

Source: Lippincott William and Wilkins’s Nursing Drug Handbook

Excretion: urine

Source: Lippincott William and Wilkins’s Nursing Drug Handbook

Source: Lippincott William and Wilkins’s Nursing Drug Handbook Source: Lippincott William and Wilkins’s Nursing Drug Handbook

CNS: 1) vertigo 2) malaise 3) headache 4) asthenia 5) CNS stimulation 6) dizziness 7) somnolenc e 8) seizures 9) euphoria CV: 1)vasodilati on EENT: 1)visual disturbance s - GI: 1)abdomin al pain 2) diarrhea 3) nausea 4) constipatio n 5) vomiting 6) anorexia 7) dry mouth 8) dyspepsia 9) flatulence - DERM: 1) rash 2) pruritus 3) sweating GU: 1)menopau sal symptoms 2) urinary frequency 3) urine retention MUSCULO SKELETAL : 1)hypertoni a -RESPI: 1)respirator y depression

Source: Lippincott William and Wilkins’s Nursing Handbook

Before Assess patient’s pain. R: to know the appropriate nursing intervention to render to relieve that specific pain. Assess History of renal impairment, allergies, and hepatic. R: because history of such will create reactions to the drug. Assess physical skin colour and lesions, orientation, reflexes, peripheral sensation, clotting times, CBC, adventitious sounds. R: to have comparative assessments before and after drug administration. Keep emergency equipment readily available at time of initial dose, in case of severe hypersensitivity reaction. R: to be able to give immediate interventions if severe reactions may occur. Monitor CV and respiratory status. R: because drug can cause respiratory depression During Give with meals and water R; To prevent GI upset Practice sterility throughout procedure. R: to prevent any further infection Give drug before onset of intense pain. R: to prevent severity of pain If respiratory rate decreases or falls below 12 bpm, withhold dose and notify physician. R: to prevent further complications. Anticipate need for laxative therapy. R: Because constipation is a common adverse effect, After Be aware that patient may be at risk for CV events, GI bleeding, renal toxicity. R: to be able to respond immediately so close monitoring must be done Monitor I&0 rates and patterns. R: because medication can cause urine

64

71 retention Warn patient to refrain performing other potentially hazardous activities that require mental alertness. R: because patient may develop dizziness or headache as drug side-effect. Monitor for signs of hypersensitivity. R: because patient has high risk for hypersensitivity Monitor bowel sounds because .R:drug may cause bowel disturbances

Source: Lippincott William and Wilkins’s Nursing Drug Handbook

Appendix E Nursing Care Plans

65

Cebu Normal University College of Nursing Cebu City Mission-Vision: “Care Using Knowledge and Compassion” Theory-based (Betty Neuman)

NURSING CARE PLAN Assessment 3 points Interventions 4 points Diagnosis 3 points Evaluation 1 point

Goals

Bibliography Theoretical Basis 15 points

2 points 2 points

72 Name of Student:_Mariedith J. Maghari Client’s Initials:____W.H.____________________________________ Classification: Age: 14yrs old_ Gender: Male Civil Status: Single Religion: Roman Catholic (body structure and functions) Allergies: No known food and drug allergies Psychological (mental processes and emotion) Diet:_Diet as tolerated____________________________________ (relationships, social expectations) Date of Admission:_November 6, 2017 @ 7:16 PM_________ (influence of spiritual beliefs)

Diagnosis/Impression: Osteosarcoma Distal Femur Left (developmental processes over the lifespan)

NURSING DIAGNOSIS Assessment Diagnosis Subjective: “Sakit kaayo siya. Magngulngol siya usahay” as verbalized by the patient Objective: -Received patient sitting on bed with ISA @ Right Arm -Swollen left leg noted -Skin warm to touch -Facial grimace noted -With vital signs of: T: 36.9°C P:76 bpm R: 17 cpm BP: 90/60 mmHg pain score: 7/10

Acute Moderate Pain related to Swollen left leg Secondary to Osteosarcoma distal femur left Theoretical basis: Acute moderate pain occurs after an acute injury, illness or surgical intervention and has a rapid onset, with varying intensity (mild to severe) and lasts for a short time (Meinhart and Mc Caffery, 1983, NIH 1986 in Potter and Perry, 1997). Proliferation of malignant osteoid tissues causes a overcrowding of cells. This then leads to the compression of cells and tissues, causing swelling. The pain coming from this swelling ranges from moderate to severe in the pain scale.

Stressor /

Physiological x

x

Socio-cultural x

x

Spiritual

Developmental

NURSING GOALS Mutual Planning (Goal attainable within the shift)

NURSING OUTCOME Interventions (with Rationale & Source)

SHORT-TERM GOALS: After 8 hrs of nursing interventions, the patient will be able to: a. report pain is controlled or relieved b. display reduced tension, relaxed manner, and ease of movement c. verbalize understanding in limiting movement in affected area

PRIMARY INTERVENTIONS Promotive: I: Provide comfort measures e.g. repositioning, maintaining alignment of affected area R: To promote non-pharmacological pain management I: Instruct patient to do relaxation techniques: deep and slow breathing, distraction behaviors. Assisted as needed. R: Helpful in decreasing perception and response to pain. Provides a sense of having some control over the situation, increase in positive attitude. I: Observe and document location, severity (0–10 scale), and character of pain (steady, intermittent, colicky). R: Assist in differentiating cause of pain, and provides information about disease progression and resolution, development of complications, and effectiveness of interventions I: Conduct health teaching in relation to current health condition R: patient awareness promotes increase in compliance Preventive: I: Obtain and accepted patient’s description of pain R: Pain is a subjective experience and must be described by patient. Provides baseline for comparison to aid in determining effectiveness of therapy, resolution and progression of problem I: Encouraged verbalization of feelings of pain R: Only the client can judge the level and distress of pain; verbalization of feelings allows prompt solutions and helps prevent further complication I: Maintain bed rest or limb rest as indicated

LONG-TERM GOALS: After 4 days of nursing interventions, the patient will be able to: a. patient will be able to verbalize non-pharmacologic methods and relaxation techniques that provide relief b. maintain stabilization and alignment of affected area c. demonstrate body positioning that promotes stability at fracture site

Actual Eval

66

73 R: provides stability, reducing possibility of disturbing alignment and muscle spasms, which enhances healing I: Maintain immobilization of affected area by means of bed rest R: Relieves pain and prevents bone displacement and extension of tissue injury SECONDARY INTERVENTIONS Curative I: Prepare for the administration of medications, and monitor response to drug therapy. Notify physician if pain does not abate R: pain control is a priority I: Administer medications as indicated R: Relieves reflex spasm and smooth muscle contraction and assists with pain management.

67

TERTIARY INTERVENTIONS Rehabilitative I: Provide for individualized physical therapy/exercise program that can be continued by patient after discharge R: promotes active role and enhances sense of control I: identify speci characteristics R: to know what requires medical follow-up I: cooperate with the family of the client to document the health of the patient R: to be able to follow up the situation of the patient Bibliography:

  

 



Smeltzer, S.C (2010) Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Philadelphia, Pennsylvania: J.B Lippincott Company Doenges, M.E (2010) Nurse’s Pocket Guide 12th Edition. Bangkok, Thailand. iGroup Press Co., Ltd. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th edition by Smeltzer, Bare, Hinkle, Cheever Nursing Interventions and Rationales. (2013, July 18). Retrieved January 3, 2018, from http://nursinginterventionsrationales.blogspot.com/2013/07/acute-pain.html NANDA NURSING. (2013, March 01). January 3, 2018, from http://nandanursing.com/acute-pain-nanda-nic-noc.html Pathophysiology of Osteosarcoma. Retrieved January 3, 2018, from https://www.pdfcoke.com/doc/98922837/Pathophysiology-of-Osteosarcoma

68

74

Cebu Normal University College of Nursing Cebu City 

Mission-Vision: “Care Using Knowledge and Compassion”

   Assessment 3 points Bibliography Diagnosis 3 points 15 points



Theory-based (Betty Neuman)

NURSING CARE PLAN

Goals

 2 points

Interventions

4 points

Theoretical Basis

2 points

Evaluation

1 point

Name of Student: Mariedith J. Maghari Client’s Initials:____W.H.____________________________________ Classification: (Please check) Age: 14yrs old_ Gender: Male Civil Status: Single Religion: Roman Catholic Physiological (body structure and functions) Allergies: No known food and drug allergies Psychological (mental processes and emotion) Diet:_Diet as tolerated____________________________________ cultural (relationships, social expectations) Date of Admission:_November 6, 2017 @ 7:16 PM____________ (influence of spiritual beliefs) Diagnosis/Impression: Osteosarcoma Distal Femur Left Developmental (developmental processes over the lifespan)

NURSING DIAGNOSIS Assessment Diagnosis Subjective: "Mungulngol usahay ni ang hubag sa akong tuhod,” as verbalized by patient. Objective: - Received patient sitting on bed with ISA @ Right Arm - Swollen left leg noted - Skin warm to touch - Facial grimace noted -Cold and clammy skin -Tingling and numbness felt @ left leg noted - With vital signs of: T: 36.9°C P:76 bpm R: 17 cpm BP: 90/60 mmHg

Impaired Tissue Integrity related to Swollen left leg secondary to Theoretical basis: Maintaining skin integrity in hospitalized patients is a vital aspect in the goal of nursing care. These are instrumental to hospital risk strategies as part of quality and safety agenda. It often reflects the convergence of clinician’s knowledge, critical thinking and caring skills. Proliferation of malignant osteoid tissues causes a overcrowding of

NURSING GOALS Mutual Planning (Goal attainable within the shift) After 8 hours of Nursing Interventions, patient will be able to: a. Report any altered sensation or pain at site of tissue impairment b. Acknowledge interventions proposed for his well being c. Participate to the interventions conveyed d. Manage to ambulate without restrictions e. Rest properly

Stressor / x x

Socio-

x

Spiritual

x

NURSING OUTCOME Interventions (with Rationale & Source) PRIMARY INTERVENTIONS Promotive: I: Execute passive or active assistive ROM exercises to all extremities. R: Exercise enhances increased venous return I: Provide the patient of rest periods in between activities. Consider energy-saving techniques. R: Rest periods are essential to conserve energy. The patient must learn and accept his limitations I: encourage a diet that meets nutritional needs R: a high-protein, high-calorie diet may be needed to promote healing Preventive: I: monitor site of impaired tissue integrity for color changes, redness, swelling, warmth, pain, or other signs of infection R: systematic inspection can identify impending problems early I: keep a sterile dressing technique during wound care R: this technique reduces the risk for infection I: Instruct patient to avoid rubbing or scratching impaired area R: rubbing and scratching can cause further injury and delay healing SECONDARY INTERVENTIONS Curative I: Give medications as appropriate. R: analgesics may reduce pain that impedes movement. I: administer antibiotics as ordered R: wound infections may be managed well TERTIARY INTERVENTIONS Rehabilitative I: instruct patient, significant others, and family in proper care of

Actual Eva

After 8 ho nursi interven patien a. Understo condition b. Acknow the interve proposed c. Participa doing ROM exercises d. Manage ambulate w restrictions e. Rested w 69 safety ensu

75 pain score: 7/10

cells. This then leads to the compression of cells and tissues, causing swelling.

wound and in doing ROM exercises R: accurate information increases the patient’s ability to manage therapy independently, reduce risk for infection, and prevent compartment syndrome I: Let the patient accomplish tasks at his or her own pace. Do not hurry the patient. Encourage independent activity as able and safe. R: Healthcare providers and significant others are often in a hurry and do more for patients than needed. Thereby slowing the patient’s recovery.

Bibliography: 

H. (2017, February 05). Impaired tissue integrity – Nursing Diagnosis & Care Plan. Retrieved January 3, 2017 from https://nurseslabs.com/impaired-tissue-integrity



Smeltzer, S.C (2010) Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Philadelphia, Pennsylvania: J.B Lippincott Company

 

Doenges, M.E (2010) Nurse’s Pocket Guide 12th Edition. Bangkok, Thailand. iGroup Press Co., Ltd. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th edition by Smeltzer, Bare, Hinkle, Cheever Nursing Interventions and Rationales. (2013, July 18). Retrieved January 3, 2017 from http://nursinginterventionsrationales.blogspot.com/2013/07/ impaired-tissue-integrity.html



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Cebu Normal University College of Nursing Cebu City 

Mission-Vision: “Care Using Knowledge and Compassion”

   Assessment 3 points Bibliography Diagnosis 3 points 15 points



Theory-based (Betty Neuman)

NURSING CARE PLAN

Goals

 2 points

Interventions

4 points

Theoretical Basis

2 points

Evaluation

1 point

Name of Student:_Mariedith J. Maghari Client’s Initials:____W.H.____________________________________ Classification: (Please check) Age: 14yrs old_ Gender: Male Civil Status: Single Religion: Roman Catholic Physiological (body structure and functions) Allergies: No known food and drug allergies Psychological (mental processes and emotion) Diet: Diet as tolerated cultural (relationships, social expectations) Date of Admission:_November 6, 2017 @ 7:16 PM____________ (influence of spiritual beliefs)

Diagnosis/Impression: Osteosarcoma Distal Femur Left

Developmental (developmental processes over the lifespan)

NURSING DIAGNOSIS Assessment Diagnosis Subjective: :Manglisod kog lakaw kay kung matamak siya kay musamot kasakit,” as verbalized by the patient. Objective: - Received patient sitting on bed with ISA @ Right Arm - Swollen left leg noted - Skin warm to touch - Facial grimace noted - With vital signs of: T: 36.9°C P:76 bpm R: 17 cpm BP: 90/60 mmHg pain score: 7/10

Impaired Physical Mobility related swollen leg secondary to Osteosarcoma Distal Femur Left Theoretical basis: A modification in movement or mobility can either be a transient, recurring or more permanent dilemma. And when it occurs, it becomes a complex health care problem that involves many different members of the health care team. Proliferation of malignant osteoid tissues causes a overcrowding of cells. This then leads to the compression of cells and tissues, causing swelling. The pain coming from this swelling ranges from moderate to severe in the

NURSING GOALS Mutual Planning (Goal attainable within the shift) After 8 hours of Nursing Intervention, pt will be able to: a) Understand her condition b) Acknowledge interventions proposed for reducing pain c) Participate to the interventions conveyed d) Rest properly

Stressor / x x

Socio-

x

Spiritual

x NURSING OUTCOME Interventions (with Rationale & Source)

PRIMARY INTERVENTIONS Promotive: I: Provide comfort measures e.g. repositioning, maintaining alignment of affected area R: To promote non-pharmacological pain management I: Instruct patient to do relaxation techniques: deep and slow breathing, distraction behaviors. Assisted as needed. R: Helpful in decreasing perception and response to pain. Provides a sense of having some control over the situation, increase in positive attitude. I: Observe and document location, severity (0–10 scale), and character of pain (steady, intermittent, colicky). R: Assist in differentiating cause of pain, and provides information about disease progression and resolution, development of complications, and effectiveness of interventions I: Conduct health teaching in relation to current health condition R: patient awareness promotes increase in compliance Preventive: I: Obtain and accepted patient’s description of pain R: Pain is a subjective experience and must be described by patient. Provides baseline for comparison to aid in determining effectiveness of therapy, resolution and progression of problem I: Encouraged verbalization of feelings of pain R: Only the client can judge the level and distress of pain; verbalization of feelings allows prompt solutions and helps

Actual Eval

After 8 hou nursing interventio patient: a) Understo her cond b) Acknowl the interven propose c) Participa the interven conveye

71

77 pain scale.

prevent further complication I: Maintain bed rest or limb rest as indicated R: provides stability, reducing possibility of disturbing alignment and muscle spasms, which enhances healing I: Maintain immobilization of affected area by means of bed rest R: Relieves pain and prevents bone displacement and extension of tissue injury SECONDARY INTERVENTIONS Curative I: Prepare for the administration of medications, and monitor response to drug therapy. Notify physician if pain does not abate R: pain control is a priority I: Administer medications as indicated R: Relieves reflex spasm and smooth muscle contraction and assists with pain management. TERTIARY INTERVENTIONS Rehabilitative I: Provide for individualized physical therapy/exercise program that can be continued by patient after discharge R: promotes active role and enhances sense of control I: identify specific signs/symptoms in pain characteristics R: to know what requires medical follow-up I: cooperate with the family of the client to document the health of the patient R: to be able to follow up the situation of the patient

Bibliography:



Smeltzer, S.C (2010) Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Philadelphia, Pennsylvania: J.B Lippincott Company  Doenges, M.E (2010) Nurse’s Pocket Guide 12th Edition. Bangkok, Thailand. iGroup Press Co., Ltd.  Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th edition by Smeltzer, Bare, Hinkle, Cheever  Nursing Interventions and Rationales. (2013, July 18). Retrieved January 3, 2018, from http://nursinginterventionsrationales.blogspot.com/2013/07/acute-pain.html  NANDA NURSING. (2013, March 01). January 3, 2018, from http://nandanursing.com/acute-pain-nanda-nic-noc.html Pathophysiology of Osteosarcoma. Retrieved January 3, 2018, from https://www.pdfcoke.com/doc/98922837/Pathophysiology-of-Osteosarcoma

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Appendix F

80 Compliance Checklist Name of Student: Mariedith J. Maghari Adviser: Mr. Francis Archangel P. Milloren, RN Approved Title: Fall Into the Unknown: Care of a Client with Osteosarcoma Distal Femur Left Suggestions/Recommendations/Corrections 1. Organize the the chapters correctly 2. Organize flow of introduction 3. Add significance of the study directed to the patient, other patients with the same condition, and the general public 4. Change injury as a precipitating factor instead of predisposing factor in Psychopathophysiology. 5. Improve Research Design 6. Improve Research Locale 7. Improve Research Instrument 8. Spell Out HEENT 9. Complete the narrative of the PA form 10. Explain presence of pain and swelling in Psychopathophysiology 11. Relate ESR to patient’s condition 12. Explain relation of tumor in urinalysis with high RBC 13. Add introduction to Nursing Management 14. Add introduction to NCPs 15. Revise NCP diagnoses 16. Add goals 17. Add response to FDAR 18. Add time for OPD visit 19. Add ideal prognosis

Compliance (Page Number) 1 2 4

Remarks

16

Complied

5 5 6 11 13 16-17

Complied Complied Complied Complied Complied Complied

18 23 29 29 29-31 29-31 33 34 36

Complied Complied Complied Complied Complied Complied Complied Complied Complied

Complied Complied Complied

Approved:

FRANCIS ARCHANGEL P. MILLOREN, RN Adviser

JEZYL C. CUTAMORA, RN, MN, Ph.D. Dean

Date:

Date: ___________________________

Curriculum Vitae MARIEDITH JUANITAS MAGHARI PERSONAL DETAILS

Address:

Kasanta St., Mactan, Lapu-Lapu City, Cebu 6015 E-mail Address: [email protected] Civil Status: Single Citizenship: Filipino Birthday: August 29, 1997 Contact Number: +63 915 3939 532

EDUCATIONAL BACKGROUND CEBU NORMAL UNIVERSITY Osmeña Boulevard, Cebu City Bachelor of Science in Nursing Academic Year 2014-Present ST. ALPHONSUS CATHOLIC SCHOOL (LAPU-LAPU CITY) INC. P. Rizal St., Lapu-Lapu City, Cebu 6015 Secondary Education School Year 2010- 2014 LAPU-LAPU CITY CENTRAL ELEMENTARY SCHOOL P. Rodriguez St., Poblacion, Lapu-Lapu City, Cebu 6015 Elementary Education School Year 2004- 2010 SUMMARY OF QUALIFICATIONS Batch Representative Nightingale Student Council A.Y. 2014-2015 Organizer, Awards and Certificates International Conference of Nurses 4 2014

Assistant Secretary Nightingale Student Council A.Y. 2015-2016 Organizer, Transportation Committee International Conference of Nurses 5 2016 Business Manager Nightingale Student Council A.Y. 2017-2018 Organizer, Sponsorships Committee International Conference of Nurses 7 2017 Best Paper, Student Category 2nd Research and Extension Congress Cebu Normal University 2017