nursing process osteosarcoma
DESCRIPTION
Nursing Process OsteosarcomaTRANSCRIPT
NURSING PROCESS:THE PATIENT WITH A BONE TUMOR
OSTEOSARCOMA
Ns. Heri Kristianto, SKep.,MKep.,Sp.Kep.MB
Pengkajian
Onset and symptoms During the interview, the nurse notes the patient’s
understanding of the disease process, how the patient and the family have been coping, and how the patient has managed the pain.
On physical examination, the nurse gently palpates the mass and notes its size and associated soft tissue swelling, pain, and tenderness.
Assessment of the neurovascular status and range of motion of the extremity provides baseline data for future comparisons.
The nurse evaluates the patient’s mobility and ability to perform ADLs
Lokasi gambaran radiologis
Locus in bone 1%
Metaphyseal lesions 90–95%
Diaphyseal lesions 2–11%
Metaphyseal lesions extending to epiphysis
75–88%
Primary epiphyseal lesions
<1%
Locus in skeleton %
Knee 50–75%
Femur 45–55%
Tibia 16–20%
Humerus 11–15%
NURSING DIAGNOSES
Deficient knowledge related to the disease process and the therapeutic regimen
Acute and chronic pain related to pathologic process and surgery
Risk for injury: pathologic fracture related to tumor and metastasis
Ineffective coping related to fear of the unknown, perception of disease process, and inadequate support system
Risk for situational low self-esteem related to loss of body part or alteration in role performance
COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS
Potential complications may include the following:
Delayed wound healingNutritional deficiencyInfectionHypercalcemia
Planning and Goals
The major goals for the patient include Knowledge of the disease process and
treatment regimenControl of painAbsence of pathologic fracturesEffective patterns of copingImproved self-esteemAbsence of complications
Nursing Interventions
The nursing care of a patient who has undergone excision of a bone tumor is similar in many respects to that of other patients who have had skeletal surgery.
Vital signs are monitored; blood loss is assessed; and observations are made to assess for the development of complications such as deep vein thrombosis, pulmonary emboli, infection, contracture, and disuse atrophy. The affected part is elevated to control swelling, and the neurovascular status of the extremity is assessed
PROMOTING UNDERSTANDING OF THE DISEASE PROCESS AND TREATMENT REGIMEN
Patient and family teaching about the disease process and diagnostic and management regimens is essential.
Explanation of diagnostic tests, treatments (eg, wound care), and expected results (eg, decreased range of motion, numbness, change of body contours) helps the patient deal with the procedures and changes.
Cooperation and adherence to the therapeutic regimen are enhanced through understanding.
The nurse can most effectively reinforce and clarify information provided by the physician by being present during these discussions.
RELIEVING PAIN
Accurate pain assessment is the foundation for pain management.
Pharmacologic and nonpharmacologic pain management techniques
The nurse prepares the patient and gives support during painful procedures.
Prescribed IV or epidural analgesics are used during the early postoperative period.
Later, oral or transdermal opioid or nonopioid analgesics are usually adequate to relieve pain.
In addition, external radiation or systemic radioisotopes may be used to control pain
PREVENTING PATHOLOGIC FRACTURE
Bone tumors weaken the bone to a point at which normal activities or even position changes can result in fracture.
During nursing care, the affected extremities must be supported and handled gently.
External supports (eg, splints) may be used for additional protection.
At times, the patient may elect to have surgery (eg,open reduction with internal fixation, joint replacement) in an attempt to prevent pathologic fracture. Prescribed weight-bearing restrictions must be followed.
The nurse teaches the patient how to use assistive devices safely and how to strengthen unaffected extremities.
Weight-bearing exercise is physical activity in which muscles and tendons apply tension to bones, stimulating them to produce more bone tissue.
PROMOTING COPING SKILLS
The nurse encourages the patient and family to verbalize their fears, concerns, and feelings.
They need to be supported as they deal with the impact of the malignant bone tumor.
Feelings of shock, despair, and grief are expected.
Referral to a psychiatric nurse liaison, psychologist, counselor, or spiritual advisor may be indicated for specific psychological help and emotional support
PROMOTING SELF-ESTEEM
Independence versus dependence is an issue for the patient who has a malignancy.
Lifestyle is dramatically changed, at least temporarily. It is important to support the family in working through the
adjustments that must be made. The nurse assists the patient in dealing with changes in body
image due to surgery and possible amputation. It is helpful to provide realistic reassurance about the future and resumption of role-related activities and to encourage self-care and socialization.
The patient participates in planning daily activities. The nurse encourages the patient to be as independent as possible.
Involvement of the patient and family throughout treatment encourages confidence, restoration of self-concept, and a sense of being in control of one’s life.
MONITORING AND MANAGINGPOTENTIAL COMPLICATIONS
Delayed Wound Healing Wound healing may be delayed because of tissue trauma from
surgery, previous radiation therapy, inadequate nutrition, or infection.
The nurse minimizes pressure on the wound site to promote circulation to the tissues.
An aseptic, nontraumatic wound dressing promotes healing. Monitoring and reporting of laboratory findings facilitate initiation
of interventions to promote homeostasis and wound healing. Repositioning the patient at frequent intervals reduces the
incidence of skin breakdown due to pressure. Special therapeutic beds may be needed to prevent skin
breakdown and to promote wound healing after extensive surgical reconstruction and skin grafting.
Inadequate Nutrition
Because loss of appetite, nausea, and vomiting are frequent side effects of chemotherapy and radiation therapy, it is necessary to provide adequate nutrition for healing and health promotion.
Antiemetics and relaxation techniques reduce the gastrointestinal reaction.
Stomatitis is controlled with anesthetic or antifungal mouthwash
Adequate hydration is essential. Nutritional supplements or total parenteral nutrition
may be prescribed to achieve adequate nutrition.
Appetite stimulants (dronabinol, cyproheptadine, or megestrol acetate) were the most common type of support used. This form of nutrition intervention seems to be effective in maintaining nutrition status as a sole modality or in combination with parenteral nutrition. Optimizing nutrition interventions by including appetite stimulants may prove to be effective in this population
Osteomyelitis and Wound Infections
Prophylactic antibiotics and strict aseptic dressing techniques are used to diminish the occurrence of osteomyelitis and wound infections.
During healing, other infections (eg, upper respiratory infections) need to be prevented so that hematogenous spread does not result in osteomyelitis.
If the patient is receiving chemotherapy, it is important to monitor the white blood cell count and to instruct the patient to avoid contact with people who have colds or other infections
Hypercalcemia
Hypercalcemia is a dangerous complication of bone cancer.
The symptoms must be recognized and treatment initiated promptly. Symptoms include muscular weakness, incoordination, anorexia, nausea and vomiting, constipation, electrocardiographic changes (eg, shortened QT interval and ST segment, bradycardia, heart blocks), and altered mental states (eg, confusion, lethargy, psychotic
behavior).
PROMOTING HOME AND COMMUNITY-BASED CARE
Teaching Patients Self-Care
Preparation for and coordination of continuing health care are begun early as a multidisciplinary effort.
Patient teaching addresses medication, dressing, treatment regimens, and the importance of physical and occupational therapy programs.
The nurse teaches weight-bearing limitations and special handling to prevent pathologic fractures.
It is important that the patient and family know the signs and symptoms of possible complications
Continuing Care
Frequently, arrangements are made with a home health care agency or home care supervision and follow-up.
The home care nurse assesses the patient’s and family’s abilities to meet the patient’s needsand determines whether the services of other agencies are needed
The nurse advises the patient to have readily available the telephone numbers of people to contact in case concerns arise.
The nurse emphasizes the need for long-term health supervision to ensure cure or to detect tumor recurrence or metastasis.
If the patient has metastatic disease, end-of-life issues may need to be explored.
Referral for hospice care is made if appropriate
Hospice care
EXPECTED PATIENT OUTCOMES
Expected patient outcomes may include:Describes disease process and treatment regimena. Describes pathologic conditionb. States goals of the therapeutic regimenc. Seeks clarification of information
Achieves control of paina. Uses multiple pain control techniques, including
prescribed medicationsb. Experiences no pain or decreased pain at rest,
during ADLs, or at surgical sites
Experiences no pathologic fracturea. Avoids stress to weakened bonesb. Uses assistive devices safely and appropriatelyc. Strengthens uninvolved extremities with
exercise
Demonstrates effective coping patternsa. Verbalizes feelingsb. Identifies strengths and abilitiesc. Makes decisionsd. Requests assistance as needed
Demonstrates positive self-concept Identifies home and family responsibilities that can be
accomplished Exhibits confidence in own abilities Demonstrates acceptance of altered body image Demonstrates independence in ADLs
Exhibits absence of complications Demonstrates wound healing Experiences no skin breakdown Experiences no infections Does not experience hypercalcemia Manages side effects of therapies Reports symptoms of medication toxicity or complications
Participates in continuing health care at homeComplies with prescribed regimen (ie, takes
prescribed medications, continues physical and occupational therapy programs)
Acknowledges need for long-term health supervision
Keeps follow-up health care appointmentsReports occurrence of symptoms or
complications. Maintains or increases body weight
Caring